Symphony COO: Stress on Nursing Homes ‘Not Getting Better Anytime Soon, But We’re Surely Not Getting Any Worse’

As the nursing home industry settles into the next uneasy phase of the COVID-19 crisis — an indefinite period in which the pandemic will dominate every decision until a vaccine becomes available — one leader emphasized the importance of finding the upside in stasis.

“We’re not getting better anytime soon, but we’re surely not getting any worse — which for me, or for us as an organization, I should say is certainly good news,” Symphony Care Network chief operating officer Michael Munter told SNN.

Over the last three months, the Chicago-based Symphony has dealt with the pressures that struck the entire post-acute and long-term care landscape, including ballooning expenses associated with COVID-19 testing and personal protective equipment (PPE) guidelines.


But the provider also managed to complete the takeover of a portfolio of buildings in Michigan during the pandemic, while still keeping a keen eye on cohorting residents and implementing other preventative measures across its existing network.

SNN spoke with Munter last Tuesday, June 9, to learn more about how the operator has worked to weather the storm of COVID-19 — and how he sees the industry evolving in the wake of the coronavirus crisis.

Where are things as we talk right now?

I’d say from a census perspective, I think things have certainly deteriorated. But I think that level of deterioration has plateaued. So while as an organization, it’s certainly challenging, I think we’ve hit the bottom of that; we’re scraping the bottom. We’re not getting better anytime soon, but we’re surely not getting any worse — which for me, or for us as an organization, I should say, is certainly good news.


That certainly tracks with a recent report that census has dropped by at least 10% nationwide. What’s the primary driver — a lack of admissions, residents requiring hospitalizations?

Because we’re such a large urban provider, what we see is that while the hospitals have, I’d say, in probably the second or third week in May started opening up for elective surgeries, the vast majority of those are still for the most part on an outpatient basis. I’d say 80% to 90% of those, give or take — and again, anecdotally derived — are being discharged either home or to outpatient therapy, but certainly circumventing any sort of institutional setting, ours or otherwise.

Do you think that this crisis will accelerate that trend, the shift to home? Or is it just a matter of waiting for a rebound once the worst of the crisis is over?

I think it’s a combination of both, to be honest. The shift in overall level of acuity to a higher level, that started really post-Affordable Care Act. This is going back a couple of years. I think this is just yet another catalyst for the continual push in that direction. There’s a large population of seniors out there, that while they would ideally like to stay home, unfortunately, because of their clinical condition — psychosocial condition included as well, psychiatric condition — might not be able to do so.

While certainly home health has been a huge net beneficiary of a lot of that circumventing of the SNFs generally, there’s still a large part of the population that requires institutional care. Using COVID as an example, the acuity of folks that did come through, albeit a much smaller percentage of what we’ve seen historically, the overall acuity level of these folks was really, really high — as you would expect.

What about the needs of people without COVID-19 who still required post-acute care? Obviously the virus didn’t stop strokes and falls.

The core operating model that we have here, of being a good post-acute partner for our hospital patients, really never changed. Obviously, times are challenging here. But being able to map our clinical clinical protocols to those of the hospital is still very much in effect — so for example, if one of our hospitals or hospital systems has a large cardiac program, we’re going to mirror that in one home or several homes, depending on how many are partnered with that health system. That has continued for the most part.

Keep in mind, too, that someone could have COVID, but also have multiple other comorbidities that need to be treated concurrently as well. So that commitment to dealing with a relatively high-acuity patient, which is the trend we spoke to earlier, really hasn’t changed at all.

On the building level, how do you go about balancing those needs — keeping people safe from COVID, which we know will be in nursing homes for some time, and continuing to provide care?

One of the things we did here at Symphony, really from day one, is follow CDC guidelines to the T — and those obviously have been refined both by [the] DPH in each of the respective states that we operate in, as well as the local health departments. For our COVID-positive patients, we follow those guidelines; they’re in COVID-positive units, so they’re cohorted with one another in private rooms, when available. Staff is not shared; ancillary staff is not shared. The idea there was to really isolate, if you will, all things COVID to ensure that that spread — that had really impacted our entire industry, until this point where testing was more prevalent — would not be an issue.

