December 18, 2020, Maggie Flynn, Skilled Nursing News - There’s no easy way to look back over 2020 in the skilled nursing sector. That’s both in the sense of the devastation wrought by the COVID-19 pandemic, and in the sense of trying to review it in a way that would make lead to any meaningful conclusions.
There are so many critical areas to examine: the treatment of workers and residents in the U.S. system of long-term care, the way reimbursement and regulation contrived to build an infrastructure with little to no stability in the face of disaster, the evolution of health care around the acute setting that left out the realities of living and dying at increasing ages.
At Skilled Nursing News, our stories sometimes capture the on-the-ground landscape that operators faced in the day to day, though more often, we look at the 10,000-foot view of the system where it all played out. The quotes that most capture the facets of the year for were chosen because they illuminate some of those critical areas due for examination in the months and years to come.
During the spring surge of COVID-19, personal protective equipment (PPE) — a necessity for any health care provider no matter what setting they worked in — became a vanishingly scarce commodity.
Prices soared to the point that a SNF using equipment as instructed by the Centers for Medicare & Medicaid Services (CMS) could spend $10,000 a day or more. The federal government’s attempts to send out equipment through the Federal Emergency Management Agency (FEMA) proved unsuccessful.
In some cases, nursing homes had to turn to “Parking Lot Guy” to ensure they had adequate supplies.
The shortages stemmed from the spike in demand worldwide, where “every economy, every government in the world, at the same time needed the same products” — and the fact that when SARS-COV-2 hit China, it was during the Chinese New Year, resulting in prolonged factor shutdowns with workers stranded across the country, according to a May 18 interview with TwinMed, LLC, a medical supply distributor based on Santa Fe Springs, Calif.
According to TwinMed spokesman Meyer Greenbaum — who served as executive vice president of business development at TwinMed for 18 years before founding his own firm, Cutting Edge HC — many businesses in the U.S. decided to pivot to producing PPE in a kind of “gold rush.”
“There were companies, millions of people, jumping into something that they had no business jumping into — therefore creating this reseller marketing,” he told SNN in May. “Direct suppliers who were selling to health care providers, they would then also have to compete with people sitting at home in their bedrooms, or in their living rooms, just flipping product to the highest bidder and bringing in products that were faulty and not fully validated. So it became sort of like the Wild West in that regard.”
It summed up so much of the mayhem of the spring for the health care sector in general — and in that mayhem, it became particularly easy for SNFs to fall through the cracks.
On March 13, CMS issued a memo to state survey agency directors on limiting the transmission of COVID-19 in nursing homes, after the first outbreak at the Life Care Center of Kirkland in the state of Washington.
The very first step in its guidance was to close off facilities to the outside world.
“Facilities should restrict visitation of all visitors and non-essential health care personnel, except for certain compassionate care situations, such as an end-of-life situation,” the memo instructed, with “all” both bolded and underlined. “In those cases, visitors will be limited to a specific room only. Facilities are expected to notify potential visitors to defer visitation until further notice (through signage, calls, letters, etc.).”
The memo also called on SNFs to cancel communal dining and all group activities, among several other measures.
Both these measures made sense at a time when very little was known about COVID-19 except its contagious potential and its extremely high fatality rate among people living in SNFs; at the Life Care Center of Kirkland, 27.2% of residents had died by March 9, when the first suspicion of COVID-19 had been reported on February 27.
They made sense with PPE in such short supply that reports were surfacing of health care workers reusing masks for days and nursing home workers using trash bags as makeshift gowns.
But after months of only being able to see loved ones virtually or through windows, and only talk with them on the phone or at a distance for a defined period of time, the toll on residents is hard to even fathom. An October report from the non-profit consulting firm Altarum highlighted the suffering of living for months with constrained contact with loved ones. Multiple respondents to the survey compared the experience to being in a prison.
The memo from CMS was meant to keep residents safe, and as a short-term measure, there was some logic to it. But as the pandemic dragged on, that memo became a padlock of sorts on any kind of visitation, and as one attorney noted, federal and state governments tend to be the ones that set the course for SNF action.
“I think facilities have been understandably very concerned about any visitation and minimizing exposure for the residents; minimizing exposure to liability I’m sure is a concern,” Tony Chicotel, a staff attorney for the advocacy organization California Advocates for Nursing Home Reform (CANHR), told SNN in July.
“I think it is going to take state and federal mandates to get outdoor visits established, and I just don’t see from a public health perspective or even from a nursing home protection perspective why we can’t mandate outdoor visits for residents who want them.”
For SNF residents and their family members, the lockdown will be one of the defining features of an intensely difficult year — and one that could have physical and psychological effects for years to come.
The word “apocalypse” has its roots in the ancient Greek word “apokálupsis,” or “revelation” — in the sense of something being uncovered. The origins of the word have been quoted frequently in the COVID-19 era, where the pandemic brought so many structural challenges and flaws in health care, government, and society to light.
COVID-19 has been an apocalypse — both in the sense of catastrophe and in the sense of revelation — for the U.S. system of caring for the elderly, where the death toll from COVID-19 in nursing homes recently passed 100,000 and counting.
Randy Oostra, the president and CEO of ProMedica Health System, has been sounding the alarm on the lack of investment in public health for some time, and ever since the Toledo, Ohio-based non-profit system took over the nursing home chain HCR ManorCare in 2019, it has focused on reinvesting in the network of 171 SNFs and other senior care facilities.
He joined SNN’s Rethink podcast in April to talk about what the pandemic was revealing about health care in the U.S., and he did not pull his punches in speaking about it.
“Think about how we judge society,” he told SNN. “It’s how we treat our folks that are in their most times of need, and we think about fragile seniors and how we invested or not invested. It almost argues, and sounds kind of harsh, but it’s almost a form of abuse that we have not made the kind of investments that we should — and we’ve sat back and let the model just go forward, and there seems to be no momentum, or even thought about changing it.”
He also accurately called out the health care sector and public health more broadly on a tendency to “tweak” the model with new buzzwords, but no “plan to change the model and direct resources towards senior care or social determinants or public health.”
Those comments were made in the spring, before COVID-19 surged yet again in summer and again in the fall, and the shortcomings of both the nation’s public health infrastructure more broadly — and the nation’s care for the elderly — got thrown into sharp relief.
And while funds have been poured into SNFs by the federal government, it’s not clear how long that can sustain operations that were already made fragile by a combination of arcane funding systems and poor state-level reimbursement that, in many cases, effectively forced Medicare to subsidize care for those covered by Medicaid.
But one thing is clear: When a pandemic hits a senior care system already struggling both financially and in terms of workforce and infection control, the results are catastrophic. Preventing another disaster like this falling on those who need skilled nursing care — and the people providing that care — means taking a hard look at where resources are going within the health care system.