Delivery of Care

A conversation: How to improve care at nursing homes in RI

A strategic response to a policy paper published by Milbank Memorial Fund, looking at federal policies

Image courtesy of Healthcentric Advisors

An elderly patient being care for.

By Marguerite McLaughlin and Gail Patry
Posted 4/4/22
A question and answer interview with Healthcentric Advisors, focused on nursing home policy moving forward in Rhode Island, using a recent Milbank Memorial Fund policy paper to frame the discussion.
What are the data that are missing about the nursing profession in Rhode Island, and what would be the best way to obtain that data? How have the continuing low rates of Medicaid reimbursement in Rhode Island hindered the ability of nursing homes to provide quality care for their residents? What is the current census of nursing home patients and their diagnoses in Rhode Island? In what ways has physical therapy and rehabilitation become the revenue stream that skilled nursing facilities have become dependent upon?
Last week, on Friday, April 1, the R.I. Office of Postsecondary Commissioner, in partnership with R.I. Executive Office of Health and Human Services and the R.I. Department of Labor and Training, in an event sponsored by the Rhode Island Foundation, held what might be best described as an elite, “stealth” Healthcare Workforce Summit at the R.I. Joint Nursing Education Center.
Attendance at the workforce summit was by invitation only; no news media was invited to attend, even though Gov. Dan McKee gave a welcoming talk. The event was not listed on his public schedule. In his talk, Gov. McKee hyped his proposed budget, saying that it contained all the funding necessary to support initiatives around job training and education. “Take a look at our budget,” the Governor urged, saying the money was in the budget to support the creation of learning centers in any community that wanted them.
What was not in the Governor’s proposed FY 2023 budget – and apparently not addressed during the health care summit – was the dire need to increase the low Medicaid reimbursements paid to providers.
The four-hour event was carried live on Facebook, but according to the tally on the page, only five people so far viewed the event. A number of people when contacted by ConvergenceRI were surprised to learn about the workforce summit – including labor leaders, nursing school educators, and quality improvement consultants.
However, Neil Steinberg, president and CEO of the Rhode Island Foundation, tweeted about the gathering: “The right people are in the room and will plan to do the right things to address these needs for ALL in Rhode Island.” Further, Steinberg thanked Gov. McKee for “setting a positive tone.”

Editor’s Note: The residents of nursing homes, already a highly vulnerable population, became one of the principal victims of the initial phase of the coronavirus pandemic as it swept through the U.S., beginning in March of 2020, resulting in a high number of deaths.

Nearly half of all deaths nationally from COVID-19 occurred in long-term care facilities in the first year of the pandemic, according to the Kaiser Family Foundation. That share dropped to 23 percent as of Jan. 30, 2022, with long-term facility residents and staff reported to account for more than 201,000 COVID-19 deaths in the U.S, according to the Kaiser Family Foundation.

The drop in the percentage of deaths at long-term care facilities has been attributed to a number of factors, including high rates of vaccinations among residents, increased emphasis on infection control procedures, increased vaccination rates for staff, and a declining population in such facilities.

Many nursing homes implemented strict control strategies in response to the coronavirus – banning visitors, isolating residents, and when vaccines became available, demanding that residents and workers receive vaccinations.

In early February, the Milbank Memorial Fund published a policy paper, “A call for federal action to improve nursing facilities.”

ConvergenceRI asked Healthcentric Advisors to respond to a series of questions about the Milbank policy analysis, looking at what they had gotten right, what they might have “missed,” and how such policy recommendations might apply to Rhode Island.

Here are the responses, prepared by Marguerite McLaughlin, MS, senior program administrator and quality improvement consultant, and Gail Patry, MS, RN, chief policy officer, at Healthcentric Advisors.

PROVIDENCE – Before we start, a few thoughts:

• The pandemic has awakened a sleeping populace, whose understanding of the industry is limited. Until they encounter it, they don’t know the financial structures that influence it, the means by which quality is measured and a host of other operational issues.

• For many, their first encounter happens during an emotional health care trauma requiring a nursing home admission. This initiation is often their first opportunity to become educated to its complexities.

• Its shortcomings, voiced by industry advocates and equal numbers of detractors, might well have continued without response had it not been for the pandemic.

• The challenges and shortcomings have been well known with many remedies and fixes proposed or implemented. However, they gain little traction because the fundamental underpinnings are not addressed. These are related to the financing of care and the regulations that dictate the current status of the LTSS [long term services and support] industry. Great efforts have been made within the industry but are often squelched by the system in which it exists.

• The Millbank Report raises many of these known issues but suggests solutions that build off a broken infrastructure.

• The nursing home industry is the second-most highly regulated industry next to nuclear power. It has also been deemed “the most dangerous job in America.” Creating more “sticks,” fines and regulations are not the solution. They, in fact, impede the growth of the industry and limit the potential of attracting employees.

ConvergenceRI: What does the report by Milbank Memorial Fund, “A Call for Federal Action To Improve Nursing Facilities,” get right in its approach, advocating that any future public health emergency funding and other federal funding should be linked to quality improvement and value-based payments?
PATRY and McLAUGHLIN: Nursing home quality has continuously improved over the last 10 years. Driving that improvement has been vast education, technology and new strategies and approaches often driven by internal industry experts seeking better and better ways to care for residents.

