Ep 03: Why Did the COVID-19 Crisis Ravage Nursing Homes?
Since its onset, COVID-19 has disproportionately impacted nursing home residents, primarily because they live with the types of medical conditions that put them at risk of severe complications. But there are other important reasons that the nursing home sector remains vulnerable to health crises.
In this episode of A Question of Care, Robert Espinoza speaks with David Grabowski, a professor at the Department of Health Care Policy at Harvard Medical School. They touch on the history of nursing homes, what COVID-19 has revealed about this sector, and how it should move forward from this crisis.
Robert Espinoza: How did the wealthiest country in the world get to a point where it can't support the health and long-term care needs of more than 54 million older adults? Welcome to A Question of Care, a podcast that explores the many answers to this question through different viewpoints and topics. I'm your host, Robert Espinoza, a national expert and frequent speaker on aging, long-term care, and the workforce.
In this episode, we're directing our focus toward nursing homes and exploring the pressing question: Why have so many nursing home residents died during the COVID-19 pandemic? And what are the forces at hand? Here to guide us on this journey is David Grabowski, an esteemed professor and authority in the field of nursing homes and long-term care for older adults.
David Grabowski: Hi. I'm David Grabowski. I'm a Professor of Healthcare Policy at Harvard Medical School, where I study issues of long-term care and post-acute care for older adults.
Robert Espinoza: Before diving into today's topic, it's important to understand the average nursing home resident. During the height of the pandemic, we got used to seeing news stories about nursing home residents dying in droves, making it easy to forget sometimes that these residents are also individuals. They are our parents, grandparents, aunts and uncles, and friends. To help contextualize our conversation, David described who makes up the average nursing home resident.
David Grabowski: Nursing home residents have a broad range of backgrounds and care needs. But your typical nursing home resident. It's usually a she, but they are in their 80s. They have, oftentimes, both limitations in terms of cognitive functioning and physical functioning, high rates of Alzheimer's and related dementia, and need for assistance with activities of daily living, such as bathing, dressing, toileting, and walking. And they also have quite a high level of medical complexity. And that means there's a real onus on coordinating both their long-term care needs and their medical needs.
And I should add one more point: that there are, within nursing homes, two very distinct types of residents. So, the resident that I just described is a long-stay resident. He or she would be receiving long-term care services. They would expect to be there for the rest of their lives. Their care would typically be financed by the Medicaid program, with some out-of-pocket private payment.
There's a second type of nursing home resident, and that's a short-stay individual, post-acute, who has come from the hospital and would typically spend 4-to-5 weeks in a nursing home before transitioning back to the community.
The final point is that there is some blurriness with these groups in that sometimes an individual comes to a nursing home as a "short-stayer" and transitions into a "long-stayer." And then sometimes you have long-stayers that will need to go to the hospital and then come back for rehab and therapy and for a short period of time be post-acute patients. However, the post-acute patients tend to be younger. They tend to have higher cognitive and physical functioning, but they have really sort of short-term needs around therapy and rehab.
Robert Espinoza: In 2020, Professor Grabowski was appointed by the National Academies of Sciences, Engineering, and Medicine to its Committee on the Quality of Care in Nursing Homes, which examined how the U. S. delivers, finances, regulates, and measures the quality of nursing home care. The committee released its final report in 2022 and offered a brief history of nursing homes, which helps partially explain why they are the way they are today. It notes how families were historically responsible for delivering care to older adults and people with disabilities. However, due to various federal policy developments in the 20th century and medical advances, nursing homes began mirroring "an acute care model with a medical focus." So, what has this medical setting model meant for nursing home residents and the sector overall?
David Grabowski: You'd be hard-pressed to find anyone who wants to live in a hospital, yet many nursing homes around the country look like a hospital and have the same setup. You know, the nurse's station at the end of the hallway, the long linoleum flooring with rooms on either side and two-to-four residents per room.
This might work in a hospital. And I stress the word "might." This does not work for a nursing home, where, as I just described, these are individuals, the long-stayers, who are going to be there for the rest of their lives, months and years in this setting. This is not very home-like. It's over-medicalized.
That's not to say we don't need clinical care. I said earlier that there's incredible medical complexity, but we need to balance the nursing part of the nursing home with the home side. And this history growing out of hospitals that, you know, these large institutional buildings with a real medical feel haven't served our residents well because it is their home, and the quality of life has suffered in these buildings. Unfortunately, many times, they haven't done either the nursing, the medical side of it, or the quality-of-life and home-like aspect of nursing home care very well either. But by over-medicalizing the delivery of services, it's created a setting where it's very institutional and not really about the needs of the residents. It's much more about the sort of need of the nursing home itself. And that hasn't, once again, served nursing home residents very well.
