The patient experience has always transcended the continuum of care, and COVID-19 has been a call to action for enhanced collaboration between acute and post-acute care providers on behalf of the patients they mutually serve. During the pandemic, the Centers for Disease Control and Prevention (CDC) has repeatedly warned of the dangers to vulnerable populations, including older adults who have serious underlying medical conditions and persons with disabilities. This segment of the vulnerable population is served in nursing homes, and regrettably, we have seen the alarming impact of an unexpected predator like COVID-19.
For Medicare beneficiaries, 43% are discharged from acute care to a post-acute service. Of them, 20% are discharged to a skilled nursing facility (SNF) bed, which is most often located in a nursing home. This transition to a SNF is intended for a short stay to address ongoing medical and rehabilitation needs. A number of patients are then transitioned to long-term care and remain as residents in the nursing home facility.
As of April 23, the CDC reported more than 3,600 COVID-19-related deaths in nursing homes, a number The Wall Street Journal suggests has exceeded 10,000. All sources believe that the numbers may be understated. As a result, the federal government has now implemented new transparency and reporting guidelines to accurately capture the impact of COVID-19 in nursing homes.
There are many reasons why nursing homes in particular are challenged to nimbly respond to COVID-19.
First, it is very difficult to achieve social distancing in nursing homes. Most bedrooms include roommates, dining occurs in centralized dining spaces, and common areas and hallways are smaller. Day-to-day activities, such as assistance with showering, dressing, eating, and toileting, require close contact between staff and residents. When visitation is stopped to protect potential spread of infection, the staff becomes the “family” for the residents, involving simple human gestures of reassurance such as a hug.
Personal protective equipment (PPE) has been in short supply throughout the healthcare system, and nursing homes were not in a position to overstock these needed items. COVID-19 infection control protocols have resulted in increased use of gloves and masks, and additional recommended equipment such as face guards are not items that are typically stocked by nursing homes.
The on-site presence of physicians in nursing homes is much less than understood by the general public. As specified in the Long-Term Care Facilities regulations, residents must be seen by a physician at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter. At the discretion of the physician, after the initial visit, a physician assistant or nurse practitioner may alternate with the physician for the required visits (1, 2). While some nursing homes have increased coverage in the building, access to physicians, including primary and specialty care, is a need identified by many nursing homes.
Nursing staffing mix in nursing homes is variable, ranging from minimal federal requirements to higher staffing levels required by state or at the discretion of the individual facility. Federal regulations require Medicare- and Medicaid-certified nursing homes to have a registered nurse (RN) on duty at least eight hours a day, seven days a week; and a licensed nurse (RN or LPN) on duty 24 hours a day. In most states, nursing staffing requirements, including certified nursing assistants, are higher than the federal requirements. However, many still fall short of recommended staffing levels, compounding the challenges to manage a critical infection outbreak within a facility.
Conservative estimates of staff turnover across the long-term care sector range from 45% to 66%. One-in-four nursing assistants and one-in-five home health aides have reported to be actively looking for another job. The continual turnover of personnel leads to the need for ongoing and repetitive training to sustain understanding and competence for internal procedures, including protocols involving infection control.
Considering the challenges that nursing homes are facing, how can hospitals and health systems embrace the opportunity to more closely collaborate with the nursing homes in their communities to support the battle with COVID-19?
With the increased presence of value-based reimbursement models such as accountable care organizations and bundled payments, many health systems have formed preferred post-acute collaboratives or networks, to include SNFs, to manage the cost of care and improve clinical outcomes across the continuum. In markets where value-based models have not accelerated, close collaboration with post-acute providers is highly variable.
On behalf of the patients served by health systems and post-acute care, the COVID-19 crisis has highlighted multiple opportunities to enhance the connectedness between acute and post-acute care.
There are multiple models to enhance access to physicians and advanced practice providers (APPs) in post-acute care, particularly nursing homes. Hospitals are seeing value in creating a “SNFist program” (e.g., a hospitalist model in a SNF), often composed of physicians and leveraged with APPs who are assigned to cover selected nursing home facilities. This model achieves multiple mutual goals, including improvements in readmission prevention, continuity of care, clinical quality, enhanced patient/family satisfaction, improved in-network keepage, and reduced cost of care.
