Hospitals and Nursing Homes Working Together

Many hospitals are actually finding themselves relatively empty, no one going to the emergency room no one going to the doctor. This is a geriatricians dream in many ways. However, it's not a dream to have people inappropriately stay away from their doctor and the emergency room.  There's the catch during this pandemic.  Similarly, while we were at the tail end of the flu season, no one is transmitting influenza right now.  That virus was stopped dead in its tracks by the total shutdown of society.

Nursing homes aren't accepting new patients, and those that have been infected will have seen a greater number of their residents die.  At the same time, nursing homes are fulfilling one of my great missions in life, which is deprescribing.  Stopping all unnecessary medications, which in older nursing home residents, happen to be most of the medications that they're on.  Ironically, the might also save lives.  On the other hand, the degree to which social isolation has occurred during this pandemic might also have a negative impact on older adults.

Hospitals are less busy, nursing homes are less full. A perfect storm for hospitals and nursing homes to work together. who would have thought?

Then, an email exchange with a colleague this morning:

Great questions.

1)  Adequate testing is definitely an issue.  At the same time, it’s a catch-22.  If you don’t test, and you don’t know and you don’t have enough PPE, it could be Kirkland again.  On the other hand, you are spot on, how often?  Specificity of testing?  I diverge:) I believe that a pandemic is the time that we need our government to help. Unfortunately, that hasn’t happened, in fact, it’s been almost the opposite.  If the government had engaged and done this right, they’d have payed attention to Italy and Spain and started testing all staff in nursing homes, provided full PPE to all nursing homes (btw, and ALFs), and we’d probably had a bit of a leg up (a bit, I say).  If we don’t have enough testing, what do we do?  Kiss our grandparents goodbye? We can’t even do that:(.  Stellar Infection Control and abundant PPE will only go so far, but is better than neither.

2)  We may have to find a “sweet spot” for testing.  Every week has been suggested? Do we test everyone? A sampling?  What’s the number? To your numbers, if you test 20%, will you find 2? What’s the confidence interval around that? 0-4?  What do you do with the ones you find?  On the other hand, test everyone every week (are there enough tests?), every 2-4 weeks?  

Here’s where the concept of “viral load” (which I am still intrigued by and for which there was a Lancet study in March that supported the concept).  If this concept is true, then we don’t need to test all staff every day, we just need to find that “sweet spot” for testing that keeps the “viral load” in the facility down to a reasonable level. At the very least, there’s a study idea in this concept.

Immunity appears potentially problematic.  Just not enough data at this point in time.  We don’t know about weather.  We don’t know about mutations of the virus.  The CDC should be comparing the genetics of this virus from around the country right now and answering the mutation question.  Who knows what they’re doing?  

3)  Don’t get me started on $$$.  The first stimulus package was a boon for every lobbyist in the country.  The Democrats and the Republicans came to feed at the trough.  Utterly ridiculous.  The unfortunate truth is that if my calculations are correct, when the dust settles, there will be 250,000 fewer older adults in the United States.  They will be amongst the highest cost Medicare beneficiaries.  Most of them will have died without going to a hospital and  utilizing excessive resources.  Many of them will have been Medicaid paid nursing home residents.  It’s real money, though not near the scale of the stimulus.  My personal view is that the government overreacted on this, where they should have been overreacting to “lock down” NHs and ALFs.  I’m a capitalist.  However, we could have just “taken a break” from capitalism for a few months, and we might have been fine.  The fits and starts are going to be so complex.  When the government tells restaurants and movie theaters that they can open, will they? Will anyone go? Will enough people go to make the business worthwhile.  That’s a whole other topic for another day.

4) A good chunk of the nursing home industry is based on its real estate.  The owners of that real estate will ultimately have a decision to make.  Do they stay in the NH business?  Do they convert their property into apartments? Dormitories?  Youth hostels?  Who knows?