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Imagine that you are the medical director of a large (>150 bed) nursing home. Two-thirds of the patients in the home now have COVID-19. Seventeen of your patients are dead. The other physicians who previously saw patients in the nursing home are no longer coming to your facility because you have COVID positive patients. You’re short on gowns and facemasks. You’re short on nurses and nurse aids so now you have to help deliver meals.

This is what Dr. Jim Wright, the medical director at Canterbury Rehabilitation and Healthcare Center in suburban Richmond is living through right now. I felt overwhelmed just listening to Jim talk about his experience since mid-March, and am so grateful that he joined to talk about COVID in the long term care setting, along with David Grabowski, author of the JAMA piece titled “Postacute Care Preparedness for COVID-19 – Thinking Ahead.”

A couple key points that I learned from Jim’s experience. The first point is that half of patients who tested positive were asymptomatic, so you really don’t know who has it or who doesn’t unless you test everyone. The only thing you really know is that if you have 5 symptomatic patients who test positive for COVID, assume there are at least 5 asymptomatic patients.

The second point is that there seems to be different clinical courses for those who are symptomatic that Jim summarized as the following:

  • Indolent course, deadly: Initial 24-28 hours of fever and severe respiratory symptoms. Then Stabilization for 3-5 days. Then decompensation on days 5-7 with death within 24 hours
  • Indolent course, convalescence
    1. Fortunately, the majority of our patients. Same course as indolent to death although continued improvement over 7-10 days.
  • Acute respiratory failure: Symptoms begin with fever and acute respiratory failure with death within 6-12 hours.
  • Sepsis-like picture: Sudden onset of AMS, hypoxia and hypotension without fever. A small subset of patients in our experience. All have tested positive for COVID (may simply have been asymptomatic carriers who developed sepsis independently

In the second half of the podcast David Grabowski walks us through the challenges facing nursing facilities and potential solutions to the looming crisis in long term care, including

  • creating COVID only specialized post acute care settings
  • increasing the level of home health care and hospital-at-home model
  • whether nursing homes that don’t yet have COVID should be forced to take COVID+ patients form hospitals.

So listen up and comment below. Also, check out some of our past COVID podcasts and new resources on our new COVID page. And here is some other links we talked about

Eric: Welcome to the GeriPal Podcast, this is Eric Widera.

Alex: This is Alex Smith.

Eric: And Alex, this is I think number six now in our COVID-specific GeriPal Podcast.

Alex: It is, and we have another host joining us today. Lynn, you want to introduce yourself?

Lynn: Hi, I’m Lynn Flint and I’m an associate professor in the division of geriatrics, and I work in the nursing home and on palliative care at the San Francisco VA.

Eric: And Alex, who else is with us today?

Alex: And today we have Jim Wright who’s a physician medical director of the Canterbury Rehab and Healthcare Center in Richmond, Virginia, and is part of the SNF Long Term Care Partners of Virginia Group. Welcome to the GeriPal Podcast, Jim.

Jim: Thanks Alex. Good to be here.

Alex: And we also have David Grabowski joining us from Boston, who is professor of healthcare policy at Harvard Medical School. Welcome to the GeriPal Podcast, David.

David: Great. Thanks for having me on.

Eric: We’re going to be talking about COVID in the setting of nursing homes, skilled nursing facilities, people’s lived experiences with that right now, and also things that we should be thinking about going forward with this group. Before we get into that heavy subject, we always start off with a song request. David, you got a song request for Alex?

David: I absolutely do. Alex, one of my all-time favorite songs and one I’ve been playing recently originally by the Talking Heads, This Must Be the Place.

Alex: Yeah, terrific song. I’m just going to play a snippet of it.

Alex: (singing)

David: Wow. That was awesome. That’s great.

Eric: Why’d you choose that song?

David: I’ve been thinking a lot about home. Obviously my home here with my family, but also just thinking more generally about the concept of my friends, my academic home and that I think most importantly, the home I grew up in and I think we’re all thinking about our parents right now. And I found my mind wandering a lot to my childhood home and where I grew up in Chapel Hill, North Carolina, and spending time with them. Talking to them every day, and it’s become a very, very important concept right now.

Jim: Agreed. You should listen to the Lumineers version of that. They’ve got a great-

Alex: Oh yeah, I listened to every version last night because I knew I loved Shawn Colvin. I saw her play this 25 years ago in Ann Arbor, Michigan. Part of her Covergirl albums as David and I were emailing about this terrific album, but I cannot imitate Shawn Colvin’s voice. I stole the chord progression from the Lumineers.

