If ever there was a year that seemed difficult to predict, it would be 2021. COVID-19 packed such a wallop last year — throwing long-term care operations beyond the pale of what was considered possible — that foretelling the events of the coming year seems fuzzy at best.
And yet there are certain givens. For one, the pandemic is still with nursing homes, and fighting it will continue to be a top priority for providers. And, fortunately for the field, it will be doing battle with a new piece of artillery — the vaccine.
Other known quantities are the critical need for funding to recover from the enormous financial toll the pandemic has taken on the field.
Clinical, financial disaster
It is this new set of realities at the outset — the presence of the vaccine and the need for funding — that providers will be working off of in the first 90 days, said Mark Parkinson, president and CEO of the American Health Care Association.
“Because COVID is so rampant even now and the crisis isn’t behind us yet, the first three months of the year will be spent primarily advocating for efforts to end the crisis and allow businesses — providers — to survive through the crisis,” Parkinson told McKnight’s Long-Term Care News in late December.
This entails, he explained, pushing out the vaccines to employees and residents as quickly as possible and working with Congress to continue to provide financial support to providers so they can stay in business.
“This hasn’t just been a clinical disaster in nursing facilities and long-term care, it’s been a financial disaster,” Parkinson said. “The funding that has been provided so far has been helpful, but it’ll have to continue into 2021.”
Other long-term care leaders who spoke with McKnight’s in late December also talked about the importance of securing adequate government funding in 2021. Katie Smith Sloan, president and CEO of LeadingAge, noted that there will be a need for a federal discussion on Medicaid and what it covers. She also said there may be “bruisingly difficult discussions at the state level” regarding how states plan to spend Medicaid dollars.
Pandemic offshoots
States will have their own pandemic-related struggles in 2021. Several longstanding issues that the health crisis has helped to heighten may be part of their agendas this year. For example, a package in the California Legislature is exploring a wage pass-through, staffing ratios and medical director certification, said Eric Dowdy, chief government affairs officer at LeadingAge California. Improving wages overall for frontline workers is a key discussion point, he pointed out.
“It’s COVID, COVID, COVID,” Dowdy said, noting that a goal this year is “to highlight the difficulties nursing homes are experiencing. How do you bring people into this environment?”
Similar themes will be at play on the other coast. For example, legislation in New Jersey stemming from the Manatt Health report, which was commissioned in 2020 to help long-term care be better prepared for pandemics, is still circulating through the Legislature, said Jim McCracken, president and CEO of LeadingAge New Jersey and Delaware.
Many of those bills have cost implications for long-term care providers regarding infection control specialists, staffing levels or personal protective equipment.
“[In 2021] we’ll be focusing on the budget and making sure reimbursement is consistent with increased cost as a result of legislation, or just general costs to providers they had to incur related to the pandemic,” he said.
Move to keep reforms
This year also may be focused, ironically, on holding onto strides made during the pandemic. Thanks to the several waivers that stemmed from the Public Health Emergency decree, the pandemic opened up the door for many long-sought-after changes that the field is not eager to relinquish. Among them: the suspension of the three-day hospital stay rule and the dramatic expansion of telehealth.
“There’s a fair amount of flexibility to providers during COVID,” Sloan said, noting the benefits of telehealth. “Some of it is beneficial in the long run. We need to look at flexibilities we want to stay in place … and what is the mechanism for them to stay in place. Some will require congressional action; some will not.”
As these flexibilities go away when the PHE ends, part of the work of 2021 will be to drive home the importance of continuing the PHE declaration, which has been extended to April, explained Cynthia Morton, executive director of the National Association for the Support of Long Term Care. Moving forward, organizations like NASL will move to make these changes permanent.
“The Public Health Emergency shined a bright light on policy that needs to change,” said Morton.
Based on the success of telehealth during the pandemic, this reform may be the easiest among the waivers to keep.
“The gains we’ve made with telehealth could not have been made with a big demonstration,” Morton noted. “It clearly has shown that beneficiaries are very open to using telehealth to communicate with their providers.”
Transformation time?
Because the pandemic may serve as a springboard for meaningful change for the field, 2021 could have the makings of being transformative in many respects. As long-term care regains its footing, there may be opportunities to engage in serious dialogue regarding where the field is heading.
AHCA is already gearing up for this moment, Parkinson noted. Once the country begins to movepast the vaccine, he believes that Congress will shift its attention toward taking necessary steps to help prevent pandemics and the resulting acute damage they can wreak on long-term care.
“I think there will be a deep look by many of the committees and a lot of independent groups to analyze what happened in long-term care,” he said. “And so, we’ll really at that point be shifting our focus to working with various groups to try to learn lessons from this pandemic and minimize the chance of it happening in the future.”
As of late December, AHCA’s board of governors was looking at a whole variety of proposals the organization is considering making “as we head into this introspective phase about what should happen to long-term care,” Parkinson said.
AHCA hopes “to have some bold proposals as we head into the spring of 2021,” he added.
Such proposals have to fit three criteria, he explained. One, they have to make a real difference in care for residents; two, they have to be capable of being implemented; and three, proposals can’t make the margin situation in long-term care any worse.
Some proposals AHCA is considering are expanded use of infection preventionists; finding ways to improve Medicaid rates so salaries of frontline employees can increase; and developing a survey process that would create more accountability for providers and regulators to improve patient care.
The PR issue
Perhaps a thornier task for 2021 and beyond will be repairing long-term care’s image in the minds of consumers and workers.
“It would be naïve to think that 100,000 people could die in long-term care facilities and that we wouldn’t have a problem with our image, that we wouldn’t have a problem with thinking that people would be comfortable putting their parents or grandparents into our buildings,” Parkinson said.
Rebuilding that image will require proving to the public that long-term care is safe for people’s parents and grandparents. Telling long-term care’s side of the pandemic story is a big part of the task.
“This pandemic was not the fault of long-term care, and the rapid spread of the virus in long-term care facilities also wasn’t the fault of long-term care or the buildings,” he said. “It has to do with the asymptomatic spread of an incredibly contagious virus. I think as the public becomes more educated on what exactly happened in these buildings and why it happened and as the buildings become safer because of the vaccines, I believe that we will slowly and steadily build back the public trust.”
It won’t happen overnight, he acknowledged.
“It will take some time, but it will come back,” Parkinson said. “At the end of 2021, census will not be as high as it was going into 2020. But in a couple of years, census will recover. It will be slow and it will be steady, and the public will come back.”
From the January/February 2021 Issue of McKnight's Long-Term Care News
