One of the ways hospital systems across the U.S. tried to manage and maintain capacity during the pandemic was the suspension of so-called elective procedures – surgeries that could be reasonably delayed or did not create imminent danger for patients who put them off.
One of the effects of this was to close off a key source of referrals to skilled nursing facilities; patients who would normally go to a SNF for rehabilitation and recovery after their stay in the hospital. And for patients who did eventually go to a hospital for a procedure, those who could go home did. Discharges to the home health setting grew significantly in 2020, while those to the SNF setting dropped and did not recover.
Even in early 2021, as hospital volumes returned to normal, referrals to the SNF setting lagged below their pre-pandemic levels.
And those patients going to the SNF setting now, as the COVID-19 storm plays itself slowly out in the U.S., are “very, very sick or clinically complex,” as Keith Boyce, president and CEO of the AdventHealth Care Centers, told Skilled Nursing News. AdventHealth Care Centers is the SNF division of the Florida-based health system AdventHealth, with 10 facilities.
Behavioral needs intensify
That complexity isn’t confined solely to medical conditions.
Executive Mental Health (EMH), a psychology practice based in Los Angeles, typically saw patients who had various forms of neurodegenerative disease or neurologic conditions, at least at the start, according to Dr. Ari Kalechstein, the president and CEO of the company. EMH provides care to acute and post-acute facilities in California and Nevada.
That was the situation roughly a couple decades ago. But the population has become considerably more complex from a psychological standpoint.
“We don’t see just older people with physical issues or dementia,” Dr. Michelle Feng, EMH’s chief clinical officer told SNN. “Now we’re seeing individuals with severe mental illness, so those who have a history of homelessness, or dual diagnosis – a lot more behavioral health or mental health complexities coming into the skilled setting. That mixed with those with cognitive issues and physical health issues make the whole population just a lot more complicated.”
While this is not necessarily a new phenomenon, it is one that COVID-19 appears to have exacerbated, Feng said.
For Ignite Medical Resorts, the pandemic has put a new focus on the behavioral health needs of its patients, since many of them live at home by themselves, chief clinical officer John McFarlane told SNN.
“We’ve had to increase our [services] of behavioral health, in terms of social work following up on [patients] to make sure they’re feeling all right, if they need any additional support services after they discharge, to make sure they’re getting all their needs met,” he said.
The Park Ridge, Ill.-based Ignite has locations in Illinois, Kansas, Missouri, Oklahoma and Wisconsin.
One of its providers in Kansas City recently added a psychiatry service that comes in to see residents, and across the company, questions about behavioral and mental health have been put at the forefront of the admissions process, McFarlane said. The goal is to account for the fact that in many cases, patients did not want to go to the hospital, let alone a post-acute care facility instead of their homes, heightening the risk of depression or anxiety, to name a few potential needs.
“We have to be really focused on that as a post-acute care provider, in terms of: Are we addressing this need on admission? Are we getting them the adequate resources both through the time they’re with us and then after they discharge?” McFarlane said. “That’s really key for us.”
For Erin Shvetzoff Hennessey, the CEO of the Minneapolis-based post-acute consultant and operator Health Dimensions Group, the pandemic saw consumers avoiding skilled nursing care altogether, “unless absolutely necessary,” she told SNN via email. She has also seen the increasing complexity surrounding mental health needs for incoming patients.
“Those who had to use skilled care during the pandemic had either medical or psychosocial conditions that prevented a return to home,” Hennessey wrote. “Behavioral patients present challenges for operators, especially for staffing, regulatory performance and resident satisfaction.”
Staffing was a particular challenge on this front, EMH found. In the nursing homes where it provides services, staff were frequently overwhelmed by the increase in their duties to patients as visitors were restricted, both Feng and Kalechstein observed. That meant EMH’s workers sometimes would be effectively serving as liaisons for family members, speaking to patients and trying to convey to staff what the particular needs were for both those families and their loved ones living in the SNF setting.
Of course, much of the country’s population is experiencing an increased level of mental health struggles, and this is no different for the population in the SNF setting, Hennessey noted.
This is another aspect of the changing needs of patients; the existing residents, as well as new admissions, have much more intense mental and behavioral health needs due to the general toll of living through the pandemic and the lockdowns and restrictions on visitors in SNFs.
“It was hard on families, very hard on the patients, who some of them didn’t understand fully why people couldn’t come in, and of course, hard on staff,” Feng said. “And so you see people start to deteriorate and start to withdraw, and that’s a really common thing we saw.”
Respiratory needs
COVID-19’s toll has been more than mental and emotional; for Ignite patients who contracted the coronavirus, there are lingering symptoms even after they’ve officially recovered and been vaccinated, McFarlane told SNN.
That means more medical complexities for these patients, particularly on the respiratory side, he explained.
“We have a lot more respiratory needs, and we do contract with a respiratory therapist at all of our locations,” McFarlane said. “The respiratory therapist is much busier, I would say, than they have been in the past, just in terms of collaborating with our clinical team, to make sure that [patients] have all their needs met.”
That includes making sure patients understand how to use their inhalers and have them in hand, as well as any other airway devices, as well as ensuring they are receiving that kind of therapy. But it also includes addressing other “degenerative” effects from COVID-19, such as fatigue and weakness that necessitate working with physical and occupational therapy.
And the chronic health care issues that have made patients more medically complex for years have not gone away, McFarlane noted.
When it comes to preparing for the needs of future patients, COVID-19’s long-lasting effects have to be accounted for, Kalechstein stressed, in order for clinicians to be able to address both the physical and mental health needs. That’s made more complicated by those effects still emerging and being studied, but the peer research is critical for EMH’s formulation of its treatment.
“What we’ve had to do is understand how COVID-19 affects the brain, and what’s the probability that as a consequence of COVID-19, certain patients may be a greater risk to experience cognitive decline or impairment,” he told SNN. “The next issue has been to understand what the residual physical symptoms may be for individuals with COVID-19 that don’t affect the brain: the pulmonary effects or the effects on other organ systems, and what the implications of that might be for mental state conditions.”
Companies featured in this article:
Executive Mental Health, Health Dimensions Group, Ignite Medical Resorts
