For the initial COVID-19 and Compliance article, titled “COVID-19 and Compliance: What Assisted Living Facilities Need to Know Today about Resident Admissions,” click here.
Every healthcare and public health tool available is engaged in the fight against COVID-19. Few tools are more precious than beds, and perhaps no bed is more precious during this time than hospital beds, where the most sick can access critical resources. To free acute care beds, individuals who may still need care (but not acute care) are shifting capable facilities, such as assisted living facilities (ALFs). However, given the infectious nature and lengthy incubation period of COVID-19, ALFs also face difficult decisions when considering admitting or readmitting hospital discharges. The purpose of this article is to discuss federal and state government and trade organization guidance directed at this difficult issue.
The American Health Care Association (AHCA) and National Center for Assisted Living (NCAL) issued revised guidance on March 30, 2020, titled “AHCA/NCAL Guidance: Accepting Admissions from Hospitals During COVID-19 Pandemic”, accessible here. The stated purpose of the guidance is to “provide guidance to long term care facilities (SNFs and ALs) to determine when making decisions about accepting hospital discharges to LTC facilities.” Even though this guidance does not have the weight of law, it provides guidance for long term care facilities as they make difficult admission decisions. AHCA and NCAL urged LTC facilities, which include ALFs, to begin preparing before the surge of patients/residents begins:
We strongly urge LTC facilities to begin now creating separate wings, units or floors by moving current residents to handle admissions from the hospital and keep current resident separate, if possible. LTC facilities should also develop plans for consolidating residents between facilities to create “new” facilities to accept hospital discharges who may be COVID positive or negative or harboring the virus because testing is not available.
AHCA and NCAL also created a table that provides guidance on what ALFs should do with admission referrals whose COVID-19 status is positive, negative, or unknown and depending on the setting (i.e., whether (1) there is no COVID-19 threat, (2) COVID-19 cases were not present in the surrounding hospital catchment area where the patient was located, (3) COVID-19 cases were present in the surrounding area or community of the hospital catchment area where the patient was located, and (4) COVID-19 cases were wide-spread in the surrounding area or community and hospitals are at or past capacity). Again this guidance is not binding, but provides a roadmap for long term care facilities that are struggling with admission decisions.
State governments have also addressed the issue of admitting and readmitting hospital patients to ALFs. For example, the Michigan Department of Health and Human Services developed a form specifically for acute care to long term care transfers. The form is intended to “facilitate communication between providers during the transition from the hospital to the post-acute care setting” and provides a flow chart to assist in determining whether a patient should be transferred. It also notes that residents of ALFs who are diagnosed with COVID-19 and sent to hospitals “should be discharged back to the facility of residence once they are clinically stable regardless of whether COVID-19 testing is still positive or negative. Continued hospitalization until residents test negative will overwhelm the healthcare system and should be avoided.”
The Centers for Medicare & Medicaid Services (CMS) issued a revised guidance document on March 13, 2020 titled “Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in Nursing Homes”. Though not specifically focused on ALFs, the document, framed mostly as a Q&A, helps to provide some additional insight into how such admissions should be handled in general. For example, CMS included the following question in the guidance document: “When should a nursing home accept a resident who was diagnosed with COVID-19 from a hospital?” CMS stated:
A nursing home can accept a resident diagnosed with COVID-19 and still under Transmission-Based Precautions for COVID-19 as long as the facility can follow CDC guidance for Transmission-Based Precautions. If a nursing home cannot, it must wait until these precautions are discontinued . . . CDC states that decisions to discontinue Transmission-based Precautions in hospitals will be made on a case-by-case basis in consultation with clinicians, infection prevention and control specialists, and public health officials. Discontinuation will be based on multiple factors.
Note: Nursing homes should admit any individuals that they would normally admit to their facility, including individuals from hospitals where a case of COVID-19 was/is present. Also, if possible, dedicate a unit/wing exclusively for any residents coming or returning from the hospital. This can serve as a step-down unit where they remain for 14 days with no symptoms (instead of integrating as usual on short-term rehab floor, or returning to long-stay original room).
For many ALFs across the country, the fight against COVID-19 is only just beginning. Acute care providers are and will continue for some time to be the first to feel the impact of COVID-19 on the general population. As time goes on, ALFs will likely play an increasingly critical role in the country’s response to the disease. Such providers should consider creating new units and developing policies (including admission and readmission policies) in advance of increasing hospital discharges of COVID-19 patients so that they are able to quickly respond to changing conditions.