What Lessons Have We Learned from the First COVID Surges? Jim Wright & Darrell Owens

Eric: Welcome to the GeriPal Podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: And Alex, who do we have with us today?

Alex: We are delighted to welcome back two very special guests who were with us early in the COVID pandemic, and really shown a light on what was happening for the rest of us who could see this giant wave coming, and were just thirsty for information and experiences from those people who were experiencing it early.

Alex: First is Darrell Owens, who’s Associate Medical Director of Palliative Care at the University of Washington Northwest Campus. Welcome back to GeriPal, Darrell.

Darrell: Thank you very much.

Alex: And second is Jim Wright, who is medical director of two long-term care and skilled nursing facilities in Richmond, Virginia: Our Lady of Hope and Westminster Canterbury. He’s a geriatrician. Welcome back to the GeriPal Podcast, Jim.

Jim: Thanks Alex. Good to see you all again.

Eric: We’re going to be talking about your experiences, recapping what we talked more than two years ago now, which is just crazy. Also, what’s happened since then for both of you? But before we dive into that topic, I think Darrell, do you have the song request for Alex?

Darrell: Yes. I would like Memories from Maroon 5.

Alex: From Cats? [laughter]

Darrell: No, I don’t know who all sings it, but the Maroon 5 version.

Alex: I’m not ready to do that one. I guess I could fake it. [laughter]

Darrell: Yeah, feel free. But I like the Maroon 5 version.

Alex: All right, here’s a little bit.

Alex: (singing)

Darrell: Thank you. Great.

Eric: Well, let’s talk about some of our own memories. Again, we’ve had Jim and Darrell on, I think it was March and the very beginning of April of 2020, I’m going to start off with Darrell.

Eric: We had you on and you were doing some really interesting and helpful things up in Seattle. Including, I think, a 24/7 palliative care intervention in the emergency room, an inpatient comfort care intervention for COVID-positive patients … doing a tremendous amount. Did I summarize that right, Darrell?

Darrell: Yes, you did. We’re one of the campuses of the University of Washington, the north end of Seattle, where we are heavily inundated with residential care homes and nursing facilities. So we anticipated, based on what was happening in Seattle, a pretty large influx of elders that were going to come through the emergency room.

Darrell: And so I’d set up in conjunction with our emergency room team and our hospitalist, a 24/7 screening process for, at the time, anybody who’s over 65. And remember back in the day, they would be PUI, a Person Under Investigation, because it took 12 hours to get a test results back.

Darrell: So we would screen, they would come in, and I would have a goals of care conversation: usually with their families, because many of the elders that we saw were cognitively impaired. Not all, but I would have those conversations with them and kind of quickly explore what we knew about COVID at the time. And we were doing that 24/7.

Darrell: That went on for me for 64 days. I was here consecutively 64 days, seeing people around the clock. At the same time, in order to offload the hospitalist service, palliative care became an admitting service. We were already an admitting service for inpatient hospice patients, but that’s only a couple a week.

Darrell: Anybody who was transitioned to comfort measures only would then come onto our service. Or, if they were in the emergency room and decided to be admitted for comfort measures only, I would admit them. And of course, we didn’t have a palliative care team; it was just me. So it was a long 63 days, and felt like it was the best work I’ve ever done in my career.

Alex: Wow.

Darrell: Pretty amazing. Pretty tough. Pretty … Just all things, right? Just really powerful. I think during that time period, we had a significant number of deaths. Not one elderly person died on a ventilator. In fact, no one in this hospital died that was not on comfort care. No CPR was performed on an elder person with COVID. They all received comfort care, and to date we’ve only had … so now fast forward, slow forward to today’s date.

Darrell: Out of everybody, we’ve only had two elders, two over 80, that have died of COVID that received CPR. One was after the surge, and I had just finished this long stretch. The hospitalist said, “We’ve got a COVID person. They’re 80-something years old. They look pretty stable. If you want to just come in this afternoon.”