Robert Espinoza: David, under what conditions would you live in a nursing home?
David Grabowski: Like everybody else, I would prefer to receive my long-term care in the community. But I would move to a nursing home if I believed my quality of life would be better there. And there are points for all of us where nursing home care may offer the set of services that I would need. And so, there's often been this zero-sum way of looking at nursing home care vis-à-vis home- and community-based services.
I'm a huge supporter of home- and community-based services. Everybody who can receive services in the home and the community should receive services in the home and the community. But it's not realistic to think that all of us will be able to do that. Sometimes, the quality of life and caregivers' lives will be higher if a family member receives services in a nursing home.
As you can imagine, Robert, I'd have some pretty strong feelings about what kind of nursing home I would want to enter into. But I would do it if I felt my quality of life in the community was at a point where it was no longer manageable, and I could have a higher quality of life in a nursing home.
Robert Espinoza: If someone you loved needed to reside in a nursing home, what would you advise them?
David Grabowski: I would want them to seek a place where both the nursing and the home are strong. And so, let's start with nursing. Nursing is all about staff. Staff are the backbone of any nursing home in the U.S. I like to say that a nursing home is only as good as its staff, and that's really true. You need a place with a strong nursing model. We can talk more about this point, but you want a place where it's well-staffed, the staff are retained and want to be there for the long term. The staff are valued and empowered.
And then the home side of it. I want to find a place that doesn't feel like that big institution we described earlier. I want to find a place where it feels like my home. It's my room. I can wake up when I want. I can go into my room and spend time doing the things that I want to do or spend time with others. If you come into my room as a staff member, you knock on the door. That's my space. I'm empowered the same way the staff in the building are empowered. If we treat residents and staff with the dignity that both deserve, that's the kind of nursing home I want my family members to choose.
Unfortunately, there aren't many of those [options] out there, and that's the real struggle. And that's why we set out for that National Academies report you described—to transform nursing homes. Because most nursing homes in the U.S. today don't have strong nursing and home-like models. That needs to change.
Robert Espinoza: In the nursing home report we're discussing, the committee lays out various factors that influence the quality of care in nursing homes, and I want to review a few of them for your thoughts. Since the beginning of COVID-19, nursing home residents and staff have been disproportionately impacted by this pandemic. We know that one of the reasons nursing home residents are vulnerable to this virus is that they often have medical conditions that put them at risk of severe complications.
But there are other reasons, as well. Why has the nursing home sector been so ravaged by this pandemic?
David Grabowski: We termed it in one of the papers we wrote, "a perfect storm." If you wanted to design a sector that would be most impacted by COVID, you would design the U. S. nursing home sector. And unfortunately, it was that perfect storm.
So, one, this is somebody's home. So it's very different than a hospital. And because it's a home, it has a very different feel regarding personal protective equipment and how social distancing might occur.
The second part of this is that staff members come in and out every day. Some of these staff live in areas with huge outbreaks in the community. Those staff are moving from room to room. Sometimes, these staff work across different buildings because we're not paying them a living wage. And so they're having to work across multiple settings.
Third, we have these residents packed into a very small space here, oftentimes sharing rooms—two, three, four residents in a room together. If one gets COVID, how do we keep the other roommates from ultimately getting COVID?
And then, four, you do have older, frailer individuals. Once they have COVID… this is not like, you know, high-school-age kids getting COVID. This is our frailest and most vulnerable individuals in the country getting COVID.
And so, what could have been just maybe needing to be in bed for a few days if you were in the community—for them meant hospitalization and death. And so that's why we saw the numbers that we did see in this setting. It was just really hard to keep [COVID-19] out. Once in nursing homes, it was really hard to keep from spreading.
We did a study with a Massachusetts nursing home where we looked at them back in April 2020. I was involved in an effort here in Massachusetts to identify nursing homes with no COVID where we might create, you know, an environment where we can move other residents into the building. We were thinking about COVID and non-COVID environments.
And we went into this building. Not a single resident was reporting any COVID symptoms in early April. We tested every resident. It turned out that nearly half of the residents in the building had COVID without even knowing in early April. By the end of the month, roughly two-thirds of the residents by that point had COVID. Thirty of them had died by the end of April 2020.
That's how quickly we would go from no symptoms to two weeks later, having 30 residents die from COVID. Things move very quickly. And the challenge was, at least back in 2020, how do we keep it out and then how do we contain it? And this was not a setting well-equipped to either keep it out or contain it.
