Most critical-access hospitals that own and operate long-term care facilities do so because no other entity is willing to in their community, according to David Snow, an attorney at Hall, Render, Killian, Heath & Lyman with rural healthcare clients.
Most hospitals in this situation have operated the long-term care facility for many years. Typically they’re a drain financially because of low Medicaid reimbursement, but the hospitals feel an obligation to the community to keep them open.
“I’ve talked with many CEOs at small rural hospitals in different parts of the country, and it’s a challenge to do both under one roof. And the long-term care side is the more challenging, but they don’t want to close them down,” Snow said.
In fact, Genesis Health System based in Davenport, Iowa, recently entered into a joint venture with long-term care provider WesleyLife to partly own and operate its nursing homes, including two attached to critical-access hospitals, to help with operating costs. “Our ability to get capital and position us moving forward was going to be particularly challenging” without a joint partner, said Glen Roebuck, executive director of home, outpatient and senior services at Genesis.
To prevent a COVID-19 outbreak, Genesis has stopped allowing visitors at its long-term care facilities as well as removed staff who display symptoms. Thus far, no long-term care patients have tested positive for COVID-19.
But Roebuck said even with restrictive measures, it’s still challenging to prevent the outbreak because employees or patients can have the virus for a few days without presenting any symptoms. “If it gets into a facility, it likely walked in through the front door,” Roebuck said.
Sanford Chamberlain has also stopped allowing visitors at its hospital and nursing home. Neither entity has seen COVID-19 patients yet.
Additionally, all nursing home workers have their temperatures taken daily and group activities have stopped.
If a nursing home resident were to contract the virus, Peterson said, the protocol is to care for them in the long-term care facility unless hospital care is appropriate. Patients would remain isolated in their rooms. If they have a roommate who isn’t sick, they’d be removed from the room, she said.
The hospital is prepared to treat COVID-19 patients and has begun adding surge capacity, which would increase its beds to 40. The Trump administration is temporarily allowing critical-access hospitals to increase their bed size beyond the maximum of 25 in response to the COVID-19 outbreak.
Sanford Chamberlain is part of the larger Sanford Health system, so it can rely on additional support staff should it experience a surge. It also can transfer COVID-19 patients after they are stabilized to its nearby Sanford tertiary medical center 130 miles away.
“Being part of the integrated system with Sanford, we know that we could have shared resources,” Peterson said.
Genesis also plans to keep its long-term care residents in place if they develop COVID-19, and it has a coordinated triage process with its hospital emergency departments should inpatient care be needed.
Employees in the long-term care settings are being told to call the ED rather than 911 to discuss the patient’s symptoms to determine if hospitalization is necessary. This also gives the EDs of its critical-access hospitals time to prepare for the patient.
“Just because someone has a positive test for COVID-19 isn’t a reason to be transferred to the hospital,” Roebuck said. “The first thing isn’t to call 911 and send them to the EDs. That will bury the healthcare system.”
Peterson said Sanford Chamberlain’s setup as a hospital and long-term care provider gives it an advantage in dealing with the COVID-19 outbreak. The teams of both entities will work together to determine if a long-term care resident needs to be admitted to the affiliated ED, which allows the hospital to prepare. “We can collectively make the decision before they come to the hospital where the best place to receive care is,” Peterson said.
Given the pandemic’s scope, any critical-access hospital could be strained by an influx of COVID-19 patients, whether it has a long-term care facility or not.
Margaret Mary Health, a 25-bed facility in rural Batesville, Ind., is in a coronavirus hot spot and has been at or near capacity for about a week and half.
“We are usually 80% outpatient and 20% inpatient and we are trying to convert to 30% outpatient and 250% inpatient” relative to previous capacity levels, said Tim Putnam, CEO of the hospital.
Margaret Mary Health was able to add beds to increase its capacity to 58. It also acquired 10 more ventilators for a total of 13.
Putnam said as many as six patients are using ventilators at once.
“We have been able to keep up, but it’s been our staff working really hard,” he said.