United States Nursing Homes: The Impact of Regulation on Quality

Abstract

The United States nursing home industry has historically faced pervasive issues that impact quality of care and quality of life for nursing home residents. In 2016, efforts were made to address quality issues within nursing homes through an overhaul of regulatory policy. The COVID-19 pandemic not only impacted implementation of the 2016 policy revisions, but also diminished the ability to collect data and analyze the effectiveness of the updated regulatory policy. Recent reports have indicated that nursing homes continue to struggle with meeting minimal quality standards. With public health emergency restrictions lifted and normal nursing home operations resuming, new opportunities are available to analyze nursing home quality and regulatory enforcement. The purpose of this dissertation is to evaluate the current state of quality in United States nursing homes and how regulations have impacted quality in this sector. A scoping literature review finds that research on nursing home quality largely focuses on the quality metrics developed by the Centers for Medicare and Medicaid Services (CMS). This includes the CMS Five-Star Rating System and its components. Current available literature infrequently includes qualitative research or full data encompassing the 2016 policy revisions. Qualitative and quantitative methods are used in this dissertation to fill these identified gaps. Qualitative interviewing gives a voice to the workers whose care performance directly impacts the outcomes used by CMS to measure quality in nursing homes. The qualitative interviews performed as part of this dissertation reveal that broadly, frontline worker views on quality do not align with quality metrics utilized by CMS. Bridging the gap between policy and frontline worker experience is vital to ensure regulations elicit action from those providing care. Findings from this research indicate that regulatory policy is not achieving this. Quantitative research identifies trends in CMS nursing home quality using data pre and post policy implementation. The quantitative analysis finds that most quality outcomes either declined or remained unchanged since 2016, with for-profit nursing homes consistently performing worse on quality metrics when compared to nonprofit and public nursing homes. The results of the quantitative analysis reveal a failure of the 2016 policy revisions intended to improve nursing home quality throughout the country. This dissertation concludes that current regulations are not having a positive impact on quality in US nursing homes. Frontline workers are mostly uninfluenced by regulatory enforcement methods when discussing their caregiving behaviors. Nursing home quality as measured by CMS has declined throughout the country, despite the 2016 policy revisions intended to improve it. Policymakers must make efforts to include frontline worker input in future policy adaptations and either revise the metrics used to measure nursing home quality or invest in further quality improvement programming to achieve the desired outcome of higher quality in US nursing homes.