Improving Nursing Home Quality: Jasmine Travers, Alice Bonner, Isaac Longobardi, and Mike Wasserman

Eric: Welcome to the GeriPal Podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: And Alex, we have a full house today. Who is with us?

Alex: We have a full house from around the world today. We have Alice Bonner, who’s Chair of the Moving Forward Nursing Home Quality Coalition. Welcome to the GeriPal Podcast, Alice.

Alice: Thank you.

Alex: Great. And we have Isaac Longobardi who is Associate Director of the Moving Forward Coalition. Welcome to the GeriPal Podcast, Isaac.

Isaac: Really excited to be here. Thanks, Alex.

Alex: I think Alice is joining from Boston area maybe, Massachusetts somewhere, and Isaac is joining from England.

Isaac: Yep.

Alex: We have Mike Wasserman who’s joining from California at this time, who is returning to the GeriPal podcast. He’s a geriatrician and Chair of Public Policy for the California Association of Long-Term Care Medicine. Welcome back to the GeriPal podcast, Mike. I hope I got that right.

Mike: You got it right. Great to be back.

Alex: And we have Jasmine Travers who’s joining us from Israel. Thank you so much for joining while you’re over there. She was a member of the committee that wrote the National Academy’s report that we’re going to be talking about today on Improving Nursing Home Quality. Also works as a one of the Co-Chairs of the Committee for the Moving Forward Coalition. She has an editorial in Jags that’s forthcoming that she wrote in conjunction with several of the other people on this podcast. And she is Assistant Professor at the NYU College of Nursing. Welcome to the GeriPal podcast, Jasmine.

Jasmine: Thank you. Happy to be here, Alex.

Eric: So before we talk about improving… So first of all, we just had a podcast not too long ago on assisted living facilities, so it seems very timely. We’re going to be talking about improving nursing home quality. Before we jump into that topic, I believe someone has a song request for Alex.

Jasmine: Yes. I do. So I am requesting The Sifters by Andrew Bird.

Eric: Can I ask why?

Jasmine: It’s an imaginative love story that deconstructs age through an intergenerational friend relationship. It’s just beautiful when thinking about age and deconstructing age and you’ll kind of see based on what lyrics Alex plays.

Alex: Great, thank you, Jasmine. I enjoyed learning this song. Here’s a little bit of it.

(singing)

Eric: That was lovely. I’m looking forward to a little bit more of that at the end.

Jasmine: That was great, Alex. Thank you.

Eric: All right, let’s jump into this topic. Improving nursing home quality. Jasmine, I’m going to start with you. You were on a National Academy of Sciences committee started in 2020?

Jasmine: Yes.

Eric: On improving the quality of nursing home care. Is that right?

Jasmine: That’s correct.

Eric: Why was this done? Why did the committee form? What was the imperative for this?

Jasmine: Pretty much there has been only one report focused entirely on nursing homes, and that was published in 1986. From that time, many of the same issues still exist within nursing homes when thinking about the financing of nursing homes, staffing issues, poor quality of care among residents, inequities and disparities that residents experience. With that, there was a significant need for a report that produced bold and actionable recommendations so that we might be able to see change actually happen. Then just kind of thinking about COVID-19 and just the issues that it magnified the report was even more important.

Eric: Yeah, well I’m just thinking about COVID-19 too. It feels like for over a decade we’ve been moving more towards in nursing homes this concept of making it more home-like, which is always a challenge in institutional-looking settings. But man, COVID-19 has kind of for a lot of places completely reversed any home-like feeling. I work in a nursing home too, and communal dining, gone, most visits for the last three years like leaving being able to leave the nursing home for most residents, gone. It’s been such a challenge. Mike, how are you thinking about this? I know you’ve been a strong advocate for nursing home patients particularly in California.

Mike: It’s interesting. Jasmine brings up that NASM hadn’t done a report in like 40 years, but 1974 was the first time the Senate Subcommittee on Aging did a scathing report on nursing homes. There have been multiple subsequent government reports on nursing home care, most recently was about eight, nine years ago from the OIG. This is a problem that’s existed for decades. Bottom line is, by my account well over 200,000 residents having died from COVID, I think lay that number of deaths in an industry, people got to start paying attention. I think that’s where we are. But there’s nothing new. I mean these problems have been there for decades.

