The nation’s most vulnerable could be exposed to Covid-19 after a mandatory waiting period for nursing home admissions was rolled back, health-care workers fear.
In response to the pandemic, the Centers for Medicare & Medicaid Services has temporarily waived a mandatory three-day hospital stay before a patient qualifies for transfer to a skilled nursing facility. The waiting period is typically required before Medicare covers a nursing home stay.
The unintended effect could be a rapid influx of patients into nursing centers who may have been exposed to Covid-19 at hospitals, said Savera Sandhu, an attorney with Newmeyer Dillion in Las Vegas. Nursing homes are being used to accept the overflow from hospitals in some of the hardest hit parts of the country.
Dropping the waiting period “will not make it safer or easier to care for patients,” said Sandhu, who counts skilled nursing facilities among her clients.
The three-day waiting period wasn’t intended for screening patients to determine whether a nursing home is the right setting or to rule out the risk of spreading infection, but to verify that Medicare would actually cover the higher cost of nursing home care.
The waiver ensures nursing homes will be reimbursed without delay as Covid-19 drives demand. It also aims to help free up in-patient hospital beds by transferring patients into nursing homes, said Jennifer Kreick, a health-care attorney with Haynes and Boone LLP in Dallas.
“There’s not enough testing being done and hospitals are under pressure to get the patients out,” said Charlene Harrington, a registered nurse and professor at the University of California San Francisco who specializes in nursing home research. “What they’re doing is making sure they’re not symptomatic. What they need to be doing is testing them before sending them to the nursing home.”
New York, New Jersey, and California have ordered nursing homes to accept Covid-19 patients. Both New York and New Jersey rank among the top 15 nationally for the highest share of populations age 85 or older—with about one out of every 45 residents in that group, according to a Bloomberg Law analysis of U.S. Census data.
Those directives are “tantamount to premeditated murder,” said Michael Wasserman, president of the California Association of Long-Term Care Medicine. “It’s dangerous and irresponsible.”
“The concern is that at this point in time we need to assume everyone is potentially Covid-positive, so the people we are bringing in could have been exposed during their hospital stay,” said DeAnn Walters, director of clinical affairs for the California Association of Health Facilities, which represents senior living facilities. “All our hospital partners take on some kind of risk. I don’t think anyone in the country is immune to risk of exposure at this point.”
Of the 613 nursing homes in New York state, 291 facilities reported 3,478 confirmed Covid-19 cases with 860 deaths as of Tuesday. New Jersey Health Commissioner Judith Persichilli said Tuesday that 188 of the state’s long-term care facilities—including nursing homes, assisted living residences and other settings—have at least one Covid-19 case, with 1,928 cases total and 128 deaths so far.
California officials declined to provide their numbers for infections and deaths in nursing homes.
The first major U.S. outbreak of Covid-19 occurred in a nursing home—the Life Care Center in Kirkland, Wash.—where the virus spread rapidly and killed 37 people.
Eliminating the Wait
There is a potential upside: eliminating the three-day stay means patients in need of skilled nursing may be able to enter facilities without having to go to the hospital at all—which could actually help limit the spread of the virus, said Jodi Eyigor, director of Nursing Home Quality and Policy for LeadingAge, a nonprofit with more than 6,000 nursing home members and partners.
“We are hearing from a lot of members that they are concerned about that” risk of transmission from incoming patients, she said. “They want to make sure they are not exposing their residents and staff to Covid. But that said, all nursing homes are advised to only accept patients for whom they can provide adequate care.”
From the Front Lines
On the front lines, it’s not just about dealing with incoming Covid-19 patients, said one nursing executive director and administrator in Wyoming, who spoke on condition of anonymity to protect his job.
The influx is likely to include patients who will require more intensive care more quickly than some nursing homes may be able to provide, the administrator said.
Many nursing homes have already established emergency action plans to deal with the influx of new hospital patients, the administrator said.
They include a system to segregate incoming patients—and the staff who care for them—from residents who were living in the home prior to the pandemic. Extra steps are being taken to ensure staff don’t intermingle, and patients who have the potential of catching with Covid-19 will be isolated.
“New residents will be isolation for a few weeks—or whatever the [Centers for Disease Control and Prevention] designates as an appropriate period of time,” he said. Spread of the infection “is not only possible, it’s probable. Every admit is going to increase the burden of care. But that’s the life we live.”
The Wyoming nursing facility is already taking measures outlined in April 2 guidance from CMS.
The CMS recommendations include everything from hand washing guidelines to the need for immediate symptom screening for all residents and staff entering the facilities. They call for all residents in skilled nursing facilities to have their temperature checked daily, and require all employees to use personal protective equipment—such as masks and gloves—when interacting with patients.
Even taking all possible precautions, some still worry about nursing homes’ ability to handle the coronavirus outbreak.
“I really feel they need to set up separate facilities to treat these coronavirus residents,” Harrington said. “Once it gets into a facility it’s very hard to manage it, even if they’re on a separate wing.”