Nursing facility residents are one of the hardest hit populations of the COVID-19 pandemic. As of October 2020, long-term care facilities account for 8 percent of total COVID-19 cases in the U.S. but 40 percent of total deaths, surpassing 100,000 long-term care resident and staff deaths. A large percentage of nursing facility residents, including the majority of long-stay residents, are individuals dually eligible for Medicare and Medicaid — people who are significantly more likely to contract COVID-19 and be hospitalized due to severe symptoms. This confluence of factors makes dually eligible individuals residing in nursing facilities among the most vulnerable populations in the U.S. during the pandemic.
This population often receives fragmented, uncoordinated care from separate Medicare and Medicaid services. To better understand the experience of dually eligible nursing facility residents during the pandemic, and how to better protect this population amid rising cases, CHCS spoke with several experts: Elaine Ryan, Vice President of State Advocacy and Office Integration, AARP; David Gifford, MD, Chief Medical Officer, American Health Care Association; Denny Chan, Senior Staff Attorney, Justice in Aging; and Michael Monson, former Senior Vice President for Medicaid and Complex Care, Centene Corporation.
Challenges for Dually Eligible Nursing Facility Residents amid COVID-19
While COVID-19 has affected all nursing facility residents, the many dually eligible individuals who are residents of these facilities are disproportionately impacted by the virus, both in terms of high infection rates and other negative consequences. A number of factors exacerbate the challenges faced by this population during the pandemic, including:
- Medical Complexity among Long-Stay Residents. The vast majority of long-stay nursing facility residents are dually eligible individuals, with many gaining Medicaid eligibility after spending down their assets paying for care. Long-stay residents are often medically complex and, as a result, are at increased risk for serious complications or death from COVID-19. Most of these individuals have at least three to five chronic conditions, require seven to eight medications, and need assistance with up to four or five activities of daily living.
- Inequities Stemming from Systemic Racism. The racial disparities of COVID-19 evident in the general population are also present in nursing facilities. Dually eligible residents are disproportionately people of color, reflecting disparities in income and wealth due to systemic racism. The number of older adults of color admitted to nursing facilities has been rising faster than their proportion of the overall population. In addition, older adults of color are more likely to be admitted to facilities that provide lower quality of care. Nursing facilities with a relatively large share of Black or Hispanic residents have been disproportionately affected by COVID-19.
- Social Isolation from Family and Caregivers. Nursing facilities’ safety measures enacted during the pandemic typically restrict social interactions, but the resulting isolation can have devastating effects on quality of life for nursing facility residents, particularly those with dementia. Nearly 48 percent of nursing home residents are diagnosed with Alzheimer’s or another form of dementia, and dually eligible individuals have a higher prevalence of dementia than Medicare-only beneficiaries. In particular, these individuals may suffer distress from isolation during the pandemic when routines are disrupted and family members cannot make in-person visits. COVID-19 has forced nursing facilities to prioritize strict safety measures, but now advocates and researchers agree that a more balanced approach would improve individuals’ quality of life (e.g., small group socialization and physically distant visitation) and mitigate the long-term effects of social isolation.
- Nursing Facility Staff Shortages. Staffing was a consistent challenge for nursing facilities before the pandemic and has been exacerbated by COVID-19, with even greater staffing shortages due to illness or absenteeism. Many nursing facility worker unions advocate for hazard pay while working under difficult conditions in a high-risk setting. Facilities that had a higher percentage of revenue from Medicaid were more likely to report both staffing and personal protective equipment shortages. With these shortages, there is a reduction in nursing facilities’ ability to meet the care needs of residents, particularly those of long-term residents with higher medical complexity.
Benefits of Integrated Care for Dually Eligible Nursing Facility Residents
An important benefit of Medicare-Medicaid integration — where all or most Medicaid- and Medicare-covered services are managed by the same entity — is the use of dedicated care managers, which may help mitigate the challenges faced by dually eligible nursing facility residents during the pandemic. Care management is an important component of integrated care programs’ support of coordinated, whole-person care, and can be especially valuable during care transitions (e.g., hospital-to-nursing facility, nursing facility-to-home), particularly in this time of heightened risk.
