Nursing Home Care Can Be Redesigned to Protect Our Vulnerable Patients

Digging through some old boxes recently I came upon a very rare treasure: an old Kodak Kodachrome photo of me from 1977. My mother had a tradition of taking pictures of me right before I embarked on new paths in life, such as standing with my Cinderella book satchel in a little blue plaid skirt on my first day of school, the day I started college at UNC, the day I graduated medical school at Duke. This grainy photo was a lost one of that genre, but a very meaningful picture for me now: it’s a 16 year-old me in 1977, 110 pounds soaking wet, the clothes on the clothesline and cows and the barn in the background, in my solid white clothes and hair in a bun for my first day of my first job –washing dishes in a nursing home. Now here I am 42 years later, six months into my new job as CEO of Eventus Whole Health, a company whose mission is to provide integrated, whole person medical care to vulnerable adults residing in nursing homes. And here we all are in the midst of the COVID-19 pandemic, where those precious, vulnerable residents are in great peril.

The accounts in the media right now about how the pandemic is impacting people in nursing homes are horrifying, but really do not reach to the deeper stories we need to understand in order to have a real impact on the lives of the people who live and work there. People who live in nursing homes live there because they have medical needs that are too complex for them to living independently. Many need help with the basic activities of daily living such as bathing, toileting, eating, and dressing. Some have dementia. Some have traumatic brain injury. Some have chronic lung disease. Some have end-stage renal disease. A majority have five or more chronic diseases, such diabetes, heart disease, hypertension, Parkinson disease, and arthritis. Mental health diagnoses such as depression, anxiety, bipolar disorder, and various forms of psychoses are common.

The people who work in nursing homes are very special people. It is very, very hard work to provide care to elderly, medically vulnerable adults. To lift and feed and bath and provide medications, clean rooms, physical therapy, kind words on a good day is difficult. To do so in the midst of the coronavirus pandemic when person protective equipment and testing is short, residents are in isolation, their families are frightened, and the media reporting is blistering can be intensely stressful. These health care workers are no less heroic than the front-line health care workers pictured daily on the news in emergency rooms and ICUs across the world.

As a country, we have not invested a lot of resources into redesigning nursing homes in a long time. The average skilled nursing facility was built more than 40 years ago, and over 500 have closed during the past 5 years. The median operating margin for skilled nursing homes last year was a negative 1.3%. The workforce taking care of our nursing home neighbors is one of the lowest paid groups in the health care industry. The overall public reputation of nursing homes is poor, because stories about nursing homes doing a good job really does not sell a lot of newspapers. The industry is both highly regulated and fragmented. The litigious environment of the industry has created complex operating models of REITs, operating companies, and services companies interacting in a somewhat disorganized ecosystem of national and regional companies and mom-and-pop small businesses. The costs of providing adequate personal protective equipment for skilled nursing facilities has been estimated to be as much as $10,000 a week, which will strain the operating margins for some nursing homes beyond viability.

In the midst of the current pandemic, we need to remember the importance of excellent chronic care management for vulnerable populations. The CDC has significant evidence showing frail individuals have worse outcomes when their routine healthcare and services are disrupted. The residents of nursing homes right now are threatened on multiple fronts: they are at risk for coronavirus infections; they are at risk of their chronic care services being disrupted; they are at risk of anxiety and depression due to isolation and lack of family and community interaction; they are at risk of reduced levels of nursing care due to lower staffing from illness and quarantine.

Eventus WholeHealth, like the rest of the health care industry, is rapidly evolving its care models to respond to the challenges of the pandemic, including the rapid deployment of telehealth services for primary care and mental health services that augment medically necessary and appropriate in-person visits, rigorous use of personal protective equipment and daily monitoring, daily team meetings, coordination of care with local health systems and health departments, and rapid deployment of testing and cohort management in facilities with positive COVID-19 patients. We are also spending a great deal of time thinking about how we can redesign our models of care in the future to provide even better technology-supported, but high touch, hands on safe, effective care for our patients residing in skilled nursing facilities, assisted living facilities, and independent senior living facilities. We are preparing for a future where the most vulnerable among us are getting the care they need and deserve. Stay tuned and stay well.