Hospitals have committees, resources, and processes in place to identify and manage infections. Specific protocols are developed, reviewed, trained, and deployed on an ongoing basis. Nursing homes also have infection control policies; however, common protocols may not exist as patients transition to post-acute care following acute care discharge. Sharing infection control policies and protocols would provide continuity of the processes and approaches being deployed. Furthermore, it would be beneficial for hospitals to offer training materials and teaching resources to augment the ever-challenging need for staff training in nursing homes due to turnover and lack of resources. Training can be provided by designated clinical resources, although using recorded training modules allows flexibility to offer the training on an ongoing basis.
Perhaps one of the positive outcomes of COVID-19 is the “paradigm busting” that has occurred and the benefits for patients to access care outside of hospitals, outpatient centers, and doctor’s offices.
When the pandemic quickly advanced, telehealth became an immediate vehicle to offer care, buoyed by CMS’ willingness to reimburse telehealth visits. Health systems have seen accelerated and significant growth in telehealth visits. For many physicians who have been slow to adopt a telehealth platform, historical challenges in access to care have been reimagined with implications for the future.
Depending on the market and supply of physicians, hospitals may now reconsider options for nursing home coverage through a combination of on-site physician resources and telehealth options to close access gaps and improve care. Moreover, advancing telehealth approaches with nursing homes will proactively enhance medical management of residents in place to avoid transfers to the emergency department and prevent hospital readmissions. Nursing homes are a prime site of care where access to care could be revolutionized via telehealth supported by local health systems.
Despite electronic health record (EHR) integration advances between hospitals and physician practices, integration with nursing homes has been more challenging.
Nursing homes have invested in separate EHRs that have been developed to address specific regulatory and reimbursement requirements. Health system information technology executives have been hesitant to invest in another “bolt on” solutions requiring interfaces. However, the lack of technology-enabled connectedness has been a barrier to efficient and accurate exchange of information when patients transition from acute care to a nursing home.
Furthermore, there are growing web-based technology solutions to assist with management of care between hospitals and post-acute services.
As hospitals and post-acute care providers evaluate their post-COVID-19 IT plans and investments, it will be important to revisit how technology solutions can further be integrated for accurate and efficient exchange of information to improve continuity of care.
Care management resources within health systems have multiple titles and responsibilities, such as transition care managers, disease-specific navigators, high-risk care managers, care managers in primary care practices, and post-acute care managers. Each role has a defined focus and associated responsibilities. Health systems continue to be challenged with the best ways to integrate care management across the enterprise and to “right-size” the number of care management personnel to focus on top priorities.
As hospitals critically evaluate current care management resources, there is an opportunity to revisit how care management processes and aligned resources can be deployed for a win/win between the hospital, physician practices, and post-acute providers to address priority needs for vulnerable populations experiencing multiple venues of care.
Our healthcare system was not prepared for the COVID-19 pandemic and the demand for PPE. While the PPE crisis in hospitals is well-known, the PPE crisis in nursing homes has been a significant factor in spread of the disease to residents and staff in nursing homes. In the future, there will be a different view and approach in responding to a crisis such as COVID-19 to address the PPE needs. As health systems review their PPE plans for the future, it will be beneficial for health systems to coordinate with nursing homes and other post-acute providers to address current PPE shortages and plan for future scenarios.
With the newly implemented federal transparency and reporting requirements for nursing homes, it can be expected that patients and families may express concerns about being discharged to a nursing home if services can be provided in the home environment. Once limitations on surgery have been lifted and patients receive care for unaddressed healthcare issues during the stay-at-home time period, hospitals will be challenged with patient throughput and acute length-of-stay management if there are delays in post-acute discharge. Moreover, post-acute spending has been noted to be 68% to 230% higher in Medicare fee-for-service patients compared to similar-age commercial patients with no difference in readmission rates.
Hospitals must proactively think about reevaluating historical discharge planning patterns and paradigms. This will likely involve growth and enhanced relationships with home healthcare and home and community-based services as alternatives to institutional post-acute care. Hospitals that anticipate and prepare for diverse discharge options will proactively have partnerships and options in place to provide seamless continuity for their patients.
The COVID-19 crisis has put the spotlight on opportunities to improve care across the continuum. New paradigms have been tested and will continue to emerge. Health systems and post-acute care providers need to rediscover and reinvent how closer collaboration will advance their mutual abilities to provide high-quality and cost-efficient care on behalf of the patients they serve.