Will the Nursing Home of the Future be an Actual Home?

Bill Thomas remembers the moment his career shifted. It was in 1991 and he was a young emergency room doctor, working a side job at a nursing home, when he was asked to see an older resident. The two struck up a conversation when she startled him with a confession: She was lonely.

It was the first time Thomas really thought about what life inside a nursing home was like for the residents. The focus was on keeping her fed, giving her shelter and ensuring she took her medications. She was surrounded by people, but couldn’t make the kind of meaningful connections that make life worth living.

“I was never the same after that,” Thomas said in an interview.

Her words hit him so hard that he stopped practicing emergency medicine and became a geriatrician working to reimagine how we care for people as they age and need help with daily tasks. He pioneered a philosophy that gave nursing home residents more control over their lives, and busted apart the traditional hospital-like nursing home into small, residential-style pods of private rooms surrounding a group living room and kitchen. He wanted residents to have access to the nursing care they needed in as home-like a setting as possible.

In the decades that followed, Thomas came to be seen as a visionary in the industry, admired for putting seniors, not doctors and medical personnel, at the center of the systems designed to care for them.

Eventually, he started thinking beyond the nursing home entirely. Starting in 2014, he traversed the country for five years, hosting what he called “non-fiction theater” to challenge how audience members view aging. He visited 125 cities, lunching with seniors and caregivers in each of them, and those conversations pushed him toward an even more radical rethink: No matter how frail, he became convinced, older people need their own homes and their own communities.

Then came Covid. The good news for Thomas is that his residential-style nursing homes had much lower rates of infection and death than traditional facilities; the smaller pods, and the greater privacy residents enjoyed, helped keep them safer from the virus.

But he wasn’t satisfied. All he could think of was how the coronavirus exposed the problems inherent in clustering older people together in one building — and how he might fix it. It was time, he decided, to really blow up the nursing home.

His new, post-pandemic vision is a system for aging in which seniors can live in small, geriatrician-designed houses meant for aging in place and receive the support they would need from a traditional nursing home, while creating a tight-knit group of neighbors. It’s his next attempt at re-imagining where people age — this time, entirely outside of a facility.

“I’m saying, let’s go beyond, let’s move past the era of mass institutionalization,” Thomas said. “Let’s create a model that’s actually based on one of the oldest ideas we have, which is people living in their own homes.”

Across the country, in the wake of the pandemic, there’s new momentum for rethinking and revamping how we care for seniors so that the places that are supposed to keep them safe never again become a dangerous breeding ground for an infectious virus.

But to make significant change, the lawmakers, researchers and advocates who want to upgrade the system don’t have to just change minds. They also have to reform the United States’ fragmented, and underfunded, system of long-term care.

It was on Feb. 29, 2020, that top officials from the Centers for Disease Control and the state of Washington shared grim news with the American public: The United States was grappling with its first coronavirus outbreak, and it was in a Seattle-area nursing home called Life Care Center of Kirkland.

“We are very concerned about an outbreak in a setting where there are many older people,” Jeff Duchin, health officer for Seattle and King County, told reporters.

His fears were justified. Nursing home residents who often share rooms and staff, who depend on others for the basic routines of life such as eating and bathing, and whose health is fragile to begin with, turned out to be particularly vulnerable to the highly contagious respiratory virus. Covid-19 plus the “congregate care” setting of nursing homes became a deadly combination.

Within weeks, over 35 deaths were linked to the Kirkland facility, a harbinger of the devastation that would spread in the coming months throughout the country’s 15,000-plus nursing homes. The Trump administration tried to prevent the disease from seeping into facilities by locking them down on March 13. Visitors were restricted, communal dining was cancelled and residents were mostly confined to their rooms, where they were isolated for months and months.

Inside the homes, multiple nursing home staff recounted to POLITICO that they faced a stressful environment, where personal protective equipment was hard to come by, and staffing woes plagued facilities as workers fell sick.

The coronavirus aimed an intense spotlight on nursing homes’ decades-old problems, according to interviews with public health experts, advocates and watchdogs. Many — like Richard Danford, the former director of the New York City Long Term Care Ombudsman Program — pointed to inadequate staffing and well-documented issues with infection control and prevention. And even in highly rated homes, the institutional-like setting — large buildings with staff traveling between different facilities — made stopping the virus’s spread next to impossible.

