In a COVID-19 Hotbed, Nursing Home CEO Says Industry ‘100% On Our Own’ for Testing, Transfers

Alex Spanko

For more than two months now, Gurwin Jewish Nursing & Rehabilitation CEO Stuart Almer has been on the front lines of the COVID-19 battle, running a 460-bed nursing home in the suburbs of New York City — a region that has borne the brunt of the coronavirus impact in the United States so far.

That bed count includes Almer’s own father, who has lived at the non-profit nursing home in Commack, N.Y. for more than a year and a half.

But as the media spotlight on nursing home deaths burns brighter each day, Almer told SNN in a May 1 interview that he’s been working without the help of officials.

“If there’s going to be any testing, any patient movement, any assistance, we seem to be 100% on our own,” Almer said.

As of this past Friday, the Long Island facility had seen 82 positive cases and 37 deaths, Almer told SNN. Of the total positives, 34 were already infected when they arrived at the facility; New York State has required nursing homes to accept coronavirus patients under a controversial policy that has drawn the ire of operators, patient advocates, and the media alike.

“Even though those patients are relatively stable, and we have accepted them, they still come in positive — and we don’t know for sure what impact that is having on the building,” Almer said. “But certainly from a family impact and public relations aspect, it’s been awful.”

SNN spoke with Almer to learn more about the stresses and successes he’s seeing on the ground; for instance, 38 Gurwin Jewish residents have recovered from COVID-19 since the start of the crisis, the CEO said.

That said, Almer reported receiving little to no help from state agencies, leading to a toll that’s both operational and personal.

“I’ve bonded with those families in a different way, because it’s my father up there,” he said. “I have not seen him in two months. It’s very, very difficult.”

Tell me about the state of your building today.

We would have anticipated a slowdown by this point, in terms of all the pressures that are coming at one time, and we have not yet seen that slowdown. We’ve been into this for roughly two-plus months without seeing much relief. In other words, the struggle to get personal protective equipment (PPE) — we have it, we’re well-stocked — but it’s still a challenge day-to-day to get certain equipment, get it timely, and of course try to get it at a cost that we can afford. Then there’s still issues such as testing kits and their availability. That’s still a great challenge.

There are constant changes daily regarding regulatory [updates], and each one of those changes … are challenging. Daily calls from the regulatory agencies, asking for data — data that we’ve already provided — and then having to respond.

Families, no matter how transparent we are, not accepting anything and just being angry and anxious that they’ve not seen loved ones in two months. They get anxious, and they call the state; they call other agencies, and then we have to respond to those agencies. So it’s just a constant assault that just does not let up.

We may be getting to see a slowdown in cases; we know, on the hospital side, there has been a slowdown, thankfully. But we just don’t feel the release of any of that pressure yet.

There’s still issues with securing enough staff. We’ve had a significant census drop, as all have, and that’s a major concern to us. Financial, operational, regulatory — all of the requests for interviews and information. We’re happy to be accommodating. It’s who we are. It’s who I am. But they all come with great challenges and risks.

Every time there may be an article, it just raises questions amongst family. Anything you do, there’s a reaction. It’s almost like the old way of conducting business has changed; the rules have changed, and how you might conduct business.

What are the primary drivers of the census drops? Is it COVID cases, is it the lack of post-acute patients, is it families taking residents home?

That’s a good question, and there are multiple reasons for it. The initial reason, and still the most significant, is the one you hit on — and that’s the elective admissions slowdown. Cases that we typically would see, we’re just not seeing. That’s number one; I expected us to be jammed with admissions at the beginning of COVID, and the opposite has happened.

Number two is: We’ve had to carefully watch and monitor our census because we have to make sure we have appropriate staff available to safely take care of patients. So that’s been another issue. If we don’t feel we can safely take care of someone, we don’t.

However, in New York, there is the mandate — I’m sure you’re aware of — that we must accept positive admissions. That, I think, has frightened many folks from wanting to put their loved ones in facilities because they’re afraid. The existing residents, their families are afraid; they’re worried about transmission from these positive residents coming in.

The other thing is, there was a regulatory change just some days ago in the state that we could not commingle positive and negative residents on a nursing unit. We were doing that, we believe, fairly well and safely, and now we can’t even do that. So we will get a further census drop as a result of that.

We’ve had to have a mass movement of residents in order to address the regulatory change. Keep this in mind: We follow the mandate, we adhere to this regulatory change, and families now become upset again. So here we are, we finally have things relatively in check. We make a change or movement of residents, and now the families explode yet again. They blame us for it. Then they’re calling here constantly, and they call the regulatory agencies, and the regulatory agencies in turn call us.

