NAHCA Calls on CMS To Increase Reimbursement to Enable the Best Possible Person-Centered Care

Carl Junction, Mo. (November 8, 2023): On September 1, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule on Minimum Staffing Standards for Long-Term Care Facilities and Medicaid Institutional Payment Transparency Reporting. The proposal generated numerous reactions and comments, as well as much talk about staffing in this care setting and its relationship to patient care. NAHCA understands that the current staffing crisis and the lack of sufficient reimbursement to pay for quality care has impacted nursing homes nationwide. We believe there are ways to address these, and we are committed to working with others to be part of those solutions. 

NAHCA has proven over the past three years that there are thousands of quality individuals who want to be professional CNAs. The Federal Regulations governed by CMS calls for nursing homes to provide “person-centered care.” However, they only pay nursing homes for the most minimal care possible. To provide true person-centered care, it cannot be formulated on a per-patient day (PPD) basis. It must be based on the patient’s needs, and these vary – often considerably – from person to person. NAHCA, although not economists or mathematicians, have determined person-centered care costs would nearly double today’s Medicaid reimbursement rate.

The United States government spent about $52.4 billion in 2021 in foreign aid ($530 billion globally between 2012 and 2021). That is more money than any other country in the world, yet our own nation's nursing homes can't receive enough funds to properly staff their buildings, leaving our elderly to suffer. When nursing homes receive adequate reimbursement to provide patient-centered care, they can provide staffing that ensures better care outcomes and quality of life – a goal we all share. 

Who decides how long it takes to care for a resident in a nursing home? NAHCA’s Board of Directors spent much of 2023 identifying what “person-centered care” is in a nursing home. In NAHCA’s efforts to identify “who” decides that 3.0 nursing care hours are sufficient to meet the basic care needs, no one in the long-term care space can tell where these numbers originate from. With that said, NAHCA did identify the realistic needs of the average skilled nursing resident.

We put forth this example: Ida Jones is an 89-year-old resident who has cognitive issues, diabetes, high blood pressure, and Parkinson’s disease. She is incontinent unless taken to the bathroom every two hours. When she has incontinence, she likes a bath to feel clean. 

Here is what Ida gets in today’s average SNF:

1.  6:15 AM – CNA says, “Good morning, Ida. It’s time to get up.” Ida wakes up a bit confused each morning, but there is no time to go slow. Ida’s CNA has at least ten more residents to get up for breakfast at 7:00 AM. So, the CNA changes Ida’s incontinence brief first thing.
2. CNA raises the bed, sits Ida up, gets her dressed, and transfers her to the wheelchair and off they go to the dining room. Wait, no brushing of the teeth? NO, time for that. No one ever looks, and the state doesn’t inspect it, because they do not want to pay for oral care.
3. CNA wheels Ida to the dining room in her assigned spot where she waits until trays come out. Since she is assisted with meals, she does not get to start eating until a CNA arrives at the table to “feed” her.
4. Ida waits to get back to her room until the CNA is finished with the dining room chores and feeding assigned residents.
5. CNA takes Ida back to her room, then to the restroom. Unfortunately, during the wait, Ida had an incontinent episode during breakfast. This requires peri wash care; and Ida still wants to sit on the toilet for a bit to see if she is finished. Ida cannot be left unattended and sits for at least ten minutes before the CNA encourages her to try again later.
6. 9:00 AM - Ida wants to lay down. CNA encourages her to go to a facility activity, but she insists on going back to bed. CNA transfers Ida from the wheelchair to her bed, removes her shoes, and helps her into bed.  
7. CNA enters the room at 11:00 AM to take Ida to lunch and repeats 1 – 6.
8. 2:15 PM - CNA comes into Ida’s room and checks incontinent brief, removes it, and takes Ida to the restroom. After ten minutes, Ida indicates she has finished. CNA provides peri care, applies a new brief, and ensures Ida is dressed appropriately.
9. Ida likes television, and CNA turns on Ida’s TV for her to enjoy while she waits for dinner at 5:00 PM.
10. Repeat steps 3 – 5.
11. 6:15 PM – Ida’s CNA has taken her back to her room, for toileting and personal hygiene care.
12. 6:30 PM – CNA turns on Ida’s television to a program she knows Ida enjoys.
13. 7:30 PM – CNA returns to Ida’s room to prepare her for bed as quickly as she can because she has at least ten other residents to get to bed. Ida is in bed by 7:00 PM with a dry incontinent brief and her television on.
14. 9:30 PM – CNA makes rounds on Ida and all assigned residents. Ida is generally wet; and if not, the CNA takes her to the bathroom. CNA rushes Ida because there are at least ten other residents the CNA must care for.
15. 11:15 PM – Night-shift CNA makes rounds and enters Ida’s room. For the next seven hours the CNA will check, change, or toilet Ida every two hours. This is a rushed experience for Ida and all the other residents because CNAs on night shift are also responsible for cleaning all resident wheelchairs, bed pans, and urinals.

For Person-Centered Care, Ida would have a day like this:

1. Natural awakening – Ida is retired and doesn’t like to get up early.
2. Mornings are her way but would include a trip to the bathroom for toileting, a warm washcloth for her face, and appropriate oral care. She may want to have coffee before going to breakfast and that should be OK.
3. Ida is fine sitting at the assisted dining table but wishes the experience was not so rushed. Consider what one facility did quite successfully -- enabling residents and staff -- including CNAs -- to take their meals together. Socialization is fun and productive for everyone; residents get to eat without being rushed, and staff get to eat and get to know their residents.
4. Ida gets to go to bed when she’s tired and not on a set schedule.
5. Ida gets to bathe everyday if she wants to. 
6. She likes to be taken to the bathroom, so she is not incontinent and to avoid soiling herself she needs to be taken to the restroom every hour.
7. She wants her CNAs who she depends on most to have the time to brush her hair, talk with her and reassure her she is safe.
8. If Ida happens to be a night owl and wants to watch tv all night she is allowed to do so, BUT the night CNA will be in every hour to assist her to the bathroom, so she has no loss of dignity by accidentally soiling herself because no one is available to take her. 

While this is just one scenario, our point is that person-centered care isn’t cookie-cutter and doesn’t happen in a set timeframe. It can take more or sometimes less time, depending on each person and each situation. But in the end, it respects residents’ dignity and choices, enables them to have quality of life, and gives CNAs the time and autonomy to provide excellent care and take pride in their work.

About NAHCA

The National Association of Health Care Assistants (NAHCA) is a professional association of and for Certified Nursing Assistants (CNAs) and represents more than 20,000 CNA members across the country. NAHCA elevates the professional standing and performance of health care professionals through recognition, advocacy, education, and empowerment to maximize success and quality care. For more information about NAHCA, please visit their website at www.nahcacna.org.

Media Contacts:

Dane Henning

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(417) 291-1502