The COVID-19 pandemic has caused tens of thousands of deaths and more than three million infections, with predictions of many more to come. Nursing home residents have been among the most affected by the pandemic. In some states, half or more of all COVID deaths have occurred among nursing home residents. The reasons for this disproportionate impact are not a mystery.
Nursing homes in the United States are generally large facilities with populations ranging from 50 to 60 residents to well more than 200 and, in a few facilities, over 300 residents. Most of these residents are fragile, with medical co-morbidities and restricted mobility. These conditions, and the fact that residents live in close proximity to each other, make them highly vulnerable to a pandemic. The situation is compounded by lack of preparation, including insufficient personal protective equipment (PPE) for caregivers and testing to identify those infected in a timely fashion.
In order to understand fully how the United States has ended up in this tragic situation, we need to take a broader view of long-term care. We are failing to provide enough community-based services, as well as quality nursing home care, to a rapidly growing population of older Americans who have serious but unmet needs. In the absence of qualitative long-term care policy and funding, even more individuals will not be able to get the care they need in the future.
Community-based in-home programs include a wide range of services, from home health care and personal care support to homemaker assistance. The expansion, however, of these services for persons dependent on public assistance has been slow and uneven. Most states spend more than 50 percent of their Medicaid funds, the biggest source of long-term care funding, on nursing home care rather than community-based services.
Furthermore, the number and accessibility of services is often inadequate, resulting in growing waitlists. In Florida, the waitlist for community-based services exceeds 75,000, grows annually and will become longer with the unprecedented growth of the older population over the next 20 years if services aren’t expanded.
A small number of states, including Washington, Minnesota, Wisconsin and Hawaii, have shown over the past several years that a serious effort to shift to in-home and community care can succeed in greatly reducing reliance on nursing homes. These states provide residents who need long-term care greater access to community-based care than states that are still heavily dependent on nursing homes.
Unless funding for home- and community-based services is substantially and steadily increased over the next several years, the failures of our current long-term care system will become worse. The United States spends less of its GDP (1 percent) on long-term care than virtually every other wealthy country. If the United States were to move to a higher level of GDP spending on long-term care services, we would be able to expand and improve access to our community-based programs and make it possible to pay care workers a livable wage, health care benefits and sick leave.
We would also be able to fund a transition from the traditional-model nursing home of 100 beds or more to a smaller, home-like, individualized care facility. In designing a more livable long-term care alternative to current large facilities, we can draw on the documented experience with facilities of 10 to 15 beds based on the Green House model.
Green House is an innovative, nationally-recognized model in long-term care to create small homes that recognize the individuality of residents and honor their autonomy, choice, privacy and dignity. The number of Green House facilities is small, with just over 300 facilities in several states, but we have enough information about their operations and costs to know that they can provide more effective, human-scale environments to help residents flourish than the traditional large nursing home model, while remaining affordable.
Existing large facilities should be reserved for short-term, convalescent and rehabilitative care, which nursing homes are already providing on an expanding basis.
If we are serious about learning and applying the hard lessons taught by the nursing home tragedy and the many years of neglect that preceded the pandemic, we will have to spend more on long-term care and address the moral failure of our underfunded system.
Larry Polivka is the director of the Claude Pepper Center at Florida State University and scholar-in-residence with the Claude Pepper Foundation, Inc. He can be reached at firstname.lastname@example.org. The Claude Pepper Center is dedicated to research, policy analysis, public information and educational and advocacy initiatives focusing on health care, long-term health care and retirement security for older Americans and citizens of other countries.