How Can Health Systems Better Support Nursing Homes During the Pandemic—And Beyond?
The tragic toll that COVID-19 has had on nursing homes globally has been well-documented; the director of the World Health Organization (WHO) recently said that in many countries, 40 percent of COVID-19 deaths have been among nursing home residents, and in some high-income countries, 80 percent of deaths have been in that population. In the early days of the pandemic, reports of nursing home facilities being understaffed and ill-prepared to adequately test both their patients and staff regularly were commonplace. Another key problem area is that most post-acute care providers do not exchange health information electronically with referring hospitals, physicians or home health providers.
In a recent editorial, two Regenstrief Institute and Indiana University faculty members laid out their case that meaningful partnerships between acute care hospitals and nursing facilities can support better quality of care for people who live in the facilities. Regenstrief research scientist and Indiana University School of Medicine Associate Professor of Medicine, Kathleen T. Unroe, M.D., and Regenstrief research scientist and Professor at IU Richard M. Fairbanks School of Public Health at IUPUI, Joshua Vest, Ph.D., wrote the piece published in the Journal of the American Geriatrics Society. In it, they stated the benefits of collaboration between health systems and nursing facilities, highlighting how health systems can support nursing home staffing, which is critical to delivering quality care, yet a constant challenge, even in normal situations. COVID-19 has exacerbated the challenges of maintaining staffing and, in some instances, created an additional need, they noted.
The article was written in response to a paper published by a research team from the University of Washington that detailed how the healthcare organization actively leveraged their existing university health system infrastructure with 16 nursing facilities to provide solutions and support.
According to the Centers for Disease Control and Prevention (CDC), there are approximately 15,600 nursing homes in the U.S. with 1.7 million licensed beds, occupied by 1.4 million patients. These types of organizations—part of a broader category of long-term care facilities, though the terms are sometimes used interchangeably—even in a non-pandemic environment, are dedicated to providing care and services to some of the most vulnerable individuals in society who need an inordinate amount of care, attention, and support, Vest points out in a recent interview with Healthcare Innovation. He also notes that these types of care facilities “are complex places that deal with staff who are often challenged and therefore not always given all the resources they need, and may not be compensated well.” He adds, “So you have these dual challenges—a high-need population, complex workforce requirements, and a vulnerable set of workers. It [presents] a real opportunity for health systems to do a lot [to help], even outside of the pandemic.”
Leaders at the University of Washington Medicine (UWM) spearheaded work that Vest and Unroe contend is an example of a profound partnership between acute care hospitals and nursing facilities. The health system implemented a three‐phase plan—an initial, delayed, and surge plan. The “initial phase” described multiple proactive steps they took with their nursing facility partners to deliver education around best practice infection control, establish surveillance protocols, and create the tracking infrastructure needed to monitor resource needs and disease spread. Every nursing facility in the country has been engaging in these efforts to varying degrees; the UWM’s team's proactive leadership allowed for standardization of these activities across their 16 skilled nursing facility system, Vest and Unroe noted.
Meanwhile, the “delayed phase” involves the organization’s support of facilities after the identification of a positive case, including on‐site implementation support for conserving personal protective equipment and infection control practices. Finally, the “surge phase” is for the case of an overwhelming outbreak, which involves sending a team of clinicians on‐site to support nursing facility staff, including physicians, advance practice providers, registered nurses, and an infectious disease provider.
Unroe notes that in this situation, the health system already had a framework in place, and had its own providers involved and invested in the care of nursing facility residents. She stresses that one crucial success factor is for post-acute care settings to have strong communication linkages with nearby hospitals and health systems. In the case of UWM, the organization was already conducting regular calls with their nursing facility partners, had a support infrastructure in place, and also provided education around key issues. In the setting of the pandemic, all of these efforts simply ramped up, she says. “That’s how we moved towards our conclusion; this example shows what’s possible if you have those infrastructure and communication systems in place. There are many good reasons to do it even without COVID-19, but then it’s there if you [ever] need it,” Unroe contends.
At the same time, when asked how she’d describe most health systems’ relationship with nursing and long-term care facilities, and how much support is typically given, Unroe says the words that come to mind are “inconsistent and unreliable.” She offers that some health systems have ownership relationships with nursing facilities, and/or have participated in bundled payments or other financial models that give them a direct reason to invest in specific nursing facilities. “In those cases, you see stronger examples [of support], and and that makes sense since there’s more integration and collaboration,” she says.
The technology problem
It’s no secret that technology at nursing homes has historically lagged behind hospitals, particularly in the areas of interoperability and functionality. Even a decade ago, long-term care information systems were largely focused on reporting functionality for federal oversight, Vest recalls. He adds that the more detailed record is something that’s coming in at a slow pace, although adoption has dramatically increased over time and is much higher than it’s been in the past. But interoperability is a whole different issue, he says. This presents a major barrier to effective patient care since around two in five hospitalized Medicare patients end up in a post-acute care setting, according to some estimates.
Unroe, however, doesn’t believe technology gaps are a legitimate excuse for weak health system/post-acute care setting relationships. She says that among the larger long-term care system chains, every single one has a working EHR system, with a few products mostly dominating the space.
In addition to EHRs, Unroe says some of the patient data points about baseline functional cognitive status are collected on every single nursing home patient in the country at regular intervals through the required Minimum Data Set (MDS) instrument, part of a federally mandated process for clinical assessment of all residents in Medicare- or Medicaid-certified nursing homes. “All Medicare and Medicaid certified facilities have to collect this detailed instrument on admission and discharge, but also at regular intervals. There is data on all nursing homes through the MDS, which is standardized across all nursing homes in the U.S. So the potential [for data sharing] is absolutely there,” she attests.
Ultimately, Vest and Unroe believe the pandemic is an opportunity to build on any existing relationships between health systems and nursing facilities, as well as forge new ones. The description from the UWM team is a helpful road map, they say, cautioning that successful partnerships are often dependent on factors such as the healthcare market and geography.
“If a health system has 60 post-acute care facilities in their network that they’re communicating with regularly, it’s unrealistic that they will put a lot of resources into each of those,” says Unroe. In a situation like the UWM case study, however, an existing university health system infrastructure to provide solutions and support to just 16 nursing home facilities is much more doable, she contends. “It would be [great] for a health system to have strong lines of communication and interoperable sharing of records for any facility they are discharging patients to or receiving patients from, but it might be better to have a smaller network and stronger relationship where actual resources are exchange,” Unroe says.