Eric: Yeah, I guess in the very beginning of the COVID pandemic really highlighting the structural issues, lack of PPE, really people ignoring it outside of just the place to send COVID patients to. But like you said, really predates COVID to these issues.

Alice: I think one of the aspects of this that you’re talking about, although they haven’t named it this, and you could name it a number of things, but part of this is about accountability. That’s actually a word that Isaac was kicking around with some of us and we were brainstorming, and then when we asked people for feedback about our basic ideas, that was one of the topics that came back. People are looking for more accountability. Part of it’s what Mike was saying, it’s accountability as a country, as a nation and as the government. What is their accountability for ensuring safety and quality when people are living in a nursing home? And it’s also accountability of the nursing homes. What are they accountable for? If you own and operate a nursing home and you’re taking people in, and you’re admitting new residents, what’s their accountability for how they manage compensation and quality delivery?

Those are just all things that you’re right, they’ve been going on for a long time. As Jasmine said, it’s not that we haven’t had any reports, but we’ve had very few reports and they just get done and they sit on a shelf, which is why the John A. Hartford Foundation said, “Well, we’re going to fund an initiative for two years and we’re going to call it a coalition. Any organization is welcome to join and come together. We’re going to think about taking those recommendations in that 600-page report and prioritizing one in each of the seven major categories, and we’re going to turn them into action plans and we’re going to test them.” So very action, action, action oriented because we’ve been talking about this stuff just for way too long. We’d love for people to join and get more involved because we’re going to need every single person that we can get to come together. Isaac, I don’t know if you want to [inaudible 00:09:34] anybody if they want to add to that.

Alex: Yeah, we probably ought to rewind a little and set a little more of that stage, Eric. What do you say to that?

Eric: Yeah, I think it would be good to talk about what the report actually said, the National Academy of Sciences report. It’s huge. I don’t know how many pages. I forgot how many, but I was reading it-

Mike: 605.

Eric: How many?

Alice: 605.

Eric: 605. Jasmine, I’m going to turn to you. If you had to distill 605 pages into a sound bite, what would you say that the big areas of focus of this report was?

Jasmine: Yeah, sure. It’s funny, we talk about 600 plus pages and it seems like a lot, which it is a lot, but we wanted so much more and there was so much more that had to be cut out. So just a very comprehensive report that we’re really proud of. Some big domains to think about, there’s care delivery in there and that’s one of the first chapters up front focused on the resident, really emphasizing that comprehensive person-centered care that has always been a part of the discussions, but actually something that has not been realized across nursing home settings, ensuring that care is equitable across residents, really identifying and fulfilling care preferences for residents. That’s another issue where residents aren’t having their goals and preferences identified. Then also thinking about those small home-like rooms, for example, in facilities that was brought up before. So creating these spaces where there are private rooms, for example, abilities to go outside and enjoy the fresh air.

Then there’s the workforce…

Eric: Wait before… Each section. For care delivery… Is it okay if I just dive into this? One is, we often see these large institutionalized nursing home settings, but maybe, I think it’s like Greenhouse Project… Alex, by the way, we got to get through a podcast on the Greenhouse Project. So smaller settings, which is a problem with efficiency too. Mike, you’re nodding your head no.

Mike: Scale is a business concept. To me, I think the Greenhouse folks have proven that you can provide quality care in a home-like environment cost effectively if it’s done right. I think we fall into too many traps in making assumptions. I think the bottom line is they’re nursing homes. These are people’s homes and we’ve lost sight of that. That came through very clear in the NASM report, and the moving forward efforts is we want to bring real, not just checklists, checkbox person-centered care back to nursing home residents, but we want them to truly live in their home.

