A Once in a Generation Opportunity Reimagining Nursing Homes

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Jeff Jerebker

Jeff Jerebker
Reprinted with permission from Musings From Jeff blog

Transforming nursing homes within the long-term care systems of support and services for frail elders and disabled can be analyzed as a three-prong approach – Staffing, Architecture and Environment, and Culture. This can only be the result of a coordinated effort involving nursing home organizations, advocacy groups, Medicaid and Medicare reimbursement, regulation, tax policies, and favorable financing incentives, which over a period of time changes the landscape of long-term care.


Government policy and lawmakers can mandate staffing requirements but it will do little good unless we begin to solve the workforce shortage, high turnover and low recruitment and retention challenges. That will require something more fundamental and substantial than mandatory staffing.

  1. Enhance proper pay and benefits for Direct Care Workers (DCW) through Medicaid and Medicare pass throughs and other imaginative approaches.
  2. DCWs must be regarded as a respected and honorable profession in serving its residents.
  3. Commitment to the development of the profession so that DCWs become a key ingredient in consistent assignment of staff, participation in care planning, and part of the leadership team within each neighborhood or unit of a nursing home.
  4. Increased educational and career opportunities for professional growth and human development.
  5. Housing and daycare offerings, education in language skills and conflict resolution are examples of workforce ingenuity.

Architecture and Environment (A&E)

  • A&E has been undervalued as to its prominence in managing disease outbreaks, resident rights to individual space and privacy, and as an essential building block to person-centered care. Some say that good care can happen in any setting and poor care can happen in a modern one. True to an extent, but the pandemic revealed that the old model totally failed.
  • There needs to be a coordinated effort to enhance A&E for both the existing inventory of nursing homes as well as promoting new models, particularly small house models.
  • The enhancement of the home and community-based services programs will also encourage traditional nursing homes to improve A&E, and new models hopefully will provide novel approaches and choices for those needing support and services.
  • Coordination of reimbursement changes and tax advantages to incentivize new A&E.

The Culture of Support and Services

Out of this triad, culture is the most abstract. How to mandate an empowering culture without being overly restrictive is an enigma not to be dismissed lightly. Every person is unique and every nursing home community is likewise. It’s the opportunity to finally create a perceptible culture for the person-centered care movement to thrive and develop.

How services are provided, resident participation in their own life experience, staff growth, and application of servant leadership has a lot to do with a unique organic culture. Without these elements it is highly unlikely that workforce and A&E will change significantly. Servant leadership and community development principles along with visionary and supportive ownership are critical in this area. Whether for profit, or nonprofit, or government.

The Nursing Home Reform Act (OBRA) of 1987, an incomplete milestone, attempted to reform nursing homes. Key components of OBRA were:

  • nursing assistants now required certification, becoming CNAs that ensured enhanced competency testing and training
  • elevated resident rights to the highest level of certification requirements
  • introduced the concept of highest practical physical, mental, and psychosocial wellbeing of every resident in the nursing home
  • federal certification surveys were to be more resident focused and outcome oriented

Incomplete because in some ways, as well intentioned as it was, OBRA did not get to the root of the problems: the hegemony of institutional culture, a deeply flawed architecture, and the challenges of the gross inequity of the workforce.

33 years subsequent to OBRA’s passage the perfect storm hit that exposed the brittleness inherent in these fundamental systems not being addressed. Resident rights did not include the right to a private room, a private bathroom, good ventilation or fresh air; and more consistent assignment of staff with appropriate reimbursement, regulations, and financing  supporting it.

OBRA did not address the specter of a rooted caste system creating acute staff shortages and high turnover. The turnover rate of nursing assistants pre OBRA is substantially the same as certified nursing assistants post OBRA.

The tragic reality of the pandemic creates another once in a generation opportunity to finally get to the existential issues that OBRA did not reach. Is it even feasible in this divisive era for ageism and ageist attitudes to abate? Can stakeholders with different agendas learn to work together for this essential transformation?

There is no need to vilify or single out the nursing home operators, professionals or even ownership. Scapegoating is futile. Some of the most dedicated people I know work tirelessly for the betterment of elders’ lives in a profession that is known for its failings and its deficiencies. Yet, it is not recognized for it’s often heroic work that goes unnoticed and unpublicized.

Basically, since 1965 the entirety of the system accepted an institutional A&E, with cost containment being the primary driver of policy and legislation. Nursing home ownership and management figured out how to survive and even profit from it.  With the pandemic we now realize the incremental changes of the past were not sufficient to avoid this tragedy.

