[This story has been updated]
Nursing homes are being asked to accept COVID-positive admissions from hospitals, according to new guidance from the Department of Public Health, even as positivity rates within nursing homes are increasing sharply.
The latest guidance from the DPH is an indication that the state is trying to alleviate the growing crush of COVID-19 cases in hospitals as they near record numbers of patients.
Until Thursday, the health department required any patient transferred from a hospital to a long-term care facility to have a negative COVID test performed in the hospital within 48 hours of their transfer, but that requirement is now waived.
“Vaccination status of an individual should not influence decisions about hospital discharge or PAC admission,” according to the DPH.
The guidance puts significant pressure on nursing homes that are already facing severe staffing challenges and testing limitations, providers said.
“Hospitalized patients should be discharged from acute care whenever clinically indicated, regardless of COVID-19 status,” Public Health Commissioner Dr. Manisha Juthani wrote in the two-page memo.
“Discharge should not be held due to a pending SARS-CoV-2 test, as receiving PAC (post-acute care) providers should now have quarantine policies in place based on COVID-19 vaccination status,” Juthani wrote. “PAC providers should be equipped to safely care for individuals with active COVID-19 who are ready for discharge from acute care.”
Matthew Barrett, president and CEO of the Connecticut Association of Health Care Facilities, said nursing homes should still be able to decide whether to accept COVID-positive people from hospitals under the guidance.
“The guidance that came out today, we don’t interpret it initially as in any way undermining a nursing home’s very appropriate authority and ability to refuse a hospital admission, if the nursing home believes it is unable to meet the care needs of the resident due to staffing issues — and staffing issues are present all across the state and especially in Connecticut nursing homes,” he said. “So we don’t view the memo that came out today or the guidance document from the Department of Public Health in any way, shape, or form undermining that clear authority.”
If a nursing home were to refuse a COVID-positive person, the hospital would be responsible for finding another place that would accept them, said Max Reiss, spokesman for Gov. Ned Lamont.
The new DPH guidance tells hospitals to notify the health department if a long-term care facility refuses to accept a patient. During discharge planning, “appropriateness of COVID-19 vaccination (and booster vaccination) prior to discharge should be evaluated.”
Hospitals should tell the post-acute care providers the patients’ COVID-19 vaccination status (including dates of vaccination, and which vaccine) and if the patients have had COVID-19 in the past 90 days.
Post-acute care facilities include long-term care hospitals, inpatient rehabilitation facilities, skilled nursing facilities and home health agencies. But the majority of the patients end up in skilled nursing home facilities.
The change comes even as state data show more than 80% of Connecticut’s nursing homes are now reporting COVID-19 cases among either staff or residents, and booster shots among staff remain low.
One hundred and sixty-nine out of 209 nursing homes in the state are reporting positive cases, according to DPH data that captures cases through Dec. 28. Several providers said that with the week lag in case counts, it’s likely that nearly every nursing home now has cases.
On Thursday, state Department of Social Services Director Diedre Gifford said the newest numbers show 1,400 infections among nursing home staff and 630 among residents. Last week, those infection numbers were 680 staff and 181 residents, according to DPH data.
Overall on Thursday the state’s positivity rate once again was over 22 percent and there were 121 deaths reported in the last week, the largest number reported in one week since last February.
Some providers believe the increase can partially be traced to the low percentage of nursing home staff that have received booster shots. As of Dec. 26, the percentage of staff that had received boosters was 31%, up slightly from the previous week’s 29%.
Among residents, about 82% have received a booster shot. After vaccines were first introduced, many nursing homes had vaccination rates over 90%.
On Thursday, Lamont announced that he was issuing an executive order mandating that nursing home staff get the booster shot by Feb. 11.
“We want all of the nurses at the nursing homes with a third shot, which I consider fully vaccinated, by Feb. 11,” Lamont said, adding “that will pay dramatic dividends that will open up capacity in our hospitals and make it easier for us to transfer people from the hospitals to the nursing homes and allow us to get back to more regular and normal hours in our nursing homes.”
Recovery centers wanted
The new order comes as providers wonder why the state hasn’t resurrected the “recovery centers” that have now been used twice to help alleviate overcrowding.
Nursing homes could transfer COVID-19-postive residents to designated recovery centers, and hospitals could discharge sick patients to those facilities for a period of time, rather than send them straight to a nursing home. The program, organized by the state, ebbed as cases plunged last spring.
The state had four recovery centers with options for more, but state officials have not indicated that they might be reopened, puzzling many providers.
“We should have the recovery centers open because what we’re going to see within the month – before Feb. 1 – is nursing home staff fall by the wayside,” said Paul Liistro, who owns nursing facilities in Manchester and Vernon. “They’re not going to be boosted. They’re not going to be protected against a contagion which is going to put them out.”
But Lamont said the issue is staffing, which is another reason for the mandate.
“We need nurses to be back on the battlefield. And that’s one of the reasons we’re putting in place this mandate so the hundreds of them that are now in quarantine will be able to get back to work because we’re sort of limited in terms of personnel,” he said.
Mag Morelli, president of Leading Age Connecticut, said there would be a lot of factors that would come into reopening the facilities, but staffing would be the biggest issue.
“It’s difficult right now to step up a nursing home,” Morelli said. “It would be difficult to start and staff a brand new nursing home. So that idea is there, but it just has not come forward to fruition yet.”
