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A House Divided: Can Nursing Homes Provide Rehab AND Residence After COVID-19?

Written By: Marc Rothman, MD

Our nation’s experience with the coronavirus pandemic over the past few months has shined a spotlight on the dual nature of nursing home operations in America and begged the question: Is it sustainable? 

When families can no longer safely and adequately care for a frail and often elderly loved one at home, we turn to nursing homes to carry out that honorable task on our behalf.  We depend on nursing home staff – aides, attendants, nurses – to not only bathe, feed, and dress our loved ones, but to respect their preferences, monitor their chronic diseases and endure their occasionally unique behaviors. In short, we ask them to treat our family like their own. This care is mostly paid for by Medicaid at very low rates.

At the same time, Medicare beneficiaries sent from hospitals to nursing homes for skilled rehabilitation anticipate a short stay and a quick recovery. Patients in rehab expect the same medical management they experienced in the hospital, despite physicians or nurse-practitioners who may only be in the facility a few hours each, with no onsite lab, pharmacy or imaging services. The presence of electronic medical records in skilled nursing facilities is more and more common but still not universal, and few are tied to any outside hospital systems or doctor’s offices.

Is this precarious balancing act – simultaneously a ‘home’ for frail elders and a ‘rehab facility’ for Medicare beneficiaries – sustainable in the long-term? I have long pondered this question, and COVID-19 begs it in my mind once more.

The current pandemic has taken a serious toll on nursing homes nationwide. Over 16,000 nursing home patients have already died, and the rest of the nursing home population is at exquisite risk. Facilities continue to face a shortage of PPE (personal protection equipment) and access to coronavirus tests. Keeping residents safe is sometimes at odds with doing no harm. At the height of the pandemic, one nurse in Florida claimed her manager didn’t want staff to wear masks because it would upset and possibly confuse the residents. And a unified approach to shutter facilities and lock out visitors has left many families frightened and angry

States have struggled with mandates to identify skilled nursing facilities for recovering COVID-19 patients in order to free up hospital beds, and CMS has appointed an independent committee to assess nursing home practices around COVID and to make recommendations. The question of whether to admit COVID-19 positive patients from the local hospital is fraught with danger and uncertainty for those already living in nursing homes. Many experts have proposed ways to do that safely, but in my mind, it gets back, again, to the wisdom of having what are really two separate and distinct populations under one roof, sharing staff, sharing resources, and sharing the risks. 

Whether or not the pandemic will trigger a reconsideration of how nursing homes and their skilled rehab components coexist is yet to be seen. I have witnessed the best of both intense post-acute skilled care and beautiful, compassionate home-like care for our nation’s elders. Sometimes that occurs under one roof, but often I wonder whether separating those functions would be better. Not an easy task given the maze of complex, inconsistent state regulations, various reimbursement sources that often pit one setting versus another, and a host of other issues. But perhaps it’s time to give that question a second thought in the post-COVID era.


References

NPR, “Discharging COVID-19 Patients to Nursing Homes Called “A Recipe for Disaster,'” Ina Jaffe, April 20, 2020

The Guardian, “Scared and Sick Amid COVID-19: U.S. Nursing Home Workers Afraid to Blow the Whistle,” Alexandra Villarreal, May 2020

USA Today, “‘Our Patients are Dropping Like Flies:’ 16,000 Dead from COVID-19 in U.S. Nursing Homes,” Tricia Nadolny and Marisa Kwiatkowski, May 2020

The Society for Post-Acute and Long-Term Care Medicine, “CMS Announces Independent Commission to Address Safety and Quality in Nursing Homes,” May 2020

Kaiser Health News, “As COVID-19 Lurks, Families are Locked Out of Nursing Homes. Is it Safe inside?” Judith Graham, May 2020



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