Journal of the American Geriatrics Society
John Wiley & Sons, Inc.
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COVID‐19, Post‐acute Care Preparedness and Nursing Homes: Flawed Policy in the Fog of War
DOI 10.1111/jgs.16499,

Table of Contents

Highlights

Notes

Gurwitz: COVID‐19, Post‐acute Care Preparedness and Nursing Homes: Flawed Policy in the Fog of War

Amid the COVID‐19 pandemic, well‐intentioned health policy proposals are being hastily adopted, sometimes at the risk of serious unintended consequences for the most vulnerable among us: residents of long‐term care and skilled nursing facilities. In the wake of the experience in Italy, and with hospitals in New York City beginning to be impacted by the pandemic, Grabowski and Joynt Maddox warned in a March 25, 2020, commentary in the Journal of the American Medical Association (JAMA)1 that many patients with COVID‐19 will need post‐acute care to recover from their illness, but that “postacute care facilities currently lack the capacity and capability to safely treat patients with COVID‐19 as they transition from hospital to other care settings.” The authors suggested that post‐acute care could serve as a “pop‐off valve” to increase hospital capacity by moving COVID‐19 patients to such a setting once acute care was no longer needed. They went on to recommend a series of changes in post‐acute care delivery to enhance capacity for the surge of patients with COVID‐19 including designating “certain postacute care facilities in each market to be ‘centers of excellence’ specializing in… the care of patients recovering from COVID‐19.”

Within days of online publication of these recommendations, Massachusetts announced a “first‐in‐the‐nation” plan to establish dedicated skilled nursing facilities to care for patients diagnosed with COVID‐19. To create these facilities, the plan called for relocating hundreds of nursing home residents from up to a dozen nursing homes across the state.2 According to the governor of Massachusetts, the goals of the policy were to “ensure that we have the right kinds of beds in the right places to serve people once the surge arrives,” and to prevent the state from having to force nursing homes to accept patients recovering from COVID‐19, triggering outbreaks in those facilities. In response to the announcement, Grabowski, one of the authors of the JAMA commentary, cautioned, “I’d prefer they use other facilities, like closed nursing homes or hospitals at specialized sites, without moving longer‐stay nursing home residents. It's very disorienting for residents to switch environments and caregivers.”2

The first Massachusetts facility to begin relocating its residents to create these new COVID‐19 postacute care sites was the Beaumont Rehabilitation and Skilled Nursing Center in Worcester. On March 28, 2020, Beaumont began moving its 147 residents to other facilities across central Massachusetts. After most of the residents had been moved, several of those still remaining in the facility tested positive for SARS‐CoV‐2.3 Contact tracing for those residents who had already been transferred was hampered because these moves had occurred just as the surge of the pandemic across the state was beginning. Although a second Massachusetts nursing facility had announced on March 31, 2020, that it would move all of its residents to create a COVID‐19 post‐acute care site, those plans were halted when 51 of 98 tested positive.4

The Massachusetts experience holds valuable lessons for states presently coping with the need for more post‐acute care beds or in planning for a possible resurgence later in the year. Past experiences from natural disasters reveal that older residents of long‐term care and skilled nursing facilities do not fare well with emergency evacuations.5 It follows that the rapid emptying of nursing homes to create post‐acute sites for the COVID‐19 surge is likely to have similar adverse consequences. Abruptly relocating large numbers of long‐term care residents to other facilities in the midst of a pandemic layers on additional risk, amplifying the negative effects on this highly susceptible population due to asymptomatic viral transmission.6

