Shared Rooms Helped Fuel COVID-19 Deaths in Nursing Homes. Are a Million Private Rooms Possible?

COVID-19 outcomes are also better. Larger facility size is significantly related to the increased probability of COVID‐19 cases. Infection rates in nursing homes with 50 or more residents were nine times higher than the rates in Green House nursing homes, one study found. It reported that lower rates were likely due to residents having private rooms and to the fact that fewer people live and work in Green Houses than in traditional nursing homes.

AARP has supported efforts to increase the availability of small-house nursing homes. “We know that residents prefer to have their own rooms and privacy in a more home-like environment, and these settings provide that,” says Rhonda Richards, a government affairs director for the organization who specializes in long-term care. “They also offer residents improved infection control, which, as the pandemic showed us, is very important.”

Growing interest, little change

Despite praise and growing scientific validation for smaller nursing homes with private rooms, they’ve been slow to spread.

Interest in the Green House Project skyrocketed during the peak of the pandemic, says Alex Spanko, the organization’s communications director. But only about 4,100 residents nationwide — less than 1 percent of the U.S. nursing home population — currently live in a Green House household. “Interest is still not really translating into firm action,” Spanko says.

The U.S. Department of Veterans Affairs changed its nursing home design approach to promote small-house homes in 2011. A VA program that funds 65 percent of a construction project for a state-owned Veterans Home has helped create 4,400 more private rooms for veterans.  

There’s been a “big push” for states to move towards smaller-home models, says the VA’s Anna Gaug, who manages the program. “We want veterans to feel at home,” she says. “They deserve to have privacy, dignity and to feel pride in where they’re living as they’re aging.”

However, the majority of the 18,000 veterans in State Veterans Homes are still in shared rooms.

Lawmakers have introduced bills in Congress to boost the small-house and private room movement. The Nursing Home Improvement and Accountability Act of 2021, for example, would fund $1.3 billion worth of infrastructure developments or modifications that are in line with small-house models in some nursing homes. Those would serve as demonstration projects to evaluate the impact.

A separate bill known as the IMPROVE Nursing Homes Act would give grants to convert traditional nursing homes into small-home facilities, bringing small-home care to 250,000 more residents by the end of the decade.

For now, though, private rooms remain the rare exception in nursing homes. The White House, in rolling out its nursing homes improvement plan last year, called shared rooms “the default option.”

The high cost of rebuilding

A.G. Rhodes’ campus outside Atlanta was constructed in the early 1990s, in the style of other hospital-like nursing homes of the time. But in 2016, after partnering with a nonprofit that coaches nursing homes toward more personalized care, the organization realized its Cobb building wasn’t conducive to the new approach. “While it worked for a certain time in history,” says A.G. Rhodes CEO Deke Cateau, it had become “archaic.”

That became more apparent with the COVID-19 pandemic. Among A.G. Rhodes’ three Atlanta-area campuses, the Cobb campus, with the fewest private rooms, suffered the most virus deaths: 14, roughly twice as many as the other locations.

National data from the time showed that people with dementia — which afflicts 80 percent of A.G. Rhodes’ residents — were twice as likely to get COVID-19 than those without it. And they were more than four times as likely to die from it. “We just fundamentally needed to have different infrastructure in order to make a difference,” Cateau says.

The move to private rooms came at a huge cost: $37.5 million. The nonprofit accepts mostly low-income Medicaid-insured residents, who tend to be less lucrative for nursing homes than residents on Medicare or who pay privately, so community support was vital. Donations provided $7.5 million and the project qualified for $6.5 million in federal tax credits for projects in low-income communities.

A $24 million loan covered the rest, but it was hard to secure, Cateau says. Nursing home occupancy rates dropped dramatically during the pandemic, from 86 percent in early 2020 to 72 percent in early 2021. It’s rebounded some, but investors remain wary.