Robert Espinoza: The report notes that about 1.2 million people help provide care and maintain nursing homes, including nurses, nursing assistants, administrators, and many others. And yet, most direct care in nursing homes is provided by nursing assistants. And nursing homes have struggled to recruit and retain these workers to the point that many say it's now a crisis.
What are the workforce challenges facing nursing homes, and what would it take to convince a nursing assistant to take and stay in this occupation?
David Grabowski: Yeah, it's a really interesting workforce, and I try to explain this to colleagues who study other parts of the healthcare system. Nursing homes have physicians, registered nurses, and licensed practical nurses. But the bulk of the workforce are these certified nurse aides.
They're doing most of the direct caregiving. So, most of those tasks we've been discussing—bathing, dressing, toileting, walking, and feeding the residents—are done by certified nurse aides or CNAs.
How do we recruit these individuals? The first thing is pay—pay and benefits. I always start by saying that it's necessary but not sufficient. And let me explain what I mean by that. Nobody wants to take these jobs if they're not well-compensated and well-supported. But that's not going to be enough to bring a lot of new individuals into these jobs and then keep them in these jobs.
Nursing homes compete with a lot of other parts of the economy. It's not just other healthcare settings. An RN might move from a nursing home to a hospital or physician's office. A CNA might move from working in a nursing home to Amazon, Walmart, or McDonald's. There are other jobs; if they pay more, it may be easier and [have] better working conditions. Then, it's not just about pay. So pay has to be a big part of this. We need to support the caregivers in nursing homes, but that's just the first step.
The second step is making these jobs worth having. And some nursing home operators have really changed the working conditions in nursing homes, empowering workers. A typical nursing home… You know, we have 16,000 nursing homes in the U.S. We have more nursing homes in the U.S. than Starbucks or McDonald's, and they need lots of workers. It's been hard to recruit individuals, given these aren't great jobs.
And guess what? This only got harder during the pandemic. We've never valued this workforce. But during the pandemic, we wrote an op-ed for The Washington Post. Several of us argued… We ran some quick calculations and discovered that nursing home work was America's most dangerous job during the pandemic. So on top of the low pay, the challenges, the difficulty of the work… it's also really rewarding work, so I'm not trying to say that no one should take these jobs. It's the opposite. We should value the important work that's being done in these settings.
But on top of everything else—the challenges of the pandemic, the fear that a lot of residents had of getting COVID themselves and bringing it home. We lost a lot of caregivers in nursing homes. And that's something I think we need to revisit as we think about nursing home policy going forward. How do we support this workforce in terms of pay, benefits, and working conditions that support the important work occurring in these settings?
Robert Espinoza: What I appreciate about the report is that it also looks to the future. It imagines the recommendations and policy changes that need to happen to transform the nursing home sector. The first overarching conclusion from the report states, "The way that the U.S. finances, delivers, and regulates care in nursing homes is ineffective, inefficient, fragmented, and unsustainable." What stands out for you from this conclusion?
David Grabowski: I love that conclusion. And the part that stands out is the "unsustainable" part.
When I say it's unsustainable, that doesn't mean it will suddenly get effective, efficient, and coordinated. What I mean by that, what we meant by that, was it's going to get worse. We have aging baby boomers. We need to change this now, or else we're not going to have a nursing home model that's sustainable for all of us.
And I often ask that question to colleagues and friends when speaking to different audiences. Where do you think you're getting your long-term care? Where do you think you're getting your nursing home care? These are the options out there. We have a very, I'll repeat the quote, an ineffective, inefficient, fragmented model. And if all of us receive our care there, we're going to have the same outcomes that older adults do today.
If we want better options, we need to go about creating those better options today, such as they're there for all of us. Because otherwise. It's even going to look worse in 20 or 25 years after the baby boomers have gone through their long-term care years. If we don't fix this now, we won't have the options for all of us going forward.
Robert Espinoza: David, are there any developments, either in policy or practice, that give you hope regarding the nursing home sector?
David Grabowski: Yeah, there's a few. So, I'm part of a group called Moving Forward. We're a coalition. I co-chair a working group on nursing on payment and financing. But there are working groups for health information technologies and workforce staffing. There's quality of care, there's regulation. So we're trying to change all the issues brought up in the National Academies report.
It's hard. This is not easy, but it's trying to take the 600 pages we wrote and the recommendations we made for the nursing home industry, work with them and put these recommendations into practice. I hope listeners will want to get involved in this effort. It's a broad coalition of workers and operators and advocates and ombudsmen, and, you name the role… medical directors. If there's a role in nursing homes, we have them represented in our coalition. But I'm optimistic, as you asked, because many of us want to roll up our sleeves and change things.
