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Long-Term Care Needs DNSs to Step Up and Advocate: How to Get Started

Directors of nursing services (DNSs) and other nurse managers in nursing homes may at times feel powerless in the face of the COVID-19 public health emergency (PHE), the ongoing staffing crisis, and years of changing priorities and chronic funding failures at both the federal and state levels. However, DNSs can take steps to reclaim some power by using their voice to advocate for their facility—and the entire long-term care sector, suggests Matthew Smyth, senior director of grassroots programs at the American Health Care Association (AHCA) in Washington, DC.

“It’s really crucial that DNSs reach out and get involved, especially now when the pandemic continues to impact nursing homes, threatening access to care for our nation’s seniors, and when the Biden administration has announced plans to increase requirements on nursing homes without meaningful assistance,” says Smyth. “You may think that your voice is not important, but you have a very unique story, and members of Congress, as well as their staff, want to hear it.”

Many members of Congress have never stepped foot in a long-term care facility, points out Smyth. “They have no idea of the challenging work that providers do. As nurse leaders, you are the front-line caregivers who see first-hand what residents, families, and staff are experiencing. Your personal story will resonate very well and may serve as a real eye-opener. You want to let members of Congress know how you are meeting the needs of residents, what struggles you are facing, and the importance of Medicare and Medicaid funding.”

While advocacy is always important, Congress is primed to listen in 2022 because it’s an election year, says Smyth. “An election year means that members of Congress are more attentive than at any other time during their term of office. They want to get re-elected, and they know that all of their constituents have the power to vote. So, they are tuning into the needs of the constituents and working to serve them.”

AHCA has identified two immediate areas of concern that would benefit from nurse leader advocacy. Smyth recommends that DNSs launch or ramp up advocacy efforts by weighing in on one or both of the following issues:

Issue 1: Extending the PHE

The United States has been under a declared COVID-19 PHE since Jan. 27, 2020. The secretary of the U.S. Department of Health and Human Services is required to renew the declaration every 90 days. “Currently, the public health emergency is due to expire in the middle of April, and we would like to extend that,” says Smyth. “This would extend important Medicaid funding, and it would also extend key waivers, including the Medicare Part A waiver of the three-day qualifying hospital stay. While we are hopeful, there is no guarantee that the Biden administration will extend the public health emergency. So, AHCA is weighing in heavily with the administration and with members of Congress to ensure that that happens, and this is an issue that DNSs can help with as well.”

If the COVID-19 PHE continues in April, there will be additional opportunities to advocate for renewal in July and hopefully in October. However, even as COVID-19 is now surging again in some countries, the Centers for Medicare & Medicaid Services (CMS) is signaling that there could be plans to phase out the PHE soon—heightening the need for advocacy.

On March 24, the agency issued a Federal Register notice indicating that it wants to continue the current MDS 3.0 v1.17.2, which was implemented on Oct. 1, 2020, to Oct. 1, 2023 (i.e., fiscal year (FY) 2024). In May 2020, CMS used the COVID-19 Medicare, Medicaid, Basic Health Program, and Exchange interim final rule to delay implementation of MDS v1.18.1 (originally slated for Oct. 1, 2020) until after the end of the PHE because it will significantly expand data collection and reporting under the Skilled Nursing Facility Quality Reporting Program (SNF QRP).

In this rule, CMS stated that it would not enforce compliance with the new SNF QRP reporting requirements until “October 1st of the year that is at least two fiscal years after the PHE ends.” If MDS v1.17.2 will only run through FY 2024, and v1.18.1 will be implemented on Oct. 1, 2024, for FY 2025, that suggests that the federal government may seek to end the COVID-19 PHE by this Oct. 1 to meet the two-year mandate.

Issue 2: Boosting monies from the Provider Relief Fund

“The Provider Relief Fund has been very helpful in providing relief to the long-term care sector, but we are trying to get the fund replenished, particularly for nursing homes, assisted-living providers, and other long-term care providers that are now facing an economic crisis due to the pandemic,” says Smyth. “Rural providers have been particularly hard-hit, often filing for bankruptcy or closing entirely, so it could be especially beneficial for DNSs at rural facilities to advocate for this.”

