照顾老年人

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CK’s 79-year-old cousin lives in a nursing home in New York. She is a widow with no children, but has devoted nieces, nephews and cousins. She has very poor vision, some hearing deficits and a wonderful sense of humor. She was living alone in an apartment. Following a recent hospitalization for a fall, she was unable to walk and entered the rehabilitation section of the nursing home. She is barely able to walk with a walker now. After 6 weeks it is clear that she requires 24-h care. One of our cousins pays for an additional four hours of private aides Monday through Friday. At other times she relies on the staff in the nursing home. The most recent time that she visited her cousin, her cousin and about seven other residents were in wheelchairs sitting in the common room. There were no staff in the room. Residents were not engaged in any activities or having any interactions with each other and were mostly physically spread apart. On a positive note, her cousin loves the nursing home food. This scenario is too common in long-term care. Nursing homes will continue to be a necessary part of care for older adults as the population of those over 80 continues to grow.

Older Adult Care

Long-term care is a continuum spanning adult day services, home health care, hospice, residential care/assisted living and nursing homes. Although surveys show that most people prefer to age in place in the community, for many this is not possible. Dementia and other chronic conditions increase the need for older adults to have skilled nursing care, which is usually not feasible within their own homes. About 1.3 million people live in about 15,600 nursing homes in the U.S. Of these about 83.5% are 65 and older (https://etactics.com/blog/nursing-home-statistics#Resident-Demographics). Although nursing homes have been historically thought of as providing simple custodial care, residents often need care that is complex. COVID-19 exposed the shocking lack of resources and reporting in nursing homes that severely impacted their ability to pivot from usual care to effective infection prevention and crisis management.

Government regulation via reimbursement has been the major method used to ensure quality in nursing homes. For example, the Omnibus Reconciliation Act of 1987 (OBRA ‘87) required nursing homes participating in Medicare and Medicaid to be aligned with specific rules of care (Israelsen-Hartley, 2020). However, the implementation of this bill and operational regulations are largely state driven and vary greatly from state to state. And, as the primary payer is Medicaid, the payment rate also varies from state to state, and it appears that long-term care and the well-being of older adults are too often the first budget lines to be decreased to meet state budget limits. Unless we address long-term strategies of payment reform for nursing homes and recognize the complexity of care, we will not have an appropriate workforce to navigate the industry into the future.

Staffing in Nursing Homes

Of the almost 3.3 million registered nursing working in the US, only five percent work in nursing homes. Staffing levels became a widespread issue during COVID-19 as nursing home residents became a large percentage of COVID-19 suffering, hospitalizations and deaths. In the U.S. five percent of the cases and 36% of deaths from COVID-19 have been among nursing home residents 

Nursing homes have been understaffed for as long as there have been nursing homes. Staff recruitment is difficult because most nurses have not had educational preparation to work in long-term care. In addition, nursing home pay is lower than hospital pay. Retention of nurses and certified nursing aides (CNA) is difficult because many leaders in nursing homes are not prepared to create a culture that values and engages its employees. Standards for nursing home administrators varies from state to state with some states not requiring a college degree and some states requiring a master’s degree. In 1998 CK convened a one-day conference of experts in long term care to analyze staffing issues in nursing homes. The conference was funded by what is now the federal Agency for Healthcare Research and Quality. Following the conference, we published our recommendations on staffing in this article: Harrington, C., Kovner, C., Mezey, M., Kayser-Jones, J., Berger, S., Muhler, M., Reilly, K., Burice, R., Zimmerman, D. (2000). Experts recommend minimum nurse staffing standards for nursing facilities in the U.S. The Gerontologist, 40(1), 5–16. And now almost 25 years later little has been done to implement these and many similar recommendations.

