Nursing Homes – Where Do We Go from Here?

Nursing Homes – Where Do We Go from Here?

Written by Jeff Jerebker and Bob Moses

Even before the birth of the three-decades-old Culture Change movement, advocates for nursing home reform viewed the physical architecture of most nursing home as antidotal to the well-being of their residents. They were crowded, poorly ventilated, and devoid of natural light. Except for private pay residents, living in one meant relinquishing privacy and sharing a room with a stranger.

After LBJ signed Medicare and Medicaid into law in 1965, nursing home construction boomed. Homes built during this era did not envision a living habitat that would promote independence, socialization, and wellness. Instead, they mimicked hospital environments with long corridors, semi-private rooms, a few common areas, and a nursing home station for every 60 residents. These modest structures housed the maximum number of residents at the lowest possible cost. The purpose was to house residents safely, feed them, and keep them alive for as long and as inexpensively as possible. Improving the residents’ quality of life, always a stated goal, was a practical impossibility for homes operating under the strictures of Medicaid reimbursement.

The first signs of rebellion against this dystopian environment arose in the early 1980s. Progressives within the system began to advocate for a more holistic approach to the well-being of nursing home residents. In a landmark legal case, the state of Colorado sided with a resident plaintiff claiming that the federal survey process of the state’s Medicaid-funded nursing homes was inadequate to assure nursing home residents a quality life. Aligned with the plaintiff were elder advocacy groups demanding change. The plaintiff lost the case in the US District Court and appealed. The US Court of Appeals reversed the decision and ordered the government to institute reforms.

Spurred by this litigation, the Culture Change movement and the National Citizens Coalition for Nursing Home Reform, growing political pressure led to passage of the Nursing Home Reform Act, a part of the Omnibus Budget Reconciliation Act (OBRA) of 1987. Revolutionary for its time, the legislation included these important reforms:

 

• CNA credentialing through approved training programs.
• The elevation of resident rights as an essential part of compliance
• A revamped federal survey process that was more resident-focused, and the promise that each resident had the right to attain their highest practical level of care and well-being from a “whole-person“ perspective.

Most importantly, OBRA reforms eliminated the widespread use of physical and chemical restraints.  Other reforms included expanded food choices, consistent assignment of staff, more stimulating activities, breakup of long hallways into neighborhoods, and spa-style bathing. There were building improvements as well, including larger common areas, artifacts on walls, and an increase in private rooms for Medicare and private -pay residents.

OBRA was an important step forward, but not the holy grail. Many rights suggested by this legislation, though well-intended, were ambiguous and unenforceable.

Alternative models arose, including The Green House, offering private rooms and bathrooms within smaller communities of 10-12 residents per household. Other nursing homes converted their larger homes into multiple household communities.

Has person-centered care humanized the structure of the traditional nursing home? Unfortunately, the changes wrought by the Culture Change movement have not sufficiently penetrated the larger nursing home world. Many of the old, tired buildings – and practices of 55 years ago – remain part of the nursing home culture, resistant to change. Many creative, caring, dedicated people and progressive leaders have labored tirelessly to enable our elders to live out their final years in more human and humane environments. Their efforts have been historic. Yet, there is much that remains to be done.

Sadly, COVID-19 has wreaked havoc upon nursing homes, and unfathomable suffering and death upon residents and staff. Pick your scapegoat; the candidates are many. We, as a society, must be held accountable. New opportunities will arise from this disaster. It is time for all nursing homes to convert to more holistic models. The underpinning of these new models requires the eradication of ageist stereotyping – a primary tenet of the Culture Change movement. We must learn to appreciate advanced aging as a singular and valued stage of elderhood.

Some of this is happening already. Public awareness is at an all-time high. Let us seize this moment. Imaginative cooperation between private and public sectors, elder advocates, financing institutions, and others can achieve wonders. We already know much of what needs to be done. And we can build on what we have already accomplished. We must marshal the resources and the will to bring lasting change to this vital profession of caring for our elders.