It is undeniable that most of us prefer not to look too closely at what goes on in nursing homes across the country. In fact, unless we have a need of nursing home services for ourselves or for our elderly loved ones, we hardly notice them at all. This, of course, is a natural aversion to sickness, aging, and death. However, after COVID-19 ravaged the elderly population in nursing homes, infecting 654,000 residents and killing 132,000 elderly Americans, social workers began to take a closer look at how nursing homes are run and how we can improve the service they seek to provide.

The Current World of Nursing Homes

There are 15,505 nursing homes in the United States with approximately 1.3 million residents.

• 84% of residents are over age 65.
• 66% are women.
• 36% experience dementia.
• Most have significant disabilities.
• Most have multiple comorbidities and are frail and disabled.
• 43% will stay less than 100 days.
• Clinical syndromes such as incontinence, cognitive impairment, delirium, and inability to walk or eat independently are frequent harbingers of nursing home placement.
• Most adults who reside in nursing homes for long periods have exhausted personal assets and rely on Medicaid for payment.
• 69% of nursing homes are for-profit.
• Over 15 million nursing assistants (CNAs) are employed in the setting.
• Most CNAs are under 55, female, have a high school education or less, and earn about $30,000 dollars.

COVID-19 Impact

The horrifying impact of the corona virus on nursing homes has presented the social work community with an opportunity to reimagine the role of nursing homes in elder care. To begin with, the physical design and operating model of these nursing homes must be revised to accommodate the need for patient isolation, social distancing, reduction in the cycling of staff and patients from the community to the facility, and staff protection during times when infectious diseases are rampant. Given these epidemic-related considerations, social workers are considering “unpacking strategies” to improve quality of care by better matching services provided with the needs of specific patient groups.

Re-Imagining Nursing Homes

Before COVID-19 ravaged the industry, nursing homes were mostly run by private "for profit" corporations that favored large, efficient "homes" they could operate at a narrow profit with Medicare and Medicaid as their main revenue source. Since COVID-19, however, discussions among social workers engaged in elder care recognize the need for more novel approaches to the traditional large, efficient, "one size fits all" care home of the 20th century.

"Unpacking" Strategies

Rather than housing all infirm elderly in one facility vulnerable to all future epidemics, "unpacking" care models into more specialized protocols would improve individual care and communal safety dramatically. Social workers are suggesting that:

• Nursing home residents requiring hospice care could be relocated to in-patient or at-home hospice programs. 
• Those with “pure memory impairment” who are relatively well otherwise could be placed in the now common “memory centers” that are specifically designed and operated to manage the needs of such patients.
• Many of the long-stay patients with multiple comorbidities might be better served in smaller facilities, such as Green houses, which often have only 18 beds and offer high-quality care.
• A substantially strengthened PACE (Program for the All-Inclusive Care of the Elderly) program that provides comprehensive medical and social services in an adult day health center supplemented by in-home and referral services.
• Better-funded traditional home care programs could also help take up patients who would have been in nursing homes.
• A critical question is how best to manage post-hospitalization short-stay rehabilitation patients. Some have called for the return of extended care wings from the 1960s and 1970s that are contiguous with acute care facilities and can offer equal staffing, supplies, and equipment for those who need short-term rehabilitation.

Matching patients with specific needs with appropriate care models, increasing training and payment for the skilled nursing staff in these facilities, and revisiting the financing and payment structures that support these facilities seem to be obvious first steps in ensuring that the residents of nursing homes receive effective and efficient care.

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