tag:theconversation.com,2011:/ca-fr/topics/nursing-homes-27767/articlesNursing homes – La Conversation2024-03-18T14:31:13Ztag:theconversation.com,2011:article/2259542024-03-18T14:31:13Z2024-03-18T14:31:13ZProfits over patients: For-profit nursing home chains are draining resources from care while shifting huge sums to owners’ pockets<figure><img src="https://images.theconversation.com/files/582294/original/file-20240315-20-7m2n83.jpg?ixlib=rb-1.1.0&rect=0%2C17%2C6000%2C3907&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The for-profit nursing home sector is growing, and it places a premium on cost cutting and big profits, which has led to low staffing and patient neglect and mistreatment.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/february-2024-baden-w%C3%BCrttemberg-na-a-resident-of-a-nursing-news-photo/1985540302">picture alliance via Getty Images</a></span></figcaption></figure><p>The care at Landmark of Louisville Rehabilitation and Nursing was abysmal when state inspectors filed their survey report of the Kentucky facility on July 3, 2021.</p>
<p>Residents <a href="https://www.documentcloud.org/documents/24170104-landmark-nursing-070321#document/p72/a2407365">wandered the halls</a> in a facility that can house up to 250 people, yelling at each other and stealing blankets. One resident beat a roommate <a href="https://www.documentcloud.org/documents/24170104-landmark-nursing-070321#document/p66/a2407364">with a stick</a>, causing bruising and skin tears. Another was found in bed with a broken finger and a bloody forehead <a href="https://www.documentcloud.org/documents/24170104-landmark-nursing-070321#document/p55/a2407366">gash</a>. That person was allowed to roam and enter the beds of other residents. In another case, there was <a href="https://www.documentcloud.org/documents/24170104-landmark-nursing-070321#document/p21/a2407367">sexual touching</a> in the dayroom between residents, according to the report.</p>
<p>Meals were served from filthy meal carts on plastic foam trays, and residents struggled to cut their food with dull plastic cutlery. Broken tiles lined showers, and a mysterious black gunk marred the floors. The director of housekeeping reported that the dining room was unsanitary. Overall, there was a critical lack of training, staff and <a href="https://projects.propublica.org/nursing-homes/homes/h-185122">supervision</a>.</p>
<p>The inspectors tagged Landmark as <a href="https://medicare.gov/care-compare/inspections/pdf/nursing-home/185122/health/standard?date=2021-07-03">deficient in 29 areas</a>, including six that put residents in immediate jeopardy of serious harm and three where actual harm was found. The issues were so severe that the government slapped Landmark with <a href="https://www.medicare.gov/care-compare/details/nursing-home/185122?state=KY&measure=nursing-home-penalties">a fine of over US$319,000</a> − <a href="https://data.cms.gov/provider-data/dataset/g6vv-u9sr">more than 29 times the average</a> for a nursing home in 2021 − and suspended payments to the home from federal Medicaid and Medicare funds. </p>
<p>But problems persisted. Five months later, inspectors levied six additional deficiencies of immediate jeopardy − the highest level.</p>
<p>Landmark is just one of the 58 facilities run by parent company Infinity Healthcare Management across five states. The government issued penalties to the company almost 4½ times the national average, according to bimonthly data that the Centers for Medicare & Medicaid Services first started to make available in late 2022. All told, Infinity paid <a href="https://data.cms.gov/quality-of-care/nursing-home-affiliated-entity-performance-measures/data">nearly $10 million in fines</a> since 2021, the highest among nursing home chains with fewer than 100 facilities.</p>
<p>Infinity Healthcare Management and its executives did not respond to multiple requests for comment.</p>
<h2>Race to the bottom</h2>
<p>Such <a href="https://violationtracker.goodjobsfirst.org/">sanctions are nothing new</a> for Infinity or other for-profit nursing home chains that have dominated an industry long known for cutting corners in pursuit of profits for private owners. But this race to the bottom to extract profits is accelerating, despite demands by <a href="https://www.gao.gov/assets/gao-23-104813.pdf">government officials</a>, health care experts and advocacy groups to protect the nation’s most vulnerable citizens.</p>
<p>To uncover the reasons why, The Conversation delved into the nursing home industry, where for-profit facilities make up more than 72% of the nation’s nearly 14,900 facilities. The probe, which paired an academic expert with an investigative reporter, used the most recent government data on ownership, facility information and penalties, combined with <a href="https://data.cms.gov/quality-of-care/nursing-home-affiliated-entity-performance-measures/data">CMS data on affiliated entities</a> for nursing homes.</p>
<p>The investigation revealed an industry that places a premium on cost cutting and big profits, with low staffing and poor quality, often to the detriment of patient well-being. Operating under <a href="https://dx.doi.org/10.2139/ssrn.4541739">weak and poorly enforced regulations</a> with financially insignificant penalties, the for-profit sector fosters an environment where corners are frequently cut, compromising the quality of care and endangering patient health. </p>
<p>Meanwhile, owners make the facilities look less profitable by siphoning money from the homes through byzantine networks of interconnected corporations. Federal regulators have neglected the problem as <a href="https://theconsumervoice.org/news/detail/latest/new-report-nursing-homes-funnel-dollars-through-related-party-companies">each year likely billions of dollars are funneled</a> out of nursing homes through related parties and into owners’ pockets.</p>
<h2>More trouble at midsize</h2>
<p>Analyzing <a href="https://data.cms.gov/search">newly released government data</a>, our investigation found that these problems are most pronounced in nursing homes like Infinity − midsize chains that <a href="https://data.cms.gov/quality-of-care/nursing-home-affiliated-entity-performance-measures/data">operate between 11 and 100 facilities</a>. This subsection of the industry has higher average fines per home, lower overall quality ratings, and are more likely to be tagged with resident abuse compared with both the larger and smaller networks. Indeed, while such chains account for about 39% of all facilities, they operate 11 of the 15 most-fined facilities.</p>
<p><iframe id="DRwGq" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/DRwGq/6/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>With few impediments, private investors who own the midsize chains have swooped in to purchase underperforming homes, expanding their holdings even as larger chains divest and close facilities.</p>
<p>“They are really bad, but the names − we don’t know these names,” said Toby Edelman, senior policy attorney with the Center for Medicare Advocacy, a nonprofit law organization.</p>
<p>In response to The Conversation’s findings on nursing homes and request for an interview, a CMS spokesperson emailed <a href="https://www.documentcloud.org/documents/24478510-nursing-home-information-request">a statement</a> that said the CMS is “unwavering in its commitment to improve safety and quality of care for the more than 1.2 million residents receiving care in Medicare- and Medicaid-certified nursing homes.”</p>
<p>“We support transparency and accountability,” the American Health Care Association/National Center for Assisted Living, a trade organization representing the nursing home industry, <a href="https://www.documentcloud.org/documents/24475011-re-nursing-home-chains-and-cms-regulation-the-conversation-deadline-34-at-5pm-est">wrote in response</a> to The Conversation‘s request for comment. “But neither ownership nor line items on a budget sheet prove whether a nursing home is committed to its residents.”</p>
<h2>Ripe for abuse</h2>
<p>It often takes years to improve a poor nursing home − or <a href="https://www.newyorker.com/news/dispatch/when-private-equity-takes-over-a-nursing-home">run one into the ground</a>. The analysis of midsize chains shows that most owners have been associated with their current facilities for less than eight years, making it difficult to separate operators who have taken long-term investments in resident care from those who are looking to quickly extract money and resources <a href="https://www.wpr.org/st-louis-nursing-home-closes-suddenly-prompting-wider-concerns-over-care">before closing them down or moving on</a>. These chains control roughly 41% of nursing home beds in the U.S., according to CMS’s provider data, making the lack of transparency especially ripe for abuse.</p>
<p>A churn of nursing home purchases even during the pandemic shows that investors view the sector as <a href="https://doi.org/10.1111/jgs.17288">highly profitable</a>, especially when staffing costs are kept low and fines for poor care can easily be covered by the money extracted from residents, their families and taxpayers.</p>
<p>A March 2024 study from Lehigh University and the University of California, Los Angeles also <a href="https://ucla.app.box.com/v/RelatedParties">shows that costs were inflated</a> when nursing home owners switched to contractors they controlled directly or indirectly. Overall, spending on real estate increased 20.4% and spending on management increased 24.6% when the businesses were affiliated, the research showed.</p>
<p>“This is the model of their care: They come in, they understaff and they make their money,” said Sam Brooks, director of public policy at the Consumer Voice, a national resident advocacy organization. “Then they multiply it over a series of different facilities.”</p>
<p><em>This is a condensed version of an article from The Conversation’s <a href="https://theconversation.com/announcing-the-conversations-new-investigative-unit-were-looking-for-collaborators-in-academia-207394">investigative unit</a>. To find out more about the rise of for-profit nursing homes, financial trickery and what could make the nation’s most vulnerable citizens safer, <a href="https://theconversation.com/for-profit-nursing-homes-are-cutting-corners-on-safety-and-draining-resources-with-financial-shenanigans-especially-at-midsize-chains-that-dodge-public-scrutiny-225045">read the complete version</a>.</em></p><img src="https://counter.theconversation.com/content/225954/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Campbell is an adjunct assistant professor at Columbia University and a contributing writer at the Garrison Project, an independent news organization that focuses on mass incarceration and criminal justice.</span></em></p><p class="fine-print"><em><span>Harrington is an advisory board member of the nonprofit Veteran's Health Policy Institute and a board member of the nonprofit Center for Health Information and Policy. Harrington served as an expert witness on nursing home litigation cases by residents against facilities owned or operated by Brius and Shlomo Rechnitz in the past and in 2022. She also served as an expert witness in a case against The Citadel Salisbury in North Carolina in 2021. </span></em></p>Owners of midsize nursing home chains harm the elderly and drain huge sums of money from facilities using opaque accounting practices while government doesn’t do enough to stop it.Sean Campbell, Investigative journalist, The ConversationCharlene Harrington, Professor Emeritus of Social Behavioral Sciences, University of California, San FranciscoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2250452024-03-14T12:46:59Z2024-03-14T12:46:59ZFor-profit nursing homes are cutting corners on safety and draining resources with financial shenanigans − especially at midsize chains that dodge public scrutiny<figure><img src="https://images.theconversation.com/files/580044/original/file-20240306-22-la93ja.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5982%2C3988&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The for-profit nursing home sector is growing, while placing a premium on cost cutting and big profits.</span> <span class="attribution"><span class="source">picture alliance via Getty Images</span></span></figcaption></figure><p>The care at Landmark of Louisville Rehabilitation and Nursing was abysmal when state inspectors filed their survey report of the Kentucky facility on July 3, 2021.</p>
<p>Residents <a href="https://www.documentcloud.org/documents/24170104-landmark-nursing-070321#document/p72/a2407365">wandered the halls</a> in a facility that can house up to 250 people, yelling at each other and stealing blankets. One resident beat a roommate <a href="https://www.documentcloud.org/documents/24170104-landmark-nursing-070321#document/p66/a2407364">with a stick</a>, causing bruising and skin tears. Another was found in bed with a broken finger and a bloody forehead <a href="https://www.documentcloud.org/documents/24170104-landmark-nursing-070321#document/p55/a2407366">gash</a>. That person was allowed to roam and enter the beds of other residents. In another case, there was <a href="https://www.documentcloud.org/documents/24170104-landmark-nursing-070321#document/p21/a2407367">sexual touching</a> in the dayroom between residents, according to the report.</p>
<p>Meals were served from filthy meal carts on plastic foam trays, and residents struggled to cut their food with dull plastic cutlery. Broken tiles lined showers, and a mysterious black gunk marred the floors. The director of housekeeping reported that the dining room was unsanitary. Overall, there was a critical lack of training, staff and <a href="https://projects.propublica.org/nursing-homes/homes/h-185122">supervision</a>.</p>
<p>The inspectors tagged Landmark as <a href="https://medicare.gov/care-compare/inspections/pdf/nursing-home/185122/health/standard?date=2021-07-03">deficient in 29 areas</a>, including six that put residents in immediate jeopardy of serious harm and three where actual harm was found. The issues were so severe that the government slapped Landmark with <a href="https://www.medicare.gov/care-compare/details/nursing-home/185122?state=KY&measure=nursing-home-penalties">a fine of over US$319,000</a> − <a href="https://data.cms.gov/provider-data/dataset/g6vv-u9sr">more than 29 times the average</a> for a nursing home in 2021 − and suspended payments to the home from federal Medicaid and Medicare funds.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/580527/original/file-20240307-28-o5dqjy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Highlighted excerpt from a report" src="https://images.theconversation.com/files/580527/original/file-20240307-28-o5dqjy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/580527/original/file-20240307-28-o5dqjy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=144&fit=crop&dpr=1 600w, https://images.theconversation.com/files/580527/original/file-20240307-28-o5dqjy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=144&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/580527/original/file-20240307-28-o5dqjy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=144&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/580527/original/file-20240307-28-o5dqjy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=181&fit=crop&dpr=1 754w, https://images.theconversation.com/files/580527/original/file-20240307-28-o5dqjy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=181&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/580527/original/file-20240307-28-o5dqjy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=181&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">This excerpt from the July 3, 2021, state inspection report of Landmark of Louisville Rehabilitation and Nursing includes an interview with a nurse who found an injured resident.</span>
<span class="attribution"><a class="source" href="https://www.medicare.gov/care-compare/inspections/pdf/nursing-home/185122/health/standard?date=2021-07-03">New York State attorney general's office</a></span>
</figcaption>
</figure>
<h2>Persistent problems</h2>
<p>But problems persisted. Five months later, inspectors levied six additional deficiencies of immediate jeopardy − the highest level − including <a href="https://www.documentcloud.org/documents/24170103-landmark-nursing-120921#document/p1/a2407371">more sexual abuse</a> among residents and a certified nursing assistant pushing someone down, bruising the person’s back and hip.</p>
<p>Landmark is just one of the 58 facilities run by parent company Infinity Healthcare Management across five states. The government issued penalties to the company almost 4½ times the national average, according to bimonthly data that the Centers for Medicare & Medicaid Services first started to make available in late 2022. All told, Infinity paid <a href="https://data.cms.gov/quality-of-care/nursing-home-affiliated-entity-performance-measures/data">nearly $10 million in fines</a> since 2021, the highest among nursing home chains with fewer than 100 facilities.</p>
<p>Infinity Healthcare Management and its executives did not respond to multiple requests for comment.</p>
<p>Such <a href="https://violationtracker.goodjobsfirst.org/">sanctions are nothing new</a> for Infinity or other for-profit nursing home chains that have dominated an industry long known for cutting corners in pursuit of profits for private owners. But this race to the bottom to extract profits is accelerating despite demands by <a href="https://www.gao.gov/assets/gao-23-104813.pdf">government officials</a>, health care experts and advocacy groups to protect the nation’s most vulnerable citizens.</p>
<p>To uncover the reasons why, The Conversation’s investigative unit <em>Inquiry</em> delved into the nursing home industry, where for-profit facilities make up more than 72% of the nation’s nearly 14,900 facilities. The probe, which paired an academic expert with an investigative reporter, used the most recent government data on ownership, facility information and penalties, combined with CMS data on affiliated entities for nursing homes.</p>
<p>The investigation revealed an industry that places a premium on cost cutting and big profits, with low staffing and poor quality, often to the detriment of patient well-being. Operating under <a href="https://dx.doi.org/10.2139/ssrn.4541739">weak and poorly enforced regulations</a> with financially insignificant penalties, the for-profit sector fosters an environment where corners are frequently cut, compromising the quality of care and endangering patient health. Meanwhile, owners make the facilities look less profitable by siphoning money from the homes through byzantine networks of interconnected corporations. Federal regulators have neglected the problem as <a href="https://theconsumervoice.org/news/detail/latest/new-report-nursing-homes-funnel-dollars-through-related-party-companies">each year likely billions of dollars are funneled</a> out of nursing homes through related parties and into owners’ pockets.</p>
<h2>More trouble at midsize</h2>
<p>Analyzing newly released government data, our investigation found that these problems are most pronounced in nursing homes like Infinity − midsize chains that <a href="https://data.cms.gov/quality-of-care/nursing-home-affiliated-entity-performance-measures/data">operate between 11 and 100 facilities</a>. This subsection of the industry has higher average fines per home, lower overall quality ratings, and are more likely to be tagged with resident abuse compared with both the larger and smaller networks. Indeed, while such chains account for about 39% of all facilities, they operate 11 of the 15 most-fined facilities.</p>
<p><iframe id="zKmDk" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/zKmDk/5/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>With few impediments, private investors who own the midsize chains have quietly swooped in to purchase underperforming homes, expanding their holdings even further as larger chains divest and close facilities. As a result of the industry’s <a href="https://aspe.hhs.gov/sites/default/files/documents/dbab91af8491ce317a66471c361d3ec4/changes-ownership-snf.pdf">churn of facility ownership</a>, over one fifth of the country’s nursing facilities changed ownership between 2016 and 2021, four times more changes than hospitals.</p>
<p>A 2023 report by Good Jobs First, a nonprofit watchdog, noted that a dozen of these chains in the midsize range have <a href="https://goodjobsfirst.org/wp-content/uploads/2023/12/Upheaval-in-the-Nursing-Home-Industry.pdf">doubled or tripled in size</a> while racking up fines averaging over $100,000 per facility since 2018. But unlike the large, multistate chains with easily recognizable names, the midsize networks slip through without the same level of public scrutiny, The Conversation’s investigations unit found.</p>
<p>“They are really bad, but the names − we don’t know these names,” said Toby Edelman, senior policy attorney with the Center for Medicare Advocacy, a nonprofit law organization. </p>
<p>“When we used to have those multistate chains, the facilities all had the same name, so you know what the quality is you’re getting,” she said. “It’s not that good − but at least you know what you’re getting.”</p>
<p>In response to The Conversation’s findings on nursing homes and request for an interview, a CMS spokesperson emailed <a href="https://www.documentcloud.org/documents/24478510-nursing-home-information-request">a statement</a> that said the CMS is “unwavering in its commitment to improve safety and quality of care for the more than 1.2 million residents receiving care in Medicare- and Medicaid-certified nursing homes.”</p>
<p>The statement pointed to data released by the oversight body on <a href="https://www.hhs.gov/about/news/2022/04/20/hhs-releases-new-data-and-report-hospital-and-nursing-home-ownership.html">mergers, acquisitions, consolidations and changes of ownership</a> in April 2023 along with <a href="https://www.hhs.gov/about/news/2022/09/26/biden-harris-administration-makes-more-medicare-nursing-home-ownership-data-publicly-available-improving-identification-of-multiple-facilities-under-common-ownership.html">additional ownership data</a> released the following September. CMS also proposed a rule change that aims to increase transparency in nursing home ownership by <a href="https://www.federalregister.gov/documents/2024/02/16/2024-03294/agency-information-collection-activities-proposed-collection-comment-request">collecting more information on facility owners and their affiliations</a>.</p>
<p>“Our focus is on advancing implementable solutions that promote safe, high-quality care for residents and consider the challenging circumstances some long-term care facilities face,” the statement reads. “We believe the proposed requirements are achievable and necessary.”</p>
<p>CMS is slated to implement the disclosure rules in the fall and release the new data to the public later this year.</p>
<p>“We support transparency and accountability,” the American Health Care Association/National Center for Assisted Living, a trade organization representing the nursing home industry, <a href="https://www.documentcloud.org/documents/24475011-re-nursing-home-chains-and-cms-regulation-the-conversation-deadline-34-at-5pm-est">wrote in response</a> to The Conversation‘s request for comment. “But neither ownership nor line items on a budget sheet prove whether a nursing home is committed to its residents. Over the decades, we’ve found that strong organizations tend to have supportive and trusted leadership as well as a staff culture that empowers frontline caregivers to think critically and solve problems. These characteristics are not unique to a specific type or size of provider.”</p>
<p><iframe id="DRwGq" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/DRwGq/6/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>It often takes years to improve a poor nursing home − or <a href="https://www.newyorker.com/news/dispatch/when-private-equity-takes-over-a-nursing-home">run one into the ground</a>. The analysis of midsize chains shows that most owners have been associated with their current facilities for less than eight years, making it difficult to separate operators who have taken long-term investments in resident care from those who are looking to quickly extract money and resources <a href="https://www.wpr.org/st-louis-nursing-home-closes-suddenly-prompting-wider-concerns-over-care">before closing them down or moving on</a>. These chains control roughly 41% of nursing home beds in the U.S., according to CMS’s provider data, making the lack of transparency especially ripe for abuse.</p>
<p>A churn of nursing home purchases even during the COVID-19 pandemic shows that investors view the sector as <a href="https://doi.org/10.1111/jgs.17288">highly profitable</a>, especially when staffing costs are kept low and fines for poor care can easily be covered by the money extracted from residents, their families and taxpayers.</p>
<p>“This is the model of their care: They come in, they understaff and they make their money,” said Sam Brooks, director of public policy at the Consumer Voice, a national resident advocacy organization. “Then they multiply it over a series of different facilities.”</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/580534/original/file-20240307-30-57sogj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Side-by-side pictures of different nursing home residents asleep with their heads near dishes of food" src="https://images.theconversation.com/files/580534/original/file-20240307-30-57sogj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/580534/original/file-20240307-30-57sogj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=389&fit=crop&dpr=1 600w, https://images.theconversation.com/files/580534/original/file-20240307-30-57sogj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=389&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/580534/original/file-20240307-30-57sogj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=389&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/580534/original/file-20240307-30-57sogj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=488&fit=crop&dpr=1 754w, https://images.theconversation.com/files/580534/original/file-20240307-30-57sogj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=488&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/580534/original/file-20240307-30-57sogj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=488&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">These pictures showing residents asleep in their food appeared in the 2022 New York attorney general’s lawsuit against The Villages of Orleans Health and Rehabilitation Center in Albion, N.Y.</span>
<span class="attribution"><a class="source" href="https://ag.ny.gov/sites/default/files/orleans_nh_petition.pdf">New York State attorney general's office</a></span>
</figcaption>
</figure>
<h2>Investor race</h2>
<p>The explosion of a billion-dollar private marketplace found its beginnings in government spending.</p>
<p>The adoption of Medicare and Medicaid in 1965 set loose a race among investors to load up on nursing homes, with a surge in for-profit homes gaining momentum because of a reliable stream of government payouts. By 1972, a mere seven years after the inception of the programs, a whopping <a href="https://babel.hathitrust.org/cgi/pt?id=umn.31951d00930792n&view=1up&seq=20">106 companies </a>had rushed to Wall Street to sell shares in nursing home companies. And little wonder: They pulled in profits through their ownership of 18% of the industry’s beds, securing about a third of the hefty $3.2 billion of government cash.</p>
<p>The 1990s saw substantial expansion in for-profit nursing home chains, marked by a wave of <a href="https://aspe.hhs.gov/reports/nursing-home-divestiture-corporate-restructuring-final-report-0">acquisitions and mergers</a>. At the same time, increasing difficulties emerged in the model for publicly traded chains. <a href="https://www.jstor.org/stable/45140855">Shareholders increasingly demanded</a> rapid growth, and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2442234/">researchers have found</a> that the publicly traded chains tried to appease that hunger by reducing nursing staff and cutting corners on other measures meant to improve quality and safety.</p>
<p>“I began to suspect a possibly inherent contradiction between publicly traded and other large investor-operated nursing home companies and the prerequisites for quality care,” Paul R. Willging, former chief lobbyist for the industry, wrote in a 2007 letter to the editor of The New York Times. “For many investors … earnings growth, quarter after quarter, is often paramount. Long-term investments in quality can work at cross purposes with a mandate for an unending progression of favorable earnings reports.”</p>
<p>One example of that clash can be found at the Ensign Group, <a href="https://www.sec.gov/Archives/edgar/data/1125376/000112537613000022/ensg12311210k.htm">founded in 1999 as a private chain of five facilities</a>. Using a strategy of acquiring struggling nursing homes, the company <a href="https://www.sec.gov/Archives/edgar/data/1125376/000112537613000022/ensg12311210k.htm">went public in 2007 with more than 60 facilities</a>. What followed was a year-after-year acquisition binge and a track record of growing <a href="https://journals.sagepub.com/doi/full/10.1177/00207314221077649">profits almost every year</a>. Yet the company <a href="https://journals.sagepub.com/doi/full/10.1177/00207314221077649">kept staffing levels below</a> the national average and <a href="https://www.justice.gov/sites/default/files/elderjustice/legacy/2015/07/12/Appropriateness_of_Minimum_Nurse_Staffing_Ratios_in_Nursing_Homes.pdf">levels recommended by experts</a>. <a href="https://journals.sagepub.com/doi/full/10.1177/00207314221077649">Its facilities had</a> higher than average inspection deficiencies and higher COVID infection rates. Since 2021, it has racked up more than <a href="https://data.cms.gov/quality-of-care/nursing-home-affiliated-entity-performance-measures/data">$6.5 million in penalties</a>.</p>
<p>Ensign did not respond to requests for comment. </p>
<p>Even with that kind of expense cutting, not all publicly traded nursing homes survived as the costs of providing poor care added up. Residents sued over mistreatment. Legal fees and settlements ate into profits, shareholders grumbled, and executives searched for a way out of this Catch-22.</p>
<p>Recognizing the long-term potential for profit growth, private investors snapped up publicly traded for-profit chains, reducing the previous levels of public transparency and oversight. Between 2000 and 2017, 1,674 nursing homes were <a href="https://doi.org/10.1093/rfs/hhad082">acquired by private-equity firms</a> in 128 unique deals out of 18,485 facilities. But the same poor-quality problems persisted. Research shows that after snagging a big chain, private investors tended to follow the same playbook: They <a href="https://doi.org/10.1093/ppar/prad001">rebrand the company, increase corporate control and dump</a> unprofitable homes to other investment groups willing to take shortcuts for profit.</p>
<p><a href="https://doi.org/10.1093/ppar/prad001">Multiple</a> <a href="http://dx.doi.org/10.2139/ssrn.3860353">academic</a> <a href="https://doi.org/10.1093/rfs/hhad082">studies</a> show the results, highlighting the lower staffing and quality in for-profit homes compared with nonprofits and government-run facilities. Elderly residents staying long term in nursing homes owned by private investment groups experienced <a href="https://doi.org/10.1093/ppar/prad001">a significant uptick</a> in trips to the emergency department and hospitalizations between 2013 and 2017, translating into higher costs for Medicare. </p>
<p>Overall, private-equity investors <a href="https://aspe.hhs.gov/sites/default/files/documents/29b280bc8ec7632e5742ab466f5429d2/ownership-structures-nh-facility-traits.pdf">wreak havoc</a> on nursing homes, slashing registered nurse hours per resident day by 12%, outpacing other for-profit facilities. The aftermath is grim, with a daunting 14% surge in the deficiency score index, a standardized metric for determining issues with facilities, according to a U.S. Department of Health and Human Services report.</p>
<p><iframe id="vmclY" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/vmclY/9/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<p>The human toll comes in death and suffering. A study updated in 2023 by the National Bureau of Economic Research <a href="https://doi.org/10.1093/rfs/hhad082">calculated that 22,500 additional deaths</a> over a 12-year span were attributable to private-equity ownership, equating to about 172,400 lost life years. The calculations also showed that private-equity ownership was responsible for a 6.2% reduction in mobility, an 8.5% increase in ulcer development and a 10.5% uptick in pain intensity.</p>
<h2>Hiding in complexity</h2>
<p>Exposing the identities of who should be held responsible for such anguish poses a formidable task. Private investors in nursing home chains often employ a <a href="https://doi.org/10.1080/08959420.2012.705702">convoluted system</a> of limited liability corporations, related companies and family relationships <a href="https://theconsumervoice.org/news/detail/latest/new-report-nursing-homes-funnel-dollars-through-related-party-companies">to obscure who controls</a> the nursing homes. </p>
<p>These adjustments are crafted to minimize liability, capitalize on favorable tax policies, diminish regulatory scrutiny and disguise nursing home profitability. In this investigation, entities at every level of involvement with a nursing home denied ownership, even though the same people controlled each organization.</p>
<p>A <a href="https://www.federalregister.gov/documents/2023/11/17/2023-25408/medicare-and-medicaid-programs-disclosures-of-ownership-and-additional-disclosable-parties">rule put in place in 2023</a> by the Centers for Medicare & Medicaid Services requires the identification of all private-equity and real estate investment trust investors in a facility and the release of all related party names. But this hasn’t been enough to surface the players and relationships. More than half of ownership data provided to CMS is incomplete across all facilities, according to a <a href="https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2023.01110">March 2024 analysis</a> of the newly released data.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/579969/original/file-20240305-20-bjd535.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Complicated graphic with 21 intertwined items" src="https://images.theconversation.com/files/579969/original/file-20240305-20-bjd535.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/579969/original/file-20240305-20-bjd535.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=423&fit=crop&dpr=1 600w, https://images.theconversation.com/files/579969/original/file-20240305-20-bjd535.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=423&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/579969/original/file-20240305-20-bjd535.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=423&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/579969/original/file-20240305-20-bjd535.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=531&fit=crop&dpr=1 754w, https://images.theconversation.com/files/579969/original/file-20240305-20-bjd535.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=531&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/579969/original/file-20240305-20-bjd535.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=531&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Nursing home investors drained more than $18 million out of a single facility through a complex web of related party transactions.</span>
<span class="attribution"><a class="source" href="https://ag.ny.gov/sites/default/files/villages_memorandum_of_law.pdf">New York State attorney general's office</a></span>
</figcaption>
</figure>
<p>Even the land under the nursing home is often owned by someone else. In 2021, publicly traded or private real estate investment trusts <a href="https://doi.org/10.1377/hlthaff.2022.00278">held a sizable chunk</a> of the approximately $120 billion of nursing home real estate. As with homes owned by private-equity investors, <a href="https://aspe.hhs.gov/sites/default/files/documents/29b280bc8ec7632e5742ab466f5429d2/ownership-structures-nh-facility-traits.pdf">quality measures collapse</a> after REITs get involved, with facilities witnessing a 7% decline in registered nurses’ hours per resident day and an alarming 14% ascent in the deficiency score index. It’s a blatant pattern of disruption, leaving facilities and care standards in a dire state.</p>
<p>Part of that quality collapse comes from the way these investment entities make their money. REITs and their owners <a href="https://doi.org/10.1377/hlthaff.2022.00278">can drain cash out</a> of the nursing homes in a number of different ways. The standard tactic for grabbing the money is known as a triple-net lease, where the REIT buys the property then leases it back to the nursing home, often <a href="https://ssrn.com/abstract=4209720">at exorbitant rates</a>. Although the nursing home then lacks possession of the property, it still gets slammed with costs typically shouldered by an owner − real estate taxes, insurance, maintenance and more. Topping it off, the facilities then must typically pay annual rent hikes.</p>
<p>A second tactic that REITs use involves a contracting façade that serves no purpose other than enriching the owners of the trusts. Since triple-net lease agreements prohibit REITs from taking profits from operating the facilities, the investors create a subsidiary to get past that hurdle. The subsidiary then contracts with a nursing home operator − often owned or controlled by another related party − and then demands a fee for providing operational guidance. The use of REITs for near-risk-free profits from nursing homes has proven to be an ever-growing technique, and <a href="https://aspe.hhs.gov/sites/default/files/documents/29b280bc8ec7632e5742ab466f5429d2/ownership-structures-nh-facility-traits.pdf">the midsize chains</a>, which our investigation found generally provided the worst care, grew in their reliance on REITs during the pandemic.</p>