Eric: I’m going to push you on that. What does that look like? As somebody who works in a nursing home, I can barely read a nursing home note anymore because if it’s on electronic medical record, it’s usually a bunch of check boxes, several pages. Nobody’s putting in a subjective, their own thoughts. It’s just these clicks. I would say 90 something percent notes I read are mostly gobbly-gook and it doesn’t tell me what’s important to people.

Mike: Electronic record keeping, Eric, is the government’s gift to defense attorneys. If you’ve done any expert witness work, you now have to read through 3,000 pages to find 12. I honestly believe that there’s a conspiracy. [laughter]

Eric: Isaac, what were you going to say?

Isaac: Well, I was going to chime in on where moving forward is going to that. I think you targeted technology, and I know if Jasmine had finished her list of topics, she would’ve talked about technology too because the NASM report makes technology really central, which I think is an important move in nursing homes, which often don’t. We are not talking about how we can not just make nursing homes more home-like, but also modernize them. Of course, those things have to go together. Technology is central to modernization. The Moving Forward Coalition, which to kind of piggyback on what Alice said, is here to bring that NASM report into action to turn those recommendations into some reality as much as we can. It’s really focused on that technology piece.

Really, what we are interested is in using technology better, and in some cases at all, right, to capture people’s goals, preferences and priorities and make them useful and relevant to care providers in nursing homes. I think that’s that modernization piece. But when we can start bringing goals, preferences, and priorities into the conversation from admission, then we can also start making the environments more home-like. So, it’s a building problem. Making things home-like is a building problem, an environment problem? It’s also what are the pieces of information we’re bringing to the table when we start providing care for residents?

Alex: Can I ask what does that look like, exactly, using technology to capture goals. When I think of capturing goals, values and preferences, I think of human interaction. I don’t think of technology. My brain doesn’t go there at all.

Isaac: Absolutely. Alice, do you want to jump in there?

Alice: I was just going to say, so we’ve got two approaches right now that are under consideration, so don’t hold us to this because they’re still evolving. We have one group that Isaac just described that is looking at goals, priorities, and preferences from the time of admission in traditional ways. So, using tools like the PELI, the Preferences for Everyday Living Inventory, or others. You could list at least 10, I’m sure. Those are evidence-based or evidence-informed tools that have been in practice. Our coalition, a group of us might take one of those tools and then put it into processes, conduct trainings with nursing home team members who would do the questions, and build on that rapport and that relationship and really focus on the trainings to be about that interaction, that personal interaction, which I as a nurse practitioner, and we’ve got other clinicians on this call, it is very important to me to have that conversation one-on-one and take the time.

We might evaluate that in a small number of nursing homes and go from there. The technology committee however, is interested in using technology and coming up with a new set of goals, priorities and preferences and basing the process on working with nursing home residents, care partners or family members if they’re involved. And the technology piece, so doing less with staff. I don’t know how that’s going to go, but I think it’s bold and courageous that they’re talking about it and thinking through it. We might have two different approaches that we would really put forward and turn into action plans.

Isaac: The bottom line is goals, preferences and priorities are everything to us. They are the bedrock.

Alex: And we’re not going to use chat GPT technology to predict what those goals, values, and preferences are. Good.

Isaac: No.

Alice: But it’s easy to just say all technology is always good, and that’s just not true. You bring up a good point.

Eric: So Jasmine, we hit on care delivery, we also hit apparently on health information technology.

Jasmine: Technology. Then there’s workforce, so thinking about the education and training of the workforce and how do we enhance that. Thinking also about minimum staffing standards, so requiring that certain positions have certain degrees. For example, bachelor’s degrees for social workers. Thinking about minimum staffing hours, which that is something that CMS has been working on over the year last year, and hopefully something will come out more about what that looks like this spring. Then wages and benefits, so ensuring competitive wages and benefits for the nursing home workforce, empowering the certified nursing assistant, increasing and improving recruitment and retention of the workforce. Then thinking about areas specific to training when it comes to diversity, equity, and inclusion as well. Those are some of the concepts within the workforce that we touch on within the report. Let me know if you want me to move on or if we want to stop there.

Eric: Well, reading the report, I learned… I probably shouldn’t say this online, I learned that you don’t need to have an RN on staff 24 hours. Well, I think in California you do. Is that right Mike?