The state currently requires nursing homes to isolate COVID-positive residents from those who are negative. Managers can do that by designating a wing or other area to quarantine the positive residents. That means the facilities would have some staff devoted to the COVID-positive area and other workers assigned to the rest of the population.
But some operators say that even with separate areas, the virus can spread quickly through nursing homes. Alzheimer’s and dementia patients may wander. It’s hard to get some residents to wear a mask. And with a staffing crisis, it’s difficult to retain enough workers for both the COVID-positive wing and the remaining population. To avoid spread, workers are discouraged from staffing both areas simultaneously.
Citing data from the Bureau of Labor Statistics, officials with the American Health Care Association and National Center for Assisted Living said the nursing home industry is suffering from the worst labor crisis of any in the health care sector. From March 2020 to November 2021, the industry lost 234,000 jobs.
“All nursing homes need more qualified staff. So even if I only have one positive resident on that unit, it will require 24-hour coverage of nurses and CNAs [certified nursing assistants]. You can see how difficult that would be to manage,” said Kevin O’Connell, CEO of Geer Village Senior Community in Canaan.
Geer faced an outbreak of coronavirus that began in late September and ran through November. Sixty-seven residents at the Geer Nursing and Rehabilitation Center contracted the virus and eight died. Twenty-two staff members were also infected.
“If that option had been available to me in the middle of our outbreak, I absolutely would have used it,” O’Connell said of the recovery centers. “We were able to have a separate unit. But like everybody’s experiencing, having the dedicated staff for that unit is a real challenge. If you don’t have dedicated staff, you risk spreading the virus to the uninfected.”
Opening recovery centers would also provide some relief to hospitals, Liistro said.
“They’re seeing this contagion take over. And I think by the end of January, they will be busting at the seams,” Liistro said. “The recovery centers would be a relief valve for the hospitals and a relief valve for the nursing homes.”
Staffing is an issue for Liistro. Because boosters are not mandated for nursing home workers, protecting staff and patients can be difficult, he said.
“At Vernon Manor, three out of 10 [employees] are boosted. So if I open a recovery unit, who am I going to have work in that recovery unit?” he said. “As far as I’m concerned, seven out of 10 people at Vernon are no longer protected. It’s 2020 all over again. Even though vaccines are everywhere, they don’t want to get boosted. The governor’s saying, ‘Open a recovery unit.’ But how am I going to staff it?”
Demand already high
In the meantime, some nursing homes have begun to accept COVID-positive residents from other facilities and from hospitals. Athena Health Care Systems, which managed two of the recovery centers under the state program, is now accepting COVID-positive residents without the state’s involvement.
Tim Brown, a spokesman for Athena, estimated that his company’s facilities had accepted dozens of COVID patients for recovery periods recently. A few of its buildings across Connecticut have dedicated areas for those residents.
Some independent nursing facilities have also offered to receive COVID-positive residents.
But as demand increases, Brown said Athena is unlikely to be able to accommodate everyone.
“Right now, we do not have enough availability for what the demand is,” he said. “We have our own staffing challenges. Like every other nursing home in Connecticut and across the country, we’re struggling to find staff.
“We’re contacted regularly by hospitals, looking to find out what our availability is and how many beds we will be able to devote to that. But we’re just not able to do that right now.”
Barrett said the recovery centers provided value during previous coronavirus waves.
“As cases surge, we continue to see the value if the demand is there, in terms of an isolation quarantine strategy, not just for hospital discharges, but for facilities that are experiencing COVID positives,” he said.
At this point, however, the state has signaled it’s not moving to immediately reopen the facilities.
“I think what controls the state’s thinking or decision making is hospital capacity,” Barrett said. “It’s our understanding that DPH is monitoring that closely.”
So far, deaths have not kept pace with the rise in cases, which providers attribute to the high percentage of residents that have been vaccinated. There were five nursing home resident deaths from Dec. 21 to Dec. 28. Four were recorded the week before.
“I can see that the vaccine is working, because we’ve had residents who were pretty sick that are now surviving or at least getting a fighting chance,” said William White, owner of Beechwood Post-Acute and Transitional Care in New London.
DPH officials indicated in a recent meeting with providers that they don’t believe the virus is spreading from staff to residents.
The majority of residents who are getting the virus aren’t getting it from staff but from visitors to their rooms or while on so-called “leaves of absence” from the facility, where they go home for the day with relatives, they said.
Once a resident gets the virus, he or she is spreading it to roommates. DPH said that staff-to-resident transmission has been minimal so far.
Several providers have expressed concerns about visitation. Most nursing homes take visitors’ temperature and ask them to wear a mask before admitting them to the building. But there is no mandate that visitors be vaccinated.
“We have no control over who is visiting and what their vaccination status is, and they are walking all over the building, and that’s tough on the staff,” said David Hunter, CEO of the Mary Wade Home in New Haven.
The rules for visitation at all long-term care facilities are set by the Centers for Medicare and Medicaid Services. But the state does have the ability to mandate that visitors show proof of vaccination before being allowed to enter, as some hospitals have done.
Barrett said no one wants to see visitation cut off completely, like it was at the beginning of the pandemic. But he said some balance may be needed with the omicron variant spreading quickly.
He said his organization would be in favor of a similar approach that some hospitals have taken – requiring visitors to show proof of vaccination before they can enter the building and visit a resident.
A previous version of this story incorrectly reported that the state was ordering nursing homes to accept COVID-positive people who were released from hospitals. The Department of Public Health issued guidance, not an order.