A long-term care facility, commonly known as a nursing home, serves as a residence and source of medical care for over a million older adults and people with disabilities across the United States. These institutions face persistent challenges, including concerns about consistent quality of care, high staff turnover, and regulatory gaps. Systemic improvement requires a multi-faceted approach that moves beyond simply meeting minimum standards to fundamentally redefining the care environment. Addressing these deeply rooted issues demands actionable strategies focused on the workforce, care models, physical design, and external accountability. The goal is to transform these settings into true homes that prioritize the well-being, dignity, and personal preferences of every resident.
Prioritizing Workforce Enhancement
The quality and quantity of direct care staff represent the single most important factor influencing resident outcomes. Chronic understaffing compromises safety and leads to preventable injuries or hospitalizations, underscoring the necessity of establishing clear minimum staffing requirements. The Centers for Medicare & Medicaid Services (CMS) has finalized a national standard requiring a total of 3.48 hours of direct nursing care per resident day (HPRD), including specific minimums for registered nurses (RNs) and certified nursing assistants (CNAs). This baseline aims to ensure every resident receives consistent attention and that an RN is on-site 24 hours a day to manage complex medical needs.
Improving the compensation and benefits for the workforce is equally important for stabilizing the labor force. The average annual turnover rate for nursing homes in the U.S. can exceed 50% for direct care workers, which creates instability that negatively affects care quality. Increasing wages and providing comprehensive benefits, such as health insurance and tuition assistance, can reduce burnout and make these careers more viable long-term. Stable staffing, where residents are cared for by the same personnel, is directly linked to better health outcomes and a higher quality of life.
Specialized training programs must be implemented to equip staff with the skills necessary for complex care needs. This education should go beyond basic certifications to include in-depth instruction on person-centered dementia care, palliative support, and managing residents with behavioral health issues. Furthermore, facilities should create defined career ladders for CNAs, allowing them to advance in their roles and take on greater responsibility without leaving the direct care setting. This investment in professional development fosters a more skilled and engaged workforce.
Implementing Resident-Centered Care Models
A fundamental shift from an institutional, task-driven approach to a resident-centered care model is necessary to improve the quality of life. This philosophy emphasizes honoring the preferences, values, and life history of each individual, moving away from rigid schedules toward flexible, individualized routines. Promoting resident autonomy means allowing choices in daily life, such as when to wake up, what to eat, and when to bathe, instead of adhering to a facility-wide schedule. This personal control is a fundamental aspect of dignity and self-determination.
Individualized care plans must be developed in collaboration with the resident and their family, making them co-creators of their care rather than passive recipients. These plans should encompass holistic needs, including social, emotional, and spiritual well-being, not just medical requirements. Therapeutic activities should be tailored to individual interests and past occupations to foster social engagement and provide a sense of purpose. Engaging residents in everyday activities, such as making coffee or setting the table, has been shown to increase cognitive function and overall quality of life.
This model also involves reducing restrictive practices that diminish a resident’s freedom and comfort. Moving away from the use of chemical restraints, such as sedating medications, and physical restraints, like bed rails, is a key component of person-centered care. Instead, staff should be trained in non-pharmacological interventions and behavioral strategies that address the root cause of distress. By prioritizing individual choice and tailoring the environment, facilities can overcome the institutional feeling and enhance the resident’s sense of belonging and well-being.
Reimagining Facility Design and Environment
The physical environment of a nursing home significantly impacts the well-being of its residents and staff, necessitating a move away from the traditional, hospital-like setting. One of the most effective strategies is the transition to a small-scale, “household” model, where units typically house 10 to 20 residents. These smaller clusters feature home-like communal spaces, including a kitchen, living room, and dining area, creating a more familiar and less overwhelming atmosphere. This design encourages a sense of community and ownership among the residents and their assigned care team.
Increasing access to private spaces is a major component of this environmental redesign. Providing every resident with a private bedroom and bathroom enhances dignity, personal control, and infection prevention. The design should also focus on optimizing sensory elements, such as improving natural lighting, minimizing disruptive noise, and ensuring good air quality. These changes can help manage residents’ sensory environment, which is particularly beneficial for those with cognitive impairment.
Facilities should also prioritize creating accessible and secure outdoor spaces, such as gardens or patios, that residents can easily access. Direct connection to the outdoors is linked to improved mental and physical health, helping to combat the social isolation often experienced in long-term care settings. Even in existing buildings, low-cost modifications to furnishings, décor, and room layout can make a meaningful difference in creating a more domestic and welcoming feel.
Enhancing Accountability and Regulatory Oversight
Strengthening the external mechanisms of accountability is necessary to ensure consistent compliance with quality standards across all facilities. The state and federal survey process, which involves inspections, must be more rigorous, frequent, and unannounced to accurately assess the quality of daily care. Enforcement actions should be consistent, and penalties should be substantial enough to deter poor performance rather than being viewed as a minor cost of doing business. Furthermore, the regulatory system must be streamlined to ensure that complex ownership structures cannot shield poor-performing facilities from scrutiny or legal action.
Increased financial transparency is a critical step in holding owners accountable for how public funds are spent. Many nursing homes utilize complex ownership structures involving related-party transactions, which can obscure where profits are being allocated and whether they are being reinvested into resident care. Requiring the disclosure of all corporate ownership and financial reports, including data from operating and property companies, allows regulators and the public to understand the true financial health and operational control of a facility. The Centers for Medicare & Medicaid Services (CMS) has been directed to implement Affordable Care Act requirements to collect and publicly report this robust ownership data.
Linking government reimbursement to measurable quality metrics, often called pay-for-performance, incentivizes facilities to invest in better care. Medicaid and Medicare payments, which cover the majority of nursing home costs, should be tied directly to outcomes such as low rates of pressure ulcers, reduced hospitalizations, and high resident satisfaction scores. Finally, empowering independent advocacy systems, such as the Long-Term Care Ombudsman Program, ensures that residents and their families have an effective, confidential channel to report complaints and seek resolution. These external checks and financial incentives work in concert to drive systemic improvement across the entire industry.