While the spread of the Delta variant attracts news, we must not forget the death and devastation that SARS-CoV_2 brought upon senior housing. To understand how this happened, without hand-wringing or other unproductive reactions, is the beginning of the solution. To fix problem it’s necessary first to understand it.
Long Term Care Track Record
From the 1960’s forward to 2019, we relocated millions of poor, old people (mostly women and many with dementias) to congregate care facilities – mostly nursing homes. From 1965 with the passage of Social Security Act and the development of the Medicare & Medicaid programs, this migration began to be codified.
A very brief (insouciant) history of a slow-moving train-wreck of a crisis:
1. Aging & the Industrial Economy.
From the mid-1960s forward, millions of old, mostly poor persons were relocated to congregate care (nursing homes in the US and care homes in the UK) many of these with dementias and other neurodegenerative disorders. Families were unable to care for these individuals at home. Since the 1990s, those who had the money relocated when necessary to assisted living, which are much newer and more “residential”. This trend siphoned off the higher income age qualified prospects, rendering the referrals to nursing homes even more destitute.
2. Cookie Cutter Solution.
The physical facilities into which these individuals were relocated were built overwhelmingly based on the hub and spoke construction model which had become popular in the 1950s. Modern “efficiency” was taking root, and these buildings were designed to minimize the number of steps nurses took to reach a patient. Thousands of these cookie-cutter buildings (nursing homes and hospitals) were designed and constructed in the US under the Hill Burton Act which provided low-cost construction loan guarantees with the proviso that the services being provided would include means-tested patients/residents. Nursing homes were built to replace “poor houses” and the architects who built them were born at the turn of the 20th century, making them adults during the Great Depression. “Granny is gonna love this!”; multi- bedded rooms, “modern” fluorescent light, shared toilet and bathing facilities and no air conditioning.
3. Whoa! How much will this cost?
Almost immediately, the federal Medicare program recognized the economic threat of the aging demographics in the US, and the projected costs of long-term care, and withdrew payment to nursing homes. Payment under the Medicaid system, which is shared between the state and the federal government, continues to today; 68% of population in nursing centers are Medicaid beneficiaries.
4. Putting the brakes on.
Almost every state by the early 1980s recognized that the painful increases in the costs of state-sponsored long-term care were unsustainable. This spawned a cascade of regulatory reform intended to bend the curve and reduce current and future costs. One result of this is the ubiquitous Certificate of Need regulations which make adding healthcare (including nursing home) inventory/capacity very difficult. This and other factors have the intended consequence: little or no new nursing home inventory has been constructed in the United States since 1991.
The consequence of this history of political neglect are at least 11,000 “zombie” nursing homes operating throughout the United States. They are zombies because they cannot reach operating breakeven based on the insurance coverage of the clients currently being served and survive only through various subsidies and cross- subsidization. There are currently approximately 15,269 skilled nursing centers operating in the US; about 4,000 of these are or could be solvent on their own terms. The rest are a fiscal mess.
Along the way, in both the US and the UK, under the guise of rooting out fraud and other agreed-upon goals, an almost relentless stream of payment and performance regulations have been layered onto nursing homes and congregate care facilities.
Where No One Wants to Go
One constant for the past 60 years has been the cultural guilt associated with “putting” Granny in a “home” (as though she were a potted plant). Nursing homes, care homes, board & care homes and other congregate centers became the only available go-to solution for families faced with life’s daunting triple-threat:
- Keeping both prime-age working adults employed
- Being perfect parents
- Taking care of Granny
The cultural metaphor for congregate care facilities is so bad, there have been television satires and movies featuring the horrible things that happen there. Meanwhile, the physical infrastructure continues to deteriorate. Through a little bit of debt and some equity financing, refurbishments have been made but the fundamental bricks and mortar of most of the nursing homes in the United States and the UK are as they were since the 1960s, early 1970s.
This raises the question: would you want to stay in a Hilton or Marriott that hadn’t been updated for 40 years?
Long-term congregate care facilities – especially nursing homes – are at the bottom of the healthcare food chain. When doctors are surveyed about their attitudes toward post-acute care, the majority look down on practicing in these settings; surveys among nurses reflect the same low regard for these practice settings.
Designing a new future
There needs to be an open dialogue about solutions that address the immediate needs, while preserving the very existence of the institutions and organizations needed to serve the most vulnerable in our populations. There are no pat answers; everyone engaged in the sector needs to be involved in the conversation to prevent lopsided, slapdash solutions that only lead to more – and possibly worse – problems.
Join us on 2nd November for the webinar: Designing the Future of Long Term Care.