Why a bottleneck of Michigan COVID-19 patients can't get admitted to nursing homes

Nov. 16--Michigan's surge in coronavirus cases and a new state policy surrounding nursing home admissions appear to be contributing to a bottleneck at hospitals where an industry association says a "significant" number of COVID-19 patients can't be discharged because they're awaiting placement in nursing homes.

The state's setting of five straight weekly COVID-19 case records and the resulting hospitalizations are nipping at the heels of state regulators as they work to implement a law signed last month that changes nursing home admission policies for COVID-19 individuals.

An October change in state policy and later enactment of a law surrounding nursing home admissions were part of a months-long debate about how to improve COVID-19 policies within nursing homes to cut down on cases and deaths. But the timing of the policies left little time for implementation ahead of a huge virus increase in Michigan.

Hospitalizations of virus patients in Michigan are up more than five-fold over six weeks, increasing the pressure on hospitals to release non-acute COVID-positive elderly patients to nursing facilities.

The ongoing implementation of the new COVID admissions law for nursing facilities is partly to blame for the bottleneck, said John Karasinki, a spokesman for Michigan Health and Hospital Association.

The hospital association did not have a figure available for how many patients are able to be discharged but are awaiting placement in a nursing facility, but anecdotal information "indicates that it is a significant amount," Karasinski said.

The Health Care Association of Michigan, which represents nursing homes, said the problems appear to be mostly located in west Michigan. But statewide facilities are prohibited from caring for patients unless they have appropriate personal protective equipment, space and staffing, the latter of which has been an issue, said Melissa Samuel, president and CEO for the association.

Only three nursing homes in Michigan have been approved to admit discharged COVID-19 patients into COVID-only units or buildings under the new government standards, earning designations as "care and recovery centers."

The transition to care and recovery centers was launched by Gov. Gretchen Whitmer in October in response to task force recommendations on how to better deal with COVID-19 in nursing facilities. Related legislation, Senate Bill 1094, was signed Oct. 22, addressing nursing facility admission policies and establishing care and recovery centers within nursing homes.

The state has about 442 nursing homes and 4,000 licensed assisted living centers.

The state is working to review applications and certify additional care and recovery centers through on-site reviews as required by the law, said Bob Wheaton, a spokesman for the Michigan Department of Health and Human Services.

In addition, the state is set to issue new guidance Monday regarding how nursing homes mayadmit an individual who had COVID-19 and what benchmarks need to be met to do so. In the interim, nursing facilities have admitted patients at their discretion for the last several months, Wheaton said.

"Some (nursing facilities) may have chosen not to (admit) knowing the policy required in SB 1094 was coming, but no regulation or policy prohibits them from doing so at this time," said Wheaton, referring to the new law.

Whitmer's administration has been working to accelerate the approval of COVID-designated care and recovery centers and guidelines for admission to non-care-and-recovery nursing facilities for several weeks after the task force recommendations were adopted in early October and Senate Bill 1094 was signed later that month.

Sen. Peter Lucido, R-Shelby Township, sponsored the legislation, which had bipartisan support when it passed in October. He speculated that Michigan's spike in cases is occurring "quicker than we can get this plan set up."

If the number of certified care and recovery centers doesn't increase soon, Lucido suggested the state should step in to set up the facilities.

"I think our government has to stand up and say, 'If they're not going to do it, we have to,'" said Lucido, who takes office in January as the newly elected prosecutor in Macomb County.

How the bottleneck occurred

For the fifth consecutive week, Michigan on Saturday broke its weekly COVID-19 case record with a total of 44,019 cases. Michigan's new cases have been doubling every two to two-and-a-half weeks.

COVID deaths also have been trending upward with the explosion of cases. There were 43 deaths on Nov. 3, followed by 65 on Nov. 7, 84 last Tuesday and 118 on Friday.

The Michigan Health and Hospital Association pointed to the timing of the passage and ongoing implementation of Senate Bill 1094 as one of the reasons for the bottleneck.

But the state health department said nursing facilities have been free to accept COVID patients while it brings the designated care and recovery centers online and develops admission policies. And two regional hubs still remain in operation as the state transitions to care and recovery centers, Wheaton said.

Lucido's bill made changes to COVID-19 policies pertaining to nursing homes that were first created through executive order by Whitmer.

Republican lawmakers had criticized Whitmer's nursing home policy, which focused on serving older Michigan residents with the virus in isolated areas of a nursing home or in regional hub centers. The more than 20 regional hubs were nursing homes that were supposed to have the equipment, capacity and staff to segregate residents with COVID-19 and prevent the spread of the virus.

But critics pointed out that a third of COVID deaths at the time occurred to nursing home residents or staff. Experts also have noted that the elderly are most susceptible to severe COVID symptoms and death.

Lucido called Whitmer's plan "disastrous" and introduced separate legislation that was vetoed by Whitmer in July. He introduced similar legislation in the fall and it began to gain traction after the Michigan Supreme Court on Oct. 2 overturned a 1945 law underpinning Whitmer's emergency powers.

Through Saturday, residents and staff from long-term care facilities, which include nursing homes, made up about 36% of the state's total coronavirus death toll.

Lucido's legislation requires the department to develop an approval and certification process for COVID-designated care and recovery centers within nursing homes that would be able to accept non-acute COVID-positive patients ineligible for admission to hospitals or other adult care facilities. The care and recovery centers, first implemented under Whitmer, would take the place of the "regional hubs" and have higher standards for operation.

Three facilities have been designated as care and recovery centers so far -- SKLD Plymouth, The Lodge at Taylor and Medilodge of Frankenmuth. Bringing more facilities online is a "top priority," Wheaton said.

"We are working to stand up CRCs as quickly and safely as possible," Wheaton said. "We have applications from a number of facilities and are partnering with LARA on the review of these applications."

New state guidance coming

The law also required the state health department to develop a process by which nursing homes could demonstrate to the state that they could provide a designated area to house individuals who had tested positive for COVID-19. Without such proof, nursing facilities couldn't care for COVID-19 patients unless they had recovered fully and were no longer contagious.

The state health department expects to issue the guidance Monday, but it won't take effect until the end of November, Wheaton said.

The law also requires a patient to continue receiving treatment at a hospital if that patient has less than 72 hours of isolation left and if the hospital has not reached surge capacity.

As positivity rates have increased in Michigan in recent weeks, staffing has become an issue as they also become infected, the Health Care Association's Samuel said.

"Other factors impacting these decisions may include the lack of liability protections, issues with physical plant capabilities, current status of PPE inventory and the impact on public perception for a building caring for COVID-19 residents," she said.

The issue is not "constrained to one region, hospital or health system but a problem shared by the majority of our members," the hospital association's Karasinski said.

eleblanc@detriotnews.com

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