David: Yeah.

Eric: Well another home that we’re going to be talking about is nursing homes. And I want to, again, very big thank you to Jim for joining us today because he is at right now in the front lines of this pandemic in Virginia. Jim, can you just describe right now what’s the state of affairs that you’re dealing with right now?

Jim: Sure. I am medical director of Canterbury rehab in Richmond, Virginia, central Virginia. We’re in the West end of the city and we are a long-term care and skilled rehab facility. We have a total capacity of about 190 beds. We have about a 60 bed skilled rehab unit, and we have a 48 bed memory unit, a secure memory unit, and otherwise a long-term care beds, 130 long-term care beds outside of those 48. About 190, our COVID crisis began on the 13th. That was our first suspected patient. And it’s been a certainly a wild, devastating ride since that time.

Jim: Currently, our numbers of COVID patients, we have… well, let’s see, I have to keep updating. We have 108 positive tests in our facility. We have had 18 deaths now as of this morning. We have had a remarkable number of asymptomatic positive test, about 50 of our total positive tests have been asymptomatic. And we did that at the request and with the assistance of our state department of health. They really wanted to get a handle on how it was spreading so rapidly through our community. Those results are just recent. We did that testing late last week, received results earlier this week. The COVID crisis here has been a never ending a series of new things to think about and things to plan for.

Jim: We’re at the point now where we basically only have about 30 patients that are negative maybe, certainly some of those could be false negative. Instead of trying to develop a COVID wing or a COVID hall in our facility, we’re trying to develop a place to cohort not tested positive so far. It’s been challenging on a number of levels which I can certainly go into if you wish. Just let me know what you’ll want me to go into here. I’ve got plenty of information and probably not a lot of time.

Eric: Well, given that you don’t have a lot of time, what have been some of the most challenging aspects of this for you?

Jim: Yeah, well, I can tell you at the beginning, because we were the first facility in Virginia to have this level of prevalence in our building. There was a lot of superstition, paranoia that we had to deal with amongst the community and amongst the staff. Staffing has been the initial challenge and the ongoing challenge for us. For example, typically, this building with an average census of 160 to 170 has two physicians and two physician extenders, the nurse practitioner and a PA. It is the perfect amount of work for that personnel on a regular day.

Jim: And usually staffing, although we have our challenges just like everyone else’s, is perfectly fine. However, when you have a building of 160, potentially critically ill people and certainly a large percentage of our positives have become very ill, it’s overwhelming even on a good day for staffing. But what happened when we had our first cases, was that nurses and aides who normally will circulate among a few different facilities, were told by their facilities that if they were to go to Canterbury and work, they would not be allowed to come back to their other facilities. And so immediately with our first test results, when it came positive, we had a drop in our staffing, a precipitous drop in our staffing.

Jim: And then unfortunately, a hospital system which provided practitioners for over half the patients in our building, they quarantined their physician and nurse practitioner that normally came here and would not send any other replacement physicians. We ended up, me and my PA, ended up with the entire building all at once. And so that first week was exhausting and very just difficult to get through day to day. Just because you have your hands full seeing patients, writing orders and trying to keep them from crashing, but then you’re also changing patients, making sure they’re hydrated, helping with meal deliveries and things like that because of the under-staffing with the aides and the nurses as well.

Jim: It was pretty crazy. We’re in a little better shape now as far as that goes. We’ve reached out beyond the state even to attract nurses. We have a contract with a staffing agency in Connecticut actually that’s supplying nurses for 30 days, so they don’t have to worry about going to different facilities. We’re putting them up in hotels and we’ve worked with the department of health for staffing as well. We’re climbing out of that hole a little bit. I was able to get my wife, Jenny, who’s a palliative care physician, she works for a local hospital group. She’s volunteered with me almost every day for the past week and a half. That’s been helpful as well. Staffing, that was a big, big challenge.

Eric: And you’re doing something interesting and I heard because we talked before about advanced care planning for this population too earlier on. Can you describe what you did there?

Jim: Yeah, so we discovered early on that the big things that we were behind on, were really drilling down in advanced care planning discussions to what would you want for your loved one if they were to worsen with COVID and end up with this COVID pneumonia or viral pneumonia? It’s a very specific ACP discussion. It is not your usual ACP discussion about whether you want feeding tube or whether you want to do things as someone is declining over a period of months to years. It is a discussion about what you would want to do if your relative was well today but dying tomorrow.

