Harvard Researchers: Officials Should Order Operators to Convert Certain SNFs for COVID-19 Care

In communities where the peak of the illness caused by the novel coronavirus hasn’t yet arrived, authorities should start designating specific skilled nursing facilities as specialized COVID-19 facilities to ease hospital capacity, according to a Wednesday essay in the journal Health Affairs.

And as they look to make those designations, authorities should not wait on nursing home operators to step up, the authors, both from the Harvard Business School, argued.

“Finally, while it will also be valuable for authorities to interact directly with facilities to gain a better understanding of their capabilities and constraints, it is important that the scorecard and designation process be as apolitical and transparent as possible,” researchers Leemore Dafny and Steven Lee wrote in the April 15 post. “We favor mandated designation over relying on volunteers because mandates can be issued fairly quickly and should mitigate potential gaming or litigation arising from these decisions.”


Multiple voices have called for specialized post-acute treatment facilities, the authors noted; the Centers for Medicare & Medicaid Services (CMS) has issued several waivers designed to make it easier to separate COVID-19 patients from other residents, and has mandated that SNFs establish separate wings and buildings for COVID-19 patients.

But this step can come with complications, as Massachusetts found out when it had to halt plans to create COVID-19-specific SNFs by transferring residents, as several of those patients turned out to have the illness. Noting this, Dafny and Lee advocated for a data-driven approach to identifying facilities that could serve as COVID-19 SNFs.

This approach included constructing a scorecard on the SNFs’ capability of dealing with COVID-19 patients, using the following criteria:

  1. Demonstrated skill and some existing staff with the appropriate training on respiratory distress and complications
  2. Relatively few long-term residents who might require relocation
  3. Significant potential capacity, to allow for scale and isolation
  4. High operational readiness
  5. High-quality management

The measures for the scorecard include a SNF’s share in “COVID-adjacent DRGs [diagnosis-related groups],” share of short-stay residents, total beds, nursing hours per patient day, and the overall quality rating, based on Medicare claims data for 2016 and current information on CMS’s Nursing Home Compare website.

In addition, Dafny and Lee excluded facilities that operate as swing-beds for hospitals, contain a retirement community, or have fewer than 50 beds; they also omitted any facilities with a one-star rating on the CMS Five-Star Quality Rating System for SNFs.

“Because of the many levels of uncertainty around models predicting the timing and magnitude of peak need, we believe it is judicious for most if not all metro areas to identify and fund potential CSCCs in the very near future,” they wrote.

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