The ecosystem of a skilled nursing facility often involves many more entities than the operator itself, ranging from equipment suppliers to third-party rehabilitation.
But in the COVID-19 crisis, the way third-party entities interact with operators has, in some cases, been drastically reset. For others, the services have evolved in ways previously unforeseen. And for SNF operators themselves, the COVID-19 emergency has led them to suddenly rethink their modes of supply — changes that could last well beyond the pandemic.
“Obviously, we’ve learned that we can’t depend on an international base to supply our domestic needs,” Phil Chase, the chief compliance officer of ReNew Health, a skilled nursing operating company based in El Segundo, Calif., with about 25 buildings in its portfolio, told Skilled Nursing News on June 24.
ReNew first began to hear about challenges within the personal protective equipment (PPE) supply chain in early March, Chase told SNN, when the president of Medline Industries explained on a group call with providers that 70% of production was in China.
According to Chase, 80% of the PPE used in America comes from those supply lines, which were shut down “100%” through February and March because the plants are located in Wuhan. Those did not come back online until late April, Chase said.
Even then, production only resumed for certain lines, he told SNN. Gowns remained a major problem, with estimates that manufacturing wouldn’t return to normal until July.
ReNew realized it would need PPE to provide the proper care for its residents, but it was down “to about 10% of our weekly order, in terms of what was supplied to us,” he added.
That led ReNew to Domestic Medical Supply Coalition (DMSC), which was formed with the goal of making PPE domestically and created by ReNew founder and CEO Crystal Solorzano.
The company was founded on March 23 to create “washable” PPE solutions for equipment that was accepted as disposable, DMSC CEO Alex Berenson told SNN on June 24, as well as to provide alternatives to depending on PPE supply lines out of China. Production was up and running in late April, shipping the first products out by the end of that month, with several factories in Los Angeles producing items for DMS.
The current product offerings include level-one isolation gowns; washable booties, surgical caps and masks; face shields; and protective eyeglasses, as well as cloth masks for children and adults, he said. The capacity is “over 100,000 isolation gowns a month,” with the potential to reach 200,000 or 250,000 per month by August. The eyeglasses and facial wear are produced by DMS partners across the country, he added.
The isolation gowns can be washed 25 times, Berenson said, though he said this is a minimum number of times, rather than an indicator that the gown will be useless at the 26th wash.
“What we’re simply referring to is that the DWR [durable water repellent] coating on the cloth itself, which allows for water repellency. That coating wears off a smidge every wash, and that’s the reasoning that we’re putting a 25-wash minimum on the garment, and that’s what we’re stating to our clients and our customers,” Berenson said. “However, you can probably get more than 25 washes out of that garment.”
DMS is shipping to “at least 25” customers in the skilled nursing space, including Genesis HealthCare (NYSE: GEN), Berenson said.
New models — and settings — of care
For third-party rehab providers, COVID-19 in some ways didn’t change anything: Patients in the SNF setting still need rehabilitation.
Though there was some confusion initially over whether third-party therapists counted as essential workers, the American Health Care Association (AHCA) detailed how therapy plans still needed to be followed, which helped clarify their status as essential, Peggy Gourgues, chief operating officer of the Plano, Texas-based Reliant Rehabilitation, told SNN in a June 23 interview.
But how that therapy and rehab was provided had to be completely overhauled in the time of COVID-19, she explained.
“Like everybody else in health care, we had to shift resources immediately to proactive measures to prevent exposure or transmission [of COVID-19] to the most vulnerable in the SNFs that we service,” Gourgues told SNN. “That largely included staffing changes. We needed to ensure we had dedicated therapists to particular COVID wings or portions of the facility to limit any crossover. We had to adapt the delivery of care.”
When the Centers for Medicare & Medicaid Services (CMS) issued guidance suspending all group activities in nursing homes in March, that meant no therapy could be provided in gyms; therapists had to adapt to providing care in residents’ rooms, with limited spacing and no equipment, Gourgues said.
AHCA at the time of its support for rehab had observed that therapists might have to go beyond their normal duties. This was a dynamic Reliant saw play out in the nearly 900 SNFs that it serves.
“We also really had to expand what we do in the facility; so many of our providers were taxed themselves with their own limitations of staffing and such,” Gourgues told SNN. “It’s really just helping the facility, helping our partners, just stepping in with overall care needs. Those were things that we had to adapt to.”
To achieve that goal, Reliant assigned staff to follow updates from the Centers for Disease Control and Prevention (CDC) and CMS, tasking them with passing the right information to therapists in the facilities — as well as helping facilities stay on top of state and local guidance related to PPE and screenings.
That included steps such as calls, tracking individuals who might have been exposed to COVID-19 positive patents and staff, and helping SNFs to determining which patients had a skilled need that would allow them to be admitted without an unnecessary hospital stay under emergency waivers, Gourgues said.
One of the newer components of COVID-19 for therapists is the ability to use telehealth, but because this was clarified relatively late in the pandemic, Reliant has only used it in limited ways, she noted. While CMS included therapy practitioners in telehealth waivers at the end of April, it was not clear until May that institutional settings could “furnish and bill for outpatient therapy delivered via telehealth during the ongoing COVID-19 Public Health Emergency,” according to an update from Reliant that cited a coronavirus FAQ document from CMS.
Even though this capability has only been in place for a short time — “and quite honestly we could have used it early on,” according to Gourgues — Reliant has been able to take advantage of the flexibility in buildings where they need to limit exposure, she noted.
For the wheelchair company Broda, which produces seating products for SNFs and has about 500 local distributors across North America, the COVID-19 pandemic upended how it normally does business.
The firm, which has offices in Missouri and Ontario, Canada, in normal times would fit its wheelchairs to patients and give demonstrations on seating in facilities, Nick Hoffmeyer, vice president of marketing at Broda, told SNN on June 22.
Broda would use meetings with facilities to demonstrate its products and how they could be used to increase patient mobility. They also would fit chairs and perform mobility assessments in facilities, and during trade shows and conventions, Broda could demonstrate its products to new potential customers on a crowded expo floor.
All that had to change with COVID-19.
“Our customer service team … every day from a support standpoint, they would have videos,” he told SNN. “They can pull the chair that the facility or administrator’s looking at and they can kind of go through it together.”
This has entailed something of a Hollywood touch, with Broda purchasing better lights and cameras to better show the equipment and have a visual aide for any support issues a facility might have. While this process was initially slow, Broda did see an increase in calls and interest; for SNFs, the questions were related to maintenance and repair or fitting products to patients, Hoffmeyer said.
It’s opened a new line of business in some ways, he said, by allowing more direct interaction with SNF providers and working to supplement its service offerings with digital assets and how-tos.
And even if the COVID-19 emergency dies down, the technologies have opened up lasting possibilities for Broda, he said.
“Whether it’s remote Montana or something from a rural standpoint, there’s some places that are really hard to get to,” Hoffmeyer pointed out. “As long as they’ve got high-speed internet, they don’t have to drive five hours out somewhere to do a service call or to fit a patient [to a chair]. So it’s allowing us to really focus resources on some of the underserved rural areas and folks that might not be getting the coverage or attention that they would normally.”