Mike: No. Well, whether you are required to or whether anyone pays attention are two different things. The staffing issue is one that really bugs me because it’s common sense that we need enough nurses, CNAs, LVNs, other staff to care for very vulnerable folks. The pushback is we can’t find folks. The metaphor I thought of this morning was if you got on an airplane and the captain said “Neither of our engines are meeting the regulatory specifications, but there’s a shortage and they’re really expensive, so we’re going to take off anyway.” Who would stay on that plane? And yet nursing home residents and their families and the rest of us somehow are supposed to buy into this idea that we can’t get enough staff, so it’s okay to give them poor care. I think the NASM report is just the beginning of the reality that as clinicians, we have to hold onto what is good care and let others figure out how to pay for it, and not go down the rabbit hole of getting caught up in what I consider gas lighting when it comes to staffing.

Alex: The issue of course came to a head in a major way, as we talked to you, Mike, about on our prior podcast during COVID. We also interviewed Jim Wright at the early start of COVID, who was running a nursing home that was just devastated by COVID. The staff were gone and he and his wife were doing so much care. We interviewed him again and we said, “What lessons have we learned?” And he expressed profound disappointment that we had this moment where the nation recognized that there’s something really bad going on in nursing homes, and that the structural factors set this up to be a disaster, and something should be done. And nothing was done. A huge piece of that that he was disappointed about was around staffing. Support for staff. I’m so glad that you have the Moving Forward Coalition, and I worry that this is such an enormous task. Staffing, to me at least, is one of the biggest, if not the biggest issues in nursing homes.

Eric: What’s the coalition thinking as far as this aspect? What’s the actionable items here?

Alice: Well I’m, I’m going to let Jasmine answer that because she is literally leading the country, along with our colleague from the Paraprofessional Health Institute or PHI. I’m glad that you asked the question because every single day, every day that Isaac and I are on phone calls, we hear staffing, staffing, staffing. People have said to us, “If you do nothing else, just focus on staffing.” So let’s be clear, we understand this is a key priority issue. The key priority issue. What Jasmine and Kezia and the committee are really focusing on is, “Okay, let’s, let’s just be logical about this. Let’s build on everything we know that’s been studied about it. Let’s bring more people into the committee who really have experience with some of these state-based programs or workforce centers, and let’s build on what we have.” This is not about going and starting with a blank piece of paper. It’s about saying, “Okay, what do we know? Where are the gaps? Where can we go from there?”

The other thing is I would say, and Jasmine can say more about this, I think the other committee co-chairs in moving forward… There’s 12 other committee co-chairs. I think they’re asking a lot about staffing and really wanting to support the work of Jasmine and Kezia’s committee, and Isaac and I spend a lot of our time on that too. So bottom line is, it needs a huge influx of people, and brain power, and dedication to solve this, and people being just singularly focused on this issue. I’ll turn it over to Jasmine. I know she has more thoughts on this.

Jasmine: Thank you for setting that up for me Alice. The focus area that we are placing our efforts on is ensuring the competitive wages and benefits, and particularly we’re focused on the certified nursing assistant workforce. Of course, we acknowledge that there needs to be more pay, better pay and better benefits across the board. We just don’t have that bandwidth to cover all areas of the workforce. As well as, there are significant issues across the workforce when thinking about education and training, for example, that need to be addressed. But we did choose to address the competitive wages and benefits, thinking about that whole idea of recruitment, getting people into the door. We know that salary, wages, benefits, all that stuff is not the only thing that’s going to get people in the door. There’s other things that we need to focus on.

Also understanding that right now, certified nursing assistants, many of them are not making a living wage. When we think about those who are babysitters, for example, we don’t bat an eye if they’re like teenagers, undergraduates. They’re getting paid $20 an hour, $25 an hour, $30 an hour. I’m hearing high numbers that babysitters are getting paid to care for one child, two children. They don’t have nearly the responsibilities that a certified nursing assistant has when thinking about utilities, groceries, rent, mortgage, all of that stuff on a monthly basis. We have a hard time just raising their hourly wage from $13 an hour where we’re like, we don’t know what to put it at, or there’s no money for it. That’s just something that we want to really focus on.

