Nursing Homes

Part of LeadingAge’s 2021 Policy Priorities


  • Seek meaningful, transformational change in the structure, care delivery, and financing of residential long-term services and supports.
  • Promote a positive vision of the future of nursing homes as an integral part of the continuum of care.
  • Advocate for nursing homes to have all the resources needed to fight the COVID-19 pandemic, including staff, testing, PPE, and vaccines.
  • Ensure regulations promote person-centered quality and support positive clinical outcomes and evidence-based best practices.
  • Promote collaborative not punitive approaches to the enforcement of regulations, focusing on outcomes, not process.
  • Advance a quality measurement system underlying the regulatory process that truly reflects quality care and quality of life for residents.
  • Ensure staff are well trained and paid a fair wage and that when wages are increased, reimbursement increases to cover new costs.
  • Address disparities in access to quality nursing homes.
  • Advocate for evidence-based reimbursement rates from Medicare and Medicaid that take into account the full range of costs to provide high-quality care with particular emphasis on staffing and supply needs.
  • Work with a coalition of national associations and state association partners to enact state civil liability protections for aging services providers relating to COVID-19 claims. Nearly half the states have enacted some sort of protections and we are still advocating for protections on the federal level.
  • Ensure the availability of wellness and mental health services to help compassion fatigue of nursing home staff
  • Ensure members have the resources needed to provide person-centered care.
  • Prevent inconsistent and flawed alerts in Medicare Care Compare.
  • Eliminate barriers to staff training, recruitment, and retention.
  • Advocate for increased telehealth support to improve the quality of life.
  • Advocate for appropriate reimbursement rates for providers who serve people with mental and behavioral health comorbidities.
  • Collaborate with lawmakers and regulators to develop and support comprehensive behavioral and mental health intervention training programs for all professions and disciplines that serve older adults
  • Support the creation and/or strengthening of mental health and wellness tools, resources, and funding to enable employers to support aging services staff members on a state and federal level.
  • Provide pandemic premium pay for essential workers, including aging services workers and work on longer range, sustainable increases in the professionalization of workforce and improved pay and benefits.

LeadingAge members are saying:

  • “We’ve been testing employees twice a week and our nursing home residents three times a week because it is the right thing to do, but we don’t know if the supply of tests we have will be able to sustain that.
  • “What’s so frustrating is that community spread is not only still happening but it’s worse here than it ever has been. Long term care residents and employees are not just tired – we’re exhausted. We are depleted. And yet we keep showing up every day.
  • “Many nonprofit care providers are seeking charitable contributions, digging deep into reserves or running on fumes to cover expenses from months of extra PPE, testing supplies, lab tests, and added care and housekeeping staff,”
  • “I’m not sure what’s worse – will more people die in nursing homes from COVID-19 or from isolation and loneliness?”


Nursing homes are an essential element of the long-term services and support system, serving individuals with serious functional impairments who are unable to live independently in the community. Although fewer than 4% of those over 65 will ever live in a nursing home, these settings provide treatment and care in a safe, home-like community that supports a quality of life when aging in the community is no longer an option.

Nursing homes have become a major focus of national attention during the Coronavirus pandemic, with 76,542 of the nation’s nearly 300,000 deaths occurring in nursing homes (as of December 12).  With the virus’s especially deadly effects on older people with chronic conditions and the congregate nature of nursing home living, it is not surprising that these organizations have been on the front lines.

Nursing homes struggled mightily in 2020 with inadequate supplies of personal protective equipment, testing mandates from CMS (and often conflicting mandates from states) without adequate testing supplies, and severe staff shortages as workers depart due to fears, conflicting family responsibilities, and fatigue and burnout.  The federal government has provided testing resources but not in sufficient quantity; conducting testing, a necessary tool to fight COVID-19, takes staff time and resources nursing homes don’t have.

Provider Relief Funds, a lifeline for many nursing homes (and other providers) in 2020, do not nearly make up for the outlays that nursing homes have had to make or the revenue lost due to vast decreases in elective surgery and consumer hesitance to enter nursing homes.