[This is] one of the things that's always struck me about nursing homes. I don't know that the current payment models, regulatory models, quality of care, and staffing are working very well for any of the stakeholders involved. They're not working well for residents or family members. They're not working well for staff in these buildings, operators, and so on. It needs to change. And so everyone comes to the table looking to change things. It's not going to be easy.
I worry that nursing homes, although front-and-center during 2020 and 2021, faded a little bit, and they're not still in the headlines. Maybe that's a good thing because that means we're not seeing the case and death rates.
But a lot of the factors, as we've been discussing, that led to those high case rates, that led to those high death rates, are still present. And so, all the causal factors are still there, and this sector isn't in a better position today than it was in 2019 or early 2020 to withstand the next pandemic.
We need to invest in this sector, not just for the next pandemic. But because it's in need of huge improvements. That needs to start today. I think the Moving Forward Coalition is an effort to try to do that slowly and make a change.
Robert Espinoza: If you could do anything to transform the nursing home sector, what would you do?
David Grabowski: I'm a big fan of the Greenhouse Model. So, let me quickly explain Greenhouse. Many of your listeners are already aware of this model. But it's basically a small-house model where 8 to 12 older adults live in a home together. Each has their own room. The residents, it's really their home. They get up when they want. You knock to go into their room. They spend their days the way they want to spend them, not how the nursing home wants them to. If they want to go outside and garden during the summer or spring, that's their prerogative. It's really about living a meaningful life.
The staff—it's not the hierarchical model that we see at a traditional nursing home. The staff is empowered, valued, and well-paid. They take on a universal worker model there where they're cooking and cleaning in the home. The meals are cooked right there. The elders eat around a table together.
So, you have these three components: an empowered staff, a resident-centered model, and a small home. That's the kind of transformation. For that model to happen, however, we need to change the kind of payment models and regulatory models. Everything around it needs to change. That's the kind of nursing home that if I was out there looking for a loved one, that's the kind of place that we would all want our loved ones to receive care. Life still has, you know, meaning in that type of environment. However, there are just so few of them, and that's the real policy failure.
Robert Espinoza: Both of my parents passed away in nursing homes located about 15 miles away from each other in northern Colorado. My mother died in December 2020 after having lived in the home for nearly seven years, and my father, in February of this year, passed away quietly in a hospice unit after only a few days.
The nursing homes where they spent their final moments embody both the offerings and the challenges David described in this episode—a duality that leaves many of us conflicted about the future of this sector.
On the one hand, moving into a nursing home was the only affordable option for both of my parents, given their needs, and that's a reality shared by many people who enter these settings. Despite the lack of choice, my mother raved about several of the home's staff members, from her physical therapist to the CNAs and head nurse and the woman who drove her to dialysis three days a week. She considered these employees good friends and the facility her home despite its many flaws—frequent odors, understaffing, distasteful food options, and its hospital-like aesthetic.
But those flaws are neither episodic nor are they minor. They are part of a broader systemic failure that leaves millions of residents and frontline workers at the mercy of any crisis.
So when COVID-19 ravaged nursing homes in its first year, it revealed not just the medical frailty of many nursing home residents but their expendability in a society that grossly devalues older adults and people with disabilities, especially if they are low-income, people of color, and women.
As David explained, nursing homes lack transparency, or checks and balances, regarding who owns and who profits from them or how they are run. It doesn't help that government funding for any part of long-term care often leaves these homes unsafe and without adequate staffing. They continue to feel less like homes and more like hospitals.
Ultimately, while nursing homes might be the best option in our current system for certain individuals, this assertion is less a fixed reality and more a sad commentary on our policy priorities as a country. Many people don't have the option to choose anything other than a nursing home, and those inequities are defined along the axes of race, class, and gender.
Imagine if the home care system was funded properly and functioned smoothly so all Americans could live in their preferred long-term care setting. How many people would choose to stay home until their final days? And is that the ideal society we should be creating?
Thank you to my guest, David Grabowski, and to you, our listeners. If you enjoyed this episode of A Question of Care, please share it on your social channels and stay tuned for future episodes.
This podcast was produced by me, Robert Espinoza, in partnership with Modry Media. Please make sure to rate and review the podcast wherever you're listening.
This transcript has been lightly edited from the original episodes to improve readability and accessibility—while preserving the guest's authentic voice and conversational style.