Despite our significant progress in making health care services more equitable to all populations, older people and those residing in nursing homes and long-term care facilities are often overlooked in mainstream discussions about health care equity.
One of the reasons contributing to their exclusion from these discussions is the current funding structure for their care. While Medicare provides reasonable reimbursement, its duration falls short, placing the major financial burden on Medicaid, which offers comparatively limited payment. Consequently, apart from a few fortunate individuals who can afford private care, most older adults have no viable alternatives. The demographic distribution within U.S. nursing homes does not mirror the overall population composition in the country, illustrating the manifestation of this effect. Research conducted by Feng et al. highlighted that from 1999 to 2008, the population of elderly Hispanics, Asians, and African Americans in nursing homes saw an increase of 54.9%, 54.1%, and 10.8%, respectively. On the other hand, the count of Caucasian senior citizens residing in these institutions dropped by 10.2% within the same timeframe. The data shows that the growth rate of minority residents in nursing homes outpaced the growth of the minority population in general, even in regions with a significant minority presence. This might suggest that minorities have unequal access to preferred alternatives for long-term care, such as home and community-based services.
Under the Older Americans Act, every state administers a Long-Term Care Ombudsman Program (LTCOP) to aid residents and improve long-term care systems. Likewise, Protection and Advocacy (P&A) programs exist nationwide to uphold the rights of individuals with disabilities, providing advocacy and legal support, and functioning independently of service providers. Even with these programs in place, when we consider the challenges associated with aging, such as lack of personal advocacy, limited mobility, and cognitive decline, it becomes apparent that this demographic genuinely requires more robust representation.
The data shows that the growth rate of minority residents in nursing homes outpaced the growth of the minority population in general, even in regions with a significant minority presence. This might suggest that minorities have unequal access to preferred alternatives for long-term care, such as home and community-based services.
For example, the long-term care facilities were largely left out of the digital transformation efforts initiated by the Health Information Technology for Economic and Clinical Health (HITECH) Act. These facilities did not qualify for the meaningful use incentives, which could provide eligible health care professionals with up to $44,000 for adopting and utilizing electronic health record systems. As a result, this segment has significantly lagged in the digitization of the health care industry and missed the associated benefits. This oversight has far-reaching indirect impacts on various aspects that influence the patients’ quality of life. An illustrative example is the high turnover rate in the industry, which is exceeding 100% annually. In 2017 and 2018, Registered Nurses (RNs) experienced the highest average turnover, with a rate of 140.7%. Licensed Practical Nurses (LPNs), and Certified Nursing Assistants (CNAs) also saw notable turnover rates at 114.1% and 129.1% respectively, though they were lower. Considering the severe toll of the COVID-19 pandemic on both residents and staff of nursing homes, we anticipate that the turnover rates will significantly increase in the post-pandemic period.
Surprisingly, a recent study by my colleagues and I has shown that factors like pay are not the primary drivers of turnover. Rather, aspects such as scheduling flexibility and improved supervision carry greater importance. Empirical research indicates that scheduling software can play a vital role in reducing turnover rates. Yet implementation of such software would face significant challenges given that long term care facilities have been left behind in our national digitization efforts.
Another example is the Nursing Home Compare. This is a 5-star rating system like that used in the hotel industry and is administered by the Centers for Medicare & Medicaid Services (CMS). Owing to the scarcity of alternative sources of information on the quality of nursing homes, the CMS system has risen to be the industry’s gold standard. It is extensively utilized by patients, medical providers, and payers to evaluate the quality of long-term care facilities. The ratings assigned to these facilities suffer due to the lack of digitization, relying heavily on self-reported quality measures. The research by my colleagues and I reveals a prevalence of exaggerations, rendering these ratings unreliable. Both the issues of staff turnover and inaccurate ratings have a significant impact on the residents’ quality of life.
As the American population continues to age and live longer, the financial challenges faced by this segment will only intensify. To address these pressing concerns, it is imperative that we explore innovative approaches, leveraging technology to fundamentally transform the way we deliver care to this population. The possibilities are limitless. For instance, technology can allow older individuals to remain in their own homes for extended periods by utilizing Internet-of-Things (IoT) devices to monitor and manage their well-being.
The role of artificial intelligence (AI)
Artificial intelligence (AI) can be leveraged to improve communication between medical teams, patients, and their families, and caregivers. Language models can effectively convey complex medical messages in easily understandable terms with a compassionate tone, potentially increasing patient adherence to medical advice. This becomes increasingly important given the low levels of trust in the medical community reported by the public. AI could help bridge the trust gap between patients and doctors.
Another crucial application of AI is managing the overall well-being of patients, which extends beyond medical care. For example, AI can assist with routine financial tasks such as automatic bill payments, expense management, and personalized recommendations, which can greatly benefit older adults, especially those with Alzheimer’s. These tasks may be simple for younger individuals but can pose significant challenges for older adults. By addressing these challenges, AI has the potential to drastically enhance their quality of life. Additionally, we can explore AI-driven virtual companionship through chats or phone calls.
While recognizing these advantages, it’s important to be aware of the potential harm that modern AI could cause to older adults, particularly considering its novelty and our limited understanding of their full impact. For instance, such systems could result in serious privacy violations, potentially with repercussions exceeding those we’re familiar with in our existing systems. Thorough testing should be conducted prior to the broad implementation of such technologies.
It is imperative to consider modern methods of financing these services, keeping in mind that with scalability, the costs can be kept modest, allowing larger providers to cover them through subscription models.
It should be noted that AI-based technologies derive significant advantages from scalability. With a larger user base, they gain access to more extensive datasets, enabling them to learn and enhance the quality of their services. This larger user pool also allows AI developers to offer their services at a substantially lower cost per user, as the true cost of providing these technologies does not increase with the number of users. This unique combination of improved quality and affordability empowers residents and their families to afford these services independently, without significant government support.
This approach would enable hospitals to concentrate on delivering advanced medical services, while nursing homes can focus on providing intensive care to a select few individuals requiring it. Simultaneously, the government’s current resources, typically allocated for routine nursing home services, could be redirected towards addressing the more urgent needs of patients requiring higher levels of care.