Plan to Reopen Nursing Homes ‘Virtually Impossible’ with Current Testing, PPE Capacity

The federal government last week cautiously began laying formal groundwork for reopening the nation’s nursing homes, which have been under COVID-19 lockdown orders since the middle of March.

But many experts both inside and outside the industry have asserted that nursing facilities can’t even think about returning to normalcy without substantially more financial and material aid from the federal government — particularly around strict new testing mandates that could end up costing almost $1 billion per month to meet.

LeadingAge, which represents non-profit operators of nursing homes and other senior care services, has been outspoken in its criticism of the government’s response.

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Soon after the Centers for Medicare & Medicaid Services (CMS) announced the multi-phase reopening plan, the group released a statement calling the proposal “not grounded in reality.”

“Our communities are tired of news conferences, photo ops, and guidance that comes without tangible resources and hands-on help,” CEO Katie Smith Sloan said in a statement. “Nursing homes and other aging services providers know how to fight the virus, but they need real help, not symbols.”

That forceful reaction has been par for the course for LeadingAge and Sloan, who in late April directly criticized President Trump for proclaiming in a national press conference that his administration was “taking very special care of our nursing homes and our seniors.”

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“This is false,” Sloan said in a response to the president’s remarks. “The time for talk, symbolism, and proclamations has passed. It’s time for action from the White House and Congress.”

Sloan joined SNN’s “Rethink” podcast to expand on her perception of the federal government’s response to COVID-19 in senior housing and care, as well as to provide her vision for what comprehensive payment and oversight reform should look like in the months and years to come.

“In any national crisis like this, you’ve got to look for the silver lining,” Smith said during the conversation. “And that, to me, is the silver lining in all of this: If we can have a serious conversation about how to create and build a less fragmented, more integrated system to provide services and supports to older adults — not just residential, but home-based care as well, and home-based services as well.”

This conversation was recorded on the morning of Tuesday, May 19, before the Department of Health and Human Services (HHS) announced $4.9 billion in direct funding for nursing homes last Friday; Sloan welcomed that news in a statement, but emphasized that more funding will be needed.

“These funds are a start in covering nursing homes’ extraordinary expenses related to this public health crisis, but will only go so far in addressing providers’ growing financial needs as this pandemic continues,” Sloan said Friday.

Highlights from Sloan’s appearance on “Rethink” are presented below; download the full episode at iTunes, Google Play, or SoundCloud. And if you like what you hear, don’t forget to subscribe.

You and your organization have been critical of the Trump administration’s response to the COVID-19 crisis in nursing homes. What’s your take on the reopening plan released last week? How realistic is it?

I would just say at the outset that we do want to have a plan to safely reopen nursing homes. But there are just too many homes out there, and other aging services providers, that are still desperately in need of testing and personal protective equipment. And without those, it is virtually impossible to reopen nursing homes safely.

We don’t know when it’s coming. But we need to make sure that that happens.

What about Seema Verma’s assertions that there’s enough tests to go around, and even a surplus in some states? She’s made comments to that effect directly to me and SNN reporter Maggie Flynn during recent press conferences.

Well, my response to that is that’s not what we’re seeing, and that’s not what we’re hearing from our members. I think there’s some geographic disparities in terms of access to testing. But there’s also lack of access to testing with quick results.

So if you have a test, and you have to send it away and don’t get the results back for three or four days, you’re in limbo for three or four days with staff. I just keep hearing over and over again from our members that getting access to testing with quick results is not an easy thing.

It’s expensive to test staff; members are telling me they’re paying $110 to $130 per test per staff [member] — now weekly with the CMS guidance. In New York, it’s twice a week from the governor with the governor’s guidance. And we don’t have a plan for who’s going to pay for that.

It’s an access issue and it’s a cost issue. It’s both — it’s access to tests that have quick turnaround, and then it’s just a cost issue when it comes to the staff.

When can providers expect to see Medicaid-specific relief, and why has it taken so long?

The answer to your first question, which is when, is: I don’t know, but it can’t come soon enough. I think the problem is that HHS has not figured out a way to efficiently get the money in the hands of providers.

