As Nursing Homes Lose Patients to Home Health During COVID, Past Shifts Show Path Forward

The size and permanence of a COVID-era shift to home health has emerged as a top metric to watch in post-acute and long-term care in 2021.

Should hospitals and patients continue to elect direct trips home even after the COVID-19 danger subsides, the natural trend could have far-reaching effects on the future of the nursing home sector: One state has already proposed a plan to buy back excess nursing home licenses as a way to right-size the landscape, and lawmakers looking to prevent another LTC catastrophe will increasingly move to bolster Medicaid coverage and logistical support for at-home services.

On the flip side, investment analysts and top real estate investment trust (REIT) landlords are banking on a return to normal patient volumes as they look for any signs of financial tailwinds for the year ahead. Occupancy looms large as a symbol of success or failure for the people who fund nursing home operations, and persistently low census could start to sound alarm bells on Wall Street and in private investment offices over the course of the year to come.


But for at least one nursing home executive, an important part of succeeding in a world where home health is increasingly more desirable is embracing the trend — and working to justify the existence of institutional services for the people who really need them.

“We do not want people in our facilities that do not need our services,” Kevin Morris, president of skilled nursing operator BaneCare Management, said during SNN’s virtual Payments, Policy, and Capital conference earlier this month. “What I’m concerned about is there are people that aren’t in our facilities that desperately need our services, and the adverse effects that might lead or result from that.”

During his time at the Braintree, Mass.-based BaneCare, Morris has seen multiple governors work to bolster alternatives to nursing home care in the Bay State. Massachusetts now ranks 10th on AARP’s long-term services and supports (LTSS) scorecard, earning high praise for the availability and wide selection of options for the state’s seniors.


“We’ve been living this for a long time in Massachusetts, so we’ve seen the migration, for lack of a better term, from one location to the next,” Morris said. “And it works out. I think it’s a great thing.”

But Morris drew on his own personal experience when discussing his concerns about the needle moving too far in the other direction. After his mother died, his father had a pair of health episodes that required hospitalization and subsequent post-acute home care, which his family was able to support on their own, Morris said — but only because of a few factors that not every family might have.

“If it wasn’t for my sister — who is an RN — that moved back in with him, and my three other siblings and I taking turns sleeping over there, there would have been a disaster on our hands,” Morris said. “That informal support, it has to be in place.”

The home diversion trends seen during the pandemic were driven by the very real stories of sickness and death in America’s nursing homes. Potential residents and family members rightfully worried about going into facilities that had become the epicenter of the COVID-19 pandemic; on top of the concerns about physical health, the thought of being kept apart indefinitely under strict state and federal visitation rules made the home health option a no-brainer for many families.

The corresponding effect on post-acute placement was swift and meaningful. Back in October — prior to the third wave of COVID infections that led to the highest weekly death counts at the start of 2021 — home health referrals were running at 109% of their 2019 rates, while nursing homes had 83% of their historic volume. The year started with occupancy at 80% or below across the continental U.S., and while the numbers may have started to level off amid impressive drops in infection rates after vaccination, nursing home beds remain empty at rates not seen previously.

At BaneCare, the COVID impact resulted in census of about 74% at the start of February, down from 96% at the time of the chain’s first coronavirus case, Morris said.

But the pandemic also provided an unintended advantage for families looking to care for their older loved ones at home: With both work and school conducted remotely, and more workplaces embracing flexibility in general, adult children were able to provide supplemental care that may have been impossible or at least impractical in a pre-COVID time.

“I just don’t think, in today’s world with people working and their children and families, that they can devote that amount of time,” Morris said. “I think right now, we’re seeing a high number of people going to home health, but I just don’t think it can be maintained.”

Part of the problem, in Morris’s view, is that people just don’t realize the need for around-the-clock institutional care for their loved ones until there’s a desperate, immediate need.

“It’s only at that point that they understand the value and the need that we hold in the continuum of care,” he said. “I think that’s what’s missing most [and what] the government, down to someone that may need to search for a loved one, doesn’t understand at this point.”

The Ohio bed-reduction plan, for its part, was designed to ensure that nursing home capacity doesn’t evaporate too quickly in specific markets, and even the industry’s fiercest critics generally agree on the need for high-quality institutional care of some kind moving forward.

The task for operators is to convince a wary public, as well as lawmakers and advocates rightfully furious about the death tolls among our most vulnerable, that nursing home care can be provided safely — something that could be an uphill battle as leaders like Morris say they fight perceptions of the sector formed decades before a deadly pandemic.

“I still have people calling me: ‘I need placement from my mother. I don’t want her to end up in a bad nursing home,'” he said. “They have no concept because they don’t want to think about it until you absolutely need it, and it’s based on things that happened 40 years ago, or the way that we used to operate 30 or 40 years ago, and that’s just not indicative of who we are today.”