En español | When Debbie Farley and her husband, Bob, developed flu-like symptoms in February, they initially thought little of it. Coronavirus hadn't spread to their community in Topeka, Kansas, at least as far as they knew. But after a month, they weren't getting much better. Bob, a 73-year-old Vietnam veteran, was admitted to the hospital and diagnosed with double pneumonia.
The next day, he tested positive for COVID-19. He was moved to the intensive care unit and spent 12 days in the hospital while Debbie quarantined at home.
After nearly two weeks apart, Debbie didn't want Bob to follow the standard protocol of being discharged from the hospital into the COVID-19 ward of a nursing home or rehab facility, where he would continue to receive treatment but where she couldn't visit him. “I talked to the doctor and told him I wanted him home,” she says. “I wanted him here to take care of him."
The coronavirus pandemic has made nursing homes and the rehab centers that are attached to many of them less desirable places to recover after hospitalizations. For the Farleys, it was limited visitation options. For others — including the hundreds of thousands of older Americans mulling or scheduling hip and knee replacements and other surgeries — it's fear of contracting COVID, which has claimed the lives of over 80,000 long-term care residents and staff, according to the Kaiser Family Foundation.
"People want more than ever now to stay out of the nursing home,” says Rachel Werner, M.D., executive director of the Leonard Davis Institute of Health Economics at the University of Pennsylvania. “The dangers and potential downsides have really been laid out to public viewing."
The result is that at-home recoveries appear to be booming. Hospital discharge data analyzed by the Avalere Health consulting firm showed overall inpatient hospital discharges were down 12.7 percent in June from a year prior, as many patients postponed elective procedures. But discharges to home health services were up 4.6 percent, while discharges to skilled nursing facilities were down more than 25 percent.
The Farleys opted for at-home rehab through a company called Interim HealthCare. Bob's periodic video calls with doctors, his oxygen-monitoring equipment and in-person nursing visits were covered by Debbie's health insurance. “We only had one person coming in — we may have all had masks on, but at least he wasn't exposed to 20 different people,” she says, referring to the threat from the coronavirus.
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Telehealth policies have loosened since the pandemic began, helping feed the surge in at-home recoveries. Medicare has relaxed guidelines for the kinds of patients eligible for services that make rehab at home possible, and many insurance plans now cover those services.
"A lot of people don't realize, when you check into a hospital, you really need to check out what the discharge plan will be,” says Elaine Ryan, vice president for state advocacy and strategy at AARP. “When you're discharged, the question is: Can you receive in-home rehabilitation? And the answer is yes. You don't have to go into those centers."
Avoiding the nursing home
Nursing homes “were fighting a PR battle” even before the coronavirus swept the U.S. and sickened more than 238,000 residents, says Fred Bentley, managing director of Avalere Health. The pandemic has made that PR problem “way, way worse."
"We are going to find patients who before COVID would have gone into a facility, no questions asked, and now they have options,” Bentley says.
That's a problem for nursing homes, which for decades have depended on Medicare payments from short-term rehab patients. Many homes rely on Medicaid payments from long-term care residents but on Medicare reimbursements from short-term patients who've been discharged from the hospital after a fall, illness or elective procedure.
"Because Medicaid rates are quite low, [nursing homes] depend heavily on patients insured by Medicare, and Medicare pays for post-hospital care in nursing homes,” says the University of Pennsylvania's Werner. Nursing homes averaged $544 per patient day in Medicare revenue from rehab patients last year, according to data from the National Investment Center for Seniors Housing & Care. That's more than twice Medicaid's rate of $216 per patient day from long-term care recipients.
But nursing homes’ Medicare revenue cratered when hospitals across the country temporarily suspended elective procedures last spring to prioritize coronavirus care. Their rehab beds have been slow to fill back up, even after elective procedures resumed, Bentley says.
"Patients who otherwise may have gone to [skilled nursing inpatient facilities] after a stroke or after a stay for heart failure where they needed a little bit more skilled care were instead going home because of the risks associated with nursing homes,” Werner says. “So that revenue source really diminished dramatically for nursing homes."
At the same time, their expenses have surged, for COVID-related necessities like personal protective equipment, staff training and stepped-up infection control measures. The Centers for Medicare & Medicaid Services (CMS) has distributed over $21 billion to help get facilities through the pandemic, but Bentley says the payments are a Band-Aid on a huge wound.
When COVID spurs innovation
The home health industry, meanwhile, has boomed. Jennifer Sheets, Interim HealthCare's CEO, says the company has seen a “huge demand increase … we've got double and triple the referrals now coming in."
Nursing homes faced growing competition from other health care providers even before the pandemic. An estimated three-quarters of U.S. hospitals had fully or partially implemented computer-based telehealth plans in 2017, according to data from the American Hospital Association, up from just over a third in 2010.
Technological advancements helped move things along, but the pandemic and the relaxation of telehealth regulations turbocharged the transition. “For many, many years we've wanted to do virtual care and remote monitoring in new and innovative ways. But there have been some obstacles and barriers and regulations,” says April Vogelsang, system senior vice president at the Illinois-based Carle Foundation Hospital & Health Alliance Medical Plans. “COVID has really lifted that and allowed us to implement things within days or weeks instead of years."
For Laura Gordon-Nolan, 60, expanded telehealth options under her Kaiser Permanente insurance allowed her to complete a cardiovascular rehab program from her home in San Diego after recent quadruple bypass surgery. Her doctors sent her a smartwatch that tracked her heart rate and her progress. “With something as traumatic as heart surgery, that gave me comfort knowing I was always in contact with them,” she says of communication with doctors.
Even for people who require round-the-clock care, nursing facilities are not the only rehab options after surgery. The Carle Foundation Hospital is one of many now with “swing beds,” recovery units that offer 24-hour skilled nursing care in a hospital setting. After surgery, patients can transition to the beds in the same hospital or transfer to a nearby facility — bypassing a nursing home or rehab facility. “They allow the ability to free up an inpatient bed and get that person out of a true inpatient setting,” Vogelsang says.
Because of COVID, experts say swing beds and home health services are likely to remain popular alternatives to nursing homes and inpatient rehab centers — straining the nursing home industry's financial outlook.
"There's a lot of concerns about putting a loved one into a nursing home: risk of infection, a lot of isolation, things going on to contain the infection,” Werner says. “There will likely be nursing homes that end up having to close as a result, and consolidation with declining occupancies."