As Nursing Homes Look to Separate COVID-19 Residents, Rural Providers Face Tough Choices

As hospitals try to cope with a surge of COVID-19 patients in need of acute care, skilled nursing facilities have moved to make preparations to take in overflow capacity from the health systems and acute care facilities.

In addition, states have begun calling on nursing home companies to create dedicated buildings exclusively for residents with COVID-19, with the goal of safely caring for the infected — and preventing the disease’s spread to others.

But the near-universal challenges of staffing and maintaining a supply of personal protective equipment (PPE) are heightened for SNFs in rural areas, and the difficulties posed by distance grow even greater during a pandemic of infectious disease.

“Rural SNFs face their own challenges, and challenges exacerbated by their location — that is no different in the case of COVID-19,” Erin Shvetzoff Hennessey, CEO of the Minneapolis-based operating and consulting firm Health Dimensions Group, told Skilled Nursing News in a March 25 e-mail. “The major issue right now for rural SNFs is ensuring they keep their workforce healthy as they do not have the labor pool that other communities benefit from. There has been a constant focus on recruiting, retaining, and educating staff.”

Preparations the same — mostly

The basics of preparing a SNF for COVID-19 are the same whether a given facility is in an urban or rural location, Brandon Farmer, the CEO and president of the Alabama Nursing Home Association (ANHA), told SNN.

“Our rural facilities have been preparing, from a protocol and policy standpoint, just the same as the urban facilities have,” he said in a March 31 interview. “They’ve been preparing utilization of the PPE, and have restricted if not almost completely limited all visitation into the building, screening employees as they come in, taking their temperature with each shift. Those protective and preventive measures are in place across the board, whether that’s rural or urban.”

In Alabama, rural facilities face a unique challenge in that they frequently lack a specific hospital in their county or city, making them “the core of the health care continuum there,” Farmer added.

That means coordinating with regional hospitals on how to handle patients who are positive for COVID-19, as well as how to transport them and when that is appropriate. At the beginning of the outbreak, rural SNFs were seeing less COVID-19 patients, but that has begun to change in recent days, Farmer noted.

The ANHA is working with the state Department of Public Health and the hospital association to identify regional areas of greatest need where hospitals might reach capacity quickly, he told SNN. That should help pinpoint places where ANHA’s SNFs can develop isolated wings or set up facilities dedicated specifically to COVID-19 patients.

“There are some regulatory challenges that have to be addressed, and some licensing challenges that have to be addressed in many capacities, so we’re working through those and trying to be a part of that solution,” Farmer said.

CMS announced an array of waivers on the weekend of March 28 designed to make it as easy as possible to move patients between health care settings and ease hospital capacity, specifically waiving requirements for transfers between long-term care facilities to make it as easy as possible for providers to keep COVID-19 patients away from those who aren’t infected.

Some of those waivers will likely make things easier; one example that’s under consideration in Alabama is reopening a closed assisted living facility that’s in good condition and could house residents, Farmer said.

In a followup e-mail, Farmer noted that some of the specific federal waivers under consideration include the physical environment waiver 42 CFR 483.90 and the “under arrangements” provision for transferring COVID-19 patients to alternate care sites while still receiving reimbursements.

In terms of state-level exceptions, waivers for licensing, certain transfer and discharge requirements, the timeframe for assessments, and pharmacy and physical plant requirements are all under consideration.

The ANHA is the state affiliate of the national nursing home trade group the American Health Care Association, which represents more than 14,000 SNFs and assisted living communities.

AHCA has been issuing guidance on the admission of patients, most recently revising its advice to reflect new findings from the Centers for Disease Control and Prevention (CDC) that illustrated how nursing home residents without any symptoms can still play a major role in spreading COVID-19. Under AHCA’s new guidance, SNFs should assume that all new patients without a negative test for the disease are, in fact, positive.