Then thinking about benefits, there are too many CNAs who are uninsured or underinsured because maybe they don’t have access to benefits or because since they get paid so little, they don’t put their funds towards those benefits. That’s an issue too. Then areas of just thinking about childcare for example, to support CNAs as well. That’s where we’re focusing our efforts. Right now we’re kind of trying to see if we can work with other committees within the workforce such as the transparency committee or finance committee to really put forth a robust action plan that will really ensure that we’re able to carry this through.

Eric: There was also a comment about expansion of the role of the CNA in the nursing home in the report. Tell me about that.

Jasmine: Within the report, and that’s kind of tricky, we say we want more education, we want expanded roles, we want individuals to be able to do more. But at the same time, when you ask people to do more, you have to pay them more too. So it’s give and take. That’s another thing that I just want to highlight when thinking about the report, the most important thing about the report because sometimes we’re asked which recommendation is the most important recommendation for it to be carried out. I know Alice talks about workforce, but at the same time we say all of the recommendations need to be carried out for change to actually happen. You see that we’re, like I said, we’re working with transparency committee and finance committee to see how we can move this forward. But yes, we want to enhance that role of the Certified Nursing Assistant, and thinking about all the responsibilities that the CNA has, and making sure that they are actually equipped to provide the care that they are in the position to provide.

They spend the majority of time with residents. The residents are complex in the care needs that they have, especially when thinking about residents who have dementia. So making sure that they have the actual education, the resources and the tools to be able to provide care for this population is significant.

Alice: The other thing I’ll add to everything Jasmine just said, which was beautifully articulated, is that one of the most common things CNAs say is that even though the salary and benefits are a huge issue for them, it’s also about the leadership and the respect. CNAs will say, “I literally feel invisible. No one calls me by my name. They don’t know my name.” How hard would it be for every medical director, every director of nurses, every administrator to know the first and last name of every CNA who works in that building? There are people who do that and it makes it a big difference. I would just add to what Jasmine said, this is about really changing the role, changing the responsibilities, and it is about respect. We have on our steering committee, we have Lori Porter from NAHA, which is the National Association of Healthcare Assistance, and she’s been very active. She has 18,000 or so CNA members in that organization. There’s a lot more CNAs who work in nursing homes, but we need to organize these people in these roles.

Eric: Since we’re on the topic of leadership in the workforce, Mike, I noticed that there was a quote from you in the 605 pages around the competencies needing to be in every piece of that leadership organizational structure. From a medical director standpoint, how do you think about that? What’s the gap there?

Mike: I want to echo what Alice said. I’ve learned so much about the literature on effective leadership in nursing homes in the last few couple years. People always say, “Show me evidence. Show me evidence,” but the evidence exists and there everyone’s ignoring it. And so, consensus-style, servant-style leadership has shown to be correlated with lower turnover, improve quality measures. That’s the administrator. I look at the leadership team, so the administrator, the DON, the medical director, the director of staff development, the infection preventionist now, the whole team because we’re running mini hospitals and there’s no way that the administrator understands geriatric medicine. I think the importance for DONs and medical directors to work together are essential. I think teamwork and effective leadership are absolutely critical. I’m glad that Alice brought it up.

Eric: All right, let’s move on to the next section. Nursing home environment and safety. Is that right Jasmine?

Jasmine: No, that was part of the care delivery with thinking about the environment safety, thinking about emergency preparedness. It was also in that section as well. We can talk about transparency and accountability if you want to go there.

Eric: Yeah, that sounds great.

Jasmine: So this is… Go ahead Mike.

