A WEEK AGO CommonWealth featured an op-ed by a representative of the nursing home industry entitled “Nursing home situation grows dire again.”  The gist of the article was a plea to the Massachusetts Legislature for $238 million in additional funding for nursing homes, ostensibly to raise the pay of the caregiving staff.

A more accurate title for the article might be “Unsafe at any expenditure,” since unsafe conditions in nursing homes existed prior to COVID-19. Moreover, despite millions of additional public funds, there has been little to no improvement in staffing levels, the provision of care, or the quality of life since the pandemic began.

As stated in the industry’s op-ed, “approximately two-thirds of our direct care staff are people of color and 39 percent are new Americans, and most do not yet earn a living wage.” It’s worth noting that the majority of both nursing home staff and nursing home residents are women, and that home care and personal care staff  generally suffer from a similar low-wage situation.

Regardless of where long-term caregivers are employed — in facilities or in home care — they  all need increased wages, better benefits, enhanced training, and an improved ratio of caregivers to care recipients to ensure the well-being of all. Furthermore, if state and federal governments are to provide more money to nursing homes, as well as home care, let’s make sure all appropriations are clearly specified for direct care and the expenditures are independently, comprehensively, and transparently audited.

Just last week, the National Academy for Science, Engineering, and Medicine issued a comprehensive analysis of the nursing home system entitled The National Imperative to Improve Nursing Home Quality: Honoring Our Commitment to Residents, Families, and Staff. The report includes a detailed set of recommendations authored by a multidisciplinary panel of more than a dozen national experts calling for immediate reform of the nation’s nursing homes. The report questioned whether Medicaid reimbursement is always inadequate, writing, “The lack of transparency or accountability in payment, funds flow, and nursing home finances make it extremely difficult to assess the adequacy of current Medicaid payments.”

President Biden recommended several reforms for nursing homes during his State of the Union address, including minimum staffing standards, increased oversight, and better financial transparency.

Both reform efforts take aim at long-standing issues that have plagued nursing home care for years. In addition to ongoing low staffing levels, Massachusetts nursing homes have suffered poor performance in other areas pre-pandemic, such as:

  • The misuse and overuse of antipsychotics can be deadly to elders, and Massachusetts nursing homes have had one of the highest antipsychotic usage rates in the country for many years.
  • A General Accounting Office analysis in 2020 indicated that infection prevention and control deficiencies were the most common type of deficiency cited in surveyed nursing homes. This is not a new issue due to the pandemic. About 64 percent of Massachusetts nursing homes had an infection prevention and control deficiency cited in one or more years from 2013-17. Also, about 16 percent of Massachusetts nursing homes were cited in multiple consecutive years, which is an indicator of persistent problems.

We are in strong support of providing livable wages and benefits to nursing home direct caregivers. And providing funds to recruit additional staff is critical. But we ask for greater oversight of those funds for the following reasons:

  • Providers have wide latitude in how they utilize MassHealth and other funds, since there are no limits on self-dealing transactions/contracts and no ceiling on administrative costs.
  • The growth of for-profit ownership in nursing homes, including significant investment by private equity firms and real estate investment trusts, makes it clear that nursing homes are profitable businesses.
  • A Boston Globe 2014 study of Massachusetts nursing home finances found that many nursing homes directed cash to subsidiaries “…paying million-dollar rental fees and helping to pay executives’ six-figure salaries…”
  • On a national basis, in 2018, the New York Times sounded the alarm, reporting that “nursing homes that outsourced to related parties tended to have fewer nurses & aides per patient, higher rates of patient injuries and unsafe practices.”

The majority of nursing homes are under for-profit ownership, many acquired by out-of-state investors. Millions of enhanced public payments have been appropriated during the past two years, ostensibly to enhance staff recruitment and retention and provide pandemic remediation. Before additional reimbursement is authorized, there should be a comprehensive, independent audit by a qualified firm and the results publicly reported.

An area where we can agree with the nursing home industry proponents is, as their op-ed states: “because of the communal nature of facilities, coupled with the contagiousness of the disease, COVID-19 moved swiftly throughout our buildings with dire results at the outset.”  We have long advocated for long-term care facilities to be small, home-like settings with single-room occupancy, with exceptions for married couples and others who may prefer to live together. A successful model of this small home arrangement can be found in the US Veterans Administration’s “small home model” and the “Green House model” of care currently operating in many areas of the country.

The future of long-term care for older adults and persons with disabilities should primarily be home care with services in the community. Most nursing facilities today are operating an outdated model of care. Massachusetts public policy should call for the diminishment of large scale, institutional facilities housing large numbers of residents. Nursing facilities of the future should be designed for small populations of 12 to 15 residents. Existing large facilities should be repurposed for other appropriate uses, such as accessible, supportive housing and housing for homeless individuals.

For much of the last century, the predominant model of care for people with severe intellectual or behavioral issues was institutional. Recently these large facilities have been abandoned. In their stead, many persons with developmental and other disabilities are now living in small, purpose-designed homes, accessible apartments, and other home care settings. The time is now for the same kind of reforms to occur for the housing and care needs of the Commonwealth’s growing population of frail older adults and persons with severe disabilities who cannot remain in their own homes for whatever reason.

Reform of nursing homes cannot occur without the assurance that all human rights be respected and enforced. One should not be expected to relinquish basic rights as a condition of admission or employment. It also is a disservice and disgrace that so many caregivers are employed in a work environment that does not respect their dedication and honor their dignity.

The cost of poor care in America’s nursing homes is staggering, whether it is measured by poor health outcomes, lives lost, the number living without their dignity or choices honored, or by the amount of money spent on treating otherwise preventable conditions. While the trauma inflicted upon nursing home residents and their loved ones is not easily categorized and calculated, the financial costs are quantifiable. The financial burden of poor care rests not only on individuals and families, but also on all American taxpayers, through the Medicare and Medicaid programs. And that burden is substantial.

The time for comprehensive transformation of nursing home operations and ownership and full and transparent accountability is now.

Paul J. Lanzikos, Arlene Germain, Richard T. Moore, and James Lomastro are members of the Dignity Alliance Massachusetts Coordinating Committee. Dignity Alliance is a statewide, grass-roots coalition of individuals and organizations dedicated to advocating on behalf of older adults, persons with disabilities, and their caregivers.