How Do You Care for Coronavirus Patients After They Leave the Hospital?

While policy makers and health care leaders have rightly focused on prevention and acute treatment, they must also work to ensure that we have the capacity to care for patients who require rehabilitation after they leave the hospital, often referred to as postacute care. Postacute care for COVID-19 survivors will be delivered by two main categories of providers: skilled nursing facilities (SNFs) and home health agencies (HHAs).

We estimate a significant shortage of available postacute care, especially for SNFs. A recent analysis projected that approximately 24 million Americans could require hospitalization and/or intensive care unit-level care over six months due to the pandemic. Given lack of epidemiological data on COVID-19 patients requiring postacute care, we estimated postacute need for COVID-19 by examining SARS-CoV, a viral respiratory infection that had similar rates of severe respiratory complications, albeit a higher case fatality rate. In the SARS-CoV epidemic in the early 2000s, approximately 3 percent of survivors required inpatient rehabilitation (provided by SNFs) and 46 percent of patients required any type of rehabilitative service (such as outpatient programs).

If we assume that survivors of COVID-19–related hospitalization will require rehabilitative services at a similar rate, and that the case fatality rate is 2.6 percent, we would expect that at least 700,000 patients will require inpatient short-stay rehabilitative care and that 10 million more may require other outpatient rehabilitative services. These estimates would change based on identification of cases with effective quarantining, actual case fatality rates, and the possibility of offering more intensive rehabilitative services to patients who are hospitalized.

Nevertheless, our estimate would overwhelm our current capacity of approximately 345,000 available SNF beds and double the current number of annual short-stay residents. This also assumes that all SNFs would accept these patients, regardless of insurance status or geographic constraints, which is unrealistic. In addition to SNFs being overwhelmed, approximately one-third of HHAs have reported that they will not have the staff or stockpile of supplies to care for patients throughout the pandemic.

Therefore policy makers and providers must answer an important question: What is the best way to expand capacity of postacute care during the COVID-19 pandemic? We recommend three strategies that should be employed to prepare our health care system for the upcoming surge in need for postacute care after COVID-19–related hospital discharges: Expand home-based postacute care offerings; train a new workforce to care for patients who are recovering from COVID-19; and designate specialized SNFs or alternative care settings specifically for patients who have suffered from COVID-19.

Expand Home-Based Postacute Care

COVID-19 is especially deadly for chronically ill and elderly nursing home residents. In response to deadly nursing home outbreaks, many SNFs are justifiably limiting admissions. For example, one Veterans’ Affairs SNF in Massachusetts (where one of us practices) has begun accepting patients for postacute care only if they have been hospitalized for more than 14 days and have not demonstrated respiratory symptoms suggestive of COVID-19. As a result, there are patients ready for discharge but in need of rehabilitative services that no one is willing to provide at this time. Universal screening of inpatients will improve delays, but millions of recovering patients may still find that no SNF will accept them. While the Centers for Medicare and Medicaid Services has smartly waived the requirement of a three-day inpatient hospital stay to qualify for SNF care reimbursement, fear of nursing home outbreaks will likely dampen the effect of this policy change. A lack of available SNF beds and the imperative to prevent exposing medically frail nursing home residents to COVID-19 necessitate the identification and development of alternative postacute care settings that allow patients to access needed rehabilitative services once they are ready to begin their recovery.

HHAs will need to ramp up capabilities to provide home-based rehabilitative services for patients recovering from COVID-19. This will require loosening restrictions on HHA eligibility and the developing novel care models that bring into the home a relatively high intensity of services that traditionally can only be provided in inpatient rehabilitation facilities and SNFs. While the new Patient Driven Payment Model reimbursement methodology for SNFs and HHAs that debuted last fall will appropriately shepherd resources to high-need patients recovering from COVID-19, additional reimbursements may be needed to cover the physical, occupational, and respiratory therapy needs of this population. These SNF-level services will need to be provided daily over weeks to months so that COVID-19 patients will be able to recover at home without risking viral transmission to other patients in a postacute care facility.

Expand The Workforce For Postacute Care

The postacute care industry is notorious for being staffed by underpaid nurses and aides. Given its relatively low wages and physically intense work, the industry is also marked by significant labor turnover. Payers and policy makers must commit to invest in this workforce if it is to remain viable. They must also realize that the personal protective equipment (PPE) shortage affects postacute care workers as well and commit to distribute PPE equitably across acute and postacute care settings.

Although current workforce capacity is probably insufficient to meet the demands of patients recovering from COVID-19, rapid workforce development can be achieved by retraining individuals whose jobs will have disappeared or become unstable due to the upcoming economic recession. For example, employees of the travel, hospitality, and other industries that depend on in-person customer service may be well-suited to postacute care work. It is unrealistic to expect HHAs and SNFs to foot the bill for this retraining; dedicated federal funds should be committed to rapidly scale up capacity in the coming months.

Designate Specialized COVID-19 Postacute Care Sites

While home-based care is the preferred method of providing postacute care while maintaining physical distancing, it is not always clinically appropriate. Many patients struggle with unstable housing or live with frail individuals who cannot risk COVID-19 exposure. In circumstances such as these, we need to contain COVID-19 as much as possible to designated health care facilities. Some acute care hospitals in the United States and China have designated themselves as dedicated COVID-19 treatment centers, which enables standardized care and avoids further community transmission to other vulnerable groups.

We must do something similar for postacute care, where certain SNFs in the community should designate themselves as dedicated COVID-19 facilities. As testing expands, patients should also be tested at discharge and be directed to those facilities as well. Recognizing that this could mean dislocation for some patients, other community buildings such as hotels could be repurposed as postacute care sites for COVID-19 patients. Such a re-purposing approach, however, would require extensive flexibility from payers, postacute care providers, and regulators.

Conclusions

Necessity is the mother of invention, and this will apply to the postacute care providers in the COVID-19 pandemic as our country accommodates a surge in coronavirus cases. While a primary focus of policy makers has rightfully been on providing hospital care, there is still more work necessary to help patients actually recover from their illnesses. Implementing these strategies will require billions of dollars from public and payer providers, but it is absolutely necessary to protect our society’s most vulnerable patient populations.

Original article by Health Affairs.