Darrell: I was exhausted. It was a Sunday morning, so I said, “Okay, I’m going to read the newspaper.” And damned if he didn’t die and get CPR before I could get there.

Darrell: That was actually the second time I cried through all of this, I just felt like I had really blown that. Like I can’t believe this happened, which was interesting that that would be the second reason I would cry.

Darrell: Then I had another one that was much later in the process that was actually vaccinated, who was over 90, who had a lot of medical issues. The hospitalist didn’t want them screened, didn’t want to have any discussions with goals of care. It was a personality issue with the hospitalist.

Darrell: Who died and got CPR, only to have multiple people then call me and say, “Well, how did you let this happen?”

Darrell: “I can’t tell you.”

Darrell: So that’s where we are now to date. The screening process is obviously shifted. We had our first surge that March that we talked about. That was long; we did okay through the summer. We had a very big second surge here in November, where the first surge was really nursing home population.

Darrell: Then our second surge in November pre-vaccination, were a lot of adult family homes, residential care homes. That was also very hard, because that was the time when we were all supposed to be wearing mask. So these people had been quarantined and kept in these adult family homes where they couldn’t get exposed. And then the staff came in and exposed them. And we had a really big surge then with another surge of deaths.

Darrell: All in all, to date, just about 112 deaths on this campus. 84 of the death certificates, I signed; that they were my patients. And of the ER screening program, I’ve seen 266 people, 266 goals of care conversations in the ER, which were pretty significant.

Alex: Wow.

Darrell: Gosh, in the ER group, at the end of the first surge, had me come to their staff meeting, gave me a beautiful award and made me an honorary member of the Emergency Medicine Group.

Eric: That’s great.

Alex: Yeah.

Darrell: Just an incredibly wonderful, wonderful group of people, and was an amazing opportunity.

Eric: What I really loved about your podcast, it started shedding a light of how a lot of our other institutions should start preparing. We thought that here, after listening to you.

Eric: I remember in particular, we asked you, “What should we do to prepare?” And you said, “Don’t expect that it’s going to be business as usual. That we’re going to have to do things differently, and we have to be open to that. You got to be open minded. And don’t say things like, ‘We’re not an admitting service,’ or, ‘We don’t do this,’ or, ‘We don’t do that.’ You got to start with what you can do. What’s your capacity on what you can do?”

Eric: So I really very much appreciated that. That also started us thinking about what we can do internally. Ultimately, I think it also led us to think, how can we help our colleagues elsewhere?

Eric: Alex and I were part of a program that did volunteering telepalliative care in New York. Honestly, I think there’s a lot, just thinking from your podcast, this is not business as usual. So, big thank you.

Eric: I wonder though, since you brought up the song Memories … not the Cats version … but if I had a time machine, Darrell, and I had a little bit of juice in that so you can go back for five minutes and tell two-years-ago Darrell something. Would you give him any advice?

Darrell: First, I would say this is not going to be over in 90 days. Because I thought I can certainly do this for 90 days. We will get it together. And I would tell him not to underestimate the grief that he is going to experience.

Darrell: So just to say some of the things that’s stayed with that: we still are to this day an admitting service. That’s become permanent. And we now continue to manage all the comfort care patients, which in the setting of a packed hospital, that’s really done some great offloading. That’s a wonderful thing that we really love.

Darrell: But for me personally, I actually got involved with David Kessler’s organization in Southern California, and went through a grief educators program for him. Then I’ve done another, almost two years, almost 500 hours of grief counseling and therapy and embarked on a national study to look at nurses and healthcare provider grief, not specifically grief for patients and families. Because that’s just becomes so eyeopening that we are just the most grief-illiterate profession and society that there is. Really positive; that was the positive. There was a lot of negative too, but …

Eric: And how does it feel right now for you?

Darrell: Gosh, it’s so super busy. We had to reopen our COVID unit this week. Our fifth floor is our hot zone, as we call it; it’s reopened. But I’m not really seeing the COVID patients now. These are vaccinated folks who come in.