It’s just a storm that continues. But it’s not driven by us. It’s driven by external factors. I can comfortably say what we are experiencing is exactly what everyone else is experiencing.

Have you received assistance from the state? New York Gov. Andrew Cuomo has said the state is ready to assist with moving residents, or diverting patients from facilities that aren’t equipped to care for them.

With regard to equipment, if there’s going to be any testing, any patient movement, any assistance, we seem to be 100% on our own. We’ve made our own adjustments to census so that we’re doing the safe thing for patients. We’re just not getting it.

It seems to be entirely regulatory, and you’re seeing the same statements come out of Albany as we are, and they’re very concerning because what we need now is help, support, and even education — and this can be done and should be done. Now would be the time to do it. Embrace the nursing homes.

We take care of 460 residents in our nursing home each day. You put all our programs together, we care for about 1,000 people a day. We need support, the recognition and not the regulatory concern — it only seems to be regulatory, not supportive, not assistance.

That’s why I agreed to the Post article, and why we even posted it on our website — because we just can’t sit back. Every day there’s another change that’s just to the negative, and the families are the most anxious. They don’t get it.

I want to share with you, there’s no one who understands the family dynamic more than me. My dad is a long-term resident here. Thankfully, he’s okay thus far. He’s been here a year and a half. He lives here, and I understand the anxiety.

But not every family member is able to keep that in check. I feel for them; they miss their loved ones. They want information; we’re providing information. It’s just turned into this very difficult storm.

What are some of the things you’ve been able to accomplish on your own?

Regarding PPE, we got ahead of this very early on in the process. As soon as we knew the issue was a concern out in Seattle, we quickly mobilized, and I remember suggesting that we acquire as much equipment and supplies as can then — including ventilators — and get ahead of it.

So we began to do that, but within a couple of days, the whole nation — if not the world — was on the same bandwagon to procure supplies. It became a challenge for everyone, and at extreme cost, but we got out ahead of it. Everything we’ve done is at incredible cost, in the millions.

We bought these moveable barriers that allow us to take our isolation unit — we have a dedicated isolation unit for COVID-19. With these barriers that we purchased, we could keep extending them as the COVID-19 situation grew, so that we can safely take care of people and try to limit any spread from that unit to anywhere else. That’s one of the successes we’ve had in managing this. I’ve actually recommended this to others — they could be used again in the future, you know, with influenza spread and the other infections — if we get a second round of COVID. But, again, it goes back to: Everything we’ve done, we’ve done really on our own.

We’re not entitled to hazard pay in terms of the federal government, as an employer of over 500 staff. When that got announced, our staff began to be concerned, saying, “Hey, what about us?” We’ve been concerned about the financial picture, even pre-COVID, and now it’s extreme for all of us, coast to coast.

We understand the difficult situation they’re in each day, but we’re not entitled. They hear about the governor announcing pay, they hear about other health systems offering pay, and then they say: “Well, what about us?” And we’re not eligible. Staff may not want to hear that, but it’s factual. We’ve offered some hazard pay in some situations, but we’re not reimbursed for this. So again, we’re on our own.

If the costs truly tally into the millions, how are you paying for it?

It pretty much comes from operations. We will expect to see a significant financial loss this year, and we’ve made some changes that will affect us and how we operate. We have not had any layoffs. I’m very proud how we’ve been able to redeploy staff.

For example, we have two adult day care programs. We were required to close those programs. We had 130 community residents coming to us per day, mostly through the Medicaid program, that we provided services to; we no longer receive that revenue, but we redeployed all of that staff to help nursing on the floors where they need it.

You ask a very good question in how we’re going to fund this. We did a campaign to raise money to help for COVID-19, and that’s a combination of cash contributions and in-kind gifts — meaning we have some young people who’ve been making face shields on 3D [printers] and donating them to us, people donating food. That has helped a bit; certainly cash contributions help.

We did receive some stimulus monies. However, in the middle of all this, we received our second state budget cut this year. So we had a 1% cut in January, a .5% cut right in the middle of COVID — and now we’ve got to spend incredible sums of money.

We are hearing that there will be relief from FEMA, and we have a preliminary application we filed with FEMA with a much greater application to follow. I anticipate that application being probably several million dollars to try to make us whole. It’s a very, very lengthy list of items that we’ll be putting into that application — for example, overtime impact, the hazard pay that we are paying, the lack of admissions to the nursing home, lack of admissions to adult day.

We have an assisted living community and a soon-to-be-built housing community, and we virtually have had no admissions in two months to those two programs because of COVID-19. Our home care agency is struggling, and when you’re not able to get staff, that adds other challenges and other costs.