Jim: And we’ve ended up with a few points, talking points which I put out on a lessons learned sheet that has been posted on AMDAs website. Some talking points that you can do a quick COVID ACP discussion in about 10 to 15 minutes. And we’ve even had some discussion about a limited, a time limited ACP, a time limited DNR/ do not hospitalized order that’s specific to COVID. And our talking points are basically COVID can be fatal, especially for folks in their 70s and 80s. The only thing that the hospital can offer that we cannot offer is mechanical ventilation, and we have enough experience now to talk about this.

Jim: Our experience as well as studies show that once an elder is at the point where they need mechanical ventilation, they typically do not survive more than 48 to 72 hours, and that’s certainly been our experience. And so you can talk very specifically about futility of care and that has helped some families that we’ve been talking to them about code status on their 80-year-old relative for years now. It has really helped to have that specific information and bring it to the families, and allow them to make an informed decision.

Jim: We’ve been surprised at how families seem to be primed. I mean, everyone’s heard about the lethality of the virus, so they’re primed for the discussion. It doesn’t take long to give them the specifics and then come to a decision about maybe a time limited DNR/ do not hospitalized. But like I said, we scrambled at the beginning. That first week, we were simply not prepared for the, in some patients, the sudden decline that you, of course, don’t have time for ACB discussions when you’re trying to triage patients. Our recommendations to the community is if you haven’t started COVID-specific ACP discussions with your families, you’re behind the ball and you need to get going.

Eric: And we’ll have links to both your lessons learned and also the AMDA page, as well as some other communications, COVID-specific communication guides around advanced care planning on our show notes too. You can just go to GeriPal. And we’ll have that too. Real quick question too. One of hardest parts is around knowing what to expect once you have the virus. It sounds like one thing is half the people don’t even know they have it. What happens to the other half in your experience right now?

Jim: We’ve seen about three different typical courses. I guess the most common has been what we call… so there’s an indolent convalescent presentation, where you will develop symptoms of generally a fever of 101 to 102, and mild to moderate respiratory symptoms that last about 48 hours. And that can be a bronchospasm is fairly common. Those symptoms do seem to respond to inhaled Bronco dilators. And then there’ll be a stabilization for four to five days, and then there’ll be recovery. Now, after that four to five days, we also have seen an increase in the risk of a secondary pneumonia. And so you still in those indolent convalescent folks, you still have to be very vigilant to monitor, perhaps check another chest X-ray at a five to seven days.

Jim: But that’s been our experience for the majority of our patients with symptomatic COVID infection. We call that indolent convalescent, but then there’s been the indolent fatal, which is a same beginning, one to two days of fever and moderate respiratory symptoms with stabilization for four to five days. And then around day five to seven, a sudden decline, so worsening of all of the above. Fever usually does not return, but respiratory symptoms certainly worsened. And within 24 to 48 hours, the resident will pass away from that. That’s our indolent fatal. And as far as the fatal cases, that would be the most common, and those are our patients that are in their 70s and 80s. Maybe multiple comorbidities or severe COPD.

Jim: And then for us, the most challenging presentation is the acute respiratory distress. You will have onset of severe hypoxia and we’ve seen oxygen SATs in the 60s. Acute onset of hypoxia, acute respiratory distress with wheezing, shortness of breath and coughing, and then death within six to 12 hours of the onset of symptoms. And that’s been a small subset of our patients. Those are usually folks that are superannuated in their 90s, for example, but we have seen those, and that can be a terrifying presentation. And then there’s a question as to whether there’s also a sepsis picture.

Jim: We’ve had people sent to the hospital for sepsis and have tested positive for COVID there, but I’m more of the thought that that’s simply sepsis from pneumonia, UTI, and they’re asymptomatic carrier. But we have seen altered mental status, hypotension, maybe weather without fever, without really significant respiratory symptoms. That’s something I’ve been a minority so I tend to think that’s just asymptomatic carriers with the usual prevalence of sepsis in our facility. Not many of those.