<p>“When these REITs start coming in … nursing homes are saddled with these enormous rents, and then they wind up going out of business,” said Richard Mollot, executive director of the <a href="https://nursinghome411.org/">Long-Term Care Community Coalition</a>, a nonprofit organization that advocates for better care at nursing homes. “It’s no longer a viable facility.”</p>
<p>The churn of nursing home purchases by midsize chains underscores investors’ perception of the sector’s profitability, particularly when staffing expenses are minimized and penalties for subpar care can be offset by money extracted through related transactions and payments from residents, their families and taxpayers. Lawsuits can drag out over years, and in the worst case, if a facility is forced to close, its land and other assets can be sold to minimize the financial loss.</p>
<p>Take Brius Healthcare, a name that resonates with a disturbing cadence in the world of nursing home ownership. A search of the federal database for nursing home ownership and penalties shows that Brius was <a href="https://data.cms.gov/quality-of-care/nursing-home-affiliated-entity-performance-measures/data">responsible for 32 facilities</a> as of the start of 2024, but the true number is <a href="http://briuswatch.org/brius-facilities/">closer to 80</a>, according to BriusWatch.org, which tracks violations. At the helm of this still midsize network stands Shlomo Rechnitz, who became a billionaire in part <a href="https://www.documentcloud.org/documents/24225027-us-v-brius">by siphoning from government payments</a> to his facilities scattered across California, according to a federal and state lawsuit.</p>
<p><a href="https://s3.documentcloud.org/documents/21069802/complaint-2.pdf">In lawsuits</a> and regulators’ criticisms, Rechnitz’s homes <a href="http://briuswatch.org/wp-content/uploads/2018/08/2018-06-12-Campbell-v-RechnitzAlamedaHWCet.al_..pdf">have been associated</a> with tales of abuse, as well as several lawsuits alleging terrible care. The track record was so bad that, in the summer of 2014, then-California Attorney General Kamala Harris filed an <a href="https://www.scribd.com/doc/268424325/Emergency-Motion-Calif-AG-8-28-14?secret_password=GhxgjwaQFhWc8aNGjmWj">emergency motion</a> to block Rechnitz from acquiring 19 facilities, writing that he was “a serial violator of rules within the skilled nursing industry” and was “not qualified to assume such an important role.”</p>
<p>Yet, Rechnitz’s empire in California surged forward, scooping up more facilities that drained hundreds of millions of federal and state funds as they <a href="https://www.washingtonpost.com/business/2020/12/31/brius-nursing-home/">racked up pain and profit</a>. The narrative played out at Windsor Redding Care Center in Redding, California. Rechnitz bought it from a competing nursing home chain and attempted to obtain a license to operate the facility. But in 2016, the California Department of Public Health <a href="https://canhr.org/wp-content/uploads/2022/10/River-Valley-Healthcare-and-Wellness-Centre-CHOW-Denial-1.pdf">refused the application</a>, citing a staggering 265 federal regulatory violations across his other nursing homes over just three years.</p>
<p>According to court filings, Rechnitz formed <a href="https://www.documentcloud.org/documents/24460115-brius-redding_042722#document/p7/a2433390">a joint venture with other investors</a> who in turn held the license. Rechnitz, through the Brius joint venture, became the unlicensed owner and operator of Windsor Redding.</p>
<p>Brius carved away at expenses, <a href="https://www.documentcloud.org/documents/24223812-windsor-nursing">slashing staff and other care necessities</a>, according to a 2022 California lawsuit. One resident was left to sit in her urine and feces for hours at a time. Overwhelmed staff often did not respond to her call light, so once she instead climbed out of bed unassisted, fell and fractured her hip. Other negligence led to pressure ulcers, and when she was finally transferred to a hospital, she was suffering from sepsis. She was not alone in her suffering. <a href="https://www.documentcloud.org/documents/24224925-windsor">Numerous other residents</a> experienced an unrelenting litany of injuries and illnesses, including pressure ulcers, urinary tract infections from poor hygiene, falls, and skin damage from excess moisture, according to the lawsuit.</p>
<p>In 2023, California moved forward with <a href="https://calmatters.org/wp-content/uploads/2023/06/CHOW-Settlement-Agreement-MAJ-SR-KRS-CD-signed-FINAL.pdf">licensing two dozen</a> of Rechnitz’s facilities with an agreement that included a two-year monitoring period, <a href="https://calmatters.org/health/2023/06/nursing-homes-california/">right before statewide reforms</a> were set to take effect. The reforms don’t prevent existing owners like Rechnitz from continuing to run a nursing home without a license, but they do prevent new operators from doing so.</p>
<p>“We’re seeing more of that, I think, where you have a proliferation of really bad operators that keep being provided homes,” said Brooks, the director of public policy at the Consumer Voice. “There’s just so much money to be made here for unscrupulous people, and it just happens all the time.”</p>
<p>Rechnitz did not respond to multiple requests for comment. Bruis also did not respond.</p>
<p>Perhaps no other chain showcases the havoc that can be caused by one individual’s acquisition of multiple nursing homes than <a href="https://skillednursingnews.com/2019/04/nursing-homes-held-by-skyline-owner-face-crisis-bouncing-paychecks-in-mass/">Skyline Health Care</a>. The company’s owner, Joseph Schwartz, parlayed the sale of his insurance business into ownership of 90 facilities between mid-2016 and December 2017, according to a <a href="https://www.documentcloud.org/documents/24170670-skylineindictment">federal indictment</a>. He ran the company out of an office <a href="https://www.govinfo.gov/content/pkg/USCOURTS-mdd-1_20-cv-01353/pdf/USCOURTS-mdd-1_20-cv-01353-0.pdf">above a New Jersey pizzeria</a> and at its peak managed facilities in 11 states.</p>
<p>Schwartz went all-in on cost cutting, and by early 2018, residents were suffering from the shortage of staff. The company <a href="https://www.medicareadvocacy.org/wp-content/uploads/2018/09/Centers-Statement-on-Nursing-Home-Hearing.pdf">wasn’t paying its bills</a> or its <a href="https://www.mass.gov/news/skyline-healthcare-owner-five-massachusetts-nursing-homes-cited-for-wage-theft">workers</a>. More than a dozen lawsuits piled up. Last year, Schwartz was arrested and faced charges in federal district court in New Jersey for his role in a <a href="https://www.justice.gov/opa/pr/owner-health-care-and-rehabilitation-facilities-indicted-38-million-payroll-tax-scheme">$38 million payroll tax scheme</a>. In 2024, Schwartz <a href="https://www.justice.gov/usao-nj/pr/insurance-producer-admits-tax-fraud-scheme">pleaded guilty</a> to his role in the fraud scheme. He is awaiting sentencing, where he <a href="https://www.documentcloud.org/documents/24443941-schwartz_plea_20240117">faces a year in prison</a> along with paying at least $5 million in restitution.</p>
<p>Skyline collapsed and <a href="https://www.nbcnews.com/health/aging/nursing-home-chain-grows-too-fast-collapses-elderly-disabled-residents-n1025381">disrupted thousands of lives</a>. Some states took over facilities; others closed, forcing residents to relocate and throwing families into chaos. The case also highlights the ease with which some bad operators can snap up nursing homes with little difficulty, with federal and state governments allowing ownership changes with little or no review.</p>
<p>Schwartz’s lawyer did not respond to requests for comment.</p>
<p>Not that nursing homes have much to fear in the public perception of their reputation for quality. CMS uses what is known as the <a href="https://www.cms.gov/medicare/health-safety-standards/certification-compliance/five-star-quality-rating-system">Five-Star Quality Rating System</a>, designed to help consumers compare nursing homes to find one that provides good care. Theoretically, nursing homes with five-star ratings are supposed to be exceptional, while those with one-star ratings are deemed the worst. But research shows that nursing homes <a href="https://doi.org/10.1177/1077558717739214">can game the system</a>, with the result that a top star rating might reflect little more than a facility’s willingness to cheat.</p>
<p>A star rating is composed of three parts: The score from a government inspection and the facility’s self-reports of staffing and quality. This means that what the nursing homes say about themselves can boost the star rating of facilities even if they have poor inspection results.</p>
<p><a href="https://nihcm.org/publications/do-nursing-homes-inflate-their-medicare-star-ratings-by-self-reporting-overly-positive-assessments">Multiple studies</a> have highlighted a concerning trend: Some nursing homes, especially for-profit ones, <a href="https://doi.org/10.1002/smj.3063">inflate their self-reported measures</a>, resulting in a disconnect from actual inspection findings. Notably, research suggests that for-profit nursing homes, driven by significant financial motives, are more likely to engage in this practice of inflating their self-reported assessments.</p>
<p>At bottom, the elderly and their families seeking quality care unknowingly find themselves in an impossible situation with for-profit nursing homes: Those facilities tend to provide the worst quality, and the only measure available for consumers to determine where they will be treated well can be rigged. The result is the transformation of an industry meant to care for the most vulnerable into a profit-driven circus.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/579741/original/file-20240305-20-b5d09r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Close-up of an elderly woman's head leaning on her hand" src="https://images.theconversation.com/files/579741/original/file-20240305-20-b5d09r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/579741/original/file-20240305-20-b5d09r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/579741/original/file-20240305-20-b5d09r.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/579741/original/file-20240305-20-b5d09r.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/579741/original/file-20240305-20-b5d09r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/579741/original/file-20240305-20-b5d09r.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/579741/original/file-20240305-20-b5d09r.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The for-profit nursing home sector is growing, and it places a premium on cost cutting and big profits, which has led to low staffing and patient neglect and mistreatment.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/february-2024-baden-württemberg-na-a-resident-of-a-nursing-news-photo/1985540302">picture alliance via Getty Images</a></span>
</figcaption>
</figure>
<h2>The pandemic</h2>
<p>Nothing more clearly exposed the problems rampant in nursing homes than the pandemic. Throughout that time, <a href="https://data.cms.gov/covid-19/covid-19-nursing-home-data">nursing homes reported</a> that almost 2 million residents had infections and 170,000 died.</p>
<p>No one should have been surprised by the mass death in nursing homes − the warning signs of what was to come had been visible for years. Between 2013 and 2017, infection control was the <a href="https://www.gao.gov/assets/gao-20-576r.pdf">most frequently cited deficiency</a> in nursing homes, with 40% of facilities cited each year and 82% cited at least once in the five-year period. Almost half were cited over multiple consecutive years for these deficiencies − if fixed, one of the big causes of the widespread transmission of COVID in these facilities would have been eliminated.</p>
<p>But shortly after coming into office in 2017, the Trump administration weakened what was already a deteriorating system to regulate nursing homes. The administration <a href="https://www.nytimes.com/2017/12/24/business/trump-administration-nursing-home-penalties.html">directed regulators to issue one-time fines</a> against nursing homes for violations of federal rules rather than for the full time they were out of compliance. This shift meant that even nursing homes with severe infractions lasting weeks were exempted from fines surpassing the maximum per-instance penalty of $20,965.</p>
<p>Even that near-worthless level of regulation was not feeble enough for the industry, so lobbyists pressed for less. In response, just a few months before COVID emerged in China, the Trump administration <a href="https://www.federalregister.gov/documents/2019/07/18/2019-14946/medicare-and-medicaid-programs-requirements-for-long-term-care-facilities-regulatory-provisions-to">implemented new regulations</a> that effectively abolished a mandate for each to hire a full-time infection control expert, instead <a href="https://www.americanprogress.org/article/trump-administrations-deregulation-nursing-homes-leaves-seniors-disabled-higher-risk-covid-19/">recommending outside consultants</a> for the job.</p>
<p>The perfect storm had been reached, with no experts required to be on site, prepared to combat any infection outbreaks. On Jan. 20, 2020 − just 186 days after the change in rules on infection control − the CDC <a href="https://www.cdc.gov/museum/timeline/covid19.html#:%7E:text=January%2020%2C%202020,respond%20to%20the%20emerging%20outbreak.">reported that the first</a> laboratory-confirmed case of COVID had been found at a nursing home in Washington state.</p>
<p>The least prepared in this explosion of disease were the for-profit nursing homes, compared with nonprofit and government facilities. Research from the University of California at San Francisco found those facilities were <a href="https://doi.org/10.1177/1527154420938707">linked to higher numbers</a> of COVID cases. For-profits not only had fewer nurses on staff but also high numbers of infection-control deficiencies and lower compliance with health regulations.</p>
<p>Even as the United States went through the crisis, some owners of midsize chains continued snapping up nursing homes. For example, two Brooklyn businessmen named Simcha Hyman and Naftali Zanziper were going on a nursing home <a href="https://pe-insights.com/news/2020/08/07/as-the-pandemic-struck-a-private-equity-firm-went-on-a-nursing-home-buying-spree/">buying spree</a> through their private-equity company, the Portopiccolo Group. <a href="https://www.washingtonpost.com/local/portopiccolo-nursing-homes-maryland/2020/12/21/a1ffb2a6-292b-11eb-9b14-ad872157ebc9_story.html">Despite poor ratings</a> in their previously owned facilities, nothing blocked the acquisitions.</p>
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<p>One such facility was a struggling nursing home in North Carolina now known as The Citadel Salisbury. Following the traditional pattern forged by private investors in the industry, the new owners set up a <a href="https://www.documentcloud.org/documents/24174455-citadellawsuit_051721#document/p18/a2409687">convoluted network of business</a> entities and then used them to charge the nursing home for services and property. A 2021 federal lawsuit of many plaintiffs claimed that they deliberately <a href="https://www.classaction.org/media/hooker-et-al-v-the-citadel-salisbury-llc-et-al.pdf">kept the facility understaffed</a> and undersupplied to maximize profit.</p>
<p>Within months of the first case of COVID reported in America, The Citadel Salisbury experienced the largest nursing home outbreak in the state. The situation was so dire that on April 20, 2020, the local medical director of the emergency room <a href="https://www.salisburypost.com/2020/04/20/john-bream-outbreak-at-citadel-nursing-home-especially-concerning/">took to the local newspaper</a> to express his distress, revealing that he had pressed the facility’s leadership and the local health department to address the known shortcomings.</p>
<p>The situation was “a blueprint for exactly what not to do in a crisis,” medical director John Bream wrote. “Patients died at the Citadel without family members being notified. Families were denied the ability to have one last meaningful interaction with their family. Employees were wrongly denied personal protective equipment. There has been no transparency.”</p>
<p>After a <a href="https://www.documentcloud.org/documents/24174486-citadelinspection_090221">series of scathing inspection reports</a>, the <a href="https://www.cms.gov/files/document/north-carolina-citadel-salisbury-05-04-2022.pdf">facility finally closed</a> in the spring of 2022. As for the federal lawsuit, court documents show that a tentative agreement was reached in 2023. But the case dragged out for nearly three years, and one of the plaintiffs, Sybil Rummage, <a href="https://www.documentcloud.org/documents/24174489-deathrecord_102423">died while seeking accountability</a> through the court.</p>
<p>Still, the pandemic had been a time of great success for Hyman and Zanziper. At the end of 2020, they owned more than 70 facilities. By 2021, their portfolio had exploded to more than 120. Now, according to data from the Centers for Medicare & Medicaid Services, Hyman and Zanziper are associated with at least 131 facilities and have the highest amount of total fines recorded by the agency for affiliated entities, totaling nearly $12 million since 2021. And their average fine per facility, as calculated by CMS, is <a href="https://data.cms.gov/quality-of-care/nursing-home-affiliated-entity-performance-measures/data">more than twice the national average</a> at almost $90,000.</p>
<p>In a <a href="https://www.documentcloud.org/documents/24459663-media-request-the-conversation-nursing-home-regulations-and-portopiccolo-deadline-124-12pm">written statement</a>, Portopiccolo Group spokesperson John Collins disputed that the facilities had skimped on care and argued that they were not managed by the firm. “We hire experienced, local health care teams who are in charge of making all on-the-ground decisions and are committed to putting residents first.” He added that the number of facilities given by CMS was inaccurate but declined to say how many are connected to its network of affiliates or owned by Hyman and Zanziper.</p>
<p>With the nearly 170,000 resident deaths from COVID and many related fatalities from isolation and neglect in nursing homes, in February 2022 President Biden <a href="https://www.whitehouse.gov/briefing-room/statements-releases/2022/02/28/fact-sheet-protecting-seniors-and-people-with-disabilities-by-improving-safety-and-quality-of-care-in-the-nations-nursing-homes/">announced an initiative</a> aimed at improving the industry. In addition to promising to set a minimum staffing standard, the initiative is focused on improving ownership and financial transparency.</p>
<p>“As Wall Street firms take over more nursing homes, quality in those homes has gone down and costs have gone up. That ends on my watch,” Biden said during his 2022 State of the Union address. “Medicare is going to set higher standards for nursing homes and make sure your loved ones get the care they deserve and expect.”</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/579699/original/file-20240304-189996-65mwly.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="President Biden sitting at a desk signing with a crowd gathered around him" src="https://images.theconversation.com/files/579699/original/file-20240304-189996-65mwly.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/579699/original/file-20240304-189996-65mwly.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/579699/original/file-20240304-189996-65mwly.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/579699/original/file-20240304-189996-65mwly.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/579699/original/file-20240304-189996-65mwly.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/579699/original/file-20240304-189996-65mwly.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/579699/original/file-20240304-189996-65mwly.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">President Joe Biden signed an executive order on April 18, 2023, that directed the secretary of health and human services to consider actions that would build on nursing home minimum staffing standards and improve staff retention.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/president-joe-biden-signs-an-executive-order-in-the-rose-news-photo/1251960535">Nathan Posner/Anadolu Agency via Getty Images</a></span>
</figcaption>
</figure>
<p>Still, the <a href="https://www.whitehouse.gov/briefing-room/statements-releases/2023/09/01/fact-sheet-biden-harris-administration-takes-steps-to-crack-down-on-nursing-homes-that-endanger-resident-safety/">current trajectory of actions</a> appears to fall short of what’s needed. While penalties against facilities have sharply increased under Biden, some of the Trump administration’s weak regulations have not been replaced. </p>
<p>A <a href="https://www.reginfo.gov/public/do/eAgendaViewRule?pubId=202310&RIN=0938-AV25">rule</a> proposed by CMS in September 2023 and <a href="https://www.reginfo.gov/public/do/eoDetails?rrid=431762">released for review</a> in March 2024 would require states to report what percentage of Medicaid funding is used to pay direct care workers and support staff and would <a href="https://www.cms.gov/newsroom/fact-sheets/medicare-and-medicaid-programs-minimum-staffing-standards-long-term-care-facilities-and-medicaid">require an RN on duty 24/7. It would also require a minimum of three hours</a> of skilled staffing care per patient per day. But the three-hour minimum is substantially lower than the 4.1 hours of skilled staffing for nursing home residents <a href="https://www.justice.gov/sites/default/files/elderjustice/legacy/2015/07/12/Appropriateness_of_Minimum_Nurse_Staffing_Ratios_in_Nursing_Homes.pdf">suggested by CMS over two decades ago</a>.</p>
<p>The requirements are also lower than the <a href="https://data.cms.gov/quality-of-care/nursing-home-affiliated-entity-performance-measures/data">3.8 average nursing staff hours</a> already employed by U.S. facilities.</p>
<p>The current administration has also let stand the <a href="https://www.cms.gov/newsroom/press-releases/cms-rules-put-patients-first-updating-requirements-arbitration-agreements-and-new-regulations-put#:%7E:text=CMS%20is%20allowing%20binding%20arbitration,to%20sign%20a%20binding%20arbitration">Trump administration reversal</a> of an Obama rule that banned binding arbitration agreements in nursing homes.</p>
<h2>It breaks a village</h2>
<p>The Villages of Orleans Health and Rehabilitation Center in Albion, New York, was, by any reasonable measure, broken. Court records show that <a href="https://www.documentcloud.org/documents/24438756-e22_00582_people_of_the_state_of_v_people_of_the_state_of_exhibit_s__16">on some days there was no nurse and no medication</a> for the more than 100 elderly residents. Underpaid staff <a href="https://www.documentcloud.org/documents/24444996-orleans_nh_petition#document/p112/a2431650">spent their own cash for soap</a> to keep residents clean. At times, the home <a href="https://www.documentcloud.org/documents/24444996-orleans_nh_petition#document/p40/a2431651">didn’t feed</a> its frail occupants.</p>
<p>Meanwhile, according to a 2022 lawsuit filed by the New York attorney general, <a href="https://www.documentcloud.org/documents/24444996-orleans_nh_petition#document/p8/a2431653">riches were siphoned out of the nursing home</a> and into the pockets of the official owner, Bernard Fuchs, as well as assorted friends, business associates and family. The lawsuit says $18.7 million flowed from the facility to entities owned by a group of men who controlled the Village’s operations.</p>
<p>Although these men own various nursing homes, Medicare records show few connections between them, despite them all being investors in Comprehensive Healthcare Management, which provided administrative services to the Villages. Either they or their families were also owners of Telegraph Realty, which <a href="https://www.documentcloud.org/documents/24444996-orleans_nh_petition#document/p11/a2431654">leased what was once the Villages’ own property back</a> to the facility at rates the New York attorney general deemed exorbitant, predatory and a sham.</p>
<p>So it goes in the world of nursing home ownership, where overlapping entities and investors obscure the interrelationships between them to such a degree that Medicare itself is never quite sure who owns what.</p>
<p>Glenn Jones, a lawyer representing Comprehensive Healthcare Management, declined to comment on the pending litigation, but he forwarded a <a href="https://www.documentcloud.org/documents/24444995-2023-04-17-296-mol-in-support-of-nom-to-dismiss-4881-0186-0702-1">court document his law firm filed</a> that labels the allegations brought by the New York attorney general “unfounded” and reliant on “a mere fraction” of its residents.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/580541/original/file-20240307-16-qd3106.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Side-by-side pictures of a man in a wheelchair with glasses in November, 2019 and the same man looking less alert, unshaven and with an eye wound in December, 2019" src="https://images.theconversation.com/files/580541/original/file-20240307-16-qd3106.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/580541/original/file-20240307-16-qd3106.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=334&fit=crop&dpr=1 600w, https://images.theconversation.com/files/580541/original/file-20240307-16-qd3106.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=334&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/580541/original/file-20240307-16-qd3106.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=334&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/580541/original/file-20240307-16-qd3106.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=420&fit=crop&dpr=1 754w, https://images.theconversation.com/files/580541/original/file-20240307-16-qd3106.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=420&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/580541/original/file-20240307-16-qd3106.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=420&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">These pictures of the same resident one month apart at the Holliswood Center for Rehabilitation and Healthcare in Queens appeared in a 2023 New York attorney general lawsuit against 13 LLCs and 14 individuals. The group owns multiple nursing homes and allegedly neglected residents, while owners siphoned Medicare and Medicaid money into their own pockets.</span>
<span class="attribution"><a class="source" href="https://ag.ny.gov/sites/default/files/court-filings/centers-filed-petition.pdf">New York attorney general's office</a></span>
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</figure>
<p>The shadowy structure of ownership and related party transactions plays an enormous role in how investors enrich themselves, even as the nursing homes they control struggle financially. Compounding the issue, the figures reported by nursing homes regarding payments to related parties <a href="https://theconsumervoice.org/news/detail/latest/new-report-nursing-homes-funnel-dollars-through-related-party-companies">frequently diverge</a> from the disclosures made by the related parties themselves.</p>
<p>As an illustration of the problems, consider <a href="https://pruitthealth.com/">Pruitt Health</a>, a midsize chain with <a href="https://data.cms.gov/quality-of-care/nursing-home-affiliated-entity-performance-measures/data">87 nursing homes</a> spread across Georgia, South Carolina, North Carolina and Florida that had low overall federal quality ratings and about $2 million in penalties. A report by The National Consumer Voice For Quality Long-Term Care, a consumer advocacy group, <a href="https://theconsumervoice.org/news/detail/latest/new-report-nursing-homes-funnel-dollars-through-related-party-companies">shows that Pruitt disclosed</a> general related party costs nearing $482 million from 2018 to 2020. Yet in that same time frame, Pruitt reported payments to specific related parties amounting to about $570 million, indicating a $90 million excess. Its federal disclosures offer no explanation for the discrepancy. Meanwhile, the company reported $77 million in overall losses on its homes.</p>
<p>The same pattern holds in the major chains such as the Cleveland, Tennessee-based Life Care Centers of America, which operates roughly 200 nursing homes across 27 states, according to the report. Life Care’s financial disbursements are fed into a diverse spectrum of related entities, including management, staffing, insurance and therapy companies, all firmly under the umbrella of the organization’s ownership. In fiscal year 2018, the financial commitment to these affiliated entities reached $386,449,502; over the three-year period from 2018 to 2020, Life Care’s documented payments to such parties hit an eye-popping $1.25 billion.</p>
<p>Pruitt Health and Life Care Centers did not respond to requests for comment.</p>
<p>Overall, <a href="https://journals.sagepub.com/doi/10.1177/27551938231221509">77% of US nursing homes reported $11 billion</a> in related-party transactions in 2019 − nearly 10% of total net revenues − but the data is unaudited and unverified. The facilities <a href="https://theconsumervoice.org/news/detail/latest/new-report-nursing-homes-funnel-dollars-through-related-party-companies">are not required to provide any details</a> of what specific services were provided by the related parties, or what were the specific profits and administrative costs, creating a lack of transparency regarding expenses that are ambiguously categorized under generic labels such as “maintenance.” Significantly, there is no mandate to disclose whether any of these costs exceed fair market value.</p>
<p>What that means is that nursing home owners can profit handsomely through related parties even if their facilities are being hit with repeated fines for providing substandard care.</p>
<p>“What we would consider to be a big penalty really doesn’t matter because there’s so much money coming in,” said Mollot of the Long-Term Care Community Coalition. “If the facility fails, so what? It doesn’t matter. They pulled out the resources.’’</p>
<p><iframe id="DGcNl" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/DGcNl/6/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<h2>Hiding profit</h2>
<p>Ultimately, experts say, this ability to drain cash out of nursing homes makes it almost impossible for anyone to assess the profitability of these facilities based on their public financial filings, known as cost reports.</p>
<p>"The profit margins (for nursing homes) also should be taken with a grain of salt in the cost reports,” said Dr. R. Tamara Konetzka, a University of Chicago professor of public health sciences, at a <a href="https://nursinghome411.org/policybriefing-dec28/">recent meeting</a> of the <a href="https://www.medpac.gov/">Medicare Payment Advisory Commission</a>. “If you sell the real estate to a REIT or to some other entity, and you pay sort of inflated rent back to make your profit margins look lower, and then you recoup that profit because it’s a related party, we’re not going to find that in the cost reports.”</p>
<p>That ability to hide profits is key to nursing homes’ ability to block regulations to improve quality of care and to demand greater government payments. For decades, the <a href="https://www.ahcancal.org/News-and-Communications/Press-Releases/Pages/Long-Term-Care-Closures-Mount-As-COVID-19-Exacerbates-Financial-Shortfalls.aspx">industry’s refrain</a> has been that cuts in reimbursements or requirements to increase staffing will drive facilities into bankruptcy; already, they claim, half of all nursing homes are teetering on the edge of collapse, <a href="https://www.ahcancal.org/News-and-Communications/Press-Releases/Pages/Long-Term-Care-Closures-Mount-As-COVID-19-Exacerbates-Financial-Shortfalls.aspx">the result, they say, of inadequate Medicaid rates</a>. All in all, the industry reports that <a href="https://www.ahcancal.org/News-and-Communications/Press-Releases/Pages/Long-Term-Care-Closures-Mount-As-COVID-19-Exacerbates-Financial-Shortfalls.aspx">less than 3%</a> of their revenue goes to earnings.</p>
<p>But that does not include any of the revenue pulled out of the homes to boost profits of related parties controlled by the same owners pleading poverty. And this tactic is only one of several ways that the nursing home industry disguises its true profits, giving it the power to plead poverty to an unknowing government.</p>
<p>Under the regulations, <a href="https://journals.sagepub.com/doi/10.1177/27551938231221509">only certain nursing home expenses are reimbursable</a>, such as money spent for care. Many others − unreasonable payments to the headquarters of chains, luxury items, and fees for lobbyists and lawyers − are disallowed after Medicare reviews the cost reports. But by that time, the government has already reimbursed the nursing homes for those expenses − and <a href="https://doi.org/10.1177/27551938231221509">none of those revenues have to be returned</a>.</p>
<p>Data indicates that owners also profit by overcharging nursing homes for services and leases provided by related entities. A March 2024 study from Lehigh University and the University of California, Los Angeles <a href="https://ucla.app.box.com/v/RelatedParties">shows that costs were inflated</a> when nursing home owners changed from independent contractors to businesses owned or controlled directly or indirectly by the same people. Overall, spending on real estate increased 20.4%, and spending on management increased 24.6% when the businesses were affiliated, the research showed.</p>
<p>Nursing homes also claim that <a href="https://journals.sagepub.com/doi/10.1177/27551938231221509">noncash depreciation cuts into their profits</a>. Those expenses, which show up only in accounting ledgers, assume that assets such as equipment and facilities are gradually decreasing in value and ultimately will need to be replaced.</p>
<p>That might be reasonable if the chains purchased new items once their value depreciated to zero, but that is not always true. <a href="https://www.govinfo.gov/content/pkg/GOVPUB-Y3_M46_3-PURL-LPS49906/pdf/GOVPUB-Y3_M46_3-PURL-LPS49906.pdf">A 2004 report</a> by the Medicare Payment Advisory Commission found that the depreciation claimed by health care companies, including nursing homes, may not reflect actual capital expenditures or the actual market value.</p>
<p>If disallowed expenses and noncash depreciation were not included, <a href="https://doi.org/10.1177/27551938231221509">profit margins for the nursing home industry would jump</a> to 8.8%, far more than the 3% it claims. And given that these numbers all come from nursing home cost reports submitted to the government, they may underestimate the profits even more. Audited cost reports are not required, and the <a href="https://www.gao.gov/assets/gao-16-700.pdf">Government Accountability Office has found</a> that CMS does little to ensure the numbers are correct and complete. </p>
<p>This lack of basic oversight essentially gives dishonest nursing home owners the power to grab more money from Medicare and Medicaid while being empowered to claim that their financials prove they need more.</p>
<p>“They face no repercussions,” Brooks of Consumer Voice said, commenting on the current state of nursing home operations and their unscrupulous owners. “That’s why these people are here. It’s a bonanza to them.”</p>
<p>Ultimately, experts say, finding ways to force nursing homes to provide quality care has remained elusive. Michael Gelder, former senior health policy adviser to then-Gov. Pat Quinn of Illinois, learned that brutal lesson in 2010 as head of a task force formed by Quinn to investigate nursing home quality. That group successfully pushed a new law, but Gelder now says his success failed to protect this country’s most vulnerable citizens.</p>
<p>“I was perhaps naively convinced that someone like myself being in the right place at the right time with enough resources could really fix this problem,” he said. “I think we did the absolute best we could, and the best that had ever been done in modern history up to that point. But it wasn’t enough. It’s a battle every generation has to fight.”</p>
<p><em><a href="https://theconversation.com/how-for-profit-nursing-home-regulators-can-use-the-powers-they-already-have-to-fix-growing-problems-with-poor-quality-care-225053">Click to learn more about how some existing tools</a> can address problems with for-profit nursing homes.</em></p><img src="https://counter.theconversation.com/content/225045/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Campbell is an adjunct assistant professor at Columbia University and a contributing writer at the Garrison Project, an independent news organization that focuses on mass incarceration and criminal justice.</span></em></p><p class="fine-print"><em><span>Harrington is an advisory board member of the nonprofit Veteran's Health Policy Institute and a board member of the nonprofit Center for Health Information and Policy. Harrington served as an expert witness on nursing home litigation cases by residents against facilities owned or operated by Brius and Shlomo Rechnitz in the past and in 2022. She also served as an expert witness in a case against The Citadel Salisbury in North Carolina in 2021.
