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The Future of LTC: The Continuing Evolution of the SNF

      The American nursing facility has been in continuous evolution since its inception in the early 19th century. The early “old age homes” were places to save “formerly respectable people from the indignities of the almshouse” (Elon et al., “Post-Acute and Institutional LTC for the elderly,” in Reichel’s Care of the Elderly, 7th ed., Cambridge University Press, 2016:659–670). In the late 19th century through the 20th century, nursing facilities were also places to convalesce from acute hospitalization. Initially known as “convalescent homes,” these facilities and programs evolved into what is now known as post-acute care. The late 19th century “homes for the incurables” — intended for those who could no longer benefit from hospitalization but lacked the family or resources to be cared for in their own homes — evolved into what we now call our institutional long-term care programs.
      Today in the United States most nursing facilities have a dual role and function: (1) providing long-term, institutional residential and nursing care for individuals who require support in their activities of daily living and lack family or resources to be cared for in their own homes, and (2) providing short-term rehabilitative, nursing, and medical care to individuals who have had a qualifying hospital stay and whose needs exceed the capacity of their families or communities to provide that care in their homes. Over the coming 5 to 20 years, I believe short-term convalescence post-acute care will become more dominant in American skilled nursing facilities and the LTC component will continue to diminish.
      Despite an increase in the aging population in the United States, along with an increase in the number of people who would qualify for nursing facility care, the number of people residing in American nursing homes has decreased over the past decade from approximately 1.5 million SNF residents to approximately 1.35 million. The reason for this change is thought to be due to two major factors: (1) the increase in the types and availability of in-home services for persons with disabilities of all ages and (2) the growth of assisted living options.
      In addition, COVID-19 has had a huge and disproportionate impact on nursing facilities. Occupancy appears to have declined by 10% to 30%, at least on a short-term basis, due to the high death rates and lower admission rates. People have been choosing to return home after hospitalization, when in non-COVID times they would likely have been automatically discharged from hospital to a SNF.
      Over the next 5 to 20 years, I believe there will continue to be a decrease in the LTC population in American nursing homes. Surveys repeatedly have shown that older people do not want to enter nursing facilities. Just as the old age homes of the 19th century “saved” older adults from the almshouse, home care and assisted living options will “save” older people from the nursing facilities that many still fear and revile. The future will provide an increasing array of options to allow care to be delivered in community-based settings rather than in nursing facilities.

      Industry Transformation

      The nursing facility industry in the United States is predominantly a for-profit venture. It has been estimated that on average the predominantly Medicaid-reimbursed LTC portion of the nursing home business model loses about 2% annually and must be subsidized from the post-acute business model that on average produces a 10% profit or margin annually. Some nursing home operators in more affluent communities are already abandoning the nursing home LTC functions and are developing “post-acute only” facilities with private-pay sister assisted living communities next door for those who are unable to return home due to their activities-of-daily-living limitations. I believe over the next 5 to 20 years we will see more stand-alone post-acute facilities and fewer nursing facility beds devoted to LTC.
      Many nursing facilities already provide medical care that could be labeled chronic hospital care. To decrease unplanned transfers back to the hospital over the coming years in the environment of growing case intensity, nursing facilities will need to upgrade their medical and nursing services to manage the increasing patient acuity. We are already seeing medical practices devoted exclusively to this type of care, and public policy will need to catch up to the evolving role of the nursing facility. Without pay equity for nurses and nursing assistants between hospitals and nursing facilities, and staffing levels commensurate with the expectations of higher acuity care, it will not be possible for nursing facilities to recruit and retain the quality and quantity of staffing required to provide top notch care. Without the appropriate policy responses, nursing homes could just become “second-rate geriatric hospitals.”
      Perhaps the COVID-induced higher unemployment rates will encourage more people to consider working in nursing facilities, but reports are that this is not the case. The opposite seems to be true, likely due to the fear of contracting COVID-19 in this high-risk environment and the historically lower wages for entry level work in SNFs. Staffing remains a critical issue in many nursing homes.

      Post-COVID Models

      After COVID, I don’t think it will be possible to return to business as usual as it was in the pre-COVID times. More restrictive nursing home admission criteria may follow state Medicaid programs becoming increasingly strained financially, pushing more care back onto families. Also, community-based services for home care and assisted living options for both the private-pay and Medicaid populations will likely continue to expand. I also think there will be an expansion of the post-acute programming, with increasing pressure to care for higher medical acuity. Again, this cannot be achieved in a quality fashion without the resources for adequate staffing and infrastructure, but whether public policies will promote or hinder this evolution remains to be seen.
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      The present enforcement regulations are intended to change corporate behavior through civil monetary penalties large enough to make it unprofitable to deliver poor quality care. However, the evidence from studies of quality improvement teaches us that the best environment for performance improvement involves nonpunitive processes and settings. Nor has adequate attention been paid to the impact of the punitive regulatory process on the front-line staff. Policy makers must recognize that the enforcement regulations have not produced what they were intended to produce — and they have had an amazingly devastating effect on front-line staff (J Legal Med 2005;26:69–83).
      Ultimately, it is my hope that the overly punitive regulatory environment will yield to more meaningful root cause analyses of why our SNFs are as they are and that an evidence-based quality improvement environment can emerge.