There is a large literature that supports the argument that more staff and more highly qualified staff (e.g. registered nurses rather than CNAs) are associated with better outcomes in nursing homes (Kim et al., 2009; Kovner, 2002). There is a wide consensus that at least 4.1 h of care per resident by direct caregivers and nurses is necessary to avoid systematic poor care (Harrington et al., 2016). Studies also demonstrated that nursing homes with more professional nurses had fewer COVID-19 infections and fewer fatalities than those with fewer professional nurses (Gorges & Kondtzka, 2020). In addition, inadequate care in nursing homes often results in hospitalizations which are substantially more expensive than nursing home care. While advocacy groups push for increased staffing, nursing home owners (70% of nursing homes are for profit) argue that increased staffing is expensive and that there are not workers available for hire. With that said, there is general agreement among economists that when wages are increased more people are available to work.

Considerable research has shown that there must be a staff with an appropriate number of professionals and direct caregivers to provide quality care to the increasingly older and more complex population in long-term care as well as navigate through any crisis such as a pandemic. Strong nursing leadership driving evidence-based practice improves quality and cost-effectiveness. Several national reports have called for a strong registered nurse (RN) presence in long-term care as a critical solution to increase quality while decreasing cost to the overall system. A study done by the Center for Medicare and Medicaid Services (CMS) found that nursing homes with a greater RN staff number had significantly fewer hospital readmissions (Appropriateness of minimum nurse staffing ratios in nursing homes, 2001). However, inadequate funding, the inability to recruit and retain appropriate staff and the perception of nursing homes as custodial care for older people have hampered any move to create a policy to ensure this level of staffing. Another study done following the pandemic on all 215 nursing homes in Connecticut found that those with higher RN staffing and quality ratings better controlled the spread of the novel coronavirus COVID-19 and had a lower number of deaths (Li et al., 2020). None of this evidence, however, has seemingly been used in setting policy. In fact, the U.S. Center for Medicare and Medicaid Services requires only one RN for 8 h/day in a nursing home. There is no federal standard set for minimum staffing and although some states have established a minimum, that minimum is below the 4.1 h and does not take into consideration the rising acuity and complexity of the residents today. Furthermore, nursing homes are incentivized to keep staffing numbers as low as possible because personnel costs are the main driver of expenditures. This is particularly important in the for-profit nursing homes.

Solutions to Caring for Older Adults in Nursing Homes

To ensure adequate staffing in nursing homes there needs to be appropriate funding to nursing homes and enough prepared health care workers for nursing homes to employ. Unless we prepare the workforce to embrace the opportunity to provide person-centered care for a diverse population with complex care needs, recruitment and retention of staff will remain elusive. There also needs to be federal regulation on nursing administrator educational and leadership preparation.

There have been some state actions to improve staffing. For example, Minnesota has a program to increase the supply of nursing aides via cost free education for participants. During Covid-19 a waiver permitted people to become CNAs without the mandatory 75 h of education.Many long-term care operators took advantage of this opportunity and are now providing these CNAs with full training so they can be part of the permanent workforce. New York recently enacted a minimum staffing bill requiring 3.5 h of nursing care per nursing home resident per day of which 1.1 h must be given by an RN. The law went into effect on April 1, 2022.

President Biden’s nursing home reform agenda includes mandatory staffing levels of 4.1 h nursing care per resident per day with a bill under consideration in the U.S. Congress to require that. One and one-half hours of that time must be provided by an RN. However, today the federal agency responsible for Medicare and Medicaid payments to nursing homes could establish improved staffing level requirements using just its regulatory authority without that law.

Setting standards for minimal staffing in nursing homes is one step forward to ensure a quality standard of care for the vulnerable population in nursing homes. But to regulate staffing without a payment system that supports it at competitive market rates and educational preparation that addresses the important role of nurses and other direct caregivers in long-term care, sets up the industry for another catastrophic scenario such as the response of nursing homes to the COVID-19 pandemic.

It is time to recognize that nursing homes are an essential component of the healthcare system. There needs to be a systematic strategy to support them with an appropriate financial model and a well-prepared workforce. We want to have a society where people can grow old with dignity and have a high quality of life. Help us by continuing to publish research about nursing homes that will impact health policy to improve the lives of older adults. The next time that CK visits her cousin we both hope that her cousin will be engaged with staff and/or other residents with activities that improve her quality of life.

