Dr. El

COVID-19 has negatively affected the ability of many long-term care facilities to maintain a full census. Less frequent elective surgeries, fewer rehab cases and more empty beds make it harder to be selective about which patients are admitted, impacting not just the financial case mix, but also the clinical mix. 

A low census leads to the challenge of balancing the urgency of filling the beds with the risks of admitting residents that the team is clinically unable to manage. 

During low-census periods over the years, I’ve observed nursing homes more routinely admit residents with increased medical acuity, illnesses unfamiliar to most staff members (for example, multiple sclerosis or HIV), and individuals with mental health and substance abuse problems. Residents admitted during low-census times are often younger than the typical nursing home resident.

Without forethought and planning to provide sufficient care for these new residents, organizations may increase their exposure to liability and regulatory risks.1 

Impact on staff

An important consideration in making admissions decisions is whether the team will be able to manage care complexities. Under normal circumstances, workers can adapt relatively easily, especially with additional training regarding new medical needs and procedures. The pandemic, though, has already necessitated that workers make significant changes in how they function.

In a short span of time, teams have had to adapt to the need to work in a very high-risk setting, constantly wear PPE, isolate residents, restrict nonessential visitors, get regular COVID-19 testing and manage with reduced staff due to positive test results and increased worker shortages. Workers in facilities with COVID-19 losses are grieving not only the demise of their former nursing home culture, but also the deaths of residents and perhaps even coworkers.

Facilities should take into account that their teams are likely to have reduced emotional reserves to manage changes in the resident mix without more support and training than usual. They also may need assistance in coping with the psychological aftermath of the coronavirus.

Adaptive strategies 

Before inundating workers with new information, staff training could begin with sessions acknowledging their losses and teaching them to recognize symptoms of stress in themselves and their coworkers, with discussion of coping techniques and resources for help. 

Admissions of residents with illnesses unfamiliar to many team members could be accompanied by information sheets and team huddles so that employees have the guidance they need to perform their functions well. This is not the time to rely on staff initiative to learn on the job; workers are tapped out. 

Leaders might also consider, rather than admitting many residents with disparate diagnoses, creating a specialty unit such as “people with MS” or “younger residents.” This reduces the new learning that staff have to absorb, gives the residents a cohort group, and better allows the team to attend to their needs. 

Younger residents, especially those with mental health and substance abuse histories, are likely to be more demanding in different ways than staff are used to. Employees may require training on mental health issues and in working as a team to address them. There may be a need for increased presence of mental health workers (psychologists, psychiatrists and social workers), with consultation regarding questionable admissions. (“Can we handle this person who requires short-term rehab but just had a manic episode?”) 

Adjusting recreational activities to increase the engagement of younger residents will be key in preventing the types of difficulties that arise when relatively energetic residents with mental health and substance abuse diagnoses have too much free time on their hands. Since the goal is problem prevention, investing time, energy and support in this area will result in what appears to be nothing because the problems were prevented. You’ll have to trust me that if you don’t invest here, there will be problems.  

For more info on working with younger residents, see “Young adults in long-term care.”

Long-term care leadership is facing a raft of challenges brought about by the pandemic, including supporting teams through shifts in resident population. With preparation and attention to the impact of these changes, bringing in atypical residents can be a reasonable way to accommodate an alteration in the usual flow of admissions.

Eleanor Feldman Barbera, Ph.D., author of The Savvy Resident’s Guide, is an Award of Excellence winner in the Blog Content category of the APEX Awards for Publication Excellence program. She also is a Bronze Medalist for Best Blog in the American Society of Business Publication Editors national competition andGold Medalist in the Blog-How To/Tips/Service category in their Midwest Regional competition. To contact her for speaking engagements and/or content writing, visit her at EleanorFeldmanBarbera.com.