I think for the most part, we’ve done a nice job in that regard. Keep in mind here, too, that as we as an industry have gone through this pandemic, we’re thankful to — here in Chicago — Gov. [J.B.] Pritzker and his office, and also the IDPH, in really assisting us — as well as all the local health departments in securing testing where needed.

It’s really gone a long way in helping us to identify where our risk was — or is, I should say — and act accordingly. We’ve been very fortunate that things, as we mentioned earlier, are beginning to improve for the most part.

How would you rate the testing capacity in your markets, and has your strategy shifted along with the pandemic?

State DPHs and local health departments have been instrumental in getting us that testing when we needed it. But that tended to be a little more reactive — i.e. something happened. As a result, we needed to act accordingly, so we need testing. Those resources were made available to us the best that they were able to do. But here at Symphony, one of the things we also did — being amazingly committed to resident care and quality — is that we were able to secure several of the Abbott rapid testing machines, with a commensurate number of tests that were allocated on a weekly basis.

We proactively test our employees, we proactively test our residents where we feel that there might be a risk or some degree of exposure, so we can further enhance the resources being provided to us at the state level.

Keep in mind most of the time, that comes at considerable cost to us as an organization — but again, it really speaks to who we are as an organization, and how seriously we take patient care and safety.

How have you been able to manage those financial concerns?

Suffice it to say, it hasn’t been inexpensive. It is expensive. I am glad that we are a fairly large operator with the conventional resources to be able to do things like this.

It’s come at material cost to the organization to do so; I’m not at liberty, unfortunately being a private company, to speak exactly to what it’s cost us but by the time the smoke clears, it will be well into the tens of thousands of dollars, minimally — further escalating going forward because, as the two of us both know, there’s really no end in sight to COVID. This is an expense that we will continue to incur in perpetuity until we feel that this has passed us by and our residents are out of harm’s way.

That’s the scary part to me — knowing that this will remain a problem in long-term care until there’s a vaccine, with no clear timeline for when we can expect one.

Unfortunately, there’s a lot of press around this. Certainly, I applaud our government universally for throwing a lot of money at many different vaccine makers and pharmaceutical companies who are certainly trying. But, like anything in life, until you can have it administered globally and universally, it’s really not much help to us.

We’re seeing a lot of calls for new oversight of nursing homes — including the president’s commission that’s supposed to be convening soon. What types of changes would you call for if you had a seat at the regulatory table?

First of all, I’d like to applaud and thank both our local health association here in Illinois, HCCI, and also Mark Parkinson and all that he’s doing at the national level for AHCA. What both Mr. Parkinson and his team have been able to do is really educate overall government as to the malaise that our industry is going through, and just how difficult it’s been — and how much more difficult it could become, should we have a second wave, or should the vaccine be delayed for any indefinite amount of time.

I think what they’ve been able to do — in terms of shining a spotlight on where we’re exposed, and really helping government officials understand just how deep a hole we’re in, in terms of lost revenue, as well as inordinate and amazingly incremental expense around PPE, certainly testing, which we spoke to earlier.

It’s something that I don’t think many people in government readily understood, unfortunately, before this happened. But I think AHCA has done a nice job in educating folks as to what our needs truly are. I truly hope that as AHCA continues to educate, we continue to receive the attention that we deserve to ensure that the safety and care that we provide is top-notch at all times.

What do you want the public to know about your work during this crisis?

What I’d like to express as someone involved, and who takes patient care as his number one, two, and three priorities, is that we’re doing everything we know how to do as an industry to protect your loved ones. We’re doing everything in terms of securing resources to make them safe.

The good news is, as I mentioned earlier in this in this interview, I see things getting better; the assistance we’ve gotten from AHCA, the assistance we get from state IDPH, from local health authorities, are really going a long way to help fortify our ability to continue to keep families’ loved ones safe when they enter.

I know there’s been a ton of negative news about possibly sending someone to a post-acute center, and what they could possibly contract when they’re there. But it’s like everything in life — things are never as bad as sometimes you think that they are.

As an industry generally — and certainly speaking for Symphony — we are highly committed to doing everything we can, usually at a tremendous personal cost to us as an organization to do so. In closing, please trust us with your loved ones.

We’re doing everything we know how to do to keep them safe. For those folks who are destined to go home, with us for short stay, we’re going to take very good care of your loved ones, and send them home in much better shape than when they got here.

This interview has been condensed and edited for clarity.

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