Linking quality to value based payments is worthwhile and applauded by industry leaders but it requires a thoughtful, trustworthy and well-designed system in place to assure its success.

Some of this has been tried but the system on which it rested failed. With deference to the hard-working public health administrators trying to direct the public health policies during a global pandemic, there was a great deal of conflicting information, unknown information [such as asymptomatic transmission], along with decisions that created unintended consequences.

The industry was following this “guidance.” For example: the decision by CMS to mandate residents’ isolation. Within the industry, many were concerned about this, fought against it and feel that it led to the death and failure to thrive by many elders. During an emergency, a home’s success is only as good as the information they are receiving. So, if payment is linked to quality but the mandate [in this case to isolate residents] causes immobility, depression and death, how does that work?

There are many examples. Why were hospitals allowed to suspend quality reporting at the height of the pandemic? Some other very fundamental considerations about linking public health emergency funding to quality is that it doesn’t appreciate the significant cost increases in providing even the most basic care. The [nursing homes] incurred huge costs for PPE, agency staffing, trying to create spaces that allowed for social distancing, while at the same time realizing decreased revenue from lower census.

With Medicaid paying for roughly two-thirds of nursing home patients, these same homes are already operating at a deficit of several dollars per day per Medicaid recipient.

ConvergenceRI: How would such policy recommendations apply to Rhode Island’s skilled nursing facilities?
PATRY and McLAUGHLIN: It would allow for some organization and physical redesign of the current setting. Some of these recommendations would help to improve and modernize physical plants that are sorely neglected. In some cases, it would open up the possibility of “Green” or “Small Houses.”

But again, nursing homes first must be able to cover basic costs for environments that support quality of care and quality of life, sufficient staffing [and sufficient wages], enhanced training opportunities, and to be able to keep up with inflation in the basic needs that they support such as food, utilities, etc.

ConvergenceRI: What got left out of the equation? In particular, from my reading, there seems to be a lack of discussion about workforce issues by the Milbank policy paper. How would you define what those workforce issues are?
PATRY and McLAUGHLIN: The workforce issues include:

• Public villainization of the industry at large that falsely characterizes the entire industry

• High stress, lower pay than other health care setting

• Expectations around working extra shifts

• Enormous responsibility placed on “charge nurses” who need extensive experience in order to succeed

• Management and leadership training that offers new skills to initiate a new environment

• Work schedules that are inconsistent, preventing frontline staff from being able to plan their personal time

• Low priority when choosing a career path

• Educators who steer students away from long-term care as a career option

• Historic pipeline issues-difficulties moving through training to testing and licensing [including current situation with new licensing contractor]

• Coordination with nursing education programs

The complexity of care has increased with the expectation that the workforce with a GED or high school equivalent degree and two weeks of training can manage the complexity at a low rate of pay.

ConvergenceRI: In Rhode Island, there has been an effort using the Managed Care population of Medicaid members to create accountable entities as a way to enforce value-based payment methodology. Yet, no accountable entities for Long Term Services and Supports have ever been created, despite that category being a major category for state and federal spending under Medicaid. How is that a problem?
PATRY and McLAUGHLIN: It limits innovation and thoughtful redesign of the industry. Though accountable care organizations are not perfect, industry leaders have been having these conversations for years. Again, the problem is not with the failure of the industry to lead or innovate, it’s the system within which it finds itself a tough nut to crack.

ConvergenceRI: What are the data needs that need to be developed about the workforce issues in nursing facilities, focused on the nursing workforce? How can that data inform quality improvement decisions moving forward?
PATRY and McLAUGHLIN: We need to know how many care providers we need in different roles, what types of care providers can be used to meet that need [this begins to look at the reinvention of the setting], and whether educational capacity is sufficient to prepare care providers.

This includes nurses, CNAs, therapists, administrators and other affiliated roles. “The Future of Nursing” recommends that an infrastructure be built to improve the collection and analysis of data on the health care workforce.

ConvergenceRI: Where do nursing homes and skilled nursing facilities fit into the continuum of health care delivery as a function of an integrated approach?
PATRY and McLAUGHLIN: They have a definite and secure place in the landscape knowing that the complex care of certain conditions will not be possible at home. The safety of both the patient and often their elderly partner will require it.

ConvergenceRI: What questions haven’t I asked, should I have asked, that you would like to talk about, reframing the data needs and policy issues that Rhode Island needs to look at in regard to skilled nursing facilities?
PATRY and McLAUGHLIN: One of the questions that need to be explored is: Why are the funds for Civil Money Penalty funds not being used to support and assist nursing homes? How is that money being spent in Rhode Island?

The federal government has been unwilling to unlock most of the $400 million stockpiled in states’ Civil Money Penalty funds. Advocates, families of residents and the national association that represents nursing homes say now is the time for the Centers for Medicare and Medicaid Services to direct those funds to combat a once-in-a-lifetime pandemic.

The money is supposed to be dispensed as grants “to support activities that benefit nursing home residents and that protect or improve their quality of care or quality of life,” according to CMS.

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