Dr. R. Tamara Konetzka, Louis Block professor in the Department of Public Health Sciences in the Department of Medicine at the University of Chicago and a member of the National Academies of Sciences, Engineering, and Medicine’s Committee on the Quality of Care in Nursing Homes, joined the April 6, 2022 LeadingAge Coronavirus Update Call. She responded to questions from Ruth Katz and from callers. A summary follows.

Q: Today the NASEM study has been released for the public. What did the committee set out to do, what was the charge?

A: Our statement of task was to study how the nation delivers, finances and regulates the quality of care in nursing homes and to make recommendations. Our task was much broader than dealing with the pandemic. There had not been a comprehensive look at nursing home quality since a 1986 report.

Q: Can you give us the short version of the process the committee followed?

A: NASEM recruited people for the committee who had relevant expertise and who did not have conflicts of interest. The process basically consisted of: five full committee meetings; ad hoc meetings with a variety of experts; research review; many small subcommittee meetings; public submission of narratives and perspectives; and peer review of our report and recommendations

Q: I know it’s hard to summarize 605 pages created over nearly two years, but what were the top line findings and highlights?

A: The Committee agreed that the way we currently deliver, finance and regulate nursing homes is inefficient, ineffective and unstainable. There are a lot of issues to fix. We need fundamental change in many areas. We can’t just take various pieces separately -we need cross-cutting wholistic change. If we don’t have that kind of fundamental change none of the recommendations individually will be successful.

Q: In a quick read, it doesn’t seem like the report lays the entire responsibility for quality

on nursing homes. Is that true?

A: Yes- there is clearly a role for Congress, a role for regulatory bodies, a role for nursing homes, a role for QIOs, and for many others. True reform will take action by many different stakeholders. We make it very clear in the report that nursing homes can’t implement some of these changes without additional resources and support. We believe that there are systemic problems that need to be fixed.

Q: It’ll be no surprise to you that the biggest issue LeadingAge member nursing homes face all day every day is workforce. We welcome the Committee’s ideas about increasing staffing. But where will the applicants come from as nursing homes aren’t the only ones having trouble finding workers. Honestly, we worry that new requirements (like those suggested by the White House) will be put on nursing homes to hire people when there just aren’t people to hire.

A: I would say that our approach differs from that of the White House. One of the ways is that we wrestled with the idea that nursing homes can’t do this on their own. In the long run we must view the changes all together to see how we might improve staffing. Some of what we are dealing with is the current macroeconomic situation, but some is related to supply and demand. We don’t pay staff enough and it is difficult work, especially during a pandemic. That is the result of the system we have set up which includes dependence on Medicaid rates. Nursing homes can’t solve the staffing problem until we see this fundamental change. That might not be satisfying in the short run, but we tried to look longer term at reforms that would mitigate staffing issues – better pay, career ladders, training etc.

Q: Was there discussion in the committee about other lower wage staff such as maintenance, dietary, housekeeping, and so on?

A: It came up but was peripheral to our recommendations. There are places in the report where the range of staff are mentioned, but we focused on direct care staff and the relationship to quality.

Another overarching point is that we think all of this will require more resources. We repeatedly referred to the Federal government and Congress having a role in implementing our recommendations. There is simply not enough money in the system. Our goal was not to think about compliance but to think about person-centered quality of care, which will take more resources.

Q: The vast majority of our nursing home members find themselves having to hire temporary agency staff….at two, three or four times the cost. Did the committee discuss that issue? Policy makers say if you have that kind of money you should pay staff more. And we know that nursing homes are taking extreme measures to solve staffing issues – measures they generally can’t afford.

A: We did talk about that and there are some details in the report. We looked at it in terms of quality and the challenge that agency staff present for continuity of care for residents. It is hard to say right now that agency staffing should be reduced since it keeps staffing levels up and that is a short- term challenge.

Q: I was glad to hear in the webinar that committee members acknowledged that Medicaid doesn’t pay adequately for nursing home care. What are the observations and recommendations for action related to Medicaid?

A: There is the issue of low Medicaid rates and there is also the issue of whether there is enough money in the system. We said there is a need for more transparency – we need to be able to follow the flow of Medicaid funds. But it can be simultaneously true that we don’t know what Medicaid rates should be and that rates are too low across the board backed up by lots of indirect evidence. Our recommendations are that we should study the rates and make sure they are adequate to cover quality care based on good data. In the longer run, however, dependence on Medicaid is not sustainable. It is not good for consumers, for care options, nor for quality of care. We want the Federal government to sponsor research to design a long term care benefit system which would be a widespread benefit and not only for people who are impoverished.

Q: What is next?

A: We are now in dissemination mode which involves briefings. Those will continue at many types of conferences, and we will be getting the word out in other ways. This may be a moment in time – the pandemic may have presented us with unique opportunities and we hope to seize them.

Q: Are there countries that do nursing home services well and does the report make mention of those?

A: As we saw during the pandemic many countries had similar issues to those in the U.S. We often look to western European countries, but they also had challenges during the pandemic. We did not spend a lot of time on other countries except in the context of methods of financing. There are countries that are better at that and they guarantee some level of access to long term care.

Q: Our members are concerned about the increasing levels of data collection and reporting requirements. What does the report say about that?

A: I know it is a constant struggle to fulfill reporting requirements. We did not address that directly. However, we did make some recommendations that would require more data- corporate structure transparency for example. We also we think it is essential to add resident experience measures. Some states have those now and we think we should be measuring resident-centered care across the board. We did not deal with the reporting burden specifically. It may reflected a bit in reform of the survey process and also the use of value-based payment, but we did not tackle the reporting issue head on.