The Future of Long-Term Care

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A nursing home administrator walks with a patient outside.

Of all sectors of America’s health care system, few have been affected more by the COVID-19 pandemic than long-term care. Nationwide, 5% of cases and 36% of deaths have occurred among residents of nursing homes, according to a database by the New York Times.

These numbers are a consequence of several long-standing trends in long-term care facilities, which have been exacerbated by the coronavirus crisis, according to Jake Quigley, an adjunct professor at Regis College, licensed nursing home administrator, and former executive director of several Boston-area senior communities. “It became not a matter of if but when COVID was to be in a community,” he says.

The industry is changing rapidly in response to the crisis, says Quigley. He notes that the future of long-term care is likely to look very different from its past: from the layout of living quarters, to how care is paid for, to staffing practices.

More than ever, facilities will need skilled administrators to navigate those changes, Quigley says. “For long-term care administrators, the demand is high and the supply is low.”

Pre-COVID-19 Trends in Long-Term Care

From a demographic standpoint, the need for long-term care has never been greater. And it’s only expected to grow with the aging of the Baby Boom generation. Consider these figures.

  • The number of Americans over 65 ballooned by a third from 2010 to 2020, according to the U.S. Census Bureau.
  • Over the next 30 years, the over-65 population is expected to keep expanding, from 56 million to 86 million.
  • Seniors over 85, the likeliest to require long-term care, will more than double in number, to 19 million.

Today, 15,655 skilled nursing facilities serve three million individuals for long-term stays of over 100 days, reports the trade group the American Health Care Association.

Despite high demand for its services, the industry faces substantial challenges, and did so even before the COVID-19 pandemic. The biggest challenge is underfunding, due to reliance on Medicaid patients who account for 57% of industry revenue.

Nationally, Medicaid reimbursement for a long-term care patient averages $206 a day, according to a survey by the National Investment Center. “Long-term care is often reimbursed at a fraction of what it costs to care for a senior in this setting,” explains Quigley.

Facilities try to compensate for their Medicaid losses by taking in more highly-reimbursed patients from Medicare, insurance, and private payors. Medicare pays an average of $503 per day. Still, for many nursing homes, budget constraints limit their ability to invest in staffing and capital improvements.

“If a long-term care facility is cited for needing an extensive repair, such as an elevator shaft, the discussion is not if they should fix it, but, ‘Can they afford to repair it?’” says Quigley.

COVID-19’s Impacts on Long-Term Care

The first U.S. outbreak of the novel coronavirus was at a nursing home in Kirkland, Washington. By January, 2021, 543,087 long-term care residents had contracted the illness nationwide, and 105,118 had died, according to the Centers for Disease Control and Prevention (CDC).

Besides funding shortfalls, several other factors made nursing homes and assisted living facilities especially vulnerable to COVID-19, Quigley says. But many found ways to overcome those problems by adopting new protocols to better protect residents and staff. Some best practices included the following.


Nursing homes typically house two residents to a room, separated only by a curtain. This made it easier for a single coronavirus case to spread and cause an outbreak. Because occupancy has declined during the pandemic, some facilities have been able to use empty rooms to quarantine residents who exhibit symptoms or test positive for the virus.

Dedicated Staffing

In the early days of pandemic, tests were in short supply, making it hard to know who to quarantine and which contacts to trace. One solution was to dedicate specific staffers to specific pools of residents, limiting contacts to small groups of people.

“This is beneficial to tracing after the fact,” explains Quigley, adding “it reduces the number of residents exposed if a staff member tests positive.”

Better Benefits

Workers were a common factor in introducing the virus to an institution. Many were at increased risk of contracting the disease because they had family at home or earned extra income by holding second jobs at other long-term care facilities. Inadequate sick leave created pressure on staff to come to work, despite health concerns.

“You’re starting to feel ill, but you can’t afford to be out of work for long periods of time,” Quigley says. “And so we saw folks coming to work as just a bare necessity to earn a paycheck.”

Providers — particularly those in assisted and independent living — had deeper pockets. As a consequence, they were able to reduce the risks faced by their staffers by providing the following benefits.

  • Expanding sick leave, so that workers could afford to stay home if they had symptoms
  • Offering bonuses, to relieve the need to work multiple jobs
  • Providing transportation and meals, to minimize exposure from public transit and eating out

Long-Term Care’s Future

Long-term care was among the first industries to suffer as a result of the pandemic, but it could also be among the first to recover. When COVID-19 vaccines became available, nursing home residents and staffers were in the first group eligible to receive them.

