Nursing Homes, Long-Term Care Facilities Cite Testing, PPE, Cost as Challenges During Pandemic

Representatives of nursing homes, assisted-living facilities, and other long-term care facilities Wednesday told lawmakers of the challenges they have been facing since the COVID-19 pandemic began, best practices they have been using, and areas where they could still use some help going forward.

The House Aging and Long-Term Care Committee has been holding hearings on the effects of the coronavirus on the industry, and on Wednesday, lawmakers heard first-hand stories of those challenges, as well as some models that could be used going forward.

Kathryn Brod, the president and CEO of LeadingAge Ohio, said that despite early data showing that the coronavirus has a disproportionate effect on the elderly, nursing homes and congregate care facilities were told to prioritize testing and personal protection equipment (PPE). If a test was needed, the health department would do only one or two tests, and if there was a positive result, the facilities were told just to assume everyone is positive. She said the problem was that meant needing more PPE to keep it from spreading, but with a shortage, that was unattainable.

Brod said that in response, the chief medical officer at one of the group's members helped to mobilize with other members to create the Post-Acute Regional Rapid Testing Program (PARRT), which was designed to assist central-Ohio long-term care facilities with testing needs.

Under the program, a team would bring test kits to a facility and swab anywhere from one to over 400 staff and residents. Completed tests were taken to laboratories either at the Ohio Department of Health (ODH) or Ohio State University (OSU) for processing.

She said they found that this kind of testing at bedside is critical with a frail population, especially since they did not want to put residents in transports to medical facilities. They also found that testing employees requires significant administration. It is a 24 hours a day, seven days a week operation, and getting every employee in one place at one time can be difficult. Processing and billing for the tests can also be very challenging.

The program also highlighted how testing is a one point in time process because everyone at a facility could test negative today and there could be a positive test tomorrow. She said they need to understand that and go back and test strategically.

Timely results are also critical. And once results are available, it can lead to staffing challenges for facilities.

She told Rep. Mark Fraizer (R-Newark) that they were able to streamline results by working with one lab at OSU, which would lead to results within 24 to 48 hours. She also said solutions need to include the local health department and taking advantage of labs that have testing capacity, but also relies on timeliness and efficiency.

Brod told committee Chairman Tim Ginter (R-Salem) that it took about two and a half weeks to get the process set up. Currently, it takes about 24 hours to get a team out to test when a facility places a call to the program's hotline.

She told Fraizer that the cost is an evolving process, and they have also looked for private funding to help pay for the program. They have also looked for donations of PPE.

Brod was joined by Judy Budi, president and CEO of Graceworks Lutheran Services in Dayton and Mike Ray, president and CEO of Greenhills Community in West Liberty.

Ray compared his facility's coronavirus response and its cost to driving with your eye on the gas tank, driving at 90 miles an hour, and questioning when you will run out of gas. He said the response of his and other facilities has been to try to work together and share ideas to bring solutions.

He said funding has also been a challenge, especially since long-term facilities did not see help in the early days of the pandemic as attention was put on the hospitals. He said there is a huge financial impact, noting that N95 masks that used to cost less than $1 each now cost $5-7, while gowns that were 25 cents each now see some distributors charging $9. He asked the lawmakers to consider increasing reimbursements to the nursing facility and assisted living waiver per diem rates to offset the high costs of PPE, increased staffing, and added communication technology.

On testing challenges, Budi said there needs to be a rapid test that can be done at the site and can be done daily. She said the current nasal swab that "has to go into the brain" is not something most staff want to go through on a daily basis.

Rep. Cindy Abrams (R-Harrison) asked the witnesses what success would look like for them. Budi said a test that is a simple as a finger prick and has results in 10-15 minutes, as well as cost-effective PPE with about a 90-day supply.

Ray told Fraizer that taking on residents discharged from a hospital has been a challenge, as they must treat them as positive cases for at least 14 days, which causes them to burn through PPE. Budi said that Montgomery County hospitals recently started testing patients 24 hours from discharge, but her facility still isolates those patients.

Richard Albertoni and Susanne Crisp of Public Partnerships LLC spoke to the committee on self-direction. Crisp said self-direction empowers individuals to manage their own services and supports. She said it is more about the daily functions of life such as dressing and grooming and not skilled nursing care. She said empirical evidence of the model so far has been positive.

"Regarding the COVID-19 issue, we have found that self-direction has been a huge boon in providing access to services that people need," she said. Individuals have a say in who is hired to come into their home, so they have a person that they know and trust. Noting difficulties home health agencies have in hiring to provide home care, she said self-direction can relieve that burden of finding individuals to go into a home.

"When a person is able to hire whom they wish, they can hire friends, family and neighbors. For people who have lost their jobs, this is a God-send. What we have seen is many people have been hired for services in the home, and that relieves the unemployment for citizens," she said.