Other facilities say they can’t afford the shift to private rooms. Fifteen years ago, White Oak Management, Inc., a for-profit long-term care provider operating 15 nursing homes across the Carolinas, started converting some shared dorms to private ones. After a decade, it had managed to move roughly a fifth of its skilled nursing beds into private rooms. Then progress halted.

“It got expensive,” says John Barber, executive vice president and chief financial officer. “We did all we could with the resources we had.”   

White Oak wants to get back to converting more rooms to private ones, but Barber says he can’t without outside money: “Maybe a low interest loan from the government to do the construction.”

Limping toward private rooms

Medicaid, the federal-state health insurance program for low-income people, is the biggest funder of nursing home care in the U.S., footing somewhere between 45 and 65 percent of the country’s yearly nursing home bill. Historically, though, the program has only paid for nursing home stays if residents are in shared rooms, unless a private room is deemed medically necessary. More private rooms have generally meant less government funding.    

Nonetheless, Cateau decided all the rooms at A.G Rhodes’ Cobb campus would be private. A “moral imperative” is driving the switch, he says. But he’s also taking a leap of faith, hoping that governments will change their funding models for nursing homes. “The reality is we’re going to have to get help federally or locally to support this,” he says.

Most providers won’t take that risk. Fewer than a quarter of U.S. nursing homes today are nonprofits like A.G. Rhodes. About 70 percent are for-profit businesses, and more than half are operated by corporate chains. Private equity firms, whose business depends on short-term profits, own a growing share.“We have a for-profit health care system, for better or worse,” says the Green House Project’s Spanko. “As long as something is profitable, the industry’s not really going to make a big shift to fix it.”

But in a move last summer, the federal Centers for Medicare & Medicaid Services (CMS) told states, which set Medicaid payment rates, that they can change their longstanding practice of not funding private-room stays. Instead, the CMS suggested that states set higher payment rates for Medicaid residents in private rooms. So far, though, there’s no requirement for states to follow this guidance – it’s optional.  

Which means it’s unlikely that private rooms will become the norm, says Charlene Harrington, a professor emeritus of sociology and long-time nursing home researcher at the University of California, San Francisco. “State Medicaid budgets are usually tight,” she says, “so they don’t want to raise the rates any more than they have to.”

Instead, says Harrington, the federal government should require that nursing homes provide private rooms in order to receive Medicare and Medicaid dollars, which are a huge source of their revenue. With occupancy rates at record lows, leaving many shared rooms unfilled, now’s a good time for homes to start the transition, she argues.

While the White House’s 2022 nursing home plan encourages more private rooms, it so far lacks specific strategies for getting there, apart from the summer guidance on Medicaid payments. The plan has “no teeth,” says Zimmerman of the University of North Carolina at Chapel Hill.

When asked if the federal government has forthcoming plans to reduce overcrowding, the CMS wrote in an email to AARP that it “does not speculate on future agency action.”

‘Private rooms are really just step one’

Private rooms alone won’t remedy nursing home system’s shortcomings. “The Green House model is a lot more than just the building,” says Spanko. “It’s about the culture, too.”

For example, moving residents into private rooms without investing in communal spaces or activity programs or more staff that bring them out of those rooms could cause increased loneliness and social isolation, an issue nursing homes really struggled with during the pandemic.

“Private rooms are really just step one,” says Spanko. “There’s another 25 steps that also need to be done to get to where we really want to be.”

Another worry is that by turning shared rooms into private rooms, facilities may have to decrease their total number of beds, limiting their ability to serve the country’s exploding population of older adults. The number of adults age 85 and older is projected to reach 19 million in 2060, up from 6.4 million in 2016.

But the U.S. needs better alternatives to institutionalized nursing home care, argues AARP’s Nancy LeaMond, chief advocacy and engagement officer. “We absolutely must address the safety issues in nursing homes. But that’s not the whole job,” she wrote in a blog post on long-term care reform. “We should also consider providing more of the supports and services that enable people to live at home — and when that is not possible, to live in environments where they will thrive.”