Some Illinois nursing home residents who have been hospitalized during the COVID-19 pandemic have been stuck in limbo. When hospitals have decided these patients were well enough to return to their long-term care facilities, some nursing homes have resisted taking them back.
The problem is bubbling up around the country, with states stepping in to varying degrees — with some forcing nursing homes to take back COVID-19 patients and others restricting them from returning.
To help address the issue in Illinois, industry groups recently forged a plan and presented it to state officials. The Illinois Department of Public Health released it Tuesday. It makes recommendations on the hand-off of patients between hospitals and nursing homes, depending on how sick the patients are.
For example, it recommends that nursing homes put residents returning from the hospital who have tested positive for COVID-19 in a designated wing or unit, keeping them apart from other residents. For returning patients who aren’t as sick, they can be isolated in their own rooms and wear face masks during treatments until their symptoms clear up or until 14 days have passed since they became sick.
Previously, federal officials recommended stricter rules: That hospitals not discharge patients until they test negative for the new coronavirus twice within 24 hours. But amid a widespread testing shortage, officials relaxed that advice.
IDPH’s new guidance is a set of recommendations, not orders — an attempt to create guidelines to ease a problem vexing both hospitals and long-term care facilities.
High-risk residents, potential for outbreaks
The nursing homes point to the precarious situation they’re in. Start, they say, by considering their clientele: elderly people who aren’t healthy enough to live on their own and typically have chronic conditions, such as heart disease or diabetes. They’re at high risk of contracting the new coronavirus, including from their own peers who were sick enough to be hospitalized.
That risk has already borne out in a number of outbreaks that have erupted in nursing homes across the state. As the number of COVID-19 cases climbs in Illinois — topping 15,000 with 462 deaths — officials have seen clusters of cases in dozens of nursing facilities statewide, according to the Daily Southtown. Illinois public health officials told WBEZ Wednesday there have been 773 identified cases, including both patients and staff, in long-term care facilities, and 133 deaths. In Cook County, there is at least one case in 63 “congregate settings,” such as nursing homes, the public health department said.
“The biggest issue is that by far most of the nursing homes are not prepared to take care of either COVID-positive patients or suspected COVID patients,” said Dr. Dheeraj Mahajan, a physician who works in Chicago-area hospitals and nursing homes. “Once we introduce COVID to a nursing home, the chances of it spreading everywhere is extremely high.”
Many doctors and aides work in multiple nursing homes. These facilities typically don’t have infection control expertise and they’re struggling to find their own masks, gowns and gloves to protect their employees from getting COVID-19 and spreading it, Mahajan said.
In Illinois, officials are expecting a surge of cases in the coming weeks, and hospitals are hustling to make room for patients.
Still, it’s not clear how many nursing home residents have been kept in hospitals because their long-term care facilities wouldn’t allow them to return. Illinois public health officials did not respond when asked if the state is tracking these cases.
But Adam Kohlrus, an assistant vice president at the Illinois Health and Hospital Association, which lobbies for nearly every hospital in the state, said the organization has heard from hospitals around Illinois trying to transfer patients to long-term care facilities, but finding resistance.
He considers the new state recommendations a blueprint for how hospitals and nursing homes can work together to transfer patients. It applies to anyone who is hospitalized — for COVID-19 or not — and needs to return to a nursing home or become a new resident. That includes people who were infected with COVID, were put on a life-saving ventilator to help them breathe and now need rehabilitation services before they can go home.
The guidelines put a lot of onus on nursing homes with the recommendation that facilities have a designated unit or wing for these patients.
Kohlrus acknowledged this could be tough for long-term care facilities, particularly for those that don’t have much money or other resources. But he ticked off a few examples of nursing facilities quickly opening up small isolation units around the state.
He also pointed to this: There are at least 120,000 people transferred between hospitals and nursing homes in Illinois a year.
“We knew out of the gate this is a really big chunk of folks and we have to work with our partners to mitigate any transfer issues as much as we can,” Kohlrus said. “If there [are] no guidelines or protocols in place … there’s no way our health care system from the hospital perspective could take a bottle necking of tens of thousands of patients at this point in time. It would kind of cripple our capacity.”
In addition to the health risks to nursing home populations and the capacity needs at hospitals, there are financial considerations for both.
Loretto Hospital CEO George Miller said he has two patients who nursing homes won’t take back. But, he said insurance companies are no longer paying the hospital to treat them, since they don’t require acute care. That creates a major financial strain for the West Side small hospital, Miller said, which already operates paycheck to paycheck.
Meanwhile, if there is a surge in patients, he’s bracing to potentially treat double the number of people in the coming weeks.
“For us to turn people away because we have nursing home patients … we can’t place, that’s our fear,” Miller said.
Pat Comstock is the COVID-19 director for the Health Care Council of Illinois, which represents about 300 nursing homes. She said facilities have been working to stave off COVID-19 and help contain spreading the virus by implementing several measures. Those include: No visitors. Screening all staff for fevers and other coronavirus symptoms. Not allowing residents to eat together. She added residents now play bingo from their doorways instead of in the dining room.
While some nursing homes are looking to create those wings for COVID-19 patients, not everyone can afford to, and not all have enough protective gear for their employees.
The bottom line: Despite the new guidance, some patients could still be left in limbo, not getting to return to their nursing home.
“Every facility is going to make their own decision about serving any residents,” Comstock said. “They’re going to want to do that in a way they determine they can safely accept any resident without the fear of further spread of the virus, without putting their staff at risk and making sure that they’re not putting other residents at risk.”
Yet nursing homes could become a bigger piece of the COVID-19 crisis — as both a place where recovering patients might need to stay and a place where there could be more outbreaks.
“When my phone rings and it’s a nursing home — this is 24/7 — it is that they just got their first case,” said Mahajan, who is a medical director at three local facilities.
Kristen Schorsch covers public health on WBEZ’s government and politics team. Follow her @kschorsch.