A year later, over 130,000 nursing home residents have died, accounting for roughly 1 in 4 of the nation’s coronavirus deaths despite comprising less than 1 percent of the population.

“It’s been like, how the hell did this happen and what lessons can we learn?” Danford said.

As Covid spread through the nation’s nursing homes last summer, Thomas fixated on one idea: We have to push deinstitutionalization further.

The vision for the new project he’s working on with Signature HealthCare — currently called “Canopy” — starts with a cluster of small ADA-accessible houses built close together, with communal greenspace and an intention that residents get to know their neighbors. The idea is that residents have much more autonomy than in a congregate setting, living in their own homes with access to the outdoors. And the goal is to enable them to tap into a tight web of services — from help eating and bathing, to physical therapy and nursing care.

The specifics are still in the works, says Nick Jacoby, the chief development officer of Signature HealthCare, a long-term care provider. But he says the first community will likely be built in a small town in rural Tennessee, on the grounds of one of the company’s existing nursing home campuses. It may include anywhere from eight to 16 homes, roughly 400 to 600 square feet each. That’s roughly the size of so-called small houses, or “granny flats,” except instead of being built in a backyard, the first homes will likely be built on the grounds of one of the company’s full-service nursing homes.

They’re still hammering out what exactly the first homes will look like, both inside and outside, thinking through questions like: “Where is the world going in terms of preference and technology and care delivery — and how do we create the home for that?” Jacoby said.

But the idea is that if residents need nursing care and help with daily living, they’ll rely on getting those services inside their home, which they’ll rent. Thomas and his partners are betting that in coming years, state and federal governments will turn their attention and money more toward what’s known as home and community-based services, transforming how the country pays for aging and ending the current regulatory emphasis on traditional nursing homes.

That shift is already underway. In the last few years, the Trump administration opened the door to let private Medicare plans begin paying for nonmedical services, such as meal delivery or a ride to the grocery store.

States have also started to shift away from paying only for institutional care in nursing homes. Instead, they’re devoting more of their Medicaid dollars toward home-and-community based services, which can consist of everything from home health aides to assistance prepping meals.

“The pendulum’s swinging to home and community-based services,” said Thomas. “And in order to make those services really work, we need better homes and better communities — and that’s what Canopy is designed to provide.”

President Joe Biden’s sweeping infrastructure plan includes a massive, $400 billion investment in covering in-home care under Medicaid — which Thomas called the “biggest rebalancing” of payments ever for long-term care. And Biden’s massive coronavirus relief package passed in March provided the first federal funding boost to home and community-based services since Obamacare’s passage. But the increase is just for a year, and advocates are already working to push for ways to permanently redirect more money toward the benefit.

“The larger public has been making clear forever that people who are aging would really rather stay in their own home,” said Anne Montgomery, the director of eldercare improvement at the nonprofit research and consulting group, Altarum, and a former senior staffer on the Senate’s aging committee.

Yet, waitlists are still long in many states, and finding care inside the home can still be a frustrating process for many Americans.

“It will be a challenge,” said Montgomery, who first learned of Thomas’ and Signature Healthcare’s project when contacted by a POLITICO reporter. “I’m pretty sure that somebody like Bill Thomas would be thinking hard about that — where he’s building or hoping to build the small houses, and what kind of services are available in that area, and how do you help organize those services into something that is accessible for the residents of that community.”

Thomas calls the new community a “middle market” offering — one aimed essentially at the middle class, people who aren’t rich but aren’t poor, and don’t want to spend down their assets to become eligible for Medicaid.

David Grabowski, a Harvard professor who studies the long-term care industry, says there’s a need for new models reaching that “middle market.” Roughly eight million seniors fall into this gap: unable to afford expensive assisted and independent living communities but too wealthy to qualify for Medicaid. That number is expected to grow to 14.4 million seniors by 2029 — over half of whom would struggle to pay for much of the private seniors housing currently on the market, according to a 2019 study in Health Affairs co-authored by Grabowski.

The rent prices haven’t yet been determined for the new venture. Signature HealthCare is trying to balance the pricing and make sure it’s affordable, Jacoby said. A person with an income of $2,382 a month can qualify for home-and-community based services under Medicaid in most states — and they also must have limited assets, such as not exceeding a certain amount in their savings account.

