Whatever else the person-centered care revolution needs, it needs more foot soldiers, experts agree.
“I think there’s a hard-wired, structural deficit in many nursing homes, in that they’re woefully understaffed,” says Ira Byock, MD, executive director and chief medical officer of Providence Health and Services Institute for Human Caring and author of the book, “The Best Care Possible.” “If you’re understaffed and you’ve got complex needs, somebody’s needs aren’t going to be met. That’s a structural problem. It’s problematic from a quality perspective, and I think it’s ethically troublesome.”

For Byock and his allies, it’s not just a matter of reducing turnover (although that would help a lot, too). It’s a matter of putting enough frontline workers at the front lines.

“Nursing homes are staffed by committed, caring people who are a joy to be around and an honor to consider as colleagues,” Byock says. “And yet, there are simply too few of them in nursing homes to answer a bell if a frail elder needs help getting to the bathroom or is wet and needs to be cleaned and changed.”

Dayne DuVall, chief operating officer of the National Certification Board for Alzheimer Care, says it’s more than a structural problem: It’s a contradiction.

“They’re trying to fit person-centered care around shift networks,” DuVall says. “We’re still going by the
schedule that was set by shift workers eons ago. My concern is that they want the persons in person-centered care to fit in the mold of how they run their business. We don’t have enough people providing care to support person-centered care.”

Few providers will dispute that they could use a few more hands on deck. But in a profession where the margins are razor thin and state and federal governments don’t care if they’re cutting fat or muscle from their budgets, it’s a tough theory to practice.

That’s why Byock says he hopes regulators will rethink their reimbursement rates if it’ll help homes staff up.

“I think Medicare will end up saving money, in total, were that done,” he says. “If you have a nursing home with only one nurse or aide to every 12 residents … and one of your residents becomes seriously ill, it may be that the most responsible thing to do at the moment is to transfer that resident to a facility with bigger staff—i.e., the emergency room at the hospital.”

In any case, regulators should do it because it’s worth doing, Byock says.

“If requiring extra staff in nursing homes is seen as an extra monetary commitment—even though it saves Medicare money in the long run—we’ve allowed the health care structures we’ve created to be a barrier to the quality we all want,” he says. “In this day and age, quality of care requires that the treatments we provide are consistent with the values, preferences, and priorities of the people we serve.”