</span></em></p>Owners of midsize nursing home chains drain billions from facilities, hiding behind opaque accounting practices and harming the elderly as government, which has the power to stop it, falls short.Sean Campbell, Investigative journalist, The ConversationCharlene Harrington, Professor Emeritus of Social Behavioral Sciences, University of California, San FranciscoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2250532024-03-14T12:46:04Z2024-03-14T12:46:04ZHow for-profit nursing home regulators can use the powers they already have to fix growing problems with poor-quality care<figure><img src="https://images.theconversation.com/files/579738/original/file-20240304-22-wj7pxu.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5760%2C3837&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Nursing homes care for more than a million people in the U.S.</span> <span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/NursingHomeHigh/7c838b5ffe0a4558bde70f78d42f123e/photo">AP Photo/Richard Drew</a></span></figcaption></figure><p>Governments at both state and federal levels have <a href="https://doi.org/10.1093/ppar/prad001">yet to fully wield their authority</a> to fight poor-quality care at for-profit nursing homes nationwide, leaving the pressing need for elder care accountability unmet.</p>
<p>Medicare has the <a href="https://doi.org/10.1093/ppar/prad001">power to improve financial accountability</a> at nursing facilities by capping profits while requiring that a percentage of revenues be spent on direct care expenditures. Already, four states – New Jersey, New York, Massachusetts and Pennsylvania – <a href="https://doi.org/10.1093/ppar/prad001">have shown this can be done</a>, passing laws requiring minimum percentages of expenditures on direct care while limiting profits.</p>
<p>I am a <a href="https://profiles.ucsf.edu/charlene.harrington">behavioral scientist</a> at the University of California, San Francisco who studies the economics of nursing homes and the implications for care. I am also the co-author of an <a href="https://theconversation.com/for-profit-nursing-homes-are-cutting-corners-on-safety-and-draining-resources-with-financial-shenanigans-especially-at-midsize-chains-that-dodge-public-scrutiny-225045">investigative piece in The Conversation</a> about for-profit nursing homes.</p>
<p>States also have the power to suspend and disqualify nursing home owners from the Medicaid program when they provide poor-quality care, commit fraud or harm residents. </p>
<p>For example, after the New Jersey comptroller <a href="https://www.cbsnews.com/newyork/news/princeton-care-center-abrupt-closure-law-violation/">concluded that the abrupt closure</a> of the Princeton Care Center nursing home in September 2023 jeopardized the health and safety of residents, the state took action. It <a href="https://nj.gov/comptroller/news/2024/20240116.shtml#:%7E:text=The%20Office%20of%20the%20State,other%20Medicaid%2Dfunded%20nursing%20homes.">moved in January 2024 to impose an eight-year ban</a> on the owners’ ability to receive Medicaid reimbursement at any nursing home and to require them to divest themselves from <a href="https://nj.gov/comptroller/news/2024/20240116.shtml#:%7E:text=The%20Office%20of%20the%20State,other%20Medicaid%2Dfunded%20nursing%20homes.">two other facilities they already ran</a>.</p>
<p>The federal government can also take aggressive actions to force the industry to shape up, even without new legislation. A 2023 <a href="https://scholarship.law.wm.edu/cgi/viewcontent.cgi?article=4001&context=wmlr">law review article</a> demonstrates that state and federal governments could use state licensure laws and federal nursing home certification requirements to prevent abuse. The article argues that governments could set clear nursing home ownership and operation criteria for individuals and companies, which can include experience, expertise, reputation, past performance and financial solvency standards.</p>
<p>Even federal prosecutors have largely unused powers to crack down on the industry. The Department of Justice <a href="https://www.justice.gov/opa/pr/department-justice-launches-national-nursing-home-initiative">has taken actions</a> against many nursing home owners and chains but rarely has moved to remove the certification of facilities despite having the authority to do so. Instead, nursing homes subject to legal action by the department generally are placed under what is known as a corporate integrity agreement and assigned a monitor to oversee regulatory compliance.</p>
<p>For example, <a href="https://oig.hhs.gov/fraud/cia/agreements/Saber_Healthcare_Holdings_LLC_et_al_03312020.pdf">Saber Healthcare Holdings</a>, which owned <a href="https://data.cms.gov/quality-of-care/nursing-home-affiliated-entity-performance-measures/data">126 nursing homes</a> in 2024, was placed under a <a href="https://oig.hhs.gov/faqs/corporate-integrity-agreement-faq/">corporate integrity agreement</a> in 2021. </p>
<p>The question remains: Why haven’t governments fully flexed their existing regulatory muscles to enforce vital reforms in nursing homes? With the welfare of vulnerable residents at stake, the urgency for decisive action has never been clearer.</p>
<p><em><a href="https://theconversation.com/for-profit-nursing-homes-are-cutting-corners-on-safety-and-draining-resources-with-financial-shenanigans-especially-at-midsize-chains-that-dodge-public-scrutiny-225045">Read The Conversation’s investigation</a> to learn more about the nation’s for-profit nursing homes and how they’re cutting corners on safety.</em></p><img src="https://counter.theconversation.com/content/225053/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Harrington is a advisory board member of the nonprofit Veteran's Health Policy Institute and a board member of the nonprofit Center for Health Information and Policy. Harrington served as an expert witness on nursing home litigation cases by residents against facilities owned or operated by Brius and Shlomo Rechnitz in the past and in 2022. She also served as an expert witness in a case against The Citadel Salisbury in North Carolina in 2021.
</span></em></p>Governments can do more to protect patients at for-profit nursing homes. A behavioral scientist who studies nursing homes weighs in.Charlene Harrington, Professor Emeritus of Social Behavioral Sciences, University of California, San FranciscoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2109732023-09-24T12:10:16Z2023-09-24T12:10:16ZHow long will a loved one live? It’s difficult to hear, but harder not to know<figure><img src="https://images.theconversation.com/files/549786/original/file-20230922-27-gg4746.jpg?ixlib=rb-1.1.0&rect=201%2C70%2C6508%2C4054&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Even for an experienced health-care professional, estimating the life expectancy of a patient with a serious illness is challenging.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/how-long-will-a-loved-one-live-its-difficult-to-hear-but-harder-not-to-know" width="100%" height="400"></iframe>
<p>Planning for the future is difficult for people living with a life-limiting illness. Clinicians, based on their experience, can offer broad estimates of survival — in days to weeks, weeks to months, or months to years. However, patients and their care partners often want greater precision when arranging or making decisions about their care. </p>
<p>An accurate prediction of survival can enable earlier conversations about preferences and wishes at the end of life, and earlier introduction of palliative care. </p>
<p>However, even for an experienced clinician, <a href="https://doi.org/10.1371/journal.pone.0161407">estimating the life expectancy</a> of a patient with a serious illness <a href="https://doi.org/10.1136/bmj.320.7233.469">is challenging</a>. It requires large amounts of data and an understanding of the relationship between the patient’s baseline health, the complexity of their medical condition and how they respond to or progress with treatment. This is where predictive algorithms could help. </p>
<h2>A tool for timely conversations and planning</h2>
<p><a href="https://www.projectbiglife.ca/respect-elder-life">RESPECT (Risk Evaluation for Support: Predictions for Elder life in their Communities Tool) is a risk communication tool</a> powered by prediction algorithms that estimate individuals’ survival — that is, how long someone will live. It was developed by the Project Big Life Research Team and validated <a href="https://doi.org/10.1503/cmaj.200022">using health-care data collected on nearly one million older adults who received home and community care</a> or nursing home care in Ontario. </p>
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<figcaption><span class="caption">RESPECT is intended to help people plan for palliative and end-of-life care.</span></figcaption>
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<p>RESPECT was designed with patients’ information needs in mind, and with the intention of empowering patients and their care partners. By providing patients with data on the survival and experiences of other individuals who had similar disease journeys, the tool can help patients understand their own illness trajectory, have earlier conversations about their preferences and wishes, and advocate for the support they need. </p>
<h2>A tool for patients, care partners and clinicians</h2>
<p><a href="https://www.projectbiglife.ca/respect-elder-life">RESPECT</a> launched publicly on ProjectBigLife.ca in July 2021. <a href="https://www.projectbiglife.ca/">ProjectBigLife.ca</a> is home to several health calculators developed by the research team as a means of translating data and evidence into tools that can help Canadians think about their health and plan for their care. </p>
<p>Using the responses to 17 questions about their health and ability to care for themselves, RESPECT provides an estimate of a person’s survival based on information gathered on people who have similar characteristics. Older adults, their care partners and health care professionals who are uncertain about the life expectancy of someone living with a critical illness can use the calculator to gain a better understanding of their decline. </p>
<p>Beyond life expectancy, RESPECT reports measures of functional decline — for example, whether the patient is able to get around their house and engage in activities of daily living, like bathing and cooking, without any assistance. </p>
<p>A patient can use this information to discuss their care needs with their care partners and health-care providers. Similarly, health-care providers can use this tool to discuss with their patient what can be expected as the patient approaches the end of life, and plan for the supports that their patient may need.</p>
<p>RESPECT is also actively used in Ontario’s retirement homes and nursing homes. Many residents in these settings have a life expectancy of less than two years. Earlier conversations about the older person’s goals and wishes for their remaining life can enable the care team to provide the best quality of life and care for the individuals under their care.</p>
<h2>Sustainable infrastructure</h2>
<p>One of the goals of RESPECT is to provide sustainable infrastructure to study, learn and improve how we use predictive algorithms for end-of-life care.</p>
<p>Despite the benefits that are emerging from the early uses of RESPECT, many questions remain about when and how it can be most appropriately used. For example, poor numerical literacy — that is, a person’s understanding of numbers, mathematics and statistics — could lead to misinterpreting the estimate provided by RESPECT. While the resources supporting RESPECT were co-developed with patients and their care partners, more research is still needed to reduce such potential harms.</p>
<p>To ensure we optimize the benefits that can be gained from prediction algorithms like RESPECT, clinical epidemiologists Douglas Manuel and Justin Presseau, along with the co-authors of this article, have created the RESPECT Learning Health System — a network of care partners, researchers and health-care professionals collaborating to address these challenges. We combine research and practice to sustainably study, learn and improve end-of-life care and experience through predictive algorithms.</p>
<h2>Identification is just the first step</h2>
<p>Only <a href="https://www.cihi.ca/sites/default/files/document/access-to-palliative-care-in-canada-2023-report-en.pdf">58 per cent of people who die in Canada</a> receive some form of palliative care prior to death. Few (13 per cent) are able to die at home with the support of palliative home care. </p>
<p>In deepening our understanding of frailty and decline, RESPECT may help clinicians, patients and their care partners be prepared for a poor prognosis and help develop a personalized plan for their care. </p>
<p>However, to improve end-of-life care delivery in Canada and enable Canadians to die with dignity, more investment is still needed within our formal health-care system to meet the need of individuals at the end of life.</p><img src="https://counter.theconversation.com/content/210973/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span> Lysanne Lessard receives funding from Canadian Institutes of Health Research for research related to the RESPECT Learning Health System.
Lessard is a member of the University of Ottawa's LIFE Research Institute.</span></em></p><p class="fine-print"><em><span>Amy T. Hsu receives funding from the Canadian Institutes of Health Research for research related to the RESPECT Calculator. </span></em></p><p class="fine-print"><em><span>Peter Tanuseputro receives funding from the Canadian Institutes of Health Research for research related to the RESPECT calculator. </span></em></p><p class="fine-print"><em><span>Sampath Bemgal does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>An accurate prediction of survival can enable earlier conversations about preferences and wishes at the end of life, and earlier introduction of palliative care.Lysanne Lessard, Associate Professor, Telfer School of Management, L’Université d’Ottawa/University of OttawaAmy T. Hsu, Brain and Mind-Bruyère Research Institute Chair in Primary Health Care in Dementia, L’Université d’Ottawa/University of OttawaPeter Tanuseputro, Associate Professor, Division of Palliative Care, Department of Medicine, L’Université d’Ottawa/University of OttawaSampath Bemgal, Assistant Professor, Management Information Systems, University of New BrunswickLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2101052023-09-17T12:07:27Z2023-09-17T12:07:27ZOlder Canadians’ savings are shaped by their long-term care preferences<figure><img src="https://images.theconversation.com/files/547630/original/file-20230911-8406-rbs70z.jpg?ixlib=rb-1.1.0&rect=15%2C38%2C5160%2C3406&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A recent study has found that Canadians are highly motivated to save money in preparation of long-term care.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/older-canadians-savings-are-shaped-by-their-long-term-care-preferences" width="100%" height="400"></iframe>
<p>Canada’s aging population is growing. According to the Organization for Economic Co-operation and Development, the proportion of Canadians aged 80 and older <a href="https://www.oecd.org/health/health-at-a-glance/">will surpass nine per cent by 2050</a>, up from 4.3 per cent in 2021. </p>
<p>This demographic shift is happening in most developed nations, and will result in a greater demand for long-term care. Québec, for instance, anticipates that <a href="https://creei.ca/wp-content/uploads/2021/02/cahier_21_01_financement_soutien_autonomie_personnes_agees_croisee_chemins.pdf">600,000 people will need long-term care by 2050</a> — nearly double the current number.</p>
<p>Meanwhile, escalated care expenses in recent years, <a href="https://www.statcan.gc.ca/o1/en/plus/4165-nurses-working-harder-more-hours-amid-increased-labour-shortage">attributed to labour shortages and exacerbated by COVID-19</a>, are a pressing concern.</p>
<h2>The costs of long-term care</h2>
<p>In Québec, <a href="https://bonjourresidences.com/blogue/couts-hebergement-chsld/">the rates (before any income-based subsidy) for public nursing home accommodations are around $2,000 a month</a>. But since public nursing homes have such long waiting lists, some choose private nursing homes instead. The costs of private nursing homes are estimated to be between $5,000 and $8,000 a month.</p>
<p>Home care — <a href="https://theconversation.com/canadians-want-home-care-not-long-term-care-facilities-after-covid-19-170620">a preferred option for many</a> — costs around $5,550 a month, excluding additional expenses like maintenance and food. Consequently, long-term care expenses present a substantial financial risk in old age, potentially motivating people to save for it ahead of time.</p>
<p>While both nursing homes and home care impose financial burdens, their distinct cost structures can influence precautionary savings in different ways. </p>
<p>Nursing homes bundle accommodation and food, offering limited additional services. In contrast, home care recipients can allocate savings for quality-of-life improvements like better food, home maintenance, etc. Additionally, people may inherently value spending more while at home.</p>
<h2>Long-term care and savings</h2>
<p>Our <a href="https://economie.esg.uqam.ca/wp-content/uploads/sites/54/2023/05/2023_02_docdt_eco.pdf">recent research project</a> aimed to understand how preferences for home-based care versus nursing homes affect people’s savings, using both survey responses and a simulation study.</p>
<p>Our research is crucial for two reasons. First, even before the pandemic, a reluctance to be institutionalized — known as <a href="https://doi.org/10.1016/j.jhe.2017.10.001">institutionalization aversion</a> — was documented. Second, COVID-19 has further <a href="https://doi.org/10.1016/j.jebo.2022.06.034">discouraged nursing home entry</a>, possibly due to excess mortality in nursing homes, as has been <a href="https://doi.org/10.1002/hec.4613">documented in many countries</a>.</p>
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Read more:
<a href="https://theconversation.com/inquiry-into-coronavirus-nursing-home-deaths-needs-to-include-discussion-of-workers-and-race-139017">Inquiry into coronavirus nursing home deaths needs to include discussion of workers and race</a>
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<p>To model savings in different care settings effectively, we needed to understand how individuals allocated their resources in those settings. To accomplish this, we developed a set of survey questions aimed at uncovering these preferences.</p>
<p>These survey questions were designed to prompt respondents to consider how they would allocate their resources depending on the long-term care setting in a well-defined, hypothetical scenario.</p>
<p>Survey respondents were randomly assigned to different long-term care settings (home care, semi-private room in a nursing home or a private room in a nursing home). Their resource allocation choices allowed us to examine how their preferences for savings varied based on the type of long-term care setting.</p>
<p>Our analysis of 3,000 survey responses shows that Canadians are highly motivated to save money to be better prepared for long-term care. This willingness to save was much larger when respondents expected to use home care; respondents anticipating home care allocated 38 per cent more resources to savings. This reflects the greater financial needs associated with home care.</p>
<h2>Long-term care insurance</h2>
<p>We used the results from our survey to calibrate a simulation study — a computer-based experiment using a combination of economic theories and survey evidence — to simulate how households and individuals make financial decisions.</p>
<p>Our simulation study examined two scenarios: one based on the Canadian system, which includes a universal subsidy that lowers nursing home costs, and one based on the U.S. Medicaid system, which features a purely means-tested subsidy that provides free long-term care and ensures a minimum standard of living for those without sufficient income.</p>
<p>Differences in individual preferences for various care settings largely explain the savings disparities. In the Canada-like system, the prospect of receiving long-term care at home substantially boosts savings. On average, individuals planning to use home care saved $25,000 (8.3 per cent) more by the age of 66, compared to those planning to use private nursing home rooms, and $29,000 (9.8 per cent) more compared to those opting for semi-private rooms. </p>
<p>Under the U.S.-like system, the impacts on savings of different care settings were much smaller. This is because, in the absence of public subsidies, the minimum costs of a room in a nursing home are much higher than those of home care. When comparing the savings of individuals opting for home care versus a private room in a nursing home, the difference in savings was almost null. </p>
<p>However, when comparing savings between those opting for home care versus a semi-private room in a nursing home, we found that the former saved 3.7 per cent more.</p>
<h2>Policy implications</h2>
<p>Assessing how individuals value additional public subsidies for each type of long-term care setting can provide policymakers with valuable insights about how to expand public long-term care insurance effectively. </p>
<p>Our research found that all subsidies are valued well beyond costs, with home care subsidies being more valued than nursing home subsidies. Under the Canada-like system, the average valuation for a home care subsidy was $2.98 per $1 spent, surpassing private ($2.72) and semi-private ($2.35) nursing home subsidies.</p>
<p>Middle-income individuals who aren’t eligible for means-tested programs, but who have limited savings, placed the highest value on these subsidies. This shows that expanding subsidies for home care can be an effective way to protect Canadians from long-term care risks.</p><img src="https://counter.theconversation.com/content/210105/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Marie-Louise Leroux receives funding from FRQSC and SSHRC-CRSH. She is affiliated with CIRANO (Montreal) and CESifo (Munich). </span></em></p><p class="fine-print"><em><span>Franca Glenzer receives funding from SSHRC-CRSH. </span></em></p><p class="fine-print"><em><span>Bertrand Achou, Minjoon Lee, and Philippe De Donder do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>While both nursing homes and home care impose financial burdens, their differing structures can influence how older Canadians save money.Marie-Louise Leroux, Professeure titulaire en Sciences Economiques, Université du Québec à Montréal (UQAM)Bertrand Achou, Assistant Professor, Economics, University of GroningenFranca Glenzer, Assistant Professor, Department of Finance, HEC MontréalMinjoon Lee, Assistant Professor, Economics, Carleton UniversityPhilippe De Donder, Research director (CNRS), Toulouse School of Economics – École d'Économie de ToulouseLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2113982023-08-22T12:25:59Z2023-08-22T12:25:59ZMost US nursing homes are understaffed, potentially compromising health care for more than a million elderly residents<figure><img src="https://images.theconversation.com/files/542411/original/file-20230811-21-ml692x.jpg?ixlib=rb-1.1.0&rect=0%2C23%2C7959%2C5266&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Nursing homes in poorer neighborhoods tend to have more critical staffing issues.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/young-male-care-worker-helping-woman-off-bed-with-royalty-free-image/1433524154?phrase=nursing+home&adppopup=true">10'000 Hours/Digital Vision via Getty Images</a></span></figcaption></figure><p><em>More than 80% of U.S. nursing homes <a href="https://thehill.com/changing-america/well-being/longevity/3809450-more-than-8-in-10-nursing-homes-face-staffing-shortages-survey/#:%7E">reported staffing shortages</a> in early 2023. SciLine interviewed <a href="https://nursing.nyu.edu/directory/faculty/jasmine-travers">Dr. Jasmine Travers</a>, a gerontological nurse practitioner and assistant professor of nursing at New York University Rory Meyers College of Nursing, and asked her how the shortage affects health care for nursing home residents, if nursing homes in poorer neighborhoods have been hit harder by the shortages, and what can be done to fix the problem.</em></p>
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<figcaption><span class="caption">Dr. Jasmine Travers discussed the impact when nursing homes are short-staffed.</span></figcaption>
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<p><em>Below are some highlights from the discussion. Answers have been edited for brevity and clarity.</em></p>
<p><strong>Who lives in nursing homes in the United States?</strong></p>
<p><strong>Jasmine Travers:</strong> There are 15,000 nursing homes with approximately <a href="https://oig.hhs.gov/reports-and-publications/featured-topics/nursing-homes/">1.2 million residents</a>. That population can range in age, although most commonly it’s those 65 years of age or older.</p>
<p><strong>What is the current state of nursing home staffing?</strong></p>
<p><strong>Jasmine Travers:</strong> In 2001, the Centers for Medicare & Medicaid Services proposed minimum staffing standards. They indicated that total nursing hours should be <a href="https://doi.org/10.1177/1178632920934785">4.1 hours per resident per day</a>. And that’s including the registered nurse, the licensed practical nurse and the certified nursing assistants. Only 25% of nursing homes were found <a href="https://doi.org/10.1111/jgs.17678">to be meeting those total nursing hours</a> in 2019.</p>
<p><strong>How did the COVID-19 pandemic affect nursing home occupancy and staffing?</strong></p>
<p><strong>Jasmine Travers:</strong> Occupancy levels hovered at about 80% prior to the pandemic. During the pandemic, occupancy went down to a low of 67%. By the end of 2022, those levels <a href="https://www.statista.com/statistics/1223881/occupancy-rate-of-certified-nursing-facilities-in-the-united-states/">had gone up to 72%</a>. </p>
<p>Lower occupancy levels can be a significant issue. Higher occupancy brings in more revenue to the nursing homes. With lower occupancy and less revenue coming in, then that’s a decrease in financial support that the nursing home needs to run their day-to-day activities.</p>
<p><strong>How does nursing home staffing affect the quality of care and health outcomes for residents?</strong></p>
<p><strong>Jasmine Travers:</strong> A number of studies show that when staffing is low, <a href="https://doi.org/10.1177/1178632920934785">emergency hospitalization visits</a> increase. Some of these visits could have been addressed by care provided in the nursing home setting. We also see increased instances of <a href="https://doi.org/10.1016/j.jamda.2004.12.003">pressure ulcers</a>, <a href="https://doi.org/10.1093/geronb/55.5.S278">urinary tract infections</a>, <a href="http://dx.doi.org/10.14283/jnhrs.2020.24">falls</a> and <a href="https://doi.org/10.1080/08959420.2011.532011">deficiency citations</a> – issued when a nursing home does not <a href="https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/downloads/SCLetter08-10.pdf">meet a certification minimum standard</a>. </p>
<p>When nursing homes are understaffed, that means there might not be a sufficient number of certified nursing assistants to, for example, answer call bells. That might translate to residents sitting in their beds needing help for longer periods of time. </p>
<p>In those instances, if a person doesn’t have someone to get them out of bed, sometimes they might try to get up themselves. And when they do that, they could be at risk of falling. Or if they stay in bed and they’re soiled, they’re at increased risk for urinary tract infections or pressure ulcers. </p>
<p><strong>What can be done to alleviate nursing home staffing challenges?</strong></p>
<p><strong>Jasmine Travers:</strong> Areas that are socioeconomically deprived or that lack good transportation, housing and schools are less <a href="https://doi.org/10.1111/jgs.17990">desirable places to work</a>. </p>
<p>Just recently, the Centers for Medicare & Medicaid Services released an announcement that they are going to allow for those in pediatric specialties to receive loan reimbursements and loan forgiveness <a href="https://www.hhs.gov/about/news/2023/06/09/hhs-announces-new-15-million-loan-repayment-program-strengthen-pediatric-health-care-workforce.html">for working in underserved areas</a>. A similar program for those working in nursing homes would likely increase staffing. </p>
<p>I’d also like to see improved wages and benefits and more investment in retention efforts to keep the people who are already working in nursing homes working there.</p>
<p>One of the biggest issues when it comes to staffing is turnover. People will stay when the work environment is changed. And when people stay longer, they know their residents more. That consistency translates to better quality of care.</p>
<p>Watch the <em><a href="https://www.sciline.org/health-medicine/nursing-home-staffing/">full interview</a></em> to hear more.</p>
<p><em><a href="https://www.sciline.org/">SciLine</a> is a free service based at the nonprofit American Association for the Advancement of Science that helps journalists include scientific evidence and experts in their news stories.</em></p><img src="https://counter.theconversation.com/content/211398/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jasmine Travers receives funding from Robert Wood Foundation and the National Institutes of Health. </span></em></p>Reduced staffing means nursing home residents make more unnecessary trips to the hospital.Jasmine Travers, Assistant Professor of Nursing, New York UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2025942023-04-12T12:09:29Z2023-04-12T12:09:29ZHuman metapneumovirus, or HMPV, is filling ICUs this spring – a pediatric infectious disease specialist explains this little-known virus<figure><img src="https://images.theconversation.com/files/520067/original/file-20230410-5874-jymbdf.jpg?ixlib=rb-1.1.0&rect=34%2C22%2C7634%2C4207&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Human metapneumovirus, or HMPV, peaks in North America from February to May, just on the heels of flu season.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/doctor-visiting-young-mother-at-home-for-routine-royalty-free-image/1471832871?phrase=children%20lung%20infection&adppopup=true">martin-dm/E+ via Getty Images</a></span></figcaption></figure><p>In the year 2000, Dutch scientists went on a mission of exploration – not to discover lands or riches, but to identify unknown causes of acute respiratory infections. </p>
<p>These illnesses, from the common cold to pneumonia, have been a plague on mankind throughout history. Most are caused by viruses, so if you’ve ever been told “you probably have a virus” by a clinician, they were likely correct. However, respiratory illnesses can be much more severe than simple colds.</p>
<p>Respiratory infections are the <a href="https://doi.org/10.1016/S0140-6736(12)60560-1">leading cause of death in children under 5 globally</a> and a major reason for hospitalization of children in developed countries. They are also a major cause of disease and death among people at high risk for severe disease, such as premature infants, older adults and those with underlying conditions. </p>
<p>However, meticulous research studies by many groups over decades had failed to identify a virus or bacteria in every person with an acute respiratory illness. Did this failure to detect a microbe result from tests that weren’t good enough, or viruses that doctors and scientists didn’t know about? The answer was partly the first; modern molecular tests are much better, so doctors find more known viruses. </p>
<p>But the Dutch group discovered a new virus, <a href="https://doi.org/10.1038/89098">human metapneumovirus</a>, abbreviated HMPV or MPV, which turns out to be a leading cause of respiratory infections. HMPV often presents like other common respiratory viruses, with congestion, cough and fever.</p>
<p>As a <a href="https://www.pediatrics.pitt.edu/people/john-v-williams-md">pediatric infectious disease specialist and virologist</a>, I have led my team in <a href="https://scholar.google.com/citations?user=Bar0h_8AAAAJ&hl=en">HMPV research for over 20 years</a>, and I’ve personally cared for many children with this infection. I’ve received emails from colleagues, clinicians and parents all over the country and the world with questions about severe and tragically fatal cases. </p>
<p>The U.S. saw a <a href="https://www.cdc.gov/surveillance/nrevss/hmpv/natl-trend.html">spike in HMPV detections</a> during the first few months of 2023. This trend is similar to the <a href="https://theconversation.com/rsv-treatments-for-young-children-are-lacking-but-the-record-2022-cold-and-flu-season-highlights-the-urgency-for-vaccines-and-other-preventive-strategies-195700">higher-than-normal case rates</a> of <a href="https://www.cdc.gov/surveillance/nrevss/rsv/natl-trend.html">respiratory syncytial virus, or RSV</a>, and influenza in the fall of 2022 and winter of 2023, likely related to decreased population immunity after two years of wearing face masks and social distancing. </p>
<p>Still, I find that many people even in health care are unfamiliar with this virus.</p>
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<h2>Origins of human metapneumovirus</h2>
<p>The human metapneumovirus was isolated from people with acute respiratory infection and sequenced in 2001 using a combination of specialized culture and molecular techniques.</p>
<p>It is related to RSV, which is the <a href="https://doi.org/10.1136/thoraxjnl-2018-212212">leading cause of serious respiratory infection in children</a> and a major problem in adults. Both viruses are in the same large group with measles, mumps and parainfluenza viruses, all of which are <a href="https://doi.org/10.1128/CMR.00015-11">leading causes of childhood disease</a>. </p>
<p>However, abundant data shows that HMPV is distinct from its cousin RSV in many ways. First, the order of genes in its <a href="https://doi.org/10.1006/viro.2001.1355">genome is quite different</a>. In addition, HMPV is missing two genes that RSV uses to overcome the immune response that would normally target it; yet HMPV has its own ways to <a href="https://doi.org/10.3390/v10090505">block immunity</a>.</p>
<p>Third, genetic analysis by several different groups shows that the <a href="https://doi.org/10.1099/vir.0.2008/006957-0">closest recent ancestor of HMPV</a> is a bird virus, <a href="https://doi.org/10.1099/vir.0.19043-0">avian metapneumovirus</a>. This is an agricultural pathogen of chickens and turkeys. Evolutionary and genetic analysis suggests that the human virus diverged from the bird virus <a href="https://doi.org/10.1371/journal.pone.0152962">several hundred years ago</a>. This is an example of a zoonosis: an <a href="https://theconversation.com/what-is-spillover-bird-flu-outbreak-underscores-need-for-early-detection-to-prevent-the-next-big-pandemic-200494">animal virus that jumps to humans</a>. In this case, HMPV became established as a permanent pathogen of humans. </p>
<p>Understanding how HMPV successfully made the leap might help predict which other animal viruses could be capable of transforming into primary human pathogens. The <a href="https://theconversation.com/as-bird-flu-continues-to-spread-in-the-us-and-worldwide-whats-the-risk-that-it-could-start-a-human-pandemic-4-questions-answered-200204">recent H5N1 bird flu outbreak</a> – which has been transmitted to humans only to a limited extent – illustrates this risk.</p>
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<figcaption><span class="caption">HMPV is a common respiratory illness during the spring months that can cause a narrowing of the airways, a barking cough and other nasty symptoms, particularly in children and older adults.</span></figcaption>
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<h2>HMPV in children</h2>
<p>Despite its being recognized only two decades ago, many studies have confirmed that HMPV is a major cause of respiratory infection in humans. Initial research groups focused on children and quickly discovered that HMPV caused respiratory infections in children worldwide, including <a href="https://doi.org/10.3201/eid0906.030017">Canada</a>, <a href="https://doi.org/10.3201/eid1708.051239">Australia</a>, <a href="https://doi.org/10.1128/JCM.42.1.126-132.2004">Japan</a>, <a href="https://doi.org/10.3201/eid0906.030009">Hong Kong</a>, <a href="https://doi.org/10.1097/INF.0b013e3180621192">South Africa</a> and <a href="https://doi.org/10.1086/383350">Argentina</a>. </p>
<p>Indeed, HMPV is a common cause of acute respiratory disease in children in <a href="https://doi.org/10.1016/S2214-109X(20)30393-4">every country</a> examined, and most children get the infection <a href="https://doi.org/10.1128/JCM.43.3.1213-1219.2005">for the first time by age 5</a>. One study using samples collected over 25 years in the U.S. found that HMPV was the <a href="https://doi.org/10.1056/NEJMoa025472">second most common</a> cause of lung infection in children after RSV. Other studies of multiple children’s hospitals in U.S. cities found that HMPV was the second most common cause of respiratory infections, leading to <a href="https://doi.org/10.1056/NEJMoa1204630">hospitalization</a> and <a href="https://doi.org/10.1056/NEJMoa1405870">pneumonia</a>.</p>
<p>Children with underlying risk factors, such as <a href="https://doi.org/10.2147/RRN.S76270">those born prematurely</a> and those with conditions like <a href="https://doi.org/10.1097/INF.0000000000002038">asthma</a>,
or those who have compromised immune systems, such as organ transplant recipients or children being treated for cancer, are at <a href="https://doi.org/10.1093/jpids/piu100">higher risk for severe HMPV</a>. Most children who become hospitalized with HMPV are otherwise healthy before they acquire it, yet <a href="https://doi.org/10.1093/jpids/piv027">many require intensive care</a> from the illness. </p>
<h2>Not just for kids</h2>
<p>HMPV is also a common cause of <a href="https://doi.org/10.1097/INF.0b013e3181684dac">serious lung infections among adults</a>. This is especially true in adults over 65 years old, or those with underlying conditions. A New York study over four winters found that HMPV was as common in hospitalized older adults as RSV or influenza, <a href="https://doi.org/10.1001/archinte.168.22.2489">with similar rates of ICU care and death</a>. </p>
<p>Studies over three winters in Nashville of adults over age 50 detected <a href="https://doi.org/10.1093/infdis/jis309">rates of HMPV hospitalization</a> and <a href="https://doi.org/10.1111/irv.12234">emergency department visits</a> that were similar to RSV and influenza. HMPV and RSV were more common than the flu in people 65 and older, presumably because many were vaccinated against the flu.</p>
<p>Another national study of adults hospitalized for pneumonia showed that <a href="https://doi.org/10.1056/NEJMoa1500245">HMPV was as common as RSV</a>, and nearly as common as influenza. As in children, HMPV is a particular problem for adults with chronic conditions such as <a href="https://doi.org/10.1086/444392">asthma</a>, <a href="https://doi.org/10.1002/cncr.30599">cancer</a> or <a href="https://doi.org/10.1016/j.jinf.2005.11.010">chronic obstructive pulmonary disease, also called COPD</a>.</p>
<p>Similar to the dire effects of flu and <a href="https://www.politico.com/news/2023/02/15/pandemic-nursing-home-covid-00082913">COVID-19 in nursing homes</a>, HMPV has also caused numerous outbreaks among vulnerable older adults in <a href="https://doi.org/10.3201/eid2502.181298">long-term care facilities</a>.</p>
<h2>Why HMPV is still so underrecognized</h2>
<p>Despite being a common cause of serious respiratory disease, HMPV remains underdiagnosed by clinicians and little recognized by the general population. Most people with an acute respiratory illness don’t get any testing, and if they do, only complex molecular testing can detect HMPV. But this testing is usually done only for hospitalized patients under select circumstances. </p>
<p>People tend to believe what they see, and therefore even health care professionals are most aware of diseases they test for frequently. But HMPV circulates predictably every year, and in North America the <a href="https://doi.org/10.1056/NEJMoa025472">peak is typically February through May</a>. So if you’ve had a cold recently this winter or spring, <a href="https://www.cdc.gov/surveillance/nrevss/hmpv/natl-trend.html">HMPV was a likely culprit</a>. Children’s hospitals around the country are seeing an <a href="https://time.com/6264539/respiratory-virus-not-covid-spring-2023/">increased number of cases</a>, including many in the ICU. Based on past research, this is almost certainly happening in adults too – it’s just that usually only those patients with severe illness are tested for HMPV. </p>
<h2>A dearth of treatments</h2>
<p>Right now, there are no specific antiviral drugs to treat HMPV as there are for flu and COVID-19. As with the many other respiratory viruses that cause colds, most infected people will do just fine with rest and fluids. </p>
<p>But some may develop trouble breathing and need to seek medical attention. Children or adults with serious underlying conditions should be especially careful, and just as with COVID-19, using hand sanitizer and washing hands can <a href="https://theconversation.com/yes-we-should-be-keeping-the-healthier-hand-washing-habits-we-developed-at-the-start-of-the-pandemic-169892">reduce transmission</a>.</p>