Darrell: We are just incredibly busy. But what I find is that it’s such a loss. We have lost so many nurses. The part that I loved of this campus was this was the community arm of the university. We are a community-based hospital. It was just a great place. Everybody knew everybody. And that’s not the case anymore.

Darrell: So many nurses have left for a variety of reasons. Many have gone on to travel, and I don’t fault them for being travel nurses. But we have a lot of travel nurses, so it’s not the same level of trust when someone’s doing a comfort care patient.

Darrell: We’ve lost hospitalists. We didn’t lose them: they left. I don’t want to say we lost them. Some wonderful hospitalists have said, “Forget it. This is not an environment. I don’t want to work.” The rest have dropped their FTE saying, “I don’t want to do this.”

Darrell: The building is the same on the outside, but the culture is absolutely not the same on the inside. That’s, I think, what we’re all missing. And to see my hospitalist colleagues just be so defeated is really, really hard.

Darrell: Because we go full speed ahead right into COVID and we’re heroes. And then we slam it into reverse, strip all the gears, and say, “It’s time for surgery right away, surgery, surgery, surgery. We need money. We need money. We need money.”

Darrell: It’s like bouncing back and forth. Then we can’t move people out of the hospital, because the skilled nursing facilities are full. So then people sit in the hospital, then we’re told that our length of stay is too long. And these patients cost too much money and we’re not making any money, but everybody’s working hard.

Darrell: So I think right now is really the hardest part. And that’s because of the really low morale that we see.

Eric: Yeah. I felt part of it too, was like, you had this idea that you just got to make it a certain amount of time. You can sprint for a certain distance. If you thought, “Come July 1st ’21, we’re going to get through this. You just got to make it to this date.” So there was hope.

Eric: And then quickly … Well, not quickly, it got dashed. And now we’re just recognizing that this is our new normal.

Darrell: Yeah. I can’t imagine not wearing mask again. And I think the one other big thing I learned that I should have said was that at least my palliative care colleagues, palliative care providers do not do anger well. They just don’t do anger well.

Darrell: I’m talking about once we moved into the phase of the whole crap show about, “Are you going to get a vaccine?”

Darrell: “I’m not getting vaccinated.”

Darrell: “Are you coming to the hospital?”

Darrell: “I didn’t get a vaccine. But now I’m in the hospital and now I’m going to be rude to you. And I’m going to be mean to you.”

Darrell: And the number of elderly people I took care of who died, who would have given anything to get a vaccine. Then the number of people that come in who are treating us like crap, literally, like we’re the enemy and saying, “These people really annoy the crap out of me.” I’m really pissed at these people.

Darrell: And my colleagues like, “Well, but we’ve taken care of people with COPD forever. We’ve taken care of people with liver disease forever.”

Darrell: And I think, “Yeah, but you know what? The people that use tobacco, if we could have said, ‘We’ll give you two vaccines three months apart, and you’ll never smoke again. And your chance of lung cancer or COPD will dramatically be reduced.’ I think that would’ve been a different story.”

Darrell: So I’m not putting them on the same plane. But so many palliative care providers … and I had been in a presentation with Ira Byock about this, who agreed that palliative care folk, it’s like, “Everybody’s good. We’re all good.” And it’s like, “No. No, we’re angry. We’re angry now. We’re not showing that to the patients, but we’re angry.”

Eric: We have emotions, we’re human. [inaudible 00:15:33]

Darrell: And it’s not bad to show them.

Alex: Well, tremendous work, first of all, that you’ve done, Darrell. And thank you again for shining a light on what your experiences were like, and what we should anticipate. And for the tremendous personal work that you did on call 24/7 to the emergency department. Just absolutely incredible; heroic, even.

Alex: And it sounds like there have been some lasting changes as a result. I don’t want to make the COVID pandemic into a utilitarian tool. That said, there is this saying, “Never let a good crisis go to waste.” In other words, it’s an opportunity to create change, to transform the service, transform the way patients are cared for, with potentially lasting positive benefits.

Alex: So I wonder if from your perspective, there have been some positive lasting changes that have resulted from this pandemic.

Darrell: Was that for me?

