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‘Targeted Investments’ Backed for Overhaul of Nursing Home Care (1)

April 6, 2022, 3:00 PMUpdated: April 6, 2022, 5:43 PM

Congress should grant the federal government the authority and resources necessary to implement costly and sweeping reforms to overhaul the U.S. nursing home industry, according to a report released Wednesday by an influential national advisory panel.

The National Academies of Sciences, Engineering, and Medicine, in conjunction with a coalition of sponsors, formed the Committee on the Quality of Care in Nursing Homes in 2020 to study how the nation provides, funds, oversees, and evaluates nursing home care.

Their report, “The National Imperative to Improve Nursing Home Quality,” calls for a number of immediate and short-term policy changes that could be implemented with some planning and coordination, while longer-term proposals could take years to reach fruition. It’s the first major study to review the state of nursing home care and provide recommendations for improvement since the 1986 Institutes of Medicine report, “Improving the Quality of Care in Nursing Homes.”

The new study “provides a clear path to guide the transformation that is needed,” Terry Fulmer, president of the John A. Hartford Foundation, said in a statement. “It has been more than 35 years since the last large-scale report assessed nursing home challenges, and as COVID-19 demonstrated, the need for reform is urgent and undeniable.”

Roughly 1.3 million Americans reside in more than 15,000 Medicare- and Medicaid-certified nursing homes, the report said. As of February 2022, more than 149,000 nursing home residents and more than 2,200 staff members had died from Covid, it said.

“All residents are vulnerable, but our report especially emphasizes the inequitable care delivered to specific groups,” including racial and ethnic minorities and the LGBTQ community, said committee member Jasmine Travers, an assistant professor of nursing at New York University’s Rory Meyers College of Nursing.

The report calls for immediate implementation of:

  • competitive wages and benefits for all nursing home staff;
  • a registered nurse on site at all times, and additional RNs based on the number and severity of residents and patients;
  • a full-time social worker;
  • an infection control specialist “with sufficient dedicated time”;
  • a study to determine “minimum and optimal” facility staffing levels, and new requirements based on the findings;
  • and paid training for certified nursing aides who perform the bulk of direct-care duties in nursing homes.

Similar proposals were included in the Biden administration’s wide-ranging plan to reform nursing home care.

Lori Smetanka, executive director of the National Consumer Voice for Quality Long-Term Care, said the recommendations support the Biden team’s plan. “We are particularly pleased that the Committee calls for increased numbers of staff, including a registered nurse 24/7 and a study on staffing levels to shape future requirements,” she said in a statement.

‘A Piercing Wake-Up Call’

“This report is a piercing wake-up call for policymakers. Decades of underfunding have left America’s nursing home system in desperate need of an overhaul,” said a statement from Katie Smith Sloan, president and CEO of LeadingAge, which represents non-profit aging services providers.

“As our nation grows rapidly older, millions of older Americans will need safe, high-quality care. It’s time to act to ensure they can access and afford the vital care nursing homes provide,” she said.

Implementing the committee’s recommendations will likely require significant funding from states, the federal government, and the nursing home industry, the report said. But just adding more money to the current system “would not likely result in significant improvements,” the report added.

Instead, the report calls for “targeted investments that—combined with current funding—would be inextricably linked to requirements for transparency” about how and where federal nursing home funding from Medicaid and Medicare is spent.

“A key barrier to effective nursing home oversight has been a lack of transparency regarding nursing home finances, operations, and ownership,” said David Grabowski, a committee member and professor of health-care policy at Harvard Medical School.

While the Centers for Medicare & Medicaid Services makes some ownership information available, the data is “incomplete, often difficult to use, and do not allow for assessment of quality across facilities owned or operated by the same entity,” Grabowski said.

The report recommends collecting, auditing, and making public detailed facility-level data on the finances, operations, and ownership of all nursing homes, Grabowski said.

The report also calls for a more “rational and robust financing system” for nursing home care, Grabowski added. It calls for moving toward a “federal long-term care benefit,” which could be tested through state demonstration projects, Grabowski said. The report also recommends designating a specific share of Medicare and Medicaid nursing home payments for direct-care services.

Since the CMS and other agencies “may not have the full authority or resources to implement the recommended actions,” the report says “all relevant federal agencies need to be granted the authority and resources from the U.S. Congress to implement the recommendations of this report.”

“Adopting and implementing the recommendations of this report will require more than funding, organizational commitment, education, and changing health policy—it will require moral courage,” the report said.

The American Health Care Association and National Center for Assisted Living said the report includes proposals that were included in their reform agenda from last year.

“As shown in the Care For Our Seniors Act we maintain that these reforms must be fully funded, the supply of available workforce must be enhanced, and policymakers and providers need to work collaboratively to make ongoing improvements to care,” the groups said in a statement. However, the groups cautioned that while they support “transparency and accountability—what we cannot support are unfunded mandates that will not solve systemic challenges or help improve resident care, but rather will compromise access to care.“

(Updates with additional reporting throughout. )

To contact the reporter on this story: Tony Pugh in Washington at

To contact the editor responsible for this story: Brent Bierman at