<p>Preventive vaccines and antibodies for HMPV are <a href="https://doi.org/10.1128/CVI.00230-15">in development</a> but are still a way off. So, for the moment, wear a mask if you’re sick and avoid others who are sick. You may dodge a repeat engagement with this virus that you’ve had but hadn’t heard of.</p><img src="https://counter.theconversation.com/content/202594/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>John V. Williams receives funding from the NIH and CDC. He previously served on a scientific advisory board for Quidel and an independent data monitoring committee for GlaxoSmithKline, neither related to the subject of the article. </span></em></p>Similar to the patterns seen with COVID-19, flu and RSV, HMPV is making a comeback after years of being repressed by people wearing masks and social distancing.John V. Williams, Professor of Pediatrics, Microbiology and Molecular Genetics, University of PittsburghLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1951812022-12-20T13:38:30Z2022-12-20T13:38:30ZThis course teaches students how to connect with older adults to forge intergenerational bonds and help alleviate loneliness and isolation<figure><img src="https://images.theconversation.com/files/501155/original/file-20221214-13380-s4jucz.jpg?ixlib=rb-1.1.0&rect=59%2C93%2C5631%2C3694&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">When bonds are forged between generations, both the young and the old benefit. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/cheerful-female-nurse-holding-hand-of-senior-woman-royalty-free-image/1356566232?phrase=elderly%20care&adppopup=true">Maskot/DigitalVision via Getty Images</a></span></figcaption></figure><figure class="align-right ">
<img alt="Text saying: Uncommon Courses, from The Conversation" src="https://images.theconversation.com/files/499014/original/file-20221205-17-kcwec8.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/499014/original/file-20221205-17-kcwec8.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=375&fit=crop&dpr=1 600w, https://images.theconversation.com/files/499014/original/file-20221205-17-kcwec8.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=375&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/499014/original/file-20221205-17-kcwec8.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=375&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/499014/original/file-20221205-17-kcwec8.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=471&fit=crop&dpr=1 754w, https://images.theconversation.com/files/499014/original/file-20221205-17-kcwec8.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=471&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/499014/original/file-20221205-17-kcwec8.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=471&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<p><em><a href="https://theconversation.com/topics/uncommon-courses-130908">Uncommon Courses</a> is an occasional series from The Conversation U.S. highlighting unconventional approaches to teaching.</em> </p>
<h2>Title of course</h2>
<p>“Legacy Building with Older Adults – Students Re-Humanizing Health Care”</p>
<h2>What prompted the idea for the course?</h2>
<p>In March 2020 – as the COVID-19 pandemic was causing widespread lockdowns across the U.S. – I heard from a chaplain friend about older adults who were dying in assisted living facilities and skilled nursing homes indirectly because of social isolation and loneliness. </p>
<p>I was finishing my dissertation, focused on developing a curriculum to assist underrepresented and underserved university students. But after hearing about the needs of older adults, I was moved to do something to help them. </p>
<p>So I shifted my focus and geared my curriculum toward bridging the needs of older adults, who are also often underserved, with young people who are learning the principles of health care. </p>
<p>I developed the concept and then piloted it at my alma mater, the University of Toledo, with counseling and pre-med students. I then further developed it to be suitable for a course aimed at connecting university students in health-care-related fields with older adults <a href="https://doi.org/10.1016/j.jagp.2020.08.005">who may feel isolated and alone</a>. </p>
<h2>What does the course explore?</h2>
<p>This course covers issues in social and cultural determinants of health. <a href="https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1">Social determinants of health</a> are the conditions in the environments where people live, play, work, attend community events – and where they age. These environments can influence what decisions people make, and the decisions they make can affect a wide range of health and quality-of-life results. </p>
<p>Students in this course connect with older adults once a week, for one hour, in person, via phone or through virtual visits. Throughout the course, students receive training materials in growth mindset, resiliency, mindfulness and goal-setting both for themselves and for the older adults. Students are also trained in reminiscence therapy, which is an approach to help students guide or support the older adult, reaffirming the value of the adults’ stories as they reminisce. </p>
<p>The sessions that involve discussions between students and older adults focus on building rapport and connecting. They also allow for an older adult to impart wisdom and share stories of their past with the students. At the end of the sessions, the older adult participants receive a digital or physical book – which I call a legacy book – that summarizes the stories the older adult shared with the student, to help reinforce that their story matters. </p>
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<figcaption><span class="caption">“Legacy builders” connect with older adults through phone calls or virtual visits.</span></figcaption>
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<h2>Why is this course relevant now?</h2>
<p>One of the most profound lessons from the pandemic has been that staying connected <a href="https://www.nytimes.com/2018/02/09/opinion/sunday/loneliness-health.html">is important for one’s health</a>. </p>
<p>Emerging research shows how social isolation and loneliness <a href="https://doi.org/10.1002/gps.5647">before and during the COVID-19 pandemic</a> are correlated with <a href="https://doi.org/10.1111/j.1749-6632.2011.06028.x">many physical and mental health problems</a>, including heart disease, diabetes, high blood pressure, heart failure, stroke, dementia, anxiety, depression and suicide. </p>
<p>Researchers estimate that health issues caused by isolation and loneliness <a href="https://doi.org/10.1177/1745691614568352">increase the risk of early death by 26%</a> and have been <a href="https://doi.org/10.17816/CP143">equated to smoking 15 cigarettes a day</a>. One of the major ways to build a foundation for addressing isolation and loneliness is building connection between generations. </p>
<p>Many older adults said the most valuable part of the program for them was the relationship and friendship they developed with their legacy builder. One older adult reported back that it was uplifting to know that she could communicate well with the younger generation, and that she is now more confident in talking with her young adult grandchildren. </p>
<p>Older adults can also learn new technology skills from their legacy builder. Many have started texting for the first time and learned how to send pictures via text. Another learned from her legacy builder to create a Facebook account for herself, and she now stays connected with the student through Facebook. </p>
<h2>What’s a critical lesson from the course?</h2>
<p>The critical lesson that I hope students take away from the course is that every person has value, and it is worthwhile to listen to the person’s stories to understand what they value and why it matters so much. </p>
<p>I want students to learn how they can reinforce the strengths and self-efficacy in another individual by valuing their stories and lived experiences. I also want health care students in particular to understand that those they serve are the experts of their own lived experiences and have a story worth listening to. On top of that, each person has something to be learned from the other. Ultimately, both leave the conversation feeling edified and uplifted. </p>
<h2>What materials does the course feature?</h2>
<p>The content mainly focuses on communication and listening skills, with <a href="https://www.gavinpublishers.com/assets/articles_pdf/Mindfulness-to-Reduce-Loneliness-and-Social-Isolation-in-Older-Adults-A-Scoping-Review.pdf">mindfulness</a>, growth mindset and goal-setting strategies. Emphasis is placed on gaining skills in interviewing, connection and building rapport. </p>
<h2>What will the course prepare students to do?</h2>
<p>The course will prepare students to treat the people they serve and care for as human beings, whether or not the student enters the health care field. </p>
<p>We all are children of someone. We all have birthdays. I believe we all deserve to live a life with a sense of dignity, respect and honor. We all need connection, and, whether it be in health care or everyday life, this is a skill that must not be left out of the curriculum.</p><img src="https://counter.theconversation.com/content/195181/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jeremy Holloway owns a program called Tellegacy that supports student connections with older adults outside of the North and South Dakota area. He receives support through the Department of Geriatrics in the University of North Dakota to provide service and a course for students and older adults in North and South Dakota.</span></em></p>Social isolation and loneliness in aging adults have been linked to numerous physical and mental health ailments. Teaching students how to listen deeply to older people can lessen those effects.Jeremy Holloway, Assistant Professor of Geriatric Education, University of North DakotaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1771382022-02-16T18:56:45Z2022-02-16T18:56:45ZNursing home residents are paying $800 a week for services they are barely getting<figure><img src="https://images.theconversation.com/files/446695/original/file-20220216-19-o4byao.png?ixlib=rb-1.1.0&rect=9%2C76%2C828%2C461&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Juniper Chrystal Halliday Residential Aged Care</span> </figcaption></figure><p>Nursing home residents confined to their rooms during COVID are like hypothetical tenants locked in their bedrooms by landlords – unable to take showers, able only to make only sandwiches for meals and cut off from visitors and socialising with fellow residents.</p>
<p>If it happened to tenants they would be entitled to stop paying rent, go to an appeals tribunal, or move out. But aged care residents have to keep paying.</p>
<p>The Commonwealth has instigated an investigation focusing on death among residents during COVID, but this narrow focus ignores the broader impacts of the pandemic on residents’ quality of life. </p>
<h2>What do residents pay, and for what?</h2>
<p>Residents in aged care homes pay what’s called a <a href="https://www.myagedcare.gov.au/aged-care-home-costs-and-fees">Basic Daily Fee</a>. This is set at 85% of the single age pension to cover meals, laundry and other daily living services. It is currently $53.56 per day.</p>
<p>About half also pay for accommodation on a means tested basis, either as an upfront <a href="https://www.acpc.gov.au/refundable-accommodation-deposit-rad-approvals/about-refundable-accommodation-deposit-rad-approvals">Refundable Accommodation Deposit</a> (RAD) or a rent-like <a href="https://www.myagedcare.gov.au/understanding-aged-care-home-accommodation-costs">Daily Accommodation Payment</a> (DAP). </p>
<p>The RAD is fully refundable 14 days after the resident leaves. The home lives off the interest. The average RAD is less than A$500,000. Some exceed $1 million.</p>
<p>Both the RAD and DAP are set by the provider, within Commonwealth guidelines.</p>
<p>Those entering residential care have <a href="https://www.health.gov.au/sites/default/files/documents/2021/03/the-role-of-refundable-accommodation-deposits.pdf">increasingly</a> opted to pay via the rent-style DAP rather than RAD. </p>
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Read more:
<a href="https://theconversation.com/aged-care-death-and-taxes-after-the-royal-commission-145297">Aged care, death and taxes after the royal commission</a>
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<p>This change appears to reflect increased awareness on the part of incoming residents and their families and advisers that the financial commitment of a RAD may not be the best option if the stay turns out to be shorter rather than longer.</p>
<p>The average length of stay is skewed by some very long stays. While the average stay is almost three years, the median (typical) stay is half as long. About 30% of residents leave within six months, mainly through death.</p>
<p>The Commonwealth pays an accommodation supplement to fully or partly cover the cost of providing accommodation to those who can’t afford either the full RAD or DAP.</p>
<p>Currently $59.49 per day, the supplement is a proxy for the average DAP.</p>
<h2>All up $791.35 a week, but it’s hard to move</h2>
<p>A resident paying the Basic Daily Fee and a Daily Accommodation Charge equal to the supplement pays $791.35 per week. </p>
<p>But for many residents confined to their rooms, the $374.92 per week Basic Daily Fee is for services no longer fully delivered. </p>
<p>For these residents a good deal of the Refundable Accommodation Deposit or Daily Accommodation Payments is for accommodation that cannot be fully used.</p>
<p>There’s an <a href="https://www.agedcarequality.gov.au/about-us">Aged Care Quality and Safety Commission</a> they could complain to. But as each resident has an individual agreement with the provider, it would have to be done one-on-one, rather than collectively. </p>
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<span class="caption">Aged care royal commissioner Lynelle Briggs.</span>
<span class="attribution"><span class="source">Kelly Barnes/AAP</span></span>
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<p>The ability to move has been limited at the best of times. Aside from the emotional upheaval involved, finding a vacancy, making financial arrangements and getting a refund of a RAD takes time. </p>
<p>The Commonwealth, providers and even the Council on the Ageing describe what we’ve got as a “<a href="https://www.health.gov.au/sites/default/files/aged-care-roadmap_0.pdf">consumer driven, market-based aged care system</a>” yet consumers aren’t able to drive. </p>
<p>They lack bargaining power and individual complaints to the <a href="https://www.agedcarequality.gov.au/about-us">Aged Care Quality and Safety Commission</a> are few and far between. No advocates have so far talked of a class action.</p>
<p>A start would be to phase out Refundable Accommodation Deposits as recommended by aged care royal commissioner <a href="https://agedcare.royalcommission.gov.au/publications/final-report-volume-3b">Lynelle Briggs</a> in March 2021.</p>
<p>This would mean residents hadn’t effectively pre-paid their rent as a lump sum.</p>
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Read more:
<a href="https://theconversation.com/1-100-australian-aged-care-homes-are-locked-down-due-to-covid-what-have-we-learnt-from-deaths-in-care-175141">1,100 Australian aged care homes are locked down due to COVID. What have we learnt from deaths in care?</a>
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<p>In the short term, immediate action is needed to ensure no resident pays on-going fees for daily services they are not receiving or for accommodation they can only occupy and use in very restricted ways.</p>
<p>But requiring providers to repay and then forgo even part of these payments might hurt their liquidity, jeopardising their ability to continue to provide care.</p>
<p>Instead, the Commonwealth needs to urgently come up with compensation arrangements and ensure charges are applied only to services that are delivered.</p><img src="https://counter.theconversation.com/content/177138/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anna Howe is affiliated with Australian Labor Party
Have also received grants in the past, but not for about 15 years!,</span></em></p>Residents being charged for accommodation they can’t fully use and services no longer delivered have nowhere to turn.Anna Howe, Honorary Professor, Department of Sociology, Macquarie University, Macquarie UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1737502022-01-21T13:42:57Z2022-01-21T13:42:57ZConflicts between nursing home residents are often chalked up to dementia – the real problem is inadequate care and neglect<figure><img src="https://images.theconversation.com/files/440793/original/file-20220113-23-w6ed7m.jpg?ixlib=rb-1.1.0&rect=42%2C18%2C3977%2C2621&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Conflicts between residents with dementia occur often in long-term care settings.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/assistant-in-the-community-center-giving-advice-to-royalty-free-image/653495116?adppopup=true">CasarsaGuru/E+ via Getty Images</a></span></figcaption></figure><p>Frank Piccolo was a beloved high school chemistry teacher in Ontario, Canada, until his retirement in 1998. “His trademark was to greet all of his students at the door at the start of class to make sure everyone felt welcomed there,” <a href="https://www.saultstar.com/2013/02/21/remembering-frank-piccolo--oconnor">wrote a former student</a>. “He had extensive knowledge of his subject matter, passion for his craft, and empathy for his students.” </p>
<p>But after Frank’s retirement, he developed dementia. When his condition declined, his family moved him to a Toronto nursing home. One evening in 2012, another resident – a woman with dementia – entered Frank’s bedroom. She hit Frank repeatedly in the head and face with a wooden activity board. Staff found Frank slumped over in his wheelchair, drenched in blood. He died three months later. </p>
<p>The Ontario Ministry of Health and Long-Term Care investigated. It found that the woman had a history of pushing, hitting and throwing objects at staff and other residents. But the nursing home didn’t address the woman’s behavioral expressions for weeks before the attack on Piccolo, <a href="https://s3.documentcloud.org/documents/21048374/inspection-report.pdf">the agency determined</a>. “There were no interventions implemented, no strategies developed,” the report stated. </p>
<figure class="align-right ">
<img alt="Frank Piccolo and his wife, Theresa, standing near each othe, on vacation, with a hillside village and the sea behind them." src="https://images.theconversation.com/files/440940/original/file-20220115-27-vtyb52.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/440940/original/file-20220115-27-vtyb52.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/440940/original/file-20220115-27-vtyb52.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/440940/original/file-20220115-27-vtyb52.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/440940/original/file-20220115-27-vtyb52.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/440940/original/file-20220115-27-vtyb52.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/440940/original/file-20220115-27-vtyb52.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Frank Piccolo and his wife, Theresa, traveling together in Italy in 2001.</span>
<span class="attribution"><span class="source">Theresa Piccolo</span>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span>
</figcaption>
</figure>
<p>As a gerontologist and <a href="http://dementiabehaviorconsulting.com">dementia behavior specialist</a>, I’ve <a href="https://www.healthpropress.com/product/understanding-and-preventing-harmful-interactions-between-residents-with-dementia/">written a book</a> on preventing these incidents. I also co-directed, with dementia care expert Judy Berry, a documentary on the phenomenon called “<a href="https://terranova.org/film-catalog/fighting-for-dignity-a-film-on-injurious-and-fatal-resident-to-resident-incidents-in-long-term-care-home">Fighting for Dignity</a>.” The film sheds light on the emotional trauma experienced by family members of residents harmed during these episodes in U.S. long-term care homes. </p>
<h2>Reporting and stigmatizing</h2>
<p><a href="https://doi.org/10.1111/j.1532-5415.2008.01808.x">Resident-to-resident incidents</a> are defined by researchers as “negative, aggressive and intrusive verbal, physical, material and sexual interactions between residents” that can cause “psychological distress and physical harm in the recipient.” </p>
<p>These incidents <a href="https://doi.org/10.7326/M15-1209">are prevalent</a> in U.S. nursing homes. But they are <a href="https://www.statnews.com/2021/11/29/resident-to-resident-incidents-hidden-source-nursing-home-harm/">largely overlooked</a> by the Centers for Medicare and Medicaid Services, the federal agency overseeing care in approximately 15,000 nursing homes across the country. Consequently, such incidents <a href="https://doi.org/10.1080/08946566.2017.1333939">remain untracked</a>, <a href="https://doi.org/10.1016/j.jamda.2015.10.003">understudied</a> and largely unaddressed.</p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/440941/original/file-20220115-18-1qy7een.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="An elderly man with severe injuries, including cut marks and bruises, across his face and forehead." src="https://images.theconversation.com/files/440941/original/file-20220115-18-1qy7een.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/440941/original/file-20220115-18-1qy7een.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=800&fit=crop&dpr=1 600w, https://images.theconversation.com/files/440941/original/file-20220115-18-1qy7een.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=800&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/440941/original/file-20220115-18-1qy7een.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=800&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/440941/original/file-20220115-18-1qy7een.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1005&fit=crop&dpr=1 754w, https://images.theconversation.com/files/440941/original/file-20220115-18-1qy7een.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1005&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/440941/original/file-20220115-18-1qy7een.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1005&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Frank Piccolo sustained severe injuries to his face and head after a woman with dementia entered his bedroom and hit him repeatedly with an activity board.</span>
<span class="attribution"><span class="source">Theresa Piccolo</span>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span>
</figcaption>
</figure>
<p>These interactions don’t just result <a href="https://doi.org/10.1001/jama.291.5.591">in injuries</a>
<a href="https://doi.org/10.1177/0733464819863926">and deaths</a> among residents. They also leave behind devastated families who then must <a href="https://www.washingtonpost.com/business/2021/08/20/nursing-home-immunity-covid-lawsuits">fight for answers</a> and accountability from nursing homes.</p>
<p>Making matters worse, <a href="https://www.gao.gov/products/gao-19-433">government reports</a>, <a href="https://doi.org/10.1017/S0714980815000094">research studies</a> and <a href="https://doi.org/10.1177/1471301220981232">media coverage</a> commonly describe these episodes with words that stigmatize people with dementia. Researchers, public officials and journalists tend to <a href="https://www.startribune.com/when-senior-home-residents-are-abusers-minnesota-rarely-investigates/450625693/">label the incidents as “abuse</a>,” “violence” and “aggression.” They call a resident involved in an incident a “perpetrator” or an “aggressor.” News outlets described the attack on Piccolo by the woman with dementia as “aggressive” or “violent.” And when reporting on <a href="https://www.thestar.com/news/gta/2013/02/09/more_than_10000_canadians_abused_annually_by_fellow_nursing_home_residents.html">the phenomenon</a> in Canada, the Toronto Star called it “abuse.” </p>
<h2>Getting to the root of the real problem</h2>
<p>Most incidents, however, do not constitute abuse. A growing body of evidence suggests the true cause of these injuries and deaths is inadequate care and neglect on the part of care homes. Specifically, there is a lack of the specialized care that people with dementia require. </p>
<p>Two of every three residents <a href="https://doi.org/10.1016/j.jamda.2021.02.009">involved in these incidents</a> have dementia. One study found that the rate of these episodes was nearly <a href="https://doi.org/10.1001/jama.291.5.591">three times higher</a> in dementia care homes than in other long-term care homes. A recent study also found <a href="https://doi.org/10.7326/m15-1209">an association</a> between residency in a dementia care home and higher rates of injurious or fatal interactions between residents. </p>
<p>But for these residents, the conflicts occur mostly when their emotional, medical and other needs are not met. When they reach a breaking point in frustration related to the unmet need, they may push or hit another resident. My research in the U.S. and Canada has shown that <a href="https://doi.org/10.1080/08946566.2018.1474515">“push-fall” episodes</a> constitute nearly half of fatal incidents. </p>
<p>Another U.S. study found that as residents’ cognitive functioning declined, they faced <a href="https://doi.org/10.1001/jama.291.5.591">a greater likelihood</a> of injury in these incidents. Those with advanced dementia were more susceptible to inadvertently “getting in harm’s way,” by saying or doing things that trigger angry reactions in other residents. </p>
<p>The Centers for Disease Control and Prevention has stated that what it calls “aggression” between residents <a href="https://www.cdc.gov/violenceprevention/pdf/ea_book_revised_2016.pdf">is not abuse</a>. Instead, the CDC noted that these episodes may result when care homes fail to prevent them by taking adequate action. And a study on <a href="https://doi.org/10.1177/0733464819863926">fatal incidents</a> in U.S. nursing homes has shown that many residents were “deemed to lack cognitive capacity to be held accountable for their actions.” </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/gk5iEo-s_6M?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">An undercover yearlong investigation into nursing homes in Ontario, Canada, revealed shocking instances of abuse and neglect by staff members.</span></figcaption>
</figure>
<h2>How incidents often occur</h2>
<p>In one study, researchers examined <a href="https://doi.org/10.1177/1054773813477128">situational triggers</a> among residents with cognitive impairments. The strongest triggers involved personal space and possessions. Examples include taking or touching a resident’s belongings or food, or unwanted entries into their bedroom or bathroom. The most prevalent triggering event was someone being too close to a resident’s body. </p>
<p>That study also found that crowded spaces and interpersonal stressors, such as two residents claiming the same dining room seat, could lead to these episodes. <a href="https://doi.org/10.1177/1471301213502588">My own work</a> and a different <a href="https://doi.org/10.1177%2F0733464820955089">Canadian study</a> came to similar conclusions.</p>
<p>Other research shows that when residents are bored or lack <a href="https://doi.org/10.1177%2F153331750502000210">meaningful activity</a>, they become involved in <a href="https://doi.org/10.1177%2F1471301213502588">harmful interactions</a>. Evenings and weekends can be particularly dangerous, with fewer organized activities and fewer staff members and managers present. <a href="https://doi.org/10.1080/08946566.2018.1474515">Conflicts between roommates</a> are also common and harmful. </p>
<figure class="align-center ">
<img alt="With a smiling staff member looking on, two nursing home residents enjoy conversation while having coffee." src="https://images.theconversation.com/files/438566/original/file-20211220-49721-z6ev8m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/438566/original/file-20211220-49721-z6ev8m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/438566/original/file-20211220-49721-z6ev8m.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/438566/original/file-20211220-49721-z6ev8m.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/438566/original/file-20211220-49721-z6ev8m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/438566/original/file-20211220-49721-z6ev8m.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/438566/original/file-20211220-49721-z6ev8m.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Residents with dementia who are meaningfully engaged in activities are less likely to become involved in harmful incidents with other residents.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/caretaker-with-senior-people-in-nursing-home-royalty-free-image/489582967?adppopup=true">Morsa Images/DigitalVision via Getty Images</a></span>
</figcaption>
</figure>
<p>A growing body of research suggests that most incidents between residents are preventable. A major risk factor, for example, is lack of adequate supervision, which often occurs when staff are assigned to caring for too many residents with dementia. One U.S. study found that <a href="https://doi.org/10.7326/M15-1209">higher caseloads</a> among nurses’ aides were associated with higher incident rates. </p>
<p>And with <a href="https://doi.org/10.4137/hsi.s38994">poor staffing levels</a> in up to half of U.S. nursing homes, <a href="https://doi.org/10.1080/08946566.2018.1474515">staff members do not witness</a> many incidents. In fact, one study found that staff members missed the majority of unwanted <a href="https://doi.org/10.1080/13607863.2016.1211620">bedroom entries</a> by residents with severe dementia. </p>
<h2>Residents with dementia are not to blame</h2>
<p>In most of these situations, the person with dementia does not intend to injure or kill another resident. Individuals with dementia live with a serious cognitive disability. And they often must do it while being forced to share small living spaces with many other residents. </p>
<p>Their behavioral expressions are often attempts to cope with frustrating and frightening situations in their social and physical environments. They are typically the result of unmet human needs paired with cognitive processing limitations. </p>
<p>Understanding the role of dementia is important. But seeing a resident’s brain disease as the main cause of incidents is inaccurate and unhelpful. That view ignores external factors that can lead to these incidents but are outside of the residents’ control.</p>
<p>Frank’s wife, Theresa, didn’t blame the woman who injured her husband or the staff. She blamed the for-profit company operating the nursing home. Despite its revenue of $2 billion in the year before the incident, it failed in its “<a href="https://www.thestar.com/news/gta/2013/02/09/more_than_10000_canadians_abused_annually_by_fellow_nursing_home_residents.html">duty to protect</a>” Piccolo. “They did not keep my husband safe as they are required to do,” she said.</p><img src="https://counter.theconversation.com/content/173750/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>I am a founding member and board member of Elder Voice Family Advocates in Minnesota. </span></em></p>Research shows that violence between patients is prevalent, often overlooked and largely unaddressed.Eilon Caspi, Assistant Research Professor of Health, Intervention, and Policy, University of ConnecticutLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1745352022-01-19T18:59:21Z2022-01-19T18:59:21ZConfusion, financial pressure, discomfort: older people can struggle with sustainable living, despite its obvious benefits<figure><img src="https://images.theconversation.com/files/441439/original/file-20220119-27-1mu2wkd.jpg?ixlib=rb-1.1.0&rect=250%2C571%2C4967%2C2902&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Improving the sustainability of Australia’s housing stock is <a href="https://www.google.com/search?client=safari&rls=en&q=building+sector+australia+emissions+the+conversation&ie=UTF-8&oe=UTF-8">crucial</a> to meeting national emissions reduction goals. But for older adults, such changes can bring both benefits and challenges.</p>
<p>My <a href="https://www.sciencedirect.com/science/article/abs/pii/S0360132321007344">recent research</a> examined the literature on environmental sustainability measures at residences for older adults. These included private homes, retirement villages and nursing homes.</p>
<p>I found that while sustainability measures can bring multiple benefits to older people, they also bring challenges. For example, people living in sustainable dwellings may use less energy and water which leads to lower bills. But older people may suffer cognitive decline and struggle to use sustainable technology devices. </p>
<p>The full effects of environmentally sustainable features must be better understood if we’re to provide seniors with high-quality residential environments.</p>
<figure class="align-center ">
<img alt="Older man walks down corridor" src="https://images.theconversation.com/files/441440/original/file-20220119-15-60lcsc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/441440/original/file-20220119-15-60lcsc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=393&fit=crop&dpr=1 600w, https://images.theconversation.com/files/441440/original/file-20220119-15-60lcsc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=393&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/441440/original/file-20220119-15-60lcsc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=393&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/441440/original/file-20220119-15-60lcsc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=493&fit=crop&dpr=1 754w, https://images.theconversation.com/files/441440/original/file-20220119-15-60lcsc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=493&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/441440/original/file-20220119-15-60lcsc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=493&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Sustainability measures can bring benefits and challenges to older people.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<h2>Sustainability and ageing: a complex mix</h2>
<p>Forecasts suggest that by 2056, <a href="https://www.aihw.gov.au/reports-data/population-groups/older-people/overview">22% of Australians</a> – or 8.7 million people – will be aged 65 or older. High-quality residential environments are important to maintaining the welfare of these people as they age. </p>
<p>Environmental sustainability is playing an ever greater role in residential development across the board, including retirement villages. And <a href="https://www.hindawi.com/journals/jar/2014/919054/">previous research</a> suggests most retirement village residents want to lead more sustainable lifestyles.</p>
<p>As climate change worsens, the dwellings of older adults should allow them to adapt to these changing conditions. The reduced ability of elderly people to regulate their body temperature means global warming is a profound threat to this group.</p>
<p>Improving the sustainability of a residential environment may include:</p>
<ul>
<li>reducing waste</li>
<li>using low carbon or recycled building materials</li>
<li>solar passive design</li>
<li>efficient heating and cooling</li>
<li>using renewable energy such as rooftop solar.</li>
</ul>
<p><a href="https://new.gbca.org.au/case-studies/building/stockland-takes-sustainability-retirement-living/">Some residential projects</a> for the elderly already include environmental sustainability. A <a href="https://www.emerald.com/insight/content/doi/10.1108/F-08-2011-0060/full/html">case study</a> of a not-for-profit retirement village in South Australia revealed practices such as innovative floor plans, thermally efficient building materials, good window orientation and a water harvesting system.</p>
<p>And my previous research <a href="https://www.sciencedirect.com/science/article/abs/pii/S0959652619341605">found</a> a range of sustainability features at eight private and not-for-profit retirement villages in Queensland.</p>
<p>However, while many retirement village developers prioritise “social sustainability” features such as care provision and social interaction, environmental sustainability is <a href="https://www.sciencedirect.com/science/article/abs/pii/S0959652617313963">largely ignored</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/intergenerational-report-to-show-australia-older-smaller-in-debt-163474">Intergenerational report to show Australia older, smaller, in debt</a>
</strong>
</em>
</p>
<hr>
<figure class="align-center ">
<img alt="elderly woman holds hands of carer" src="https://images.theconversation.com/files/441450/original/file-20220119-25-1qtv5d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/441450/original/file-20220119-25-1qtv5d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/441450/original/file-20220119-25-1qtv5d.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/441450/original/file-20220119-25-1qtv5d.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/441450/original/file-20220119-25-1qtv5d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/441450/original/file-20220119-25-1qtv5d.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/441450/original/file-20220119-25-1qtv5d.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Forecasts suggest that by 2056, 22% of Australians will be aged 65 or older.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<h2>On the plus side</h2>
<p>The benefits of environmentally sustainable features in in older adults’ residential environment include:</p>
<p><strong>- reduced resource consumption:</strong> sustainable dwellings usually require less water and energy use, which lowers living costs. This is especially important for older adults who often have reduced financial capacity after retirement. Older people also use energy <a href="https://www.sciencedirect.com/science/article/abs/pii/S0301421597000402">more intensively</a> than other groups because they have fewer household members, greater heating requirements and spend more time at home. </p>
<p><strong>- reduced health risks:</strong> environmentally sustainable measures can lead to healthier indoor environments. For example, good ventilation and high-quality air conditioning often lead to improved indoor air quality and more comfortable ambient temperatures.</p>
<p><strong>- alleviated environmental challenges:</strong> many older people want their homes to be more environmentally friendly. Doing their bit to alleviate global problems such as greenhouse gas emissions can provide them with peace of mind.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-great-australian-dream-new-homes-in-planned-estates-may-not-be-built-to-withstand-heatwaves-166266">The Great Australian Dream? New homes in planned estates may not be built to withstand heatwaves</a>
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</em>
</p>
<hr>
<figure class="align-center ">
<img alt="elderly person's hands on heater" src="https://images.theconversation.com/files/441438/original/file-20220119-15-124namg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/441438/original/file-20220119-15-124namg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/441438/original/file-20220119-15-124namg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/441438/original/file-20220119-15-124namg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/441438/original/file-20220119-15-124namg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/441438/original/file-20220119-15-124namg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/441438/original/file-20220119-15-124namg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Sustainable dwellings usually require less water and energy use,</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<h2>The potential downsides</h2>
<p>The challenges of environmentally sustainable home features for older adults include:</p>
<p><strong>- financial pressure:</strong> the income of many older adults is substantially reduced after retirement. This <a href="https://www.sciencedirect.com/science/article/abs/pii/S0301421511005222">can conflict</a> with the high initial investment of developing an sustainable housing and the cost of replacing existing systems with sustainable ones.</p>
<p><strong>- reducing energy consumption:</strong> in some cases, sustainability measures can involve tolerating slightly higher or cooler temperatures. For example, moving from a gas-heating system to a more sustainable type may <a href="https://www.sciencedirect.com/science/article/pii/S0301421515001172">delay</a> the arrival of heat in a room and leave older people uncomfortable for a short time. This may conflict with older people’s <a href="https://ideas.repec.org/a/eee/enepol/v84y2015icp250-256.html">increased sensitivity</a> to ambient temperatures.</p>
