After the Hospital

April 3, 2020

Photo via Canva

As hospitals rush to free up beds for new patients with COVID-19, where is the safest place for them to send patients recovering from the disease who still need care?

Listen to the full episode below or scroll down for the transcript and more information.

Click here for more of our coronavirus coverage.

The Problem

As hospitals try to free up space for new patients with COVID-19, they need to discharge patients who are recovering from the disease. Even though they no longer need to be hospitalized, many of those patients will still need some level of medical care.

Known as post-acute care, this often takes place at a skilled nursing facility. But with nursing homes especially susceptible and already struggling to protect residents and staff from the disease, many are worried about the risks of bringing COVID-positive patients into these facilities to recuperate.

The Tradeoffs

There are three main paths experts have put forward for where hospitals should send COVID-19 patients for their post-acute care:

Traditional Nursing Homes

Several states — including California, New York, New Jersey, Pennsylvania and Washington — have told nursing homes that they must accept COVID-positive patients, recommending they set up COVID-only wings or floors. This adheres to CDC and CMS guidance and offers the quickest and greatest number of spaces, but nursing homes and their advocates have blasted these orders, saying it would put their other residents and staff at risk and that they lack the tools — such as personal protective equipment, the ability to isolate patients and adequate staffing — to care for COVID-positive patients.

Special COVID-Only Facilities

At least two states — Connecticut and Massachusetts — have designated select nursing homes to serve as COVID-only facilities. This eliminates the need for facilities to isolate infectious residents, but it requires moving existing residents to other facilities, which research shows can have adverse effects. Some experts, including Harvard's David Grabowski, have recommended establishing these facilities in dorms or hotels to avoid the need to move existing residents.

Care for People at Home

Home health agencies are the largest provider of post-acute care, serving about twice as many people as skilled nursing facilities. New research shows if patients get intensive, hospital-like care at home, it can lead to lower costs and fewer hospital readmissions. The Centers for Medicare and Medicaid Services has expanded the use of telehealth for home care, but Rachel Werner, executive director of the Leonard Davis Institute of Health Economics, says CMS would likely have to increase its support for in-person visits, remote monitoring and caregiver payments to achieve the necessary level of care.

Episode Transcript

Dan Gorenstein: As capacity in some hospitals dwindles, a new question becomes critical: Where do COVID patients go when they’re no longer sick enough for the hospital, but still need serious care? 

From the Annenberg Studio at the University of Pennsylvania, I’m Dan Gorenstein and this is Tradeoffs.

David Grabowski was like many of us at the beginning of March, absorbed in coverage of the coronavirus.

David Grabowski: I was reading about this nursing home out in Kirkland, Washington.

News clip: The Life Care Facility considered the epicenter of the outbreak.

Grabowski: Was hearing that a number of individuals at that facility had the virus.

News clip: Today the death toll of those who had coronavirus connected to the Life Care Center in Kirkland rose to 10.

Grabowski: I had this mental image that we might be dealing with the coronavirus in every nursing home in the country.

Gorenstein: David is a health policy researcher at Harvard Medical School. He’s one of the few academics who has devoted his career to studying places just like that Washington nursing home.

The places where people go after they leave the hospital — skilled nursing facilities, rehabs and long-term care hospitals, what are known as  post-acute care facilities —tend to be a bit of a health policy backwater.

But the sheer scale of all the places patients land after discharge could be a lifesaver for hospitals looking to open up bedspace.

Grabowski: There are more skilled nursing facilities than Starbucks.

Gorenstein: Altogether, there are about 30,000 post-acute medical facilities and home health agencies, a $60 billion dollar a year industry that cares for about 5 million people.

As hospitals press to free up bedspace for the oncoming surge of patients, political leaders in states including New York, New Jersey, Pennsylvania and California have ordered nursing homes and these other facilities to accept COVID-postive patients, asking them to segregate those patients from everyone else. 

Grabowski: If you think about a nursing home or other long-term care setting, who lives there? It’s individuals who are older, individuals with high levels of chronic illness, and this virus has been incredibly harmful for older adults, for those with chronic illnesses.

Gorenstein: The Centers for Disease Control and Prevention said on March 30 that more than 400 nursing homes and long-term care facilities have confirmed cases of COVID-19, more than double the number reported the week before.

Grabowski: That’s the tension: Hospitals need to discharge patients; skilled nursing facilities, however, for the most part, can’t safely care for those patients without harming other residents and their staff. 

Gorenstein: And David, what alternatives do we have to sending people recovering from COVID-19 to mainstream nursing homes?

Grabowski: What I would argue we want to do is create more specialized settings here where we can discharge COVID-positive patients to a COVID-only skilled nursing facility or long-term care hospital.

Charlie Baker: Good afternoon. I want to run through a few updates on the Commonwealth’s COVID-19 plans.

Grabowski: The state of Massachusetts has actually done something incredibly interesting. They are moving as a state to create 12 specialized COVID-only nursing homes. 

