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Returning COVID patients to unprepared facilities a “recipe for disaster”

As Florida becomes the new epicenter of the COVID-19 outbreak in the U.S., the state is trying to ensure that nursing homes and rehabilitation facilities aren’t quickly overwhelmed by patients still suffering from the disease.

So far, it has dedicated 11 facilities solely to COVID patients who need post-acute or long-term care: those who can’t be isolated at their current facilities, as well as those who’ve gotten over the worst of their illness and who can be moved to free up hospital beds for the flow of new patients.

One of those facilities is Miami Medical Center, which was shuttered in October 2017 but now transformed to care for 150 such patients. In total, the network of centers will handle some 750 patients.

“We recognize that that would be something that would be very problematic, to have COVID-positive nursing home residents be put back into a facility where you couldn’t have proper isolation,” Florida Gov. Ron DeSantis (R) said during a press briefing last week. “[That] would be a recipe for more spread, obviously more hospitalizations and more fatalities, and so we prohibited discharging COVID-positive patients back into nursing facilities.”

Whether 750 beds will be enough to accommodate the state’s needs remains a question, but it’s a necessary first step, given testing delays that in some cases stretch more than a week. Experts have warned that patients recovering from COVID shouldn’t be transferred to a facility without being tested first.

Without dedicated facilities, hospitals in Florida in dire need of beds for new patients might have had no other choice.

Key Role for Testing

There are no national data on the percentage of hospitalized COVID-19 patients who need rehabilitation or skilled nursing care after their hospital stay.

In general, about 44% of hospitalized patients need post-acute care, according to the American Health Care Association and its affiliate, the National Center for Assisted Living, which represent the post-acute and long-term care industries.

But COVID has “drastically changed hospital discharge patterns depending on local prevalence of COVID-19 and variations in federal and state guidance,” the groups said in an email to MedPage Today. “From a clinical standpoint, patients with COVID-19 symptoms serious enough to require hospitalization may be more likely to require facility or home-based post-acute medical treatment to manage symptoms. They also may need rehabilitation services to restore lost function as they recover post-discharge from the acute-care hospital.”

The level of post-acute care these patients need runs the spectrum from long-term acute care hospitals and inpatient rehabilitation facilities to skilled nursing facilities and home health agencies.

The variation is partly due to the heterogeneity of the disease itself. While some patients recover quickly, others suffer serious consequences such as strokes, cardiac issues, and other neurological sequelae that require extensive rehabilitation. Others simply continue to have respiratory problems long after the virus has cleared. Even those who are eventually discharged home sometimes require home oxygen therapy or breathing treatments that can require the assistance of home health aides.

Yet post-acute care systems say they haven’t been overwhelmed by a flood of COVID patients. Several groups, including AHCA, NCAL, and the American Medical Rehabilitation Providers Association (AMRPA) confirmed to MedPage Today that there’s actually been a downturn in post-acute care services during the pandemic.

That’s due to a decline in elective procedures, the societies said, adding that demand is starting to pick back up and that systems will need to be in place for preventing COVID spread in these facilities.

Testing will play a key role in being able to move patients as the need for post-acute care rises, specialists told MedPage Today.

“You shouldn’t move anyone until you know a status so that the nursing facility can appropriately receive them and care for them,” said Kathleen Unroe, MD, who studies long-term care issues at the Regenstrief Institute and Indiana University in Indianapolis.

AHCA and NCAL said they “do not support state mandates that require nursing homes to admit hospital patients who have not been tested for COVID-19 and to admit patients who have tested positive. This approach will introduce the highly contagious virus into more nursing homes. There will be more hospitalizations for nursing home residents who need ventilator care and ultimately, a higher number of deaths.”

Earlier this week, the groups sent a letter to the National Governors Association about preventing COVID outbreaks in long-term care facilities. They pointed to a survey of their membership showing that, for the majority, it was taking 2 days or longer to get test results back; one-quarter said it took at least 5 days.

The Centers for Medicare & Medicaid Services (CMS) recently announced that it would send point-of-care COVID tests to “every single” nursing home in the U.S. starting next week. Initially, the tests will be given to 2,000 nursing homes, with tests eventually being shipped to all 15,400 facilities in the country.

Hospitals can conduct their own testing before releasing patients, and this has historically provided results faster than testing sites or clinical offices, especially if they have in-house services. However, demand can create delays, experts said.

Preparing for the Future

Jerry Gurwitz, MD, a geriatrician at the University of Massachusetts Medical School in Worcester, says now is the time to develop post-acute care strategies for any future surges.

Gurwitz authored a commentary in the Journal of the American Geriatrics Society on an incident in Massachusetts early in the pandemic where a nursing home was emptied to create a COVID-only facility, only to have residents test positive after the majority had already been moved.

“We should be thinking, okay, what are the steps, what’s the alternative to emptying out nursing homes? Can we make a convention center, or part of it, amenable to post-acute care patients?” Gurwitz said. “Not just a bed to lie in, but possibly providing rehabilitation and additional services? That could all be thought through right now in a way that would be logical and lead to the best possible outcomes.”

Organizations can take the lead from centers that have lived through a surge, like those in New York City. Rusk Rehabilitation at NYU Langone Health created a dedicated rehabilitation unit for COVID-positive patients.

“We were able to bring patients out from the acute care hospital to our rehabilitation unit and continue their COVID treatment but also give them the rehabilitation they needed” — physical and occupational therapy (PT/OT) — “and the medical oversight that enhanced their recovery and got them out of the hospital quicker and in better shape,” Steven Flanagan, MD, chair of rehabilitation medicine at NYU Langone, said during an AMRPA teleconference.

Flanagan noted that even COVID patients who can be discharged home will have long-term issues, so preparing a home-based or outpatient rehabilitation program will be essential.

Jasen Gundersen, MD, chief medical officer of CareCentrix, which specializes in post-acute home care, said there’s been more concern from families and patients about going into a facility, leading to increased interest in home-based services.

“We should be doing everything we can to support patients in the home,” Gundersen said. “Many of these patients are elderly and were on a lot of medications before COVID, so we’re trying to manage those along with additive medications like breathing treatments and inhalers.”

Telemedicine has played an increasing role in home care, to protect both patients and home health aides, he added.

Long-term care societies have said that emergency waivers implemented by CMS have been critical for getting COVID patients appropriate levels of post-acute care, and they hope these remain in place as the pandemic continues.

For instance, CMS relaxed the 3-hour therapy rule and the 60% diagnostic rule, Flanagan said. Under those policies, in order to admit a patient to an acute rehabilitation unit, facilities must provide 3 hours of PT/OT every day, 5 days per week.

“Not every COVID patient could tolerate that level of care, but they still needed the benefit of rehabilitation that allowed them to get better quicker and go home faster,” he said.

Additionally, not every COVID patient fits into one of the 13 diagnostic categories that dictate who can be admitted to a rehab facility under the 60% rule, he said, so centers “could take COVID patients who didn’t fit into one of those diagnoses and treat them and get them better.”

AHCA and NCAL said further waivers or policy changes would be helpful, particularly regarding basic medical necessity requirements for coverage within each type of post-acute setting.

But chief among priorities for COVID discharges to post-acute care remains safety, the groups said.

“The solution is for hospital patients to be discharged to nursing homes that can create segregated COVID-19 units and have the vital personal protective equipment needed to keep the staff safe,” they said. “Sending hospitalized patients who are likely harboring the virus to nursing homes that do not have the appropriate units, equipment and staff to accept COVID-19 patients is a recipe for disaster.”