Grabowski: As Case Counts Rise and PPE Issues Persist, Nursing Homes Face Grim ‘Groundhog Day’

As COVID-19 continues to bring sickness and death to American nursing homes, Harvard University professor David Grabowski has become one of the most-quoted experts on the steps that operators and the government should take to stem the tide.

But as the summer turns to fall during a pandemic that started in late winter, the long-term care researcher has found himself ringing the same alarm bells that he’s been sounding since the earliest days of the crisis — with frustratingly little progress.

Grabowksi co-authored a recent paper, published in the journal Health Affairs, that found one in five nursing homes still reported “severe shortages” of staffing and personal protective equipment (PPE) in late July, with particularly acute supply problems among for-profit facilities.

Advertisement

A pair of U.S. senators cited that analysis last week in demanding answers about the nation’s PPE struggles from Vice President Mike Pence, leader of the White House Coronavirus Task Force.

“My wife has now gotten to teasing me about these things, and saying: ‘Are they interviewing you about testing and PPE? You’ve been saying that since March!’ It does have this ‘Groundhog Day’ feel,” Grabowski said, referencing the 1993 comedy in which Bill Murray’s character finds himself reliving the same early February day for years on end.

But here in the real world, the repeating patterns of COVID-19 in congregate care settings have deadly consequences: The federal government last month acknowledged that weekly case counts in nursing homes exceeded the previous peak recorded in May, with Centers for Medicare & Medicaid Services (CMS) administrator Seema Verma pointing to persistent infection control problems at nursing homes as a primary driver.

Just this week, the Kaiser Family Foundation released an analysis showing COVID cases in long-term care facilities creeping up in August along with community spread in certain areas. That increase came after declines in May and June following the initial peak in April, according to the non-profit.

SNN spoke with Grabowski in mid-August to determine where progress — no matter how gradual — has been made on stemming the COVID tide in nursing facilities, as well as the federal government’s increasing push to tie relief funding to positive COVID outcomes.

Are there really any areas where we’ve seen progress, or are we just repeating the same mistakes?

There’s very much a “Groundhog Day” feel to all of this. We keep seeing the same headlines of cases in nursing homes, fatalities in nursing homes, staff bringing it in asymptomatically, a lack of PPE, a lack of testing. I could go on and on here — a lack of support for staff.

I think that’s really frustrating. I’ve been saying this since March: It doesn’t have to be this way. We know how to fight this virus, and we have some pretty good defenses like PPE and testing and support for staff — and we just haven’t chosen to really invest in those.

I think Administrator Verma is correct — certainly there’s a role for good infection control. But if we’re not paying for staff in these buildings, we’re not providing PPE, if we’re not providing testing, I’m not certain how we have good infection control. I appreciate there’s a little bit of a chicken-or-the-egg.

But from her perspective, I would think that the emphasis is less on “this is a facility problem around poor infection control.” I think this has been more a resource issue, to be honest. Nobody’s absolving nursing homes of accountability; they certainly still need to be accountable in terms of quality. I think everyone’s been straight about that. But let’s give them the resources, and then continue to expect good care from them.

It’s got to start somewhere, and I think that’s kind of backwards the way she’s framing it there. I would say: Let’s give you the resources, and then ensure that you’re performing at a high level, and that you’re providing good infection control, that you’re staffing the buildings correctly. I think we all want these dollars, the relief funds, to flow to the direct caregivers, to infection control.

I would think most people are supportive of just doing that directly. I don’t think many in the nursing home industry mind — if you want to buy us PPE and send it to us, all the better right? Take out the middleman if you want to send us testing.

To your question very directly: What is better? I do think our knowledge base is better today than it was back in March. Obviously it took a few weeks in March to figure out the asymptomatic spread; it took us some time to figure out how to safely cohort. I do think we have a better understanding of how to effectively contain this virus. I do think as well that we’ve made a little — and I stress a little — bit of progress in terms of PPE and testing.

I think the key point there is that we’ve bought this testing through CMS, it’s only a few hundred facilities. … My understanding is that first, it’s still very early, and second, there’s going to be issues around: Are we properly guiding the facilities about the use of the antigen testing machines? And then are we providing them with supplies going forward? Are we going to prioritize nursing homes for these supplies? I understand there’s quite a bit of shortages there. And if we provide these machines, yet don’t follow up with testing supplies, it’s the PPE crisis or debacle all over again. Let’s hope — and I know you’ve written on this issue — that they’re able to execute there. I think that would be really helpful.

And then I think going back and providing PPE, I think that’s 1A and 1B. It’s been 1A and 1B since, what, March-April? And they really haven’t nailed that one yet.

That’s the hope — that Administrator Verma and others will want to very directly take these issues on. Let’s start that today. I think CMS deserves some credit around the testing. It’s a good plan; now let’s execute on it. I think the jury’s still out on that one.

We know now that the government has a plan to get all of the testing devices out to facilities by the end of September, but there are also concerns about the strain it will place on nursing home staffers — many of whom may not have experience with collecting and interpreting antigen testing results.

That’s right. I’ve even heard some of them wondering: “We’re required to test by our state. Does this actually count?” Which would make absolutely no sense if the federal government’s sending one set of tests, and the state has a different requirement.

