The deadline for nursing home industry stakeholders to apply for a spot on the federal government’s special commission on safety and quality passed last weekend, but not everyone who threw their hats into the ring will win a seat — and the problems facing the industry run deeper than any one group could solve in a single report.
SNN reached out to CEOs and other leaders in the post-acute and long-term care industry with the same group of questions: If you had a seat at that table, what changes would you ask for? What topics would you want to educate other stakeholders on? Where could you find common ground with regulators, resident advocates, and other participants in the initiative?
Though the exact details of their responses varied, the leaders shared a common theme: the need for collaboration among all stakeholders, coupled with substantial support for an industry currently enduring the toughest crisis in its history.
Read on for our group’s detailed answers in their own words, condensed and edited for clarity.
Inspired to share your own thoughts? Drop us a line at firstname.lastname@example.org, and we may feature your comments in a subsequent compilation of CEO perspectives.
Erin Shvetzoff Hennessey, CEO, Health Dimensions Group
First, I would want the country to know how hard our profession is working to protect those we serve, and our heartbreak of having many of the deaths from COVID-19 in senior living and long-term care. These deaths are not failures; they are the devastating impact of a novel virus that is easily transmittable, and deadly to the elderly.
There is no one that loves seniors more those in our profession. We know how to care for them, and we want to be a part of the solution.
What changes would you ask for?
- Testing: We need preferred access to testing, and ongoing testing. As states begin to open up, ongoing testing is critical to our success.
- Funding: Skilled nursing has long faced challenges of underfunding, and to fight this virus and just like other professions, we need funding.
- Prioritization of PPE: PPE is a key part of preventing the spread of COVID-19 and has been a major challenge for providers, we need prioritization and ongoing supply.
- Regulatory partnership: 99% of providers are doing the best they can, every single day. Creating a culture of punishment in the regulatory environment during a pandemic will do more harm that good. We welcome the support of local and federal regulations, but need collaboration.
What topics would you want to educate other stakeholders on?
- While the media and public health efforts have largely focused on hospitals, our staff are heroes too — going to work each day and putting themselves and their families at risk in settings that have not been prioritized for PPE, testing, or funding.
- We understand the need for re-opening states, and that we need to balance health and the economy, as you cannot have one without the other. If we have the resources we need to protect our residents, we could start to open states and economies.
Where could you find common ground with regulators, resident advocates, and other participants in the initiative?
- There is not one person at the table that does not put residents first — operators, regulators, residents advocates, anyone. We all want to protect our residents and together we have the resources to do it — we just have to work collaboratively.
- If we all know where COVID-19 hits hardest nursing homes, let’s focus there!
George Hager, CEO, Genesis HealthCare
Federal and state governments need to align on a single overall approach
The same fundamental political structure on which our country was founded, the federal-state balance of power, has made for a fractured response to COVID-19. A pandemic requires a centralized response. Currently, we are finding a patchwork of federal and state regulations and support that are often in conflict, which wastes precious time and frankly endangers lives.
Even two months into this pandemic, there is wide state and county variability around critical issues regarding availability and speed of diagnostic testing, access to personal protective equipment, allocation of stimulus funding, and policies around cohorting patients within nursing homes.
There are also differing requirements and enforcement practices around the reporting of data. We endorse full transparency in reporting the number of cases and COVID-related deaths. What we need is to align around medical science and standardized practices as much as possible.
Ensure a uniform, universal, and subsidized rapid testing approach
Every day counts, and faster, broader testing is one of our greatest weapons against the spread of this virus. By identifying who has it and who doesn’t early and frequently thereafter, we can separate positives from negatives in order to save lives.
Certainly, dealing with a new virus is always going to mean some additional time ramping up diagnostic testing. That said, the federal and state governments needed to agree on universal testing for nursing homes from the outset, ensuring priority at the same level as hospitals.
A single set of rules for all states to follow consistently is critical; otherwise, administrative bureaucracy is taking attention away from clinical care. Since May 11, when the administration mandated testing of residents and employees, there has been varying response at the state level— with some states still without clear plans — made worse by lack of lab capacity to process the tests, pushing up turnaround times.
Finally, AHCA has estimated that nationwide, the cost to conduct testing all facilities ONE-TIME is approximately $440 million. Using this figure, one month of testing will cost approximately $1.9B. That will require significant additional funding to pay for this volume of testing, and we need to ensure that the capacity exists to undertake this testing and provide timely results.
Stockpile personal protective equipment
Across our facilities, our PPE utilization is, on average, 20 times more per day compared to usage prior to this pandemic, and costs have increased an average of 300% to 700% because of supply chain issues. The nation must have emergency reserves of these critical supplies on hand — and not just for pandemics, but also for aggressive flu seasons.
State and federal stockpiles need to be amplified significantly, and supported by a viable logistical delivery structure that can be activated quickly. Nursing home operators must also invest in larger emergency reserves.
Align on an approach to cohorting positive patients away from negatives
Collaboration to establish safe places to separate and care for COVID-19 positive and COVID-19 negative patients is needed now more than ever, and we need to agree on an approach.
