As both the chief medical officer for Signature HealthCARE and president of AMDA, the Society for Post-Acute and Long-Term Care Medicine, Dr. Arif Nazir has a micro- and macro-level view on how skilled nursing facilities are fighting the coronavirus.
And even in these early days of the crisis, Nazir believes that the sweeping emergency steps the government has taken — from expanding telehealth coverage to waiving the three-day stay rule for Medicare SNF coverage — will make a permanent mark on the industry.
“I do agree a new era of health care is upon us,” Nazir said on the most recent episode of SNN’s “Rethink” podcast. “I really do not believe that many of these things will be reverted back, and they don’t need to be reverted back.”
Nazir joined “Rethink” to talk about what he’s seeing on the front lines as the top doctor for the Louisville, Ky.-based Signature, a leading player in the post-acute and rehab space. But he also used the opportunity to discuss the viability of some of the large-scale ideas that policymakers have floated to beat back the coronavirus tide, from using nursing homes as hospital overflow units to converting existing infrastructure into emergency sites of care.
Excerpts from the interview, condensed and edited for clarity, are presented here. Be sure to download the full episode from SoundCloud, iTunes, or Google Play — and subscribe wherever you listen to podcasts.
Editor’s Note: The COVID-19 situation has been evolving rapidly; please note that this interview was recorded on the morning of Friday, March 20.
Let’s start with the building-level situation. What are you seeing on the ground from residents, caregivers, and their families?
That’s a very good question. When you think about working in a stressful environment, our teams in the nursing homes, unfortunately or fortunately, are used to working under that environment — particularly over the last few years, and maybe a decade or two.
I think nobody has seen more change than our frontline staff in the nursing homes, skilled facilities, because the health care system is expecting a lot from them, right? We hear people likely say that the hospitals of yesterday are nursing homes today — well, that statement is loaded and it is true. But unfortunately, that change and that evolution, from the staff perspective, has not come along with a lot of strategic inpouring of resources and training and expertise.
Over the last many years, we have made our staff do things which have been out of their comfort zone. So they are very used to being safe in stressful situations. Particularly with the passing of the Patient-Driven Payment Model, or PDPM, as it is known, the acuity has risen as expected, and so they have been working under stress. But nothing has really mirrored the stress of the recent pandemic.
I think stress absolutely is there — just from the fact that these staff members have personal lives, too. There are already many of them who are struggling in terms of their day-to-day at their homes, their personal life, and to deal with this unpredictable environment where they do not know exactly what they’re dealing with, and the whole social and financial structure changing around them — all of that causes stress.
But I would say though, that if I have to choose one word in regards to what I’m hearing, and I’ve been to a couple of nursing homes myself — but I’m limiting my visits for obvious reasons — the one word that comes to mind after I hear those stories and visit them is commitment. It is just unbelievable for me to see how much commitment people can show in the face of adversity. If anybody wants to see that in play, I think nursing homes are the examples for that.
I really just cannot say enough about how patient and committed our staff are. CMS, the Centers for Disease Control, and all the experts — very rightly so — are sharing a lot of information which actually has to be operationalized. Now, operationalizing things in nursing homes should never be taken lightly. It really requires a lot of system-level change for people to design, and for others to go through to respond to it. It just amazes me how well and how quickly our staff at the front line are adjusting, based on the feedback and the input they are getting from the home office or from the CDC and so forth. So I’m just really in awe of how well they are performing at this point — and trying to stay ahead of all of that.
In terms of families, that has been a very hard thing — for the families to be cut off from their loved ones in the nursing home. We had a lot of struggles there initially; the families were just not understanding why we are recommending that. But of course, naturally, it has taken some time for them to understand the seriousness of the issue.
I think the national dialogue, which finally, finally is emerging, has been very helpful to make them more aware, and they’re more understanding. As you have seen in some of the pictures — really heart-wrenching pictures — where family members are trying to see their loved ones through the windows, and trying to do picnics outside their rooms.
So they are all trying to adjust, but this is also new — and when you add the level of dementia and cognitive impairment among the patients themselves in the residence, it has been very hard for them to really understand why they can’t see their loved one, or for them to be off their routines. All of that has been very tough.
Of course, all of that then adds further, more stress from among our staff. So kudos and really, really great work from our staff and the front line so far.
I think it’s critically important that as an industry, operators are open and honest about the stakes of keeping people away from nursing homes — I’m personally a little disturbed by some of the media narratives emerging from local outlets that have framed the situation as: these nursing homes are keeping our loved ones from us.