Alex: Yeah, it’s for you, Darrell. Yeah.

Darrell: I actually do; I do think so. I think on a national level, the fact that a nurse practitioner can order home health when they couldn’t order home health before is small, but huge, if you’re that provider.

Darrell: Here in our institution, the ability to continue on as an admitting service and contribute in that way is incredibly valuable and important. And I think the work that even here in this institution, we are now doing around grief; grief is becoming a part of the training for all of the nurses and the recognition of the importance of that.

Darrell: I think all of those things are really important and really lasting. I think what I could go the rest of my life and never hear the word again, would be burnout or resilience. I just could go forever without an administrator talking about resilience or burnout again, because I have found those words to be used in a way that seems punitive.

Eric: Wellbeing?

Darrell: Yeah. Wellbeing is fine, but you know, “You got to get more resilient, get more resilient.”

Eric: Yeah.

Darrell: “Be resilient in this [inaudible 00:17:57].”

Eric: I say that a little bit mockingly, like just saying a word is not going to make significant changes to the system.

Darrell: Yeah. Pizza parties and meditations are not the answer.

Eric: An online module on wellbeing or resilience is not going to really change-

Alex: Mandatory online module.

Eric: Mandatory. You got to do it at night.

Alex: Yeah. Resilience pizza.

Eric: I’m hoping I can turn to Jim and then maybe we could just have a discussion together, because I also remember Jim’s podcast. So just to summarize, Jim-

Jim: I’m not sure I do.

Eric: I remember it clearly. That one, I felt like, “Oh my God, what is life like for Jim? How is he surviving and standing?” Basically you had practitioners, physicians, nurse practitioners that normally would be there.

Jim: Right.

Eric: But the system wouldn’t send them in, because majority of your patients in the nursing home were COVID positive, and they were all quarantined. So it was you and your PA, you said-

Jim: Right.

Eric: … that ended up having to care for the entire building during this massive COVID surge where the majority of the patients turned up positive.

Jim: And my wife, she’s a palliative care [inaudible 00:19:14].

Eric: Your wife’s a palliative care physician, right?

Jim: Yeah. She came in and they were in the same system as the other physicians that were supposedly prevented from coming in. But she bucked the system and came in.

Eric: You were seeing patients, you’re writing orders. You were changing them, keeping them hydrated, helping with meal deliveries. Because the staffing issue is not just physicians and NPs: it was nurses, it was everything.

Jim: It’s [inaudible 00:19:43].

Eric: It was just like, oh my God, how did you survive it?

Jim: Well, I took good care of myself during that time. I mean, and of course I started out with a lot more resources than I have now. I mean, I’d spent 20 years working in long-term care and finding a good work-life balance, staying healthy, having a lot of outside interests. I could go pretty deep then, and I was able to push through and sprint for those couple of months.

Jim: It was really March through June, I guess, that we saw the worst of our outbreak. I’m no longer with that facility; that facility’s called Canterbury, which is not associated with my current Westminster Canterbury. But we got through that three months sprinting the whole time.

Jim: I did take a vacation at the end, and got away from it for two weeks. Went to Zion National Park and the area around there, and just got away from the cell phones and internet and everything with my family and spent some time there.

Jim: But the only reason I made it through was because my wife came in to help me. My PA was there, and I had a good group of nurses, administrator aides. We all banded together and did what we needed to do. Then I was able to go home and decompress.

Jim: One of the blessings of COVID was that I have two college-age children. One kid that was out of college, working in DC. Everything was closed down, and they all came back home. So when I got home at nighttime, my whole family, that normally we’d be scattered all over the place, my whole family was there. And we’d spend every evening together. So I was able to recharge and then go back early the next morning.

Jim: So just a combination of things enabled me to get through. And probably like Darrell, just envisioning an end that turned out to be a lot further off than originally thought. And just feeling like, “Well, if we keep going on for another week, it’ll be over.”

Jim: I can tell you, that was tough. But probably what was more tough was the second spike in December and January of 2020 and 2021. Because at that point, I feel like my resources, my personal resources were not as robust as they were back earlier that year.

