Last week, I suggested that in the wake of the coronavirus pandemic, nursing homes may need to take patients from over-burdened hospitals. At the same time, care settings such as assisted living facilities (ALFs) might have to accept nursing home residents who must be relocated to make room for those post-acute patients. Now, it looks like that is beginning to happen.
Massachusetts has designated 12 nursing facilities to take COVID-19 patients, and the state is beginning to move nursing home residents, starting with 147 in a Worchester facility. And the American Health Care Association, a trade group representing much of the nursing home industry, agrees with these changes, as long as they are managed carefully.
New York is doing this in a very different way. In an effort to free-up desperately-needed hospital beds, it has ordered all nursing facilities to accept hospital discharges, even those who have tested positive for COVID-19.
The crucial difference
The crucial difference: Massachusetts is organizing a system where only designated facilities take coronavirus patients discharged from hospitals. New York wants all nursing facilities to take these patients. The issue: How to make this work while still protecting extremely vulnerable residents and patients at nursing facilities who do not have coronavirus. These transfers should not happen if they put current residents at risk.
The idea of using certain nursing facilities to offload some of the hospital burden was not mine alone. David Grabowksi, a professor of health policy at the Harvard University Medical School, made an even more detailed proposal in a March 25 column in JAMA (paywall). And Anne Tumlinson of the consulting firm ATI Advisory has made similar suggestions.
Equipment and skilled staff
The first priority should be to identify those facilities that already have ventilators, the staff skilled at managing them, and strong infection controls. It is essential to protect current residents, who are at extremely high risk form COVID-19. Remember, a typical nursing home may include both a skilled nursing facility (SNFs) that provides post-acute services such as rehabilitation and a unit for long-stay residents with severe functional of cognitive limitations.
In some cases, these units may be separate enough. But using SNFs to care for COVID-19 patients may require the facilities to move long-stay residents, many of whom have dementia or functional limitations, to other facilities. Some may go to other nursing homes, others to assisted living, and some back home.
Freeing up beds
What about post-acute patients, who may be in skilled nursing facilities (SNFs) for a few days to a few weeks. They must also be moved out before COVID-19 patients are allowed in. For them, those SNFs not designed for COVID-19 may be a good alternative.
Because so many hospitals have stopped doing elective surgeries, especially knee and hip replacements, the demand for that common SNF rehab has fallen off sharply. That may free-up more beds for non-COVID hospital discharges.
As I noted when I first raised the idea, even in the best of circumstances these moves will be incredibly disruptive to residents, their families, staffs, and the facilities themselves. But in a pandemic where hospital beds may be insufficient to handle the need, designated skilled nursing facilities are a smart alternative.
Issues to be resolved
But a number of complicated issues still have to be resolved.
How should the system handle someone who is suspected of having coronavirus but has not tested positive? Where should they stay? There is no room in hospitals. And nursing homes without intensive infection control are inappropriate. Until we have enough test kits and technology to read those tests within hours rather than days, this will remain a critical problem.
Then, there is staff. If aides, nurses, and techs are going to be required to treat sicker patients with more complex conditions, they need to be trained. And if they are going to be asked to care for COVID-19 patients, they absolutely must have essential personal protective equipment, such as masks, gowns, and gloves. Without the training and the equipment, this idea is a non-starter.
Finally, there is the matter of payment. Many long-stay nursing home residents are in those facilities only because it is where Medicaid will pay for their care. The current crisis is an ideal opportunity to change that. States should expand their home and community based programs for frail older adults and younger people with disabilities. They should pay enough for settings other than nursing homes so these vulnerable people can get the care they need in the safest and most appropriate place possible.
The system can make this shift work, but only if hospitals, nursing homes, assisted living facilities, home care agencies, states, and the federal government work together. And they don’t have much time.
You need to dig a bit deeper, still. Nursing homes and rehab facilities can be a graveyard even without the coronavirus patients. Neglect bordering on abuse is not unknown. In my family’s only contact with such a facility, my mother-in-law developed a bed sore about 2″ long that went so deep it involved her spine. She couldn’t speak because of a stroke, she couldn’t solid foods. The “staff” paid little or no attention to her approved diet and the only way we found out about the bed sore was when my wife saw it one day. Needless to say, we sued. They settled because our lawyer recommended it. I think he just didn’t want to spend the time. The staff was overheard by my sister-in-law talking about that “old white bitch,” not clear whether it was to my sister-in-law or mother-in-law. The sweet old lady died of chronic bladder infection, malnutrition, and abuse. The “director” of the facility was “shocked.” First time it ever happened. Yeah. Right.