A wrenching conflict is emerging as the COVID-19 virus storms through U.S. communities: Some patients are falling into a no man’s land between hospitals and nursing homes.

Hospitals need to clear out patients who no longer need acute care. But nursing homes don’t want to take patients discharged from hospitals for fear they’ll bring the coronavirus with them.

“It’s a huge and very difficult issue,” said Cassie Sauer, president of the Washington State Hospital Association, whose members were hit early by the coronavirus.

Each side has legitimate concerns. Hospitals in coronavirus hot spots need to free up beds for the next wave of critically ill patients. They are canceling elective and nonessential procedures. They are also trying to move coronavirus patients out of the hospital as quickly as possible.

The goal is to “allow hospitals to reserve beds for the most severely ill patients by discharging those who are less severely ill to skilled nursing facilities,” Seema Verma, administrator of the Centers for Medicare & Medicaid Services, said a few weeks ago as the federal agency relaxed rules restricting which Medicare patients can receive nursing home care.

Nursing homes are alarmed at the prospect of taking patients who may have coronavirus infections. The consequences could be dire. The first nursing home known to have COVID-19, the Life Care Center in Kirkland, Washington, saw the virus spread like wildfire. It killed 37 people.

“We’re looking at case fatality rates of 30, 40, 50% in nursing homes when coronavirus gets introduced,” said Christopher Laxton, executive director of AMDA — the Society for Post-Acute and Long-Term Care Medicine, which represents nursing home medical directors.

Fears extend to patients with other conditions, such as strokes or heart attacks, who’ve been in the hospital and do not have COVID-19 symptoms but could harbor the virus.

In its most recent guidance, the American Health Care Association, an industry trade group, said nursing homes can accept patients “who are COVID negative or do not have symptoms.” If someone has symptoms such as a dry cough or fever, they “should be tested for COVID-19 before being admitted to the facility.” If someone is COVID positive, they should be kept only “with other COVID positive residents.”

But nursing home doctors worry this doesn’t go far enough. According to a resolution by the California Association of Long Term Care Medicine, nursing homes should not have to take patients known to have the coronavirus unless “they have two negative tests that are 24 hours apart, OR 10 days after admission AND no fever for 72 hours.” A new AMDA resolution echoes this caution.

“We have an obligation to our patients to draw the line,” said Dr. Michael Wasserman, president of the California association. “Increasing the number of COVID-19 positive residents in facilities — whether these facilities have patients with the virus or not — raises the risk of infecting the uninfected and dramatically increasing the number of deaths.”

For their part, hospital leaders say an emphasis on testing before discharging patients is impractical, given the shortage of tests and delays in receiving results.

“Many nursing homes are requiring a negative COVID-19 test even for patients who were in the hospital for nothing to do with COVID,” said Sauer in Washington state. “We don’t agree with this. It’s using up very limited testing resources.”

Nowhere are tensions higher than in New York, where Gov. Andrew Cuomo has said 73,000 extra hospital beds will be needed within weeks to treat a surge of COVID-19 patients. Hospitals in the state have 53,000 beds.

On Wednesday, the New York State Department of Health issued an advisory noting: “No resident shall be denied re-admission or admission to the NH [nursing home] solely based on a confirmed or suspected diagnosis of COVID-19.”

Speaking on behalf of nursing home physicians, AMDA voiced strong opposition, calling the policy “over-reaching, not consistent with science, unenforceable, and beyond all, not in the least consistent with patient safety principles” in a statement.

Some nursing homes are sending residents with suspected coronavirus to hospitals for evaluation and then refusing to take them back until tests confirm their negative status.

“Essentially, they’re dumping patients on hospitals and saying, ‘Too bad — you’re stuck with them now,’” said a consultant who works closely with hospitals and spoke on the condition of anonymity.

Others want to do their part to serve COVID-19 patients. “It is our obligation to keep the health care system flowing,” said Scott LaRue, president of ArchCare, the health care system of the Archdiocese of New York.

LaRue has no illusions about keeping the coronavirus out of ArchCare’s five nursing homes, which, combined, have 1,700 beds.

“In New York City the virus is everywhere,” he said. That means it has to be managed, not avoided. “Our intention is to take COVID-19 stable patients” and move them to a single floor at each nursing home, he said.

That will happen under two conditions, LaRue said. First, ArchCare will need sufficient personal protective equipment — gowns, masks and face shields — for its staff. Currently, the system can’t get face shields. It was due to run out of gowns by Wednesday.

Second, ArchCare will need to test whether its protocols for managing COVID-positive patients are working. Those include putting patients in isolation, monitoring them more closely, limiting the number of people who can go in, and ensuring that staff use personal protective equipment and are trained properly.

So far, only one of its nursing home patients is known to have COVID-19.

“We won’t know for 14 days if the steps we’re taking are working,” LaRue said.

But it’s unrealistic to expect other nursing homes to follow suit.

“I would be surprised if 10% to 15% of skilled nursing facilities in the U.S. could take a COVID-positive patient and treat that patient safely while ensuring that other residents in the home are safe,” said David Grabowski, a professor of Health Care Policy at Harvard Medical School.

In a new commentary in the Journal of the American Medical Association, Grabowski calls for establishing “centers of excellence” to care for patients recovering from COVID-19 and building “temporary capacity” in hot spots where the need for post-hospital services is likely to surge.

That’s beginning to happen. On Tuesday, Cuomo announced that a field hospital being built by the U.S. Army Corps of Engineers to house overflow coronavirus patients at the Jacob K. Javits Convention Center in New York City would include 1,000 beds for patients who don’t need acute care services.

On Wednesday, a unit of Partners HealthCare, a large Massachusetts health care system, announced a new center for patients recovering from COVID-19 on the fourth floor of Spaulding Hospital for Continuing Care, a long-term care hospital in Cambridge. The center, set to open soon, will have 60 beds and accept patients from Massachusetts General Hospital and Brigham and Women’s Hospital.

In the Twin Cities area of Minnesota, Allina Health, which operates 11 hospitals, is partnering with Presbyterian Homes & Services to convert a 50-bed skilled nursing home to a “step-down site,” said Dr. Emily Downing, a vice president of Allina Health. The goal is to help COVID-19 patients recover so they can return to nursing homes or senior living communities.

Katie Smith Sloan, president of LeadingAge, which represents not-for-profit nursing homes, home care agencies and assisted living centers, said she was hearing about nascent plans to reopen closed nursing homes for COVID-19 patients. Government agencies need to make financing available to build extra capacity to care for these patients, she said.

As for patients who need less intensive care or who need to be quarantined after the hospital to ensure they aren’t infectious, other options exist.

“King County has bought a hotel and is leasing another and is looking at what are now empty ambulatory surgery centers or a Christian summer camp in the area,” said Sauer of the Washington State Hospital Association.

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