At this most challenging time, there is no place for blaming. We need to ask what did we learn and how can we do things better. Several lessons are apparent. First, the emptying of nursing homes displacing large numbers of long‐term care residents is the worst possible option for creating post‐acute care capacity to decompress hospitals. Second, nursing homes have become an epicenter for the shifting pandemic7, 8, 9, 10 and thus must be prepared to care for large numbers of residents with COVID‐19 infection. At a minimum, this requires appropriate safety equipment and training to minimize risk to staff and uninfected residents. Third, testing in nursing homes is of paramount importance, especially with the high prevalence of asymptomatic infection. As stated by Dr. Deborah Birx, coronavirus response coordinator for the White House Coronavirus Task Force, “No matter what we do in the future, we have to assure that nursing homes have sentinel surveillance; that we are actively testing in nursing homes both the residents and the workers at all times. That's how we solve this in the beginning.”11 Finally, this is not a time to stand on the sidelines. It is essential for geriatrics health professionals to be allowed to take a more active role in the formulation and implementation of policies that impact the geriatric population during this health crisis. This is especially true for policies relating to post‐acute and long‐term care.

Military metaphors have been overused in describing this horrible pandemic. Forgive me then when I say that the most vulnerable among us should not become the casualties of friendly fire and our good intentions.

ACKNOWLEDGMENTS

Conflict of Interest

The author has declared no conflicts of interest for this report.

Author Contributions

The author is solely responsible for this work.

Sponsor's Role

No specific funding was received for this work.

REFERENCES

1 

GrabowskiDC, Joynt MaddoxKE. . Postacute care preparedness for COVID‐19: thinking ahead. JAMA.2020, doi: 10.1001/jama.2020.4686 [Epub ahead of print].

2 

WeismanR, KrantzL. State hunting for 1,000 nursing home beds to treat recovering coronavirus patients. https://www.bostonglobe.com/2020/03/31/metro/state-hunting-1000-nursing-home-beds-treat-recovering-coronavirus-patients/. Accessed April 4, 2020.

3 

WeismanR. Nursing home halts residents’ move after a positive COVID‐19 test, families say. https://www.bostonglobe.com/2020/03/31/metro/nursing-home-halts-residents-move-after-positive-covid-19-test-families-say/. Accessed April 4, 2020.

4 

CreamerL. 51 of 98 residents in Wilmington nursing facility test positive for coronavirus. https://www.wbur.org/commonhealth/2020/04/03/wilmington-nursing-home-covid-19-residents. Accessed April 4, 2020.

5 

WilloughbyM, KipsainaC, FerrahN, et al. . Mortality in nursing homes following emergency evacuation: a systematic review. J Am Med Dir Assoc.2017;18:, pp.664‐670.

6 

KimballA, HatfieldKM, AronsM, et al. . Asymptomatic and presymptomatic SARS‐CoV‐2 infections in residents of a long‐term care skilled nursing facility—King County, Washington, March 2020. Morb Mortal Wkly Rep. 2020;69(13):, pp.377‐381.

7 

BarnettML, GrawbowskiDC. Nursing homes are ground zero for COVID‐19 pandemic. https://jamanetwork.com/channels/health-forum/fullarticle/2763666. Accessed April 11, 2020.

8 

Wilde MathewsAW, KampJ. Coronavirus strikes at least 2,100 senior facilities across U.S., killing 2,300 people. https://www.wsj.com/articles/coronavirus-strikes-at-least-2-100-nursing-homes-across-u-s-killing-2-000-residents-11586554096. Accessed April 11, 2020.

9 

HarrisAJ, LelandJ, TullyT. Nearly 2,000 dead as coronavirus ravages nursing homes in N.Y. region. https://www.nytimes.com/2020/04/11/nyregion/nursing-homes-deaths-coronavirus.html. Accessed April 11, 2020.

10 

WillonP, DolanJ. California moves to protect nursing home residents from the coronavirus. https://www.latimes.com/california/story/2020-04-10/gavin-newsom-california-coronavirus-nursing-homes-mercy-ship-seniors. Accessed April 11, 2020.

11 

. White House Coronavirus Task Force Press Briefing. April 9, 2020. https://www.youtube.com/watch?v=qEQKXC6bYDk.

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