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A Valuable New Framework For Improving The Care Of Older Adults


Imagine, for a moment, a functioning, well-developed system for improving the lives of frail older adults. Imagine that, instead of our current chaotic, dangerous, and needlessly expensive patchwork of care for seniors, the U.S. had a well-coordinated care model that leverages and supports paid aides, family caregivers, safe and appropriate housing, and new technology.

And imagine a system that makes it possible for older adults to live in the setting most appropriate for them, links their personal care with medical treatment, and provides the financial support to pay for it.

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For the past year, a broadly diverse group of long-term care policy experts have been working to develop such a framework. Today, they released the results of their labors, done under the auspices of The Convergence Center for Policy Resolution. Full disclosure: I served as a member of the group’s steering committee.

The report, called Improving Care for Older Adults, is more of a broad framework for reform than a step-by-step cookbook. While it includes some specific examples of ways to improve the quality of long-term care for older adults, it mostly provides policymakers and care providers with guidelines for reform. It focuses on five essential themes:

  • Care settings: Older adults need appropriate, safe, and supportive housing as they age. Facility- based care should financially sustainable even as it provides the best possible quality of life for its residents. Government should encourage new models of care for those living at home. It also must provide appropriate incentives for high-quality care in nursing homes, assisted living facilities, small group homes, and other congregant settings.
  • Better integrating longterm care into communities. Government should encourage models that better link subsidized housing with long-term care and health care. Operators of long-term care facilities should strive to better engage with their neighbors.
  • Family caregivers: Policymakers should recognize the central role played by family and friends and develop models that support and train those family caregivers. Support and training must recognize and respond to cultural differences among families.
  • Direct care workers: Along with family members, direct care aides and others providing paid personal supports and services are the backbone of the long-term care system, both for those in facilities and for many living at home. To make sure the US has enough people to provide care, these workers should be paid appropriately, well trained, and given opportunities for career advancement.
  • Funding: No true reform of the long-term care system is possible without adequate funding. This means Medicaid payments for low-income long-stay nursing home residents must be adequate to support quality care. It also will require a fully-funded public catastrophic long-term care insurance program that meshes with private insurance and Medicaid. This model is similar to what a 2016 Convergence project recommended.

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The main report was accompanied by three detailed papers focusing on housing, Medicare’s Five Star rating system for nursing homes, and the effects of widespread Covid-19 related deaths on the residents and staff of long-term care facilities.

The Five-Star paper urged the Centers for Medicare and Medicaid Services (CMS) to refocus its nursing home rating system from primarily measuring safety to including quality of life metrics as well as more transparency about staffing.

However, the main report is much more of a broad roadmap than a turn-by-turn set of specific policy recommendations. In that way, it is quite different from the National Academies of Science, Engineering, and Medicine’s recent report on nursing home reform.

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Surveying the ecosystem

The National Academies report was narrow and deep: More than 600 pages of specific recommendations for improving the care of nursing home residents. The Convergence framework looks at the entire ecosystem of care for older adults in only about 16 pages, plus its package of more specific recommendations.

Like the National Academies report, this Convergence paper anticipates that federal and state regulators and Congress will likely address the complex issues of long-term care in bite-sized pieces. Complex, broad-based reform seems improbable in the current political climate. But the report points to many small steps that can improve the care older adults now receive.

The Convergence group included 31 members: Academics, researchers, advocates, representatives of direct care workers and operators of long-term care facilities, and experts in senior housing, finance, and technology. Its members ranged from conservatives to progressives. Combined, the members brought hundreds of years of expertise in long-term care to the group.

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The most important outcome of this project, led by Stuart Butler of the Brookings Institution, is that a diverse group of policy experts could reach broad consensus on many critical long-term care issues. Congress should take note.



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