Positive paradigms emerging for long term care living
December 1, 2020
So far, almost 40 percent of the nation's more than 240,000 COVID-19 deaths are from seniors living in nursing homes and long-term care facilities. As the coronavirus pushes into what incoming-President Joe Biden calls the "very dark winter," efforts are being made to prevent a repeat of this continued death spiral and apply lessons learned so far. So what lessons can be learned and what can be done to inspire a meaningful shift in how the country cares for – and spends on – its elderly people?
In general, the solution to the massive numbers of baby boomers aging has been a push away from institutionalization and toward allowing seniors to stay living in their homes and in community-based settings.
A push is expected in Congress under a Biden administration to help get Medicaid funding re-oriented toward community-based care. During the presidential campaign, president-elect Joe Biden outlined a detailed plan for taking care of the nation's elderly, but with COVID-19 and the economic recovery to accomplish, it may never get much attention from Congress, who would have to fund these changes.
To deal with the nursing home/COVID-19 problem, last spring, CMS established the Independent Coronavirus Commission for Safety and Quality in Nursing Homes to conduct a comprehensive assessment of nursing homes' response to the COVID-19 pandemic. The commission, in its report, declared that "the time has come for a turning point in nursing home care," but the recommendations were mostly focused on testing, visitation and how and whether to isolate patients. It made little mention of long-term changes, and few changes have even been proposed.
Several very creative and innovative models are already up and running as pilot projects around the U.S. For many years, a nontraditional model of smaller facilities known as "Green House" homes has existed around the country. They are less institutionalized long-term care facilities, in which 10 to 12 residents get their own private rooms and bathrooms with access to an open kitchen and a common area. Some Green House facilities serve larger numbers of people.
A June report found that 95 percent of Green House facilities had stayed COVID-19- free between early February and late May, while cases and deaths among residents and staff were lower compared to national nursing home data.
These facilities could be a model for how the nation deals with its elderly housing moving forward. So far, these non-traditional smaller facilities have been about one-fifth as likely to get the coronavirus as those who live in typical nursing homes – and one-twentieth as likely to die of the disease it causes.
These Green Houses demonstrate that all nursing homes, and other elderly housing facilities could make improvements like modifying physical spaces and perhaps providing for smaller, more community-based settings for seniors by dividing existing nursing homes into smaller "pods." That could help contain and prevent infections from ripping through large congregate populations and perhaps prevent an entire facility from needing to go into lockdown during an infectious-disease outbreak.
There are other creative models and innovative facilities around the U.S. as well. In Maryland, there's the Community Aging in Place – Advancing Better Living for Elders (CAPABLE), a Johns Hopkins School of Nursing program, that sends a registered nurse, an occupational therapist and a licensed handyperson to enable seniors, especially those who are low-income people of color, to live safely and independently at home. This pilot program – which was highlighted in the elder care and child care proposals rolled out by Biden during the campaign – began as a trial in Baltimore and now operates in more than 27 sites in 16 states, translates about $3,000 per person into $20,000 in medical cost savings.
Another model program, pioneered in San Francisco's Chinatown, is PACE (Programs of All-Inclusive Care for the Elderly), which works with people age 55 and older who require a nursing home level of care to fulfill their health needs in the community. It provides Medicare and or Medicaid participants with services and care at an adult day health care center as well as at home and by referral. Right now, that program is available in 31 states and may require participants to use a PACE-preferred doctor. (For more details, visit http://www.medicare.gov/pace/.
Assisted-living facilities continue to be an alternative for people who do not need round-the-clock nursing care, but Medicaid coverage of these facilities remains inconsistent. A handful of states have recently introduced publicly-funded long-term care plans, led by Washington state and Hawaii. That idea is also being considered in California, Michigan, Illinois and Minnesota.
The biggest problem for many of these innovative community-based ideas is that they are competing against the more entrenched and powerful $137 billion dollar nursing home industry, which provides homes for 1.3 million seniors and has pushed to thwart some state efforts to fund these community-based options.
While there is clearly a need for innovative and creative ways to house seniors, during COVID-19 current nursing homes remain focused on stockpiling masks and gowns, and for the most part are not really thinking about broader concepts. Unfortunately, fixing these problems ends up on the back burner. When the crisis eventually abates, it will fall to creative public officials to push these ideas.
Also contributing: Washington Post; Wall Street Journal; Market Watch; Next Avenue.