I think there is some confusion on the part of nursing homes. It seems like this could be a game-changer if it really was implemented well, and even with the delays we’ve had with testing, the ability to do this in real time would be really productive.

Do you think there’s a more efficient way to send that testing and PPE relief to providers? We’re already seeing controversy in the media about companies with histories of Medicare fraud settlements receiving federal stimulus funding, and I do think watchdogs are rightfully skeptical about the funds trickling down to workers without problems. Could the government send money directly to workers, or distribute PPE at scale to facilities?

We’ve not nationalized the supply chains or done these things centrally, and so you push this to nursing homes. And you’re right, hopefully that’s not a broader problem. Like every industry, there are bad apples in nursing homes. There are some, I think, that haven’t maybe put their dollars back into direct patient care — either through wages or through buying supplies or PPE or what have you. I would like to see us cut out the middlemen here. Just provide it directly.

There’s been so many snafus with both the testing and the PPE. I think with staffing, as you suggested, they could provide these dollars directly by earmarking it, or using wage floors or wage pass-throughs so it’s not just: “You have to pay staff X.” It’s actually funding that mandate by providing the dollars directly.

I think you did see a little of that in the value-based competition aspect of the most recent $5 billion funding round, but I also wonder if that’s a little bit backwards — a facility with rising case counts would in theory require more support than one with the virus under control.

I like trying to earmark some of these dollars. What I didn’t like — our research and others has found that cases are really tied to just the location of your [facility]. I think you really have to risk-adjust that appropriately, and make certain that you’re accounting for the community spread when you reward or punish facilities for cases. It’s great if you want to reward certain homes in a market and punish others, but just making certain you do that with the underlying [understanding that] it’s very different.

Early on, I think there were a lot of facilities in some parts of the country that were sort of: “Oh, look at how good we’re doing,” where the facilities here in the Northeast that were not doing so well — even five-star facilities and places that have had very good infection-control records. I think that was as much about just asymptomatic spread as it was about anything else.

I like this idea of rewarding facilities, but rewarding them within markets where you’re really adjusting for that underlying spread.

Editor’s Note: After this interview was conducted, more details about the value-based purchasing aspect of the HHS relief funds were released, with American Health Care Association (AHCA) CEO Mark Parkinson confirming last week that individual buildings’ performance would be compared with facilities in areas with similar levels of overall community COVID-19 infection rates.]

You’ve testified before Congress during the pandemic, and there’s hearings going on in statehouses across the country about nursing home reform. It’s frankly rare for long-term care to get so much attention for such a sustained period. Do you think there’s political will for major structural change?

Nobody thinks about their own long-term care until they actually need it, and very few of us plan ahead. People don’t want to think about it. Something very similar has happened in the country — we really haven’t wanted to plan for these services, and really think about how people access services, and the quality of those services, and what we spend on them, and where those services are delivered.

If nothing else has come out of this — and there’s been so many negative implications and impacts of this pandemic — but I think one of the silver linings maybe is that there’s a lot of eyes on the sector now.

I’ve been studying long-term care since the late ’90s, and this is really the first time that I think there’s been widespread attention on this issue, and a real feeling that things need to change. I’m really impressed by just the range of individuals talking about it — and that goes to the very top.

Even going back pre-COVID, there were mentions of long-term care in the [presidential] campaign, but it felt like a second- or third-order issue. We’ve already heard Vice President Biden and his team introduce a pretty comprehensive long-term care plan. There’s nothing like that that’s ever been put on the table, as you know.

I mean, there’s been one significant piece of financing legislation, the CLASS Act that was part of the Affordable Care Act, and that was ultimately repealed. This interest right now in really investing in home- and community-based services, and potentially rethinking what nursing homes look like — I’m really impressed by the interest here.

Hopefully, we have the resources to do this once the pandemic is over, and hopefully we have the political [will] and will of the people to continue to go down this path. One of the disappointing parts, I think, with long-term care is that it often gets lost once other issues come up. My hope is that we won’t lose our attention on long-term care, but rather continue to think about how we can improve the models.

Most of us have been writing and arguing a long time for more home- and community-based models. I think that would be a huge step. But I also think there’s going to be a group of individuals who need nursing homes — and how do we make that the best model possible?

I want to keep people out of nursing homes, but I also want to make nursing homes as strong as possible. And I think this is an opportunity to really improve both long-term care generally, and nursing homes specifically.

The Biden plan is particularly interesting because there’s this old saw that politicians always pander to older voters by vowing to protect Social Security and Medicare, but long-term care is never part of that conversation.

Oh, no. We see that time and time again. Everyone says: “Oh, we must have great benefits.” Well, no. This is a pretty select segment of older adults. You don’t cut Social Security, you don’t cut Medicare, but we’ve left long-term care to Medicaid, and it’s not paid for very generously. And I don’t think many of us want to think about it, or really hold politicians’ feet to the fire about actually making improvements.

I think that’s a great place to wrap up — I’ll be in touch in a few months, and hopefully things will be different.

Or we can have the same conversation and talk about testing and PPE again, right? My wife has now gotten to teasing me about these things, and saying: “Are they interviewing you about testing and PPE? You’ve been saying that since March.”

It does have this “Groundhog Day” feel where it’s like: If they’re not going to fix it, the government’s not going to address it, you’re going to continue to have this problem.

This interview has been condensed and edited for clarity.