The deadly coronavirus pandemic has brought into startlingly clear detail how vulnerable our nation’s healthcare system can be. As hospitals continue to be taxed with COVID-19 patients, the disease has done more than upset the acute-care side of things. It has disrupted the entire post-acute care framework.

Across the country, states, municipalities and healthcare systems have been grappling with where, when and how to treat COVID-19-positive patients during and after their recovery without putting others in harm’s way. Among the questions they are asking themselves: Where do you send a positive patient from the hospital after treatment? Can nursing homes sufficiently and safely handle them? What steps do nursing homes need to take to make sure they are not putting long-stay residents at risk?

Two approaches 

In the early days of the outbreak, two heavily hit Northeastern states offered contrasting approaches. New York, desperate for acute-care beds, mandated that its nursing homes accept patients regardless of their COVID-19 status. Meanwhile, nearby Massachusetts designated 12 facilities COVID-19 facilities. The first to answer this call was Beaumont Rehabilitation and Skilled Nursing Center in Worcester.

While providers were quick to acknowledge the difficult situation New York was in, the state’s mandate received swift rebuke. The American Health Care Association and AMDA: The Society for Post-Acute and Long-Term Care Medicine issued a statement against the move. “The question all state officials must consider is whether the risk of introducing a virus with an estimated 30% or higher mortality rate into a nursing home or assisted living community outweighs the risk of hospitals being overcrowded,” they said. “Regrettably, this is a difficult decision that many officials will be facing now or in the near future. However, it is not a binary decision. Alternative settings for patients recovering from COVID-19 must be considered and implemented now, including large field hospitals, dormitories, hotels, and shuttered nursing homes or hospitals.”

The Massachusetts action, by contrast, earned praise because it represented a coordinated state effort. However, it, too, drew mixed reviews because of the risks involved in transferring residents out of the Worcester facility. 

“I don’t think that should be the norm,” said David Grabowski, Ph.D., Department of Health Care Policy, Harvard Medical School. “If it was all they could do on short notice, that’s understandable, but I wouldn’t want that to be our steady state going forward.”

Collaborative response

The burden placed on nursing homes along with the range of post-acute care responses around the country have confounded and frustrated medical and public policy experts like Grabowski. These authorities believe that with a little bit of discussion and coordination among the various players — government, hospitals, and nursing homes and other post-acute providers — states can develop game plans that are sounder and safer for everyone.

In their March 29 statement, AMDA and the American Health Care Association first recognized the need for coordination. They urged states to follow the lead of states such as Louisiana, Florida, Iowa and Michigan, which, like Massachusetts, embarked on a more strategic and collaborative approach. 

“Ideally, what should happen is the hospitals, the long-term acute- care facilities, the skilled nursing facilities, the assisted living people should sit down together and say, ‘What’s our capacity here?’” commented Howard Gleckman, senior fellow at The Urban Institute. “How many ventilators do we have in the hospitals today? What is the maximum ventilator capacity in our acute-care hospitals right now? What is the worst case … for what you’re going to need? Then you say to the other facilities: How much of this overload can you handle? SNFs, how many can you take? You’ve got a group of people talking about this.”

To help push states forward, Gleckman, Grabowski and other policy experts in April penned a white paper, “Post-Acute Preparedness in a COVID-19 World,” which offers strategic recommendations for treating COVID-19 patients in and after the crisis. These include: identifying skilled nursing facilities that can accept non-COVID-19 patients from the hospital and ensuring that specialized SNFs have the management, clinical team and staff to care safely for COVID-19-positive patients during the surge. For stage 3, as the country emerges from the surge, it suggests tapping post-acute providers to serve on the front lines of administration of vaccines.

Michael Wasserman, M.D., CMD, a board-certified geriatrician, president of the California Association of Long Term Care Medicine and medical director of Eisenberg Village, Los Angeles Jewish Home, has been active in nudging California to oversee coordination of post-acute COVID-19 facilities. In a proposal to California, he used an acronym, ICOS, to describe the state response. It would entail identifying appropriate facilities (Infrastructure), creating multidisciplinary teams and operations (Clinical and Operations), and creating and having sufficient Staffing.

He also believes that geriatricians need to be part of the conversation. They were not playing a big role as of mid-April, he said.

“On the state, federal and local levels, there are no geriatricians or clinical people with expertise in long-term care or post-acute care in the incident command center management or team,” he said. “So decisions are being made without the real experts who know the medicine behind this. If I can make a recommendation: Find a geriatrician with experience in long-term care and post-acute care and make them part of the incident command team. Before you put out a policy, ask them what the result will be.”

How it will look

The post-acute response won’t necessarily look the same in every state, Grabowski noted. Different areas would leverage different resources — hotels in some instances, wings of nursing homes in others, more specialized nursing homes in other areas, to be post-acute COVID-19 facilities.

“It’s finding the balance of what are the right set of resources in an area,” he said. “Some of this could be retrofitting buildings. Some of this could be using existing providers. I do think there is not a one-size-fits all solution.”

There are several factors to take into consideration if nursing homes are going to accept COVID-19 patients, according to Grabowski. For example, providers will need to be reimbursed for providing specialized care, so that care should be high-quality. 

“Thinking through how to vet the providers who would ultimately do this, I would hope you attract the very best providers in the state,” he said. “I don’t think this is the time for different providers that are only there for the higher margins.”

Along these lines, a concern among medical and policy experts is if nursing homes get into the COVID-19 business, profit may trump care. 

“What I don’t want to see … is the side of the industry that’s going to focus on how much money we can make from COVID patients through PDPM,” Wasserman said. “They [may be] trying to move out Medicaid patients to bring in Medicare COVID patients … All of a sudden, they are big money makers.”

Silver lining

There may be good yet to come from this crisis. For example, hospitals may finally begin working with nursing homes as an equal partner, as opposed to just the next stopping point in recovery.

“If there is any silver lining … ultimately, some of these siloes will break down a little bit and some hospitals will recognize the role that SNFs can play,” said Anne Tumlinson, CEO of ATI Advisory, a research and advisory services firm in Washington, D.C., which published the “Post-Acute Preparedness” white paper.

In this scenario, hospitals will work together with facilities to make sure they have the necessary resources to handle treatment of COVID-19-positive patients, such as adequate personal protective equipment (PPE).

Treating COVID-19 patients also might bring about a paradigm shift in nursing homes, Wasserman hopes.

“It truly requires a team and expertise from every department head,” he said, mentioning the role of infection control for housekeeping and infection preventionists, and social service’s role in coordinating advance directives. “These are skill sets that need leadership and expertise that don’t necessarily come from traditional administrators.”

No doubt, as they have had to do at every turn of this crisis, nursing homes will learn as they go.