The Choice You Need to Get Right: COVID Era Nursing Home Selection

Choosing the right nursing home has never been more important or harder. It looks like COVID-19 infection rates finally are receding from the devastating levels we’ve been seeing. That’s great news, but as this tsunami of disease and death moves out, it is revealing many homes whose staffs and finances have been left in shambles.

An unknown number of older and disabled people have avoided nursing homes during the past year, choosing instead to shelter in place in their own homes or with family and friends. For them, a nursing home was the last place to be.

However, their need for professional care did not disappear, and there is only so much that telehealth and remote health monitoring tools can do. As residents and staff receive vaccines and nursing facilities can demonstrate they are safe places to live, many people and their families will be considering relocating to a long-term care facility.

Two enormous cautionary flags in this process were raised last week in studies about the nursing-home industry. I am including links here to the studies but warn you they are not easy reads.

The first piece of research found that nursing homes owned by private equity (PE) firms charged higher prices and delivered inferior care. “Our estimates show that PE ownership increases the short-term mortality of Medicare patients by 10 percent,” the authors found, “implying 20,150 lives lost due to PE ownership over our 12-year sample period. This is accompanied by declines in other measures of patient well-being, such as lower mobility, while taxpayer spending per patient episode increases by 11 percent.”

This doesn’t mean you should avoid all homes with such ownership. But it does mean you should determine who owns a home before moving yourself or a loved one into it. If ownership has changed hands during the past five years – a period of heightened for-profit investments in homes – you should keep digging, including requesting documents that touch upon profits and performance. Any home that declines such a request should be removed from consideration.

The second study is arguably even more troubling. The current issue of the Health Affairs journal contains results of a extensive look at staff turnover at more than 15,000 nursing facilities around the country.

During the 2017-18 period, it found that the midpoint or median annual turnover rates were 140 percent for registered nurses, 114 percent for licensed practical nurses, and 129 percent for certified nursing assistants. Given the stresses and often low pay experienced by these predominantly female employees, I was expecting high turnover rates but hardly rates this high. Keep in mind that half of all homes had higher turnover rates, including some whose staff turned off three times or more during the year.

And this was the picture before the pandemic. When researchers look at 2020-21 turnover rates, it would hardly be a surprise to find them much higher. In the 20-20 hindsight that critics like me employ to make a living, is it any wonder that nursing homes were ill-equipped to handle this crisis? Here is what the article said:

Recent concerns regarding the spread of COVID-19 in care facilities have heightened awareness of the possible implications of nursing staff stability for infection control, which may prove a particularly important consideration during the current pandemic and in future public health emergencies. Facilities with lower turnover rates may be better positioned to withstand challenges, such as absences because of sickness. Staff members at such facilities may also be more familiar with the infection control protocols of their facility. Finally, lower turnover likely entails fewer individuals entering the facility, which could limit the spread of infectious disease.

Medicare’s Nursing Home Compare tool should but does not include a reliable measure of staffing volatility. Medicare is in the process of updating its consumer health tools but many are of limited value today. Fortunately, the authors of the Health Affairs piece found that the star ratings for nursing homes provided a helpful top-level gauge of staff turnover. “Low-rated (one-star) facilities had the highest median turnover rate (135.3 percent),” the study found, “whereas the highest-rated (five-star) facilities had the lowest median turnover rate (76.7 percent).”

While Medicare staffing data is lacking, the non-profit Long Term Care Community Coalition does a quarterly report on staff levels for specific homes. Here is its most recent report – the third quarter of last year – including state-by-state links to individual facilities.

My new book, Get What’s Yours for Health Care, has more details on how to choose a nursing home.