August 28, 2020

After the Deluge

Nursing homes are at a crossroads. Unpopular before the pandemic, Covid-19 has brought them to a new low. There was the epidemic itself, which swept through nursing homes and assisted living facilities, causing an estimated 40 percent of all thevirus-related deaths in the U.S. Then there was the response to the epidemic: the draconian measures taken to control the outbreak caused social isolation, depression, and sometimes confusion in residents.  Next were the institutional consequences: the deaths that inevitably result when vulnerable people became ill (with a mean age of about 85 and multiple underlying health conditions, nursing home residents are at the highest risk of contracting and then dying from Covid-19) led to empty beds but the quarantine made it difficult to fill them. Empty beds meant less revenue, this at a time when costs were rising due to the need for frequent deep cleaning, personal protective equipment, and supplementary staff. 

The future looks grim as nursing homes face a loss of confidence in their ability to provide good care and as state budgets, which determine the level of nursing home reimbursement through Medicaid (the homes' major source of revenue), are strained by the recession. What, then, will become of nursing homes after the deluge? 

In a provocative essay, Charles Sabatino of the American Bar Association argues that “it’s time to defund nursing homes.” Institutional care as defined by the average American nursing home, he suggests, is simply not what old people or their families want. It’s demeaning, disrespectful, and disgraceful. Moreover, to those who claim the institutional environment is necessary to keep the oldest, frailest members of society safe, the monumental failure of nursing homes to prevent sickness and death during the COVID-19 pandemic provides ample evidence that even in this arena, the nursing home is a failure. Medicare and Medicaid, which together fund a large proportion of skilled nursing home care (Medicare pays for short term rehabilitative care while Medicaid pays for long-term residential care) hold the key. They should pay for care only, Sabatino says, if the nursing homes are small and homey, provide all their residents with private rooms and bathrooms, and embody a culture focused on the goals, interests, and preferences of their residents—not the nurses, nursing assistants, administrators, and others who run the institution. 

Geriatrician, palliative care specialist, and health care policy expert Joanne Lynn distinguishes among the various populations found in nursing homes and suggests different strategies for each group. People recently discharged from a hospital who need short-term rehabilitation or further medical care that they cannot receive at home—the “post-acute” patients who stay in skilled nursing facilities for a few days or at most a few weeks and whose care is paid for by Medicare—can continue to receive this type of treatment in a hospital-lite environment. People with severe brain damage, whether from dementia, stroke, or prolonged lack of oxygen, and who are unaware of their surroundings and do not recognize their family members can likewise remain in a hospital-style institution. People who are dying and who need more assistance than can be provided through home-hospice should not have to go to a skilled nursing facility under the guise that they need rehabilitation in order to have 24-hour, residential care. Instead, they should be eligible for inpatient hospice. That leaves the large fraction of the current nursing home population who are dependent on others for many of their basic daily needs—bathing, dressing, walking—due to multiple physical problems and/or moderate dementia. For those individuals, Lynn argues, the best environment is a model very much like what Sabatino advocates. This type of facility already exists: it is called the Green House Project. What is the Green House Project and how did homes built along this model fare during the pandemic? 

Green Houses are the brain child of Bill Thomas, a pioneering geriatrician who has been designing progressively better nursing homes since he introduced the Eden Alternative—bringing pets and plants into nursing homes—in the early 1990s. He then went on to mastermind what would become the culture change movement, or bringing resident-centered care to nursing homes. The model was fleshed out by the consortium of nursing homes that banded together to form the Pioneer Network, which advocated breaking large, hospital-style nursing homes into multiple discrete households, eliminating the centrally-located nurses’ station to promote integrating nursing care into daily life, and decreasing the differentiation of labor which compartmentalized care. But while many facilities endorse culture change, few have implemented its principles on a wide scale. Enter the Green House. Green Houses are built along the lines envisaged by the culture change movement—they make use of “universal workers” rather than siloing staff members into discrete categories and they are built around honoring the preferences of residents. But the critical difference is that they are small. Instead of breaking a large institution into multiple households, the Green House is a single, freestanding household with 10-12 residents. Its guiding principle is that to be homey, it needs to be built like a home and function like a home. 
The first such home was built in Tupelo, Mississippi in 2003. 

Today, there are 300 Green House sites across the country. The big question is whether these facilities in fact improved the quality of life for their residents. Have they been able to meet the health and safety requirements imposed upon conventional nursing homes? Have their costs been higher than those of standard nursing homes? And how did they fare during the Covid-19 pandemic? The most comprehensive attempt to answer the questions about quality of life and health and safety requirements is from the THRIVE Research Collaborative (The Research Initiative Valuing Eldercare), published in 2016. While the model was seldom fully implemented, the version that was utilized did not lead to a decline in the “quality indicators” established by the Centers for Medicare and Medicaid to evaluate nursing home care; it did lead to lower rates of hospitalization and greater use of hospice care than conventional facilities. Staff turnover, normally alarmingly high, was lower in Green House facilities. 

Measures of resident and family satisfaction have been harder to come by as studies tend to be very small and qualitative in nature, but enthusiastic articles have appeared in the popular press—and I cannot remember encountering any similar level of excitement, however anecdotal, about standard nursing homes. Based on the limited data available, I have been guardedly optimistic. But the Covid-19 experience has tipped the scale for me: with 95 percent of nursing homes and 92 percent of assisted living facilities reporting no cases, the Green Houses have been remarkably successful. 

Here is what we know—256 out of the existing 298 facilities supplied data for the period March-May, 2020. In the 229 nursing homes, which served 2384 elders, there were 32 positive cases among residents and only one death. In the 24 assisted living facilities serving 224 elders, there were 15 positive cases and 3 deaths. Compare this to all nursing homes in the US, as reported by CMS: as of mid-August, there have been just under 50,000 deaths in 1.5 million residents, with slightly below 200,000 confirmed cases and another 120,000 suspected cases. I

In summary, Green House nursing home residents were far less likely than their conventional nursing home counterparts to contract Covid-19, and if they did get sick, they were far less likely to die. Small really is better. 

My suspicion is that after the deluge, when the pandemic finally fizzles, legislators and healthy policy mavens will look to new regulations to try to prevent or at least diminish the ferocity of future outbreaks. Requiring nursing homes to have infectious disease consultants—a rule that was instituted by the Obama administration and undone by Trump—makes sense. Demanding regular testing for nursing assistants if there is another viral epidemic with similar characteristics makes sense—as was recently mandated by CMS for nursing homes during Covid-19. Systematically engaging residents and families in discussions of their preferences regarding end of life care before they are faced with a crisis is good generally a good policy, because nursing home residents are always at high risk of death, not just during a pandemic. 

But more effective change will not come from regulations. It will require a wholesale rethinking of institutional long-term care. The Green House project is a good place to start.