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The COVID-19 pandemic exposed systematic issues within the nursing home industry in America. Low staffing levels and poor quality of care resulted in thousands of preventable deaths in long-term care facilities. This article discusses the contributing factors that made COVID-19 such a crisis in nursing homes and what’s next for the industry.
Nursing homes as we know them originated with the almshouses of the 18th and 19th centuries and were essentially charitable living quarters for the poor, disabled, and the aged. These almshouses, and eventual nursing homes, were intended to be lively places that provided a higher level of care for those in need. It wasn’t until the 1950s –– when they became intrinsically connected to government programs like Medicare –– that they became the antiseptic, hospital-like facilities that we think of now.
As of 2020, there are about 14,939 nursing homes in the United States, serving around 1.6 million residents. These skilled nursing facilities are for those who are not ill enough to be in a hospital but who can not live independently, and they employ nurses, in addition to other medical professionals. Some people are in nursing homes for a short-term stay after a hospitalization while others, such as those with Alzheimer’s or dementia, are long-term residents.
Data from the U.S. Census Bureau indicates that the senior population grew by 34 percent between 2010 and 2020. The Bureau also predicts that by 2030, the entire generation born between 1946 and 1964 will be over the age of 65 —which means one in five U.S. residents will be of retirement age.
The explosion in population and the increase in life expectancy may have broad-ranging impacts on quality of life for older adults. Future Social Security benefit policy may be impacted to account for the growing number of individuals receiving benefits. The population growth will also ultimately increase the demand for caregiving services and long-term care facilities such as nursing homes.
According to Genworth, the average yearly cost for a private room in a nursing home was $105,850, a 3.57 percent increase from the year prior, reflecting an upward trend that has remained consistent over the past few decades.
It’s not clear why the costs of nursing homes have risen so exponentially, even outpacing growth in other health-care sectors. One hypothesis suggests it’s because occupancy rates are high and the nursing home market is highly concentrated, with a small amount of nursing homes controlling a relatively large market. These conclusions enable nursing homes to charge a premium for their services.
While Medicare does not cover long-term nursing home stays, Medicaid does cover the costs. However, Medicaid eligibility is complex and individuals must make under a certain amount of money per month to qualify. In some states such as Florida, Medicaid covers nursing home costs but requires residents to contribute the majority of the little income they make towards their care, with only a monthly personal allowance of $135 for personal needs.
Data from the National Center for Health Statistics found that nearly 60 percent of nursing homes are chain-affiliated for-profit businesses owned by corporations. The same report found that nursing homes across the country account for 1,660,400 certified beds. Within the long-term care facility industry, corporations are shifting away from institutions that only serve residents that need medical care. Instead, they are building diverse communities that offer specialized medical care that nursing homes provide, along with the more independent living situations typical of retirement communities and assisted living.
As of April 4, 2021, over 640,000 nursing home residents had tested positive for the disease, 131,584 of whom have passed away from complications due to the COVID-19 virus. This data also indicates 566,723 staff members contracted COVID-19 and 1,877 members have died from the disease. Nursing home residents account for a vulnerable subsect of the population and represent 30 to 60 percent of total COVID-19 deaths in many First World countries. The impact of the illness reaches far past data sets, though.
Occupancy rates fell 2.5 percent in the third quarter of 2020, continuing a steady decline since the onset of the outbreak. This goes beyond the death of residents. Many people stay in nursing homes following an elective surgery, which fell sharply with hospitals rescheduling or delaying surgeries due to the pandemic. Additionally, at the beginning of the pandemic, news stories about nursing home deaths, such as the hundreds who died in Washington, reportedly contributed to overall distrust regarding the facilities.
Infections have been a growing problem for nursing homes well before COVID-19. A 2014 study found that between 1.6 and 3.8 million infections occur annually in U.S. nursing homes and result in the deaths of 388,000 residents. The uneven quality of care in nursing homes is a big part of why these deaths occur. Virus transmission can occur when staff do not regularly wash their hands or sterilize equipment.
