ACCORDING TO Medicare Payment Advisory Commission (MedPAC), “post-acute care includes rehabilitation or palliative services that beneficiaries receive after, or in some cases instead of, a stay in an acute care hospital. Depending on the intensity of care the patient requires, treatment may include a stay in a facility, ongoing outpatient therapy, or care provided at home.”1 These settings include inpatient rehabilitation facilities (IRF), either free standing or within an acute care hospital, long-term acute care (LTAC) hospitals, skilled nursing facilities (SNFs) as well as outpatient and home health services. While the Centers for Medicare & Medicaid Services (CMS), the largest payer source for postacute care, has been working to standardize measures of quality, each of the inpatient providers of postacute care has its own set of admission criteria and quality reporting requirements. To investigate the impact of the pandemic, publications and interviews with postacute care providers were conducted. The providers report that the current coronavirus disease-2019 (COVID-19) pandemic has shown that the limitations created by the various admission criteria and practice rules may be better managed by the providers of postacute care services.
WAIVERS OPENING DOORS
In March of 2020, the CMS announced COVID-19 emergency waivers2 relieving providers from certain regulatory requirements prior to being admitted into a postacute care setting. Nurse leaders from the IRF, LTAC, and SNF settings reported that these waivers allowed them to provide much needed bed availability to the acute care hospitals in their communities. For example, the IRF's 60% rule was waived. The rule requires at least 60% of admissions to fall under 13 diagnostic categories. Under the waiver, IRFs can admit patients who need the services of an inpatient rehabilitation setting as determined by the rehabilitation physician. LTACs received a waiver releasing them from a 25-day length of stay requirement to be designated as an LTAC. This simple waiver allowed them to utilize their expertise in respiratory diseases to treat patients with a shorter length of stay without concerns about the negative impact it could have on their designation as an LTAC. SNFs were granted waivers to admit patients who had depleted their long-term Medicare benefit days. Even COVID-19 patients, active and post-COVID, were able to be admitted and successfully treated based on their individual needs.
Each of the nurse leaders interviewed described the ability of their organization to adjust both processes and physical plant to meet the needs of the patients. IRFs and LTACs are under the Conditions of Participation (CoPs) for Acute Care Hospitals, requiring them to have all of the same infection prevention policies and practices, including a designated infection control practitioner over the program. They do not generally have as many airborne infection isolation rooms (AIIR) as would be available in an acute care setting. SNFs do not have the same regulations, although requirements for safe infection prevention practices are included in their regulations. The availability of an infection control practitioner and AIIR rooms is even more restricted. In all of the settings, interviewees reported that COVID-19 led to the creation of temporary COVID units. One SNF provider interviewed realized their first COVID-positive case post-discharge after a 15-day length of stay without symptoms or any cause for isolation precautions. Immediate measures were initiated to trace appropriate contacts, limit visitors, and test patients. Staff and patients tested positive, leading to anxiety among families and patients, some choosing to leave the facility. The facility staff continued their COVID-19 measures of masking, social distancing, and isolation precautions when needed. It took weeks for the facility's census to return to normal a level. Early in March, when COVID-19 cases stressed the acute care systems in the northeast, inpatient rehabilitation hospitals were transforming entire units into COVID units. From moving necessary equipment and changing offices to storage areas to designating nursing and therapy staff to work in the unit, 1 chief nursing officer (CNO) describes an interdisciplinary approach that physically rebuilt a nursing unit in 24 hours. The rehabilitation hospital opened its COVID unit after discovering that acute care hospitals in the area expected patients to remain in postacute care as long as their medical needs could be met. The CNO says emergency plans became daily operations overnight. A Director Patient Care Services, a state away in a different rehabilitation hospital, reports a similar experience. With an active pulmonary rehabilitation program and no LTACs in the state of New York, they were ready to take the more complex COVID-19 patients who had continued needs for a higher level of respiratory support. Without the waivers, some of the admissions that these 2 exemplar IRFs were able to admit, treat, and discharge home would have not had the opportunity to benefit from the intense level of rehabilitation offered only in IRFs. Likewise, patients admitted to an LTAC requiring ventilator support while recovering from COVID, yet not a patient with a longer length of stay as traditionally called for in LTACs, have shown to benefit from a stay in an LTAC. The American Hospital Association described the importance of partnerships between acute care providers with IRFs and LTACs in optimizing much needed resources to treat COVID-19 patients.3 IRFs and LTACs have clinicians specialized in improving function, strength, dysphagia, and pulmonary difficulties—all common to the recovering COVID-19 patient. In an interview with Executive Vice President of a large postacute care health care company, she described a population change within the organization not in type of medically complex patients, but in numbers of these patients. Explaining that her hospitals have always treated medically complex patients, but been limited as to the volume of patients at any one time due to the 60% rule, “Referral sources are seeing the great results of the rehabilitative care our hospitals provide, while managing the medical concerns of our shared populations.”
