The coronavirus pandemic is stressing hospital capacity to its limits, and one way to reduce this pressure it to move patient care downstream. That means keeping as many patients as possible out of the hospital in the first place, and getting those who have been hospitalized discharged as quickly as possible to make room for other, more critical patients. The problem: many of those alternative care settings face enormous challenges of their own.
The nation has potential resources. It could turn to 17,000 skilled nursing facilities (SNFs), Long-term Acute Care Hospitals (LTACHs) and Inpatient Rehabilitation Facilities (IRFs). Or, those who don’t need complex care could go home, where more than 11,000 home health agencies have staff to care for them.
The severity of the situation can’t be overstated. If we cannot reduce the burden on hospitals, the result will be unthinkable: Some patients will die simply because hospitals do not have the space or resources to care for them.
The right settings
The goal is to find a way to get all patients—not just those with COVID-19– in the right settings. That means reserving acute care hospitals for the very sickest, moving post- acute patients to SNFs and LTCAHs, moving long-stay residents from nursing homes to assisted living, and moving assisted living patients to home, wherever possible.
Make no mistake, this will be incredibly disruptive to patients, their families, and the health delivery system. But we are already upending senior care in the US, and it may be necessary to free up needed capacity to handle an historic health crisis. The challenge: These other care settings may not be prepared.
To better understand the options, divide people into three groups—those who have COVID-19—the disease caused by coronavirus, those who might have it, and everyone else.
Those with the disease may need high-intensity support, including ventilator care. Anne Tumlinson of the consulting firm ATI Advisory, found that in addition to acute care hospitals, about 380 LTACHs and 170 SNFs have the equipment and staffing to provide that level of care.
But there are problems: Anne finds that the locations of many are mismatched with need. For instance, there are dozens of LTACHs in Louisiana, East Texas, Michigan, and western Pennsylvania. But in the San Francisco Bay area, hard hit by COVID-19, there are two. In Seattle, there is one. In much of rural America, there are none. Nor are there intensive care units. And it is not realistic to expect that critically ill patients on ventilators can be moved long distances.
SNFs have other issues. Not only are fewer of them capable of handling these patients, but many SNFs struggle with infection control in the best of times. Adding to the challenges, many SNFs share buildings with long-stay nursing homes, whose frail elderly residents are most vulnerable to death from COVID-19. Those facilities already are banning all outside visitors. Imagine their concerns about bringing a critically ill COVID-19 patient into their facility.
And what about patients who test positive but do not need complex medical care: where do they go?
For most, home is the best choice. But what about people who cannot care for themselves, have no caregivers, or need some level of personal care that family cannot provide?
One radical idea: Temporarily move non-COVID residents of SNFs to assisted living facilities (ALFs) to free up SNF beds for post-acute care. Boost staffing and increase payment levels for SNFs but toughen quality and safety standards.
And because so many nursing home residents are on Medicaid, temporarily expand the ability of Medicaid to pay for their long-term care if they are moved to an ALF.
Then, there are those patients who think they may have COVID-19, or more worrisome, may not yet have confirmed cases but are likely carriers.
SNFs and COVID-19
Finding a place for them also is tough. Overburdened hospitals want to discharge these patients quickly—for their own safety and to make room for those who need critical care. Medicare’s recent decision to temporarily pay for SNF care even when patients have been hospitalized for less than three days will help.
The problem: Many SNFs do not want to take patients at risk of carrying coronavirus. Many are refusing to take hospital discharges until those patients have tested negative—twice—for coronavirus. This can hold up transfers for days. So can slow prior authorizations by health plans for SNF post-acute care.
And the transfer problems go the other way as well. Many SNFs and ALFs are too quick to send residents to the emergency department for minor medical issues. In the current environment, that practice needs to stop.
Finally, these facilities are confronting the same shortages of staff and equipment as hospitals—perhaps even worse. They too are struggling with limited personal protective equipment and the like.
What about staff?
The staffing challenges are compounded by the spread of coronavirus. What does a SNF do if one patient tests positive? Which staffers does it send home? What do facilities do about personal care aides who are reluctant to report their own illnesses because they don’t have paid medical leave? How do they identify aides who may have had an exposure at a second job?
Home health agencies have the same problems, made more complicated because aides may see multiple clients during the course of a day. If an aide has a patient who thinks she may have COVID-19, is the aide required to take two weeks off? And who will take her place?
COVID-19 is stretching of health system to its breaking point. SNFs, ALFs, and home care providers have a key role to play to reduce some of that pressure. But they first need to address key issues of their own.