Leadership Recovery: The Future of Nursing Homes

October 27, 2020 by David Nitkin | Categories: Leadership Recovery | Tags: nursing homes, scenarios

The Issue

Nursing homes were unstable even before COVID-19 hit. They were like tinderboxes, ready to go up in flames with just a spark. The tragedy that unfolded in nursing homes is seen by experts as the result of decades of neglect of long-term care policy. What do sector experts forecast for the sector’s future as distinct from documenting the problems of today? This blog updates an earlier EthicScan review of nursing home trends, forecasts and outlook literature issued in the period 15 March-30 June. What you read here deals with more recent professional literature published in the period 1 July-15 October.

Nursing Homes During COVID’s First Wave

COVID-19 fed on and exposed underlying pre-existing weaknesses in the long-term care system involving nursing homes and long-term care facilities. The major systems weaknesses were already apparent:

1. Many nursing homes face populations with higher levels of care needs: As our population ages, many more residents have more serious complications and vulnerabilities as well as more specialized and complex care needs, including chronic care issues that can include environmental illnesses, dementia and other mental-health issues.

2. The stock of homes is outdated: Many homes were built in the 1970s or earlier, and suffer from antiquated standards such as three or four persons per room, lack of isolation rooms, and inappropriate ventilation, heating and cooling systems. Many nursing homes in Canada are physically not designed for infection control practices that are needed to avoid COVID-19 or to contain its spread.

3. Oversight and inspection are weak: In most jurisdictions, there are few or negative consequences of inspection process. Often the same inadequate or dangerous problems are cited over and over again and there were no consequences when homes ignored the damning ill-management findings of real time investigator’s reports. In the US, 82 per cent of nursing homes were found to have a deficiency in infection prevention and control; 48 per cent had such deficiencies cited in multiple years during the same period.

A data analysis of the most serious breaches of Ontario’s long-term care home safety legislation reveals that six in seven care homes are repeat offenders, and there are virtually no consequences for homes that break that law repeatedly. A Marketplace study in Ontario isolated 21 violation codes for some of the most serious or dangerous offences, including abuse, inadequate infection control, unsafe medication storage, inadequate hydration, and poor skin and wound care, among others. The analysis showed repeated violations for neglect, lack of infection control, medication errors, and poor skin and wound care. In total, 632 homes in the Ontario database, 538 — or 85 per cent — were repeat offenders.

Photo by Ivanoh Demers

4. Horrific death toll, including premature avoidable deaths: COVID-19 has reaped a horrific toll on America’s 2.5 million nursing home residents and their families, resulting in more than 50,000 resident deaths. People living in nursing homes make up less than 1 percent of the US population yet account for approximately 40 percent of all COVID-19 deaths to date.

5. Death and distress among minority long-term care staff: Black, Filipina (Asian) and Latino (Caribbean) workers, who make up more than half the LTC direct care workforce in Canada faced grave threats from COVID-19 in their workplaces and in their communities. They do so all while receiving substandard wages, few or no benefits, including paid sick leave, and little training dealing with residents with multiple chronic illnesses. A proportion of nursing home staff were working in more than one nursing home and other healthcare facilities, silently bringing the virus in and out of nursing homes in the early weeks of the virus.

6. LTC facilities are isolated: Most nursing homes lack of strong connections – networking, telemetry, patent monitoring, and continuum of care—to the broader health care system that could provide needed clinical support. This is true for the large majority of Ontario’s 623 LTC homes, comprising 75,676 residents. The limitation is documented in 360 LTC homes (57.7%) that are for profit, 162 (26.0%) that are non-profit, and 101 (16.2%) that are municipal homes.

7. For-profit ownership: On average, and compared with both non-profit and municipal homes, for-profit homes in Ontario are smaller (lowest mean number of licensed beds), have the lowest proportion of single-occupancy rooms, have older design standards, and have the highest proportion of chain ownership. For-profit entities now dominate the nursing home industry, with some allegedly to be acting more as investment players and speculators rather than as health-care providers. Their critics allege that not enough revenues are devoted to appropriate care. Previous research shows that for-profit LTC homes deliver inferior care across a variety of outcome and process measures, raising the question of whether for-profit homes have had – and in the future, must have– worse COVID-19 or other pandemic outcomes than non-profit homes.

For all these and other reasons, this is neither a sustainable system nor one prepared for future outbreaks, particularly in light of a large cohort of rapidly aging “baby boomer” population. Strong and immediate steps are needed to prepare for the next wave of infection, but at the same time, experts say we must re-imagine and invest in a more resilient, person-centered LTC system that operates as part of our health-care services delivery continuum.

Long-Term Care Principles and Outlooks

Will these tragedies lead to concerted, real reform in the future? COVID-19 has exposed the cracks in our tenuous system of providing and funding long-term care, and there are no easy fixes. The experts concur that we are well past due for comprehensive policies that takes care of aging citizens seriously and funds it accordingly and in a wider range of settings. Those principal insights or outlooks include the following:

1. Adequate funding, from short-term bailouts toward transformation: In the short term, nursing homes will have to be saved, because despite their vulnerabilities, they are a necessary part of any solution. Underfunding in Canada has been chronic and with economic lockdowns; there simply aren’t public coffers to solve the problem. Some advocates estimate that it will take up to $15 billion in federal US funds for nursing homes simply to survive the current COVID pandemic. Recent congressional and parliamentary relief package planning have started to address the anticipated shortfall, though experts say they will not be enough. In the long-term, however, we will need to abandon bailouts and look at transforming the way we pay for and provide long-term care.