Additionally, some nursing homes have insufficient infrastructure. In 2017, 14 people died in a Florida nursing home after Hurricane Irma knocked out the facility’s air conditioning system. This came after the nursing home declined to call 911 or send patients to nearby hospitals for care.
Over 80 percent of residents in nursing homes are 65 and over which accounts for the most vulnerable portion of the population. COVID-19 can be a stealthy disease, transmitting silently among younger people, who then inadvertently transmit the disease to older adults who are at a greater risk of severe complications from the virus.
Further, while protective equipment may have accounted for asymptomatic staffers, 20 percent of nursing homes lacked access to personal protective equipment (PPE) that could have controlled outbreaks and prevented deaths. At the same time, many facilities who purchased this equipment and provided hazard pay to staff experienced near-bankruptcy, with 55 percent operating at a loss according to an August 2020 survey. Yet, without access to protective equipment or adequate staffing, vulnerable nursing home residents are at a much higher risk for exposure. Many of these residents live in close quarters and share communal spaces, making social distancing difficult.
Systematic errors also impacted this vulnerable population. Notably, over 9,000 recovering COVID-19 patients were sent back to nursing homes prematurely as the pandemic raged in New York state. This is 40 percent higher than the state reported at the time. These patients returned to understaffed and overwhelmed nursing homes, likely contributing to outbreaks among residents and their staff.
Many nursing homes simply do not have adequate staffing to meet the needs of their residents. According to a 2020 report, over half of nursing homes did not meet appropriate staffing levels designated by the Centers for Medicare & Medicaid Services 80 percent of the time. Low staffing can result in a higher likelihood of medical error, neglect, accidents, and cleanliness maintenance.
This is not the fault of the staff themselves. As an example, the ratio of certified medical staff to patients in Virginia nursing homes is 1 to 5 in the daytime and 1 to 10 at night, which is comparable to the national average. However, a 2019 study found that 54 percent of nursing homes met these appropriate staffing less than 20 percent of the time.
The COVID-19 pandemic has revealed the shortcomings of the U.S. nursing home industry. Long-standing problems like low staffing levels have been made clear by the large death toll in long-term care facilities.
Nursing homes are also overly reliant on Medicare and Medicaid to operate at a high level and still be profitable — a priority for these mostly for-profit facilities. However, this leaves coverage gaps as people who need this care may not fit the eligibility requirements and are left with high bills they cannot afford to pay, which contributes to inadequate standards.
This has led to a fundamental distrust in nursing homes, with individuals fleeing these facilities due to fear and isolation. Consequently, there’s now a growing trend of family members withdrawing their loved ones from nursing homes to opt for in-home care.
The good news – if I may be so optimistic – is that COVID-19 has taught us a hard lesson about the conditions in U.S. nursing homes. The Department of Health and Human Services (HHS) allocated $5 billion dollars of CARES Act money to nursing homes. The Centers for Medicare & Medicaid Services issued new guidelines regarding transparency around COVID-19 infections in nursing homes that will likely translate into permanent guidelines around other infectious diseases. A recent study found that higher staffing levels in nursing homes resulted in less COVID-19 deaths among patients. These developments translate into more regulation and scrutiny for nursing homes that will hopefully lead to better conditions for residents.
With that said, nursing homes face more challenges than just the fallout from the pandemic. Over the next 10 years, federal spending for programs that benefit older adults such as Social Security and Medicare is projected to rise to 10 percent of the U.S. gross domestic product, accounting for two-thirds of non-defense spending. Consequently, government policy regarding these benefits is likely to change with the rise of senior populations in the country in order to keep these programs solvent.
This concern contributes to the overall diversification of nursing homes. By expanding their offerings beyond medical care in a hospital-like setting, these communities could afford to better staff these homes with qualified professionals, and their revenue wouldn’t need to fully rely on government money. These facilities could also continue to serve patients as they age, allowing individuals to stay in a familiar home if and when their medical care needs change, as opposed to moving to a new facility entirely.