Post-Acute Bed Capacity Concerns Loom as COVID-19 Cases Grow

As the number of confirmed COVID-19 cases in the U.S. mounts, concerns about hospital bed capacity are rising in proportion — and skilled nursing facilities need to be ready to help ease the stress on the acute care system, according to multiple providers.

The Centers for Medicare & Medicaid Services (CMS) seemed to confirm this line of thought on March 13, when the agency rolled out guidance announcing the waiver of the three-day stay rule, which requires a stay of three days in a hospital before Medicare will cover SNF care.

“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,” CMS administrator Seema Verma said last week.

That waiver has already come in handy for accountable care organizations (ACOs) who are looking to create health care savings — primarily by allowing them to directly send patients to a SNF when appropriate, as Marlene Bober, vice president of practice development at the American Case Management Association (ACMA), pointed out.

And data released from the National Investment Center for Seniors Housing and Care (NIC) on Wednesday indicated that the average nursing home occupancy was at 83.8% in the fourth quarter, based on numbers reported from 29 contributors through November and December of last year. That could suggest capacity in some markets.

But the primary consideration has to be whether or not the patients being discharged to the SNF setting have a skilled need, she told Skilled Nursing News.

“We don’t want to be sending all kinds of patients [to a SNF] just because we want to free up a bed for the hospital,” Bober said. “In today’s world, even forgetting about coronavirus, you always want to think home first. The hospital’s not a place that everyone needs to be — there’s a lot of germs and things there.”

Three-day stay waiver potential

But with alarming stories emerging from Italy about the pressure on that country’s health system, and one analysis from the Harvard Global Health Institute predicting dire strain on the U.S. hospital system if the coronavirus spreads unchecked, bed capacity is becoming more of a concern. Several skilled nursing providers have already begun to hear from their hospitals about the need for SNFs to step up and provide overflow bed capacity for the acute care setting.

And while many providers are determined to serve as good partners amid the spread of the novel coronavirus, easing the burden on hospitals requires overcoming some logistical and clinical hurdles.

“We’ve already been alerted by a lot of our hospitals to be prepared to take patients that they can get out of the hospital, so they have more space freed up — whether it be isolation units or certain other types of areas where they can accept COVID-19 patients,” Tim Fields, the co-founder and CEO of the Niles, Ill.-based Ignite Medical Resorts, told SNN.

Fields also noted the three-day waiver announced by CMS last week as a major piece of the puzzle in terms of how SNFs can help hospitals prepare for a COVID-19 patient surge, though the Ignite team as of Monday was still awaiting confirmation on how Medicare wants SNFs to admit and bill for those patients admitted on the three-day waiver.

Once the billing snags are untangled, Fields expects the three-day waiver to be one of the ways SNFs can help ease the strain on the acute care system as it takes on an influx of COVID-19 cases, though how that plays out exactly will vary by market.

“The three-day waiver obviously helps because they can get patients out quicker, they don’t have to wait three midnights to get in,” he said. “They can also accept patients from home … it’s all to unclog the ER. I think what you found in other markets, like Italy or China, is that the hospitals were not prepared to take on the influx of these cases. So I think the U.S. government is starting to try to learn from that.” 

Bober agreed, though she also stressed such decisions should be made on a case-by-case basis if the patient needs skilled care.

“To give an example, let’s just say a patient came into the ER and they developed an infection or something where they’re stable, but instead of tying up a hopsital bed, we could transfer them to a skilled facility, if they had the need for IV infusion or something like that,” she explained. “Prior to all of this, we had that three-day rule. So this [waiver], I think it definitely helps the organizations to revisit and take a look at: Is this a potential patient that could go to a SNF right from the ER?”

Start talking before the surge

SNFs and hospitals have to be in open communication as COVID-19 continues to spread, and Cascadia Healthcare, which has operations in the Pacific Northwest region of the U.S., has already begun to take steps to ensure that both sides of the health care spectrum know what’s expected of them.

“In Idaho, where we are the largest post-acute/skilled provider, we are still at the front end of the spread of COVID-19,” Steve LaForte, director of strategic operations at Cascadia, told SNN via e-mail. “But we have begun discussions with one of the largest hospital systems in Idaho, St. Luke’s, about how we can increase our dialogue and create efficient systems for managing discharges from the hospital and hospitalizations from our facilities, in order to ensure that the best care is given and neither provider is creating any inefficiencies or overwhelm for the other.”

In Texas, where the short-term-stay-focused Bridgemoor Transitional Care operates, hospitals have been asking about bed availability, the services Bridgemoor offers, and the patients it can take in, president Mark Fritz told SNN. Some of the health systems have requested infection control protocols and procedures; for them, the fact that all of Bridgemoor’s rooms are private has been a major positive, he said.

One patient group that’s been top of mind, in Fritz’s conversations, has been pulmonary patients.

“I think what they’re looking at if some patients they would normally keep in the hospital a few more days, they could send out,” he said “Things like [chronic obstructive pulmonary disease], pnuemonia, pulmonary hypertension, pulmonary embolism, bronchitis — any kind of respiratory failure was their priority.”

There are, however, some key logistical considerations that SNFs have to consider as they work with hospitals on taking in new patients. For one thing, they might end up facing their own bed capacity problems.

“We’re already running high occupancy, so it’s not like we have a lot of open beds right now,” Fields told SNN. “But if we get to the point where we’re getting more influx, we’re also going to have to change our pattern, in terms of who we can safely discharge back home. That might be: How do we have a more defined care plan in place, to get some of those folks that can get transitioned home transitioned home, so we have beds open?”

Bed availability was also top of mind for the Cedar Park, Texas-based Bridgemoor’s managed care partners, Fritz told SNN — or at least that was the impression he received from the conversations that the managed care organizations (MCOs) have had with the operator.

For Cascadia, St. Luke’s has requested that the SNF operator keep an eye on hospitalizations, particularly those related to influenza, and focus on not sending patients out “unless it’s truly an acute situation that can’t be handled at the facility,” LaForte told SNN.

One thing was clear — whether it’s between the SNF and the hospital, the SNF and the patient and family, or between the SNF and the MCO, communication will be essential in the coming weeks and months.

“Our guidance for others is to jump into these conversations as soon as possible across the care continuum, and start to get plans in place to manage patients and residents between the hospitals and the SNFs,” LaForte wrote.