For long-term nursing facility stays, even if care managers are not able to be physically present during the pandemic, virtual and phone outreach can be used to stay on top of individuals’ needs. Integrated care programs also prioritize information sharing between care managers and nursing facilities. Two national health plans, Molina Healthcare and Centene, implemented new or expanded partnerships with nursing facilities to gain access to the facilities’ electronic medical records, allowing the plans’ care managers to stay apprised of changing member needs without placing additional burdens on facility staff.
Although many people who reside in nursing facilities require a level of care that only these facilities can provide, integrated care programs have a financial incentive to divert people to community- or home-based care when appropriate. This aligns with the overwhelming preference of older adults to live at home rather than in an institutional setting, a sentiment that has strengthened during the pandemic. Integrated care plans also have additional resources to help secure stable housing and establish the necessary home health services, which are often major barriers to dually eligible individuals returning to or remaining in the community.
Policy Changes in Response to COVID-19
Policymakers and the nursing facility industry have responded to the COVID-19 crisis with a variety of measures to control the spread of the virus and meet the care needs of individuals. For example, the federal government and states have introduced new flexibilities and made policy improvements during the pandemic to support nursing facility residents. Nevertheless, there remain opportunities in both the short and long term to make other program and policy improvements, including:
- Expanding Telehealth and Televisits. Federal regulations quickly instituted telehealth flexibilities when COVID-19 began, removing restrictions and increasing access for facility residents. The sharp pivot toward virtual visits when facilities restricted visitor access may have also supported patient-family interactions with relatives who do not live close to facilities. While in-person visits are restricted, televisitation practices can help boost family interactions with residents and strengthen social support. Building the televisit infrastructure at nursing facilities — through purchasing devices, training staff, and ensuring residents feel comfortable using devices — is a potentially useful long-term strategy to strengthen residents’ connections to loved ones.
- Ensuring Data Sharing and Transparency. The federal government did not require facilities to report COVID-19 cases to the Centers for Disease Control and Prevention until April 19, 2020, causing concern among many residents and their family members about a lack of transparency. Family members and advocates have called for more open and timely sharing of information from nursing facilities and the Centers for Medicare & Medicaid Services (CMS), and data and reporting have since improved. However, CMS does not require nursing facilities to report race and ethnicity data for COVID-19 cases and deaths, which limits the ability to identify and address disparities within nursing facilities.
- Aligning Nursing Facility Payment. The COVID-19 pandemic has illuminated challenges caused by a fragmented Medicare and Medicaid payment system for nursing facilities. Nursing facilities are reimbursed at a higher rate for short-stay Medicare patients than long-stay Medicaid patients, leading to issues of cost-shifting, shortfalls, and financial incentives that do not place the patient at the center of decision-making. Recommendations to improve nursing facilities after the pandemic advocate for realignment of Medicare and Medicaid payments, bringing Medicare rates in line with costs and raising Medicaid rates proportionate to delivering high-quality long-term care. Expanding home care reimbursement is also an important component of increasing access to more home care options for dually eligible individuals. In addition, states can direct relief funding to nursing facilities and require accountability to invest in staff benefits and protections. In New Jersey, for example, a recent relief package accompanied by long-term care industry reform bills addresses challenges experienced by nursing facility residents during the pandemic.
Strengthening Supports Moving Forward
Nursing facilities are an essential system of care for the most acute, vulnerable populations, many of whom are dually eligible. Unfortunately, congregate settings that house individuals with many health care needs are also among the highest-risk settings for contracting COVID-19. As the pandemic continues, improving transparency, data reporting, and public recognition of the challenges and disparities that individuals in nursing facilities face are critical to ensuring the health and well-being of this population. Additionally, maximizing the use of coordinated systems to transition individuals who are able to return to their homes remains a key priority for dually eligible individuals who need long-term care.