Jan. 1, 2001 -- They occupy the last rung on our nation's disjointed healthcare ladder, the places where the frailest, weakest, and most burdensome among us spend their final days.
Our nation's nursing homes -- the products of years of societal, political, and economic indecision -- care for an aging population that is living, and often suffering, longer. But while recent studies show there has been some improvement in the quality of care, decades-old problems such as inadequate staffing fester like a wound that will not heal.
Created by a combination of low wages, labor-intense work, often-poor working conditions, and the strain of too many residents per worker, inadequate staffing is one of the thorniest issues facing the nation's 17,000 nursing homes, which care for 1.6 million people. But it is far from the only issue.
Largely supported by federal funding, nursing homes say they find it difficult to offer higher wages. On average, nursing home nurses earn 15% less than their counterparts in acute-care hospitals, and half receive no health benefits, according to government figures. The tight job market also makes it hard to find workers, given the rigors of feeding, bathing, and changing elderly people all day.
The Institute of Medicine, in a landmark 1986 report, wrote the following paragraph, which could have been written yesterday:
"Not all nursing homes have enough professional staff who are trained and motivated to carry out these tasks competently, consistently and periodically. Care is expensive because it is staff-intensive. To hold down costs, most of the care is provided by nurses' aides, who, in many nursing homes, are paid very little, receive relatively little training, are inadequately supervised, and are required to care for more residents than they can serve properly. Not surprisingly, the turnover rate for nurses' aides is usually very high -- from 70% to over 100% per year -- a factor that causes stress in resident-staff interactions."
And quality of life, the report says, "is intimately related to the quality of resident-staff relationships."
In interviews with government officials, nursing home administrators, industry representatives, elderly advocates, and academicians, all told WebMD that the system is in dire need of repair before the huge number of baby boomers reaches old age and further taxes an already burdened system. But reaching consensus on how to fix it isn't as easy.
"Even if we need nursing homes for 3% of the baby boomers, the burden will be enormous," says Garth Brokaw, president of the Fairport Baptist Home near Rochester, N.Y.
While the staffing issue always has been serious, it is reaching crisis levels because the medical needs of patients have increased. Half of nursing home residents -- most of them women -- suffer from dementia, and many are incontinent and have swallowing problems. Without adequate staffing, many don't eat or drink enough. Overall, the number of nursing home residents who needed help with three or more daily activities increased from 72% in 1987 to 83% in 1996, according to government statistics.
Twenty years ago, advocates say, many of these medical problems were not as widespread. Back then, fewer people lived to age 85. Today, the Census Bureau estimates that 4.3 million Americans are 85 or older; it projects that number will double by 2030. Medical advances have helped make the difference -- but not much improved the quality of care in nursing homes, advocates say.
"No one cared -- it's real simple," says Delaware state Sen. Robert Marshall, who spearheaded his state's efforts to reform the industry there. "No one knew or recognized the weaknesses in nursing homes."
The federal government has increased nursing-home oversight, tightened regulations, and scolded the states for lax and inconsistent enforcement. The industry's for-profit providers, who own most of the nation's nursing homes, say recent Medicare cuts are hurting care, and they are lobbying to restore this funding. They point to the fact that five nursing home companies have gone into bankruptcy since the cuts went into effect more than three years ago.
Advocates say better employee training is required to prevent pressure ulcers, malnutrition, dehydration, unnecessary bed restraints, and overmedication. Legislators on Capitol Hill have introduced numerous bills that would set minimum staffing requirements and mandate criminal background checks for nursing home staff.
In all, 36 states have some type of minimum staffing requirements that apply to nursing homes, according to the National Conference of State Legislatures. About 18 states have enacted regulations that require nursing homes to spend a portion of increased funding on new hires. But those laws are still too new to have made much of an impact on staff retention, according to a paper published by the North Carolina Division of Facilities Services.
In Delaware -- one of the more ambitious states in tackling nursing home inadequacies -- eight new laws have imposed minimum staffing requirements, criminal background checks, and tougher training requirements for poorly paid nursing assistants, the backbone of the industry.
"They are excellent laws, and overdue laws," says Mary McDonough, director of the state's Long Term Care Residents Protection Division. In one year, she says, 33% of the 9,715 people who applied for nursing home jobs had some type of criminal background, including 5% with felony convictions. "It was a sobering fact," says McDonough, a former federal prosecutor.
People like Mary Ann Kehoe in Wisconsin and Rose Marie Fagan in Rochester, N.Y., are working to change how care is delivered to the elderly. The Pioneer Network, to which Fagan is affiliated, wants nursing homes to run more like real homes and less like medical institutions. Kehoe and her organization, Wellspring, have taken training to a new level, resulting in lower staff turnover and fewer medical problems.
But all of those interviewed agree that these changes are piecemeal, because there is no unifying voice demanding a major overhaul of the system. Nor have they changed the quality of care in nursing homes all that dramatically, some say. Indeed, there are an estimated two million nursing assistants in this country, and advocates say another 500,000 are needed within the next two years.
"I've been working on this since 1975, and I haven't seen a lot of improvement," says Charlene Harrington, professor of nursing at the University of California at San Francisco. "We are shocked that care is terrible, but we haven't spent money to get good care. It's a negative attitude toward the aged. They are not valued in our society."
Others believe there's been some positive change. Bruce C. Vladeck, PhD, former head of the U.S. Health Care Financing Administration, says that years ago, nursing homes found it difficult to attract doctors and registered nurses, and there was little data to measure changes in care.
"We are beginning to develop quality indicators," says Vladeck, now director of the Institute for Medicare Practice and professor of health policy and geriatrics at Mount Sinai School of Medicine in New York City. "Is it enough? Is it fast enough? No. It is better."
Laurence Lane, vice president of government relations at Genesis Health Ventures, says elderly care is an issue that our society stumbled over even before the Great Depression of the 1930s, when people took care of their own, and religious and fraternal organizations took care of those who had no one. "We, as a nation, are struggling mightily with what is public good and what is not public good," he says.
Indeed, just who should have responsibility for caring for the elderly today has yet to be determined, says Joshua Wiener, PhD, of the Urban Institute. "There isn't clear vision and there isn't consensus on what we ought to do," says Wiener, adding that at least 15% of us will spend at least one year in a nursing home before we die.
Government and industry have responded in part by funding and establishing alternatives to nursing homes. Since the late 1980s, there has been a trend away from traditional nursing homes in favor of those that include assisted or independent living beds. The proportion of non-nursing beds rose from 6.9% in 1987 to 11.3% in 1996, according to government statistics.
Nursing homes began to spread in the 1960s, because people were living longer and family members, primarily women, were entering the work force and no longer were able to care for aging relatives. It was then that Medicaid, which now funds about 48% of all nursing home costs, and Medicaid, which now funds about 12%, were established.
"There was a need, but nobody particularly knew how to do it," said John Schnelle, PhD, professor at the UCLA School of Medicine and director of the Bourne Center for Gerontological Research.
As businesses began to recognize the need, money was found, and the federal government responded with incremental funding increases, says Schnelle. But "there wasn't a strong incentive to spend on staffing," he says, and consumer advocacy groups had yet to get organized.
Fagan says nursing home employees are not bad people and that the industry is not in the condition it's in because of the system.
"A nursing home is the microcosm of our society at large," she says. "We don't value old, and we don't value women. It's a segment of our society we don't value, so there is no surprise we don't value the caregivers either."
Says Wiener: "Everyone assumes that they will die on the tennis court after their fourth set. Americans are the only [people] who think dying is an option."