For years David Grabowski, a professor at Harvard Medical School in the Department of Health Policy, has researched the economics of aging and long-term care systems from the perspective of financing and service delivery, a field whose interest has exploded as a result of the covid pandemic. Grabowski is also a member of the national committee of specialists of the National Academies of Sciences, Engineering and Medicine of
USA that has prepared for the government of Joe Biden some practical recommendations with which to improve care in nursing homes. His position is clear: investment in home and community care, emphasizing telemedicine, and in smaller residence models, with better trained and paid staff, where the resident is placed at the center of the system.
One of the quotes we have heard about what happened with Covid-19 and the elderly in nursing homes is that “the pandemic has lifted the veil on what has been an invisible social disease for decades.” Once that reality has been revealed, what has been learned?
In the first place, that we were not at all prepared to face something of this magnitude. I mean personal protective equipment, testing, and proper air ventilation. All of that has to be reviewed. The second lesson is that in the US, and I think it is also the case in Spain, we have nursing homes that are too large. There is a lot of data to suggest that larger nursing homes are associated with higher outbreaks, so we need to reduce the size of the facility. A third lesson was that we don’t support our people, so many professionals left the industry. There is also another important lesson that can be drawn from why some residences had more Covid outbreaks than others. Regardless of the size and availability of protective equipment, in a small study we found that if you had more staff, and more part-time workers, assisting in different buildings, there was a greater chance of spread. So we need to improve those jobs, not only because professionals need to be supported, but also because fewer workers per resident also means fewer opportunities for infection to spread.
Now we have the feeling that the pandemic is over, but is it like that for everyone?
S,
it seems that society has finished with her
. Everywhere, including in Madrid, I see that almost no one wears a mask anymore, but in care settings for the elderly there is still a lot of vulnerability. Here some of the key measures of the pandemic, such as personal protection, tests, and, especially, vaccination reinforcements are still very important. The pandemic has not ended in nursing homes. I would say that now we have to involve them. It was never a good idea to isolate them, as we did in the US with the ban on visitors. That was a terrible policy. Instead, it is necessary to support them with protective measures: that is where we need to focus our efforts. And then, in the long run,
change the nature of these buildings and the way we deliver care.
Among the recommendations that the national panel of experts have drawn up for the US government to improve care in residences, which ones would you highlight?
It included a comprehensive set of recommendations on how to reform nursing homes, involving, among other measures, changing staffing, increasing investment, changing regulation, and strengthening health information technologies. But a large part of those recommendations emphasize resident-centered care and investment in those types of models that put the resident at the center. Many retirement homes in the US, and probably also here in Spain,
are designed around personnel and a systematization
: everyone eats at the same time; everyone gets up at the same time; the caretakers enter the room when it suits them… It is a model that in a certain way deprives the residents of their dignity.
These are recommendations that are in line with the Green House project, a small-sized residence model, implemented in the US some two decades ago…
I know, actually, what it does
Green House
it is turning the conventional model on its head in many respects. About this project, many people are left with the idea that they are small residences, and yes, they are like that, and as we also collect in our recommendations, we must move towards that model, invest in renovating existing residences and build new ones with that premise, but that’s a long-term goal.
It is expensive to build residences
It’s a slow process. so
in the short term
, we can begin to incorporate other principles of the Green House movement, such as what I was telling you about putting the resident at the center and also empowering the staff. For example, in most nursing homes in the United States, the system is very hierarchical: the administrator tells the nurses what to do, they tell the nursing assistants, and in the end they don’t have much control over their role. In the model
Green House
Thanks to the
staff stability and work planning
, greater satisfaction is maintained in the teams. It is what we recommend, and if at the moment we cannot have the small building, I know that we can have better personnel models.
In this model and in line with your recommendations, what would be the role of doctors?
In the US we have the problem of fragmentation, since we pay for medical services under the Medicare program, and for long-term care through Medicaid, and this affects whether they can be counted on in nursing homes. In an article, a colleague called the nursing home doctors “missing in action.” There are some innovative proposals on attention, such as the role of
specialized nurse
, which has an advanced degree to assume certain functions of a clinical type, and can be integrated into the building. In this way, better care can be ensured and, therefore, fewer transfers to the hospital or emergency department. Another formula would be
telemedicine
. Historically, we have invested very little in it, but during the pandemic we had the opportunity to do so, and the telematics attention increased enormously. It is true that many, older or not, like to be face to face with their doctor, but I think it can be considered a very useful measure in certain services where we have a shortage of professionals, such as in the field of mental health or in areas rural of the country We need to invest in this, as it will help us fill certain gaps, and I also hope that we keep this in mind for the future.
How could new technologies help?
Telemedicine will help bring clinical care to the residence. Although here we should also address what is happening with the data records, and the terrible situation that each provider has their own. I understand that here they also have
problems with the lack of interoperability of electronic records
. We do not have common records and this does not make sense in 2023.
If we look at other countries, is there a system that you find inspiring?
In many ways, one often looks at
netherlands
; they are a kind of gold standard. They have placed the emphasis on home and community care, with a large investment. They have a state tax based system. In my opinion, we should move towards that
centralized model, with national financing
, because in the US there are hundreds of thousands of people waiting to have home and community care. This without stopping investing in the residence models that we mentioned. Sometimes it is considered that we either invest in home and community care or in nursing homes, and I think it is a false dichotomy.
What can we do as a society to get closer to these models of care?
I have the feeling that although there is interest in moving towards that model, at least in the United States, it has not yet become a
political matter
It’s seen as a family problem, so it won’t come into the public eye until we push our government to become more involved in long-term care, both as payer and insurer. We are seeing something like a marginal approach, from the margins. we are missing one
systematic approach
like the one we propose in the report, with major global reforms that would completely transform the system.
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