The Need to Reframe Nursing Homes as Community Hubs (2025)

The more than 15 000 nursing homes in the US have drawn increased scrutiny since COVID-19 ravaged both residents and staff. For instance, the National Academies of Sciences, Engineering, and Medicine (NASEM) issued a major report in 2022 that painted a grim picture of the quality and financial sustainability of a system characterized by large institutions with high staff turnover.¹ A coalition of experts and organizations, the Moving Forward Nursing Home Quality Coalition, is now focused on advancing the NASEM recommendations. Meanwhile, the Convergence Center for Policy Resolution, an organization that brings together a wide range of stakeholder organizations to find agreement on policy steps, issued a report last August calling for rethinking many elements of postacute and long-term care for older adults.

The primary focus of the reports is appropriately on chronic staffing problems and the effects on quality. But this increased scrutiny also raises questions about the very nature of nursing homes and their role in communities. Surveys of older adults and in-depth interviews with members of the public indicate the traditional, large nursing home is unattractive to most people. Although many nursing homes have developed additional business services within communities, such as hospice and home care, rarely do they interact directly with their local community. In principle, far more nursing homes could open their doors to the local community and offer various forms of assistance and services inside and outside their walls. They could provide more respite care and day care to relieve family caregivers, enlist staff to train family caregivers, and provide skilled services in a person’s home. Indeed, there is a growing awareness among advocates for direct care workers and family caregivers that successful care for older adults requires much greater collaboration and integration between professional and family caregivers. The lack of connection to the community also exacerbates the deep isolation felt by many nursing home residents and housebound individuals. This contrasts with the medical hubs developed by many nonprofit hospitals and Federally Qualified Health Centers that reach into their communities to provide many social as well as medical services.

Fortunately, there is growing interest in exploring new models of nursing homes and integrating nursing home services and facilities into the community. The participants in the Convergence initiative, for instance, called for creating a “broad constellation” of care settings, both in size and in function. One model attracting increasing interest, known as Green Houses, is far smaller than a traditional nursing home and can be nestled within communities; cross-trained staff undertake multiple roles and staff turnover is lower.²^,3 Another approach gaining interest is to adapt to the trend toward multiage living. This model could take the form of Green House style floors within existing apartment buildings, allowing more social interaction and the use of common amenities. Some nursing homes in the Netherlands and long-term care facilities in the US offer rent-free accommodation to college students willing to spend time socializing with older residents and helping with chores. In the UK, “extra care housing” provides nursing home and assisted living–style services to older people by creating a virtual nursing home in a community. Residents have their own apartments with 24-hour monitoring and regular medical and social services, and nearby communal spaces.

Unfortunately, significant obstacles impede many efforts to turn such possibilities and examples into reality. Policy reforms and administrative actions are needed to remove these barriers. Regulation at the federal and state level is often a major impediment to change. For example, because amendments to the Hill-Burton Act in 1954 envisioned institutional care settings based on large hospital-like facilities, the resulting facility design and use rules, licensing requirements, state certificate-of-need programs, payment formula, and other regulations can make it difficult and expensive for design innovations such as Green Houses to take root. In addition, the federal Home and Community-Based Services (HCBS) Settings Rule complicates or blocks reimbursement for certain Medicaid HCBS services, such as adult day and assisted living services, if offered to local residents in an “institutional” setting. A recent report provides a comprehensive review of the barriers triggered by the rule.

To encourage innovative community-focused nursing homes, the Centers for Medicare & Medicaid Services (CMS) should revise current regulations and payment models and encourage states to do likewise. And just as the CMS supports pilot programs and state waivers for medical services, it should launch pilot programs with payment and rule changes to test ways in which nursing homes could become accessible care hubs for older adults.

Chronic shortages of care workers, who receive low pay and benefits, is a major challenge. Due to these shortages, most nursing homes are consumed with finding staff to provide care for their residents, rather than thinking about ways their staff can also serve the wider community. Certainly the immediate focus must be on improving basic pay and benefits for nursing home workers. But in parallel, a long-term strategy is needed to elevate the roles of nursing homes caregivers into true and satisfying careers. This strategy will require an overhaul of federal and state training and licensing for care workers. Improving job satisfaction and enabling professional caregivers to undertake multiple care roles in the community, including assisting family caregivers and working with older individuals in a variety of institutional and other settings, will also require changes in licensing and wages.

The Need to Reframe Nursing Homes as Community Hubs (2025)

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