Significant parts of the world are growing old. During this century, several regions will experience a marked increase in the proportion of adults over 65 years old. This transition is well underway in the United States as the so-called baby boomers, born between 1946 and 1964, began turning 65 in 2011. It is projected that the US population aged 65 and over will reach 83.7 million by 2050, equivalent to more than 20% of the entire population.1 The US is not unique in this. By 2040, the median age in Japan will be 70, and it is anticipated that Asia, Latin America and the Caribbean will join Europe and North America as having more people older than 60 than children under age 15.
The need for long-term care is growing alongside the rapidly aging population. In 2018, over 14 million Americans needed long-term care services.2 By 2025, it is projected that 1 out of every 5 Americans will be retirement age, and just over half of those individuals will require long-term care.3
Despite unprecedented growth in the long-term care industry, there are serious deficiencies in patient safety and quality of care. In the US, the Office of the Inspector General estimated that 22% of Medicare beneficiaries in skilled nursing facilities, and 46% in long-term care hospitals experienced adverse events.4 Over half of these adverse events were thought to be preventable. Reports also suggest that a large majority of nursing homes fail to meet federal quality standards.5
The most common safety issues in long-term care include pressure ulcers, falls, medication administration errors and nosocomial infection.6 It has been suggested that the high incidence of adverse events in long-term care compared to hospitals is due to lower levels of staff training, lower staff to resident ratios, longer term stays, and a broader scope of care.7
In the US, there have long been attempts to improve the quality of long-term care, beginning with the Nursing Home Reform Act in 1987, which imposed federal standards to bolster inspections and nursing home quality enforcement.8 The 2006 Advancing Excellence in America's Nursing Homes Campaign, which later morphed into the National Nursing Home Quality Improvement Campaign, was another attempt, which promoted nine goals to improve quality in nursing homes.9 In 2013 the Commission on Long-term Care adopted 28 public policy recommendations in service delivery, workforce and financing in long-term care.10 There have also been attempts to measure patient safety in long-term care settings, such as the “Nursing Home Compare” program offered by the Centers for Medicare & Medicaid Services. However, the scores in these systems have been criticized as having a weak and inconsistent relationship between facility metrics and actual performance.11 In the US, improvements have been stymied by a general lack of research focused on quality of care and patient safety in long-term care settings, with a specific lack of studies on the effectiveness of improvement initiatives. The large majority of research has concentrated on hospital-based acute care.12
The COVID-19 pandemic spotlighted the quality and safety of long term care. From the start, nursing homes in the US were centers of outbreaks and excess mortality from COVID-19. Staff and residents of long-term care facilities accounted for 31% of all COVID-19 deaths in the US as of June 20, 2021.13 Data from more than 20 other nations with significant numbers of long-term care facilities show that they accounted for more than a third of COVID-19 deaths, though housing less than 2% of the population14
There is a growing body of research on the quality of care and patient safety issues that arose during the pandemic.15–17 It is clear that the pandemic exacerbated existing underlying problems. As stated by one author: “The coronavirus has exposed and amplified a long-standing and larger problem: our failure to value and invest in a safe and effective long-term care system.”18 Anecdotally, resourcing issues during the pandemic made it commonplace for homes and staff to sidestep basic quality and safety guidelines, leading to a worsening of the already sub-standard quality and safety protocols in such settings.
There are notable exceptions. This issue of the Journal includes a commentary from a continuing care retirement community in New York State. Professor Wilcox, a current resident of the facility, was in a unique position to describe how safety can be maintained during a pandemic.19 In a rare achievement, his care home has experienced zero COVID-19 deaths. The solution included imposing conservative control measures and frequent testing of residents and staff, prompt contact tracing, and a big bang adoption of vaccine as soon as it became available. Implementation was aided by participation of the managers, experts, and the residents themselves.
In related work, Micocci and colleagues describe the evaluation of rapid SARS-COV-2 point-of-care testing in a nursing home setting.20 They found that both standard operating procedures and knowledge of contextual factors associated with care homes were needed for safe use of these tests.
Also in this issue, two different papers demonstrate the importance of communication in securing timely, high-quality care. Hannawa takes the unusual perspective of alpine rescue teams, where aviation and healthcare come together.21 In this context, the crucial interpersonal communication process of sense-making is essentially the same in both industries.
Samuels and colleague demonstrate that CANDOR harm-in-healthcare training can improve empathy and communication skills in healthcare workers.22 Their findings provide evidence for optimism that these skills can be taught.
On a positive note, there has been a growing call to arms to address this quality and safety gap for the elderly. The United Nations General Assembly declared 2021–2030 the “Decade of Healthy Ageing” to bring together stakeholders for a “concerted, catalytic and collaborative action to foster longer and healthier lives”.23 This includes a focus on appropriate and person-centred long-term care. The Joint Commission and several other US organizations, such as the Agency for Healthcare Research and Quality, and the Institute for Healthcare Improvement, have set specific goals and directed projects to address quality and safety in long-term care, such as the AHRQ's front-line personnel training program.24,25
For the moment, the spotlight is being held in place on long-term care facilities by media outlets calling for reform26,27 Similar calls with specific recommendations are coming from organizations focused on the health of aging populations such as the AARP.28 Governments across the world are recognizing the need to understand and improve the industry. For example, the US and Canada have initiated commissions to review and make recommendations on quality and safety in long-term care homes.29,30
Collective action will also be needed from stakeholder groups, which include the government, public agencies, private organizations, and researchers. Broader changes may also be needed. For example, it has been suggested that improvements in safety have been stalled due to the punitive regulatory environment, which discourages open communication and reporting of errors..31 As with other aspects of patient safety, culture change will likely be needed to effect real improvements.
We should not let this crisis go to waste. The failures in long term care facilities exposed by the pandemic underscore the need to do much better. Not only do we need to be prepared for future catastrophic events, we need to be prepared to provide a reasonable quality of care during normal times.
People who make the life-changing decision of moving into a retirement home accept the sacrifices they are making in terms of down-sizing and independence. They should not have to accept inadequate safety.
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