Jim: And it was doubly cruel. I mean, it was right when we were all getting vaccines. I got vaccinated. I was just looking at my vaccine card the other day. December 21st: that was right in the middle of our spike, where we had at another facility, we’d made it through Our Lady of Hope. We’d made it through the whole pandemic with hardly any cases. And then we had a big spike, and another 15, 16 people died right around the time when the vaccines were there. So we could have just made it another couple of weeks. We would’ve made it through the pandemic relatively unscathed.

Jim: And Christmas Day I spent all day at the facility watching people die from COVID, and helping families visit so they could spend the last minutes with their loved ones. It was really horrible.

Jim: So following that, I really felt like I was pretty much depleted as far as my ability to push through another period like that. So that’s my long answer to how did I make it through? Yeah. I made it through. I seriously doubt whether I would be able to professionally survive another outbreak like we had at Canterbury. But realistically, I think the chances of that are pretty low.

Eric: If you had a time machine and you could give any advice to Jim from April of 2020?

Jim: Oh gosh. You know, I was thinking about that when you asked Darrell. I don’t think I would’ve done anything differently. [inaudible 00:25:26]

Eric: It’s also interesting. If you told yourself, Jim from 2020, that, “Oh, it’s going to be a lot longer than just a couple of weeks or months.” You got to really think: do you really want to tell Jim from 2020 that? Because-

Jim: Right.

Eric: … would Jim from 2020 have done the same thing?

Jim: Yeah. Yeah. I mean, I would’ve just said, “It’s going to be terrible. Get some sleep, make sure you exercise every day.” Yeah.

Eric: Yeah. How are things now for you?

Jim: Well, they’re good. Personally, professionally, they’re good. But I’m in this stage right now in my career where … What happened to me coming out of the pandemic was that I was very energized by the way all of the shortcomings were exposed. The shortcomings of how we deliver long-term care in this country were exposed for the first time. So that the entire country was focused on how poorly we deliver care for our elders, especially in for-profit facilities.

Jim: And so my vision and my conviction was that real change would come from this, and that we would all come together: professionals, family members, owners and operators, we would all come together and finally push through the changes that needed to happen in order to prevent another pandemic, another 150,000 elders from dying in the next pandemic. That, of course, as we know, did not happen.

Jim: We are really in the same situation that we were in March of 2020, as far as elders being warehoused in nursing homes, nursing homes being understaffed. No-

Eric: Do you feel like the staffing issue is … because it feels worse now than ever before.

Jim: It’s worse.

Eric: Like when you look at the amount of MDs, NPs, nurses that want to do nursing care right now? Feels like nobody really does.

Jim: Well, right. I mean, the exact opposite has happened; the spotlight has been shown on long-term care. Everyone sees how terrible it is. So instead of a national movement to make this a place where people do want to work, we’re in a standstill.

Jim: In Virginia, we had this push to implement staffing standards. People are shocked to know that in about 50% of the states in America, there is no federal or state requirement for staffing ratios. A nursing home can simply say, “We have enough to provide quality of care to our residents.” But there’s no law that enforces a certain number of aides or nurses.

Jim: In Virginia, we actually convened a Joint Commission on Healthcare. I was involved in that, was talking regularly with representatives and senators on the state level. It came up for a vote in this recent General Assembly, and really just disappeared in a subcommittee without a trace.

Jim: So it really opened my eyes to how very little power our elders have, first of all, and very little power that our patient advocacy groups have, even physicians like myself have. And how much power the owners and operators have, the for-profits have.

Jim: And really, it’s come to the point where we as a country have turned over the care of our elders to investment groups. These investment groups that own for-profits and find that they’re actually very profitable.

Jim: I’m at the point where I’ve gone from a feeling of being energized and convinced that we’re going to have a national referendum and a national push to address all these shortcomings, to … I’m in a position now where it’s very demoralizing to be a worker, a physician, a nurse, an aide in the long-term care industry. Because we’re left with a realization that, “Wow, maybe we were right. No one really does care about elders.”