<p><strong>- confusion and complexity:</strong> Older adults can have <a href="https://academic.oup.com/bmb/article/92/1/135/332828">reduced cognitive capabilities</a> affecting memory and information processing speed. As a result they may struggle to use sustainable technologies such as smart thermostats. Research has <a href="https://www.sciencedirect.com/science/article/abs/pii/S0301421514006259">suggested</a> ways of overcoming this, such as better recognising the diversity of older adults to achieve a better “person-technology fit”.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/buildings-produce-25-of-australias-emissions-what-will-it-take-to-make-them-green-and-wholl-pay-105652">Buildings produce 25% of Australia's emissions. What will it take to make them 'green' – and who'll pay?</a>
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</p>
<hr>
<figure class="align-center ">
<img alt="Four older women shelter from the sun under umbrella" src="https://images.theconversation.com/files/441437/original/file-20220119-25-fkfanl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/441437/original/file-20220119-25-fkfanl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=407&fit=crop&dpr=1 600w, https://images.theconversation.com/files/441437/original/file-20220119-25-fkfanl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=407&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/441437/original/file-20220119-25-fkfanl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=407&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/441437/original/file-20220119-25-fkfanl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=512&fit=crop&dpr=1 754w, https://images.theconversation.com/files/441437/original/file-20220119-25-fkfanl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=512&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/441437/original/file-20220119-25-fkfanl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=512&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Older people may have increased sensitivity to hot or cold temperatures.</span>
<span class="attribution"><span class="source">Paul Miller/AAP</span></span>
</figcaption>
</figure>
<h2>Next steps</h2>
<p>Older adults have unique needs which their homes <a href="https://www.sciencedirect.com/science/article/abs/pii/S0360132321007344">must satisfy</a>, even when sustainability features are being adopted. </p>
<p>Ageing should be seen as a dynamic process with physical, psychological and social dimensions. And the complex interrelationships of ageing, environmental sustainability and the residential environment also need to be recognised.</p>
<p>Best practices and lessons learned in creating sustainable living environments for older adults should be <a href="https://www.sciencedirect.com/science/article/abs/pii/S0959652618325241">shared</a>. </p>
<p>Finally, developers making sustainability decisions should consult other stakeholders. These include contractors, occupational therapists, researchers and most importantly, older adults themselves.</p><img src="https://counter.theconversation.com/content/174535/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Xin Hu does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>People living in sustainable dwellings may use less energy and water which leads to lower bills. But older people may suffer cognitive decline and struggle to use sustainable technology devices.Xin Hu, Lecturer, School of Architecture and Built Environment, Deakin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1706202021-11-11T15:42:10Z2021-11-11T15:42:10ZCanadians want home care, not long-term care facilities, after COVID-19<figure><img src="https://images.theconversation.com/files/431304/original/file-20211110-27-1tvfyy6.jpg?ixlib=rb-1.1.0&rect=0%2C345%2C4193%2C2628&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">People protest outside the Tendercare Living Centre long-term care facility during the COVID-19 pandemic in Scarborough, Ont., in December 2020. </span> <span class="attribution"><span class="source">THE CANADIAN PRESS/Nathan Denette </span></span></figcaption></figure><iframe style="width: 100%; height: 175px; border: none; position: relative; z-index: 1;" allowtransparency="" src="https://narrations.ad-auris.com/widget/the-conversation-canada/canadians-want-home-care--not-long-term-care-facilities--after-covid-19" width="100%" height="400"></iframe>
<p>The COVID-19 pandemic has shed light on the precarious living conditions of the elderly in nursing homes in Canada.</p>
<p>During the first wave of the pandemic, from March to August 2020, more than 80 per cent of Canadian COVID-19 deaths were tied to nursing and seniors’ homes, according to the <a href="https://www.cihi.ca/sites/default/files/document/covid-19-rapid-response-long-term-care-snapshot-en.pdf">Canadian Institute for Health Information</a>. </p>
<p>The pandemic put nursing homes in the spotlight in terms of how they’ve been managed, their lack of staff and COVID-19’s impact on the living conditions of the dependent elderly people who reside within them.</p>
<figure class="align-center ">
<img alt="A person on a stretcher is placed into the back of an ambulance." src="https://images.theconversation.com/files/431302/original/file-20211110-23-1ci2z6l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/431302/original/file-20211110-23-1ci2z6l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=433&fit=crop&dpr=1 600w, https://images.theconversation.com/files/431302/original/file-20211110-23-1ci2z6l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=433&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/431302/original/file-20211110-23-1ci2z6l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=433&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/431302/original/file-20211110-23-1ci2z6l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=544&fit=crop&dpr=1 754w, https://images.theconversation.com/files/431302/original/file-20211110-23-1ci2z6l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=544&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/431302/original/file-20211110-23-1ci2z6l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=544&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Paramedics take away a person from Revera Westside Long Term Care Home during the COVID-19 pandemic in Toronto in December 2020.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Nathan Denette</span></span>
</figcaption>
</figure>
<p>COVID-19 and the media coverage of the crisis in long-term care have raised public awareness about the risks associated with such facilities. It may have also permanently affected perceptions and preferences when it comes to long-term care.</p>
<p>In the fall of 2020, we partnered with <a href="https://portal.askingcanadiansprojects.com/">Asking Canadians</a>, a Canadian online panel survey organization, to conduct a poll of more than 3,000 people in Ontario and Québec between 50 and 69 years old. The goal was to learn how the pandemic had affected their views on long-term care.</p>
<p><a href="https://ire.hec.ca/wp-content/uploads/2021/09/cahier_IRE_7_nursing_home_aversion_post_pandemic_savings_long_term_care.pdf">The survey</a> asked questions about long-term care preferences and whether respondents were more supportive of home care because of COVID-19.</p>
<h2>Majority want to avoid nursing homes</h2>
<p>The survey shows the pandemic has dramatically changed perceptions, preferences and ultimately the financial behaviour of Canadians when it comes to long-term care. </p>
<p>A full 72 per cent of our respondents said they were less inclined to enter a nursing home, and 70 per cent of them said the pandemic caused them serious concerns about exposure to health risks in long-term care facilities.</p>
<p>At the same time, about 25 per cent said they planned to save more for old age because of COVID-19 and their desire to avoid entering nursing homes in favour of home care.</p>
<p>Lastly, we observed strong support for tax policy that would subsidize home care, with 70 per cent of respondents calling for it. This increased support for home-care policies in the post-pandemic era is driven by the desire to avoid entering nursing homes.</p>
<p>At its essence, our study shows the COVID-19 pandemic has made Canadians fear sub-standard living conditions in nursing homes and has made them realize the urgency of finding adequate care alternatives and solutions for our elderly population. We can only hope that policy-makers use this opportunity to address the issue.</p>
<figure class="align-center ">
<img alt="A woman sits in her room at a seniors' residence, blinds drawn." src="https://images.theconversation.com/files/338770/original/file-20200601-83297-19rjf36.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/338770/original/file-20200601-83297-19rjf36.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=438&fit=crop&dpr=1 600w, https://images.theconversation.com/files/338770/original/file-20200601-83297-19rjf36.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=438&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/338770/original/file-20200601-83297-19rjf36.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=438&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/338770/original/file-20200601-83297-19rjf36.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=551&fit=crop&dpr=1 754w, https://images.theconversation.com/files/338770/original/file-20200601-83297-19rjf36.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=551&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/338770/original/file-20200601-83297-19rjf36.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=551&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A resident sits in her room at a seniors’ residence in Montréal in January 2020.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Ryan Remiorz</span></span>
</figcaption>
</figure>
<h2>The global population is aging</h2>
<p>The findings of our survey provide important information for any country with aging populations and increasing health needs. According to <a href="https://www.oecd.org/els/health-systems/help-wanted-9789264097759-en.htm">a study by the Organization for Economic Co-operation and Development</a>, the number of people aged 80 and above is expected to grow from four per cent of the total OECD population in 2010 to 10 per cent in 2050. </p>
<p>Canada is not exempt from this trend. The number of people in Québec who need help with the activities of daily living is likely to almost double <a href="https://creei.ca/financement-soutien-autonomie-personnes-agees-croisee-chemins/">from 315,000 in 2020 to more than 600,000 in 2050</a>. </p>
<figure class="align-left ">
<img alt="A woman assists an elderly man sitting in a chair by a window." src="https://images.theconversation.com/files/431307/original/file-20211110-19-3gw3o5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/431307/original/file-20211110-19-3gw3o5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/431307/original/file-20211110-19-3gw3o5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/431307/original/file-20211110-19-3gw3o5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/431307/original/file-20211110-19-3gw3o5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/431307/original/file-20211110-19-3gw3o5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/431307/original/file-20211110-19-3gw3o5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Canadians want home care, but it’s expensive.</span>
<span class="attribution"><span class="source">(Pexels)</span></span>
</figcaption>
</figure>
<p>COVID-19 has caused both policy-makers and the population in general to think about alternative solutions to nursing home care, particularly home care. But home care is expensive, even when governmental subsidies exist — <a href="https://www.clhia.ca/web/CLHIA_LP4W_LND_Webstation.nsf/resources/Consumer+Brochures/$file/Brochure_Guide_Long_Term_Care_ENG.pdf">it has a much heftier price tag than public nursing home care</a>.</p>
<p>And for those who don’t have family members who can provide informal care, public long-term care homes are often their only choice.</p>
<p>The pandemic has forced society to question the appeal and expense of home care versus long-term care facilities. Canadians who want to opt for home care will need to start saving for retirement accordingly in case they become dependent and want to avoid nursing homes.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/after-covid-19s-tragic-toll-canada-must-improve-quality-of-life-in-long-term-care-homes-139763">After COVID-19's tragic toll, Canada must improve quality of life in long-term care homes</a>
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<hr>
<p>Policy-makers must also develop adequate long-term care standards to ensure a deadly disaster like the one that occurred during the COVID-19 pandemic doesn’t happen again. That will require building new, safer nursing homes and adequately staffing them, training long-term care workers in safety and sanitation protocols and paying them a better wage.</p>
<p>But our survey shows Canadians would overwhelmingly prefer home care options as they age. Governments must make home care a viable option for their aging citizens by making it more affordable via a variety of means, including subsidies and tax exemptions.</p><img src="https://counter.theconversation.com/content/170620/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Leroux Marie-Louise receives funding from FRQSC and SSHRC-CRSH. </span></em></p><p class="fine-print"><em><span>Bertrand Achou receives funding from SSHRC-CRSH. </span></em></p><p class="fine-print"><em><span>Franca Glenzer receives funding from SSHRC-CRSH. </span></em></p><p class="fine-print"><em><span>Minjoon Lee and Philippe De Donder do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A study shows the COVID-19 pandemic has made Canadians fear sub-standard and dangerous living conditions in nursing homes. They want home care, and tax policies that will support it.Marie-Louise Leroux, Professeure titulaire en Sciences Economiques, Université du Québec à Montréal (UQAM)Bertrand Achou, Associate Researcher, Economics, HEC MontréalFranca Glenzer, Assistant Professor, Retirement and Savings, HEC MontréalMinjoon Lee, Assistant Professor, Economics, Carleton UniversityPhilippe De Donder, Research director, Toulouse School of Economics – École d'Économie de ToulouseLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1697342021-10-18T06:12:03Z2021-10-18T06:12:03ZAged care staff urgently need training to report and prevent sexual assault<figure><img src="https://images.theconversation.com/files/426822/original/file-20211018-27-1nzhgi2.jpg?ixlib=rb-1.1.0&rect=33%2C44%2C7315%2C4858&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://image.shutterstock.com/image-photo/azerbaijan-baku-october-15-2017-600w-768686728.jpg">Shutterstock</a></span></figcaption></figure><p>An estimated <a href="https://www.abc.net.au/news/2020-10-22/aged-care-royal-comm-told-of-50-sex-assaults-a-week/12801806">50 sexual assaults</a> occur nationally every week in Australian residential aged care facilities. Despite this shocking figure, none of the Aged Care Royal Commission’s <a href="https://agedcare.royalcommission.gov.au/publications/final-report">148 recommendations</a> released earlier this year specifically address the prevention of sexual violence. </p>
<p>Our recent <a href="https://pubmed.ncbi.nlm.nih.gov/34399034/">study</a>, published in the International Journal of Older Persons Nursing, found two-thirds of aged care staff had not received any training in prevention of sexual violence in the previous 12 months. Staff confirmed aged care approved providers often do not have dedicated or specific procedures to prevent or manage incidents.</p>
<p>Failing to combat sexual violence in aged care homes demonstrates an apathy towards older survivors and reinforces the existing difficulties faced by older people to achieve a basic human right: to live free from sexual violence.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/4-key-takeaways-from-the-aged-care-royal-commissions-final-report-156109">4 key takeaways from the aged care royal commission's final report</a>
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<hr>
<h2>Reacting, not preventing</h2>
<p>Australia’s approach to preventing sexual violence in aged care focuses on mandatory reporting obligations set down by the <a href="https://www.agedcarequality.gov.au/sirs">Aged Care Quality and Safety Commission</a>. The rules require staff to define “victim impact” and “incident seriousness”. This approach lacks a scientific basis and deprives the older person of their autonomy – a right included prominently in the Royal Commission recommendations. It also shifts responsibility of complex social, legal and health issues unfairly onto care staff.</p>
<p>In response to the concerns from the aged care sector about how to apply the new rule, this month the regulator released the <a href="https://www.agedcarequality.gov.au/sirs/decision-support-tool/unlawful-sexual-contact">unlawful sexual contact decision support tool</a>. This tool seeks to define incidents as “Priority 1” or “Priority 2” according to how staff, not the survivor, have the perceived seriousness.</p>
<p>Criminal acts of sexual violence, including those perpetrated by staff members, may fall under the tool’s less urgent category – if the resident doesn’t require medical or psychological treatment as judged by the person using the tool. This means reporting to the regulator only needs to occur within a 30-day period. The longer reporting period could put others in danger and cause distress to residents and co-workers.</p>
<p>The regulator <a href="https://www.abc.net.au/radio/programs/worldtoday/anger-over-new-online-sexual-assault-reporting-tool-in-aged-care/13572522">has argued</a> there’s an expectation aged care providers will report any “serious” incident immediately to police and to the regulator. In a statement, the Aged Care Quality and Safety Commission told the ABC this was covered by the question: “Are there reasonable grounds to report the incident to the police?”</p>
<p>However, an earlier <a href="https://www.health.gov.au/resources/publications/prevalence-study-for-a-serious-incident-response-scheme-sirs">report commissioned from KPMG</a> into the prevalence of abuse between aged care residents found aged staff reported no (58.1%) or minor (35%) physical or psychological impact afterwards for those raped or otherwise sexually assaulted survivors. </p>
<p>This report also revealed only 3 of the 1,259 incidents deemed Priority 1 or “very serious” were reported to the police. Although this was before the advent of the decision tool, it highlights the dangers of placing responsibility on individual staff members with inadequate training. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1445149603683201031"}"></div></p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/only-3-8-of-australian-aged-care-homes-would-meet-new-mandatory-minimum-staffing-standards-new-research-165877">Only 3.8% of Australian aged care homes would meet new mandatory minimum staffing standards: new research</a>
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<hr>
<h2>Expecting aged care staff to do forensic work</h2>
<p>A fundamental flaw in this tool is that it assumes certain capabilities of aged care staff. </p>
<p>What constitutes reasonable grounds to report to police is a complicated forensic concept. In the aged care setting, incidents of sexual violence may involve both a survivor and a perpetrator with <a href="https://pubmed.ncbi.nlm.nih.gov/30469073/">cognitive impairment</a>. This adds to the already difficult task of “proving” an act of sexual violence has occurred. When the crime involves staff assaulting a resident, <a href="https://humanrights.gov.au/our-work/part-2-sexual-harassment-perspective-bystanders">bystander stress</a> and the daunting task of reporting a co-worker add further complexity. </p>
<p>Asking aged care staff to take on decisions that require policing expertise is dangerous.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/426821/original/file-20211018-57123-1nshi9r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="woman cries in hands" src="https://images.theconversation.com/files/426821/original/file-20211018-57123-1nshi9r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/426821/original/file-20211018-57123-1nshi9r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/426821/original/file-20211018-57123-1nshi9r.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/426821/original/file-20211018-57123-1nshi9r.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/426821/original/file-20211018-57123-1nshi9r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/426821/original/file-20211018-57123-1nshi9r.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/426821/original/file-20211018-57123-1nshi9r.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Asking care staff to determine victim impact is a problem.</span>
<span class="attribution"><a class="source" href="https://images.unsplash.com/photo-1456162018889-1d2b969f7084?ixlib=rb-1.2.1&ixid=MnwxMjA3fDB8MHxwaG90by1wYWdlfHx8fGVufDB8fHx8&auto=format&fit=crop&w=2073&q=80">Unsplash/Danie Franco</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/its-hard-to-think-about-but-frail-older-women-in-nursing-homes-get-sexually-abused-too-107013">It's hard to think about, but frail older women in nursing homes get sexually abused too</a>
</strong>
</em>
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<h2>Tailored training could help</h2>
<p>At the Health, Law and Ageing Research Unit we have developed an <a href="https://www.monash.edu/__data/assets/pdf_file/0008/2535758/PREVENTING_UNWANTED_SEXUAL_BEHAVIOUR_IN_RESIDENTIAL_AGED_CARE_SERVICES.pdf">e-training intervention</a> to improve sexual violence incident detection, management and prevention. It aims to promote collaboration with expert dementia and sexual violence support services.</p>
<p>The e-training intervention covers key definitions and characteristics, detection, management and ways to support resident victim-survivors, as well as tools to teach staff how to manage residents and prevent incidents.</p>
<p>Participants in our <a href="https://pubmed.ncbi.nlm.nih.gov/34399034/">study</a> who did the training reported better awareness, enhanced reflection on their current practice and improvement in sexual violence workplace management. The majority said they found the training relevant, practical and useful.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1369172598903349249"}"></div></p>
<h2>Only part of the solution</h2>
<p>This training provides a first step to identify the learning needs of this population. It provides a model curriculum to guide development of training initiatives nationally and internationally.</p>
<p>Advocate’s for reform have repeatedly detailed <a href="https://www.lawreform.vic.gov.au/wp-content/uploads/2021/07/Sub_3_Ibrahim_et_al_Health_Law_and_Ageing_Research_Unit_final.pdf">what else should be addressed</a>. This includes engaging government, insurers, boards of management and executives to resource and develop an organisational culture that eliminates sexual violence. </p>
<p>Preventing sexual violence should be of critical concern to Australia. We must move past reactive measures and unsubstantiated approaches such as asking staff to assess the impact of sexual violence. Instead we should be developing solutions to protect residents from incidents ever occurring.</p><img src="https://counter.theconversation.com/content/169734/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Joseph Ibrahim received funding from Commonwealth Social Service (2015-17) and State Health Department (ongoing) for research, education and consultancies into residential aged care services and health care services. He also is an independent advocate for age care reform details available at <a href="https://www.profjoe.com.au/">https://www.profjoe.com.au/</a></span></em></p><p class="fine-print"><em><span>Amelia Grossi is a research assistant for The Victorian Institute of Forensic Medicine, Health, Law & Ageing Research Unit, Monash University. </span></em></p><p class="fine-print"><em><span>Daisy Smith is a research officer for The Department of Forensic Medicine, Health Law & Ageing Research Unit, Monash University.</span></em></p><p class="fine-print"><em><span>Meghan Wright is a research assistant for The Victorian Institute of Forensic Medicine, Health, Law & Ageing Research Unit, Monash University.</span></em></p>There are around 50 sexual assaults in Australian aged care homes every week. But staff are expected to assess the severity and impact of incidents without training.Joseph Ibrahim, Professor, Health Law and Ageing Research Unit, Department of Forensic Medicine, Monash UniversityAmelia Grossi, Monash UniversityDaisy Smith, Research Assistant, Monash UniversityMeghan Wright, Research assistant, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1669312021-10-07T12:22:03Z2021-10-07T12:22:03ZWhat’s on the menu matters in health care for diverse patients<figure><img src="https://images.theconversation.com/files/424524/original/file-20211004-15-1dz9eaw.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2121%2C1412&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Family members often take on the burden of preparing and delivering meals to their relatives.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/care-for-old-woman-patient-in-hospital-royalty-free-image/623189070">SoumenNath/E+ via Getty Images</a></span></figcaption></figure><p>Food is a powerful part of community and medicine. It has the potential to <a href="https://doi.org/10.1016/j.appet.2020.104654">build connections</a>, elicit nostalgia, spark joy, mark celebration and <a href="https://www.npr.org/sections/thesalt/2017/01/17/509520895/food-as-medicine-it-s-not-just-a-fringe-idea-anymore">promote healing</a>.</p>
<p>It also <a href="https://link.springer.com/book/10.1007/978-1-4613-1221-5">plays a role</a> in determining whether the health care system is inclusive and equitable.</p>
<p><a href="https://scholar.google.com/citations?user=r-BakwEAAAAJ&hl=en">I study the challenges</a> that older adults and their family caregivers face in the U.S. health care system, especially for those from racial or ethnic minority communities. <a href="https://doi.org/10.17226/24624">Health disparities</a>, such as unequal access to care based on race and ethnicity, affect many communities in the U.S. </p>
<p>Sociocultural characteristics such as <a href="https://doi.org/10.1007/s11606-019-04847-5">language</a>, <a href="https://doi.org/10.17226/10260">skin color</a>, <a href="https://doi.org/10.1111/j.1525-1497.2006.0512.x">religious beliefs</a> and <a href="https://www.rwjf.org/en/library/research/2017/09/immigration-status-and-health.html">immigrant status</a> can present access barriers to high-quality health care. I’ve found that food can also be a source of alienation and exclusion in the U.S. health care system. To many patients, it is a salient reminder that the system was not built for them.</p>
<h2>Current food standards at health facilities</h2>
<p>Current regulations around food in health care environments such as hospitals and long-term care facilities emphasize <a href="https://www.osha.gov/SLTC/etools/hospital/dietary/dietary.html">occupational and food safety</a>. Dietary quality standards are based on <a href="https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/som107ap_a_hospitals.pdf#page=361">clinical need</a>, and specialized foods cater to patients who have difficulty chewing or swallowing, for instance. Health care facilities and the organizations providing menu recommendations to them consistently advertise an alignment with taste preferences, allergy-related needs and nutritional quality.</p>
<p>Although some facilities offer kosher and halal options, culturally inclusive options are often neglected. For instance, some facility menus prominently feature sandwiches and salads that only reflect American cuisine. Without culturally inclusive menus, patients might be given foods that don’t align with their cultural or religious preferences. As one family caregiver I interviewed for my ongoing study of older Asian immigrants from multiple ethnic communities described, “My mother-in-law would get to the nursing home and my father-in-law hadn’t eaten all day until 5 o'clock. He likes to eat roti and curry for lunch and dinner, but they would just give him a sandwich.”</p>
<p>Another participant had to help her mother come to terms with a new diet in an assisted living facility. “So she’s in this new place and one day they served kielbasa and sauerkraut, and she’s looking at it like, ‘What’s that?’ and I was like ‘Oh, sausage, you’re not going to like that, and [sauerkraut] … you’re not going to like that either.’”</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/424518/original/file-20211004-15-wmutde.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Person in scrubs wheeling bowls of food in stacked on a cart in a nursing home." src="https://images.theconversation.com/files/424518/original/file-20211004-15-wmutde.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/424518/original/file-20211004-15-wmutde.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/424518/original/file-20211004-15-wmutde.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/424518/original/file-20211004-15-wmutde.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/424518/original/file-20211004-15-wmutde.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/424518/original/file-20211004-15-wmutde.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/424518/original/file-20211004-15-wmutde.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Many health care facilities do not take cultural preferences into account in the foods they offer patients.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/smiling-nurse-giving-food-to-people-royalty-free-image/909586122">Jasmin Merdan/Moment via Getty Images</a></span>
</figcaption>
</figure>
<p>Subsequently, these patients may lack important nutrients to manage their health conditions and <a href="https://www.aafp.org/afp/2021/0700/p34.html">maintain</a> their <a href="https://doi.org/10.1016/j.metabol.2016.12.005">weight</a>. Undernourishment can cause negative physical and mental health effects, including <a href="https://dx.doi.org/10.1016%2FS0140-6736(12)62167-9">frailty</a>, or an increased vulnerability to <a href="https://dx.doi.org/10.1016%2Fj.cger.2010.08.009">adverse health conditions and diseases</a>, and <a href="https://doi.org/10.1016/j.clnu.2010.01.006">depression</a>. <a href="https://doi.org/10.3390/nu11010102">Functional decline</a> due to undernourishment can also lead to an increased risk of <a href="https://doi.org/10.1111/j.1532-5415.2009.02137.x">falls, hospitalization and death</a>.</p>
<p>The caregivers I interviewed believed that the health care system wouldn’t be able to accommodate their relatives’ needs and felt resigned that it would not change. As one caregiver said, “I would say that the hospitals need a lot more work. My mom is quite religious and also has diet restrictions. When she went to the hospital, all those days, most of the time she was not eating at all.”</p>
<h2>Improving patient health and well-being</h2>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/424527/original/file-20211004-27-n4xwq7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Indian older adult sitting in chair eating a meal." src="https://images.theconversation.com/files/424527/original/file-20211004-27-n4xwq7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/424527/original/file-20211004-27-n4xwq7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=742&fit=crop&dpr=1 600w, https://images.theconversation.com/files/424527/original/file-20211004-27-n4xwq7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=742&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/424527/original/file-20211004-27-n4xwq7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=742&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/424527/original/file-20211004-27-n4xwq7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=933&fit=crop&dpr=1 754w, https://images.theconversation.com/files/424527/original/file-20211004-27-n4xwq7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=933&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/424527/original/file-20211004-27-n4xwq7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=933&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Older adults may become undernourished if the food they are provided does not align with their religious or cultural restrictions.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/elderly-indian-woman-recovering-in-a-care-home-or-royalty-free-image/1338398176">Paul Maguire/iStock via Getty Images Plus</a></span>
</figcaption>
</figure>
<p>Offering culturally inclusive foods in health care facilities has the potential to <a href="https://doi.org/10.1186/s12877-017-0540-2">support mental well-being</a> and even <a href="https://doi.org/10.1111/jocn.13163">promote joy</a> among older adults. It can foster a sense of <a href="https://www.mcknights.com/blogs/guest-columns/food-offers-more-than-sustenance-for-nursing-home-residents/">belonging</a> and <a href="https://doi.org/10.1016/j.jef.2015.11.004">community</a> in a place where it can be <a href="https://doi.org/10.1016/j.ijnurstu.2011.05.012">difficult to form relationships</a>. It could also help patients and their families understand the <a href="https://scholarworks.waldenu.edu/dissertations/5655">types of treatment-aligned meals</a> they can prepare and eat at home. </p>
<p>Culturally inclusive food may also be critical to helping patients feel they are respected and being treated with dignity. This is especially the case when they may be adjusting to <a href="https://doi.org/10.1001/virtualmentor.2008.10.4.mnar1-0804">language differences or unfamiliar healing traditions</a>. It could build their trust in their clinicians and the health care system by demonstrating <a href="https://cornerstone.lib.mnsu.edu/etds/614/">commitment to supporting diverse patients</a>.</p>
<h2>Supporting caregivers and the local community</h2>
<p>A health care system that offers inclusive foods supports more than just patients. </p>
<p>Family caregivers have myriad responsibilities, including helping their relatives with <a href="https://www.caregiving.org/caregiving-in-the-us-2020/">transportation and dressing themselves</a>. The caregivers in my study often must also prepare and transport food to ensure that their relatives are eating. One participant estimated that “it was about an extra half an hour to an hour every day to prepare the food and then bring it in … going straight from my workplace to the hospital.”</p>
<p>The local community could also benefit. Health care organizations could work with <a href="https://sarep.ucdavis.edu/sites/g/files/dgvnsk5751/files/inline-files/FarmToHospitalInitiativesWeb.pdf">local vendors</a> that supply ingredients from different ethnic traditions, <a href="http://foodsecurity.org/farm-hospital-supporting-local-agriculture-improving-health-care/">economically supporting</a> the community. Health care facilities could also employ <a href="https://health.usnews.com/wellness/articles/2016-11-16/nursing-homes-spice-up-food-offerings">chefs</a> and <a href="https://doi.org/10.1016/j.jand.2013.03.012">dietitians</a> from diverse backgrounds to ensure meal quality.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/424526/original/file-20211004-15-1su0pgn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Nurse offering a bowl of food to an older adult in a wheelchair." src="https://images.theconversation.com/files/424526/original/file-20211004-15-1su0pgn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/424526/original/file-20211004-15-1su0pgn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/424526/original/file-20211004-15-1su0pgn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/424526/original/file-20211004-15-1su0pgn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/424526/original/file-20211004-15-1su0pgn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/424526/original/file-20211004-15-1su0pgn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/424526/original/file-20211004-15-1su0pgn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Offering culturally aligned foods at health care facilities can help improve the well-being of patients.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/asian-beautiful-therapist-doctor-serve-food-to-royalty-free-image/1332045449">Kiwis/iStock via Getty Images Plus</a></span>
</figcaption>
</figure>
<p>Finally, the U.S. health care workforce is becoming increasingly diverse and multicultural. But health care workers from racial and ethnic minority communities still grapple with hiding their <a href="https://doi.org/10.1037/a0027724">cultural identities</a> to <a href="https://doi.org/10.1001/jamanetworkopen.2018.2723">belong in the workplace</a>. Having <a href="https://doi.org/10.1177%2F0021886308314460">access to traditional foods</a> may help health care workers feel more included in their workplace, or at least alleviate some of the burden to “fit in” by beginning to build an organization that welcomes diversity.</p>
<h2>Emerging approaches to cultural inclusion</h2>
<p>Implementing culturally inclusive meals across the country’s health care system requires a concerted and long-term effort. In a health care environment where every penny is pinched, it might be hard for facilities to come up with multiple choices at mealtime. It requires revisiting regulations around dietary quality in health care facilities and ensuring <a href="https://doi.org/10.1002/nop2.343">cultural sensitivity</a> among care providers and staff. It also requires facilities to have the human resources, funding, knowledge and support to ensure these efforts can be sustained.</p>
<p>Some health care facilities have already dedicated considerable effort to provide culturally inclusive meals to patients and residents. <a href="https://www.modernhealthcare.com/article/20180106/NEWS/180109970/how-a-n-j-hospital-developed-culturally-sensitive-care-for-its-growing-asian-american-population">Holy Name Medical Center in Teaneck, New Jersey</a> offers a bowl of rice to its its Asian American patients instead of a sandwich, and warm instead of cold water to drink per cultural preference. Rather than depending solely on individual workers to modify their practices, they emphasize a system-level commitment to inclusion and educate clinicians and other health care workers on different aspects of Asian cultures.</p>
<p>Similarly, one of the assisted- and independent-living facilities owned by <a href="https://viharcare.com/">Bria Health Services</a> near Chicago has a special unit catering to the dietary, language and cultural preferences of South Asian adults. It’s not clear that segregated units are necessarily the ideal answer – ideally anyone at any facility would be served culturally appropriate and appetizing food. But it’s a starting point.</p>
<p>Achieving a strong and inclusive health care system requires ensuring it is built for everyone. And food is one fundamental way to do it.</p>
<p><em>This work was developed in collaboration with Merin Oleschuk, Emma Willoughby and Sudha Raj.</em></p>
<p>[<em>The Conversation’s science, health and technology editors pick their favorite stories.</em> <a href="https://theconversation.com/us/newsletters/science-editors-picks-71/?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=science-favorite">Weekly on Wednesdays</a>.]</p><img src="https://counter.theconversation.com/content/166931/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Minakshi Raj received funding from the University of Illinois at Urbana Champaign Campus Research Board and the Center on Health, Aging and Disability to support the ongoing research reported in this article.</span></em></p>Some older patients forego the food provided at their health care facility because it isn’t aligned with their religious and cultural preferences.Minakshi Raj, Assistant Professor of Kinesiology and Community Health, University of Illinois at Urbana-ChampaignLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1644792021-08-17T12:12:32Z2021-08-17T12:12:32ZNursing home residents and staff are traumatized from the pandemic - collaborative care can help with recovery<figure><img src="https://images.theconversation.com/files/415744/original/file-20210811-20236-1j1ivns.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2110%2C1417&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Trauma-informed care ensures that both patients and staff feel supported in their care decisions.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/elderly-woman-in-assisted-care-home-royalty-free-image/527812174">Owen Franken/Corbis Documentary via Getty Images</a></span></figcaption></figure><p>For older adults, social isolation may have dredged up past traumas that are difficult to come back from. And for those living in <a href="https://www.gao.gov/products/gao-21-367">nursing homes that have been the center of outbreaks</a> throughout the COVID-19 pandemic, these new traumas can make resuming care as usual even more difficult.</p>
<p><a href="https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/older-adults.html">Older adults more vulnerable to COVID-19</a> stayed home out of fear. People in nursing homes were further isolated when the Centers for Medicare & Medicaid Services <a href="https://www.cms.gov/files/document/qso-20-14-nh-revised.pdf">required nursing homes to stop outside visitation and group activities</a> in the interest of public safety. Full closure lasted six months, with gradual reopening. Some states chose to <a href="https://www.aarp.org/caregiving/health/info-2020/nursing-home-visits-by-state.html">keep more restrictive measures in place</a> for much longer.</p>