全文翻译（仅供参考）

CK 79 岁的表弟住在纽约的一家疗养院。她是个寡妇，没有孩子，但有孝顺的侄女、侄子和堂兄弟。她的视力很差，有一些听力缺陷和极好的幽默感。她一个人住在公寓里。在最近因跌倒住院后，她无法行走并进入疗养院的康复科。她现在几乎不能带着助行器走路。6 周后，很明显她需要 24 小时护理。我们的一个表兄弟在周一至周五额外支付了四个小时的私人助理费用。在其他时候，她依靠疗养院的工作人员。她最近一次拜访她的表弟时，她的表弟和其他大约七名居民坐在公共休息室里的轮椅上。房间里没有工作人员。居民之间没有进行任何活动或进行任何互动，并且大多在身体上分散。积极的一面是，她的表弟喜欢疗养院的食物。这种情况在长期护理中太常见了。随着 80 岁以上人口的持续增长，疗养院将继续成为老年人护理的必要组成部分。

老年人护理

长期护理是一个连续统一体，涵盖成人日间服务、家庭保健、临终关怀、住宿护理/辅助生活和疗养院。尽管调查显示大多数人更愿意在社区中就地养老，但对许多人来说这是不可能的。痴呆症和其他慢性病增加了老年人对熟练护理的需求，而这在他们自己的家中通常是不可行的。美国约有15,600家疗养院约有 130 万人居住。其中约 83.5% 为 65 岁及以上。尽管疗养院历来被认为提供简单的监护服务，但居民往往需要复杂的护理。COVID-19 暴露了疗养院令人震惊的资源和报告不足，这严重影响了他们从常规护理转向有效的感染预防和危机管理的能力。

政府通过报销进行监管一直是确保疗养院质量的主要方法。例如，1987 年的综合协调法案 (OBRA '87) 要求参与医疗保险和医疗补助的疗养院与特定的护理规则保持一致（Israelsen-Hartley，2020）。然而，该法案和运营条例的实施很大程度上是由国家驱动的，并且因州而异。而且，由于主要支付者是 Medicaid，支付率也因州而异，而且似乎长期护理和老年人的福祉往往是为了满足州预算限制而首先减少的预算线. 除非我们解决养老院支付改革的长期战略并认识到护理的复杂性，否则我们将没有合适的劳动力来引导该行业走向未来。

疗养院的人员配备

在美国近 330 万注册护理人员中，只有 5% 在疗养院工作。在 COVID-19 期间，人员配备水平成为一个普遍的问题，因为疗养院的居民在 COVID-19 的痛苦、住院和死亡中占很大比例。在美国，5% 的 COVID-19 病例和 36% 的死亡病例发生在疗养院居民中

只要有疗养院，疗养院就一直人手不足。员工招聘很困难，因为大多数护士没有接受过长期护理工作的教育准备。此外，疗养院的工资低于医院的工资。留住护士和认证护理助理 (CNA) 很困难，因为疗养院的许多领导者还没有准备好创造一种重视员工并让员工参与其中的文化。疗养院管理员的标准因州而异，有些州不需要大学学位，有些州需要硕士学位。1998 年，CK 召开了为期一天的长期护理专家会议，以分析疗养院的人员配备问题。该会议由现在的联邦医疗保健研究和质量机构资助。会议结束后，我们在这篇文章中发表了关于人员配备的建议：Harrington, C.、Kovner, C.、Mezey, M.、Kayser-Jones, J.、Berger, S.、Muhler, M.、Reilly, K.、Burice, R ., Zimmerman, D. (2000)。专家建议美国护理机构的最低护士配备标准老年学家，40（1），5-16。近 25 年后的今天，在实施这些和许多类似建议方面几乎没有做任何事情。

有大量文献支持这样的论点，即更多的工作人员和更高素质的工作人员（例如注册护士而不是 CNA）与疗养院的更好结果相关（Kim 等，2009；Kovner，2002）。人们普遍认为，为避免系统性的不良护理，每位居民至少需要由直接护理人员和护士提供 4.1 小时的护理（Harrington 等人，2016 年）。研究还表明，与专业护士较少的疗养院相比，拥有更多专业护士的疗养院感染 COVID-19 和死亡人数更少（Gorges & Kondtzka，2020）。此外，疗养院的护理不足通常会导致住院费用大大高于疗养院护理。虽然倡导团体推动增加人员配备，但疗养院业主（70% 的疗养院是营利的）认为增加人员配备成本高昂，而且没有可供雇用的工人。话虽如此，经济学家普遍认为，当工资增加时，更多的人可以工作。