As the industry gradually returns to a sense of normalcy, it might look significantly different from pre-pandemic times. Beyond the new practices developed during the pandemic, Quigley foresees other long-term shifts.

Integration with Accountable Care Organizations

Medicare offers financial rewards to accountable care organizations (ACOs), a form of managed care network, to provide better outcomes at lower costs. By including nursing homes in their networks, ACOs can save money compared to extended hospital stays. They can also improve the financial stability of nursing homes by paying higher reimbursement rates than Medicaid offers.

A 2019 study for the American Public Health Association found that one-quarter of nursing home residents came from ACOs, and that homes with ACO patients were more likely to have five-star ratings from Medicare.

Home-Like Facilities

In the traditional T-wing layout, a long-term care institution resembles a hospital. A nurse’s station is placed at the center of two long wings, with patient rooms lining the hallways.

Newer models are different, such as congregate housing. It replaces the often institutional feel of a nursing home with the more intimate setup of a group home. Meadowlark Hills, a pioneering facility in Manhattan, Kansas, has six households of 12 to 24 residents. Each unit has its own front door and doorbell, with shared living and dining rooms and dedicated staff.

“Creating that smaller kind of home feel is often going to result in better care and a better experience,” says Quigley.

Pandemic Prevention

Future long-term care facilities should be better prepared for future pandemics, Quigley expects.

  • They’ll leave more open beds and offer more private rooms to isolate sick residents
  • Personal protective equipment will be kept on hand
  • More facilities will have full-time infection preventionists
  • Some may require COVID-19 vaccination as a condition of employment

Strengthening Staffing

Many long-term care facilities offered retention bonuses to staff during the pandemic. Quigley hopes they’ll continue to pay higher wages and offer more generous benefits, such as extended sick leave, to reduce turnover.

More broadly, he’d like to see public policymakers classify long-term care staff as essential workers. Like some public school teachers, they might be offered tax incentives and student loan forgiveness for staying in the field.

Opportunities for Administrators

The profound changes ahead for long-term care are driving demand for administrators, Quigley says. The U.S. Bureau of Labor Statistics (BLS) projects that jobs for medical and health services managers will grow by 32% over the next ten years, compared to 3% for management jobs in general.

Many of those administrators are health professionals who have clinical experience. A Master of Health Administration (MHA) degree can accelerate entry to administration by developing a wide range of non-clinical abilities. Says Quigley, “An administrator needs skills in financial planning and analysis, marketing and sales, public policy knowledge and execution, human resources, clinical practices, managing multiple departments, and managing a multidisciplinary team.”

He notes that an MHA degree can also decrease the number of training hours needed for state licensing as a nursing home administrator. In Massachusetts, for example, a master’s degree reduces the internship requirement by half: from 1,040 hours to 520.

Be Part of the Future of Long-Term Care

With the elder population continuing to grow, there’s never been a greater need for high-quality long-term care facilities and the well-trained administrators to run them. A program such as the online Master in Health Administration at Regis College can prepare health care professionals to meet the multifaceted and far-reaching challenges of this industry. It can also be a first step toward a career in other areas of health care administration, such as hospitals.

Explore how an MHA degree can prepare you for a career protecting senior Americans from future pandemics, and helping them lead healthier, more fulfilling lives.

Recommended Readings

Effective Health Leadership During Covid-19 and Beyond: An interview with Mary Ann Hart, MHA Program Director

How to Become a Hospital Administrator

What Is Health Administration?


American Health Care Association, “Data and Research”

New York Times, “More Than One-Third of U.S. Coronavirus Deaths Are Linked to Nursing Homes”

U.S. Census Bureau, “Projected Age Groups and Sex Composition of the Population”

McKnight’s Long-Term Care News, “Nursing home the site of first US coronavirus outbreak”

Meadowlark, “Healthcare Households”

Medical Care, “Inclusion of Nursing Homes and Long-term Residents in Medicare ACOs”

National Investment Center, “Medicaid Reimbursement Rates Draw Attention”

Provider Management, “NHA Licensure Requirements by State”

Skilled Nursing News, “How Nursing Homes Can Bolster Infection Control”

U.S. Bureau of Labor Statistics, “Medical and Health Services Managers: Job Outlook”