Nursing homes today will mark the end of a devastating era in healthcare that nonetheless provided the sector with previously unimagined operating flexibilities.

Now that the COVID-19 public health emergency is over, providers will become acutely aware of how well waivers worked to funnel more patients to them and help retain new staff with less prescriptive training requirements. For some, the PHE’s end will also mean the end of much-needed supplemental pay.

“The Public Health Emergency waivers have been a critical lifeline, as nursing homes have struggled to keep their doors open and fight against an unprecedented, once-in-a-century crisis,” Mark Parkinson, president and CEO of the American Health Care Association said earlier this week. “As we move forward, we will carry on advocating to eliminate Medicare’s three-day-stay requirement and creating a realistic career pathway for temporary nurse aides.”

Those may be the most impactful changes for nursing homes. But May 11 also ends several pieces of guidance and regulatory flexibilities that had been extended or tweaked since COVID first spread across the US in early 2020.

Some of the other post-PHE changes include the Centers for Medicare & Medicaid Services allowing facilities to conduct testing of staff and newly admitted residents at their own discretion; requiring the resumption of emergency preparedness drills; and the yet-to-be-finalized wind-down of a federal vaccine mandate for healthcare workers. Many reporting, vaccine education and infection control and prevention requirements are still in effect, however.

While many in the skilled nursing sector acknowledge that they are much better prepared today to identify, prevent and treat COVID-19, most also have still been relying on additional government flexibilities and support to run their businesses amid heightened staffing and inflationary pressures.

Nursing homes have lost more than 210,000 workers since February 2020, with fewer than 10,000 returning monthly. Other healthcare settings, including assisted living, have rebounded above their pre-pandemic staffing levels.

“Recovery has been slow, especially in rebuilding our workforce,” Parkinson noted, adding that AHCA is putting workforce legislation high on its nation priority list. “Nursing homes cannot solve this crisis on their own, and we will continue to urge policymakers to pass supportive policies that prepare for a growing elderly population.” 

Aide requirements resume

Under the PHE, federal regulators initially offered a blanket waiver of long-standing federal requirements that all nurse aides receive a minimum of 75 hours of required training and pass a state-level competency test before working directly with patients.

CMS revoked some COVID-era rules last year but extended the sector a lifeline by issuing new temporary nurse aide waivers on a state, county or facility basis. About 20 states had received such waivers, with several citing testing backlogs; with the lifting of the PHE, remaining temporary aides in any of those states now have four months to get certified.

AHCA estimates that thousands of needed workers could lose their jobs. Parkinson is encouraging Congress to pass the Building America’s Health Care Workforce Act, which would instead give temporary nurse aides 24 months to earn their certification.

In Pennsylvania, where providers had grappled with extensive testing backlogs due to a lack of proctors and testing sites, “the situation certainly has been improved,” Pennsylvania Health Care Association President and CEO Zach Shamberg told McKnight’s Wednesday.

Over the course of the pandemic, PHCA said the waiver allowed some 4,500 new certified nurse aides an alternative, on-the-job training option for which they were paid. That was based on each skilled facility converting an average of eight temporary aides to full-time employees, with about 17% of facilities not using TNAs at all. 

Now, many providers are back to the difficulties they had before the pandemic: how to recruit would-be CNAs and get them into a state-approved training program and tested quickly.

Shamberg said state advocates are backing legislation to permit entry-level personal care assistants and med techs in Pennsylvania as ways to entice more workers.

“We took a program that we built at the beginning of the pandemic and made it into something successful,” he said. “There’s got to be a substitute for that now.”

Required 3-day stay resumes

One of the most widely embraced changes of the pandemic was a waiver that allowed skilled nursing providers to be paid for providing care to patients who had not had a preceding three-day inpatient hospital stay.

The goal in lifting the waiver was to create flexibility for patients and space in hospitals that found themselves overloaded with COVID cases. But it proved a lifeline for nursing homes, especially in the pandemic’s early days, when referrals from elective surgical procedures fell to zero in many places, as well as later.

LeadingAge asked the Department of Health and Human Services to make the 3-day stay waiver permanent while it worked with Congress to eliminate the requirement entirely.

Individual providers also have repeatedly appealed for the rule’s elimination, but that’s not likely to happen, given past cost estimates, one CMS leader told attendees at a national skilled nursing conference last month. 

Still, some hospitals also have expressed concerns about patient backups without the ability to hasten transfers to nursing homes.

Medicare beneficiaries in many Medicare Advantage and accountable care organizations no longer need a 3-day stay to access post-acute care, and AHCA said it will continue to advocate for a permanent change for all Part A patients.

“Seniors who receive care in the hospital, regardless of their inpatient or observation designation, must be able to access post-acute care in a skilled nursing facility when they need it without fear of considerable out-of-pocket costs,” Parkinson said. “Eliminating this policy best meets the beneficiary’s access to care needs, reduces out-of-pocket costs, and is fiscally prudent for the Medicare Trust fund.”

Financial support dwindles

The end of the PHE has already triggered one major payment concern: reenrollment of Medicaid patients. The federal government allowed patients to stay on its rolls without requalifying during the pandemic, but states are now pushing to drop beneficiaries whose circumstances have changed.

Several estimates have found that thousands, including some long-stay nursing home residents, could lose coverage. In Arkansas, which plans to complete its redeterminations in six months, state officials terminated coverage for nearly 73,000 people in April alone.

Even in more liberal states, there are serious Medicaid concerns. Two providers in New Jersey recently told McKnight’s they had faced past problems ensuring timely form submissions to their state Medicaid office; they expect more delays and unintentional terminations as the state Medicaid program faces major staffing shortages of its own.

Providers whose patients are cut from Medicaid could turn to billing family members, but such relatives aren’t necessarily under any obligation to pay for their relatives’ care.

And then there are the states that have tied additional Medicaid funding to the PHE itself. In Texas, for instance, the state’s pick up of a $19 a day COVID bump is scheduled to end later this month.

The state did not increase rates during COVID and anything passed this legislative session won’t go into effect until September.

“If we lose PHE funding in May and are not made whole until September, that’s three-and-a half months when we are asked to balance caring for our most vulnerable seniors, paying our dedicated staff — and in the midst of the nation’s worst nursing shortage — recruiting and retaining qualified nurses,” said Samantha Milstead, executive director of operations for Focused Care at Midland, a skilled nursing community located in rural West Texas.

“If the federal government has decided the emergency is over, and our state legislators have recognized long-term care delivered well, with the goal of improving health outcomes and quality of life requires increased funding,  then they must acknowledge we need a safety net to keep us from plummeting into the gap,” Milstead told McKnight’s. “Abandoning long-term care providers is abandoning the residents we care for.”