Mike: I can’t help myself on this one. This is my passion and I’m on the transparency committee. $160 billion a year are spent on nursing homes. When you hear, “We need more money to pay for staff,” you have to say to yourself, “Where’s the money presently going?” We do not have transparency. I think transparency is going to be… I actually put transparency first. The reason I put it first is if we could see where all the existing money is actually going, I think we could garner public opinion more effectively to say, “Wait a minute, how come the money’s all going off to other businesses, and other related parties, and real estate owners? How come it’s not actually ending up paying for nurses?” We need to have a national discussion on this. So to me, transparency is key. We’re putting out some very specific recommendations. Actually, number one, getting CMS to implement regulations that were put in statute 13 years ago that they have not implemented yet. If CMS actually implemented those statutes, we would have much greater ability to look transparently at nursing home ownership.

Alice: I’ll just add to what Mike said. That’s an example of that committee is head down doing that work at a very detailed level. They’ve brought on experts, they’ve brought on additional people who are researchers or consultants who do this work all day long, and have added a lot of content. They’re working with Isaac on figuring out what would an actual blueprint for transparency, or a letter to Congress, or something that would have meaning behind it that would be backed by a bunch of national organizations, what would that look like and how would we keep it moving forward?

Because it’s not enough to just send a letter to Congress or write a blueprint. We all know that. What can we do that’s meaningful that are really the next steps? And some of that really does get at what’s required, what are nursing homes required to do? So we don’t like to go in that direction unless it’s a particular incentive that we think we can use for the benefit of residents, the benefit of the people living in the nursing home. There is a lot of that very tactical work. So Isaac, I don’t know if you want to add to that. You’re working with that…

Isaac: Accountability is such an in interesting word to me, because as you were alluding to at the beginning, Alice, there are so many angles to it. I think we should get back to the residents and their family members and care partners when we’re talking about accountability. So we make this data available, as Mike says we need to, and we do. Who gets to see it and how become important questions after that. Obviously, our regulators need to see that and need to be able to use that. Nursing home operators and administrators should see that too because it helps them improve the quality of the service they provide. Arguably most importantly, we need to make sure that care partners and residents, when they’re selecting the nursing homes they want to be in and thinking about the care that they want to receive should have access to that data as well. It needs to be presented in a way that they can understand. Mike, I feel like you have more to say on that.

Eric: I also found it was interesting in the report, which I never knew. There are some nursing homes that also own hospices, so you may not just be selecting the nursing home that you’re going to, but potentially the hospice that you’re going to.

Alice: There’s a lot of relationships that are absolutely impossible to figure out. I’m somebody who I was in a role at CMS where it was my job to not understand them. I’m just being really honest, it’s really hard to figure them out. There’s databases and they don’t talk to one another, and there’s people in charge and they’re in different divisions. It’s the way we’ve set it up, which is to fail to get to what we want. We want anyone in the public if they have a sixth grade education, whatever, but people who don’t understand or know about healthcare, they should be able to look at information on a website and figure out who owns the nursing home. Plain and simple.

Mike: And keep in mind, to put it in perspective, the vast majority of nursing homes are set up so that the operation is its own separate limited liability company that really isn’t expected to make money, and in fact often loses money, whereas all the other entities around it are profitable. That allows the industry to say, “We lose money all the time.”

Eric: What are those other entities, Mike?

Mike: Number one, real estate. I mean that’s been a huge issue. You can go back at the history of the nineties in the last decade, look at companies like Kindred and Genesis, and Manor Care. Basically before Genesis went public, they basically sold off all the real estate and left a skeleton and an organization that ultimately failed. It’s Business 101 to look at this. The point is, and there’s then others as Alice mentioned. You mentioned hospices, staffing agencies. There are nursing home owners that own staffing agencies that charge themselves and arm and a leg and then they complain about the staffing agency that they own. Don’t get me going there. This is absolutely critical that we know where all the money is going because I actually believe, and I’ve seen it, if you spend all the money that comes into a nursing home on care and staff, you can have a really good nursing home and they do exist. This isn’t rocket science.

Jasmine: They do.

Eric: Okay, Jasmine, I’m going to go to goal four.