Medicaid is the primary payer for nursing home care, covering six out of ten stays, but Medicaid rates do not cover the cost of care. The pandemic has further eroded inadequate Medicaid reimbursement rates in most states.  LeadingAge anticipates that 2021 will bring unprecedented demand to Medicaid programs as states struggle to cover newly uninsured individuals and make up for other economic impacts of COVID.

Visitation limitations imposed by CMS, state policies, and nursing homes themselves, while protecting resident health have had huge consequences in terms of resident loneliness and isolation and created exponential increases in demand on staff time, while nursing homes are more seriously understaffed than ever before.

Nursing home providers are fully complying with new reporting requirements through the National Healthcare Safety Network (NHSN), but they are hobbled by multiple, sometimes inconsistent requirements to file additional reports. In addition, nursing homes have increased focused surveys for infection control, and Covid-19 outbreaks.

The mainstream media has devoted considerable effort to stories about coronavirus infection and death in nursing homes, with resultant misconceptions by the public and policymakers about the realities of nursing homes. Yet few stories point out the link between community spread and nursing home resident and staff infection rates.  Nursing homes continue to care for individuals that need help with activities of daily living and supervision while fighting this pandemic.

More than before, consumers are avoiding moving into nursing homes, with a national occupancy rate of 71%, an all-time low.


                                                           117th Congress

  • COVID-19 relief. We support the House and Senate introduction of legislation that will provide funds and other relief for aging services.
  • Nursing Home Reimbursement. Pursue broad reimbursement policies that ensure adequate funding for nursing home care across payers and actuarial soundness. Advocate for policies to ensure that payments/reimbursements for Medicare and Medicaid services, including those delivered through managed care, adequately cover the services provided including paying caregivers in these settings a fair wage.
  • NASEM Study: We support the study underway by the National Academies of Sciences, Engineering, and Medicine to evaluate the current long term care survey process, the link to care outcomes, and alternative strategies to assure quality nursing home care.
  •  IMAGINE Proposal: We propose the creation of an aging-forward immigration system that would engage foreign-born workers to address the workforce crisis faced by many nursing homes and aging services providers.
  • CNA Lock-Out: We support the reintroduction of the Nursing Home Workforce Quality Act and Ensuring Seniors’ Access to Quality Care Act that would allow reinstatement of a nurse aide training program once a nursing home has been determined by CMS to be in substantial compliance. The ability of nursing homes to provide in-house training is especially critical given the uncertainty about educational offerings available post-COVID in colleges.
  • Observation Stays: We support the reintroduction of the Improving Access to Medicare Coverage Act that would mandate that all time spent in a hospital, regardless of admission status, would count toward the 3-day qualifying stay required for SNF services under the Medicare benefit.  The waiver of the 3-day stay requirement during COVID reinforces the lack of rationale for this restriction on Part A eligibility.
  • Telehealth: We support the reintroduction of the RUSH Act and other solutions to improve access to telehealth services in nursing homes.
  • Medical Expenses: We support the reintroduction of the Medical Expense Savings Act to make permanent the reduction in the adjusted gross income threshold that must be exceeded before a taxpayer can claim an itemized tax deduction for medical expenses.
  • Elder Justice Reauthorization: We support the reauthorization of the Elder Justice Act that identifies and addresses elder abuse and neglect where it happens, not disproportionately targeting nursing homes.
  • Professionalize the Workforce: We will work with the incoming administration to fill in details of the workforce provisions of the platform’s caregiving proposal to treat LTSS workers with respect and dignity. LTSS settings must feature greater standardization of competency-based training requirements and education needed to prepare the frontline workforce to deliver quality care
  • Medicare Part B Coverage for Mental Health: We support the reintroduction of the Mental Health Access Improvement Act of 2019, a proposal to expand the types of providers allowed to provide mental health services through Medicare Part B.
  • Covering Social Workers Under Medicare: We support the reintroduction of the Improving Access to Mental Health Act, a proposal to increase access to services provided by licensed clinical social workers in Medicare.