Alex: Yeah. I want to just commend you for the work you’re doing and also for being transparent and coming on GeriPal, and posting lessons learned, and to be helpful to other skilled nursing facilities, post-acute care facilities that may be going through this. Just got a call this morning from a friend who’s head of public health for Bay Area County Dementia Care Facility in his region. I won’t say the name because it’s not news yet. Half the residents just tested positive. This is just going to roll across the country and you are being transparent about it. It’s really helpful to other people. Thank you. I want to give Lynn and David a chance to ask you questions because I know that your time is limited with us. Lynn or David, do you have any questions to ask?

Lynn: I have so many questions. Thank you so much for sharing all this. The thing that was really going through my mind as you were describing these different clinical courses, in particular, it sounds like you’re managing a lot of these residents in the facility. I wonder if you could talk a little bit about the day-to-day management, and in particular, symptom management.

Jim: Which is all we’re doing, of course, is symptom management and vigilance for a secondary pneumonia. We can at least do something about that. Yes, thanks for that question. We have seen that for many people, bronchospasm is an associated symptom. And so we have seen rapid acting Bronchodilators help with symptoms. We have paid very close attention to CDC guidelines about limiting the use of nebulizer treatment in the facility over concerns of aerosolized in the virus. But we have not given a blanket prohibition against using nebulizers because some people simply do better. And so we use a informal strategy to assess people that might do okay with an MDI with a spacer, and my PA is very good about watching carefully and making sure that the patient is actually able to use that. Of course, the nurses doing it, but they have to be able to breathe in at the right time even with a spacer.

Jim: We started with nebulizers, the usual approach that we do for people with bronchospasms, but we could’ve been more prepared about not use it. We probably use nebulizers a little bit too much, but anyway, bronchospasm is common. We have seen a benefit in prednisone, but again, there is concern that extended use of steroids can increase the potential for viral replication. They’ve seen that in other similar viruses. We will give a steroid burst maybe one or two days and then reassess. And either oral 60 milligrams of prednisone vs Solu-Medrol IM, no IV steroids. So those are what we’ve used a fair amount, and then of course, a supplemental oxygen for symptomatic hypoxia. We’ve used that as well.

Jim: We’ve had to use some high flow oxygen with non-rebreathers to get people just up into the 80s sometimes to provide comfort, even though I’m sure that’s aerosolizing virus as well. Those have been our big things and then some other stuff that had been just Musinex and Robitussin, and stuff like that to help people clear of mucus. And then unfortunately at this point, I have… my usual day starts with signing hard scripts for morphine and lorazepam for comfort meds. And that’s been a particular important lesson that we’ve learned, is prescribe those comfort meds early.

Jim: Have them in the cart for the patients to use because you can have that acute respiratory failure that you don’t want the patient waiting for an hour while the nurse faxes the hard script to the pharmacy or even waits to get it out of the staff box. You try to have plenty of morphine and lorazepam available on the unit. We’ve increased the amount in our staff box as much as we can, which is not very much in Virginia. I think you can only have three bottles of liquid controlled substances in your staff box. Maybe two bottles of morphine and a bottle of the lorazepam.

Jim: But we have a Pyxis, which is like a vending machine for medications and we’ve really stocked it with morphine and Adavan. We’ve used some fentanyl patches for people that just chronic air hunger as well. And then looking again, keeping… well, you always want to keep your differential list as long as possible. We try not to maintain tunnel vision for respiratory symptoms and fever. We’ve tried to make sure that we’re monitoring for secondary pneumonia, which can be really tough if someone’s developing a viral pneumonia, and treating accordingly. And then looking for any other signs, any other causes of your regular causes of fever and decline in your nursing home patients as well.

Jim: Antibiotics, we’re using those as well. I can tell you that we are not using the Plaquinel Zithromax combination. I don’t feel that supported by good science yet, so we’re not using that.

Alex: David, do you want to jump in here? It looked like you had a question.

David: Yeah, absolutely, similar to Lynn, I could ask Jim a whole afternoon of questions here, but maybe I’ll just ask one. We’ve been hearing a lot about a lack of personal protective equipment or PPE among caregivers, and I’m curious what your experience has been and then going forward, what’s your current supply and what are you facing? Because this is something that we’re reading a lot about right now.

Jim: Yeah, yeah. It’s an ongoing struggle. We’re always on the verge of not having enough. And we certainly started out like most people did, with not enough N-95 masks. Certainly, I don’t think we’re ever going to have that ideal situation where we can change masks and gowns between each patient. Trying to figure out creative ways of reusing gowns and masks. We have established a whole COVID ward of 60 beds in our facility where you can simply use the same gown and mask, everybody’s positive there. You can use the same gown and mask, and therefore, conserve your gowns on that ward. But when you’re in other words where you have newly diagnosed asymptomatic positives, that’s a challenge.

