The COVID-19 emergency has prompted policymakers and health care executives to rethink senior care in the United States, particularly when it comes to greater investment around the home.
But increased support for home-based care services should not automatically mean the death of nursing homes and other long-term care facilities. That is a “false dichotomy” that has become embedded in the senior care conversation over the last year, according to Harvard professor and researcher David Grabowski.
Grabowski, who also serves as a commissioner on the Medicare Payment Advisory Commission (MedPAC), wrote about home- and community-based services (HCBS) in a new commentary published in the journal Nature Aging.
“If there is a silver lining to COVID-19 and long-term care, the pandemic will hopefully accelerate the decades-long push towards expanding HCBS while also causing a reconceptualization of nursing home care,” Grabowski wrote. “These are not competing goals but rather complementary ones.”
Instead of scrapping one in favor of the other, the respective places of home-based care and nursing home care should be reimagined within the broader senior care ecosystem. Home- and community-based services should be invested in more heavily, while nursing home operators should be incentivized to invest in safer, more sustainable models.
In terms of the first point, payment has gradually improved over the year. In 1995, for example, Medicaid spent 18 cents out of every long-term care dollar on home- and community-based services. Today, that number has reached 57 cents per dollar, Grabowski noted.
But even with an increased number of seniors receiving care in the home and community, there are approximately 1 million seniors still living in nursing homes. In other words, if the goal is to completely eradicate nursing home care, the U.S. would, in turn, create a huge gap in care for that population.
“Abolishing nursing homes might serve some individuals well, but it also may leave others without access to needed services,” Grabowski wrote. “For these individuals requiring nursing home care, the problem is not nursing homes per se, but rather the way in which countries like the USA structure their nursing homes. It is not that countries like the USA need to spend less on nursing homes, they need to spend their nursing home dollars differently.”
U.S. spending on home- and community-based services, however, lags significantly behind other developed countries around the world. Grabowski argues that more money needs to be spent on long-term care in general, with the majority of additional spending going to HCBS.
Currently, only 15% of U.S. seniors 80 or older receive care at home. In Switzerland, Denmark, Mexico and Sweden, that figure is above 30%. Israel and Lithuania have 48% and 61% of their seniors 80 or older receiving some sort of care in the home, respectively.
“The opportunity to expand home- and community-based services is significant,” Grabowski wrote. “The U.S. lags behind other industrialized countries in the proportion of seniors 80 and older who receive care at home, and demand for the services will only accelerate along with the aging population.”
An increased investment in home-based care would help more than just seniors. It would also ease the burden on their family members, who are often taken away from their jobs to care for loved ones on their own.
As for nursing homes, Grabowski believes the way forward is more small-home, brick-and-mortar living areas. He pointed to the Green House models, which have been far more successful at preventing COVID-19 exposure among residents.
Nursing homes in the U.S. currently do not feel like homes at all, he argues. Providing a more home-like feel with more space and a well-compensated staff would help curb negative stigmas by making them safer and more likely to increase quality of life.
“The goal should not be to abolish nursing homes, but rather abolish the institutional models and the underfunding of HCBS that have plagued long-term care for far too long,” Grabowski wrote.