<p>Not only did residents lose their <a href="https://doi.org/10.1016/j.jamda.2020.07.035">right to visitors</a> and contact with the rest of the world, but nursing home staff were <a href="https://doi.org/10.3928/00989134-20201012-02">covered in personal protective equipment</a> that made it harder to connect because of communication challenges. In addition, staff were busier than ever because of <a href="https://abcnews.go.com/US/pandemic-made-shortage-health-care-workers-worse-experts/story?id=77811713">staff shortages and greater care demands</a>, leaving <a href="https://doi.org/10.1001/jama.2020.10419">little time to provide social support</a>.</p>
<p>Isolation, emotional neglect and fear of life-threatening disease can be traumatic in their own right. Furthermore, they can exacerbate past traumas that caregivers may not be aware of. </p>
<p>I am an <a href="https://scholar.google.com/citations?hl=en&user=2QRMGd4AAAAJ">associate professor of social work at the University of Maryland, Baltimore County</a>, and my research focuses on quality of life and care in nursing homes. As nursing homes begin recovering from COVID-19, it will be important to address both the trauma residents and staff endured during the pandemic, as well as past traumas they may have endured.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/415745/original/file-20210811-27-18wk99w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Health care worker talking to an older patient." src="https://images.theconversation.com/files/415745/original/file-20210811-27-18wk99w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/415745/original/file-20210811-27-18wk99w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/415745/original/file-20210811-27-18wk99w.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/415745/original/file-20210811-27-18wk99w.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/415745/original/file-20210811-27-18wk99w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/415745/original/file-20210811-27-18wk99w.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/415745/original/file-20210811-27-18wk99w.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Older adults are more likely to have experienced a traumatic event that may affect how they respond to care.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/senior-man-having-a-health-exam-royalty-free-image/1282163901">Marko Geber/DigitalVision via Getty Images</a></span>
</figcaption>
</figure>
<h2>What is trauma?</h2>
<p><a href="https://www.apa.org/topics/trauma">Psychological trauma</a> results from exposure to abuse, disasters, violence and other harmful or life-threatening events that are often out of one’s control. These events can have lasting adverse effects on mental, physical, social, emotional or spiritual well-being. People with a history of trauma report <a href="https://doi.org/10.1093/geront/gnw146">more distress and pain in medical settings</a>, and are more likely to be anxious, depressed and distrustful when receiving medical care. These factors make it more difficult for them to engage with providers and respond to care.</p>
<p>Trauma-informed care is especially relevant to older adults. They have a <a href="https://doi.org/10.1093/geront/gnw146">greater risk of having experienced something traumatic</a> by virtue of the fact that they have been around longer. Older adults are also likely to have experienced potentially traumatic <a href="https://doi.org/10.1080/00981389.2018.1447531">loss of their loved ones or physical abilities</a>. Furthermore, many older people grew up during a time when <a href="https://doi.org/10.1080/00981389.2018.1447531">trauma and other mental health challenges were often not addressed</a> due to heavy stigma. These unresolved issues may resurface when faced with the <a href="https://39k5cm1a9u1968hg74aj3x51-wpengine.netdna-ssl.com/wp-content/uploads/2019/06/Trauma_Informed_End_of_Life_Care_Kusmaul.pdf">additional challenges of aging, including end of life</a>. </p>
<h2>What is trauma-informed care?</h2>
<p><a href="https://ncsacw.samhsa.gov/userfiles/files/SAMHSA_Trauma.pdf">Trauma-informed care</a> is an approach that takes a person’s past traumatic experiences into consideration when providing care and creates services that minimize re-traumatization. It’s currently used in a variety of settings, such as <a href="https://traumaawareschools.org/traumaInSchools">education</a>, <a href="https://www.ptsd.va.gov/professional/treat/care/index.asp">mental health</a>, <a href="https://www.traumainformedcare.chcs.org/what-is-trauma-informed-care/">health care</a> and <a href="https://www.nasmhpd.org/sites/default/files/DRAFT_Essential_Components_of_Trauma_Informed_Judicial_Practice.pdf">criminal justice</a>. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/fWken5DsJcw?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Trauma-informed care recognizes that life experiences play a role in an individual’s health and well-being.</span></figcaption>
</figure>
<p>It’s particularly useful when there are <a href="https://scholarworks.sfasu.edu/jhstrp/vol4/iss2/3/">power differentials between clients and providers</a>. These include situations where the provider can control which programs or services a client can access, or by the type of report they provide on the client’s progress. Organizations that are trauma-informed work to flatten their power structure, meaning that hospitals, social service agencies and nursing homes give their patients and clients the ability to choose how they receive services. </p>
<p>Organizations also work to make their clients and staff feel safer in <a href="https://www.traumainformedcare.chcs.org/what-is-trauma-informed-care/">a variety of ways</a>:</p>
<ul>
<li><p>Ensuring the safety of their care settings. This is not always easy or one size fits all. For example, locked doors will make some people feel safer and others less safe. </p></li>
<li><p>Fostering trust through transparency. Organizations will hold high expectations for care, but also give their staff the tools to work independently and make decisions without micromanaging.</p></li>
<li><p>Offering opportunities to connect with people in similar situations. This may include social events, mentoring and group therapy or self-help.</p></li>
<li><p>Collaborating in service provision. This involves a “doing with,” rather than serving or “doing for” mentality. For example, instead of scheduling an appointment on a client’s behalf, staff may provide contacts at local agencies and help the client to call and set up services on their own.</p></li>
<li><p>Empowering clients and staff. Clients and staff have a voice in deciding how they want to work with each other. This could include having a variety of times that services are available, virtual or in-person meetings and the ability to choose their provider. </p></li>
<li><p>Respectful of identity. Organizations take into account cultural, historical and gender issues that may have affected how someone has previously been treated. This is particularly important when working with older adults, who may have had a lifetime of discrimination and past trauma.</p></li>
</ul>
<p>Trauma-informed care is still in its early stages when it comes to older adults. <a href="https://www.nhpco.org/education/tools-and-resources/trauma-informed-end-of-life-care/">End-of-life and hospice care</a> settings are in the process of implementing it, and it is <a href="https://scholars.org/contribution/how-integrate-trauma-informed-care-nursing">required but not yet fully integrated in nursing homes</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/415746/original/file-20210811-23-1ubk1e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Caregiver holding the hands of an older adult." src="https://images.theconversation.com/files/415746/original/file-20210811-23-1ubk1e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/415746/original/file-20210811-23-1ubk1e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/415746/original/file-20210811-23-1ubk1e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/415746/original/file-20210811-23-1ubk1e.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/415746/original/file-20210811-23-1ubk1e.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/415746/original/file-20210811-23-1ubk1e.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/415746/original/file-20210811-23-1ubk1e.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Trauma-informed care for older adults requires caring for the caregiver as well.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/caregiver-supporting-woman-during-corona-outbreak-royalty-free-image/1225586155">Morsa Images/DigitalVision via Getty Images</a></span>
</figcaption>
</figure>
<h2>Trauma-informed care starts with staff</h2>
<p>The COVID-19 pandemic has had significant psychosocial effects on older adults in nursing homes and in the community. Residents and families need to trust nursing homes again. Care that incorporates the principles of trauma-informed care and takes each individual’s unique life experiences into account is essential for older adults with potentially traumatic life experiences, especially in light of the potential trauma caused by a global pandemic.</p>
<p>For older adults in long-term care settings, organizations can take steps to ensure that residents feel safe both from the threat of disease and isolation. This starts with <a href="https://doi.org/10.1016/j.jamda.2020.06.010">supporting their staff</a>.</p>
<p>[<em>Over 100,000 readers rely on The Conversation’s newsletter to understand the world.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=100Ksignup">Sign up today</a>.]</p>
<p>Trauma-informed nursing homes need to ensure their that workers have access to personal protective equipment and health care to <a href="https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/race-ethnicity.html">mitigate disparities</a>. Racial and ethnic minorities are <a href="https://phinational.org/resource/racial-gender-disparities-within-direct-care-workforce-five-key-findings/">over-represented among direct care workers</a> and may need trauma-informed care themselves to be able to provide trauma-informed care to residents. Without trauma-informed care at all levels, staff will burn out and <a href="https://doi.org/10.1016/j.jamda.2020.08.002">shortages will worsen</a>. </p>
<p>Nursing home staff that feel supported in their efforts are essential to collaborative, quality care. Trauma-informed care goes both ways.</p><img src="https://counter.theconversation.com/content/164479/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nancy Kusmaul receives funding from the Better Nursing Home Care Fund of the Oregon Community Foundation. Nancy Kusmaul was a previous Health and Aging Policy Fellow. </span></em></p>COVID-19 hit long-term care facilities hard. Addressing the trauma that residents and staff endured is key to regaining trust in a space that may no longer feel safe.Nancy Kusmaul, Associate Professor of Social Work, University of Maryland, Baltimore CountyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1549432021-06-14T20:07:03Z2021-06-14T20:07:03ZThere are problems in aged care, but more competition isn’t the solution<figure><img src="https://images.theconversation.com/files/405827/original/file-20210611-22-zrmfdb.jpg?ixlib=rb-1.1.0&rect=413%2C176%2C2970%2C1466&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Karen McFarland/Shutterstock</span></span></figcaption></figure><p>The solution to most problems in most markets is more competition.</p>
<p>Whether it’s the market for hairdressers, for massage therapists or for general practitioners, usually, the more of them there are in any town or suburb, the greater is the range and quality they offer and the lower the price.</p>
<p>It’s part of the thinking behind a <a href="https://www.health.gov.au/health-topics/aged-care/about-aged-care/aged-care-laws-in-australia">range</a> of government legislation designed to increase competition and consumer choice in residential aged care.</p>
<p>Yet in research just published by the <a href="https://melbourneinstitute.unimelb.edu.au/__data/assets/pdf_file/0008/3811607/ri2021n07.pdf">Melbourne Institute</a> using the de-identified records of 2,900 nursing homes provided to the aged care royal commission we found no such effect.</p>
<p>No matter how competition was measured, we found no statistically-significant differences in price or quality as indicated by a range of measures including nursing hours worked per resident, assaults per resident, complaints per resident, the use of antipsychotic drugs and avoidable early deaths. </p>
<p>We measured the amount of competition for each nursing home in three ways: by the number of competitors within a 10-kilometre radius, the distance in kilometres to the nearest competitor and a measure of market concentration known as the Herfindahl-Hirschman Index.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/aged-care-death-and-taxes-after-the-royal-commission-145297">Aged care, death and taxes after the royal commission</a>
</strong>
</em>
</p>
<hr>
<p>We found great variation in competition (much more in cities, much less in regions) along with slight decreases in competition in urban and remote areas (notwithstanding government measures designed to promote it) and minor increases in competition in regional Australia.</p>
<p>But we found no evidence linking competition to measures of quality of care, with the possible exception of registered nurse hours, although this linkage wasn’t present in all measures of competition.</p>
<p>Competition was weakly associated with price if at all.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/405846/original/file-20210611-27-qto1yk.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/405846/original/file-20210611-27-qto1yk.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/405846/original/file-20210611-27-qto1yk.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=242&fit=crop&dpr=1 600w, https://images.theconversation.com/files/405846/original/file-20210611-27-qto1yk.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=242&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/405846/original/file-20210611-27-qto1yk.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=242&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/405846/original/file-20210611-27-qto1yk.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=304&fit=crop&dpr=1 754w, https://images.theconversation.com/files/405846/original/file-20210611-27-qto1yk.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=304&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/405846/original/file-20210611-27-qto1yk.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=304&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
<span class="attribution"><a class="source" href="https://melbourneinstitute.unimelb.edu.au/__data/assets/pdf_file/0008/3811607/ri2021n07.pdf">Extract from report</a></span>
</figcaption>
</figure>
<p>On the other hand, we found strong links between ownership and quality of care.</p>
<p>For most measures of quality, government-owned facilities provided much higher quality of care than for-profit providers and not-for-profit providers.</p>
<p>On prices, government-owned facilities charged by far the lowest price per resident per day — 23% lower than for-profits and 8% lower than not-for-profits.</p>
<p>In trying to think of the reasons why competition should not result in competition on prices or on the quality of service, a number of possibilities present themselves.</p>
<h2>Residents know little about what they are getting</h2>
<p>One reason is that demand for aged care places often arises suddenly due to significant changes in health conditions such as falls, dementia and loss of balance meaning they have little choice but to use the first facility that becomes available.</p>
<p>Another is that consumers have little information about quality with which to make decisions. Unlike the United States and the United Kingdom, Australian authorities do not yet provide a five-star system of ratings that can be easily understood.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/4-key-takeaways-from-the-aged-care-royal-commissions-final-report-156109">4 key takeaways from the aged care royal commission's final report</a>
</strong>
</em>
</p>
<hr>
<p>And prices are extremely hard to understand.</p>
<p>Demand often arises from consumers who experience sudden changes in their cognitive and physical conditions that make it difficult to search for information, and weigh options and exercise choice.</p>
<p>With users hamstrung, there are few <a href="https://www.youtube.com/watch?v=tNKUNp8H5MI">market forces</a> to discipline providers.</p>
<h2>We could empower users…</h2>
<p>Measures that would help include publishing quality ratings (<a href="https://agedcare.royalcommission.gov.au/publications/final-report">recommended</a> by the royal commission), simplifying prices (not recommended, although the commission recommends an independent pricing authority) and providing consumer advocates to help people navigate through the system (recommended).</p>
<p>Given that most consumers transition from home care to residential care, it would help if advocacy services were integrated into home care services. </p>
<p>An alternative would be to abandon the pursuit of competition and set up a system of enforced standards, funded for different categories of care along the lines of the casemix system used in hospitals.</p>
<h2>…or regulate more strongly on their behalf</h2>
<p>Although this was recommended in the commission’s final report it would be harder to implement than it is in hospitals.</p>
<p>Aged care is about making life comfortable whereas health care is about fixing problems, making consumer preferences much more important in aged care.</p>
<p>Harnessing the power of consumer preferences is a worthy goal, and there is a great deal we can do to move toward it, but there’s a long way to go.</p><img src="https://counter.theconversation.com/content/154943/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Anthony Scott receives funding from NHMRC and ARC</span></em></p><p class="fine-print"><em><span>Yuting Zhang receives funding from Australian Research Council and National Health and Medical Research Council, National Institutes of Health in the US. </span></em></p><p class="fine-print"><em><span>Jongsay Yong and Ou Yang do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Examining the records of 2,900 nursing homes we’ve found no evidence that where there’s more competition there’s better care or lower prices.Ou Yang, Research Fellow, The University of MelbourneAnthony Scott, Professor, The University of MelbourneJongsay Yong, Associate Professor of Economics, The University of MelbourneYuting Zhang, Professor of Health Economics, The University of MelbourneLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1618722021-06-09T14:34:57Z2021-06-09T14:34:57ZGetting ‘unstuck’: Women who care for others should feel OK stepping back<figure><img src="https://images.theconversation.com/files/404340/original/file-20210603-21-1xp10tx.jpg?ixlib=rb-1.1.0&rect=14%2C0%2C3120%2C2354&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Women often feel stuck caring for others. We must consider how we can learn from them and from care scholars about how to get "unstuck."</span> <span class="attribution"><span class="source">(Mario Azzi/Unsplash)</span>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>Having people constantly rely on you can make you feel stuck. Author Makenna Goodman’s novel <a href="https://milkweed.org/book/the-shame"><em>The Shame</em></a> speaks to the experiences of people who feel stuck in relation to others with care needs who depend on them. </p>
<p>In talking about wanting to escape the responsibility of caring for her children, the novel’s narrator wrestles with whether she’d ever be able to “escape the pain of both being a bad mother and being without them.” </p>
<p>The book registers the “stuckness (one feels) from adhering to a rigidly cultivated life” and the complete and utter heartbreak that can come with not being able to live up to the moral, feminine expectations you’ve set for yourself. “What if life could be otherwise?” is a question that seems to underpin the book. It’s also a question I have been exploring as a feminist sociologist of care. </p>
<p>While <em>The Shame</em> focuses on the life of one mother, I was reminded of the stories of other paid care workers and unpaid family or friend carers when reading it. <a href="https://www.brookings.edu/essay/why-has-covid-19-been-especially-harmful-for-working-women/">With the COVID-19 pandemic, women</a>, and some men, have been pressed to take on additional care, work or family responsibilities.</p>
<p>Women often feel stuck caring for others. We must consider how we can learn from them and from care scholars about how to get “unstuck.”</p>
<h2>Care has limits</h2>
<p>Paid <a href="https://hbr.org/2021/05/frustrated-patients-are-making-health-care-workers-jobs-even-harder">care workers are working non-stop</a> and doing additional unpaid work. Family and friend care providers are <a href="https://theconversation.com/we-must-eliminate-profit-making-from-child-care-and-elder-care-159407?utm_medium=amptwitter&utm_source=twitter">also working extra hard</a>.</p>
<p>And for many across Canada, this was the case before the pandemic. </p>
<p>My research aims to rethink practices and meanings of “care,” with a focus on how exactly people say “no,” step back or otherwise renegotiate responsibilities for care. <a href="https://curve.carleton.ca/b3e20de5-5f3f-47d0-8095-0e3a8c3cf3b0"><em>Care has limits</em></a> is the title of my dissertation. I have learned from former care providers, including those who reached their limits and walked off the job, and have conducted team-based research in nursing homes, where I have learned from residents, workers and family members. </p>
<p>Through my research, paid and unpaid carers reported struggling to move on or seek care for themselves when they were at the end of their rope. “My body literally, you know, gave out on me,” one woman said, before noting that “even then … it was still so hard to leave.”</p>
<p>Moral expectations for women to care for others can be dangerous when lived out or pushed to the limit, especially when wider conditions of social neglect or limited options to share responsibility are at play. Some <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4804270/">experience the weight of this more than others</a>.</p>
<figure class="align-center ">
<img alt="Female friends sit on a couch, supporting each other." src="https://images.theconversation.com/files/404915/original/file-20210607-23-uypu2s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/404915/original/file-20210607-23-uypu2s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/404915/original/file-20210607-23-uypu2s.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/404915/original/file-20210607-23-uypu2s.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/404915/original/file-20210607-23-uypu2s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/404915/original/file-20210607-23-uypu2s.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/404915/original/file-20210607-23-uypu2s.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Women are often coerced into caring for others at the expense of themselves.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>My point isn’t that people should stop caring or that care work is only burdensome, constraining or oppressive. I recognize how — with the right conditions — care relationships can be <a href="https://theconversation.com/covid-19-stigma-and-the-scandalous-neglect-of-people-living-with-dementia-140817">imaginative, life-enriching spaces</a> of joy, creativity, purpose and connection. </p>
<p>What I am critical of is <a href="https://www.thestar.com/opinion/contributors/2020/03/02/larche-international-has-a-history-of-exploiting-women.html">how women are coerced into caring for others at the expense of ourselves, against all odds and regardless of conditions</a>. I’m critical of how compliments like “Aw, honey, no one can care the way you do” are thrown around without being accompanied by the needed supports, resources or conditions to be able to pull off such a project. </p>
<p>So how do we get unstuck? </p>
<h2>Getting unstuck</h2>
<p>We can learn from those who feel trapped or tethered about the kind of changes that are needed. </p>
<p>As I have come to appreciate, women do a lot of work to break down gendered, moral ideals of care that feel like chains. At the limits of care, we reorient to our sense of selves, rethinking what it means to be a “good” woman, wife, mother, daughter or worker. </p>
<p>“Well, then who am I? … Who am I, then?” one woman asked, noting that resigning from paid care work was an incredibly disruptive life experience that involved rethinking who she was and what she owed others.</p>
<p>Others questioned arrangements of care that set them up as “<a href="https://vikkireynoldsdotca.files.wordpress.com/2018/09/zone-of-fab-poster-24x362222.jpg">lone wolves”</a> or as the “only ones” who could meet a person’s needs. The ways they had felt “special” or “unique” as primary carers had become problematic to them, and they shared stories about asking for help or trusting others to step in.</p>
<p>We can learn from how women go about sharing responsibility or loosening the grip of moral expectations to care against all odds. </p>
<p>We can also learn from scholars and advocates who have long been committed to investigating and transforming the social organization of care — <a href="https://www.wbur.org/cognoscenti/2021/04/08/biden-infrastructure-care-policy-structure-mignon-duffy-kim-price-glynn-care">reckoning with systemic inequities</a> that diminish those who provide and those who need care, while also reflecting on the <a href="https://www.nytimes.com/2021/05/09/business/child-care-infrastructure-biden.html">importance of care infrastructure</a> that is central to the running of the economy. </p>
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Read more:
<a href="https://theconversation.com/coronavirus-crisis-shows-ableism-shapes-canadas-long-term-care-for-people-with-disabilities-137478">Coronavirus crisis shows ableism shapes Canada's long-term care for people with disabilities</a>
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<p><a href="https://thecareeconomy.ca/statement/">The Care Economy Statement</a>, developed by sociologist Pat Armstrong and colleagues, is a notable example that pushes for integrated, equitable responses that put the care economy at the centre of policy. It speaks to the necessity of public sector supports and to the dangers of the state’s reliance on the unpaid work of women.</p>
<p>Emphasizing that “conditions of work are the conditions of care,” the statement underscores the need for public sector supports, and highlights that “unpaid work simply cannot take up the slack.”</p>
<p>We need major investments that enact care as a public, collective responsibility, not a for-profit, private one. There are <a href="https://thecareeconomy.ca/statement/">statements to sign</a>, <a href="https://www.healthcoalition.ca/">coalitions to join</a>, <a href="https://pipsc.ca/news-issues/make-revera-public">social movements</a> to support and <a href="https://ottawacitizen.com/opinion/braedley-a-scathing-summary-of-how-ontario-mismanaged-long-term-care">promising policy and practice recommendations</a> for governments to implement.</p>
<p>As care duties, conditions, needs and capacities change over time, it’s worth talking about consent and how to ensure women have options to say “no,” or to share responsibilities. It’s worth rethinking normative, feminine life paths that promise so much, and remaking conditions of work, life and care that haven’t been working for a while. </p>
<p>Some of the ways women are “stuck” or “set up” are about the devaluation and <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/gwao.12293">over-reliance on women’s unpaid work</a>; they have been organized and designed that way, which means they can be otherwise. Let’s rework that.</p><img src="https://counter.theconversation.com/content/161872/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Janna Klostermann receives funding from the Social Science and Humanities Research Council of Canada.</span></em></p>Women often feel stuck caring for others. We must consider how we can learn from them and from care scholars about what needs to change.Janna Klostermann, Postdoctoral fellow in Sociology, Brock UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1609832021-05-20T19:58:03Z2021-05-20T19:58:03ZChoosing the care you’ll receive at the end of your life doesn’t always go to plan. Here are some tips to make sure it does<figure><img src="https://images.theconversation.com/files/401120/original/file-20210518-15-rjojeu.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5760%2C3837&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>Advances in medical technology have dramatically altered the process of dying. It’s now possible to prolong life, with the frightening reality that this may simply extend our dying process.</p>
<p>Advance care planning is designed to empower us to retain some control over the last stages of our life by communicating our wishes about what we want, or don’t want, in terms of medical treatment. Generally this planning is done in well in advance of a medical crisis, while people are well.</p>
<p>However, <a href="https://www.tandfonline.com/doi/abs/10.1080/07481189408252656">evidence</a> <a href="https://pubmed.ncbi.nlm.nih.gov/16548797/">suggests</a> these plans may not work as intended in a crisis, because the message the patient thought to be crystal clear appears unclear to doctors and family.</p>
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<em>
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Read more:
<a href="https://theconversation.com/only-25-of-older-australians-have-an-advance-care-plan-coronavirus-makes-it-even-more-important-144354">Only 25% of older Australians have an advance care plan. Coronavirus makes it even more important</a>
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<hr>
<h2>Let’s go through an example</h2>
<p>The following is a mix of several similar real world patients, but names and some specific details have been altered to avoid identifying any particular case.</p>
<p>“Doug Jones” was a 75-year-old man with severe Parkinson’s disease that was making it increasingly difficult for him to manage at home, even with lots of help.</p>
<p>Doug’s swallowing had became progressively more difficult due to his disease, to the extent that Doug’s doctors had advocated for placement of a PEG feeding tube. This would be a tube through his tummy wall directly into his stomach, so he could be fed without swallowing. Doug had declined this on the grounds that eating and drinking were “about the last pleasure I have”. He recognised the risk of choking to death, but didn’t care.</p>
<p>Weeks later Doug was admitted to hospital after choking on a piece of orange. The orange had totally obstructed his airway, resulting in severely low levels of oxygen in the blood and cardiac arrest. It was over 30 minutes before the piece of orange was able to be removed.</p>
<p>On arrival in hospital, tests suggested Doug had suffered profound brain damage due to very low oxygen delivery. However, at this early stage, while it was reasonable to have grave concern, it was not possible for doctors to be certain about the outcome.</p>
<p>Well before all this happened, Doug had written an <a href="https://www.advancecareplanning.org.au/?gclid=CjwKCAjwy42FBhB2EiwAJY0yQucAvYAS_LKpbzDFCbRnxuWE0hrfkaZbNshsFDoJyPwxBsvqwtqgjhoC4gYQAvD_BwE">advanced care directive</a>. This is a document that states Doug’s preferences for future medical care, should he lose the capacity to make decisions. In this he stated:</p>
<blockquote>
<p>I do not want to be any worse than I am now; I do not want heroic treatment and I never want to go into a nursing home.</p>
</blockquote>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/end-of-life-care-no-we-dont-all-want-whatever-it-takes-to-prolong-life-41495">End-of-life care: no, we don't all want 'whatever it takes' to prolong life</a>
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<p>After reading the advance care directive, the doctors explained they could not predict with certainty how things would turn out. They explained Doug would need to be kept on life support for some days, to give him “the best chance” and to “see how things go”.</p>
<p>As days passed it became clear Doug had suffered profound brain injury. He did start to breathe for himself but required hoist transfers and assistance with all activities of living, including turning, bathing and toileting. He remained non-verbal and was fed through a nasogastric tube. Occasionally he appeared to understand what was being said to him.</p>
<p>After six weeks, Doug was discharged from hospital to a high level nursing home.</p>
<p>When we reviewed what happened, the doctors who had looked after Doug agreed this outcome was, in all probability, exactly what Doug feared and wanted to avoid. They felt it was very sad.</p>
<figure class="align-center ">
<img alt="Doctors rushing patient through hospital corridor" src="https://images.theconversation.com/files/401800/original/file-20210520-17-39otkx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/401800/original/file-20210520-17-39otkx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/401800/original/file-20210520-17-39otkx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/401800/original/file-20210520-17-39otkx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/401800/original/file-20210520-17-39otkx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/401800/original/file-20210520-17-39otkx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/401800/original/file-20210520-17-39otkx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">It can be very challenging for doctors to interpret and act on advance care directives, often because it’s almost impossible to predict exactly how treatment will affect a patient.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<h2>Why didn’t Doug’s advance care directive work?</h2>
<p>Like so many, Doug had stated outcomes he didn’t want. He said “I do not want to be any worse than I am now. I would never want to go into a nursing home”. </p>
<p>However, as Doug’s doctors pointed out, they could not be certain when they first saw him exactly what the outcome would be (though it was very likely to be bad).</p>
<p>When asked if, when they first saw Doug, they had thought there was any real chance he would return to his previous level of function, they were unequivocal. None of them thought he would.</p>
<p>So how can we explain these conflicting answers? </p>
<p>The initial thought process the doctors applied focused on whether there was certainty of a particular outcome, but certainly is something that’s impossible to predict with absolute confidence. In contrast, risk is much easier to recognise. Had Doug asked doctors (and family) that he did not want to take the risk of an unacceptable outcome it would have made it much easier for them</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/do-you-want-to-be-resuscitated-this-is-what-you-should-think-about-before-deciding-105506">Do you want to be resuscitated? This is what you should think about before deciding</a>
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</em>
</p>
<hr>
<p>A second problem is that, like many patients, Doug stated things he “does not want”. There are lots of things in life we don’t want, but that we endure. The important question is not what we don’t want, but what we won’t accept and wouldn’t consent to.</p>
<p>Doug also wrote his plan a bit like an instruction. A lot of people do this thinking an instruction will be more convincing, but it doesn’t work like that.</p>
<p>Instructions written well in advance of the event, before all the circumstances are known, can be very unreliable. Most doctors can cite many examples of patients who have totally changed their mind when faced with a crisis.</p>
<h2>Here are some tips when writing yours</h2>
<p>Doctors and family members feel very uncomfortable faced with instructions from someone who is no longer able to explain their reasoning. This disquiet makes them question whether the instructions are well informed, adequately thought through, applicable to the situation, and firmly held. An emotional request generally inspires more confidence.</p>
<p>Doug might have had more success had he written something like:</p>
<blockquote>
<p>If my doctors think that it is unlikely that I will be able to return to my current level of health, or that it is likely that I will require full time nursing home care, then I would not want to consent to life-saving or life prolonging treatment.</p>
<p>I know it won’t be easy, but I ask my family and doctors to respect my wishes should they have to decide about treatment for me.</p>
</blockquote>
<p>Focusing on unacceptable risk and lack of consent, as well as adding an appeal for wishes to be respected, speaks to the heart and creates the sort of confidence doctors and families need to make difficult decisions.</p><img src="https://counter.theconversation.com/content/160983/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Charles Corke is Clinical Lead for the Barwon Region Advance Care Planning Service. He presents and writes on the topic of ACD including 'Letting Go - how to plan for a good death' published by Scribe, Melbourne. </span></em></p>Evidence suggests messages the patient thought to be crystal clear often appear unclear to doctors and family.Charles Corke, Associate Professor of Medicine, Deakin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1584852021-05-09T10:35:58Z2021-05-09T10:35:58ZSeniors have a right to express their sexuality in long-term care homes, but staff need guidance<figure><img src="https://images.theconversation.com/files/394340/original/file-20210409-13-cbwdzr.jpg?ixlib=rb-1.1.0&rect=234%2C403%2C7829%2C5371&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">In the absence of guidelines or training regarding sexual expression in long-term care homes, most staff are 'just winging it' on potentially sensitive issues.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Long-term care (LTC) homes have received considerable media attention over the past year. This has led to many discussions about how we can <a href="https://www.cbc.ca/news/canada/british-columbia/ltc-standards-ccpa-1.5814004">improve and re-imagine long-term residential care</a> post-pandemic. </p>
<p>Care staff navigate a wide variety of resident needs. One need that is often overlooked is sexual expression. By <a href="https://doi.org/10.3928/00989134-20130418-01">sexual expression</a>, we mean a range of behaviours, practices, identities and relationships.</p>
<p>Sexual expression is associated with multiple benefits for resident <a href="https://dx.doi.org/10.1016%2Fj.esxm.2018.11.001">health and well-being</a> and is <a href="https://www.routledge.com/Addressing-the-Sexual-Rights-of-Older-People-Theory-Policy-and-Practice/Barrett-Hinchliff/p/book/9781138189188">recognized as a human right</a>. The need to address sexual expression in LTC has garnered more attention recently as <a href="https://globalnews.ca/news/3802497/canada-sti-rates-seniors/">sexually transmitted infections have been on the rise among seniors</a>.</p>
<h2>Navigating sexual expression in care homes</h2>
<p>Most care staff do not receive education or training on how to anticipate and respond to sexual expression in care homes. In absence of related policies or standards, <a href="https://doi.org/10.1093/geroni/igx004.3715">staff are left unprepared for residents’ sexual expressions</a> and, as a <a href="https://doi.org/10.1007/s13178-019-00421-0">research participant aptly described</a>, they “just wing it” in response. In this context, individual beliefs, values and biases can <a href="https://doi.org/10.1016/j.nedt.2016.02.012">play a significant role</a>.</p>
<p>This haphazard approach can lead to outcomes that harm residents, frustrate and confuse health-care workers and family members, damage caring relationships and/or erode public trust. As scholars engaged in research on <a href="https://doi.org/10.1016/j.jaging.2020.100849">sexual expression in long-term care</a>, we have seen this first hand in our interviews with residents, family members, managers and related health professionals.</p>
<h2>What does “winging it” look like in practice?</h2>
<p>A “just winging it” approach creates an unpredictable and uncertain environment. Forms of sexual expression are enabled and supported in some care homes or by some staff, while being stigmatized in and by others.</p>
<p>For instance, we heard about one care home that afforded residents privacy for masturbation and exercised <a href="https://doi.org/10.1007/s13178-019-00421-0">discretion about these arrangements</a>. This included keeping the door closed, the blinds shut and ensuring staff don’t enter unannounced. </p>
