Texas and Arizona have emerged as new potential COVID-19 hotspots in the latter half of June, but despite widespread knowledge of the danger to elderly residents, skilled nursing facilities in those states still face hurdles in securing testing and timely results.
New COVID-19 cases in Texas have climbed significantly since mid-June, according to data from Johns Hopkins University, which has been tracking the spread of the illness.
On June 25, Texas Gov. Greg Abbott announced that the state would pause the implementation of the next phases of its reopening plan; the same day, he issued an executive order suspending elective surgeries in Bexar, Dallas, Harris and Travis counties in order to boost hospital capacity.
On June 30, Abbott issued a similar order for hospitals in Cameron, Hidalgo, Nueces and Webb counties.
Arizona has also seen a spike in cases, according to the Johns Hopkins data. Arizona Gov. Doug Ducey on June 29 ordered the state’s bars, gyms, movie theaters and water parks to shut down for a month after the state saw an increase in the number of cases and hospitalizations.
Given that multiple studies have found a correlation between community spread of COVID-19 and nursing home outbreak severity, SNF leaders and operators in both states are worried about testing capacity as they try to prepare for the fallout of the growth in cases.
“Community spread plays a huge part in it; it just makes total, logical sense, and we can see it happening here,” David Voepel, the CEO of the Arizona Health Care Association, the local affiliate of the nursing home trade group American Health Care Association (AHCA), told Skilled Nursing News on July 1. “We saw from Day One, when it hit down in Tucson. It was at a dialysis center and subsequently at the hospital, and that spread to the nursing homes. It was all right there in Tucson. It was all right there in the community.”
That makes securing testing all the more paramount for nursing homes in both states. But doing so comes at a cost as SNFs navigate murky or nonexistent guidance, as well as the realities and pitfalls of lab processing capacity.
Spending hundreds of thousands on testing
In Texas, the surge in cases in the community came just after the state finished its “100% testing” in nursing homes, Kevin Warren, the president and CEO of the Texas Health Care Association (THCA), AHCA’s affiliate in the Lone Star State, told SNN.
That initiative, which Abbott announced on May 11, mandated the testing of all residents and staff in Texas SNFs and took about a month to finish because of the volume of tests required, Warren said: roughly 90,000 residents and 120,000 to 150,000 staff.
Even then, there were some snags in testing, he noted. One lab had all the results “considered null and void,” which forced more than 20 facilities to retest. Other facilities had to retest residents due to delays in getting the results back. But overall, the initiative was useful, he emphasized, allowing providers to find where COVID-19 might be lurking among staff or residents — and take steps to mitigate and contain the spread.
But as cases in the state surge again, a one-time testing push is not going to be sufficient. Even a biweekly testing initiative wouldn’t do the job, at least not according to Derek Prince, CEO and managing partner of The Woodlands, Texas-based chain HMG Healthcare, LLC.
The company has 29 post-acute and long-term care facilities in Kansas and Texas.
Originally, HMG planned to continue biweekly testing for all of its employees after testing all staff and residents. But with the recent spike in cases, it had to change gears in mid-June, especially because by that point the state “had not reassessed its opening policy,” according to Prince.
“Given the surge of the number of cases here in Texas, we’ve actually moved from biweekly testing to weekly testing, and then we are still testing our residents as needed,” he told SNN on July 2. “Obviously as they come in from our acute care partners, they are cohorted on an isolation unit. We go the 14 days, they’re isolated, and then we test them.”
HMG is using two different private laboratories for this testing, one in North Carolina and one in Florida. The labs send the kits to each facility, the facilities collect the samples, which are shipped overnight to the labs; the results are returned electronically.
Performing adequate due diligence, and making arrangements to secure the labs, took between three and four weeks for HMG, Prince told SNN. There is currently no reimbursement for testing, and HMG is “predominantly” covering the costs on its own. The company is also conducting testing for contract staff such as housekeepers, rehabilitation workers, and laundry workers; overall, HMG is testing about 2,500 employees each week.
“It was $100,000 for us when we did our initial testing [of residents and staff] in May, and it ballooned up between $200,000 and a quarter-million here in June,” Prince said. “We’re just now getting into July, so … it depends, but I would assume it’s not going to go down.”
Results — and future testing — in the dark
The initial baseline testing announced covered by the state Texas, but there’s been no discussion on whether that testing will continue in SNFs, or whether reimbursement of any sort is on the way, Prince noted.
Arizona is still working through its initiative to test both nursing home residents and staff, Voepel told SNN.
The state in mid-May began to test all residents with a polymerase chain reaction (PCR) test, which identifies the genetic material in the virus itself. For all staff, Arizona opted for antibody tests, which show the proteins developed by the human body in response to the disease. The next phase, which started in June, involved giving all staff who were negative for antibodies a PCR test.
All this testing was for 148 SNFs in Arizona, Voepel noted. But as with Texas’s testing, it’s not clear whether Arizona will have plans for continual testing.
Even now, there is very little guidance on best practices for surveillance testing, Donna Taylor, the chief operating officer of the non-profit senior living provider LifeStream Complete Senior Living — which has 167 SNF beds between two communities and 400 staff members — told SNN via email on July 2.
“We have paid between $100 and $200 [per] test (and in some cases, we have also paid $150 [per] hour for swabbing in addition to the cost of the test),” she wrote. “But the potential human ‘cost’ of not using an aggressive testing strategy is too high.”
Prince agreed, telling SNN that HMG will continue testing for as long as it can.
“When we weren’t testing, we were chasing something that we couldn’t see, and it ballooned out of control that much quicker,” he told SNN. “It’s just a much safer process, putting the testing in.”
For testing to be reliable, however, the results have to be timely, and at the start of the testing initiative in Texas, providers saw delays of up to two weeks in getting their results back, Warren told SNN. There was no particular region that stood out, but the demand for capacity is a concern that THCA has raised — and one it will continue to work with the state health department on, he told SNN.
“Once we get into the reopening, however testing is a part of the reopening plan, we have got to ensure that we have very quick turnaround test times, so that we are responsive to families and to these facilities, who are making decisions based on the results of the test,” Warren said.
In Arizona, the timeliness varies. The state lab can process test results, Taylor told SNN, but because of capacity issues, it will only do this for a resident with symptoms. As a result, LifeStream has to find other sources for testing, where the results can take seven to 10 days to come back.
“That’s pretty scary when you have a concern about a potential outbreak,” she wrote. “We are using a number of labs — we have used a third-party provider who collects the samples and sends them to various labs throughout the country (wherever they can get processing done); we have used local labs that can give us supplies but we have to do the swabbing ourselves; we have sent staff to retail labs like CVS or Walgreens. With Arizona’s number of cases rising, there are no good options right now.”