You just hit a very important point there. I’ve been trying to really bring this perspective to the world for a while, in my various roles: We need to not take lightly the role of positivity in our setting. The fact that we have made nursing home staff, and the operators, and the teams who work in nursing homes so defensive all the time, based on negative media projection of what really happens in nursing homes, we are shooting ourselves in the foot.
You just cannot create high-quality structures based on negativity where people have to, no matter how hard they work, be thrown under the bus based on one bad outcome. We have to remember that we as a society — doesn’t matter if we are media, we are laypeople, whoever we are — we really have to look at the bigger picture.
People working in nursing homes provide the hardest care imaginable. It’s very taxing physically, it is very taxing emotionally, and it never really pays enough for all the hard work that is being done. Most of these people are driven on emotions, on ideas, on their passion — and their personal commitments to others and humanity.
So if we do not do a good job of presenting that well, we really take the passion out of them. It can be very, very depressing, honestly, for the frontline to see that: when the whole setting is not acknowledged for all the hard work that is done. So I think positivity in the face of crisis is going to be huge. And I really hope and really expect the media community to be very careful about that.
Let’s zoom out a bit and talk about some of the bigger-picture solutions we’ve been seeing. CMS positioned its decision to waive the three-day hospital stay requirement for Medicare nursing home coverage as a way to ease the burden on hospitals — specifically by allowing them to take non-COVID-19 patients, leaving precious acute-care beds free for coronavirus cases. How realistic is that?
Everybody knows how much effort has been put into, and how much advocacy has been pushed forward, to get this three-day waiver rule. It’s interesting how a crisis would kind of change things and make things happen very quickly. So we’re excited about this notion of a three-day waiver. But what really concerns me in both my roles — and most importantly, in my role as a geriatrician — I really do not think that the world really understands is how frail patients are in nursing homes. That’s my biggest worry.
So the key to your question is the term “non-COVID patients,” right? To me, that is where the issue is: How are we going to really know which patients are truly negative? Because the stories I’m hearing, we just don’t have enough testing available. Many patients who are getting admitted to nursing homes without having, quote-unquote classical symptoms, are not even being tested for COVID. So what assurance do we really have that which patients who are being touted as COVID-negative are really negative, right?
This is a very sensitive issue. We really need to make sure that we have, before we start making nursing homes a bed-overflow health care partner for acute-care hospitals, we absolutely have to make sure that we perfect the science of realizing which patients truly are negative and which patients are positive. Because I cannot overemphasize the importance of the fact that that one COVID-positive patient can significantly harm many, many patients in nursing homes — and actually pretty much bring the whole building down. We saw that happen in the nursing home story out of Washington state.
So that’s my biggest concern, that we really just cannot be very, very pushy about this without making sure that we have the right testing, the right protocols in place. Yes, if we can do that, then it actually makes for a reasonable strategy to think about it. But we just have to, again, realize that nursing homes are not hospitals. Just making a general policy where non-COVID patients, no matter how sick they are, are going to end up in nursing homes is really not the right choice either.
There has to be some framework around it — like what kind of acuity, what kind of illness — and then making sure that we have a way to understand which nursing homes really do have the capability of providing that very high-acuity care.
I think in the framework of some of those sensitivities, I think we should be able to do that. But one thing I’m just going to highlight here is that: Why does it take for a crisis like this to actually hit for us to start thinking this way? Why were we not proactive in thinking about such kinds of partnerships 15, 20 years [ago]? Why did not we really invest in funding our post-acute skilled nursing homes previously? Why aren’t we ready for this? Why are at a place where more than 70% of nursing homes actually run a negative profit?
We are behind the ball on this. Had we funded and had we strategized better in regards to how nursing homes and skilled nursing facilities can be a better partner to hospitals — had we strategized before, and funded it well, I think we would not be facing the crisis we face today.
It’s interesting that you mention how the crisis is really accelerating solutions to problems that have been around for years — not just the three-day stay waiver, but also the telehealth restrictions that CMS basically erased with the stroke of a pen. When this is over, will it be possible to go back? It’s hard to unring these bells.
This just brings to my mind my own training as a geriatrician. One difference between well-trained geriatricians and many other doctors is that geriatricians are really good at strategizing for a negative outcome in the future. Actually, for geriatricians, so many negative outcomes — like deaths — are actually not maybe a negative outcome. A peaceful good death, which is planned well, actually is a great positive outcome — so geriatricians have this perspective of thinking things through and being proactive.
