As the chief medical officer for publicly traded nursing home giant Genesis HealthCare (NYSE: GEN), Dr. Richard Feifer has a bird’s-eye view on the strategies that hundreds of individual nursing homes have implemented in the fight against COVID-19.
Appearing on the most recent episode of SNN’s “Rethink” podcast, Feifer was blunt about the decisions that operators face as the pandemic drags on, calling on the federal government to take all steps necessary to provide as much personal protective equipment (PPE) as possible — while also advising providers not to necessarily wait for officials when considering the implementation of stricter guidelines.
“In some cases, it means that organizations might get out ahead of CDC on some infection control practices,” Feifer said. “And in some cases, that may turn out to be unnecessary. But it’s better to risk overreacting in the face of this pandemic than to risk under-reacting, or being a little bit too late — because lives are at stake.”
A transcription of the interview is presented below; the episode is also available on SoundCloud, Apple Podcasts, and Google Play. If you like what you hear, be sure to subscribe on the podcast service of your choice so that you never miss one of our twice-monthly episodes.
Please note that this interview was conducted and recorded on the morning of Wednesday, April 1, and thus reflects the situation as of that date.
Tell me about what you’re seeing on the ground as of today.
This is obviously an unprecedented situation. Nobody’s even imagined a pandemic like this before, and therefore nobody’s fully prepared. We have residents and families who are having to confront situations that weren’t even thought of just a few weeks ago — and providers as well. It’s evolving and changing every single day. So from a skilled nursing and nursing home perspective, we have to be nimble.
We are learning on the fly; we’re sharing with one another across the industry in ways that are truly extraordinary, and we’re having to figure out answers to new problems on a minute-to-minute basis. Some of our biggest challenges right now involve access to testing patients with potential coronavirus disease, as well as the supply of personal protective equipment — especially masks and gowns to keep both the staff safe, as well as the residents.
Let’s dive into the PPE — obviously it’s garnering national attention across care settings. Just this week I saw a case where a doctor at a hospital in New York said she was given a Yankees-branded rain poncho to use as a gown. How bad is the shortage at Genesis, and for nursing homes more broadly?
We’re all struggling with the national shortage of PPE. Everyone’s experiencing that, and everyone’s dealing with it in somewhat different ways. Across Genesis, we’ve been able to maintain a supply of standard face masks, and N95s, for situations where there’s high risk and when they’re needed — and gowns, up until this point. And we’ve done that largely by going to various sources around the world to obtain supplies where we can, when we can, and by shifting supply around among our various facilities all around the country — from areas that don’t need quite as much, as they’ve been able to obtain, to facilities that do because they’re in hotspots.
That’s getting us by on a day-by-day basis. But that’s not sustainable. The nation’s shortage is going to reach a critical point at some point in the next few weeks, and then we’re going to be looking at alternatives that are certainly not preferable — but they may be necessary backup plans. So you mentioned using somewhat unusual coverings, whether it’s garbage bags, or raincoats, or what have you. We are not at that point yet, and we hope to not get there.
But in order for that to turn in a positive direction, so that we really don’t need to resort to such solutions, we need a greater supply. We need greater federal intervention. We need full implementation of the Defense Production Act and other solutions like that.
I feel like there’s a lot of confusion out there about the availability of testing. We saw CMS earlier this week change its rules around lab providers, so that they can now be reimbursed for actually going into the nursing homes and providing those tests. What are you seeing at Genesis in terms of access to testing? Functionally, how is that working right now, and what needs to happen to get more people tested?
There is a huge gap related to the access of testing in skilled nursing facilities today — and any suggestion otherwise fails to see what’s actually on the ground in America’s nursing homes. And that gap is costing lives. I can’t say it any more clearly. This is deeply concerning.
There is a shortage of the swab kits that the laboratory suppliers to nursing homes are telling us on a daily basis — and that shortage has been getting worse day by day, not better. And even when we can obtain the swab kits, the turnaround time for labs for nursing homes ranges from three days — that’s the fastest — up to 11 days. This is completely unacceptable. We need to sound the alarm nationally.
So many of the strategies that we’re seeing the federal government and states employ depend on accurate, widespread testing — the idea of separating nursing homes into facilities for people with and without COVID-19, for instance.
Absolutely. One of the principles of epidemic management that we’re focused on is cohorting patients — cohorting patients who are positive for coronavirus disease away from those who are not. That’s optimal in separate facilities, where there’s no risk of spread within a facility. But cohorting is the principle, and you can’t cohort patients if you can’t know with reasonable certainty who has the disease and who doesn’t.
The data from CDC, published in the MMWR just last Friday, suggesting that 57% of people who test positive are asymptomatic, who don’t have symptoms. That’s deeply worrisome. So that’s one of the reasons why we must do testing.
How is morale among the staff at Genesis? How have the frontline workers responded to the crisis?
The people who are coming to work each day in America’s nursing homes and throughout the health care system — the nurses, doctors, aides, therapists, PAs, NPs, all of them — they’re the heroes, and they are coming to work, and they’re putting themselves at risk to care for those that are in our facilities. They are doing all that they can in extremely challenging situations. We are doing all we can to support our leaders and support our frontline health care providers and caregivers to keep morale up.
