En español | Some of the states hardest hit by the coronavirus are mandating that hospital patients recovering from COVID-19 be transferred to nursing homes, in some cases forcing uninfected residents to move elsewhere.
The result: Some of the country's frailest patients in need of long-term care are being moved around like dominos. And some nursing home residents are facing yet more risk of COVID exposure.
- New York led the way in late March, with a sweeping directive intended to free up much-needed hospital beds by ordering nursing homes to take COVID-19-positive patients.
- Massachusetts followed with its own order but has apparently dialed it back after criticism.
- New Jersey instructed nursing homes that they could not reject medically stable patients diagnosed with COVID.
- California issued its own stern order only to soften it a couple of days later, after an outcry from advocates for patients.
The decrees follow a federal ban on almost all nursing home visits, leaving residents isolated from family support and protection. The rulings have applied ever more pressure on the more than 15,000 nursing homes across the country, many reeling from COVID-19 as resident deaths mount and stressed staff members search for elusive masks, gloves and gowns.
At least 7,000 COVID-19 deaths have occurred among people living in or associated with nursing homes, according to a New York Times investigation, meaning 1 in 5 coronavirus deaths in the U.S. are tied to a nursing home.
Transferring COVID patients from hospitals to nursing homes threatens to make the problem worse. In addition to housing the most vulnerable Americans, many nursing homes already have poor infection control records. Personal protective equipment is hard to come by, and testing kits are often scarce.
As the number of transfers increases, AARP is asking Congress to prohibit long-term care facilities from discharging patients due to inability to pay for services during the pandemic. It also wants Congress to require the facilities to report data on discharges and transfers, which can be physically and emotionally difficult for patients leaving hospitals and for nursing residents displaced to make room for COVID patients.
"This notion of transferring people was something we expressed a lot of concern about,” said Elaine Ryan, AARP vice president of state advocacy and strategy integration, citing a lack of transparency around the process.
"People didn't know where they would go,” she said. “How disturbing is it not to have one of their family members tell them?”
'Not possible to fully comply with directives'
New York issued an order late last month that “No resident shall be denied re-admission or admission to [a nursing home] based on a confirmed or suspected diagnosis of COVID-19.” The advisory prohibited nursing homes to require that a hospitalized resident deemed medically stable be tested before admission.
The American Health Care Association (AHCA), the leading U.S. trade group for nursing homes, and other long-term care advocates criticized the order. “Nursing homes are the accelerant for COVID-19,” said Los Angeles-area geriatrician Michael Wasserman, president of the California Association of Long Term Care Medicine. “Everyone's talking about the surge. Ultimately, the surges come from nursing homes if we don't put a moat around the long-term care continuum."
Nursing home residents, who typically have multiple health problems, are highly vulnerable to the coronavirus. In 2016, almost 85 percent of the patients in nursing homes were age 65 and older, according to a recent CDC report. Of those who stayed at least 100 days, nearly 45 percent were 85 and older.
The American Health Care Association says discharged hospital patients should return only to nursing homes with separate COVID-19 units. Ideally, those units are staffed with employees with access to personal protective equipment. The federal Centers for Medicare & Medicaid Services (CMS), which regulates nursing homes, endorsed the idea of separate COVID units this month.
But geriatrician David Gifford, the AHCA's chief medical officer, said the federal guidelines have limited impact. “We are doing everything we can with the resources we've been given to slow the acceleration of the virus for our residents, the most vulnerable,” he said by email. “But without [personal protective equipment], tests and healthy workforce, it is not possible to fully comply with CMS and CDC directives."
A spokeswoman for a trade group for California hospitals urged hospitals and nursing homes to work together. “This is not a situation of good and bad, good guys and bad guys,” said Jan Emerson-Shea, vice president for external affairs for the California Hospital Association. “Hospitals absolutely do need the ability to discharge patients who no longer need that level of care."
Hospitals need to make room for others, she said, from women giving birth to other COVID patients. Some nursing homes may be able to take discharged COVID-19 patients, and some may not, she said: “There are no easy answers."
Residents forced to move
Massachusetts recently announced plans to convert some nursing homes to COVID-19 patient treatment facilities, despite opposition from advocates for nursing home patients.
AARP Massachusetts expressed alarm over the transfers. “Moving these residents from their nursing homes can be unsafe and/or traumatic for them and their families,” wrote AARP state director Michael E. Festa and state president Sandra Harris in a letter to Gov. Charlie Baker (R), “particularly when a move is involuntary and sudden."
For now, Massachusetts appears to have put its plans on hold. In New Jersey, meanwhile, three long-term care facilities are in talks with state facilities about accepting COVID-19 patients, NJ.com reported.
In Louisiana, the state health department prohibited moving COVID-19 patients into nursing homes for at least 30 days.
One idea gathering support from nursing home advocates: moving COVID-19 patients to hotels, cruise ships and conference centers. “Save the nursing homes for those who live in the nursing homes and don't have the disease,” said Karl E. Steinberg, a geriatrician and president-elect of the Society for Post-Acute and Long-Term Medicine, the national group representing long-term care medical directors, and a nursing home and hospice care medical director near San Diego.
A spokeswoman for California's nursing home trade group agreed. “There are shuttered hospitals,” said Deborah Pacyna, director of public affairs for the Sacramento-based California Association of Health Facilities. “There are nursing homes that are closed that can be reopened."
California health officials issued a March order stating that nursing homes “shall not refuse to admit or readmit a resident based on their status as a suspected or confirmed COVID-19 case.” But officials soon modified the order, saying nursing homes could refuse such patients in certain cases.
Two days later, California Gov. Gavin Newsom (D) directed state officials to give priority testing to hospitalized patients being transferred to nursing homes, as well as to nursing home residents showing COVID symptoms. He also announced that 600 nurses were being retrained and dispatched to help the state's nursing homes comply with COVID-19 rules and to help treat residents with coronavirus.
The USNS Mercy, the Navy hospital ship originally sent to Los Angeles to help hospitals treat people who don't have coronavirus symptoms, is now taking nursing home patients who don't have COVID-19. That should help ease pressure on skilled nursing facilities in parts of Southern California, Newsom said.
Charlene Harrington, a well-known nursing home expert and professor emeritus at the University of California, San Francisco, favors the creation of COVID-19 post-acute facilities around the state. Patients discharged from hospitals would be tested for the virus and, if positive, transferred to those facilities.
Nursing homes, she said, are already too dangerous: “Anyone in a facility right now is so vulnerable."