But there’s a reason housing for this population hasn’t proliferated in the United States: it can be pricey to build.

“They’re going to have to overcome the financing issues,” said Grabowski, who’s discussed the new project with Thomas. “It’s a really innovative model. … But the big barrier is, it’s really expensive for individuals to set up these kinds of communities.”

But pressure is growing to find a way to make this kind of new model work. For policymakers, advocates and innovators, the coronavirus represents the best chance they have for meaningful change. They view the pandemic as a reset: a time to analyze not just what went wrong and how to fix it, but to push hard for reform.

The country’s system of paying for seniors’ care is a serious impediment. Long-term care has historically been viewed as, first and foremost, health care, coming out of state and federal budgets. But the country is at a pivotal moment, grappling with how to take a more holistic view of caring for older adults — to focus not just on their medical care, but also on their housing and their social lives.

Not all Americans will have the luxury of choosing where they live when they’re old, whether it’s because they can’t afford to, their insurance coverage won’t pay for it, or a sudden illness forces them into a nursing home. Others may choose to live in a facility, and advocates are pushing to reform not just the nation’s financing structure, but to revamp traditional nursing homes with strengthened staffing ratios, better infection control measures and increased wages for nurses, which improves patient care as well as staff morale. Several legislative proposals are working their way through Congress to bolster care for seniors both inside and outside the nursing home.

“The pandemic has revealed a lot of the cracks and flaws in our system of long-term care writ large, but also in nursing home care,” said Katie Smith Sloan, the president and CEO of LeadingAge, which represents nonprofit aging services providers. “I think this gives us an extraordinary opportunity to really look at what needs to change going forward.”

The window of opportunity for change may be small — but advocates and policymakers are adamant that the tens of thousands of deaths inside nursing homes need to spur reforms.

“‘We can’t just go back to business as usual after the tragedy we have seen in nursing homes,” said Lori Smetanka, the executive director of National Consumer Voice for Quality Long-Term Care. “That’s not an acceptable solution.”

This article was written with the support of a journalism fellowship from The Gerontological Society of America, The Journalists Network on Generations and The John A. Hartford Foundation.

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Bill Thomas remembers the moment his career shifted. It was in 1991 and he was a young emergency room doctor, working a side job at a nursing home, when he was asked to see an older resident. The two struck up a conversation when she startled him with a confession: She was lonely.

It was the first time Thomas really thought about what life inside a nursing home was like for the residents. The focus was on keeping her fed, giving her shelter and ensuring she took her medications. She was surrounded by people, but couldn’t make the kind of meaningful connections that make life worth living.

“I was never the same after that,” Thomas said in an interview.

Her words hit him so hard that he stopped practicing emergency medicine and became a geriatrician working to reimagine how we care for people as they age and need help with daily tasks. He pioneered a philosophy that gave nursing home residents more control over their lives, and busted apart the traditional hospital-like nursing home into small, residential-style pods of private rooms surrounding a group living room and kitchen. He wanted residents to have access to the nursing care they needed in as home-like a setting as possible.

In the decades that followed, Thomas came to be seen as a visionary in the industry, admired for putting seniors, not doctors and medical personnel, at the center of the systems designed to care for them.

Eventually, he started thinking beyond the nursing home entirely. Starting in 2014, he traversed the country for five years, hosting what he called “non-fiction theater” to challenge how audience members view aging. He visited 125 cities, lunching with seniors and caregivers in each of them, and those conversations pushed him toward an even more radical rethink: No matter how frail, he became convinced, older people need their own homes and their own communities.

Then came Covid. The good news for Thomas is that his residential-style nursing homes had much lower rates of infection and death than traditional facilities; the smaller pods, and the greater privacy residents enjoyed, helped keep them safer from the virus.

But he wasn’t satisfied. All he could think of was how the coronavirus exposed the problems inherent in clustering older people together in one building — and how he might fix it. It was time, he decided, to really blow up the nursing home.

His new, post-pandemic vision is a system for aging in which seniors can live in small, geriatrician-designed houses meant for aging in place and receive the support they would need from a traditional nursing home, while creating a tight-knit group of neighbors. It’s his next attempt at re-imagining where people age — this time, entirely outside of a facility.

