Officials Eye Nursing Homes as Failsafe for Overloaded Hospitals During Coronavirus Spread

A sweeping ban on nursing home visits dominated headlines both inside and outside the industry over the weekend, but buried in the federal government’s recent emergency COVID-19 guidelines was a waiver of the three-day hospital stay rule for Medicare skilled nursing coverage.

Under normal conditions, a Medicare beneficiary must remain in the hospital for three consecutive days — on a formal inpatient basis — before he or she can receive the subsequent 100 days of Medicare coverage for a rehabilitative stay in a nursing home.

The Centers for Medicare & Medicaid Services (CMS) frequently waives this requirement in cases of localized emergencies such as hurricanes and tornadoes, though its most recent blanket suspension of the three-day requirement covers “those people who need to be transferred as a result of the effect of a disaster or emergency.”


In explaining the reasons behind those changes, CMS administrator Seema Verma said that the waiver could allow nursing homes to accept overflow from hospitals as the number of coronavirus cases presumably spikes over the coming days and weeks.

“Our actions allow hospitals to reserve beds for the most severely ill patients by discharging those who are less severely ill to skilled nursing facilities,” Verma said Friday.

On paper, such a move makes sense. If there’s been one overarching trend in the post-acute and long-term care industry over the last two decades, it’s been acuity creep: Today’s nursing home residents are yesterday’s long-term hospital patients, and today’s assisted living residents are yesterday’s nursing home residents.


Even just over the last two years, many skilled nursing operators have beefed up their clinical capabilities — from adding ventilators to dialysis treatment to specialized cardiac programs — in the run-up to the new Patient-Driven Payment Model (PDPM) for Medicare reimbursements, which incentivizes operators to take on higher-acuity residents.

At the same time, nationwide occupancy levels at nursing homes have been stuck at or near cycle lows for some time now, most recently clocking in at 83.3% — presumably indicating spare room at facilities across the country.

But that plan may not necessarily work in reality, according to David Grabowski, a professor of health care policy at Harvard Medical School and a member of the Medicare Payment Advisory Commission (MedPAC). The need to separate residents with COVID-19 from those without the infection may pose too much of a challenge in most scenarios, particularly given the potential for deadly outbreaks such as the one seen in Kirkland, Wash.

“Given what happened in Kirkland, and given how hard nursing homes are already working to maintain an infection-free environment, and to keep visitors out and keep the mental health of the residents strong — this idea that we’re going to ask existing nursing homes to take COVID-19 patients in addition to their regular patients, I just don’t think that’s going to work,” Grabowski told SNN.

That said, he offered multiple scenarios that governments and operators could potentially pursue over the coming days. Skilled nursing communities with multiple buildings, or physically separated units, could potentially set up separate COVID-19 containment areas that could siphon off some of the stress on hospitals, though Grabowski noted that it’s simply a logistical impossibility for many SNF physical plants.

“For the majority of nursing homes, that’s not practical, but that’s worth recognizing — that there are some places that can do this,” he said.

Additionally, officials could lean more heavily on hospital-based SNFs, but those sites only number about 600 nationally, according to Grabowski. As the crisis unfolds, Grabowski predicted that both the government and health care providers will have to explore all possible steps, such as cordoning off wings of hospitals and treating them as SNFs for both discharge and reimbursement purposes, or finding excess capacity in assisted living communities and hotels.

“I don’t know that the existing SNFs are going to be able to take on all these additional patients and segregate them from their existing patients,” he said. “I really think that there’s going to need to be some solution here.”

New York Gov. Andrew Cuomo floated one such solution that could bridge the gap: taking the unprecedented step of using federal manpower to retrofit unused buildings as health care facilities.

“Start now, bring in that Army Corps of Engineers. This is what they do. They build,” Cuomo said on CNN Monday. “I’ll give them dormitories. Build temporary medical facilities, but they have to do it. I’m not shy, but a state doesn’t have the capacity to build that quickly to that level.”

That idea could dovetail nicely with the other overarching trend that the industry has seen in recent years: nursing home closures. Between 2015 and 2019 alone, 550 nursing homes were forced to shutter across the country, according to a recent analysis from long-term care trade group LeadingAge.

But even if sweeping federal action could increase the physical supply of both acute and post-acute beds, one persistent skilled nursing problem — one that’s stymied operators even during non-emergency times — would remain: staffing.

“It’s already hard to recruit individuals into this area,” Grabowski said. “In the middle of a major pandemic, are these workers going to step forward? I just don’t know where they’re going to recruit them from.”

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