The money to Medicare providers — they all know who they are. They pay them anyway, they know where their bank accounts are; they can wire the money.

But with Medicaid providers and other providers — assisted living, for example — the administration doesn’t have that data readily available, and they’ve wanted desperately to avoid an application process. That’s what they’ve been telling us.

So they’re looking for an efficient way of getting the money out, some kind of a workaround, and clearly have not been able to figure out what that is. In the meantime, our providers are hanging on by their fingernails trying to keep their organizations afloat.

That’s an anecdote that I think illustrates a major problem that so many people have always known about long-term care: Because providers largely rely on Medicaid, which varies by state, funding is scattershot and checkered even in good times. Do you think this experience might spur kind of reform around unified payment and oversight?

In any national crisis like this, you’ve got to look for the silver lining. And that, to me, is the silver lining in all of this: If we can have a serious conversation about how to create and build a less fragmented, more integrated system to provide services and supports to older adults — not just residential, but home-based care as well, and home-based services as well.

Right now, not only is it fragmented from a finance point of view, a regulatory point of view, but just imagine the consumer trying to navigate this complicated system; it’s not even a system. It’s a complicated array of services, and to try to figure out what is best for themselves or their loved ones at any time — aging is not linear, right? Everybody’s aging experience is different.

So it’s really important to have choice, it’s really important to have an array of services, and it’s really important to be able to figure out how to get access to those and how to pay for them. My hope is that this pandemic will lead us into that serious conversation that we should have had decades ago, and we haven’t.

That’s my big fear, that the response to this crisis won’t amount to anything more than fines and a handful of new regulations — and I think the fact that we don’t really think about nursing homes until there’s a major problem helped to lead us where we are today.

Yeah, I think that’s right. Particularly with nursing homes, we’re living with a regulatory system that was created in 1987 — and over 30 years ago, nursing homes looked different than they do today. The people who lived in nursing homes, and are served by nursing homes, were different than they are today. And yet we have not taken a hard look at whether we have a regulatory system that actually supports today’s reality, and can prepare us for the future.

We have, for a long time, been calling for a deep review, and taking a hard look at: What are we trying to achieve with our regulations in nursing homes? And are we doing that with the system we have in place?

I would argue we aren’t. It’s a very punitive system. It’s not one that fosters quality, which is really what ultimately we all want — and so it’s time for not just a refresh. It’s really a rethink, and a reevaluation of how we regulate nursing homes. Hopefully, that’s something will come out of this as well.

Let’s say you have a seat on the president’s upcoming nursing home commission, or even had carte blanche to rebuild the system as you saw fit. What would some of your focus areas be?

Certainly one of them is just the emphasis on culture and person-centered care in nursing homes, and making sure that we can have a system that facilitates that.

Second is really focusing on who works in nursing homes, our heroic frontline workers who are right now risking — and sometimes losing — their lives. But we have for a long time paid them too little, recognized them too little. We need to professionalize the people who work in nursing homes, because they’re special people that are doing amazing work — and yet I think as a country, we just haven’t given them their due, and we need to do that.

The third is we need to pay nursing homes for what they do. You know that Medicaid certainly doesn’t cover the cost of care, particularly in some states, and there’s just a huge gap between what is expected — to provide quality care for somebody who’s in a nursing home on Medicaid — and what the Medicaid rate covers.

As a result of that, our members who are non-profits, you end up diversifying services, but you also end up doing a lot of fundraising to try to meet that gap. We shouldn’t have to do that. We should be paying for what we value, which is quality care in nursing homes.

And then I think that the whole issue of how we pay for long-term care in this country needs to be given a hard look. You know, now it’s family pocketbooks, and when you run out of money, then it’s Medicaid. And family pocketbooks were never designed to be the deductible for Medicaid.

So we need to really take a look at: How are we going to help? Now that we’ve got growing numbers of older people, we know that 50% of them are going to need long-term services and supports. How do we pay for that as a nation? How do we demonstrate that we actually value older adults and are willing to pay for the services and supports they need so that they can live a life of purpose?

