Skilled Nursing Residents Deserve Better than ‘Warehousing’

by Jeff Shaw

The seniors housing industry, government and society as a whole must collaborate to improve care for our frailest seniors.

By Martin Siefering, Principal and Senior Living Practice Leader, Perkins Eastman

“When we, as a society, see that it’s appropriate to warehouse our elders, and to put them in small spaces, to underpay their staff so that there are chronic staffing shortages — I think if we see that as an adequate treatment of our elders, then we’re going to have a bad time. We are going to see this over and over again.” — James Wright, medical director at Canterbury Rehabilitation & Healthcare Center in Richmond, Va., where over 45 people to date have died, as stated for the Washington Post on April 11, 2020.

While the COVID-19 pandemic has impacted the lives of all Americans, it has had the biggest impact on those who live and work in our nursing homes.

Typically older adults who have multiple chronic conditions and live in nursing homes are some of the most at-risk for the virus. We have, as a society, too often housed our most fragile, vulnerable population in badly outdated nursing homes, primarily built in the 1960s and 1970s and reliant on Medicaid reimbursement. And it is no surprise that these environments are also less than ideal for the caregivers who work there.

The combination of these factors, along with inadequate preparation, has created the unfortunate circumstance where thousands of Americans are now dying in our nursing homes from complications of the COVID-19 virus. This has profound implications to our larger healthcare systems and to our economy at large.

For those who have followed the nursing home tragedies in the media, one might place the blame for the deaths on the owners who are only interested in making a profit, but it is not that simple — we all have responsibility.

“We all opted for this type of environment for our elders. And as a result, this virus spread through a publicly funded nursing home like wildfire. … Without improvements, a publicly funded nursing home is a virus’ dream,” adds Dr. Wright.

Change is possible

This is a terrible time for nursing homes, but there is reason for hope.

For years, progressive organizations have been developing and testing solutions to keep people out of nursing homes, improve the roles and compensation of caregivers, and create alternative physical environments that improve the quality of life for the residents. These solutions, which have already been trialed and tested in small numbers, positively address the quality of lives for the caregivers and those who need care. Additionally, they have many of the qualities necessary to prevent the spread of infectious disease.

In order to focus on solutions, we need to have an understanding of the barriers present that prevent industry-level change.

The majority of any nursing home’s revenue comes through reimbursement from Medicaid, which is jointly funded by the federal government and individual states. Partially due to this, nursing homes have been grossly underfunded for many years.

Skilled nursing revenue streams have been continually squeezed. Increases in income have not kept up with the ballooning operating costs, and very little provision is made within the reimbursement stream for capital improvements. This has left us with badly outdated facilities that do not respond to the needs of today’s nursing home residents, plus poorly compensated staff.

In these environments, staff are often treated like commodities, not paid reasonable wages, not given autonomy to act on behalf of those they care for, and not given the tools that they need to be successful. It is no wonder that staff turnover for nursing home workers is one of the highest for all professions.

Why do people live in nursing homes?

Skilled nursing facilities are often the only way for seniors to access their Medicaid benefits, most critical for those who have limited financial resources.

People who have any degree of affluence have choices: they can hire private home health aides, or can live in a retirement community or an assisted living community. But for those with very limited income, these choices are not available — they must seek Medicaid reimbursement, which is only generally available in a nursing home setting.

Another segment who must live in nursing homes: those who need complex, extensive, long-term nursing care 24 hours a day — services that cannot realistically or economically be provided in any other location. These, the frailest of the frail, are the members of our society who are at the greatest risk when they come in contact with infectious disease, and those who we should protect the most.

Responsibility for the state of skilled nursing falls on the shoulders of each and every American citizen of voting age; we are the ones who elect the officials that have for decades turned their backs on the needs of these vulnerable and impoverished residents and the staff who care for them.

A great many of our frailest citizens have no choice but to live in facilities where two, three or four residents sleep in the same room and share a bathroom. In most facilities, large groups of 50 to 60 residents are grouped together into an institutional “nursing unit,” with a large number of caregivers circulating throughout. Not only do these environments fail to support the resident’s quality of life, they are ideal environments for viruses to spread.

Alternatives to the status quo

There are obvious approaches to solving these problems. For starters, we could allow people options for how they access their Medicaid benefits. This will reduce the number of people who must live in nursing homes, decreasing the warehousing effect, incentivizing the renovation and replacement of outdated housing, and bringing new innovations into the market.

The other solution is to replace and improve a smaller portfolio of nursing homes for those who require extensive, long-term nursing care 24-hours a day, which would be developed to a higher standard in terms of quality of life for the residents and caregivers and also more resistant to the spread of infectious disease.

Though there has been considerable innovation in the development of nursing homes over the last 30 years, limited funding for capital improvements has prevented any broad, paradigm-shifting change from occurring. Notably, however, the Veterans Administration (VA) and numerous progressive nonprofit organizations have selected one of these models, the ‘small house,’ as the standard for all of their nursing home construction.

These innovative environments follow a model where 10 to 14 residents live together in private rooms, in autonomous “households,” and are cared for by a small and dedicated number of caregivers. The adoption of this model already provides proof that these new models work: infectious disease can be better contained, and satisfaction levels are higher for staff, residents and families.

It has been proven that this small-house model can be created from the older stock of nursing homes in addition to new construction in a variety of sizes and configurations. Although publishable evidence is not yet available to confirm that these environments are more resistant to the spread of COVID-19, there is strong anecdotal evidence that communities following this model have fared well. These physical structures and their radically different operating model contain principles that should lead to significantly better outcomes.

Only with the voting public’s ownership and overwhelming support for change are any solutions possible. It is disgraceful that tens of thousands of Americans have died in our nursing homes, which are largely funded by tax dollars. As a society, it is up to us to learn from this moment and take steps to move beyond the warehousing of our elders. We all deserve better.


Martin Siefering is co-leader of architecture firm Perkins Eastman’s senior living practice.

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