Jasmine: Goal four is to create a more rational and robust plan financing system, and that was focused really on establishing a federal long-term care benefit. The issue is that we don’t have a long-term care system. When thinking about nursing homes and who’s able to finance nursing homes, of course you have private pay where those people can afford, and then you have Medicaid. But you don’t have… And that’s for low income who qualify for Medicaid, but you don’t have anything for those in between. This goal right here focused primarily on developing that federal long-term care benefit, which is one of the recommendations that I think was very bold. Then it talks a little bit more about other pieces of thinking about financing, so also directing proportions of Medicaid payments, for example, towards staffing and resident care, which has been part of discussions previously as well.

Eric: So Isaac, is the actionable item change in US healthcare system financing?

Isaac: This is a good time to addendize a little on what moving forward is about. I think, yes. I think most of the people participating, and I’m not going to speak for everyone, and the financing committee, do believe in a long-term care benefit and want to build the foundation to create a movement to make that a big part of our social safety net in our society. But moving forward is really committed to things we can do now together. I think we’ve made the determination that we probably can’t do long-term care benefit in the next two years, so we’re looking at thinking about financing systems in smart ways to try to create better incentives around two things. One, is investing in better environments.

That kind of tees back to Mike’s conversation on real estate a little bit. We can go down that rabbit hole. The other one is incentivizing, what Jasmine is working on, which is better staffing, payment and compensation. That’s where we’re looking at financing as an issue, but we’re also interested in those big reforms and we want to be part of a movement that makes that happen. It’s just a big, big bite.

Eric: It also seems like I’m starting to see there are all these different pieces with these goals, but if you don’t focus on one, transparency of ownership, who owns a staffing agency that is supplying the nursing home, who owns the real estate, just dumping money into the system by itself is not the solution.

Alice: I think that’s really something I would say we probably talk about that every week because you’re right. I mean everybody who’s come together to be a committee co-chair or on the steering committee, or do other work with us, we want to fix the entire system. We’re not going to do that in the remaining 18 months. What we have to do is keep our focus still on the big picture and still think about the system reform, not lose sight of that. But for now, for right now, what can we do that are the smaller things that we can focus on? So, getting nursing homes to have everybody on the staff know each other’s first and last names, that’s not costly, that’s culture. We can do that. Getting nursing homes to ask people who are newly admitted within the first few days or something of admission about their goals, preferences and priorities, that’s in the regulations now. They’re required to do that now.

That’s not a new thing. But most nursing homes don’t do it, so that’s an opportunity. We can work on that. That’s what we’re trying to do is keep the big picture, get people who will still work on those things. That’s why we have work groups. Isaac spent a lot of his time setting up and scheduling calls for work groups, and putting different teams of people together. Part of that is because we’ve got both short-term and longer-term things and we want to do both of those things. We believe we can. We know we can.

Eric: Okay. Jasmine, I’m going to your next goal. I think we got two more goals to cover.

Jasmine: Yeah, because we already did technology. Goal five is focused on quality insurance, so designing a more effective and responsive system of quality assurance. That’s focused on enhancing the oversight of nursing homes, holding them accountable, enforcing regulations that are in place, but enforcing them in a way that’s meaningful and intentional, paying attention to surveyors and making sure that they have what they need to actually do the job that they’re meant to do when it comes to nursing homes and oversight.

Then also thinking about the Ombudsman program. Increasing funding for this program, Ombudsmen are really just significant and critical when it comes to advocating for resident needs. So ensuring that we have enough staff that are available to do that with Ombudsman. Another thing within goal five is important, the whole idea of transparency too is to keep track of these bad actors. People who are showing evidence of repeat patterns of poor quality care and you see them changing names, for example, just increasing, just oversight on that. Then the enforcement when it comes to that. So maybe denying any new or renewed licensure for these nursing homes, for example.

Eric: Mike, I’d love to hear from you real quick. Do you have a love/hate relationship with state surveys and CMS? How do you think about this?

Mike: No. Honestly, you got to look at why and how they were set up. The state survey agencies were set up as regulators, as traffic cops. The Ombudsman were set up as advocates. Honestly, one of the things I’ve recognized recently is the Ombudsman program is way under-resourced. I completely agree that we need to build on an existing statute, which is the Ombudsman program, and help support their efforts. Then, when it comes to the surveyors, that’s a complex area that needs its own week-long podcast. I’m not even going to go there.