Certainly, when they have an exposure and come down with symptoms, or have any suggestion that they might have coronavirus disease, they can’t come to work. They need to go home and be quarantined for 14 days, and so that puts significant strain on staffing. Additionally, some people have medical conditions that get in the way of their ability to work. And then there’s a lot of anxiety out there — and I do appreciate that.
So staffing was a challenge. It was a challenge even before this pandemic in American nursing homes, and this has made the situation worse. So far, we’ve been able to keep up with appropriate and necessary staffing levels, but that problem is going to get worse as well.
We’ve seen senior living providers, such as assisted and independent living companies, see an opportunity to solve their staffing problems given the record-high unemployment filings, particularly among people who worked in the service sector; if you worked at a restaurant or bar or hotel that closed because of COVID-19, you could easily slot into a hospitality-focused senior living campus. It could be a win-win for operators and people who need jobs. But nursing home workers are more specialized, obviously, making it harder even with some loosening of the rules around aide certification.
The federal waivers around aide certification, and other steps that are being taken to make it easier to have providers potentially use their license across state lines — these are all really important and very helpful steps. But they’re not enough.
The challenge that we’re facing right now with regard to staffing is one that is likely going to get worse as this pandemic gets worse, rather than better. I wish we could leverage all those unemployed people who are out there, but there’s a certain skill level that’s required to perform care in a nursing home — and that’s a huge challenge that we face.
I also wanted to touch on telehealth. CMS has taken pretty rapid steps to remove tons of barriers to providing remote care in nursing homes, but how easy is it for a facility to implement a telehealth program given everything else that’s going on?
The telehealth waivers that were put in place this week and recently are extraordinarily helpful, and very important, and will go a long way to ensure that physicians, nurse practitioners, PAs, and others are able to support nursing staff and provide care for residents in skilled nursing facilities. This is one of the most important steps that the federal response has provided, to support that care.
Telehealth doesn’t fully replace in-person care, however, and we do believe that there’s still an important place for having physicians, nurse practitioners, and PAs in nursing homes side-by-side with their nursing colleagues, evaluating patients in person.
But when that’s not possible, then certainly telehealth is an excellent solution. And it is something that we all can — and are — implementing nationwide right now. So we’re grateful to the federal response to support that.
Is there anything else that federal or local governments can do right now to really make life easier for you and your teams on the front lines? Is there anything that maybe is on your wish list that hasn’t happened yet, and that you think the industry should be advocating for right now?
Well, it’s not going to get easier for any of us right now. So, if you don’t mind, I’ll reframe the question. What I’d like to see is federal and local support for collaboration across the health care industry at a local level — collaboration with departments of health, and collaboration with acute-care hospitals. What we’re starting to see is insufficient collaboration; we’re seeing a more narrow or siloed approach, occasionally, as to where patients should go and how we should manage the surge that we’re seeing of patients.
Some states and some local municipalities have done a great job of this, where we’ve seen hospital systems and skilled nursing facilities work together to figure out the best way to care for the overwhelming volume of patients that are coming at us. And they work together to figure out the safest way to care for those with COVID-19 disease, and the safest way to care for those who do not — and who are the frail elderly in American nursing homes and are highly vulnerable.
That collaboration is important, and federal and local officials could be supporting that. In some cases, we are not seeing that; we’re seeing an approach that just looks at the needs of acute-care hospitals without taking into taking into account the lives and the risks to those lives in nursing homes. And that deeply worries me.
I don’t want to talk about positives coming out of this crisis, per se, but it seems like a lot of the concepts that for individual nursing home operators have been more theoretical or big-picture — like population health management, or social determinants of health, or collaboration across the continuum — become very real very fast.
Absolutely, you know, we’ve been talking about population health and population health approaches for a number of years now — and that perspective, a population perspective, it’s never been more needed than it is right now. So we all need to band together and think about how to care for the entire population in our communities, and figure out the safest way to do that without just worrying about one cohort at the risk of another.
Before I let you go, what are some of the biggest lessons you’ve learned through this crisis so far? What do you think operators really need to know right now as they look out onto the next month, two months, three months of this crisis?
I think we need to remember that this is something that we’re learning about — this pandemic — every day that goes by, and we need to be constantly thinking ahead about what questions we haven’t even thought to ask yet. If we just wait for guidance from CDC or the department of health, or CMS or any other officials, we may lose this battle, because they’re making it up as they go, just like we are.
We need to all be creative. We need to use our best judgment. We need to put safety and infection control first. That, right now, is all that matters. And in some cases, it means that organizations might get out ahead of CDC on some infection control practices.
And in some cases, that may turn out to be unnecessary. But it’s better to risk overreacting in the face of this pandemic than to risk under-reacting, or being a little bit too late — because lives are at stake.
It’s always easier to back off on an intervention if it turns out not to be effective or not practical or not necessary. But you can’t turn back the clock and start doing something a few weeks ago if we learn later how important it is, and we missed the boat.