“I’m saying, let’s go beyond, let’s move past the era of mass institutionalization,” Thomas said. “Let’s create a model that’s actually based on one of the oldest ideas we have, which is people living in their own homes.”

Across the country, in the wake of the pandemic, there’s new momentum for rethinking and revamping how we care for seniors so that the places that are supposed to keep them safe never again become a dangerous breeding ground for an infectious virus.

But to make significant change, the lawmakers, researchers and advocates who want to upgrade the system don’t have to just change minds. They also have to reform the United States’ fragmented, and underfunded, system of long-term care.

It was on Feb. 29, 2020, that top officials from the Centers for Disease Control and the state of Washington shared grim news with the American public: The United States was grappling with its first coronavirus outbreak, and it was in a Seattle-area nursing home called Life Care Center of Kirkland.

“We are very concerned about an outbreak in a setting where there are many older people,” Jeff Duchin, health officer for Seattle and King County, told reporters.

His fears were justified. Nursing home residents who often share rooms and staff, who depend on others for the basic routines of life such as eating and bathing, and whose health is fragile to begin with, turned out to be particularly vulnerable to the highly contagious respiratory virus. Covid-19 plus the “congregate care” setting of nursing homes became a deadly combination.

Within weeks, over 35 deaths were linked to the Kirkland facility, a harbinger of the devastation that would spread in the coming months throughout the country’s 15,000-plus nursing homes. The Trump administration tried to prevent the disease from seeping into facilities by locking them down on March 13. Visitors were restricted, communal dining was cancelled and residents were mostly confined to their rooms, where they were isolated for months and months.

Inside the homes, multiple nursing home staff recounted to POLITICO that they faced a stressful environment, where personal protective equipment was hard to come by, and staffing woes plagued facilities as workers fell sick.

The coronavirus aimed an intense spotlight on nursing homes’ decades-old problems, according to interviews with public health experts, advocates and watchdogs. Many — like Richard Danford, the former director of the New York City Long Term Care Ombudsman Program — pointed to inadequate staffing and well-documented issues with infection control and prevention. And even in highly rated homes, the institutional-like setting — large buildings with staff traveling between different facilities — made stopping the virus’s spread next to impossible.

A year later, over 130,000 nursing home residents have died, accounting for roughly 1 in 4 of the nation’s coronavirus deaths despite comprising less than 1 percent of the population.

“It’s been like, how the hell did this happen and what lessons can we learn?” Danford said.

As Covid spread through the nation’s nursing homes last summer, Thomas fixated on one idea: We have to push deinstitutionalization further.

The vision for the new project he’s working on with Signature HealthCare — currently called “Canopy” — starts with a cluster of small ADA-accessible houses built close together, with communal greenspace and an intention that residents get to know their neighbors. The idea is that residents have much more autonomy than in a congregate setting, living in their own homes with access to the outdoors. And the goal is to enable them to tap into a tight web of services — from help eating and bathing, to physical therapy and nursing care.

The specifics are still in the works, says Nick Jacoby, the chief development officer of Signature HealthCare, a long-term care provider. But he says the first community will likely be built in a small town in rural Tennessee, on the grounds of one of the company’s existing nursing home campuses. It may include anywhere from eight to 16 homes, roughly 400 to 600 square feet each. That’s roughly the size of so-called small houses, or “granny flats,” except instead of being built in a backyard, the first homes will likely be built on the grounds of one of the company’s full-service nursing homes.

They’re still hammering out what exactly the first homes will look like, both inside and outside, thinking through questions like: “Where is the world going in terms of preference and technology and care delivery — and how do we create the home for that?” Jacoby said.

But the idea is that if residents need nursing care and help with daily living, they’ll rely on getting those services inside their home, which they’ll rent. Thomas and his partners are betting that in coming years, state and federal governments will turn their attention and money more toward what’s known as home and community-based services, transforming how the country pays for aging and ending the current regulatory emphasis on traditional nursing homes.

That shift is already underway. In the last few years, the Trump administration opened the door to let private Medicare plans begin paying for nonmedical services, such as meal delivery or a ride to the grocery store.

States have also started to shift away from paying only for institutional care in nursing homes. Instead, they’re devoting more of their Medicaid dollars toward home-and-community based services, which can consist of everything from home health aides to assistance prepping meals.

