As the Covid-19 pandemic tears through nursing homes, many patients and their families, who were on the fence, are choosing to receive care at home instead.
Even before the start of the pandemic, insurers and some hospitals had begun to venture into in-home care. The novel coronavirus, and regulatory changes that allow Medicare to pay for hospital-level care at home, have accelerated that trend.
Post-acute referrals to skilled nursing facilities are down significantly from last year, according to data from CarePort Health, which provides care coordination software for hospitals and post-acute providers. All referrals hit their lowest point in April, when hospital volumes also fell.
But in the fall months, when volumes recovered, referrals to skilled nursing facilities were still down by double-digits. As of October, they were down 17%, while referrals to home-health providers were 9% above baseline.
“It’s significant not only because it’s down 20%, but it’s also significant because these tend to be your high-margin Medicare patients that are really important to the patient mix at a nursing home,” said Dr. Lissy Hu, CEO of CarePort Health. “The more needs that those patients have, the more the tilt is toward skilled nursing facilities. But there have always been patients who could go either way. There’s where a lot of this shift has happened.”
Patients recovering from a surgery, pneumonia, or other hospitalization, might need to be discharged to a skilled nursing facility. As they recover, patients have access to a team of doctors, nurses and physical therapists.
Patients who were hospitalized for Covid-19 “disproportionately” need facility-based care, Hu said. But transferring these patients out of the hospital is challenging.
Skilled nursing facilities, rightfully worried about bringing in Covid-19 patients, faced wide-ranging requirements from states. Some were stringent, requiring two negative tests for a patient to be admitted. In other states, they were required to accepts patients if they were deemed medically stable.
At the same time, many skilled nursing facilities struggled to acquire enough masks, hand sanitizer and other protective equipment for their staff. While the PPE situation has improved in recent months, staffing is still very much a challenge, Hu said.
Restrictions on visitors, implemented to prevent the spread of the coronavirus, have also resulted in more patients seeking in-home care. But that comes with its own challenges. While skilled nursing facilities have everything in once place — from pharmacy services to physical therapy — more coordination is needed to bring all those services into the home.
“In many ways, the discharge to home is more complex than the discharge to a facility,” Hu said. “How am I going to get a patient to dialysis? Or get meals cooked at home? There needs to be a lot more care coordination to be able to get all of those services in place and ensure when you refer patient to a home-health agency that nurse comes into the home within 48 hours of discharge.”
As for whose job it is to coordinate all of that — it depends. Sometimes, it might be the patient’s primary care physician, or a care coordinator affiliated with the hospital or their insurance company. Sometimes, there can be confusion over who is coordinating what services. But as more patients opt for in-home care, hospitals and post-acute care providers are working together more closely.
“There’s been a lot more back-and-forth sharing of data, working together to coordinate the care of patients. That’s one thing that will probably continue to happen,” Hu said. “This divide between acute and post-acute, as they become more dependent on each other, what we’re going to continue to see is that distinction continuing to blur in terms of the divide between acute and post-acute.”
Even with the broader shift to in-home care, nursing homes will continue to have a significant role as the U.S. population ages, and more people have chronic conditions.
“Skilled nursing facilities are always going to be an important part of the care continuum,” Hu said.
Photo credit: Drazen Zigic, Getty Images