Jim: We have a big spreadsheet that’s been a literal lifesaver for us. A big spreadsheet with everyone’s names, test results, when they were tested, and when their quarantine is over and all of that stuff that we go by. And so you cohort your visits, you know all your positives. You can wear the same gown. The problem is what do you do when you’re seeing your negatives? Do you presume they’re positive? Do you wear a gown before you see that negative patient? D you throw it away before you see another negative patient because that supposedly negative patient could be positive and you could be spreading it around that way. That’s the problem.

Jim: I mean, if we can cohort the positives, you can wear one gown all day, but unless it’s soil. But it’s going from, from negative to negative patient is the issue. And so we’ve worked with the department of health on strategies to reduce gown use there. And so one option which makes sense to me is using gowns that are specific for a room and you have your name on it, you hang it on the back of the door, you go in that room, you put on that gown and you see that patient, you hang it back up. And then if it’s a cloth gown, laundry can launder them every day. If it’s a paper gown, I think if you’re using that gown for that room and hopefully, you’re going to cohort negatives in a room, you can do it that way.

Jim: And at this point I think we only have 30 negative patients, so let’s say 15 rooms, 15 gowns that you would need in order to do that. It’s a never ending struggle thinking, “Can I reuse this gown again or do I really need to throw it away? Am I going to go back out to the COVID positive ward in a few minutes and can I just hang it up in my office or at the end of the hallway? Where am I going to put it?” It’s exhausting, but I don’t think anyone’s going to ever be at the point where they can do what would be ideal, which is a fresh gown on for every patient.

Eric: Jim, I want to be mindful of your time. I know you have a billion other things to do, so you can stay on if you’d like, but I recognize that you may need to leave. My very last question to you is from a personal level. How on earth are you coping with all of this? You don’t even need to answer that question because I want to cry just asking that question.

Jim: Yup. I can say that my family has been really important and I’m getting home every night for dinner. That’s good. Even if dinner is at eight o’clock, it’s good to hear how everyone’s day went. It’s good to hear stories from the outside world.

Alex: Yeah, Our hearts go out to for what you’re doing, Jim. Just incredible work under such hard circumstances.

Jim: Yeah, it’s been rough. We’ll get through it.

Eric: Thank you again, Jim. Thank you for everything that you’re doing. Honestly, I’m crying too, Jim. I think for geriatricians and palliative care doctors, I think we’re okay with crying. Thank you again for joining. We’ll have again on the GeriPal website, links to the AMDIS site, and also your lessons learned. And again, I very much appreciate you joining us today and thank you for everything that you are doing.

Lynn: Thank you.

Jim: All right. Take care. Bye. Bye.

Alex: All right, we want to switch gears now and talk more health policy. David Grabowski published a paper in JAMA. This is a viewpoint called Post-Acute Care Preparedness for COVID-19: Thinking Ahead. My first question was going to be with all this emphasis on the hospital and ICU beds, and whatever, why should we be thinking about post-acute care? But now I feel like, hey, Jim just made about, well damn, well, you better be prepared to start thinking about post-acute care. But is there anything that you want to emphasize about why this topic is important, David?

David: Sure. Like everybody else, I started thinking about COVID -19 after the outbreak in the Life Care Center in Kirkland, Washington. And I was super concerned and very much what Jim just described in his facility. I was worried, is this going to happen in every facility across the country to some degree. And I hadn’t really been thinking about the other population that nursing homes treat. It’s not just their long-stay residents or their existing resident pool. They’re obviously constantly taking short-stay post-acute patients from hospitals. And it hadn’t really dawned on me that, “Oh wait, they’re going to be asked to take on COVID positive patients from hospitals in addition to keeping their long-stay residents safe.”

David: And it wasn’t until the administration relaxed the three-day rule, which requires, as I think probably all of your listeners know, but I’ll quickly say it. It requires Medicare beneficiaries to have a three-day hospital stay in order to qualify for skilled nursing facility payment. And it dawned on me that when they relaxed that rule, CMS was very interested in getting individuals out of the hospital as quickly as possible into those skilled nursing facility beds. And that’s what really drove the paper that you just mentioned in JAMA.

