Therapy Continues During Crisis, But Worries Over Protective Supplies and Employment Loom

Many therapy teams consider their services essential to nursing home residents — even after the federal government guided the sector to prohibit unnecessary visits to facilities amid the spread of the novel coronavirus.

Even with the push to reduce “unessential” services, the government opened the floodgates for nursing facilities to serve overflow patients from hospitals by waiving the three-day hospital stay requirement to be followed by Medicare skilled nursing coverage. The emphasis on nursing home care should include in-house and third party therapy teams, some industry leaders say — and they remain determined to get vulnerable patients home more quickly with much needed physical, occupational, and speech therapy services during the pandemic.

So even with heightened concern amid the spread of the virus, and with the threat of protective gear declining, therapists are still jumping in to help patients get well — in spite of great risk and putting in extra hours. At times, therapists have been asked by nursing homes to take temperatures and other non-therapy related tasks.

“As direct care staff, therapy professionals in a SNF should anticipate being asked to provide additional public health support activities within the center,” the American Health Care Association noted last week.

Waivers to nursing homes free up hospital beds

In addition to the blanket waiver of the three-day stay rule across the country, individual states — so far Florida and Washington state — have received special 1135 Medicaid waivers that allow them to legally break a host of rules in order to focus solely on fighting the virus.

“It’s really valuable and important to patient care that we’ve got the 1135 waivers — specifically the three-day stay has been waived. That gives us the ability to accept patients from the community without having to go to the hospital for three midnight’s for an inpatient stay,” Cynthia Morton, executive vice president of the National Association for the Support of Long-Term Care (NASL) said, adding that the waivers will prove helpful to hospitals and families that aren’t able to care for a loved one experiencing too many co-morbidities to stay at home.

While the waivers are set to assist growing patient needs during an overburdened health care system, NASL has contacted the Centers for Medicare & Medicaid Services (CMS) to obtain more clarification about licensing restrictions per state.

“We have many therapy teams that provide services near state lines,” Morton added.

Therapy is an essential service for nursing home patients, and therapists are proud to be part of the team, Morton said. Patients are there to be rehabbed and recuperated in order to go home, and so far, NASL isn’t hearing any restrictions for therapy care, she said.

Both trade groups and individual operators have generally considered therapists to be “essential” under the ban on visitations, though SNN has reported anecdotal cases where buildings turned away therapists.

“We want to keep their care stable. We want their care to be continual. And we want people who can be, in the normal course, recuperated and sent home because they may be a little scared right now … We want to keep those care processes continuing and advancing [for those] who need to be discharged,” Morton said.

Dwindling protective gear

If the U.S. doesn’t find additional personal protective equipment (PPE) such as masks and gowns, 20% of the nursing homes in the country will be depleted by this week, the American Health Care Association (AHCA) announced last Wednesday.

“We’ve got to conserve the PPE because at the moment, we are in a bit of a shortage … We’re trying to be very careful about therapists working in the buildings, but we’re not hearing problems of therapists getting into buildings,” Morton said.

NASL is working very hard to get more PPE, she said — a concern that has been voiced to CMS, although there’s no known movement yet.

For third-party therapy companies like the Frisco, Texas-based based Aegis Therapies, so far not a single nursing home has declined therapy services,

“So clearly, our customer base is viewing therapy as essential personnel,” Aegis Therapies chief clinical officer Mark Besch said, adding that the company is working with clients on collaboratively adjusting staffing patterns to find the best options.

Aegis is currently working with an physician for guidance around major decisions dealing with protective gear shortages, and acknowledged that the problem is “worse in some parts of the country than others,” Aegis Therapies president and CEO, Martha Schram, said.

The company is looking “every night for some possible sources online,” she added.

Protecting staff at all costs

So far, Aegis has not had a case of being forced to decline therapy due to lack of PPE, and if shortages were to continue, the company would look to infection control guidelines to indicate appropriate modes of care.

That said, if faced with a lack of PPE, “we are not going to tell a therapist to treat that patient without the appropriate personal protective equipment. And so the alternative then is to say, we cannot provide that care,” Besch said.

He recommends that all providers reach out to local health departments to seek further guidance.

“We’re told that some health departments may have access to some supplies. But as a last resort, we realized that we may be faced with making that decision, and we will for the protection of all involved,” Besch said.