<p>In contrast, staff at another care home shamed a resident for her private use of a vibrator. She said that staff made her feel embarrassed and judged.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/398386/original/file-20210503-13-1409k13.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A younger woman brushing an older woman's hair." src="https://images.theconversation.com/files/398386/original/file-20210503-13-1409k13.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/398386/original/file-20210503-13-1409k13.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/398386/original/file-20210503-13-1409k13.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/398386/original/file-20210503-13-1409k13.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/398386/original/file-20210503-13-1409k13.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/398386/original/file-20210503-13-1409k13.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/398386/original/file-20210503-13-1409k13.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Practices in care homes vary widely. At one home, staff helped a resident prepare for a date. At other LTC facilities, dating is discouraged.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Approaches to residents dating also varied considerably. At one home, staff helped a resident prepare for a date. This required staff collaboration to provide the resident with emotional support in anticipation of the outing, assist with dressing and grooming and co-ordinate transportation. Whereas, at other care homes, <a href="https://doi.org/10.1016/j.jaging.2020.100849">dating and intimacy were discouraged or disparaged</a>.</p>
<p>One of the more troubling inconsistencies we found was in the treatment of residents with dementia who displayed sexual behaviours. In some cases, staff/management reacted with hostility, while in others the response was one of compassion, empathy and communication. </p>
<p>In one case, a family member spoke about how her father experienced drastically different responses at two care homes. At the first home, he was vilified, punished and ultimately relocated because of his sexual expressions. At the second home, <a href="https://doi.org/10.1016/j.jaging.2020.100849">the staff worked with him to manage these expressions and redirect unwanted or public gestures</a>.</p>
<blockquote>
<p>“I don’t think my dad’s sexual expression was appropriate, but the way they handled it at [second care home] was to redirect and treat the man with respect. It removed the shame and … helped us get through this crisis and just see our dad as dad again, as opposed to this sick monster, which everybody made him seem like.”</p>
</blockquote>
<p>“Just winging it” leads to inconsistent responses to similar situations and resident behaviour. This produces very different experiences for residents and family members and can lead to significant harms for all parties involved. To address this, we recommend the development of principle-based guidelines to support staff, residents and families in navigating sexual expression in LTC.</p>
<h2>The case for a principle-based approach</h2>
<p>Principle-based guidelines are instructional documents that guide users to make decisions on the basis of <a href="https://global.oup.com/ushe/product/principles-of-biomedical-ethics-9780190640873?cc=ca&lang=en&">ethical principles</a>. They don’t attempt to prescribe rules for every situation. Instead, they emphasize, and in some cases prioritize, central values that can be applied as cases arise.</p>
<p>The type of document we envision would highlight a set of principles such as autonomy, dignity and safety, provide a rationale for their inclusion, and offer examples of how to uphold them in practice. </p>
<figure class="align-center ">
<img alt="An older couple on a park bench" src="https://images.theconversation.com/files/398387/original/file-20210503-15-tgg0cu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/398387/original/file-20210503-15-tgg0cu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/398387/original/file-20210503-15-tgg0cu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/398387/original/file-20210503-15-tgg0cu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/398387/original/file-20210503-15-tgg0cu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/398387/original/file-20210503-15-tgg0cu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/398387/original/file-20210503-15-tgg0cu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Principle-based guidelines could include elements such as dignity, autonomy and safety.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>The principles can include those already well established in bioethics such as autonomy, justice, beneficence and nonmaleficence (the principle of doing no harm). They can also include principles specific to organizations or professional regulatory bodies, such as respect for resident privacy or person-centred care. </p>
<p>Although different jurisdictions may have different legal, policy or cultural contexts, principle-based guidelines can incorporate these features and provide an excellent basis for decision-making.</p>
<h2>Benefits of guidelines</h2>
<p>Principle-based guidelines offer several potential benefits.</p>
<p>First, principle-based guidelines offer a more consistent approach to decision-making about sexual expression than currently exists. They provide shared concepts and language that can help care staff discuss complicated and “<a href="https://ilcuk.org.uk/wp-content/uploads/2018/10/pdf_pdf_184.pdf">taboo</a>” issues in a more systematic way, less prone to personal biases.</p>
<p>Second, the guidelines provide flexibility to address diverse expressions (for example hand-holding, new relationships, sexual acts) and varying degrees of complexity (such as matters of <a href="http://doi.org/10.1017/S0714980819000813">consent for residents with fluctuating cognitive capacity</a>).</p>
<p>Third, such guidelines affirm residents’ sexual rights and encourage organizational accountability for addressing them. It communicates to all parties that this is something to be anticipated in care homes. This can help to destigmatize sexuality in older adulthood and for those with chronic health conditions.</p>
<p>As with any guidelines, how they are interpreted and applied — as well as who is given voice — will affect their outcomes. Principle-based practice guidelines should be accompanied by provincial policy implementation as well as staff training and education. Such guidelines better position care homes to anticipate and respond to sexual expression and support residents’ needs for intimacy, connection and pleasure.</p>
<p><em>This article was co-authored with Duncan Steele, Senior Consultant in Organizational Ethics with Alberta Health Services. His interests include values-based decision-making, resource allocation and priority setting/assessment in health care, and the intersection of health ethics and economics in value prioritization frameworks.</em></p><img src="https://counter.theconversation.com/content/158485/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Julia Brassolotto receives funding from Alberta Innovates, SSHRC, and CIHR. </span></em></p><p class="fine-print"><em><span>Alessandro Manduca-Barone and Lisa Howard do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>In the absence of guidelines or training regarding sexual expression in long-term care homes, most staff are ‘just winging it’ on potentially sensitive issues.Alessandro Manduca-Barone, Research Associate - Faculty of Health Sciences, University of LethbridgeJulia Brassolotto, Assistant Professor, Public Health and Alberta Innovates Research Chair, University of LethbridgeLisa Howard, Instructor, Faculty of Health Sciences, University of LethbridgeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1575612021-04-13T12:42:22Z2021-04-13T12:42:22ZOne change that could help nursing homes recover from COVID-19 fears and become safer places for aging parents<figure><img src="https://images.theconversation.com/files/394174/original/file-20210409-15-1yhrmwq.jpg?ixlib=rb-1.1.0&rect=19%2C70%2C4230%2C2752&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Low pay for nursing home workers has contributed to high staff turnover.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/reportage-in-the-amaryllis-nursing-home-in-nice-france-a-news-photo/629416759">BSIP/Universal Images Group via Getty Images</a></span></figcaption></figure><p>Two weeks after the <a href="http://doi.org/10.1056/NEJMoa2001191">first U.S. case</a> of COVID-19 was identified in Snohomish County, Washington, in early 2020, my dad had a stroke at his home just across Puget Sound. More COVID-19 cases were about to surface at a nearby <a href="https://www.seattletimes.com/seattle-news/times-watchdog/coronavirus-spread-in-a-kirkland-nursing-home-for-weeks-while-response-stalled/">skilled nursing facility,</a> marking the beginning of a crisis for nursing homes across the country.</p>
<p>My dad was incredibly lucky. It was minor stroke, and he didn’t need nursing home care. But <a href="https://www.ncbi.nlm.nih.gov/books/NBK563216/">the type of stroke</a> he had is a leading risk factor for cognitive impairment and vascular dementia. I know that nursing care may be in his future.</p>
<p>Throughout the pandemic, nursing homes have been in the headlines as places with uncontrolled COVID-19 cases and <a href="http://doi.org/10.1001/jama.2020.13484">social isolation</a>, which research shows can <a href="https://doi.org/10.17226/25663">worsen people’s health</a>. <a href="https://www.nytimes.com/interactive/2020/us/coronavirus-nursing-homes.html">About a third</a> of all reported U.S. COVID-19 deaths have been in nursing homes, also making them one of the <a href="https://www.scientificamerican.com/article/nursing-home-workers-had-one-of-the-deadliest-jobs-of-2020/">most dangerous places to work</a>. </p>
<p>As the only child of aging parents, the stories from the pandemic left me worried about the idea of handing over the responsibility of caregiving to a nursing home someday. <a href="https://familymedicine.uw.edu/chws/team/bianca-frogner/">As an expert in health care delivery systems</a> who has called upon policymakers to prioritize nursing homes throughout the pandemic, I know it does not have to be this way.</p>
<p>There is one step in particular that nursing homes can take that I believe would improve the environment for residents: invest in staff to reduce turnover and allow nurses to spend more time with each resident.</p>
<h2>Nursing homes and their role in the pandemic</h2>
<p>Nursing homes, including skilled nursing facilities that deliver medical services or rehabilitative therapy, provide 24/7 care to about <a href="https://www.cdc.gov/nchs/fastats/nursing-home-care.htm">1.5 million residents</a> in the United States.</p>
<p>People are often admitted to nursing homes when they need assistance with <a href="https://www.ncbi.nlm.nih.gov/books/NBK470404/">daily activities,</a> such as dressing, bathing and feeding themselves. They may need medical or rehabilitative therapy either long term or while recovering after surgery. Nursing homes are often an option for people with dementia as their <a href="https://www.alzheimers.net/10-16-15-dementia-care-whats-covered-by-medicaid">health deteriorates</a>; <a href="https://www.cdc.gov/nchs/fastats/alzheimers.htm">half of nursing home residents have dementia</a>, including Alzheimer’s disease.</p>
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<p>Researchers have examined whether nursing homes with <a href="https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/downloads/usersguide.pdf">high ratings</a> from the Centers for Medicare and Medicaid Services were associated with fewer COVID-19 cases, <a href="https://www.aging.senate.gov/imo/media/doc/SCA_Konetzka_05_21_20.pdf">but</a> <a href="https://doi.org/10.1111/jgs.16689">they</a> <a href="https://www.npr.org/2020/06/26/881935246/why-were-some-nursing-homes-spared-the-devastation-of-covid-19-depends-who-you-a">found mixed results</a>.</p>
<p>One factor that was associated with lower infection rates was <a href="https://doi.org/10.1111/jgs.16689">more minutes</a> spent per patient with registered nurses. That means more staff.</p>
<h2>Challenges facing nursing home staff</h2>
<p>Hiring more people is not an easy task. Since before the pandemic, nursing homes’ ability to <a href="https://doi.org/10.1377/hlthaff.2018.05322">meet minimum staffing expectations</a> set by the federal government has been a challenge.</p>
<p>Demand for nursing home staff is high. The U.S. Bureau of Labor Statistics projects job growth for certified nursing assistant positions will be <a href="https://www.bls.gov/ooh/healthcare/nursing-assistants.htm">twice the average rate</a> of that for other occupations over the next decade, mostly driven by an aging population with complex health needs. Demand for registered nurses is <a href="https://www.bls.gov/ooh/healthcare/registered-nurses.htm">also expected to be high</a>. Yet the supply of workers is limited. </p>
<p>A recent study found that, on average, a nursing home’s entire nursing staff could <a href="https://doi.org/10.1377/hlthaff.2020.00957">turn over at least once in a year</a>, and some more than three times in one year. In the most recent national jobs report, nursing and residential care facilities as a group <a href="https://familymedicine.uw.edu/chws/publications/the-challenge-in-tracking-unemployment-among-health-care-workers-and-why-it-matters/">continued to see</a> a <a href="https://www.bls.gov/news.release/empsit.htm">downward trend in employment</a> compared with other sectors of health care.</p>
<p>There are reasons for the high turnover in nursing homes and low supply of nursing home workers. It has been well documented that nursing assistants, for example, have <a href="https://www.bls.gov/oes/current/naics3_623000.htm">low wages, averaging $14.84 per hour in nursing homes</a>, <a href="http://doi.org/10.1093/geront/gnr025">few benefits</a>, <a href="http://doi.org/10.1016/j.gerinurse.2014.01.001">job dissatisfaction</a> and a <a href="http://doi.org/10.1111/jan.13577">lack of career mobility</a>. The pandemic has made it <a href="https://doi.org/10.1377/hlthaff.2020.01269">even more difficult</a> for nursing homes to recruit, given concerns over insufficient personal protective equipment and high rates of COVID-19 infections and death among staff.</p>
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<img alt="A nursing assistant with a badge holds a sign reading: Respect, Protect Nursing Home Workers" src="https://images.theconversation.com/files/394173/original/file-20210409-19-1n7wbo3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/394173/original/file-20210409-19-1n7wbo3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/394173/original/file-20210409-19-1n7wbo3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/394173/original/file-20210409-19-1n7wbo3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/394173/original/file-20210409-19-1n7wbo3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/394173/original/file-20210409-19-1n7wbo3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/394173/original/file-20210409-19-1n7wbo3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Employees at a nursing home in New York protest their working conditions during the COVID-19 pandemic.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/employees-a-parker-jewish-institute-for-health-care-and-news-photo/1253092062?adppopup=true">Alejandra Villa Loarca/Newsday via Getty Images</a></span>
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<p>Now, an emerging threat to the supply of workers is low uptake of the COVID-19 vaccine due to a <a href="https://www.npr.org/sections/health-shots/2021/03/31/982772372/federal-program-to-bring-vaccine-to-nursing-homes-missed-around-half-of-staff">lack of trust</a> among nursing home staff in institutions that were supposed to protect them.</p>
<h2>3 ways forward</h2>
<p>Over the past year, I have <a href="https://www.medpagetoday.com/geriatrics/generalgeriatrics/90055">written</a> and <a href="https://waysandmeans.house.gov/sites/democrats.waysandmeans.house.gov/files/documents/Frogner%20Testimony.pdf">testified</a> before Congress about investing in the careers of nursing home staff by raising wages and improving their job safety.</p>
<p>These facilities could have better chances of recruiting from among the <a href="https://www.bls.gov/news.release/empsit.htm">2.3 million leisure and hospitality workers</a> who remain unemployed because of the pandemic if they made nursing home jobs safer and increased pay. Leisure and hospitality is the <a href="https://doi.org/10.1177/1077558716688156">most common industry</a> from which health care has drawn workers, according to my research.</p>
<p>[<em>The Conversation’s science, health and technology editors pick their favorite stories.</em> <a href="https://theconversation.com/us/newsletters/science-editors-picks-71/?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=science-favorite">Weekly on Wednesdays</a>.]</p>
<p>President Joe Biden recently called for a <a href="https://www.washingtonpost.com/us-policy/2021/04/02/caregiving-elderly-white-house-infrastructure/">$400 billion investment</a> through an expansion of Medicaid – the state-federal program that insures low-income people, those with disabilities and millions of older people – to strengthen home-based care. In-home care visits are often more affordable than nursing homes for those whose family or friends can care for them in the home or the community. The investment aims to significantly improve pay and benefits for home health and home care aides.</p>
<p>Nursing homes should not be left behind. If just 5% of that $400 billion went to nursing home staff, my colleagues and I estimate it could <a href="https://thehill.com/opinion/healthcare/499097-why-do-we-only-care-about-long-term-care-in-a-crisis">raise the wages of certified nursing assistants</a> in nursing homes by $5 per hour for at least one year. Staff would be under less <a href="https://theconversation.com/why-nursing-home-aides-exposed-to-covid-19-arent-taking-sick-leave-150138">pressure to work multiple jobs</a>, and the industry could draw more experienced workers.</p>
<p>Another way to improve staffing: The federal government could increase reimbursements through Medicaid – the primary government payer of nursing homes – to the level of Medicare, which reimburses at a higher rate. That would put nursing homes in a better position to pay their staff more and invest in better care.</p>
<p>Finally, if increasing pay led to a larger supply of workers, nursing homes would have more flexibility to explore <a href="https://doi.org/10.1377/hlthaff.2021.00081">novel models of care</a>. Those models include dedicating more staff to fewer residents – potentially through smaller nursing homes – which could lead to better health care for residents.</p>
<p>The problems are fixable. Improving nursing home staffing and care models can help spare millions of families – including mine – the future agony of deciding whether nursing homes are a good place for mom or dad.</p><img src="https://counter.theconversation.com/content/157561/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Bianca Frogner receives funding from the Health Resources and Services Administration, U.S. Department of Health and Human Services.</span></em></p>Nursing homes have struggled through COVID-19 deaths and lockdowns. Giving nurses more quality time with patients can help them win back trust.Bianca Frogner, Associate Professor of Family Medicine, University of Washington School of Medicine, and Director of the Center for Health Workforce Studies, University of WashingtonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1556372021-03-04T13:12:40Z2021-03-04T13:12:40ZEven before COVID-19, US nursing homes were filling empty beds with psychiatric patients<figure><img src="https://images.theconversation.com/files/386359/original/file-20210225-13-9pqrdn.jpg?ixlib=rb-1.1.0&rect=7%2C0%2C5047%2C3369&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Many elderly residents of nursing homes are seeing younger patients move in, often with mental illnesses. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/senior-man-in-wheelchair-wearing-protective-mask-to-royalty-free-image/1217994683?adppopup=true">Steve Smith via Getty Images</a></span></figcaption></figure><p>One year ago, a nursing home in Kirkland, Washington, <a href="https://www.nytimes.com/2020/03/21/us/coronavirus-nursing-home-kirkland-life-care.html">became an early battleground</a> for the U.S. coronavirus outbreak. The disease has since <a href="https://www.nytimes.com/interactive/2020/us/coronavirus-nursing-homes.html">decimated nursing home populations</a> – more than one-third of the COVID-19-related deaths in the U.S. have been nursing home residents and staff. Virtually unnoticed is what has followed: In some nursing homes, a shift has occurred in the type of residents who live there, and COVID-19 is one of the reasons. </p>
<p>As older residents die from the pandemic and as more families choose to keep elderly relatives at home, some of these facilities are <a href="https://www.kansascity.com/news/local/article149002179.html">accepting more younger patients</a>, including some with drug addictions and mental illness. Some patients have schizophrenia. Some have psychosis. This change in clientele can have a dramatic impact on <a href="https://doi.org/10.1111/jgs.16017">the daily functioning of nursing homes</a>, a change that administrators and staff <a href="https://skillednursingnews.com/2019/06/despite-demand-nursing-homes-face-major-behavioral-health-hurdles/">may be unprepared to handle</a>. </p>
<p><a href="https://ysu.edu/faculty-experts/martin-don">As a neuropsychologist</a> who has been working in skilled care facilities for more than 25 years, I have seen this transition up close. The migration of psychiatric patients to these facilities began in the 1950s, then sped up in the 1980s, when state psychiatric hospitals began rapidly shutting down. Today, about 95% of these hospitals are closed. The ones still open hold collectively about 37,000 beds, <a href="https://www.governing.com/archive/sl-amid-shortage-psychiatric-beds-mentally-ill-face-long-waits-treatment.html">nearly 90,000 short of what’s needed</a>.</p>
<figure class="align-center ">
<img alt="The Life Care Center in Kirkland, Washington." src="https://images.theconversation.com/files/386364/original/file-20210225-23-qg3l4k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/386364/original/file-20210225-23-qg3l4k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/386364/original/file-20210225-23-qg3l4k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/386364/original/file-20210225-23-qg3l4k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/386364/original/file-20210225-23-qg3l4k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/386364/original/file-20210225-23-qg3l4k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/386364/original/file-20210225-23-qg3l4k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">The COVID-19 outbreak at the Life Care Center in Kirkland, Wash., in February 2020 showed the high risk elderly people face from the pandemic.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/the-entrance-of-life-care-center-of-kirkland-where-one-news-photo/1204231197?adppopup=true">Jason Redmond/AFP via Getty Images</a></span>
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<h2>Bringing in younger psychiatric patients</h2>
<p>Primarily because of the deaths caused by the pandemic, many nursing homes now have <a href="https://www.nj.com/coronavirus/2020/11/at-nj-nursing-homes-empty-beds-continue-eight-months-into-the-pandemic.html">lots of empty beds</a>. And to put it bluntly, they need money to survive. The National Health Care Association and National Center for Assisted Living estimate the U.S. long-term care industry will see a <a href="https://www.ahcancal.org/News-and-Communications/Press-Releases/Pages/Long-Term-Care-Faces-Worst-Financial-Crisis-In-Years;-Closures-Loom-Without-Additional-Funding.aspx">16% drop in revenue</a> in 2021 and some 1,670 closures or mergers. In some states, nursing homes can be <a href="https://ctmirror.org/2020/09/20/pandemic-deals-another-blow-to-nursing-homes-plummeting-occupancy/">penalized with Medicaid funding cuts</a> if their occupancy drops too low.</p>
<p>Even many high-end nursing homes, once solicitors of only the affluent, <a href="https://www.npr.org/2010/12/09/131912529/a-new-nursing-home-population-the-young">have been taking younger patients</a>, some in their 30s and 40s, most who have only Medicaid.</p>
<p>These younger patients often have coexisting conditions: substance abuse problems along with psychiatric illnesses. Some have lost contact with their families. Some are without income; others are on disability. Often, they have no place to go. Even for those getting help from their families, the cost of extended care is not affordable, nor can families provide the care themselves. Although estimates vary widely, the best assessment suggests more than 125,000 young and middle-aged adults, most with mental illness, <a href="https://www.sandiegouniontribune.com/sdut-mentally-ill-nursing-homes-032209-2009mar22-story.html">lived in nursing homes before the pandemic</a>. </p>
<p>While federal law requires alternatives to this type of institutionalization for younger patients who spend years in a nursing home, implementation of these laws varies from state to state. Insurance companies <a href="https://www.chron.com/news/houston-texas/article/Younger-patients-lacking-options-are-turning-to-1686362.php">often prefer nursing homes</a> as a more cost-effective option than in-home or supervised care, especially for those with severe mental illness. But putting psychiatric patients near elderly and infirm residents can cause problems. Active drug addicts may seek medications, particularly opiates. Active psychotics can be volatile, even violent. These patients may live in nursing homes for years and eventually <a href="https://bhbusiness.com/2020/01/31/former-nursing-homes-finding-new-life-as-behavioral-health-facilities/">saturate</a> <a href="https://www.mcknights.com/blogs/guest-columns/seven-strategies-for-treating-psychiatric-patients-in-snfs/">the facility</a> with a significant psychiatric population. </p>
<p>The staff members at these homes often don’t know how to care for this kind of patient. They need training similar to what’s given at psychiatric hospitals. Instead, <a href="https://www.iadvanceseniorcare.com/placement-of-mentally-ill-individuals-in-nursing-homes-todays-legal-warfare/">they can become overwhelmed</a>. They deal with behavioral issues, including assaults. Behavioral health nurses <a href="https://www.americansentinel.edu/blog/2018/01/23/nursing-turnover-and-retention-strategies/">have the highest turnover rate</a> among nursing specialties. One-third of them quit within two years. </p>
<p>For nursing home administrators, this is just one more confounding problem they face. COVID-19 has been a devastating experience for them. The virus has ravaged their facilities. One administrator told me she lost nearly one-third of her residents to this illness. I could relate – more than 100 of my patients have died from COVID-19 in the last year.</p>
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<figcaption><span class="caption">An AARP video discusses the impact of COVID-19 on nursing home residents.</span></figcaption>
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<h2>A tremendous emotional toll</h2>
<p>Certainly, death is always a presence in a nursing home. But the <a href="https://coronavirus.jhu.edu/us-map">sheer number of deaths</a>
due to the pandemic has been staggering. Death, grief and fear are not a good psychological cocktail. The emotional toll on workers is tremendous, and with COVID-19, the already high employee turnover rate <a href="https://aspe.hhs.gov/basic-report/covid-19-intensifies-nursing-home-workforce-challenges">has climbed</a>. Three administrators told me more than a quarter of their staffs have quit. Many are nursing aides, making barely above minimum wage and justifiably terrified at the prospect of catching a virus that could be lethal. These aides are often the only ones there to hold the hands of patients as they die.</p>
<p>Residents who survive the pandemic have endured <a href="https://www.aarp.org/caregiving/health/info-2020/covid-isolation-killing-nursing-home-residents.html">tremendous hardships</a>. To be stuck in your room, mostly alone, for a year can be profoundly depressing. Friends die and are removed in the middle of the night. Those who remain, some with dementia, may think their friends and family have abandoned them. Residents testing positive for COVID-19 are generally moved to a different part of the home, which is unsettling for them and increases their confusion and mood swings. </p>
<p>Finding housing solutions benefiting both psychiatric patients and an elderly population is a long-haul problem. Money is one of the answers; the <a href="https://nami.org/Home">National Alliance on Mental Illness</a> has lobbied Congress for more. In particular, <a href="https://www.healthyplace.com/other-info/mental-illness-overview/finding-group-homes-for-mentally-ill-adults">funds are needed</a> for group homes where residents with mental illness can eventually transition back to the community. The Department of Housing and Urban Development offers programs that help the elderly and those with disabilities get safe, decent housing. Generally, a person must receive Medicaid to qualify for these services, and <a href="https://www.heraldtribune.com/news/20200329/new-housing-for-low-income-homeless-people-with-mental-illnesses-is-coming">demand for any of these alternatives</a> far exceeds availability.</p>
<p>[<em>Over 100,000 readers rely on The Conversation’s newsletter to understand the world.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=100Ksignup">Sign up today</a>.]</p>
<p>At least the immediate future at many nursing homes <a href="https://www.msn.com/en-us/news/us/safest-place-in-the-city-covid-19-cases-in-nursing-homes-drop-89-25-as-residents-get-vaccinated/ar-BB1e3cjo?ocid=uxbndlbing">is looking better</a>. Many of my patients have been vaccinated. Death rates are dramatically lower. Facilities now allow family to visit, albeit with strict protocols. Soon residents will be able to socialize with each other again. Still, the pandemic’s toll on residents, families and staff will linger for years. The year 2020 has traumatized many of us, including me.</p><img src="https://counter.theconversation.com/content/155637/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Don Martin does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>A neuropsychologist who works in these skilled care facilities describes the changing populations. With COVID-19, many nursing homes are now struggling to stay in business.Don Martin, Director, Urban School Counseling Graduate Program, Youngstown State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1561092021-03-01T10:00:33Z2021-03-01T10:00:33Z4 key takeaways from the aged care royal commission’s final report<figure><img src="https://images.theconversation.com/files/386908/original/file-20210301-19-ivvb6c.jpg?ixlib=rb-1.1.0&rect=60%2C0%2C6720%2C4476&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>The Royal Commission into Aged Care Quality and Safety’s <a href="https://agedcare.royalcommission.gov.au/publications/final-report">final report into aged care</a> has laid out an extensive plan to overhaul Australia’s aged-care system. </p>
<p>Among the 148 recommendations, the report calls for a new system underpinned by a rights-based Act, funding based on need, and much stronger regulation and transparency.</p>
<p><div data-react-class="InstagramEmbed" data-react-props="{"url":"https://www.instagram.com/p/CL3bG6-L_JT","accessToken":"127105130696839|b4b75090c9688d81dfd245afe6052f20"}"></div></p>
<p>Over two years, through more than 10,500 submissions and 600 witnesses, the two commissioners heard extensive evidence of a system in crisis. Australians might have expected the commissioners to provide one streamlined blueprint for reform.</p>
<p>But the commissioners diverged on a number of large and some smaller recommendations. This makes the already complex path to reform even more confusing. It reduces the power of the final report. More disappointingly, it gives the government room to pick and choose recommendations as the cabinet likes.</p>
<p>Nonetheless, if the major recommendations are adopted, Australia will get a transformed aged care system over the next five years.</p>
<p>Here are our top four takeaways from this landmark report.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/paid-on-par-with-cleaners-the-broader-issue-affecting-the-quality-of-aged-care-155753">Paid on par with cleaners: the broader issue affecting the quality of aged care</a>
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<h2>1. Australia needs a rights-based aged-care system</h2>
<p>In its recommendations, the final report highlights Australia needs a new Aged Care Act to underpin reform. The new Act should set out the rights of older people, including their entitlement to care and support based on their needs and preferences. </p>
<p>This would be a significant shift away from the current ration-based system, and would bring aged care more in line with the principles of Medicare. </p>
<p>Practically, this would mean the number of people in the system would no longer be capped — the long waiting lists for care would disappear over time. The current aged-care programs, such as home-care packages and residential care, would be replaced by a single program. </p>
<p>Under this new program, all older Australians in need of support would be independently assessed, and allocated care according to their personal needs and preferences — whether at home or in residential care. </p>
<p>This is a huge step forward, and, with the right support, would enable older Australians more choice and control over their care. </p>
<h2>2. The system needs stronger governance</h2>
<p>Ineffective governance and weak regulation of aged care must end. The final report calls for much stronger governance, regulation of the quality of care, prudential regulation, and an independent mechanism to set prices. </p>
<p>These changes would ensure the “quasi-market” aged-care system, as commissioner Tony Pagone described it, was much better regulated, holding providers to a higher standard of care, and better able to address any service gaps in the system. We might see the introduction of home care in locations where home-care services were not previously available, for example.</p>
<p>This change would require all aged-care providers to be accredited against the new standards. We hope that process would weed out some of the poorest performers in the sector. The new system would have offices across the country, to provide on-the-ground support to older Australians and providers.</p>
<p>Unfortunately, the commissioners diverged on the exact mechanisms for these changes. Pagone wants an independent commission to be responsible for aged care, at arms-length from the health department. Meanwhile, commissioner Lynelle Briggs wants governance to remain with a reformed department, but with quality regulation managed by an independent quality commission. </p>
<p>Given the department’s poor track record on managing aged care, we need to see a major change of culture. We urge the government to accept commissioner Pagone’s recommendation.</p>
<h2>3. We need to improve workforce conditions and capability</h2>
<p>The final report makes numerous important recommendations to enhance the capability and work conditions of formal carers. It calls for better wages and a new national registration scheme for all personal care workers, who would be required to have a minimum Certificate III training.</p>
<p>Residential care facilities would need to ensure minimum staff time with residents. By July 1 2022, this would be at least 200 minutes per resident per day for the average resident, with at least 40 minutes of that time with a registered nurse. </p>
<p>The facilities would be required to report staffing hours provided each day, specifying the breakdown of residents’ time with personal care workers versus nursing staff.</p>
<p>While these measures are good, they are the bare minimum, and would only give facilities a minimum 2 or 3 star <a href="https://agedcare.royalcommission.gov.au/system/files/2020-06/AHS.0001.0001.0001.pdf">rating</a>. But coupled with recommendations for stronger transparency, including the publication of star ratings and quality indicators to compare provider performance, providers might be incentivised to go above this minimum standard.</p>
<h2>4. A better system will cost more</h2>
<p>The final report makes a series of complex recommendations about fees and funding, with the commissioners diverging in view as to the specific arrangements. But essentially, the proposed new funding model would provide universal funding for care services, such as nursing. </p>
<p>This means there would be no requirement for aged-care recipients to pay a co-contribution, like public patients in public hospitals. Instead, the expectation is people pay for their ordinary costs of living, such as cleaning, subject to a means test and up to a maximum amount in residential care. </p>
<figure class="align-center ">
<img alt="A carer holds the hand of an elderly person." src="https://images.theconversation.com/files/386961/original/file-20210301-13-4nz8dm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/386961/original/file-20210301-13-4nz8dm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/386961/original/file-20210301-13-4nz8dm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/386961/original/file-20210301-13-4nz8dm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/386961/original/file-20210301-13-4nz8dm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/386961/original/file-20210301-13-4nz8dm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/386961/original/file-20210301-13-4nz8dm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A rights-based system means funding is determined by each individual’s needs.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p>These changes would coincide with the phase-out of the burdensome <a href="https://agedcareonline.com.au/news/152/15/Aged-Care-Refundable-Accommodation-Deposit-RADs-and-Daily-Accommodation-Payment-DAPs">refundable accommodation deposits</a>, which some residents currently pay as a lump sum to providers when they enter residential care. This approach is a shift away from the current muddled set of means-tested arrangements, and may help offset some of the additional spending needed to pay for a rights-based system.</p>
<p>Unfortunately, the report does not touch on how much the recommended changes would cost. Australia should be prepared to pay the price of a better aged care system.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/view-from-the-hill-royal-commission-confronts-morrison-government-with-call-for-aged-care-tax-levy-156207">View from The Hill: royal commission confronts Morrison government with call for aged care tax levy</a>
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<p>The government has been underspending on aged care. Most <a href="https://agedcare.royalcommission.gov.au/sites/default/files/2020-07/research_paper_6_-_australias_aged_care_system_-_assessing_the_views_an._.pdf">Australians agree</a> the government should provide more funding for aged care. Commissioner Briggs has the more persuasive proposal for funding the new system. She wants the government to introduce legislation by July 1 2022 that establishes an aged-care improvement levy of 1% of taxable personal income. </p>
<p>Commissioner Pagone is weaker on this point. He wants the Productivity Commission to investigate the establishment of an hypothecated aged-care levy (meaning the money raised by the levy can <em>only</em> be spent on aged care).</p>
<p>Either approach will be politically difficult, but Australians should demand their government lock-in a secure funding supply. That will help produce an aged-care system that protects the rights, upholds the dignity, and celebrates the contribution of all older Australians.</p><img src="https://counter.theconversation.com/content/156109/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stephen Duckett is a member of the board of directors of the Brotherhood of St Laurence which, among other services, is a provider of aged care. Grattan Institute began with contributions to its endowment of $15 million from each of the Federal and Victorian Governments, $4 million from BHP Billiton, and $1 million from NAB. In order to safeguard its independence, Grattan Institute’s board controls this endowment. The funds are invested and contribute to funding Grattan Institute's activities. Grattan Institute also receives funding from corporates, foundations, and individuals to support its general activities, as disclosed on its website.</span></em></p><p class="fine-print"><em><span>Anika Stobart does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Disappointingly, however, this report gives the government room to pick and choose recommendations as the cabinet likes.Stephen Duckett, Director, Health Program, Grattan InstituteAnika Stobart, Associate, Grattan InstituteLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1511912021-01-07T21:36:56Z2021-01-07T21:36:56ZEnabling better aging: The 4 things seniors need, and the 4 things that need to change<figure><img src="https://images.theconversation.com/files/377146/original/file-20210105-17-68ty2y.jpg?ixlib=rb-1.1.0&rect=0%2C26%2C3594%2C2538&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">People protest outside the Tendercare Living Centre long-term-care facility in Scarborough, Ont. on Dec. 29, 2020. This LTC home has been hit hard by the second wave of the COVID-19 pandemic.