David: How are we going to set up a post-acute care system that has both the capacity to take on all these patients that are coming from the hospital system, but also the capability to do this care safely? Otherwise we’re going to hear story after story that Jim just told, but it’s not going to be starting within the facility, it’s going to be introduced from a patient discharged from the hospital.

Lynn: Yeah. I’m so glad that you wrote that paper and put it out so quickly. It’s so important. Always, I really worry that nursing homes aren’t getting enough attention in general, and this is the same story, I think. Again, so many questions I have for you too, but I do wonder, first of all, I mean, if you could have a wish list of resources starting with post-acute care facilities, how could Medicare CMS be doing, how could they help support this preparation for this incoming pool of patients?

David: Yup. It’s interesting here, we’re almost flying blind with respect to which facilities have seen COVID positive patients, which facilities have capacity, what States are doing on the ground. Everything’s being pieced together right now either by researchers, by reporters. Some of this is being published here and there, but there’s no centralized resources. I think the first thing, Lynn, I would like to see would be just a record of which facilities have had outbreaks just so we can learn what’s the extent of this.

David: As we all mentioned, Jim was so open and forthcoming about what’s happening in his facility. Nobody’s looking to name and shame, we’re looking to learn. And what an opportunity that Jim just provided us to teach us best practices in an outbreak and moving forward, how to prevent outbreaks. I would want as just a very simple data resource, tell us what facilities have COVID positive patients. That’s very simple. Above that, I would love to see what different States are doing to increase post-acute care capacity.

David: And I’ll just use a couple of different examples because States are taking very different routes here. Now, the state I live in, Massachusetts, has created 12 specialized post-acute care facilities. They’re going to take 12 skilled nursing facilities and create about 1,000 new beds. That’s, in some ways, I think a great move on the part of Massachusetts. I’m a little nervous in that some of those new beds are going to be created by moving existing long-stay residents to other homes. Everybody listening probably is well aware of the transfer trauma literature and just how harmful that can be for a long-stay resident tap to shift homes. But it’s probably better than having a COVID positive patient introduced into the facility.

David: Connecticut is introducing a policy very similar to Massachusetts. I think those are two States that are, I think, really being progressive here in terms of trying to figure this out. A number of other States are oddly mandating that all nursing homes accept COVID positive patients. I know several of you are out in California, so I’ll start there. California has mandated that skilled nursing facilities admit COVID positive patients, New York, New Jersey, Illinois. There’s a whole set of States there. I think that’s a really harmful practice and policy. And to your question about data resources, it would be great to see a national database of what every state is doing around this issue.

Eric: David, can I ask quickly about that?

David: Go ahead. Go ahead.

Eric: LA Times, couple of days ago, Mike Wasserman, the president of the California Long Term Care Association, he said, I’m going to quote, “Because of their extreme vulnerability to this novel virus, taking a patient who might have highly contagious pathogen is akin to premeditated murder.” Big words. I think he was trying to get a response. Why do you think it’s a bad idea?

David: Sure. We’re working so hard and we just heard Jim, I asked him about personal protective equipment. Think about the effort that he’s going in just around PPE and doing infection control, and keeping residents safe, and the gowns, and imagine the amount of time that his staff is spending changing in and out of those gowns and trying to keep those COVID free wing of his nursing home, COVID free. It’s just really challenging and costly. Why would we want to send a patient to a facility unless that facility had the infrastructure, had the staff, had the PPE to do that care safely?

David: Otherwise, this is just a bad policy. And so, mandating that every facility accept COVID positive patients, I think we really… I wouldn’t want to prevent COVID positive patients from going to a nur… if a nursing home has the capability and the capacity to do this. I heard about a facility in New York that was able to take out a multimillion dollar line of credit, set up a wing in that facility to care for COVID positive patients. That sounded incredible. There just aren’t many nursing homes in the country that can take out millions and millions of dollars in a line of credit to do that. And so I think we have to be cognizant of just the limited resources that most nursing homes have towards doing this safely. And so I prefer a policy or a strategy of letting nursing homes tell us whether or not they can do this care safely.

Lynn: I also thought it made a lot of sense that you said we really need to incentivize the facilities to do things like that. And so Medicare should probably be paying them a higher day rate for those COVID 19 post-acute patients.