Eric: We’ll leave it at that. Isaac, were you going to say something?

Isaac: I was just going to speak to the Ombudsman program and build on Mike. I mean, our committee five, which is working on quality assurance, is actually really focusing on the survey. They do deserve a podcast of their own because they’re doing some great thinking. I think the Ombudsmen who are empowered are just doing amazing work. Alice and I got to speak to some Ombudsmen in New Jersey who are really working with the governor to improve nursing home quality in so many ways. I think one easy thing is for states to empower their Ombudsmen more to really have a seat at the table when we’re talking about quality. They’re just fantastic allies in this work.

Eric: All right, Jasmine, last one. We’re doing all this stuff to improve nursing home quality, but at some point we have to demonstrate that it did something. What’s the last goal?

Jasmine: Exactly?

Eric: Which I guess is the second to last goal, but we already discussed health in information technology.

Jasmine: Right. The last goal is around expanding and enhancing quality measurement and continuous quality improvement. One of the major recommendations that came out of that is related to adding some type of measurement for the resident and family experience. We talked about the Consumer Assessment of Healthcare Providers and Systems, so the CAP measures. Another thing that we were focused on within goal six was adding a number of measures to Care Compare to new measures such as palliative care and end of life care, our resident care plans being implemented because that’s an important thing.

It’s one thing to write up a care plan and do these check boxes that was said before, but are these actually being carried out within the setting, and a number of other new measures. Then also thinking about just increasing the weight of certain measures within Care Compare that are already there. Another thing that I’m really excited about is this health equity measure that we are advocating for to be developed and included within either Care Compare or some other platform, but so that we can really be able to evaluate these disparities in the interventions that are being implemented and what the progress is on these disparities over time.

Alice: Well said.

Eric: Okay. I know we’re running out of time. I have one last question for each of you. You got a magic wand. It’s running low on power, so it could do one actionable item to improve nursing home quality. What are you going to use that magic wand on? Mike Wasserman?

Mike: Well, I use this term all the time. I want to take the emperor’s clothe off. I literally wave the magic wand and provide complete transparency of where every dollar ends up. I think it would be transformative,

Eric: Great. And easy to access. Anybody can see that. Alice?

Alice: I would create a federal agency or put a division in a federal agency that would just focus on building the pipeline for staffing, and I would give it enough billions of dollars that it could really have an impact.

Eric: Great. Isaac?

Isaac: It’s an extremely difficult question. I’d probably zoom out, which is not my job. I’m the project manager, so my job’s to zoom in. But I’m going to zoom out and say that I think the big solution to nursing homes is the big solution to a lot of our societal problems, which is valuing caregivers across the board. I think if we value caregivers, if we value those jobs, we will have better nursing homes.

Eric: Excellent. Jasmine, you’re the last.

Jasmine: All right, so I’m going to zoom out too, and I’m going to bring us full circle when thinking about the song that we started with and deconstructing aging. I would say reframing aging, reframing how we view nursing homes and view nursing home work. At that point, then we can start to really intentionally make change within nursing homes and have just the mindset of what that looks like and what resident quality care and home-like environments, and all that kind of stuff is really.

Eric: I love that. Alex. I think we also found a new podcast host because she also tied in the song.

Alex: I know.

Eric: That’s usually my job, and I feel so good because Jasmine did it. [laughter]

Alex: Led right into it. Well played. Well played. Here we go. A little bit more of The Sifters by Andrew Bird.

(singing)

Eric: Thank you, Alex. And thank you, Alex, Mike, Isaac, and Jasmine for joining us on this podcast. It was a blast. Thanks for all your hard work in improving nursing home care.

Alice: Well, thank you for having us and we hope a lot of your listeners will think about checking out the Moving Forward Coalition and joining us. We love company. Thank you.

Jasmine: Thank you.

Eric: And we will have links to the articles. We’ll add the Jags articles when they come out. Just go to our show notes on the GeriPal website. With that, thank you everybody, and thank you all our listeners for supporting the GeriPal Podcast.