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president of research at LeadingAge, which represents
practitioners, nursing staff and therapists, Mor said. “We

about 2,000 not-for-profit nursing homes. “Our public

should probably be thinking about population-based med-

health infrastructure has not sufficiently understood or

icine much more broadly,” said Mor, suggesting some kind
been supported in developing the competencies around
of capitated model.

the special needs of older adults,” she said. “ All of this is ex-
posing the poor underbelly of the system.”
Northwell has been facilitating phone calls at least once a
Hebrew Home’s Reingold pointed to varying ownership
week with high-volume referral partners to discuss the lat-
est strategies on medical guidance, infection control, avoid-
models as part of the problem, claiming that for-profi t pro-
viders prioritize their investors. While there isn’t defi nitive
ing unnecessary admissions, PPE and testing, Carney said.
evidence on how ownership structure affects care quality
The Hartford Foundation is partnering with the Institute for

Healthcare Improvement to offer 20-minute national hud-
at SNFs, the sector has seen significant consolidation and

dles to better coordinate care and mitigate COVID-19.
private equity investment.
“The pandemic is showing us there is no true cohesive
As long-term care providers consolidate, their parent

infrastructure here that integrates skilled nursing as part of
companies are trying to manage their facilities more effi -

these communities,” Johns Hopkins’ Bonner said. “Many
ciently by shifting staff between homes based on demand, more collaboration between doctors and advanced practice
said Fred Bentley, managing director at Avalere. communities don’t have people in critical positions who
“That causes huge problems because staff are carriers understand what is happening in nursing homes.”

and don’t realize it,” he said. Too many groups oversee post-acute care, said Bonner,
More SNFs have been generating li- noting CMS, the Health Resources and
quidity by selling real estate assets to Services Administration, the Agency

private equity firms, which then lease Our public for Healthcare Research and Quali-
back the space to the operator. health ty and others all play diff erent roles.
“In good times that strategy has “There needs to be a bigger nation-

largely worked, but in times of crisis, I infrastructure has not al strategy governed by one agency,”
worry that it is a bit like a landlord and suffi ciently understood she said. “Next is advocacy. Where is
tenant,” Grabowski said. “Th e leas- or been supported the public outcry over the way we are

es aren’t flexible in terms of what is in developing the treating older adults? It is unconscio-

happening during the pandemic, and competencies around the nable. We need to fix it, and fix it now.”

conversations aren’t often how to best
special needs of older
direct dollars to make certain that it is Flying blind
adults.”

going to PPE and staff and not in the Fear often impedes a coordinated re-
pockets of the private equity owner.” Dr. Robyn Stone, senior vice president sponse, experts said.
“We have been flying blind some-

of research at LeadingAge
Change the system what about the extent of the problem—
Over the short term, skilled-nursing some of that is rooted in nursing homes
facilities should establish “centers of excellence” models that are not willing to share their data because they are
for facilities outfitted for exclusively treating COVID-19 pa- worried about litigation, punishment from the government

tients, Grabowski said. or bad press,” Grabowski said.
Taking a longer view, increasing investment in hospi- Compliance surveys drive operational changes and
tal-at-home programs can alleviate some of the burden on that shouldn’t be the case, Fulmer said. “I know surveyors
long-term care facilities, although staffing will be an obsta- don’t try to make organizations miserable, but it does come

cle, experts said, noting that telehealth can mitigate access down to that sometimes. Where is the balance of getting

issues. “Investment in the workforce is a huge piece of this,” these places surveyed so they can float problems and fi x

Stone said. “Aides and certified nursing assistants do the li- them versus enacting penalties and regulations?”
on’s share of care but there is little investment in them.” From now on, Hebrew Home will plan to have a two-
“We need to figure out how to make long-term care an month supply of PPE on hand, said Reingold, noting that

attractive career,” Reingold said. they have to be wary of which types they store since the la-
Tweaking reimbursement may help pay for these tex used in some surgical masks deteriorates.

changes, experts said. Mor and Grabowski suggested that Staffing plans will need to factor in 30% of direct care

Medicaid must pay a higher rate commensurate with the staff not being available. Residents and families will need

costs of delivering high-quality long-term care to frail to connect virtually. SNFs will need to be transparent and

older adults. That will require greater federal contribu- accountable in their infection rates, Reingold said. Th ey
tions in models that integrate medical care with social will also need to have more cash on hand, he said. As for
needs of patients are required, they said. the pandemic and related operations, Reingold told his
Two examples are Medicare Advantage institutional spe- staff that they plan “this to be the way of life for two years.”

cial needs plans and nursing home-led accountable care “We as a society need to figure out what we’re going to

organizations. do to protect these people,” he said. “Or are they just not
But this requires a perspective change that facilitates worth it?” 
June 8, 2020 | Modern Healthcare 15