The government, hospitals, and skilled nursing facilities need to work together to ensure that when hospitals are overburdened, there are dedicated facilities or isolated, dedicated areas within skilled nursing facilities to take COVID-19 positive patients for their post-acute recovery period.
Reimbursement arrangements should be worked out in advance, taking into account the higher cost of setting up and operating such a facility or area — from the PPE and staffing, to patient transportation and specialized equipment and medications.
Karen McDonald, Chief Clinical Officer, Mission Health Communities
Goal: Post-acute or long-term care is placed within the same priority level for access to national stockpile when or if a national emergency is ever called again.
Goal: A database of registered and practical nurses is created to offset the staffing shortages caused by a pandemic.
Goal: Interstate licensure is immediately implemented for registered nurses, licensed practical nurses, and certified nursing assistants. The lag time by some states’ boards of nursing impeded our ability to get sister communities to assist.
Goal: Recognize long-term care as an important member in the chain of health care — the ability to care for our nation’s most vulnerable on-site, without having to transfer to the hospital.
Goal: Align the CDC and local health department rules on employee exposure. Placing “low risk” employees out of work for two weeks severely hampered our ability to care for our residents.
Goal: Align local and state department of health reporting with CDC reporting.
- As we have shown, we can adequately care for people; keep the waiver in place for the required three-day hospital stay for Medicare payment.
- Giving us PPE 10 weeks AFTER our first need was a very nice gesture, but too little, too late.
- Have local and state unemployment offices prioritize the jobs we have open in nursing homes — as we have jobs!
- Amend the reporting requirements on the 72-hour new cases; it would be better to report daily during this time only.
Owen Hammond, CEO, and Steve LaForte, Director of Strategic Operations, Cascadia Healthcare
First and foremost, there needs to be collaboration, and collaboration most likely requires understanding. Regulators, legislators, and advocates tend to excoriate us first, second, and third, and there doesn’t seem to be a desire to understand.
Their collective view of the industry, to us, feels mired in where we were 20 to 25 years ago — not appreciating the acuity changes, the operator changes (moves away from big corporate chains/public companies to smaller to mid-sized regional companies), the staffing pressures, the competition from others along the continuum (AL, home health et al).
In order to get to a place where the stakeholders can actually collaborate, it seems like a shared understanding would have to be developed, which probably requires some facilitated “get to know each other” discussions.
From there, how can be the regulatory process be less punitive and more improvement of outcomes oriented?
Relative to the foregoing, how do we move from a civil monetary penalty (CMP) system to a system where operators who violate regulations are required to put CMP type of money back into mandated, directed, and monitored improvements to operations that benefit residents and are designed to improve outcomes?
An extension of the 1135 waivers to collect and analyze data on the effects and benefits (and negatives) of the same, and whether or not some or all should be left in place.
On the foregoing, create a pathway to retain the waivers for telehealth and expand reimbursement for the same, and probably create a pathway to maintain some if not all of the three-day stay waiver
And finally, an examination of compacts for clinical staff to create easier mobility of staff and lessen staffing shortages by regions, with compacts for medical directors, nurses, and CNAs.
Mark Fritz, CEO, Bridgemoor Transitional Care
The past several weeks have spotlighted that the fundamental business of skilled nursing facilities (SNFs) really is long-term care. The facility is permanent home for 70% of long-term nursing home residents.
The traditional SNF is not intended to be a sub-acute care setting for critically ill patients. The primary reason we saw so many failures was not necessarily because the facilities were providing substandard care, but because the SNFs are not equipped to treat patients with high-acuity needs. The traditional SNF, designed to provide a home-like environment that facilitates congregation and interacting, was a prime setting for the spread of a novel virus.
I believe there is plenty of room for operators and regulators to find common ground at this time of reflection. If a licensure distinction could be made to relax some of the long-term care (LTC) regulations, to consider the resident’s quality of life and end-of life-requirements, the operators could more efficiently meet the real needs of the residents who permanently reside in SNFs.
The sub-acute, more critically ill patients could then be managed more appropriately in a transitional post-acute setting that is more conducive to their needs.
Right now, in some states that provide Medicaid funding for assisted living, they manage residents with a health profile typical of most LTC residents and manage very well within a more relaxed regulatory framework. This is where a separate certification within the SNF licensure could help distinguish between long-term care and transitional or subacute post-acute care operating models.
Taylor Pickett, CEO, Omega Healthcare Investors
We think CMS has done an exemplary job so far of listening to operators and getting ahead of this pandemic. The timeliness and extent of their measures have gone a long way to supporting an industry intently focused on patient care.
This task force is another example of the collaboration needed to defeat a shared enemy: COVID-19. Operators, regulators, resident advocates, and all other key constituents have aligned interests in their focus on resident care and staff safety.
We believe a task force that can share best practices — while consolidating data requirements, limiting the duplication of paperwork while retaining transparency — will be beneficial and should further enhance operator efforts.