大量研究表明，必须有一支配备适当数量的专业人员和直接护理人员的工作人员，才能为日益老龄化和更复杂的长期护理人群提供优质护理，并度过大流行等任何危机。强有力的护理领导推动循证实践提高了质量和成本效益。一些国家报告呼吁在长期护理中建立强大的注册护士 (RN)，作为提高质量同时降低整个系统成本的关键解决方案。医疗保险和医疗补助服务中心 (CMS) 进行的一项研究发现，RN 员工人数较多的疗养院再次入院的人数显着减少（疗养院最低护士人员配备比率的适当性，2001 年））。然而，资金不足、无法招募和留住合适的工作人员以及将疗养院视为老年人看护机构的看法阻碍了制定政策以确保这种人员配备水平的任何举措。大流行后对康涅狄格州所有 215 家疗养院进行的另一项研究发现，那些拥有较高 RN 人员配置和质量评级的人能够更好地控制新型冠状病毒 COVID-19 的传播，并且死亡人数较少（Li 等人，2020 年））。然而，这些证据似乎都没有被用于制定政策。事实上，美国医疗保险和医疗补助服务中心只需要一名注册护士在疗养院工作 8 小时/天。没有最低人员配备的联邦标准，尽管一些州已经建立了最低限度，但该最低限度低于 4.1 小时，并且没有考虑到当今居民日益增长的敏锐度和复杂性。此外，由于人事成本是支出的主要驱动力，因此鼓励疗养院将人员数量保持在尽可能低的水平。这在营利性疗养院中尤为重要。

在疗养院照顾老年人的解决方案

为确保疗养院有足够的人员配备，需要为疗养院提供适当的资金，并为疗养院提供足够的准备好的医护人员。除非我们让员工做好准备，抓住机会为具有复杂护理需求的多样化人群提供以人为本的护理，否则招聘和留住员工将仍然难以捉摸。还需要有关于护理管理员教育和领导准备的联邦法规。

已经采取了一些国家行动来改善人员配备。例如，明尼苏达州有一个计划，通过对参与者的免费教育来增加护理助理的供应。在 Covid-19 期间，一项豁免允许人们在没有 75 小时强制性教育的情况下成为 CNA。许多长期护理运营商利用这一机会，现在为这些 CNA 提供全面培训，以便他们成为长期劳动力的一部分。纽约最近颁布了一项最低人员配备法案，要求每位疗养院居民每天接受 3.5 小时的护理，其中 1.1 小时必须由注册护士提供。该法律于 2022 年 4 月 1 日生效。

拜登总统的疗养院改革议程包括强制人员配备水平，即每位居民每天 4.1 小时的护理服务，美国国会正在考虑一项法案要求这样做。其中一个半小时必须由注册护士提供。然而，今天负责向疗养院支付医疗保险和医疗补助的联邦机构可以在没有该法律的情况下仅使用其监管机构来制定改进的人员配备水平要求。

为疗养院的最少人员设置标准是向前迈出的一步，以确保疗养院中弱势群体的护理质量标准。但是，如果没有以具有竞争力的市场价格和教育准备来支持护士和其他直接护理人员在长期护理中的重要作用的支付系统来规范人员配备，则为另一种灾难性场景设置了行业，例如疗养院的反应到 COVID-19 大流行。

是时候认识到疗养院是医疗保健系统的重要组成部分了。需要有一个系统的战略，通过适当的财务模型和准备充分的劳动力来支持他们。我们希望有一个人们可以有尊严地老去并拥有高品质生活的社会。通过继续发表有关疗养院的研究来帮助我们，这将影响卫生政策以改善老年人的生活。下次 CK 拜访她的表弟时，我们都希望她的表弟能够与工作人员和/或其他居民一起参与改善她生活质量的活动。

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