Shortage of Nursing Home Beds Prompts Creative Solutions
By Melinda Young
The nursing home crises of too few beds and not enough staff is expected to continue for the foreseeable future. Case managers, discharge planners, and transition of care leaders need to find alternative solutions that will keep patients safe and avoid unnecessary hospitalizations.
The results of recent research into a population of veterans shows what can work when a nursing home bed is not an option or when the patient does not want to go there — which has occurred more often since the COVID-19 crisis began in 2020.
Researchers found a stark decline in VA patients transitioned to nursing homes during the pandemic, partly due to fewer beds and patients’ fear of COVID-19.1
“What we’ve heard from our case managers is veterans were stating a clear preference to not go to a nursing home,” says Portia Y. Cornell, PhD, MSPH, lead study author and an assistant professor of health services, policy, and practice at Brown University. “At that point, a case manager has to figure out where the veteran is going to get care.”
Alternate Options
Alternative options include a home care program and telehealth. “What a case manager needs to do is pool all of those resources. It can be a little more complicated than finding a nursing home bed,” Cornell says.
The following are Cornell’s suggestions for how case managers can find the best alternative post-discharge resources for patients:
• Caregiver support services. The VA offers a home care program that provides caregiver support and training. Some caregivers are even eligible for cash benefits, depending on the veteran’s service record and disability.
A monthly stipend for caregivers can help them afford to stay home with the patient, since they often give up a job to do so. A caregiver support program can provide training, mentoring, phone follow-up, and emotional support for patients’ caregivers.
The idea is to support patients by also supporting the well-being of the people who are taking care of them. “It’s complicated to take care of someone who has dementia, or to learn how to transport someone out of bed,” Cornell says.
A caregiver program could provide one-on-one coaching, online educational programs, video health, and phone support. Some states provide caregiver support services and cash benefits through Medicaid, but they are not as comprehensive or generous as the VA’s program.
• Phone support. “The VA has an ongoing initiative to expand access to telehealth for veterans,” Cornell says. “That includes telehealth from home with a tablet or computer.”
Another telehealth option is to visit a local outpatient clinic and meet with specialists via a phone/video connection at the clinic.
“Before the 2020 pandemic took off, the VA was already doing a lot of things to expand access to telehealth,” Cornell explains.
In March 2020, the VA issued a nationwide directive, canceling all non-urgent in-person appointments. This forced providers to pivot quickly to telehealth services. “If anyone had not figured out how to use the new system and how to use telehealth, they had to learn very quickly,” Cornell says. “Whatever they needed to do, they did it.”
Telehealth encounters expanded to all disciplines and have become more broadly available. If patients cannot access a computer or tablet for video calls, then health systems can provide one.
“Even if a veteran doesn’t have a smartphone, tablet, or computer, the VA can help with that as well. It’s part of bridging the digital divide,” Cornell says. Since patients may live in remote and rural areas without high-speed internet access, it also is important to maintain phone support as a tool, she adds.
• Home care services. Patients living at home also may need medical and non-medical assistance, such as housekeeping services, wheelchair ramp installation, and other home modifications. These may require community resources or finding a home care agency that also can provide help with cooking, cleaning, bathing, and dressing.
“The VA has funds for both skilled home care and homemaker services,” Cornell says. Other payers may not provide much assistance for these.
There also are capacity and access barriers to home care services in the pandemic era. “Anecdotally, the need went up for home health services, but the capacity didn’t go up,” Cornell says. “The VA programs that offer those supports saw a lot of interest and did what they could, but in the short term they could only do so much. The VA is investing more and more into home-based care.”
The goal for every case manager is to ensure any care transition is good for patients. “That can only happen if home support and caregiver support are adequate,” Cornell notes. “They need equipment, and to understand infection control.”
There always will be patients who need 24-hour skilled nursing care, and they need access to nursing home services. But alternatives can work for many patients. “The VA is looking at how they can support home-based programs and community-based programs like assisted living,” Cornell says.
Patients should receive care in the most home-like setting possible, where they can preserve their independence, she adds.
REFERENCE
- Cornell PY, Magid KH, Corneau E, et al. Decline in veterans’ admissions to nursing homes during COVID-19: Fewer beds, more fear, and finding alternative care settings. J Am Med Dir Assoc 2023;S1525-8610(22)00999-9.
The nursing home crises of too few beds and not enough staff is expected to continue for the foreseeable future. Case managers, discharge planners, and transition of care leaders need to find alternative solutions that will keep patients safe and avoid unnecessary hospitalizations.
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