                                                  Executive Branch

  • COVID-19 Policies, Guidance, and Resources: We will work with HHS (including CDC, CMS, HRSA, NIA, and others) to provide feedback on members’ needs related to guidance for addressing COVID-19. We advocate for policies on operations, including visitation, that will help our members balance residents’ health and safety with psychosocial well-being. We will provide feedback on training materials and resources to ensure that they are useful and accessible to nursing home staff that have been stretched thin by months of crisis-level operations due to the public health emergency. We will offer input into the need for financial assistance through Provider Relief Funds, advise on the development of any related quality incentive programs, and seek answers to implementation questions and need for guidance on the use of funds.
  • Extension of Public Health Emergency.  We support the immediate extension of the Coronavirus Public Health Emergency for another 90 days. It is set to expire on January 20, 2021.
  • Vaccine distribution.  We support the seamless implementation of the Pharmacy Partnership and rapid, efficient distribution of vaccines to all individuals over age 65.  We encourage HHS to implement consumer education programs to encourage immunization.
  • Personal Protective Equipment: We advocate to HHS and the Administration to prioritize nursing homes and aging services providers in the distribution of personal protective equipment to help limit transmission of COVID-19 and protect the staff providing care to vulnerable older adults.
  • Provider Relief Fund Reporting: We will continue to work with CDC and advocate for CMS to implement streamlined reporting processes that will provide the Administration with the necessary information for addressing the pandemic while ensuring providers are not burdened with duplicative, time-consuming, or unnecessary data reporting. We advocate to HHS that Provider Relief Fund Reporting balances the need for accountability while minimizing the reporting burden by utilizing information that is already reported through other programs. (e.g. instead of reporting revenues via cost report, in our financials, and to PRF portal, perhaps cost reports could be used as one of the items submitted and then supplemented by the PRF portal reporting for COVID specific items.)
  • Regulatory waivers: We advocate that CMS continue 1135 regulatory waivers to allow providers the flexibility to focus their resources on preparing for and responding to COVID-19 outbreaks in their communities and those additional flexibilities be considered.
  • Distribution of testing materials. We call on the Administration to ensure that all aging services providers have adequate COVID-19 testing materials and that nursing homes specifically have the testing resources needed to comply with CMS requirements.
  • Project ECHO nursing home initiative.  We ask HHS to monitor the ECHO nursing home initiative and continue it beyond March 30 if it appears to be producing positive results.  We urge considering funding ECHO for other aging services settings.
  • Integrated MA benefits. We support ongoing flexibility for Medicare Advantage plans to add or amend benefits and policies that improve access to services or deliver a more integrated approach to care, (e.g., adding new supplemental benefit – home-delivered meals during the pandemic) and doesn’t add administrative burden to providers.
  • Requirements of Participation (RoPs): We will provide feedback to CMS to ensure that regulations and interpretive guidance are clear and evidence-based. We support proposed changes that eliminate duplicative, unnecessary, and burdensome requirements that do not support quality care.
  • Survey and Certification: We call on CMS to improve consistency and accuracy in the survey and certification process. We will propose alternatives focused on a collaborative approach to quality improvement and utilization of enforcement remedies that reflect a just culture.
  • Quality Measures: We will promote activities to establish quality measures that are evidence-based and accurately reflect quality care. We ensure nursing homes are not negatively impacted under the SNF Value-Based Payment program or SNF Quality Reporting Program payments due to waived data reporting requirements during the public health emergency.
  • Medicare Care Compare: We will provide feedback on the new Medicare Care Compare site to ensure important information is clearly displayed and consumers are not misled by icons and formatting that prioritize information that does not accurately capture nursing home quality information.
  • Patient-Driven Payment Model (PDPM): We provide feedback to CMS on members’ experiences to promote successful implementation of PDPM.
  • Alternative Payment Models: We engage in activities geared toward the development of alternative payment models, such as the Unified Post-Acute Care Prospective Payment System Technical Expert Panel.
  • Trauma-informed Care: We will continue to support the effective implementation of trauma-informed care, as required in skilled nursing facilities, but applicable across service settings.
  • Use of Antipsychotics: We will work with federal and state regulators to ensure the appropriate allowances and safeguards for antipsychotic medications particularly in nursing home environments.

  • Visit the Advocacy Action Center to let your representative and senators hear your voice on the issues facing nursing homes.
  • Host a Coffee Chat with Congress in your community to help your members of Congress understand how policies impact nursing homes and the people who live and work in them.
  • Mobilize with the Advocacy Champions toolkit and let your representatives and senators know you support nursing homes and the care they provide for residents.