Gorenstein: Massachusetts Gov. Charlie Baker discussed the move at a news conference Monday, March 30.

Baker: This step will help us avoid imposing a mandate on skilled nursing facilities to take COVID-19 patients from hospitals. And we’ll have those facilities that are actually stood up to do this work, much better positioned to do it well, to do it right and to do it safely.

Gorenstein: Connecticut has announced a similar plan. 

Grabowski applauds the approach, but it means moving frail, sick, older adults out of the facilities they live in now. 

Grabowski: There are incredible health risks for them. The thought of of changing not only their their physical space, their building that their their living in, their home, but also changing their caregivers and their daily routine. That can be incredibly traumatic. I like the idea of building new skilled nursing facilities within hotels, building them within dorms.

Gorenstein: There’s another option that doesn’t involve costly and time-consuming retrofitting.

Rachel Werner: There’s a large portion of people that we could send home if we give them enough support to go home.

Gorenstein: Rachel Werner heads up the Leonard Davis Institute of Health Economics at the University of Pennsylvania and is an economist and physician.

Rachel points to new research that shows if patients get intensive, hospital-like care at home, it can lead to lower costs and fewer hospital readmissions.

Werner: People have set up the equivalent of a hospital at home to prevent people from being hospitalized. They send them home with 24/7 monitoring, using remote technology and frequent visits from nurses and doctors, and it prevents those hospitalizations. And I think if we can do that for acutely ill patients, we can probably do it for patients requiring rehabilitation after recovery from acute illness.

Gorenstein: And so what changes do you think would be necessary to beef up the care at home services?

Werner: There are two main things that would be required to make this work. One is Medicare would have to start paying for more visits at home. Currently, it’s limited to one visit per day. And so they would have to pay for telephone or video based visits during this period of rehabilitation at home. The other piece that Medicare would need to be able to pay for is to pay informal caregivers to provide the type of care that is needed to help people rehabilitate at home.

Gorenstein: Is that a safe proposition?

Werner: Caregivers with a little bit of training are very capable of taking care of patients in terms of helping with day-to-day things that many people need. There may be some concerns about transmission of the COVID virus to household contacts, and we would have to continue using the kind of precautions to prevent spread of COVID that we would in a health care setting, including masks and gowns. But I think that those are addressable problems that could easily be fixed.

Gorenstein: At the end of March, the Centers for Medicare and Medicaid Services  relaxed rules so hospitals can discharge patients quickly, including potentially to hotels and dorms. 

More at-home telehealth services are also now available to people on Medicare, but a CMS spokesperson did not respond when asked if the agency is considering adding steps like paying for multiple visits a day and reimbursing live-in caregivers. 

Rachel, at the same time, one of the potential downsides, I imagine, to sending people home is that they might end up not getting adequate care. And research that you’ve done has shown that that can happen.

Werner: Right, and so in the pre-COVID era, we did some research that was published about a year ago showing that when patients go home instead of to a skilled nursing facility, they’re more likely to be re-hospitalized in the 30 days after they get home compared to patients who go to a skilled nursing facility. And it’s not surprising because the care that people get at home under the current system is much less intense compared to the 24 hours, seven-days-a-week care that they get at a skilled nursing facility. In a world in which we’re providing more intensive care at home the difference in readmission rates would be much lower than what we observed in the past.

Gorenstein: At a time when just about everyone in health care is looking to the federal government for more money, Rachel says evidence suggests sending people home after the hospital could pay off.   

Werner: Comparing people who went home to people who went to skilled nursing facility, we found that on average, those people who went home, Medicare paid over $5,000 less for their care than they did for the same types of people who went to a skilled nursing facility instead.

We have an opportunity here, which we have never had before, which is to really rethink what we can do at home.

Grabrowski: I feel like with coronavirus, we’ve been playing catch up from the very beginning. We were obviously behind on testing. We’ve been behind on physical distancing. We’ve been behind on building enough hospital ICU beds. Post-acute care is actually an opportunity for us to get ahead.

Gornstein: Figuring out the safest place to send people recovering from COVID-19 is just another of the many challenges facing our health care system.

But it’s also an opportunity to rethink how and where we care for people after they leave the hospital.

And it could be a rare chance in this pandemic to actually save money while still providing high-quality care.

I’m Dan Gorenstein, this is Tradeoffs.

Episode Credits


David Grabowski, PhD, Professor of Health Care Policy, Harvard Medical School

Rachel Werner, MD, PhD, Executive Director, Leonard Davis Institute of Health Economics, University of Pennsylvania

Music composed by Ty Citerman, with additional music this week from Blue Dot Sessions

This episode was reported, produced and mixed by Ryan Levi.

Additional thanks to:

Ruth Katz, Mitesh Patel, Rebecca Turner, Mark Miller, the Tradeoffs Advisory Board…

…and our stellar staff!