David: Absolutely. And that’s the next step that really hasn’t been dealt with yet in any of the stimulus packages. And hopefully, it’s coming in this next package where they’ll actually direct dollars. Because if you’re asking nursing homes to take on these more costly patients and do this care safely, and maintaining the health of those residents, but also other residents in the facility while protecting the staff, you really need to pay them a rate commensurate with the increased costs of doing that care. I’m hopeful that that’s coming, without that payment adjustment, I think this is destined to fail.

David: And so, I would add one part to that line Lynn, though, that given that we’re going to pay more for those patients, I think we want to be very careful about the providers that we allow to operate these specialized facilities or these wings. I really think we’re going to give a lot of money to them, but much will be expected and I wouldn’t just entrust any provider I really think we want the best providers stepping forward. And I would hate to have providers just doing this because there’s a lot of money on the table. We want providers that are going to produce good outcomes for these patients.

Lynn: Yeah. I could even imagine a scenario in a building, a facility that does a widespread testing strategy and swinging long-stay patients who are positive but not asymptomatic into a Medicare unit. I don’t know possible now without the three-day rule.

David: Right? Yeah, no, I think there’s real possible unintended consequences here. And so we just want to be really careful on how we design this payment policy, but then also, how we set up the types of facilities or what safeguards do we put in place such that only certain facilities are chosen to operate these more specialized settings.

Lynn: And I think another great point that you raised, is that there’s not just the post-acute care facilities, there is home health. And maybe the thing that we really need to pay attention to is that it’s 80% to 85% of only adults who get this are surviving. It’s a prolonged illness and so they’re going to be deconditioned and have additional needs. How can we get the home health world ready for this?

David: Home health has tremendous promise. One of the real risks that we’ve been discussing is introducing a COVID positive patient into a facility environment where they could potentially infect other residents. Being discharged home on the surface already sounds better in that they’re isolated from older adults, putting aside their spouse or family, and that was actually going to be my first point. That if we’re going to discharge individuals home, we need to, both, educate family members but also maybe encourage them through different payment models. We have cash and counseling. We’d have other models that help pay family members.

David: And I think in certain instances, we may need to help incentivize family members, not so much to do the care, but given where the economy is currently at and given how many family members are out of work, there’s a real opportunity to leverage family provision of care by helping out and relieving some of the burden on formal care sources. That’s a first thought, that we obviously don’t want them going home and infecting their family, but potentially we could actually leverage that family.

Lynn: Yes, they do.

David: And those things. And the second part of this, I think is really important, it is really ramping up home health capabilities. I don’t think as the home health benefit has been traditionally structured. I don’t know that it would be well suited to treat a lot of these COVID positive patients who are recovering in the home. As you know, home-health has been very therapy driven, but it’s largely been PT and OT, some speech, lots of potentially skilled nursing. But I wonder if we’re going to need a different mix and a broader mix of services. And so how do you pair traditional home health with maybe home based primary care. I really like a lot of the telemedicine rules that have been by CMS over the last couple of weeks. And so I think that that’s really encouraging and potentially allows a much broader mix of services than I think home-health has offered historically.

David: The final point I would make about home health is just training up the staff around infection control. And I was talking to a home health group here in Massachusetts and it was interesting, they had to completely retrain their workforce around doing all of the PPE, and putting it all on, and using it safely, and discarding it in a trash can outside the individual’s home as they were leaving. And so having this dedicated trashcan there and just having a set of procedures in place that they’d really never had to utilize before. And I think that’s going to be really important in a lot of home health agencies that have just never done this. They haven’t had access to PPE, much less train their workforce on how to use it.

Lynn: Yeah. It’s like redesigning the system in a lot of ways. Yeah.

David: And the other model here I was going to raise, Lynn, quickly was just they haven’t been well utilized, and it goes back to your earlier question about payment. But a lot of interest right now in hospital at home type models. Even if we can’t meet your needs with home-health, maybe we could do it with a more institutional level of services. This is basically taking the hospital room and bringing it to the individual’s apartment or house. And it’s really exciting on the surface. And historically, it hasn’t been paid at parody, meaning the hospital systems that invest in these hospital at home type models haven’t really been compensated for it.

David: We’ve now well seen CMS relax that rule, the rules around this and hospital systems can actually do hospital at home for roughly this similar reimbursement. I think we’re going to see a growth in these models. It’s just an issue of staffing and capacity, and whether hospital systems can grow to actually meet this demand. But this seems like a really important model and that the concerns I expressed about home health, can this model actually meet all the needs of these highly dependent recovering patients. It’s not clear home health is the right model for every patient and maybe the right model for some. Hospital at home sounds really appropriate for a lot of these patients.

