Skip to Main Content

Nursing homes have been at the epicenter of the pandemic, though they have fallen off the radar for those who aren’t living or working in one, or don’t have loved ones in them.

About 1.3 million Americans live in the country’s 15,000 nursing homes, where they are cared for by roughly 3 million staff members. As we write this, nearly 170,000 nursing home residents are estimated to have died from Covid-19. Many, many more were isolated from family and friends during the 20-month lockdown. Bed sores, severe weight loss, depression, and mental and functional decline have spiked among nursing home residents. And nurses, certified nurse aides, and others who work in these facilities, putting their own lives at risk, have worked in the most challenging of conditions without adequate pay or support.


Sadly, the care of nursing home residents and support for those providing that care have been long-standing issues. As we heard from a daughter and caregiver of two parents with dementia who needed nursing home care, “The pandemic has lifted the veil on what has been an invisible social ill for decades.”

President Biden recommended several reforms for nursing homes during his State of the Union address. These included minimum staffing standards, increased oversight, and better financial transparency. Although these provide a start, much more comprehensive and system-level action is necessary to transform this care in the United States.

Over the past 18 months, we served on a 17-member committee assembled by the National Academies of Sciences, Engineering, and Medicine that was charged with making bold, actionable recommendations to improve nursing home care.


The committee’s report, which was released Wednesday, concluded that the way the U.S. finances, delivers, and regulates care in nursing home settings is ineffective, inefficient, inequitable, fragmented, and unsustainable. To create a more rational approach to nursing home care, our committee made recommendations across seven key themes.

First, to ensure that nursing homes deliver comprehensive, person-centered, equitable care that ensures residents’ health, quality of life, and safety, promotes autonomy, and manages risk, residents’ and family’s preferences, goals, and values in care planning must be prioritized to help develop innovative approaches such as small-home models that improve residents’ quality of life. The U.S. must also strengthen emergency preparedness such that the country never has a repeat of the past two years.

Second, to ensure a well-prepared, empowered, and appropriately compensated workforce, it is essential to put in place competitive wages and benefits, enhanced minimum staffing standards, and increased training requirements that include diversity, equity, and inclusion. The days of underpaid and undervalued caregivers working in understaffed nursing homes must end.

Third, too many nursing home corporations use complex ownership structures to siphon dollars away from resident care. To increase financial transparency and accountability by nursing homes, policymakers must collect, audit, and make available detailed facility-level data on the finances, operations, and ownership of all nursing homes in real time in a readily usable database.

Fourth, the report provides a strategy to move toward a federal long-term care benefit that provides adequate financial coverage of comprehensive nursing home care. Medicaid currently plays a dominant role as the default payer of nursing home care, but eligibility is limited by income and asset tests, and it is constantly subject to state budget constraints.

Fifth, a more effective and responsive system of quality assurance is needed for nursing homes. State agencies currently survey nursing homes under the direction of the Centers for Medicare and Medicaid Services to ensure they are complying with the requirements to receive payments from Medicare and Medicaid. The survey process often fails to identify serious care problems, fully correct and prevent recurring problems, and investigate complaints in a timely manner. Moreover, CMS, which ultimately determines a facility’s eligibility to participate in the program, does not provide sufficient oversight of, or transparency in, the survey process. As such, state survey agencies must be given adequate resources for increasing oversight of state survey performance and evaluating strategies to improve quality assurance activities.

Sixth, it is essential to expand and enhance the measurement of nursing home quality and continuous quality improvement programs. Quality measures that reflect what residents and families experience and want from nursing homes must be developed and reported. The quality of care is particularly concerning for several high-risk populations, such as minoritized and LGBTQ+ people, who experience significant disparities in care.

Seventh, financial incentives must be used to support the adoption of health information technology in all nursing homes, which can contribute to increased efficiency in care delivery, enhanced care coordination, improved staff productivity, promotion of patient safety, and reduced health disparities.

The pandemic has indeed “lifted the veil” on U.S. nursing homes. The big question is whether the country has the will to do anything about it. If so, implementation of the committee’s integrated set of recommendations will, as we wrote, “move the nation closer to making high-quality, person-centered, and equitable care a reality for all nursing home residents, their chosen families, and the nursing home staff who provide care and support them in achieving their goals.”

David C. Grabowski is a professor of health care policy at Harvard Medical School. Marilyn Rantz is Curators’ Professor emerita in the University of Missouri Sinclair School of Nursing and the Department of Family Medicine in the University of Missouri School of Medicine and a member of the National Academies of Sciences, Engineering, and Medicine since 2012. Jasmine L. Travers is an assistant professor at New York University Rory Meyers College of Nursing.

Create a display name to comment

This name will appear with your comment

There was an error saving your display name. Please check and try again.