To me, the government’s actions right now are very reactive. And that is what human nature is: Things we do not understand, unfortunately, fall low in our priority list, and we never prioritize them — even though the geriatric community knew how important it was to really plan telehealth well, how important it was to work on issues like three-day waivers, and so many other things that are happening right now. I wish that there was an opportunity for the government to understand them proactively, and then strategically deal with them a long time ago.
It is very important that CMS understands, and government understands, that there’s a very well-trained geriatrician community, there’s organizations like AMDA. … It’s very important for policymakers to start working strategically and proactively, because there are so many other disasters that could hit us where we will be stuck in this kind of situation.
Reactivity never leads to the best answers, but I’m at least glad, in response to your question, that finally we have seen that telehealth is available for our seniors now; we’re seeing a three-day waiver. We’re seeing some extra funding finally going into nursing homes. But I wish we could have done this in partnership with other organizations proactively, a long time ago.
It just makes me sad that for the very educated, strongest country in the world, it takes a pandemic for us to make the right moves now, finally.
But I do agree a new era of health care is upon us. I really do not believe that many of these things will be reverted back, and they don’t need to be reverted back. I mean, why should not telehealth be a very important part of our day-to-day practice?
My jaw almost hit the floor when I saw the government basically waive HIPAA enforcement — privacy under HIPAA has been such a foundational part of the health care landscape for decades, and CMS just wiped it away overnight.
We make things to be quote-unquote fundamental based on our perspectives. To me, way more fundamental is the fact that the care needs to be promptly available and needs to be interdisciplinary.
The fact that we went overboard on HIPAA regulations, that we actually put barriers to interdisciplinary care and to meaningful exchange of communication between providers, I think we just went way too overboard — so much so that we pretty much compromised the most fundamental aspect of any care, which is that it needs to be well communicated to all players, and then it needs to be interdisciplinary.
We need to make sure what we learn from this is: Let’s not tie our hands, or our provider or practitioners’ hands, or health care systems’ hands, by making regulations that are too stern, so that they take the operability away to provide good care.
What about this idea of using alternative sites of care to help alleviate the pressure on the system? Washington state and Florida have received 1135 waivers that allow nursing homes to keep receiving Medicaid reimbursements if they’re forced to evacuate to an unlicensed facility, and Gov. Andrew Cuomo of New York has basically begged the federal government to commandeer university dorms and other buildings as care sites.
AMDA actually just passed a resolution … that absolutely is a must, that nursing homes and skilled nursing facilities should just not be seen as default places for COVID-positive patients. I think it will be a disastrous approach, as we already talked about it. Then the [question] becomes: Where do we go with these patients? We just cannot let them line up in the hallways.
In that resolution, actually, we do also propose a solution, which is exactly what you mentioned — we need to repurpose new places. For a nation that has really invested so much in our casinos and our stadiums and our entertainment, and all that — that’s fine and dandy — I think now it’s time for us to start thinking about: What about health care? I think at this point, a lot of funding needs to go very quickly in meaningful alternative sites of care. Again, this could be repurposed hotels, convention centers, whatever that may be.
But again, I would like to highlight — very importantly — that this is not a decision which policymakers should just make in a silo. This is a time for them to pull in organizations like Signature HealthCARE, which have shown so much innovation over the years, to AMDA, the Society for Post-Acute and Long-Term Care, and many of the national leaders — geriatric or senior organizations who know the setting really well — to really pull them in before they finalize any policy.
It’s not just about engineering, that you have to put a building, a structure together. There’s a whole lot of science that goes into how well these things can be built to make sure that they are geriatric-friendly, they can really do the job. We need to make sure that we go about it very smartly. It requires a big collaborative effort. And again, AMDA, Signature — we are all here to help in that regard.
I do hope there’s a big movement towards that. We do need these specialty centers where COVID patients can get the best care. And we know the setting, we know these patients, we know interdisciplinary care. We the geriatricians are ready to jump in and help and provide expertise in any way we can. So I think it’s a very viable option. It absolutely should be looked into.
I think that’s a great place to close, but I also wanted to extend a special thanks to you and everyone on the front lines of this crisis.
I’m just going take a second to really acknowledge and commend my teams on the front line. Doesn’t matter who you are — doctor or nurse practitioner, nurse, CNA, LPN, operator, family member. Whoever you are, my hat’s off to you. You’re just doing amazing, heroic work, and we just can’t thank you enough as a country for doing that. It’s time for everybody to come together to be positive. It’s not time to point fingers. Let’s just be positive and let’s put all our expertise together.