Like the staffing crisis, the COVID-19 pandemic exacerbated an already ongoing crisis in rural healthcare. Between 2008 and 2018, nursing home closures spurred the growth of 44 new nursing home deserts (i.e., counties without a nursing home) in the United States, and 91 percent of the new deserts were in nonmetropolitan counties, according to the February 2021 policy brief Trends in Nursing Home Closures in Metropolitan and Nonmetropolitan Counties in the United States, 2008-2018 from the RUPRI Center for Rural Health Policy Analysis.

By summer 2020, closures related to COVID-19 began in Michigan, Rhode Island, and Illinois, according to AHCA reporting. Announced closures have continued to hamper long-term care throughout 2021 and early 2022 in multiple states, including New York, Nebraska, Minnesota, Wisconsin, and Missouri. While many closures are occurring in rural areas, no facility is immune–even a historic 126-year-old nursing home in Cleveland, OH, will close its skilled nursing facility this summer.

“Two senators—the Republican Sen. Susan Collins of Maine and the Democratic Sen. Jeanne Shaheen of New Hampshire—have introduced the Provider Relief Fund Improvement Act (S.3611),” notes Smyth. “This bipartisan bill includes a number of provisions that would be very helpful in distributing funds that may be remaining in the Provider Relief Fund, as well as extending the public health emergency. We are asking members of Congress to co-sponsor this legislation, and DNSs could help advocate specifically for that.”

Who to contact

The first step in advocacy is knowing who to contact, says Smyth. “It is crucial that you contact only your members of Congress. Both senators and representatives pay the most attention to their own constituents, so you need to weigh in with them.”

AHCA members can identify who to contact through the organization’s online system or any of the 50 state chapters, adds Smyth. However, all DNSs can find out who represents them at the federal level via Congress’s Find Your Members webpage. Note: Want to advocate at the state or local level as well? Find out who to contact at usa.gov/elected-officials.

Ways to get in touch

Member websites provide information on the various ways to make direct contact. These include the following:

  • Social media. “All members of Congress have Facebook, Twitter, and Instagram pages that you can use to correspond with them,” says Smyth. Generally, social media contact is considered to be the lowest level of advocacy due to the volume of messages most members receive, as well as the relative anonymity of anyone who may post (i.e., it’s hard for congressional staffers to know who is actually a constituent), meaning it is a good first step but often the least impactful.
  • E-mail or a snail-mail letter. A one-page letter can often provide more bang for the buck than a social media post. “Member websites have a Contact page that tells constituents how to weigh in,” says Smyth. These contact options typically include either an e-mail address or a way to submit comments on the site itself, as well as mailing addresses. While it’s important for DNSs and other nurse leaders to center their letters around their front-line experiences, there are resources available to help guide letter writing. For example, Berkeley Library at the University of California offers Contacting Elected Officials: Tips for Contacting Elected Officials and the ThoughtCo reference site has a similar article, Tips for Writing Effective Letters to Congress.
  • Telephone calls. Many activists suggest that phone calls are an effective way of contacting members of Congress because even calls that go to an automated voicemail system are transcribed, reviewed, and dealt with more immediately than messages submitted by other means. However, to talk to a human staffer (or to get in touch more quickly via snail mail), it may be easier to contact members through the local office instead of the Washington, DC, office.

    While the merits of phone calls compared to letters or e-mails can be debated, all of these contact methods work. “Every member of Congress has a staff person whose sole responsibility is to reply to constituent e-mails, letters, and phone calls,” says Smyth. “So, any correspondence that you provide will be heard.”
  • Nurse visits to the member’s local office. “If your member has an office in their district that is not too far away, you could even stop by,” says Smyth. “A number of offices are now open, and the members and their staff are very receptive to hearing from constituents face to face. DNSs are incredibly busy, but this is a terrific way to advocate.”
  • Member visits to the facility. “AHCA provides a lot of invitations to encourage members of Congress to tour long-term care facilities,” says Smyth. “That may be something that DNSs want to do—reach out and invite the member to come and see first-hand what battles you are fighting to provide quality care to your residents.” Note: AHCA offers A “How To” Guide to Facility Tours for Elected Officials, which covers everything from how to issue the invitation to how to follow up after the tour.
  • Association meetings. Professional associations can also offer opportunities for contacts with members of Congress. AHCA holds a fly-in meeting every June in Washington, D.C., to bring together providers and members, notes Smyth. “That is a great opportunity to share stories one on one that DNSs may want to participate in.”

DNSs who still have questions about how to advocate can contact Smyth at [email protected]. “I would be glad to help direct anyone and help provide support in any way possible so that you can reach out to your senator and House member,” he says.

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