Testimony of Dr. Tara A. Cortes, Executive Director of The Hartford Institute for Geriatric Nursing (HIGN) before The New York State Senate and The New York State Assembly | August 3, 2020

Good Morning Committee Chairs and all Members of the Legislature present. My name is Dr. Tara A. Cortes and I am Executive Director for The Hartford Institute for Geriatric Nursing (HIGN), an aging-focused center of the New York University (NYU) Rory Meyers College of Nursing. Given my experience and expertise in the fields of aging and health policy, I look forward to sharing my recommendations for improving outcomes at residential healthcare facilities across New York, especially during times of crisis such as the COVID-19 pandemic.  

Our nation’s 15,000 nursing homes have become “ground zero” in the COVID-19 pandemic, linked to 43% of all deaths. In New York, more than 6,000 residents in long-term care facilities have died from the virus, accounting for roughly a quarter of the state’s COVID-19 fatalities — clearly exposing the vulnerability of this population. This is troubling to the many families who place their loved ones in nursing homes to receive the nursing care and supportive services they cannot get living independently at home.  

Although residential long-term care is usually thought of as being simply custodial, the care needed in these settings is actually some of the most complex care delivered across the health care continuum.  Most residents have multiple chronic diseases and very often have dementia as well. There are no protocols to prescribe care because each individual has different multiple conditions. With the increase in the number of people living to 85 and beyond, and the increase in complexity of those living in residential long-term care, the need for quality nursing homes - nursing homes that provide the right care at the right time by the right staff - is more acute than ever.  But, there has been an historical neglect of long-term care and nursing homes have been marginalized, even siloed, and denied a seat at the healthcare table for policy and reimbursement issues. The increasing complexity of caring for people in long-term care has never been recognized, resulting in chronic understaffing, low pay and inadequate resources.

The current state of nursing homes, coupled with the virulence of COVID-19, has created the perfect storm that has led to so many deaths. While the vast majority of nursing staff have strived to provide the best possible care, we are now witness to the impact of the shocking lack of resources and reporting that severely hampered the ability to pivot from everyday care to effective infection prevention and crisis management. It is disheartening to see the virus ravage even the most excellent nursing homes and to see blame cast upon them when they have exhausted all efforts to procure personal protective equipment and adequately manage COVID-positive patients transferred from hospitals.   

Many of the issues contributing to this perfect storm are long-standing and will necessitate both immediate response and a long-term strategy. One of the first issues to be addressed is to ensure that providers of long-term care services are at the table as full partners with hospitals when setting policy or reimbursement rates. There should be a partnership formed between these two entities to ensure collaboration and coordination of care as well as equitable distribution of dollars. Our society has long been hospital-centric with community-based care a second thought.  Throughout the months of March, April and even May, hospitals received the lion’s share of PPE while nursing home administrators went to parking lots in New Jersey or anywhere to find whatever medical supplies they could in order to protect their staff. In the meantime, staff often had to use garbage bags as gowns and handkerchiefs as masks. When the CARES Act was passed in July it allocated $175B for hospitals and $4.9B for nursing homes affected by COVID-19.  Nursing homes are now experiencing a dwindling census as people are afraid to put their loved into a nursing home and fewer elective surgeries are resulting in admissions to nursing homes for rehabilitation at a Medicare rate. With nursing homes relying on mostly Medicaid-only payments because of the way long-term care payment is structured, nursing homes are in financial distress. Layoffs and decreased capacity could be in their immediate future.  Unless healthcare dollars are distributed in a way that recognizes the value and need for quality care for older people for whom home is no longer a viable residence, we risk the same loss in the next crisis.  

The second issue that needs to be addressed is the workforce in long term care. Ensuring quality and cost-effective care at any time, but especially in a time of crisis, requires a professional staff that bases decisions and practice on evidence. 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. A study done on all 215 nursing homes in Connecticut found that those with higher RN staffing and quality ratings could better control the spread of the novel coronavirus and reduce deaths.  None of this evidence, however, has ever been considered in setting policy. In fact, CMS requires only one RN for 8 hours/day in a nursing home. The other 16 hours can be covered by a licensed practical nurse with less than one year of technical education while an RN has a college degree. In addition, a lower pay scale in long term care as compared to hospitals means it is harder to recruit not just RNs, but also direct care givers. Direct care givers are often the eyes and ears of the residents, yet turnover is very high because of the pay and the difficult workload. The increased complexity in long term care and the need for a staff that has the capacity and resources to respond to any crisis requires the appropriate staff, both in number and in education, to ensure quality care.

Many of us have had a loved one in long term care, and if you have not yet, you will. We need our nursing homes to have the resources and ability to not just be regulated and meet regulations, but also to provide the best care to keep people functioning at their own best level, address “what matters” to them, and allow them a peaceful and dignified death.  

Thank you for the opportunity to testify. We welcome any additional questions the Committees may have. (Please contact Konstantine Tettonis, NYU Government Affairs, kt1249@nyu.edu)