I consider the approaches by some well-intended advocates to propose tougher enforcement and mandatory staffing levels (nursing only) as superficial. Similar to OBRA’s shortcomings, these approaches still don’t get to the core of the challenges. This is analogous to treating the symptoms of an illness and not its root causes. We need to aspire to more than patchwork, more than incremental changes; it’s time to address its essence for real transformation.

I have my own ideas as to some legislative and policy redesigns. However, I am more about the process of change;  an inclusive one encompassing all the stakeholders – elders, direct care workers advocates, geriatricians and gerontologists, ownership and policy makers that will shape and create a new nursing home that is part of the long-term care continuum. A process where the elders right to excellent care and meaningful and dignified quality of life are the north star and acts as the glue that holds the process together. Otherwise, it will be no different than 1987 and these festering inadequacies will remain with only marginal improvements.

If all that results from the COVID19 tragedy in nursing homes is more punitive enforcement, ownership transparency and mandatory nursing staffing levels then the opportunity for true holistic transformational change in nursing homes would be lost.

Jeff Jerebker was the Founder and CEO of Pinon Management, former Treasurer of the Pioneer Network, Co-Founder of the Live Oak Project, and Board Member of Kallimos Communities.

4 comments on “A Once in a Generation Opportunity Reimagining Nursing Homes

  1. Jack Cumming on

    As I wrote in a recent article (https://www.seniorlivingforesight.net/i-want-to-cry-part-3-why-is-dignity-not-the-norm/), I favor abandoning the Skilling Nursing Facility experiment, which was accelerated with the Medicare and Medicaid legislation of 1965. It was then thought that a SNF would be a lower cost, more humane alternative to hospitalization. Today, we consider it less desirable than it seemed then to force people to spend their final days in a shared room with a stranger who may have intrusive dementia.

    In 1965, that was thought to be an improvement over confinement in a ward with fifty others (as my grandmother was during her final years at the Marlboro Psychiatric Hospital in Marlboro, NJ). I remember visiting her there, and it was a noisy place with white beds side by side with a white nightstand between them. There were few seats, so visitors sat on the bed. Privacy was not an option.

    Those wards are now fully a thing of the past, and a movement toward higher acuity assisted living with homelike quarters could similarly supplant today’s Skilled Nursing Facilities with their concept of a medical workspace. Thus, I favor replacing SNFs, just as Wards have been replaced, to make living through one’s final months more humane.
    Not everyone agrees, including the optimistic reformer who has given us this article. It is a daunting course to imagine that a Congress that puts party before country is ever going to enact sensible legislation. The article points out the flaws in OBRA, and that was when Congress was beginning to fall into the self-destructive downward spiral that now leads our daily news. I love what the author calls for here, but I think that it may be a hopeless dream to imagine anything this constructive in the America of today.

    This calls for caution on the part of people who are seeking a safe solution for the prospective challenges of aging, say, by moving into a Continuing Care Retirement Community (CCRC, or Life Plan Community, LPA). Once a CCRC is in place and established with a SNF of a certain size and configuration, it is rare – extremely rare – for that existing model to be replaced or repurposed as long that CCRC remains in business. In other words, new models for aging may emerge, and they will supersede not only today’s evolving concepts for SNFs but also the CCRCs that feed patients into onsite SNFs. Hence, considering if the existing SNF is a place where you would want to end your days is a central factor to consider when shopping for a home for life.

    There is another side to this as many CCRCs are closing or delicensing their SNFs, keeping people in Assisted Living perhaps a bit longer, but then outsourcing their care thereafter to an offsite SNF or other facility. This can make spousal visits difficult if the couple have lost their driving privileges. Again, this is something to be aware of when shopping.

    Sales representatives may give assurances, but you should obtain a side contract to give legal standing to those sales representations lest you later find that the intent of management when you moved in has shifted in a different direction. Such side contracts are not uncommon. For instance, many CCRCs require a separate “guarantor” contract to bind family members into supporting Mom or Dad if the parents’ financial resources run out.

    Our current thinking about aging is so siloed, and there are so many special interests seeking to be favored, that it seems unlikely that anything constructively positive will emerge anytime soon. Germany formed a Grand Coalition of its two major parties, akin to Republicans and Democrats agreeing to work together on a shared platform and only introducing legislation after thought leaders and more had deliberated on what can make the most sense. That Grand Coalition was able to give Germany the Hartz IV reforms which make aging in Germany far less traumatic than aging in America.

    Can we make a difference? That’s an open question.

    • Jeff on

      Thank you Jack for your thoughtful comment.
      You may label me an “optimistic reformer”, (as a matter of fact I’ve been using this moniker since I read your response), yet I share your sentiment that our political system is broken, maybe despairingly so. As such I had this sense of futility even as I was writing this essay.

      I appreciate your insights in this response.

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