If the pandemic has put a spotlight on healthcare disparities in underserved communities, it also has made clear longstanding shortcomings of the country’s long-term care system. “If we look at one thing coming out of the pandemic, it should be that the long-term care system in this country is fundamentally broken and that we have undervalued it and underpaid for it for decades,” said Rachel Werner, M.D, Ph.D., a professor of medicine and health care management at the University of Pennsylvania Perelman School of Medicine and the Wharton School.
Werner was speaking during an April 24 virtual seminar put on by Penn’s Leonard Davis Institute of Health Economics, of which she is executive director. She noted that the weaknesses of our long-term care system have become apparent through the COVID pandemic as people describe the struggles they are having in providing care to sick patients and keeping the infection under control in their facilities. “But it is not just the pandemic causing these problems,” Werner said. “We have a fundamentally broken system, and I think we need to think about how we are going to fix the system by having a universal way to pay for long-term care for everybody in this country in a way that fully compensates the people providing it.”
Also on the panel with Werner was Joshua Uy, M.D., associate professor of clinical medicine at the Perelman School of Medicine, who also serves as the medical director for a nursing home. He serves as the course director for geriatrics for both the family medicine residency program and the Perelman School of Medicine for medical students.
He gave some startling examples of the difficulties nursing homes are dealing with every day. “Here in West Philly I know a nursing home that ran out of gloves. I know another nursing home that has no eye shields. I don’t think any nursing home has enough gowns. Certainly nobody has enough N95s,” he said. “So, for example, one Friday I was doing CPR on a patient by myself because nobody else had an N95 or a PAPR. I had to wait until EMS came, doing chest compressions and bagging. And we have had problems with PPE where we have had four nursing home nurses die of the virus in West Philly. None of that made the news. None of that gets recognized.”
In discussing the PPE shortage, Uy said the fact that the hospitals are getting the bulk of the supplies and the nursing homes have shortages actually just exacerbates the problem. In addition, most nursing homes don’t operate with a staff that they can surge to the nursing home, like a health system can surge outpatient clinicians to inpatient service. “Most nursing homes use agency nurses on occasion, but when you have 20 to 30 percent of your staff get infected or told they can’t work, just as you are trying to increase your level of care, suddenly you are really, really short,” he said. “And there isn’t a pool of staff you can pull from. An agency can’t supply that much staff, so staffing shortages have been really brutal.”
Nursing homes also have trouble accessing enough tests, he said. “Right now in Philadelphia we do tons of drive-through testing, but we would love to have 7,500 tests and just swab all the nursing homes once,” Uy said. “But the testing is allocated to outpatient settings, so the nursing home is left with very few tools in this pandemic.”
Asked if he has seen any strong response from state and local government to address these concerns, Ury said, “I think we are sort of in bystander outrage mode, and we are slowly moving to useful interventions. There are a lot of interventions that look good on paper, but in terms of the actual help that is getting to nursing homes, it is not quite there in terms of the will of the government to shift resources and supplies. I am hopeful it will get there but it is still not fully activated yet.”
Uy also was asked about an example of a strike force program set up in Maryland to help stressed nursing homes. He called it a great example of coordination between health systems, nursing homes and state government. “But it is a fairly reactive strike force,” he added. “The nursing home has to reach out for help. The National Guard provides patient management for one to two days and then they leave. So it is not the most ongoing relationship for these nursing homes. It is a short-term solution where it is basically a 911 for the whole facility. It meets a certain need. It certainly would be a key part of the process, but there is a need for a more robust organization to meet the information needs, staffing needs, material needs than this.”
He also was asked whether there are certain metrics that public health officials might monitor to catch signs of nursing homes under stress in an early stage? Uy rattled off a list of several questions to ask: Do they have enough testing, enough PPE, enough staff? Are their infection control policies appropriate for asymptomatic spread? Are they monitoring patients with temperature and pulse ox as closely as they need to? Is their communication with families robust enough? Are they triaging the right patients to the hospitals and not sending the wrong patients? “You could make a checklist of those things,” he said, “and you would have a pretty good snapshot of whether a nursing home is keeping its head above water or not.”
Asked if there were one big thing government could do that would have the most impact, Uy pointed to the scattered nature of the response. “The problem with running a nursing home is the that the Department of Health sometimes supplies testing and has some supply of PPE, but they don’t manage the day-to-day issues of the pandemic, including palliative care,” he said. There are FEMA resources, there is the Healthcare Association of Pennsylvania, but there is no coherent one-stop shop where you outreach to nursing homes to assess a checklist and see how they are doing with PPE, testing, staffing, medical management, and coordination of lab and diagnostic support, he added, and there is no way to compensate for the staffing shortage. “There is a need for a virtual command center to pull everything together. That requires support from health systems, nursing homes, and different agencies in the government, and there just isn’t the appetite to put that amount of effort into this.”
Treating High-Acuity COVID Patients at Home
One of the main areas of discussion among the virtual seminar panelists was where to properly care for COVID-19 patients once they leave the hospital. Changes to billing by CMS is allowing home healthcare agencies to innovate with virtual visits and remote patient monitoring.
“In many ways, the coronavirus pandemic is revealing the strengths and importance of home care because we now have a situation that for many public health reasons, figuring out how to care for sick patients at home is better than sending to facilities in terms of reduced exposures and reduce transmission, especially as nursing facilities are stressed,” said Nina Ross O’Connor, M.D., chief medical officer for Penn Medicine at Home. “We have found that home care has been a really effective model for coronavirus treatment. We are part of a consortium of home health agencies in Southeast Pennsylvania, and the number of patients they are caring for and the ways they innovate to deliver this care is inspiring. To give some context, Penn Medicine Home Health has 180 COVID-positive patients at home they are caring for who are actually fairly sick with high acuity, and the hospitals have 355 patients total, so a good proportion of the COVID-positive patients in Penn Medicine at the moment are receiving care at home, which is a testament to the fact that this really can work.
“There are certainly some challenges the home health model faces with coronavirus,” she added. One is that home care does not provide 24-hour care. In a normal setting, they rely a lot on private duty or family caregivers to supplement what home health does. Typically this works well for many patients, O’Connor said, but there is reduced availability of private-duty nurses at the moment, especially for patients who are COVID-positive. Also, family members might be sick or reluctant to go into the home. “The other trend we have seen is that some patients are afraid to have home care come into their home during the pandemic,” she said. Everyone is focused on social distancing. “So we have been able to develop a lot of technology to deliver visits in new ways. For each patient, we deliver the right mix of virtual visits and in-person visits, according to their preferences and personal needs. We have always provided some remote monitoring and virtual visits. Now we are doing more of that and we have extended that in creative ways to other disciplines, including physical therapy, occupational therapy, and even some counseling and mental health services we are doing virtually.”