I say this a lot, but Medicaid’s role in long-term care is something I knew nothing about until started covering this industry, and that fact comes as a surprise to a lot of people I know who don’t have firsthand experience with a parent or family member. In a lot of ways, I think we’re reaping what we’ve sown as a nation here.

I think that’s right. I think the other thing that’s coming out of this is how little people understand what a nursing home actually is, and where it fits into the health care system.

I think we’ve been sort of the stepchild of that system for a long time, but really understanding that a nursing home is a home — people live there. They live there for a period of time, and they may develop deep relationships with the staff that work there.

It’s not a place to go for a three-day stay and you’re out. It’s a place where people go and they live for some period of time, and I think that that is not well understood.

You hit on a good point that nursing homes sit in a weird middle ground between housing and health care — on the investment side, it’s generally lumped in with senior living properties, which provide vastly different kinds of services. Even on the building level, it’s kind of two models jammed together under one roof — more medical post-acute care and more custodial, residential long-term care — and we’re seeing the dangers of leaders misunderstanding that distinction. Should we rethink that kind of two-models, one-building system?

I think it’s time for that conversation. I absolutely do, and I think this crisis is putting a fine point on it. I think what we have today, it’s not necessarily working. So we really do need to re-look at the model, and then I think you throw in telehealth.

The genie is out of the bottle with telehealth now, and so what does that mean for the delivery of health care and services to older adults? Will more people be receiving care in their homes, with support from home health, as opposed to a nursing home? How will that play out? I think we don’t know, but I think it is a game-changer.

Do you think there’s the political will to have these conversations beyond the typical cycle of hearings, blame, and fines? All the things we’re talking about sound great, and would mark a huge improvement over the status quo, but they would likely require multiple acts of Congress to achieve

It’s a good question, and up to now we have not had the political will. I think when you have that and you have, frankly, a lot of ageism, you can’t even start that conversation. The only way I think we’re going to get to the point of having political will is if a lot of older people don’t make it through this crisis, and people begin to realize that we’ve lost an entire generation — and that’s not right. That’s not the country that we want to be part of, and we need to re-look at our values as a country and what we want to invest in.

Right now, I think it’s: Let’s get through this, let’s get the economy running. Let’s get through this, and then we’ll put it all behind us. And that’s not going to lead to tangible solutions. So we’re trying to keep track of all the data that we can, and figure out how to make the right arguments. But what we’re dealing with now, I think, is a confluence of ageism and lack of public policy.

I think we’re at a really critical point where lawmakers can either decide to be both reactive and proactive, or fall back on the old pattern.

For us, it’s figuring out: When will people have the appetite to have that conversation? When will they have the headspace to be able to begin to think beyond the immediate crisis? It’s a health care crisis, and now we’ve got the economy on top of it. There’s a lot of things that we have to wade through in order to be able to create the space for that conversation, but it’s essential.

For my last question, I just wanted to give you the opportunity to highlight some of the work that’s happening on the front lines.

Well, thank you for that. It is absolutely inspiring to talk to members and hear what they’re doing to navigate this crisis. The staff that show up for work every day, knowing that they’re putting their lives at risk. The relationships that they’ve built with the residents, and the grieving that they’re doing when they those those relationships.

The constant pivoting — every day brings a new set of guidance, challenges, difficulties, and every day, the leaders in our member organizations are having to rethink what they do, and how they do it, and who they do it with. I’ve never seen such fortitude, such determination, and such compassion.

They desperately are trying to do the right thing, and what the right thing is, in the time of a crisis, seems to change all the time; standards of care are changing, partly because of guidance from the federal government, partly because of the reality they’re in.

That kind of agility is a sight to behold, and I have nothing but enormous admiration for the work they’re doing. And I think the challenge for them is there’s no end in sight. They are expecting a second wave, and so it’s not like this is all just going to end on July 4.

This is the new normal for a period of time, and I think it just creates an enormous amount of stress and strain. And I admire them for being able to keep their heads up and their eyes focused on what’s most important — which is keeping their staff, their residents safe and healthy.

This interview has been condensed and edited for clarity.

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