Lynn: Yeah. And also kind of that SNF at home type of thing.

David: Absolutely.

Eric: I’m Also part of our ethics committee here, thinking about triage decisions in limited resources. There’s a lot of focus on ventilators, but man, like we just had a podcast with folks at Sinai. That was our last one. And they spent an hour trying to figure out how to get a caregiver to someone’s home. They had to call like 16 different agencies. It’s unlikely in San Francisco that we’re going to need to be in a position where we’re going to have to triage vents. We’re triaging. We’re rationing the workforce. The workforce is the most challenging part about this right now.

David: Completely agree. And I think there’s some ideas to help grow this workforce. One is simply we need to increase wages. And so this has been a, a workforce, both Eric and home care, and home health, but also in nursing homes, and I’m referring to the certified nurse aides that typically make close to minimum wage. Many of them don’t have paid sick leave, so we really haven’t invested in them. We need to invest in them right now. They’re on the front lines. They’re the backbone of this system. If they get sick, and we heard Jim say this earlier, staffing has been his hardest challenge. And I’m hearing that from a lot of providers nationally, both in home health and in nursing homes. And so how do we grow that workforce?

David: And I think there’s an opportunity right now to get more nurse aid certified to really streamlined training. CMS has actually relaxed the certification process for nurse aides. I don’t agree with that, but I do agree with waiving fees and really making the process as seamless as possible. If that’s online, if there’s opportunities to make it easier for nurse aides to get trained and certified. We need to grow this workforce. We have a lot of hotel workers, a lot of restaurant workers, a lot of individuals who were working in retail but now need jobs. This is an opportunity to really invest and grow in this workforce.

David: I hope that different communities are thinking broadly about growing this workforce because I think we’re limited with our RNs and LPNs, and therapists, and other positions. We’re going to have to be more creative there. But with nurse aides, there’s a real opportunity to grow the pool of potential providers.

Alex: And now a number of these proposals might take more time and some will take action at the state level or at the federal level. Well, if you had to choose one proposal that’s highest yield, low hanging fruit that could be done quickly, what would you say is the top of the list?

David: There’s certain things that are outside the control of these facilities, but like getting them PPE, that would be my number one — getting PPE to the entire ward. That’s not something though that many of these nursing homes can control or home care agencies. I think they’re often, unfortunately at the back of the line, although I’m hearing more and more that hospital systems and healthcare plans are appreciating that if they don’t share and collaborate with a long-term care and post-acute care settings, they’re going to get all of these patients coming to their hospital or generating healthcare claims for their health plan. They need to be proactive in helping these nursing homes and these home health agencies get the PPE they need.

David: I think that would be the number one simplest thing of how do we protect the workforce. If I had to say one of these rules that we could Institute today, and we’ve already talked about it, but I’ll go back to it. I really believe that mandating that post-acute providers accept COVID positive patients, it’s a backwards policy. I would really love to see a greater flexibility. And I think if you’re going to mandate that facilities take on these patients, it’s going to lead to negative outcomes. What I think they need to do is begin to create alternate settings for this care.

David: And so, Alex, I think I would really focus on creation of a plan for how do we deal with this coming surge. And I think something we could do today is States need to start investing in those alternate sites.

Eric: David I really want to thank you for joining us. It’s been a roller coaster discussion, both cognitively and emotionally. And I really appreciate you joining us, and Jim for joining us, and Lynn too, thank you for being a co-host. Before we end, I need a little bit of relief. Alex, can you give us a little bit more.

Alex: This will be some sort of relief, hopefully not comic.

Alex: (singing)

Eric: I feel better already, Alex. That was awesome.

Alex: I backed off of going for the really high note. Thank you so much David. Really appreciate you joining us today.

David: Yeah, thanks for having me on. Really appreciate what you guys are doing and I hope long-term care facilities, broadly much like Jim described, are coping okay and working to keep this terrible virus at bay. Thanks for everything you guys are doing.

Eric: Lynn, thank you too for joining us.

Lynn: You’re welcome.

Eric: And for all of our listeners, thank you for joining us today and with our past podcasts. Thank you Archstone Foundation and everybody please stay safe out there. Goodbye.

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