Inside an Ambulance Company’s Plan to Redeploy EMTs as Nursing Home CNAs — During COVID and Beyond

Staffing shortages were a problem for skilled nursing facilities well before the current national emergency, but COVID-19’s behavior has exacerbated the challenges.

Asymptomatic workers who moved from facility to facility — and who, by nature of their work, from patient to patient — were a major part of the reason the Life Care Center of Kirkland in Washington had such a severe outbreak, and pose a major obstacle to successfully keeping the novel coronavirus out of the SNF setting.

And because of a shortage in testing across the country, it’s difficult to get a clear picture of who may have the virus and who might not.


Those factors add to the difficulty of staffing a SNF adequately during the pandemic. After local reports of such shortages at SNFs that it served, the San Leandro, Calif.-based Royal Ambulance decided to redeploy some of its emergency medical technicians (EMTs) at facilities in need with a title change: The EMTs would work as certified nursing assistants (CNAs).

The program, called Project “Helping Hands,” had sent more than 40 EMTs to eight facilities for one or multiple shifts as of May 8, Royal Ambulance senior territory manager Mac McKissack told Skilled Nursing News on an interview recorded that day.

“Our peak kind of hit that second week of April, where a lot of our SNF customers were seeing staff shortages during shifts,” he told SNN.


When McKissack saw the names of facilities that Royal Ambulance worked closely with, he reached out to the administrators and found that their greatest need was staffing — which he pointed out had been the case even prior to the COVID-19 pandemic.

Royal Ambulance was at the same time seeing a decline in call volumes, even as it had “a clinically qualified workforce,” according to a press release. So McKissack reached out to a SNF with which Royal worked closely.

“Within two hours we had two EMTs deployed at that facility,” he told SNN on May 8. “And then we had two EMTs around the clock for 24 hours for about two weeks. That’s really how the project started.”

Alameda County, Royal Ambulance’s home county, approved the change of workforce, as did San Mateo and San Francisco counties; Royal Ambulance is working closely with the Alameda County Emergency Medical Services Agency and most of the SNFs in that county to provide staffing, McKissack said.

In Santa Clara County, Royal Ambulance was still working to get approval as of last week. The county requested that the company create and present a plan for how the EMTs are trained to perform CNA duties, so Royal Ambulance developed a program that it has been testing on its EMTs; it’s almost ready for presentation to the county, McKissack explained.

The EMTs are performing everything a CNA might do in the nursing home; the only constraint is that they cannot pass medications, he added. The EMTs themselves volunteer to participate in the project, but they still are paid; they simply go from a basic life-support ambulance shift to working in the SNF.

Royal Ambulance puts out available shifts that EMTs can pick up, and though it cannot always guarantee availability, it has built up a roster of about 30 to 40 people who are the first call for filling holes at a SNF.

“Some facilities are able to say: We need two shifts per day for the next two weeks,” McKissack told SNN. “But honestly, most of the requests are for last-minute requests, when facilities have no-call, no-shows. That’s the most of what we’re getting, and those are one-offs.”

Predicting the need is difficult, but McKissack said he has noticed is that it depends on when the SNFs get their facility-wide COVID-19 tests. Once facilities receive their tests, the EMTs tend to get called in. After a couple weeks, the usual staff can return to work and the SNF does not need Royal Ambulance’s EMTs, McKissack said.

“My conversations with the customers, now that the program is in place and the word has been around the Bay Area — they call me preemptively, saying they’re going to get their tests soon, and they’re anticipating nurses, CNAs, staff to choose to self-quarantine,” he said.

And even though this program was sparked by the COVID-19 crisis, Royal Ambulance plans to keep it available to its skilled nursing customers after the pandemic passes.

“This is something that can be used,” McKissack said. “It doesn’t have to be for COVID. SNFs experience flu outbreaks, and if there’s an outbreak in a facility, even if it’s not related to COVID … there’s staff shortages. So we’re happy to keep this option available for them.”

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