Albertoni said a person who is in Medicaid long-term care might be in an institution like a nursing home or the person might get their services through a home or community-based agency. Under the model a person who needs personal care services can use an agency, or the person can self-direct.

"You decide you want to be the employer of this yourself. You want to pick your own worker, maybe a neighbor or somebody you know. The reason it is important is you are bringing in somebody to your home that you trust," he said. "Somebody who is going to bathe you, dress you, getting to pick that worker is an act of control and self-determination. It's especially important during a pandemic because you are not having an agency worker go from home to home and potentially transmit the virus. So this a solution for the pandemic."

He said in Ohio only about 1 percent self-direct, while in other states it is 10 to 15 times that amount.

Ginter asked the witnesses if there is a way to streamline the process while maintaining checks and balances. Crisp said Ohio has a step-by-step process. One way to streamline it is to make it more of a concurrent process, she said, and it would not take legislation.

Tom DiMarco of Interim HealthCare spoke on how the pandemic has impacted home health and hospice agencies in the state. He also spoke on issues with obtaining PPE for his industry, saying it was almost impossible. His organization has spent more than $572,000 in purchasing PPE. While PPE has become easier to obtain, pricing has remained high.

He also said patient services were put on hold do the lockdown. His group has been able to do telehealth services, though Medicare has not allowed the use of telehealth as a means of providing care except for hospice.

Interim HeathCare's Medicaid business "has been a breakeven at best scenario," noting reimbursement rates before PPE costs are factored in. He urged lawmakers not to slash funding Medicaid for home care funding any further.

Joe Russell for the Ohio Council for Home Care and Hospice made similar arguments. He said Medicaid skilled home health reimbursement rates are the same as they were in 1998, and the pandemic has put home health agencies in a position to have to worry more about money than patient care.

Russell raised concern that the lower rates could lead to more poor Ohioans being forced into an institutionalized environment.

He said his group recommends allowing home health and hospice agencies to use telehealth services past the pandemic period, and is continuing to advocate for more testing. He also advocated for improvements in state Medicaid policies.

Asked about a 35-minute time limit, Russell said it was something that was put in place in the last administration. He said in their industry, there is a reimbursement base rate and a unit rate that is based on the length of the appointment. The change and addition of the time limit has made Ohio one of the most complicated models in the country, and it has caused some vendors to leave the state. He said it is very difficult to know which rate a vendor will get.

Beverley Laubert, the Department of Aging ombudsman, gave the committee stories of how the pandemic has affected facilities, residents, and families. In lieu of visits, regional ombudsman representatives have been contacting residents, families, and providers by phone and video, and has spoken to over 6,000 individuals since visitation restrictions began.

She said residents and their families have told them of the impacts on quality of life and quality of care and they are working to address those problems. Representatives of her office have received about 2,230 complaints since the end of February, lower than the number received in a similar period last year.

Involuntary discharge is the most frequent complaint her office handles year after year, but during the pandemic, hearing officers have had to hold hearings virtually.

Visitation concerns are second, with complaints not just being able to visit, but the way restrictions are being handled. She noted one son was in the middle of a visit with his mother on the day guidance was issued and told the leave the facility immediately. One daughter reported her father's nursing home prohibited "window visits," and when Laubert visited, she noticed no visible problems that would have prevented families from talking with residents from a distance.

Many complaints have been about end of life, an exception provided in the public health order. She said homes have turned away families unless the resident was actively dying.

Rep. Doug Green (R-Mt. Orab) asked Laubert what enforcement authority her office has if it finds a violation. She said her office does not have authority and works on making the regulations work for consumers. Representatives of the office do a lot of educating and notification, but if they do find something egregious, they can work with the attorney general's office, the Ohio Department of Medicaid, or other enforcement agencies to make sure regulations are carried out in the way they were intended.

Ginter said he is troubled by what Laubert presented to the committee.

Rep. Stephanie Howse (D-Cleveland) asked about stories were ombudsmen were not allowed access to facilities. Laubert said most facilities have been cooperative, and there have been facilities where the ombudsman was able to tour it virtually through a staff member walking through with an iPad, handing it to residents to speak.

Jean Thompson testified on behalf of the Ohio Assisted Living Association. She said that while assisted living and nursing homes aren't the same, they both care for high risk populations in congregate settings during the crisis.

She said assisted living has not received any of the federal money for financial support to skilled care facilities, and said her group hopes future distributions by the state and federal government will include assisted living facilities. Assisted living facilities have also not received direct distribution of PPE from the federal government.

She also said that 126 facilities have reported that they have begun allowing visitation under guidelines issued by the DeWine administration, and said it has overall been going well, although one community said it had some families that were not up to date on social distancing policies.