LEADING THROUGH CHANGE
Leadership throughout a pandemic starts long before the pandemic. Coaching staff through increases in documentation that seem to take staff away from the bedside is a skill in postacute care finely tuned by nurse leaders, resulting from the highly regulated sector of health care. For postacute providers, this has been evident over the last several years. In each of the 3 inpatient settings described here, changes to admission criteria, required assessments, and quality measures happen on an annual basis. These changes have obligated nursing leaders to be diligent in communicating upcoming changes to staff, the impact on patient care processes, and expectations of compliance. Annual changes to the admission and discharge quality measures in IRFs have created a document that has grown from 8 pages in 2014 to double that now consisting of data elements covering patient demographics, function, cognition, medical status, wounds, falls, and other outcome information. The annual changes to the document are not merely in growth, but often change the way an element is evaluated, requiring clinicians to change assessments and processes. Moore4 describes the challenges facing LTACs in Massachusetts as decades of attempts to downsize the numbers of beds available for critically ill patients to recover via increasing regulations, stating that policymakers do not understand their important role prior to the pandemic. According to SNF nurse leaders interviewed, new requirements for quality measures implemented annually create a similar stir in the workforce.
COVID-19 has only been different in its speed of change and volume of information needing to be absorbed by caregivers. In the beginning, as reported by all interviewees, shortages of personal protective equipment (PPE) created a great deal of stress from staff. Guidance from departments of health and the Centers for Disease Control and Prevention (CDC) seemed to change daily. One CNO described making decisions for the moment—knowing they would likely change either the next day or in some cases the same day. In postacute care, staff are not in the habit of wearing facemasks with more than a few patients at any given time. Instituting universal masking for staff created not only anxiety, but also challenges to processes and long-held beliefs. Many infection preventionists who were suddenly teaching principles of reusing PPE, that only a few weeks prior were taboo, felt like they were betraying their own teaching. Others, determined to ward off the virus, walked around the hospital wearing layers of masks. Nursing leaders worked around the clock to bring staff back to a level of calm and compliance that adheres to the CDC's recommendation for conserving PPE and follows the science of transmission. Coaching anxious staff through masking guidance that is safe for the wearer and the patient in the early weeks of the pandemic was a daily task for nurse leaders. SNF regulations have changed throughout the pandemic, including the testing of all staff twice per week in some areas. Explaining to staff that they would all have nasopharyngeal swabs twice each week is not the highlight of any nurse leaders' day.
Postacute providers work with patients and families, as they transition into the new normal life after catastrophic accidents. Those same skills are used in working with staff during the ever-changing times of a pandemic. A clinical nurse specialist in a rehabilitation hospital explains that they changed all of their beds to private rooms, stopped visitation, and instituted screening of staff prior to reporting for their shift. She reports a plethora of emotional report resources offered from simple 5-minute mindfulness exercises to mental health tip sheets and an employee assistance program for mental health counseling. These efforts are not unlike those provided by others interviewed. Nurse leaders have been on a marathon of crisis management since March with no end in sight. Postacute care nurses are well versed in longer lengths of stay, spending weeks with patients and families, and witnessing improvements in outcomes. The patient population has changed to patients that may not be participating in as much therapy as usual, need much more respiratory support, and have no visitors to provide support during these long lengths of stay. These stressors take an emotional toll on postacute care nursing staff, much like the strain seen on the faces of the critical care nurses shown by media outlets. Nurse leaders must be tuned into their staff looking for signs and symptoms of COVID as well as burnout and depression brought on by the unprecedented trial of our time. Nurse leaders interviewed reported working without days off for weeks at a time to support staff and patient care activities.
One final leadership challenge, while common to nurse leaders, is staffing. One or 2 nursing staff members out sick during flu season spark the backup staffing plans to activate. When an entire unit of staff is out suffering from a combination of COVID, quarantine, or pending tests, it can break any backup plans to pieces. Interviewees in large health care systems share staff during crisis times, but stand-alone postacute providers do not have that option. The CDC's recommended strategic plans for crisis capacity5 are helpful but may still not fulfill all of the needs created by exposures to staff. The use of contract staff has been severely limited due to use in acute care and high-paying critical care areas.