Eric: There was a really interesting JAMA Health Forum article that was published not too long ago, looking at turnover rates in pre-pandemic, during the pandemic, and now. And what they found was turnover increased dramatically [inaudible 00:31:10] pandemic for all healthcare workers. But right now it’s improving in all areas except for long-term care, which is getting worse.

Jim: Right, right. You think it can’t possibly get worse. But I know facilities I’ve worked in that have never had problems with staffing, and have very, very rarely had travel nurses. Now, that’s pretty standard. Yeah.

Eric: Yeah.

Jim: So I’m not sure in this environment, I’d be able to really do what I did two years ago. I think back to that time, I was much more energetic, much more sure of myself, much more convinced about a lot of things. And I think anyone working in long-term care now is really filled with more questions and more anger and frustration that at any time in their career. Again, I’ve been working in this field for 25 years. Not to sound all doom and gloom.

Jim: I guess what I would say, where I am now, is I’m still convinced I’m in the right place. And I’m convinced that we do have the ability to care for our elders in a better way. And my advocacy has turned to saying, “Well, if I can’t be part of a huge tidal wave of legislative process that’s going to happen and going to fix this, then I’m going to go ahead and do this myself.”

Jim: I am part of a group called Homecoming, is what we call ourselves. We’re designing and currently looking for partners to build a different type of nursing home. We’re looking at greenhouse models, small home living. By the way, the greenhouse model was one of the models that showed up very good during COVID. Small home living with a high staff-to-patient ratio: those models showed a much lower infection rate and much lower mortality rate for COVID.

Jim: So we’re looking at a new way of providing a home for people, especially with dementia. That’s really where my heart is. A way that restores to them the freedoms that they lose when they go into a memory center, the purpose that they lose when they go into a memory center, and the community that they lose. We’re looking at a way to restore all those three losses that we find in people that are in facilities, especially memory centers, and we call it Homecoming. Our website is homecomingrva.org. RVA is for Richmond, Virginia.

Jim: I’ve spent a lot of my energy and attention in just trying to do it with a small group, and showing perhaps maybe being a test case for a way that we can prepare for the next pandemic and provide a home for people living with dementia that makes people feel like there is hope. There is a way that life continues in dementia, as opposed to the current thought that folks have now. When they’re thinking about a life lived in dementia, quite frequently, the feeling is, “I never want to live with dementia. Just shoot me if I ever get that diagnosis.”

Eric: Yeah.

Jim: We want to provide a place that’s hopeful, a place that shows that really life can continue, and that human life is valued no matter what your cognitive abilities are.

Alex: We’ve talked at length with other guests on this podcast about the enforced social isolation and loneliness. Nowhere is that more true than in the nursing home setting.

Jim: Right.

Alex: I wonder if you could share with us about your personal experience as medical director for nursing homes, where there was months unending, seemingly, loneliness, social isolation.

Jim: Right. Yeah. Yeah. We call it confinement syndrome or the isolation pandemic. Besides people dying, gasping for breath, it was the worst part of the pandemic: is seeing these elders limited to moving around in their rooms. Maybe getting out into the hallway before being told to go back in, seeing the cessation of activities.

Jim: I think we could do a lot better than bingo. But man, in the middle of the pandemic, when you could no longer have group activities, bingo looked pretty good. Group dining: I can’t tell you how much of a joyful atmosphere there was in my facilities when we finally were able to have the dining room filled again, and have families come in.

Alex: Yeah.

Jim: I think, although the CDC made some missteps during the pandemic, like we all did, what they really got right was enforcing family visitation again. I was in favor the moment that regulation came out, that nursing homes had to allow families to come in, and could not restrict visitation.

Jim: I know a lot of my colleagues had problems with that, but the risk of bringing COVID again into your facilities was so far outweighed by the benefit of having families present. Again, like I said, besides the deaths, I never want to see elders confined to their rooms again and prevented from having meals together. I never want to see that again. Horrible.

