The National Academies of Sciences, Engineering, and Medicine (NASEM) published a critical report during the pandemic, finding that “the way the United States finances, delivers, and regulates care in nursing home settings is ineffective, inefficient, fragmented, and unsustainable.” NASEM issued a call to action for improving nursing home care as “a moral imperative.”
The COVID-19 pandemic’s devastating impact on nursing home residents, family caregivers, and staff also heightened the attention of state policymakers on systemic problems in nursing facilities. As a result, some states are leading the way to instituting financial, delivery, and regulatory reforms to improve quality standards and quality of life. A session at NASHP’s annual conference showcased state thought leadership on such reforms, specifically nursing home payment methodologies, ownership transparency, staffing and training standards, person- and family-centered care, and diversions and transitions to the community.
A National Overview
David Grabowski, professor of health care policy at Harvard Medical School, provided a national overview on Medicaid nursing home payments. While research suggests that increased Medicaid payment leads to higher nursing home staffing and better quality, states vary in the amount of funds that go directly to resident care. Moreover, Medicaid generally pays nursing homes below acuity-adjusted costs — with only one-fifth of nursing facilities receiving 100 percent plus of Medicaid-allowed amount payments as a share of acuity-adjusted costs. Despite these payment challenges, research demonstrates that states can improve nursing home staffing and quality through minimum staffing standards, wage pass-through policies, and minimum revenue spending requirements directed toward patient care.
Ohio and New Jersey are two states where state leadership has prioritized nursing home reform, especially in light of the tragedies that befell nursing home residents during the pandemic.
Ohio’s ‘North Star’ for Nursing Home Quality and Accountability
The Ohio Department of Health licenses and/or certifies approximately 960 nursing facilities serving over 66,000 individuals in 2023. Ursel McElroy, director at the Ohio Department of Aging, presented Ohio’s recent efforts in nursing home quality and accountability standards. In February 2023, Governor Mike DeWine launched a Nursing Home Quality and Accountability Task Force. The state hosted numerous face-to-face and virtual listening sessions for residents and their caregivers, nursing home administrators, and one designed specifically for individuals with disabilities. This culminated in a recommendations report to systematically improve nursing home quality. The 23 recommendations within the report span across four dimensions:
- Enabling excellence
- Ensuring oversight and accountability
- Empowering residents
- Facilitating data-based decisions
These four dimensions act as a “North Star” for Ohio’s nursing home strategy — a guidepost for nursing home transformation that elevates collaborators’ viewpoints as the integral voice to these policy conversations. Some of the immediate recommended actions from the report include transitioning Ohio’s COVID-19 Regional Rapid Response Assistance Program toward a permanent nursing home technical assistance program, developing a career pathway model for nursing home positions, and designing a public-facing nursing home dashboard
New Jersey’s Nursing Home Reforms
The New Jersey Department of Health licenses and/or certifies approximately 357 nursing facilities serving over 37,000 individuals. New Jersey’s nursing home reforms emphasize a foundation for person-centered, home-like environments that promote autonomy, privacy, and dignity. Kaylee McGuire, deputy commissioner of aging and disability services at New Jersey’s Department of Human Services, outlined the state’s recent payment and quality initiatives. These initiatives include:
- The establishment of a patient care ratio requirement for nursing facilities to spend at least 90 percent of their Medicaid revenue on patient care
- Increased ownership transparency and related party disclosures through the change of ownership and licensing process
- A $50 million Medicaid quality incentive payment add-on bonus program
Additionally, the fiscal year 2023 budget for the New Jersey Department of Human Services includes a $1.5 million annual appropriation allocated for interagency collaboration on long-term care integrity and oversight. As New Jersey continues forward with its nursing home reforms, McGuire emphasized coordinated efforts to strengthen long-term care integrity and oversight, rate rebalancing, and possible shifts to single occupancy.
Key Takeaways
The nexus of both research and practice of nursing home policies can help guide state policymakers to redesign payment strategies, improve data collection and measurement, and invest in the direct care workforce. These reforms include crafting thoughtfully designed policies that are person-centered to empower the voices of residents and their caregivers. A focus on transparency — such as with New Jersey’s nursing home facility data — allows for user-friendly, accessible data for individuals and their families to make informed decisions about their care. The investment in direct care workers, such as training and wages, helps to ensure a well-sustained, quality workforce. Ohio and New Jersey’s efforts are led from the highest levels of state government with a commitment to transform nursing home care and move from a point-in-time compliance mindset to ongoing improvement-oriented policies.
Acknowledgements
The conference session “There’s No Place Like Home: Rethinking Nursing Facilities” was developed with generous funding from The John A. Hartford Foundation and West Health. New Jersey and Ohio participate in NASHP’s Aging Policy Academy, a multi-state technical assistance collaborative with the goal to strengthen policies for an aging population, in partnership with West Health.