</span> <span class="attribution"><span class="source">(THE CANADIAN PRESS/Nathan Denette)</span></span></figcaption></figure><p>Canada’s population is rapidly aging, but is it aging well? In our November 2020 report “<a href="https://www.queensu.ca/sps/sites/webpublish.queensu.ca.spswww/files/files/Publications/Ageing%20Well%20Report%20-%20November%202020.pdf">Ageing Well</a>,” we found both good and bad news. </p>
<p>The good is that <a href="https://www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=1710000501">Canadians are living longer</a>. Back when medicare became the backbone of our health-care system about 60 years ago, seniors made up <a href="https://www150.statcan.gc.ca/n1/pub/91-520-x/2014001/c-g/desc/desc2.5-eng.htm">7.6 per cent of the population</a>. They <a href="https://www150.statcan.gc.ca/n1/pub/91-215-x/91-215-x2019001-eng.htm">now constitute 17.5 per cent</a> and will be almost <a href="https://doi.org/10.25318/1710005701-eng">25 per cent in 2041</a> — 10.8 million people whose average age will be in the low 80s just over 20 years from now. They should all age happily and well.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/377653/original/file-20210107-21-1i18gc1.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/377653/original/file-20210107-21-1i18gc1.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/377653/original/file-20210107-21-1i18gc1.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=373&fit=crop&dpr=1 600w, https://images.theconversation.com/files/377653/original/file-20210107-21-1i18gc1.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=373&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/377653/original/file-20210107-21-1i18gc1.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=373&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/377653/original/file-20210107-21-1i18gc1.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=468&fit=crop&dpr=1 754w, https://images.theconversation.com/files/377653/original/file-20210107-21-1i18gc1.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=468&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/377653/original/file-20210107-21-1i18gc1.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=468&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
<span class="attribution"><span class="source">(Ageing Well, Queen's University School of Policy Studies)</span>, <span class="license">Author provided</span></span>
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</figure>
<p>The bad news is that they don’t want to live in old-folks’ homes where current policy tends to put them. Also, ensuring they have the support services they need to age well will require major changes to how, where and by whom those services are provided, and change can be difficult to implement in any dimension of health care. </p>
<p>Providing those services <a href="https://www.cihi.ca/sites/default/files/document/nhex-trends-narrative-report-2019-en-web.pdf">will also cost each of us more</a>, both individually and as taxpayers. Canada is heading into a less robust economic period, in part due to the need to pay down our <a href="https://www.reuters.com/article/us-canada-economy-budget-idUSKBN26K2RK">COVID-19 debt</a> — and we may be hard-pressed to pay that bill.</p>
<p>Long-term care (LTC) in all Canadian provinces has become more or less synonymous with the care and services provided in nursing and retirement homes owned and operated by private for-profit and not-for-profit companies, charities and municipalities. </p>
<figure class="align-right ">
<img alt="An elderly woman waves from behind a curtain" src="https://images.theconversation.com/files/377212/original/file-20210105-19-t1d31y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/377212/original/file-20210105-19-t1d31y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=718&fit=crop&dpr=1 600w, https://images.theconversation.com/files/377212/original/file-20210105-19-t1d31y.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=718&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/377212/original/file-20210105-19-t1d31y.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=718&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/377212/original/file-20210105-19-t1d31y.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=902&fit=crop&dpr=1 754w, https://images.theconversation.com/files/377212/original/file-20210105-19-t1d31y.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=902&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/377212/original/file-20210105-19-t1d31y.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=902&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Elizabeth Jeppesen, 94, who tested positive for COVID-19, waves from a window in her room at Tabor Home, a long-term care facility in Abbotsford, B.C., in November 2020.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Darryl Dyck</span></span>
</figcaption>
</figure>
<p>Relative to many other developed countries, the foundation of Canadian policy to meet the needs of the elderly is aptly described as “warehousing,” housing designed primarily to optimize the efficient provision of nursing and personal care. Most if not all such care homes also do their best to provide other services too, but it’s fair to say that meeting seniors’ social and recreational needs plays second fiddle to meeting their personal and health-care needs. </p>
<h2>What seniors need to age well</h2>
<p>What do our seniors want? It’s not to live in an institution, the possible exception being the poor soul who has lingered too long in an <a href="https://www.cihi.ca/en/guidelines-to-support-alc-designation">alternative level of care</a> bed: no longer in need of intensive in-hospital care but still requiring some services not readily available in most Canadian provinces other than LTC facilities.</p>
<p>To age well, seniors have four interrelated needs:</p>
<ol>
<li><p>Housing appropriate to their needs and preferences. For most, their strong preference is for the family home in the same community with familiar neighbours, surroundings and amenities. They want to age in place and remain there as long as they possibly can, receiving the care and support services they need at home.</p></li>
<li><p>Flexible health and personal care, and household support appropriate for each individual or elderly couple as their needs wax and wane. These needs usually increase as they age, but not always. Evidence shows clearly that if the well-being of seniors is supported in all its dimensions, and if the delivery of services begins “upstream” at the first sign of trouble, the prevention and slowing — if not reversing — of the <a href="https://doi.org/10.1016/S0140-6736(20)30367-6">onset and progression of both dementia and other manifestations of frailty can be achieved</a>.</p></li>
<li><p>Socialization is another of the four key needs of aging well, a need met best by enabling seniors to remain in their own communities with their families, friends and neighbours and recognizing their familiarity with the range of the services their community provides.</p></li>
<li><p>Meeting seniors’ lifestyle and/or recreational needs is also vital to aging well, especially as they’re integrated with the individual’s or couple’s social needs. Sadly, data indicate that seniors, like too many other Canadians in our contemporary online society, are succumbing to “couch potato” tendencies that erode the beneficial effects both of social interactions and regular exercise.</p></li>
</ol>
<p>With respect to the money we spend to help our seniors age well, Canada is an outlier among developed countries. We spend less overall (<a href="https://www.oecd.org/health/long-term-care.htm">in 2017, 1.3 per cent of Canada’s GDP</a>) on long-term continuing care and services; only Spain spends less (0.7 per cent). Implementing the likely recommendations to come out of several provincial <a href="https://theconversation.com/we-need-inquiries-into-why-coronavirus-is-ravaging-long-term-care-homes-138688">COVID-related LTC reviews</a> will likely take us to the OECD average, or slightly above it. </p>
<figure class="align-center ">
<img alt="An older couple in their home" src="https://images.theconversation.com/files/377213/original/file-20210105-17-1dx9hln.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/377213/original/file-20210105-17-1dx9hln.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/377213/original/file-20210105-17-1dx9hln.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/377213/original/file-20210105-17-1dx9hln.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/377213/original/file-20210105-17-1dx9hln.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/377213/original/file-20210105-17-1dx9hln.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/377213/original/file-20210105-17-1dx9hln.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Most seniors do not want to live in long-term care facilities. They want to continue living in their family home, in the same community with familiar neighbours, surroundings and amenities.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>However, our outlier status will remain accentuated by our remarkably <a href="http://www.oecd.org/els/health-systems/47884520.pdf">imbalanced spending of $1 on home care for every $6 spent on institutional LTC</a>. Most others spend roughly equal amounts, and those most highly regarded for the high quality and happy outcomes of enabling seniors to age well — Denmark and the Netherlands, for example — do the reverse. They spend more on home and community services than on institutional care.</p>
<h2>Four factors that must change</h2>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/377655/original/file-20210107-15-1ut5wr9.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/377655/original/file-20210107-15-1ut5wr9.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/377655/original/file-20210107-15-1ut5wr9.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=217&fit=crop&dpr=1 600w, https://images.theconversation.com/files/377655/original/file-20210107-15-1ut5wr9.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=217&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/377655/original/file-20210107-15-1ut5wr9.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=217&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/377655/original/file-20210107-15-1ut5wr9.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=273&fit=crop&dpr=1 754w, https://images.theconversation.com/files/377655/original/file-20210107-15-1ut5wr9.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=273&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/377655/original/file-20210107-15-1ut5wr9.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=273&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Source: Conference Board of Canada 2016, BC Care Providers Association 2019, and the Financial Accountability Office of Ontario 2019. The BCCPA and FAO projections were made provincially and converted to Canada-wide projections.</span>
<span class="attribution"><span class="source">(Ageing Well, Queen's University School of Policy Studies)</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>Given our foreseeable demographic and economic circumstances, continuing with the same policy choices defies comprehension. </p>
<p>First, as COVID-19 has clearly demonstrated, care homes are dangerous places in which infectious diseases can spread easily; some <a href="https://theconversation.com/how-some-oecd-countries-helped-control-covid-19-in-long-term-care-homes-141354">80 per cent of deaths in the first wave in Canada were in LTC homes</a>. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/2ClSB0Gwda0?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">The authors of the Ageing Well report present highlights from their research.</span></figcaption>
</figure>
<p>Second, given the increased number and advancing age of the baby boomer generation, continuing with our warehousing propensity is doomed to failure. The number of care-home beds that would be required is simply beyond what we could afford. This is compounded by the fact that such beds were already subject to <a href="https://www.fao-on.org/en/Blog/Publications/ontario-long-term-care-program">long waiting lists</a> even before their <a href="https://www.publichealthontario.ca/-/media/documents/ncov/ltcrh/2020/06/covid-19-outbreak-de-escalation-ltch.pdf?la=en">post-COVID-19 downsizing to eliminate shared rooms and washrooms</a>. </p>
<p>Third, to reiterate, few seniors want to live in long-term care, preferring strongly to remain in their own homes and communities or in various alternative forms of communal housing in which they have access to home and community services. </p>
<p>And fourth, the cost of institutional accommodation and care — to residents, their families and the public purse — exceeds by far what it would cost to provide an extended range of seniors’ needs through beefed-up home and community support services. That would be expensive too, but it’s an approach to helping our seniors age well that our country could afford.</p>
<p>Substantial change to Canada’s long-term support service systems is long overdue. It’s time to get at it.</p><img src="https://counter.theconversation.com/content/151191/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Canadians are living longer, but are they living well? The challenges to aging well go beyond the problems in long-term care. Substantial change to Canada’s support service systems is long overdue.Don Drummond, Stauffer-Dunning Fellow in Global Public Policy and Adjunct Professor at the School of Policy Studies, Queen's University, OntarioDuncan Sinclair, Professor of Health Services and Policy Research, Queen's University, OntarioLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1484292020-12-01T13:24:23Z2020-12-01T13:24:23ZRapid COVID-19 tests can be useful – but there are far too few to put a dent in the pandemic<figure><img src="https://images.theconversation.com/files/372068/original/file-20201130-17-1elf41t.jpg?ixlib=rb-1.1.0&rect=254%2C0%2C3354%2C2223&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Rapid tests for COVID-19 are easy to administer and give fast results. </span> <span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/ExchangeCollaborativeTestingStrategy/cd621b49cd784744a268b9e648ecccdf/photo?Query=covid%20rapid%20test&mediaType=photo&sortBy=&dateRange=Anytime&totalCount=463&currentItemNo=28">AP Photo/Julio Cortez, File</a></span></figcaption></figure><p>Since September, the Food and Drug Administration has <a href="https://www.fda.gov/medical-devices/coronavirus-disease-2019-covid-19-emergency-use-authorizations-medical-devices/vitro-diagnostics-euas#individual-antigen">approved seven COVID-19 tests</a> that yield results in 30 minutes or less, offering hope for vast improvements in test access and efficiency throughout the U.S. Most of these are <a href="https://theconversation.com/antigen-tests-for-covid-19-are-fast-and-easy-and-could-solve-the-coronavirus-testing-problem-despite-being-somewhat-inaccurate-137977">antigen tests</a> that look for viral proteins and can be processed on portable machines or cards. </p>
<p>The idea behind these rapid tests is to detect symptomatic, pre-symptomatic and asymptomatic infectious people before they can spread the coronavirus. But despite massive distribution of these tests by federal officials – including <a href="https://www.hhs.gov/coronavirus/testing/rapid-test-distribution/index.html">to date over 40 million</a> of <a href="https://www.cbsnews.com/news/covid-rapid-test-abbott-labs-150-million/">150 million rapid tests ordered from the medical company Abbott</a> – COVID-19 transmission has been surging in every state since early November. </p>
<p>This calls into question whether the current influx of rapid tests can actually slow the spread of COVID-19. </p>
<p>In some targeted applications – and if people take other precautions including mask wearing and social distancing – rapid tests can be a valuable tool. But the current state of availability and accuracy of these tests greatly limit how effective they are at slowing the spread of the virus in communities.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/372069/original/file-20201130-13-1q24h4i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A healthcare worker placing a sample into a the small Abbott ID Now processing machine." src="https://images.theconversation.com/files/372069/original/file-20201130-13-1q24h4i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/372069/original/file-20201130-13-1q24h4i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/372069/original/file-20201130-13-1q24h4i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/372069/original/file-20201130-13-1q24h4i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/372069/original/file-20201130-13-1q24h4i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/372069/original/file-20201130-13-1q24h4i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/372069/original/file-20201130-13-1q24h4i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Rapid tests like the Abbott ID Now require only small, portable machines and can give results in 15 minutes, but they sacrifice accuracy.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/VirusOutbreakCalifornia/2b7302f66ad440708223cfdb75dc12e9/photo?Query=covid%20rapid%20test&mediaType=photo&sortBy=&dateRange=Anytime&totalCount=463&currentItemNo=53">AP Photo/Jeff Chiu</a></span>
</figcaption>
</figure>
<h2>Speed over accuracy</h2>
<p>Rapid antigen tests are an attractive option because in addition to their speed, they are <a href="https://theconversation.com/rapid-screening-tests-that-prioritize-speed-over-accuracy-could-be-key-to-ending-the-coronavirus-pandemic-143882">cheap and easy to produce</a> and therefore more broadly available than the <a href="https://theconversation.com/how-does-the-coronavirus-test-work-5-questions-answered-133118">more commonly used gold-standard PCR tests</a> in theory. But these attributes come with a trade-off: <a href="https://www.theatlantic.com/health/archive/2020/10/do-rapid-antigen-tests-have-accuracy-problem/616681/">less diagnostic accuracy</a>. This makes them an excellent candidate for <a href="https://theconversation.com/will-the-new-15-minute-covid-19-test-solve-us-testing-problems-145285">use as a screening tool</a>, though less useful for accurately diagnosing SARS-CoV-2 infection. </p>
<p>One-time testing does not mean that a person can <a href="https://www.nytimes.com/2020/11/21/upshot/coronavirus-test-thanksgiving-plans.html">safely travel or mingle without precautions</a>. And while no test is perfectly accurate, there are real questions about the performance of the new rapid tests. </p>
<p>A few test manufacturers <a href="https://www.quidel.com/sites/default/files/product/documents/EF1438903EN00.pdf">reported accuracy</a> between 84.0% and 97.6% in individuals who are tested within five days after developing COVID-19 symptoms. There is, however, an apparent gap between the reported performance of these tests and <a href="https://www.nytimes.com/2020/11/02/health/coronavirus-testing-quidel-sofia.html">what is achieved in the real world</a>. Anecdotally, these tests seem to <a href="https://www.nytimes.com/2020/11/02/health/coronavirus-testing-quidel-sofia.html">miss recent, mild and asymptomatic infections</a> – in fact, rapid tests are authorized by the U.S. Centers for Disease Control and Prevention only for <a href="https://www.cdc.gov/coronavirus/2019-ncov/lab/resources/antigen-tests-guidelines.html">use in symptomatic COVID-19 patients</a>. And of course, people can still be infected soon after getting tested. </p>
<p>For rapid tests to effectively limit spread of the coronavirus, experts suggest that they must be <a href="http://doi.org/10.1001/jamanetworkopen.2020.16818">conducted with high frequency</a> – you might miss some cases, but if everyone were getting tested all the time, you would catch a lot of cases too. But even frequent testing is not a panacea. It’s only one part of an approach that must also include social distancing, mask wearing and other precautions.</p>
<p>A highly publicized example of how a rapid testing strategy can go wrong occurred when President Trump and many in his inner circle contracted COVID-19, likely stemming from a single superspreading event. Everyone was reportedly getting daily rapid tests, but they were largely ignoring other measures like face masks and social distancing. It is likely that someone was <a href="https://www.technologyreview.com/2020/10/07/1009636/rapid-covid-tests-can-work-white-houses-mistakes-trump-abbott/">infected and asymptomatic, tested negative, and then started the outbreak</a>. </p>
<h2>Widespread, repeat testing</h2>
<p>Detecting pre-symptomatic and asymptomatic individuals who are infectious is critical to controlling the coronavirus. <a href="https://dx.doi.org/10.1101%2F2020.06.22.20136309">Rapid tests can do this</a>, but only if people are screened repeatedly on a schedule – much as what has been <a href="https://www.bostonglobe.com/2020/11/02/sports/with-careful-planning-total-commitment-nba-constructed-safest-place-earth/">happening in some professional</a> and intercollegiate sports. </p>
<p>The idea is that by testing people early and often – perhaps even <a href="https://www.nytimes.com/2020/07/03/opinion/coronavirus-tests.html">as much as every day</a> – rapid tests <a href="https://theconversation.com/will-the-new-15-minute-covid-19-test-solve-us-testing-problems-145285">can catch infected people before they spread the coronavirus to others</a>. But on a national scale, that is a huge number of tests.</p>
<p>Researchers have estimated that the U.S. would need to perform at least 20 million rapid tests per day to <a href="https://www.rapidtests.org/">drive down infections</a>. The 150 million rapid tests ordered by the government in late August were earmarked for high-risk populations, but would barely cover one week for the population at large. And don’t forget that logistic capabilities, compliance to frequent testing and the infrastructure to act quickly on results all need to happen as well.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/372071/original/file-20201130-17-b1ufyk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A healthcare worker administering a rapid test to an elderly man." src="https://images.theconversation.com/files/372071/original/file-20201130-17-b1ufyk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/372071/original/file-20201130-17-b1ufyk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/372071/original/file-20201130-17-b1ufyk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/372071/original/file-20201130-17-b1ufyk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/372071/original/file-20201130-17-b1ufyk.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/372071/original/file-20201130-17-b1ufyk.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/372071/original/file-20201130-17-b1ufyk.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Nursing homes were some of the first places to receive rapid tests.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/VirusOutbreakNursingHomeTesting/92040888c49f470bac9c060c1a90a047/photo?Query=nursing%20home%20covid&mediaType=photo&sortBy=&dateRange=Anytime&totalCount=617&currentItemNo=33">AP Photo/Ted S. Warren</a></span>
</figcaption>
</figure>
<h2>A targeted approach</h2>
<p>There simply aren’t enough rapid tests being produced for the general public to get repeat testing, so the federal government has <a href="https://www.kff.org/coronavirus-covid-19/issue-brief/state-reporting-of-cases-and-deaths-due-to-covid-19-in-long-term-care-facilities/">prioritized deployment of rapid tests to the high-risk population of nursing homes</a>. Federal guidelines for rapid test use in long-term care facilities are a great example of what a testing program might look like – but also illustrate the <a href="https://www.nytimes.com/2020/10/07/health/nevada-covid-testing-nursing-homes.html">current challenges in the use of rapid tests</a>.</p>
<p>If even one person in a nursing home tests positive, all staff and residents must be <a href="https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-antigen-testing.html">tested every three to seven days</a> until the facility has been free of COVID–19 for 14 days. When a facility has no cases, all staff are required to get tested <a href="https://www.cdc.gov/coronavirus/2019-ncov/downloads/hcp/nursing-home-testing-algorithm-508.pdf">according to their county’s test-positivity rate</a> – the <a href="https://www.cms.gov/files/document/qso-20-38-nh.pdf">higher the rate, the more testing is needed</a>.</p>
<p>[<em>The Conversation’s science, health and technology editors pick their favorite stories.</em> <a href="https://theconversation.com/us/newsletters/science-editors-picks-71/?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=science-favorite">Weekly on Wednesdays</a>.]</p>
<p>Yet nursing homes have had problems with <a href="https://www.nytimes.com/2020/09/29/health/covid-nursing-homes-testing.html">accuracy, staffing and costs</a> while using these tests and find themselves <a href="https://khn.org/news/article/nursing-homes-still-see-dangerously-long-waits-for-covid-test-results/">again in crisis during the current surge</a>. While the rapid tests certainly helped catch many cases and should be used in these settings, they cannot single-handedly overcome <a href="https://www.npr.org/sections/health-shots/2020/10/26/927841874/they-work-in-several-nursing-homes-to-eke-out-a-living-and-that-spreads-the-virus">larger issues that contribute to spread in these settings</a>. </p>
<p>Rapid tests can be effective in highly controlled settings where people are tested frequently and other mitigation measures are in place. Look to the <a href="https://www.latimes.com/science/newsletter/2020-10-12/coronavirus-today-nba-bubble-success-covid-lakers-coronavirus-today">success of the NBA bubble</a> as proof. But in other settings where isolation, mask wearing and social distancing are hard to implement or not followed – like nursing homes or the White House – rapid tests have not kept the virus at bay. </p>
<p>Current testing capacity is nowhere near the hundreds of millions of tests per week required to protect the general population. To date, the promise of cheap and convenient COVID-19 tests being the sole means of controlling disease transmission has not been realized.</p><img src="https://counter.theconversation.com/content/148429/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dr. Bonnie LaFleur receives funding from NIH, NCI, NIA. She is affiliated with Cofactor Genomics as a consultant. </span></em></p><p class="fine-print"><em><span><a href="mailto:kellingson@arizona.edu">kellingson@arizona.edu</a> receives funding from Centers for Disease Control and Prevention, Arizona Biomedical Research Commission, Arizona Area Health Education Centers, National Association for City and County Health Officials. </span></em></p>In September, production of rapid tests really ramped up in the US. But due to low accuracy and massive numbers needed, these tests alone are unlikely to have much of an effect on the pandemic.Bonnie LaFleur, Professor of Biostatistics, University of ArizonaKatherine Ellingson, Assistant Professor of Epidemiology and Biostatistics, University of ArizonaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1501382020-11-23T19:56:28Z2020-11-23T19:56:28ZWhy nursing home aides exposed to COVID-19 aren’t taking sick leave<figure><img src="https://images.theconversation.com/files/370158/original/file-20201118-23-1olawc0.jpg?ixlib=rb-1.1.0&rect=18%2C27%2C6020%2C3983&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Nursing home aides have protested working conditions that can push them to work while sick.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/employees-a-parker-jewish-institute-for-health-care-and-news-photo/1253092062">Alejandra Villa Loarca/Newsday via Getty Images</a></span></figcaption></figure><p>The COVID-19 pandemic has devastated America’s nursing homes, but the reasons aren’t as simple as people might think.</p>
<p>To understand how nursing homes became the source of <a href="https://www.kff.org/health-costs/issue-brief/state-data-and-policy-actions-to-address-coronavirus/#long-term-care-cases-deaths">over one-third</a> of U.S. COVID-19 deaths, you have to look beyond just the vulnerability of the residents and examine how nursing homes pay and manage their employees.</p>
<p>The average nursing aide <a href="https://www.bls.gov/ooh/healthcare/nursing-assistants.htm">earns just $14.25 an hour</a>, less than $30,000 a year. Many are women who work at multiple nursing homes to make ends meet. Partly as a result of that, the typical nursing home has <a href="http://doi.org/10.3386/w27608">staff connections to 15 other facilities</a> – each an opportunity for the coronavirus to spread. That risk is magnified by a reluctance among many nursing aides to take sick days when they are ill, even though federal law currently requires employers to provide paid sick leave for coronavirus-related reasons.</p>
<p>An alarming number of infections in long-term care facilities – <a href="http://doi.org/10.3386/w27608">nearly half</a> – have been traced to staff who work in multiple health care facilities and who engage in “presenteeism,” meaning they continue to work even after being exposed to or falling ill from COVID-19.</p>
<p>As law professors who specialize in <a href="https://law.arizona.edu/shefali-milczarek-desai">employment, immigration</a> and <a href="https://law.arizona.edu/tara-sklar">health law</a>, we have spoken with many nursing home aides to try to understand why this is happening and find ways to avoid it. The story of one of them represents what many others have experienced. We’ll call her Salma rather than use her real name to protect her from retaliation. </p>
<p>Like <a href="http://doi.org/10.1377/hlthaff.2018.05514">about a third of nursing aides</a>, Salma is an immigrant. She often spends 12 hours a day cooking, cleaning and caring for residents’ most intimate needs, such as bathing, dressing, feeding and providing medication.</p>
<p>When Salma fell ill earlier this year, she requested paid sick leave, but her employer refused to provide it. She tried to assert her rights under her state’s paid sick time law, but she said her employer responded by threatening to report her to immigration authorities. When she explained that she had legal status, Salma said, her employer changed tactics and threatened to report her to the Internal Revenue Service because no payroll taxes had been deducted from her wages, as she was paid off the books. Salma was afraid she would lose her job, so she continued to go to work.</p>
<p><a href="https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3733990">Our research</a>, drawing on interviews with nursing aides like Salma and <a href="https://doi.org/10.1093/jlb/lsaa036">emerging studies</a> of other <a href="https://www.umass.edu/lrrc/research/working-papers-series/survey-essential-workers%E2%80%99-safety-and-security-during-covid-19">essential workers during COVID-19</a>, shows how <a href="http://dx.doi.org/10.2139/ssrn.3675866">employee policies</a>, particularly for low-paid aides, have sharply raised the risks, and how access to paid sick leave could lower them.</p>
<h2>A long-running problem</h2>
<p><a href="https://www.texashealthinstitute.org/uploads/1/3/5/3/13535548/thi_pandemic_influenza__equity_report_2012.pdf">Historical records</a> from previous outbreaks in the U.S., including the 1918 influenza pandemic and the 2009 H1N1 epidemic, show that immigrants and people of color are more likely to contract and die of infectious diseases. While preexisting conditions account for the severity of illness, they do not explain why these segments of the population are more likely to become sick in the first place. </p>
<p><a href="https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/race-ethnicity.html">Data show</a> this is due to large percentages of immigrants and people of color performing essential labor, such as nursing aide roles, that requires close contact with many other people. </p>
<figure class="align-center ">
<img alt="An assisted care facility staff member checks a resident's temperature" src="https://images.theconversation.com/files/370631/original/file-20201122-21-ulgrno.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/370631/original/file-20201122-21-ulgrno.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/370631/original/file-20201122-21-ulgrno.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/370631/original/file-20201122-21-ulgrno.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/370631/original/file-20201122-21-ulgrno.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/370631/original/file-20201122-21-ulgrno.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/370631/original/file-20201122-21-ulgrno.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">In assisted care facilities and nursing homes, residents are often in contact with many staff members and one another.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/resident-has-his-temperature-checked-in-his-room-at-an-news-photo/1228785162">Craig F. Walker/The Boston Globe via Getty Image</a></span>
</figcaption>
</figure>
<p>Our research asks why nursing aides are more likely to spread the virus. To answer this question, we examined laws and policies that affect them, including paid sick time.</p>
<p>San Francisco became the first U.S. jurisdiction to require paid sick leave in <a href="https://sfgov.org/olse/PAID-SICK-LEAVE-ORDINANCE-PSLO">2006</a>. Other cities, counties and states followed, and now there are approximately <a href="https://www.abetterbalance.org/paid-sick-time-laws/?export">40 of these laws</a> nationwide. </p>
<p>Paid sick leave laws require employers to pay workers who take time off when they or any family members are sick, injured or seeking medical treatment. <a href="https://www.azica.gov/sites/default/files/media/070317%20FAQ%20Updates.pdf">Some laws</a> explicitly allow for paid sick leave during a public health emergency, such as COVID-19. Most are based on an accrual model. This means employees must earn paid sick time hours; typically one hour of paid sick leave is earned for every 30 hours worked. Local paid sick time laws apply to private-sector employees and, in some cases, state and local government employees. </p>
<p>In March 2020, Congress passed the nation’s first <a href="https://www.dol.gov/agencies/whd/pandemic/ffcra-employee-paid-leave">universal paid sick leave law</a>. This emergency law, which expires at the end of the year, provides most employees in the country with up to 80 hours of paid leave if the worker has been exposed to, is ill from, or is caring for someone infected with COVID-19.</p>
<p>However, a <a href="https://www.umass.edu/lrrc/research/working-papers-series/survey-essential-workers%E2%80%99-safety-and-security-during-covid-19">large survey</a> earlier this year showed that many essential, low-wage employees still could not access paid sick leave after the law went into effect. That survey and our research show that these employees tend to either believe they have no right to paid leave or that their employer will retaliate if they try to use it. Many fear they could lose their jobs. </p>
<p>Even a short period of lost income can be financially devastating for these individuals. <a href="https://www.umass.edu/lrrc/research/working-papers-series/survey-essential-workers%E2%80%99-safety-and-security-during-covid-19">Among Latina essential workers</a>, 43% surveyed said that even while employed they didn’t earn enough to adequately provide food for their families.</p>
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<h2>How to make sick leave work as intended</h2>
<p>So, can paid sick leave laws be made more accessible for essential workers like Salma? </p>
<p>Our research highlights both the inadequacies of existing laws and policies and what might be done to strengthen them.</p>
<p>[<em>Research into coronavirus and other news from science</em> <a href="https://theconversation.com/us/newsletters/science-editors-picks-71/?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=science-corona-research">Subscribe to The Conversation’s new science newsletter</a>.]</p>
<p>First, nearly all paid sick leave law violations require federal or state labor agency intervention or the employee loses out. These agencies, however, often <a href="https://www.nelp.org/publication/building-robust-labor-standards-enforcement-regimes-in-our-cities-and-counties/">lack adequate resources</a> to investigate potential employer violations and hold employers accountable if they retaliate against workers. </p>
<p>Second, most of these agencies are highly centralized and do not conduct effective outreach to immigrant communities, so both employers and employees are often unaware of paid sick leave laws. A handful of states and local governments offer <a href="https://www.epi.org/publication/state-ag-labor-rights-activities-2018-to-2020/">pioneering examples</a>. Massachusetts, for example, posted guidance online in multiple languages about sick leave and other workers’ issues. Washington, D.C., conducted tele-town halls with strategies to help workers and employers understand their respective paid sick time rights and obligations during the pandemic.</p>
<p>An approach that both empowers employees while informing employers about the benefits of paying employees to stay at home when sick can help save lives.</p><img src="https://counter.theconversation.com/content/150138/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Over one-third of America’s COVID-19 deaths have been nursing home residents. Employee policies, particularly for low-paid aides, have sharply raised the risk.Shefali Milczarek-Desai, Assistant Clinical Professor of Law and Director of the Immigrant Workers' Rights Clinic, UA James E. Rogers College of Law, University of ArizonaTara Sklar, Professor of Health Law and Director, Health Law & Policy Program, University of ArizonaLicensed as Creative Commons – attribution, no derivatives.