U.S. nursing homes get a D+ — concerns around quality and safety were ‘troubling’

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Americans gave nursing homes a D+ for the quality of care, and the majority said they would be uncomfortable having themselves or a loved one admitted to such a facility, according to a new West Health-Gallup poll.

Quality of care, cost, and the potential emotional and mental toll of nursing-home living were  the top concerns. The perceived safety of nursing homes also was a concern.

Read: Nursing home? No thanks. 70% of people surveyed would rather not.

“At the end of the day, people don’t want to be in a nursing home,” said Tim Lash, president of West Health and chair of the West Health Policy Center. West Health is a nonprofit, nonpartisan organization focused on improving care and lowering costs for older adults.

The survey, which was conducted by Gallup, comes in the wake of the pandemic, when early COVID-19 deaths were heavily concentrated among older people and many of these deaths occurred in nursing homes. 

“Cost has been a concern, but concerns around quality and safety were even more troubling,” Lash said.

Medicaid, the public public health insurance program for people with low income, is the primary source of payment for 62% of nursing home residents. To qualify for Medicaid, those residents essentially must have no remaining assets or income. 

“It’s a vulnerable population that is hostage to that environment,” Lash said.

Earlier this month, the U.S. Department of Health and Human Services (HHS), through the Centers for Medicare & Medicaid Services (CMS), issued a proposed rule to create staffing requirements for nursing homes — including national minimum nurse staffing standards — for the more than 1.2 million residents living in nursing homes. 

There are about 15,000 nursing homes in the U.S., and 70% of them are for-profit institutions, according to the Centers for Disease Control and Prevention.

Lash said the government needs to go much deeper in improving care at nursing homes to address not just staffing, but the quality of that staffing, and the quality and safety of care provided. 

“I don’t think we have an option not to engage. The staffing update was necessary but insufficient. It has to go much deeper,” Lash said.

According to the Gallup poll, more than four in 10 U.S. adults graded nursing homes negatively for overall quality of care – 36% gave them a “D” (poor) and 6% an “F” (fail). Another 33% grade nursing homes as satisfactory, a “C,” while few rated them positively with an excellent “A” (1%) or good “B” (8%) grade. These ratings averaged out to a D+ grade for nursing-home quality of care overall.

Seven in 10 U.S. adults said they would be very or somewhat uncomfortable with being admitted to a nursing home if they could no longer care for themselves. Nearly as many, 61%, felt the same way about the prospect of admitting a relative or family member into such a facility.

Meanwhile, about one in five Americans say they would be at least somewhat comfortable with each scenario, while about one in three are neutral.

The survey asked adults who said they would be uncomfortable living in a nursing home to indicate why, by choosing up to three reasons from a list of eight possible concerns.

The quality of care was by far the top reason for discomfort with living in a nursing home, with 70% choosing it. Cost also was a top factor at 49%, as were concerns about the potentially negative impact an admission could have on respondents’ mental and emotional health at 45%.

“Mental health is largely stigmatized in society,” Lash said. “That 45% of people cited that surprised me, but it’s a bright spot that we’re seeing the importance of it.” 

Fear of losing independence was mentioned by 34%, while slightly fewer, 28%, said they do not want to die in a nursing home. A total of 27% said they had concerns about their physical safety in a nursing home facility. 

More women than men cited quality and personal safety, while men were more likely to fear losing their independence or dying there, the survey found.

Safety was an area of significant weakness for nursing homes. Just one in four (26%) saw  nursing homes as safe places, while 41% said they are not. About a third said they don’t know.

In addition, more than four in 10 U.S. adults (42%) said nursing homes are not very or not at all effective in keeping residents safe from avoidable harms such as infections, pressure wounds, and abuse and neglect. A similar percentage (44%) considered them at least somewhat effective.

Lash said the government needs to stop thinking in silos of care and look more broadly at ways to care for the growing older population, such as improving access to home health care.

“Home – that’s where we all want to be,” Lash said. 

The nursing home industry association – the American Health Care Association/National Center for Assisted Living  – said it recognizes “that few people desire to go to a nursing home—the fact that we get older and will possibly need a lot of care can be difficult to accept.”

“This, in turn, leads to misperceptions about the value and benefits of nursing home care. But when you ask actual long-term residents and family members, approximately 75% are satisfied with the care they or their loved one is receiving,” the industry association said.

“The reality is that nursing homes provide life-affirming care to more than one million seniors and individuals with disabilities every single day, and the quality of care they provide continues to improve. We need to focus on continuing to strengthen our nation’s nursing homes, so that everyone who needs this level of care can receive the best care possible,” the industry association said.

Still, Lash said it’s important that voters keep pressure on the government to require greater quality from the nursing home industry.

“Ultimately, we need the voters to hold the people accountable,” Lash said. 

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