2. Better alternative care models: Because caregiving at home is not feasible for many care recipients and families, there needs to be safe, affordable residential options. Better options can help ensure that the tragedy currently unfolding in nursing homes never happens again. Smaller-scale, high-quality group models, such as the Green House Project, provide care in small, self-contained, family-style houses with a small number of residents. Such models could offer one form of community-based alternative to nursing homes. The Dutch report positive outcomes with small-scale “Dementia Village” options and models that combine child care and long-term care. Though building out these models requires substantial investment, the experts see how critical that investment is.

3. De-institutional strategy: Some stronger critics argue we literally have warehoused our elderly. They call for prioritizing and reimbursing home-based care, while at the same time divesting away from free-standing institutions. Beyond the pandemic, we will have to invest considerably more in care in all settings. Government policies need to act upon the reality that we have shifted long-term care on families at home. Funding has not kept up with that trend, meaning that more is demanded of families, who are often responsible for providing informal, unpaid care.

Many family households with multi-generational residents can’t provide this level of needed care. An adult child who cares for an aging parent will face (income and expenditure) losses equivalent to $100,000 a year, on average— roughly the same cost as a nursing-home stay. Taxation policies should prioritize relief for home-based care to ensure that it’s paid for, whether it’s provided by family members or professionals. Many families have wanted to provide care at home even before COVID-19, and after the pandemic many more may choose to do so if they can be helped to afford it.

4. Regulation needs a principles-based and pragmatic plan:
More LTC facility regulation and monitoring is not a sufficient response. There needs to be a national long-term care plan that includes:

(a) more up to date national and transparent data on care;
(b) incentives for better education of staff;
(c) protocols for continuum of care to benefit both care facility patients and their respite-needy families; and
(d) support of various kinds for families who have elderly and/or frail parents.

5. Need for scenario development and testing: The coronavirus has exposed and amplified a long-standing and larger problem: our failure to value, propose, test and invest in a rational safe and effective long-term care system. There are choices to be made but we’re not devoting sufficient investment in long range strategy for any natural disasters, of which COVID and climate change are but two examples

In summary, more funding alone is not the answer. Nor is more regulation a sufficient response. Rather, we need a combination of investment rather than funding, incentives-based regulation, and a new strategy that fully supports a range of institutional and non-institutional care.

The Need for Scenarios, Not Forecasts

There are many calls today for systems reform and commissions of enquiry. The literature published by individuals and expert prestigious panels unfortunately does little to imagine, test and cost genuine alternative scenarios or elements comprising configurations of the safe and effective long-term care system of the future. What literature exists largely documents current problems while all the while public and private assessments of the problem are clear.

Good strategy need not be extrapolating from the present; that is forecasting. Rather it can be based on setting 15-25 year descriptions of possible futures, then working backward from the future to the present. Based on ideas presented at EthicScan discussion webinars, here is an example of the kind of scenario elements and perspectives not being developed to their full long-term costing potential:

INPUTS	IMPROVE CURRENT SYSTEM	IMPROVE CHOICES IN NEW SYSTEM	DEINSTUTIONALIZE
Meaning	Accept what we have today is what we will have tomorrow	Different models: alternative green, village, cluster facilities	Fund care and equipment in at-home care
Funding	Band-aid fixes, enhancing current facilities stock	Change buildings and functions	New systems inducing bond market instruments; change funding model
Networking	Enhance networking	Invest in clinical informatics	Create genuine continuum of care
Enforcement	More penalties for negligence and repeat offences	More transparency	More of a costed and viable national plan
Funding Model	Reward treatments	Empower families seeking home care support	Reward health outcomes
Moral duty	Restore trust in current facilities	Engage stakeholders in adding choices	Put family responsibility in the pilot seat of long-term reform
Workforce	Pandemic-sensitive pay increases	National plan for more and better trained care providers	Tie employee reward, recognition and pay to good care and health outcomes
Private vs Public enterprise	With growing public debt, privatization will inexorably increase	More community-owned not-for-profit options	Enhanced long-term public-private partnerships

Conclusion

(Not an actual Health Card)

Quality of life for the frail elderly, as well as quality of end-of-life and a good death, should be non-negotiable long-term care objectives. The hundreds of older adults who died unnecessarily and prematurely in nursing homes due to COVID in the period March- September 2020 deserved not only more of the last months or years of their lives but also a good death. We failed them. We have a moral duty and an ethical responsibility to fix this—not just to prepare for the second wave of COVID-19 and other future infectious diseases but to envisage and deliver a root-and-branch overhaul of the LTC sector that helped that crisis wreak such avoidable and tragic havoc.

We are in a moment of crisis for nursing homes. Regrettably, the available literature is long on current diagnosis but short on detailed alternative scenarios. The literature is long on high-sounding principles but inadequate in terms of detailing, costing and assessing macro-choices. Now should be a time of reckoning with the fundamental flaws in the organization of long-term care in this country. There are no easy fixes, but we must do better.

David Nitkin, founder of EthicScan, is a full-time organizational ethicist. David’s original writing, teaching, consulting and research focuses upon ethical decision making; enhancing corporate accountability and reporting; and developing corporate ethics assurance programs, including transparency, risk management, integrity management, and safe partnering.

David has provided ethics training, advice and research for over 200 clients both internationally and in Canada who collectively employ over 750,000 employees. He consults and trains widely with a variety of clients, including corporations, industry associations, public service sector organizations (integrity commissions, human rights commissions, and anti-corruption tribunals social agencies, professional ethics certification organizations, not-for-profits; and civil society organizations.

The Issue

Nursing Homes During COVID’s First Wave

Long-Term Care Principles and Outlooks

The Need for Scenarios, Not Forecasts

Conclusion

Further Reading