All of the PPE — I signed one check about a month ago, and I had to do a double-take. It was a check to get some advanced ordering of PPE for the tune of $150,000. Not $3,000 or $8,000 — $150,000. We have gone from paying pennies per unit for an item to dollars, and I’m not being dramatic, whether you’re talking about masks, gowns. Gowns are impossible to get ahold of. We’re just not paying pennies any longer.

We’re going to count on FEMA money; we’re going to hopefully get some state relief. Hopefully there’ll be more stimulus monies. But we don’t know what we’re going to look like later this year, and we’ll have to make changes. We’ll have to make adjustments.

We’ve been a very, very good employer in terms of our benefit packages and other things that we do. We’re going to have to take a close look at these things. I’ve already gone out publicly to our staff, saying this is significant and could impact us to the millions. But I also said, and I think I said it in the Post article, that this will cost all facilities in the multi-millions — and we need to be here, because we have people to take care of.

If you had a seat on the president’s nursing home task force, what kinds of things would you recommend?

So it’s a good question. I would love to be at the table at any level, including the federal level. I happen to be very active in three trade associations that represent us — two locally and one nationally. In fact, I’m on the board of the different associations, so I do have a significant voice.

I clearly can outline a few things that I think should be done differently going forward, should this happen again, to have proper planning. The first thing and the main thing: COVID-positive patients should not have been introduced to nursing homes. That just created a tremendous, tremendous stir and upset.

Every county has vacant buildings. In fact, it’s likely that every county has a vacant former nursing home building. Those buildings can be converted to be COVID-positive buildings for the short run. Now, I recognize there’s a cost, and there’s a need to staff buildings like this, but there are vacant buildings available. I’ve got to believe that if an analysis was done, the cost of doing that — even with staffing, even with renovating a building to prep it to be ready — would cost less than the impact that each one of us are experiencing, which again, is in the millions.

I’m aware of the old John J. Foley building, which is out east in Suffolk County, right off the Long Island Expressway. It’s a perfect Suffolk County location, and it sits vacant to this day. It’s got a few hundred beds, and that to me would be the Suffolk County COVID-19 hub. But that’s just one example, and I know that buildings exist and other counties. That’s clearly one thing that should be done differently — and again, not a mandate to take positive [cases].

We have a 28-bed licensed ventilator unit. We bought five additional ventilators, costing about $50,000 in total, because we expected a surge in ventilator cases. Turns out that never happened; a lot of things we expected to happen did not happen. But like other facilities, [we] do have spare ventilators we’re not using right now. We would have been happy to deploy those ventilators elsewhere when the crush occurred. Had we been asked, others certainly could have redeployed them. I would have loaned them, sold them — whatever it would take to help support anyone in need of a ventilator. We never want to hear that anyone who needs a ventilator doesn’t have one, and we have excess

These are opportunities that, nationwide, probably exist, if that information was sought.

By the way, there are some positive things that have come out of this that we appreciate, and maybe can extend going forward. For example, we finally have some potential for reimbursement for telemedicine right now. We’re all working in more of an electronic world, and we’ve begun to do some home care cases where we can bill through the formal telemedicine program. I’m not as versed on the specifics, but I know we are doing now some telemedicine and getting paid. That clearly needs to be embraced on a national level, would be helpful right now.

For example, adult day care — these 130 folks who are coming to our program every day, they’re at home. They’re not getting the services that they need now while they’re in the home, and this is a perfect application for telemedicine. We can check in on them, guide them if we see something of concern, point out how they need to address it.

Perhaps we help them address it; we have two home care agencies, and we have the ability to provide those services should it be necessary. But we would also need regulatory change that allows us to take someone who’s on the adult day care program, and yet have home care come into the home.

These are the types of things that if we had a seat at the table, we could push legislatively. One thing that happened early on, that we appreciated, was the elimination of the three-day qualifying stay under Medicare for someone to enter our system on short-term rehabilitation.

I’ve always been an advocate that that should be eliminated. If it’s known that someone needs rehabilitation — someone is 96, still was able to have their surgery — and we know they’re going to need long-term care, they shouldn’t have to be waiting days before they qualify. We know they’re going to need rehabilitation, inpatient.

So that three-day stay was lifted early on, which was great. It allowed us to secure people who need services sooner. What we didn’t know was that the elective slowdown would be so dramatic, they wouldn’t come anyway. But elimination of the three-day stay — I was celebrating when I saw that.

Third, I believe we have an opportunity now to provide rehabilitation to long-term care residents when they come in — the same way we treat short-term rehab. There was a change in the rehabilitation reimbursement system, and now it’s been made more flexible during this COVID period. That has been a help for us as well, and should have some financial positive implications for us.

This interview has been condensed and edited for clarity.

Alex Spanko

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