That can exacerbate another challenge for rural SNFs: the nature of the building itself. Smaller physical plants pose difficulties for cohorting patients coming back from the hospital, Mark McKenzie, the CEO of the Fort Worth, Texas-based Focused Post Acute Partners, told SNN in a March 27 interview.

As a result, it’s drawing on guidance from the CDC, the Centers for Medicare & Medicaid Services (CMS), and AHCA to develop cohorting plans, he said.

“As we’ve talked to some of our hospitals, we have a handful of buildings that, because of the types of patients that we have, it would be difficult for us — even if one of our own patients went to the hospital and somehow got [COVID-19], it would be difficult,” he said. “I’m talking about a couple of our buildings that are smaller in nature, but also happen to have a cognitively impaired unit … we are really working as an organization, and across the system, regardless of a certain industry, on how to manage those particular patients.”

For many rural SNF providers, occupancy has been a challenge — which might actually be of help in the case of COVID-19, since it translates to open beds for potential hospital overflow, Hennessey told SNN in the March 25 message. That’s harder to do in a community that is already operating near full occupancy, she noted.

While the bed capacity for a rural SNF is less likely to be an issue, and they’re more likely to be able to open wings or repurpose entire buildings, any residents that needed to be moved would have to go to the closest SNF, which could be several miles away, Hennessey said in a March 31 message.

“This would only be a last resort if beds are needed in the continuum and to relieve hospital pressure, or to isolate COVID-19 patients in one SNF,” she wrote. “Normally, family visitation is a huge barrier to moves, but right now we are not allowing visitors so this may be an easier conversation than it would be during more ‘normal’ times.”

Navigating supply challenges

The shortage of PPE has loomed across the health care continuum, with harrowing stories emerging across the country of hospital doctors and nurses rationing or reusing equipment.

The nursing home sector hasn’t been immune either; in mid-March, AHCA held a call warning that masks and gowns were running short, with supplies slated to run out in a matter of weeks.

In Alabama, the shortage is more forward-looking, rather than occurring in buildings today, according to Farmer. That said, the situation can vary from building to building. If a facility has had an exposure, then it has to be “aggressively” making use of PPE — but not all buildings have had this happen.

“It’s the anticipation of the fact that we know that those products are going to be harder to come by as we move forward, and so you’re going to be running out of them,” he said. “That’s what the preparation is for.”

For Focused Post Acute Partners, it was fortunate in that its primary PPE supplier was able to give them some warning of a supply chain crunch before the COVID-19 outbreak hit the U.S. in a major way. From December 2019 to the end of January, Focused Post Acute was able to secure its usual orders plus an additional 50%. Then it returned to normal levels, McKenzie explained.

By picking supplies they would not normally have purchased, Focused Post Acute was able to build a limited stockpile, though McKenzie noted that there were indeed limits.

“They did a good job of managing — not allowing us to be, as a business partner, to be greedy or over-purchase,” he said.

In the meantime, the operator has been following CMS and CDC guidelines around the allocation of PPE, constantly reviewing the guidelines to make sure that it is “keeping within the loosened expectations, but still being practical,” McKenzie said.

In addition, Focused Post Acute has been keeping a portion of supplies set aside in the event admitting a patient that’s either COVID-19-positive, or who develops symptoms after admission.

One step that helped was a focus on education of staff around hygiene practices, which was happening as standard procedure because of the start of flu season, McKenzie noted. That meant when COVID-19 began to gather momentum, there was a foundation on which to build education for staff members.

PPE orders have generally been permitted using historical trends, and for some communities, that results in a very small allocation, Hennessey noted in the March 25 e-mail. Though Health Dimensions Group’s communities — which include SNFs and assisted living facilities — have access to procurement through various sources, rural SNFs might have a more difficult time getting an increase in PPE allocations or having the funds necessary to stock up, she added.

“In smaller communities, small fluctuations in census have a large impact financially, and the delay of non-essential surgeries will impact them,” Hennessey said. “The overarching concern in light of COVID-19 is the financial strength of rural communities to withstand an operational pressure like a pandemic.”