“The pendulum’s swinging to home and community-based services,” said Thomas. “And in order to make those services really work, we need better homes and better communities — and that’s what Canopy is designed to provide.”

President Joe Biden’s sweeping infrastructure plan includes a massive, $400 billion investment in covering in-home care under Medicaid — which Thomas called the “biggest rebalancing” of payments ever for long-term care. And Biden’s massive coronavirus relief package passed in March provided the first federal funding boost to home and community-based services since Obamacare’s passage. But the increase is just for a year, and advocates are already working to push for ways to permanently redirect more money toward the benefit.

“The larger public has been making clear forever that people who are aging would really rather stay in their own home,” said Anne Montgomery, the director of eldercare improvement at the nonprofit research and consulting group, Altarum, and a former senior staffer on the Senate’s aging committee.

Yet, waitlists are still long in many states, and finding care inside the home can still be a frustrating process for many Americans.

“It will be a challenge,” said Montgomery, who first learned of Thomas’ and Signature Healthcare’s project when contacted by a POLITICO reporter. “I’m pretty sure that somebody like Bill Thomas would be thinking hard about that — where he’s building or hoping to build the small houses, and what kind of services are available in that area, and how do you help organize those services into something that is accessible for the residents of that community.”

Thomas calls the new community a “middle market” offering — one aimed essentially at the middle class, people who aren’t rich but aren’t poor, and don’t want to spend down their assets to become eligible for Medicaid.

David Grabowski, a Harvard professor who studies the long-term care industry, says there’s a need for new models reaching that “middle market.” Roughly eight million seniors fall into this gap: unable to afford expensive assisted and independent living communities but too wealthy to qualify for Medicaid. That number is expected to grow to 14.4 million seniors by 2029 — over half of whom would struggle to pay for much of the private seniors housing currently on the market, according to a 2019 study in Health Affairs co-authored by Grabowski.

The rent prices haven’t yet been determined for the new venture. Signature HealthCare is trying to balance the pricing and make sure it’s affordable, Jacoby said. A person with an income of $2,382 a month can qualify for home-and-community based services under Medicaid in most states — and they also must have limited assets, such as not exceeding a certain amount in their savings account.

But there’s a reason housing for this population hasn’t proliferated in the United States: it can be pricey to build.

“They’re going to have to overcome the financing issues,” said Grabowski, who’s discussed the new project with Thomas. “It’s a really innovative model. … But the big barrier is, it’s really expensive for individuals to set up these kinds of communities.”

But pressure is growing to find a way to make this kind of new model work. For policymakers, advocates and innovators, the coronavirus represents the best chance they have for meaningful change. They view the pandemic as a reset: a time to analyze not just what went wrong and how to fix it, but to push hard for reform.

The country’s system of paying for seniors’ care is a serious impediment. Long-term care has historically been viewed as, first and foremost, health care, coming out of state and federal budgets. But the country is at a pivotal moment, grappling with how to take a more holistic view of caring for older adults — to focus not just on their medical care, but also on their housing and their social lives.

Not all Americans will have the luxury of choosing where they live when they’re old, whether it’s because they can’t afford to, their insurance coverage won’t pay for it, or a sudden illness forces them into a nursing home. Others may choose to live in a facility, and advocates are pushing to reform not just the nation’s financing structure, but to revamp traditional nursing homes with strengthened staffing ratios, better infection control measures and increased wages for nurses, which improves patient care as well as staff morale. Several legislative proposals are working their way through Congress to bolster care for seniors both inside and outside the nursing home.

“The pandemic has revealed a lot of the cracks and flaws in our system of long-term care writ large, but also in nursing home care,” said Katie Smith Sloan, the president and CEO of LeadingAge, which represents nonprofit aging services providers. “I think this gives us an extraordinary opportunity to really look at what needs to change going forward.”

The window of opportunity for change may be small — but advocates and policymakers are adamant that the tens of thousands of deaths inside nursing homes need to spur reforms.

“‘We can’t just go back to business as usual after the tragedy we have seen in nursing homes,” said Lori Smetanka, the executive director of National Consumer Voice for Quality Long-Term Care. “That’s not an acceptable solution.”

This article was written with the support of a journalism fellowship from The Gerontological Society of America, The Journalists Network on Generations and The John A. Hartford Foundation.

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