Alex: Let me ask you the same question that I asked Darrell. There’s opportunity in crisis. And some say this is the opportunity to sacrifice some … What are they called, sacred cows? You’ve talked already about how there was opportunity that was missed for real legislative change on a state or a national level. I think the other guest we had on the time that you were on was David Grabowski, who’s a policy researcher at Harvard.

Jim: Yeah. He’s great.

Alex: He’s great. He’s been advocating consistently for policy change.

Jim: Right.

Alex: What positives can you take away from this? What positive changes occurred that as a result of the pandemic, or what opportunities were leveraged because of this crisis moment, to institute needed change?

Jim: Alex, nothing.

Alex: Yeah.

Jim: That would be my answer. I would love to say six months or a year from now that President Biden’s initiatives got passed because of this. Or the recommendations from the National Academy of Sciences, that 600-page report that came out earlier this year, all of those recommendations were passed. I’d love to say that.

Jim: But at this point, seriously, not a single good thing, not a single opportunity has been taken advantage of in the nursing home. All I see are the same patterns, the same institutions, the same understaffing, the same business model, the same pursuit of profitability. All of that is intact. The same shared living spaces.

Jim: We are sitting ducks for the next pandemic, absolutely sitting ducks for the next pandemic, with not a single change being made that really means lower mortality or better quality of life for elders in nursing homes.

Eric: Well, let me ask you this, Jim. And I’m going to turn to Darrell, similar question. If you could make one change, you got one change, what would it be?

Jim: It would be implementing staffing standards in all 50 states, using the studies that are out there and saying, “You cannot admit any patients until you meet these staffing standards.”

Jim: They don’t have to be punitive, because I know staffing is a problem now. Nursing homes should not be punished for understaffing. At the same time, you cannot tell our communities that you are going to take care of elders when you don’t have the staff to do so.

Jim: So I would say the one single change that could be made is that all 50 states have staffing regulations. And if you can’t meet those staffing regulations, the only penalty is that you can’t admit any further patients. So that would be the one thing that would make a difference.

Jim: Studies show that facilities that had better staffings prior to the pandemic had lower infection rates and lower mortality rates. And it just makes sense to everybody. So that is the one change that I would make.

Eric: And going to you Darrell, after hearing all this, I mean, you work a lot with the nursing home population, too. Even in your hospital, doing what you do in palliative care as an NP, as a director, do you have one thing that you’d like to see changed? If you had a magic wand, what would you use it on?

Darrell: I have to agree with Jim, only from the hospital perspective, I don’t think a damn thing has changed. We went through COVID, and now we’re right back to, “Let’s do as many knees and hips and everything else as we can, because surgery is the cash cow and that’s what we need.” We saw a broken system and we haven’t done anything to fix it, I think, in general and across the big system.

Darrell: I think we’ve made some small positive changes. But if I could make one change, I think it would be that what the pandemic has shown is the value that the nurse practitioner brings to the table. And I would say that in all 50 states, we need to have full practice authority, like we do in about half of the states.

Darrell: After your last podcast, it was amazing the number of people who would ask me, “Who was the physician in charge?” And I would say, “I don’t have a physician in charge. I’m an attending. I’m credentialed as an attending. The other associate medical directors were my trainees.”

Darrell: So if there was one thing we could do is we could bring to the table that in all 50 states, we would have full practice authority for nurse practitioners who demonstrated that competency. And we would add that to the mix of our system.

Eric: I love that idea.

Darrell: It’s not popular.

Eric: I think it’s great.

Eric: Well, I want to thank both of you for being on. But before we leave, let’s give Alex a little bit more time with Memories from Cats. [laughter]

Alex: Not from Cats.

Eric: Not from Cats.

Alex: Maroon 5.

Alex: (singing)

Eric: I think that’s a very, very wise pick of a song for this podcast, thinking through the last two years and everything you’ve both been through. Thank you for joining us on this podcast.

Darrell: Thank you for having us.

Jim: Thank you for hosting.

Eric: And thank you, Archstone Foundation for your support, and to all of our listeners.