Post-Acute and Long-Term Care Medical Association (PALTmed) appreciates the Biden Administration’s continued focus on patients and residents in post-acute and long-term care. The proposals presented during the State of the Union address and detailed in a fact sheet aim to move the post-acute and long-term care (PALTC) setting toward a better, more equitable healthcare system that provides quality care to the millions of vulnerable older adults who require these services. Over the last three decades, the Society, with its 5,000+ members including medical directors, attending physicians, nurse practitioners, physician assistants, and other professionals who care for PALTC patients, has engaged in the same mission to improve the quality of and access to care. We acknowledge that many of the proposals in the President’s State of the Union address still need to be detailed. As specific strategies are being developed, we ask the Administration to be broad, innovative, and practical in their thinking about efforts to reform PALTC.
Those responsible for clinical care in PALTC have spent the last two years battling the worst pandemic in recent history, with a disproportionate burden of disease, suffering, hospitalization, and death being borne by residents and staff of nursing home, assisted living, and other PALTC settings. Now, we stand at a pivotal moment to take bold new action. We welcome some of the proposed initiatives the President has outlined, including reduced occupancy or single-occupancy resident rooms, full- time infection preventionists, launching a Nursing Home Career pathway and greater ownership transparency in our setting. Unfortunately, some of the proposed policies appear to double down on the same punitive measures that for the last three decades have not materially improved the patient or resident experience in PALTC. We strongly urge this Administration to seize this critical moment and take bold action to move our healthcare system into the 21st century, starting with a reimagining of PALTC.
The Society has embraced this bold vision and strategy in a special issue of our medical journal, JAMDA – The Journal of Post-Acute and Long-Term Care Medicine, focused on thoughtful, evidence-based, and innovative solutions to the many challenges in PALTC (https://www.jamda.com/issue/S1525-8610(21)X0011-4). We urge the Administration to review these ideas, and we stand ready to engage with the White House and Federal agencies to explore their implementation.
We must start strengthening the PALTC workforce by ensuring a safe work environment for direct care staff that provides adequate compensation and benefits, plentiful training and career advancement opportunities, and engaged and competent clinical leadership. This must also include training and growing physician expertise in this complex field. The Administration might start by immediately issuing a self-identifying specialty code for PALTC, as the Society requested from the Centers for Medicare & Medicaid Services (CMS) nearly four years ago.
Likewise, while we applaud the Administration’s proposal to increase ownership transparency, a new approach must also strengthen and make more transparent the role of clinical leadership. The facility medical director, required by the OBRA 1987 law, is responsible for coordination and oversight of the overall clinical care in the facility. And yet, after the more than 30 years since that law passed, this vital position remains a sadly underutilized and invisible role to most patients, families and even others in the healthcare field. The Administration can easily change this, for a start by compiling and disseminating a public listing of medical directors of every Medicare/Medicaid certified nursing facility in this country, as we have advocated for the last several years.
Furthermore, a medical license alone does not confer a knowledge of nursing homes' complex regulatory framework, or of basic geriatric medicine and bioethics principles. Thus, another step would be to require nursing home medical directors to have a minimum level of training and knowledge in order to carry out the many tasks that have been identified to fulfill this complex leadership position well and ensure the safety of our vulnerable PALTC residents, as is being done by a few states of the union.
With modern communication technology, it is simply unacceptable that patients and their families are unable to speak with the medical director, or even know who this person is, or what preparation for the role they might have. Federal and state public health officials should also have a direct line of communication to these experts as they grapple with various emergent issues involving nursing homes. We have seen a stark contrast in the response to COVID-19 in facilities where the medical director is well-trained, fully engaged, and knowledgeable about geriatric medicine and infection prevention and control practices, versus those where they are not. As always, we stand ready to work with CMS to enact and implement these changes and train medical directors.
With respect to technology, the Administration has focused on improving the nation’s infrastructure through broadband access and information technology and yet remains silent on moving PALTC medicine to be on par with the rest of healthcare. The benefits of telemedicine, for example, to reduce burdensome transfers and provide better, more timely clinical management have been amply demonstrated over the last two years. The flexibilities in permitting telemedicine visits that have been in place during the pandemic need to be made permanent.
When it comes to broadband access and interoperable information technology, PALTC is a forgotten sector of our healthcare system. Faxes remain the predominant communication tool in 2022. This is not 21st-century healthcare and must be addressed immediately. The Society has worked alongside our partners in the PALTC Healthcare Collaborative to develop innovative solutions that would provide for better interoperable communication and be accessible by patients and their families. We urge the Administration to work alongside these dedicated experts to bring these ideas into reality.
Finally, we must change the way we look at care providers in PALTC. As evidenced by the many stories during the COVID-19 pandemic, those who work in PALTC are dedicated professionals, individuals who take the same oath to care for their patients as those in other healthcare settings. They are at the bedside every day, caring for people with dementia, people at the end of life, and those with multiple comorbid conditions who simply seek to maintain their quality of life and dignity in their later years. Policies that demoralize and demonize nursing homes and their staff have led many caring professionals to leave PALTC. This is not sustainable, particularly if the Statement Responding to President Biden’s Nursing Home Reform Proposals Biden Administration introduces minimum staffing requirements without a concomitant program of support for recruiting, training, and adequately compensating this workforce. It is past time for us to invest in this sector of healthcare as one that offers noble and valuable work, much as we do with the rest of our healthcare system.
Post-acute and long-term care has become increasingly important in recent years, caring for patients with hospital-level acuity and providing services and supports to our nation’s most vulnerable. We must institute policies that incentivize innovation, attract, train and retain a qualified workforce, promote a culture of safety, and treat those who need our care with dignity and respect. We stand ready to work with any and all agencies and organizations to achieve our vision – “A world in which all post- acute and long-term care patients and residents receive the highest-quality, compassionate care for optimum health, function, and quality of life.”
Note: Effective August 13, 2024, AMDA - The Society for Post-Acute and Long-Term Care Medicine is now Post-Acute and Long-Term Care Medical Association (PALTmed).