In the future, alternative settings allowing for privacy, specialization, and person-centered care will likely replace the facility of today.
Photo by Brian Bullock on Flickr, https://bit.ly/3kdZ9K5Oh, 2020. You aren’t over yet, and I cannot imagine what final miseries you hold in store in your waning days. I’ve always been a glass-half-full person who looks to see the good in others — a consensus-builder, a holder of space, a proponent of the “there is always a lesson to be learned from adversity” philosophy, a believer that things will turn out the way they are meant to, and one with faith in the general kindness of humanity. I have to concede sadly that you, 2020, have taken a serious swipe at my core beliefs.
The probably 100,000 nursing home and assisted living residents who will have died, mostly unnecessarily, because of the pandemic are a heartbreaking statistic, especially for those of us who have devoted our careers and our lives to respecting and caring for this population. Let’s consider them for a moment, as I am sure many of us do every day, and pay homage to these casualties — and on a larger scale, to all the families and all the community-dwelling people in the United States and around the world who have died or been scarred by COVID-19.
Let us pause here for a moment of reflection.
But let’s not illuminate and enumerate all the shards of negativity. It is too easy and intoxicatingly self-pitying to wallow in the laundry list of what 2020 has wrought. What have we learned from the pandemic, and how will it lead us forward? I was asked for my thoughts on what the future holds for PALTC, and I am going to share a variety of ideas, some of which are already becoming a reality, and others that are probably purely aspirational.
- •Telemedicine. We have learned that we can do a lot without having to leave our home or office, including virtual visits. And it looks like the Centers for Medicare & Medicaid Services is finally going to allow much more latitude in PALTC and permit billing nursing home visits via telemedicine. These virtual visits are not a complete substitute for in-person visits, but they are a great addition to our arsenal, and they show great promise for improving access to care in several areas, including advance care planning, behavioral health, and dermatology, to name a few. I welcome this change, but with the caveat that telemedicine needs to be used when appropriate and not across the board.
- •Technology. Other technological advancements will continue to improve our ability to keep our patients safe. I predict and welcome the increased availability of wearables, including continuous monitoring of blood pressure, heart rate and rhythm, sleep parameters, blood glucose, and other potentially important physiological metrics. I think we will have improved remote monitoring that will help reduce falls, as well as smart mattresses that reduce the incidence of pressure ulcers. Pharmacogenomics may evolve further to help guide our treatment of our patients’ conditions.
- •Environment. In our skilled nursing facilities, the death toll from COVID-19 has brought to light many of the imperfections in our systems of care. The wisdom of mixing the post-acute/skilled population of medically ill and complex people with the long-term/custodial population of generally less ill but functionally dependent and/or cognitively impaired residents is being questioned, and rightfully so. The days of three-to-a-room arrangements with six patients sharing a bathroom are numbered. As new physical plants are built out, the layouts will increasingly allow for single, private rooms — a plus for actual privacy and for infection prevention and control.
- •Specialized units. The heterogeneity of the population in many nursing facilities presents further issues, such as the many patients with serious mental illness and/or dementia who demonstrate significant behavioral health concerns that place them, other residents, and staff at risk. These residents are often ambulatory and may be physically assaultive, explosive, quick to escalate, and difficult to defuse. Some may have criminal and correctional histories, and some are manipulative. A nursing home with the traditional frail elder population is not the ideal setting for these patients, who could be better served in a more dedicated psychiatric unit or, possibly, a small group home with trained staff. I hope we will be able to help relocate some of these individuals, to their own benefit and that of our facilities and residents.
- •Survey. Despite our highly regulated nursing home system, it has become increasingly obvious that the federal survey process has done little to improve the quality of overall care provided in our facilities. Some facilities plan for and try to “game” the annual survey: They get their deficiencies, draft their plan of correction, give their in-service training, and then go back to business as usual. I believe we will see some meaningful reforms in the survey process, such as the pilot project the California Department of Public Health is rolling out, entitled the Quality & Safety Survey Model, which will embed a surveyor with a facility, include frequent visits, and embrace a more consistent, quality assurance performance improvement (QAPI)–oriented approach to making enduring improvements to care processes. I see great potential in moving away from a purely punitive survey process while continuing to penalize facilities for serious, harmful, or willfully negligent violations.
- •Alternative settings. I am hopeful that we continue to move toward affordable home- and community-based services, allowing people to remain in their homes or reside in homelike residential communities (like six-bed group homes, personal care homes, residential care facilities, or whatever you call them in your state) and avoid large, institutional settings whenever possible.
- •Workforce. Workforce shortages in our sector have also been magnified by the pandemic, and they are not getting better. But I am hopeful that there will be some innovative ways to incentivize young people to enter the field, especially as nursing assistants and nurses, where we are facing the most severe deficits. I don’t know what the solution will be, but it is critically important, so I hope someone a lot smarter than I am can figure out a way to do it.
- •Image. While those smarter people are solving our workforce problem, if they can figure out a way to improve the public image of nursing homes, they must do it, too. So much of our media coverage has been focused on awful cases of abuse or neglect, and so little attention is given to the wonderful, compassionate care that is provided every day in our facilities. AMDA – The Society for Post-Acute and Long-Term Care Medicine’s #WeArePALTC initiative has tried to make a dent in this perception, and we need more people to tell real-life stories about the kindness and goodness that abound in our nursing homes.
- •Medical directors. I’ve heard the idea of creating a medical director “utility,” funded by facilities across each state. This would create a system where the individual facility medical director is paid by the utility — and can be objective, concentrate on quality, and speak for the best interests of the residents without being dependent on facility management for a salary — and won’t be dismissed in favor of a physician who can drive census. It’s intriguing.
- •Real estate. On a similar note, I’ve heard a suggestion that the owners of the real estate should be forced to share accountability for the care given in facilities. The profit motive and the various shell companies, side companies, and related party transactions that are somewhat common in the industry may be detrimental to the quality of care. Making them accountable would be difficult to implement, but it could reduce the pressure on facility administration to maximize profits.
As 2020 draws to a close, I am trying to stay positive. We have seen how nimble and proactive our Society is, working together across state lines and beyond. I pray our country too can move into a more collaborative, compassionate space where people respect each other and can converse in spite of differences of opinion.
And I truly believe that in the wake of the huge disaster COVID-19 has been in our nursing homes, there will be some enduring good that comes of it, when all is said and done. We will certainly be better equipped to handle infectious diseases in the future, and I hope many of my other musings come to fruition as well. In the meantime, let’s keep doing what we are doing and protect the precious elders we have the privilege of caring for.
Dr. Steinberg is president elect of AMDA – The Society for Post-Acute and Long-Term Care Medicine and editor emeritus of Caring for the Ages.
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