Looking to regional health departments by country is advisable when additional information is needed, Beach and Schram said.

On a positive note, daily education is growing with every passing day that Aegis is in communications with therapy teams.

“I think actually, as each day goes by our repertoire, if you will, of scenarios are growing. And that actually helps us be more responsive, Schram said.

But one therapy company has leadership experiencing more questions than answers with uncertainty around how CMS defines essential personnel. 

“We’ve had some nursing facilities say to us, nope, you can’t come in, you’re non-essential personnel. We’re not doing therapy, and other facilities say, yeah, come on in. You guys are essential personnel, and we want you here,” Key Rehab and GeroPsych senior vice president of clinical and regulatory affairs Michael J. Gorman said, adding that he needs CMS to more clearly define “essential” to help him make clearer decisions for his team.

Grey areas of safety

There are also grey areas muddying the waters of knowing when to safely outsource a therapist. For example, Gorman received an e-mail from a vice president about a therapist who used a public bathroom at a truck stop in Texas, and then again at a McDonald’s location in Oklahoma. The question was around her limitations in returning to work given her potential exposure to the virus.

“I’m thinking, I don’t know. How am I supposed to know what they’re doing in the restroom at Miami, Okla.?” he asked.

But similarly as the Aegis team suggested, he contacted a regional health department point person, the Bureau of Community Health Services at the Kansas Department of Health and Environment, and received a speedy answer.

“She was quick, and I think knowledgeable, so that it really helps to have a resource to go to say: Well, what do we do in this convoluted case?” he said, adding that the therapist was safe to proceed to work because the cities in question were unaffected by the virus.

In another case, Gorman received a call from a supervisor in Iowa, and was told a patient was put in an isolated room but did not have COVID-19. He was asked to send in therapists for physical and occupational therapy, but neither company had enough protective gear.

“So how are we supposed to do therapy? They said, well, you have to go get your own N95 masks. And you can’t get an in 95 mask — they’re on back order. Then I was told, you guys need to have your own masks and gowns. And you’re supposed to send people out, I asked?”

Currently, Gorman plans to follow up with the facility and talk to the director of nursing and make sure that the story is accurate. He admits to struggling with the Centers for Disease Control and Prevention (CDC) website to quickly determine where the virus has spread.

Many facilities in rural areas are more isolated, especially the mom-and-pop buildings, and it can be very difficult for them to get accurate information, he said, adding that some of his clients are some of these smaller standalones.

“Nobody there has time to study Medicare or CDC regulations,” he said.

Intricate screening process

Paragon Rehabilitation — the therapy arm of the Louisville, Ky.-based Trilogy Health Services, conducts a diligent screening process when a therapist returns to work, which includes learning where the therapist has traveled and where they plan to work next.

After this process, Paragon decides whether a therapist has had potential exposure to the virus during their travels, Paragon Rehabilitation’s chief operating officer Madhu Krish, said.

“Then if you are coming to our campus, we do ask you verbally, did you go to any other campus? Even if you are a full-time employee with us, you might be doing some PRN job somewhere else, so we are asking them to make sure: Did that campus have potential exposure?” he said.

When the therapist returns to campus, Paragon has a team waiting at the door for screening to ensure the therapist has no symptoms or temperature.

Some cuts to contract therapists

Anecdotally, in-house therapists are seen as more essential than contract therapists.

“I think the concern there is that they go from facility to facility so they’re at a higher risk of disease transmission,” American Speech–Language–Hearing Association (ASHA) director Monica Sampson told SNN last week.

Concerns about employment and income loss are amping up, and these part-timers may be relied on less right now due to the vulnerable nature of heath care workers and the patient population.

Some facilities are prioritizing speech — and specifically swallowing therapy — over cognitive and other kinds of care, ASHA has heard anecdotally.

“We think someone who is receiving services for swallowing safety is more likely to receive them than someone who’s being seen for cognition or language,” she said.

Swallowing disorders are often associated with high-risk conditions, and can lead to compromised swallowing and result in aspiration, which “is basically food or liquid going into your lungs, which can result in pneumonia and poor nutritional intake,” Sampson explained.

Stroke or traumatic brain injury — as well as a host of neurodegenerative conditions like amyotrophic lateral sclerosis (ALS), multiple sclerosis, and dementia — call for this kind of therapy.