MAKING THE CASE
Postacute care has provided bed capacity for non-COVID patients to allow acute care hospitals to care for more acutely ill patient during the pandemic. When do COVID-19 patients need postacute care? Not all of them do, but there are important sets of patients that need the services of IRFs, LTACs, and SNFs. Shan et al6 share a case study of an 80-year-old woman admitted to an inpatient rehabilitation unit after 1 month in acute care fighting COVID-19.6 On admission, she could only walk 150 ft with a front-wheeled walker, suffering tachycardia and decreased oxygen saturation with ambulation. Therapies focused on increasing endurance and activity tolerance, while continuing to meet her medical needs. After an 11-day stay, she was able to go home with family, walking 250 ft without an assistive device. Her gait speed, heart rate, and oxygen saturation had all improved. This case example demonstrates that the population of post-COVID patients with pulmonary needs will continue to require postacute care to reach their goals and go home to their families.
As the aftermath of COVID-19 is studied, the long-term sequelae of health conditions become evident. Neurological conditions are being studied in the post-COVID population. Nath7 lists encephalitis, Guillain-Barre syndrome, and viral meningitis as a just a few. Warnings regarding the inflammatory nature of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) virus warn clinicians to be alert for complications in their immunocompromised patients, who are at greater risks. The cognitive deficits and functional decline seen with neurological disorders are commonly treated in all levels of postacute care.
Geberhiwot et al8 reveal the results of a review of 143 patients 2 months after hospitalization from COVID-19. Fatigue, dyspnea, joint pain, and chest pain were experienced by as many as 50% of the cases reviewed. The need for a multidisciplinary approach to follow-up care became evident. The team scrambled to gather together physicians, infectious disease, physical therapists, occupational therapists, speech-language pathologists, nurses, and psychologists. The group searched existing structures within a hospital to create space to care for these patients, some in an inpatient setting and some on an outpatient basis. What they created was a postacute care hospital specific for COVID-19 patients. The expertise needed to treat the “long haulers,9” as some have coined them, already exists in post-acute care. The level of support they need exists in the multiple settings open to receive post-COVID-19 patients. As long as the current waivers are in place, postacute hospitals will be able to meet this need.
Throughout the global COVID-19 pandemic, postacute care nurse leaders have shown the flexibility of services provided, including physical space, people, and processes. Leadership challenges have been fluid and intense, but met with the tenacity of our acute care colleagues. The important role in the continuum of care has been demonstrated to the communities served and the regulatory bodies governing practice. While the pandemic is still far from over, the providers interviewed were proud of the response of the postacute sector of health care and it dedication to meet the needs of the patients we serve. Postacute providers serve their patients and acute care partners in their communities. Nurse leaders in acute care and postacute care need to collaborate now and in the future to guide the decision-making of regulatory bodies and legislators in where patients' needs are best met.
1. Medicare Payment Advisory Commission. Post-acute care http://medpac.gov/-research-areas-/post-acute-care
. Accessed August 28, 2020.
2. Centers for Medicare & Medicaid Services. Coronavirus waivers & flexibilities. https://www.cms.gov/about-cms/emergency-preparedness-response-operations/current-emergencies/coronavirus-waivers
. Published March 11, 2020. Updated August 20, 2020. Accessed August 20, 2020.
3. American Hospital Association. Partnerships with post-acute care hospitals key to COVID-19 response. https://www.aha.org/case-studies/2020-08-11-partnerships-post-acute-care-hospitals-key-covid-19-response
. Published August 8, 2020. Accessed August 8, 2020.
4. Moore D. COVID-19 patients recovering with nowhere to go. The Boston Globe. https://www.bostonglobe.com/2020/05/19/nation/covid-19-patients-are-recovering-with-nowhere-go/
. Published May 19, 2020. Accessed August 1, 2020.
5. Centers for Disease Control and Prevention. Strategies to mitigate healthcare personnel staffing shortages. https://www.cdc.gov/coronavirus/2019-ncov/hcp/mitigating-staff-shortages.html
. Updated July 17, 2020. Accessed August 25, 2020.
6. Shan M, Tran Y, Vu K, Eapen B. Postacute inpatient rehabilitation for COVID-19. BMJ Case Reports CP. 2020;13(8):e237406. https://casereports.bmj.com/content/13/8/e237406
. Published. Accessed August 25, 2020.
7. Nath A. Neurologic complications of coronavirus infections. Neurology. 2020;94(19):809–810. doi:10.1212/WNL.0000000000009455.
8. Geberhiwot T, Madathil S, Gautam N. After care of survivors of COVID-19—challenges and a call to action [published online ahead of print August 26, 2020]. JAMA Health Forum. doi:10.1001/jamahealthforum.2020.0994.
9. Woods N. Covid-19 long-haulers: what you need to know about the virus' lasting symptoms. The Huffington Post. https://www.huffingtonpost.ca/entry/covid-long-haulers-symptoms_ca_5f405e28c5b6305f32578d37
. Published August 21, 2020. Updated August 25, 2020. Accessed September 2, 2020.