As you know, earlier today, President Trump declared the rapidly evolving COVID-19 situation a national emergency. This bold move empowers CMS to waive certain federal requirements in Medicare, Medicaid, and CHIP to rapidly expand the Administration’s aggressive efforts against COVID-19 led by the White House Coronavirus Taskforce…
…The flexibility we are offering will be a godsend to the providers, clinicians, plans, facilities, on the front lines of this fight. We encourage them to carefully review the broad range of options available to them.
— from a press release by Center for Medicare & Medicaid Services administrator Seema Verma, March 13, 2020
Two months after the first known COVID-19 infection arrived in the US, the Trump administration declared a national emergency, and the Center for Medicare & Medicaid Services (CMS) began to waive certain requirements, allowing hospitals and health care providers to bill for services in a more flexible manner during the pandemic.
CMS also placed new limits on nursing homes, restricting “visitors and nonessential personnel with a few exceptions such as end-of-life situations.”
Two more months have now passed, and the COVID-19 pandemic has been devastating to US nursing homes. Thousands of facilities have reported cases of COVID-19 among residents and staff. Although less than 0.5% of the US population are housed in nursing homes, nursing home residents currently account for approximately 25% of the confirmed deaths due to COVID-19. In some states — such as Massachusetts and Pennsylvania — residents of nursing homes account for 50% of all deaths.
From Seacoastonline.com: “Almost 80% of the people who have died from COVID in New Hampshire are associated with long-term-care facilities,” state epidemiologist Benjamin Chan said Wednesday.
Here in Colorado, outbreaks of COVOD-19 have been reported at 152 senior care facilities, according to Colorado Department of Public Health & Environment.
Virtually all US nursing homes are in full lockdown mode, with residents unable to see their families or participate in communal meals or activities. Severe staff shortages exist because many workers are unable, or unwilling, to work in conditions where testing is insufficient and where personal protective equipment (PPE) is in short supply.
According to a May 22 article titled “Nursing Home Care in Crisis in the Wake of COVID-19”, by David C. Grabowski, PhD, and Vincent Mor, PhD, posted to the JAMA Network website (formerly the Journal of the American Medical Association):
…The virus spreads from the community to nursing homes via staff without sufficient PPE. The federal government recently announced that all US nursing homes would receive one week of PPE. Although a good start, the sector will need additional PPE for many weeks because universal precautions must be in place to account for patients with COVID-19 and staff who are asymptomatic. Nursing home staff will need to be trained and supported in good infection control. Additional pay and support for staff, along with short-term programs to supplement this workforce, will be necessary…
I mentioned my late mother, Shirley Hudson, in a previous editorial series; she spent the final years of her life in assisted living facilities in Seattle before passing away in 2017. The orderly staff appeared to be overwhelmingly African immigrants; I assume the wages were not overly generous. I rarely saw anyone use protective gloves; I don’t recall ever seeing someone wear a mask. But the place was kept neat, and clean. The overall atmosphere was much like a big foster family overseen, perhaps, by obsessive compulsive parents.
An alarm sounded if an unaccompanied resident attempted to leave by the front door, or through the basement parking lot.
I seriously doubt the staff at Mom’s facility, back in 2017, had training in dealing with a viral epidemic. I can’t imagine what such a facility would do with “one week of PPE” when it’s clear the pandemic has already lasted more than three months and shows little evidence of coming to a speedy conclusion.
More from Dr. Grabowski’s article:
Long-term nursing home residents recovering from COVID-19 will require extensive medical and social care. Medicaid must begin to pay a higher rate commensurate with the costs of delivering high-quality long-term care to frail older adults. In many states, this will require greater federal contributions. However, this will not be sufficient to ensure access to high-quality medical care for these individuals. Because Medicare still covers medical services for these long-term nursing home residents, models are needed that integrate medical care with the social needs of patients recovering from COVID-19.
Many people recovering from a SARS-CoV-2 infection — whether they’ve been hospitalized or not — quarantine themselves in a private home until they are no longer a danger to others. But a nursing home represents a perfect storm during the COVID-19 pandemic. Residents and staff interact in close quarters. Many of the residents have underlying health conditions, and nearly all belong to age groups most vulnerable to fatal outcomes. The low wage staff cannot help but feel fearful — that they will themselves become infected, and that they will spread infection among the residents.
CMS — the federal bureaucracy that certifies nursing homes and writes the checks — has forbidden family members from visiting… certainly a cause for depression and feelings of abandonment.
What nursing homes desperately need right now, it seems, is help from professional physicians and nurse practitioners, serving as primary care clinicians, collaborating with nursing home staff and therapists.
Dr. Graboski writes, “Nursing homes will have to attract health care professionals who want long-term relationships with their frail patients.” But where do we imagine these additional ‘health care professionals’ coming from? According to data from the World Health Organization (WHO) website, the US — the country with by far the world’s most expensive healthcare system — has only about 25 physicians per 10,000 population. This compares with, for example, 40 per 10,000 in Russia, 41 per 10,000 in Spain, 42 per 10,000 in Germany and 54 per 10,000 in Sweden.
The cynics among us might respond: “These old people were going to die anyway, sooner rather than later. Their quality of life is already compromised, shut up in facilities full of tired old people with failing memories, often confined to wheelchairs, playing Bingo and watching the Disney channel.
“Give them a week’s worth of PPE and they’ll be just fine. Let’s get the economy open, for heaven’s sake.”
Read Part Two, on Monday…