Nursing homes say they need more help from the state; their residents have accounted for 58.6% of covid-19 deaths in Ky.

By Melissa Patrick
Kentucky Health News

As they remain the main sites for deadly infections of the novel coronavirus, Kentucky's nursing homes are asking for more help from the state, which says much of the help they seek has already been provided or can't be rendered.

At a legislative committee meeting Aug. 26, the head of Kentucky's main nursing-home association said nursing homes are grateful for the federal dollars and testing programs the state has funneled to them during the pandemic, but it's not enough.

Betsy Johnson told legislators, "I believe
the toughest days are actually ahead of us."

"We still need help," Betsy Johnson, president of the Kentucky Association of Health Care Facilities, told the Interim Joint Committee on Health, Welfare and Family Services.

"We need a lot of help, mainly funding to retain our workforce, which has been decimated, funding to require additional PPE and to support ongoing covid testing," she said. PPE, personal protective equipment, includes masks, gloves and gowns.

Johnson also pointed to research that found quality ratings of facilities was not a factor in coronavirus outbreaks. The Centers for Medicare and Medicaid Services five-star quality rating system gives 69 of the state's nursing homes a two-star or below average rating and 61 of them a one-star or much below average rating. 

"The experts agree covid-19 cases in the community are top factors in whether there is a covid outbreak in a facility," she said. "Covid deaths in a long-term-care settings have nothing to do with the quality of that facility."

WKYT-TV image

The day before the hearing, the Georgetown News-Graphic reported that the death toll at Dover Manor, a long-term care facility in Georgetown, had reached four, and all the deaths had occurred within four days of each other. On Aug. 26, WKYT-TV reported the long-term care facility's fifth death. 

On Aug. 29, the state's daily long-term care report showed 26 residents and 12 employees at Dover Manor had active cases of the virus. Since March, 59 residents and 26 staff have tested positive.

“You don’t have this many positive cases in a facility without a breach in your infectious-disease protocols, so we're very concerned," Crystal Miller, public health director at the WEDCO District Health Department, told WKYT. She said some employees have quit and the department is educating the remaining employees about PPE and how to isolate residents who test positive.

Scott County's coronavirus case numbers started rising in late June and didn't come back down till mid-August, according to the WEDCO covid-19 report. The CMS five-star rating system gives Dover Manor one star. 

At the committee meeting, Johnson said a July survey of nursing homes showed that their labor and benefit costs had risen 8 percent since the pandemic hit in March; nearly 51% of homes had less staff; nearly 21% saw an increase in use of employment agencies; and such agencies had increased their costs between 10% and 75%.

Johnson reminded the lawmakers that her association has warned them for some time that there is a "workforce crisis" in long-term care, and "Covid-19 has only made this worse." 

She also pointed to the state's use of federal relief money to pay for its "strike teams," which help with staffing issues in nursing homes hit hard by the virus but put them in direct competition with the state for much-needed employees.

An advertisement in Madisonville showed the state is paying registered nurses $65 an hour, licensed practical nurses $50 an hour and nursing assistants $32.50 an hour, "significantly higher than the average nursing facility can pay," Johnson said, while still expressing thanks for the help the teams give.

Asked about the strike teams at the governor's daily press conference later that day, Cabinet for Health and Family Services Secretary Eric Friedlander said they have been used, but not recently. "That has obviously been a very controversial piece, " he said.

Johnson said an April survey of her association's members found 87% were in need of some form of personal protective equipment; 9% said they didn't have a week's supply of surgical masks; 10% didn't have a week's supply of N95 respirator masks; and 10% didn't have a week's supply of gowns.

The survey also found PPE costs had increased by 10% or more. Sen. Danny Carroll, a Paducah Republican who owns a non-profit agency that provides therapy and medical-based child care, said he had been told the cost of a case of gloves had increased from $49.70 to $108. 

Johnson added that nursing home are also squeezed financially by an 8% drop in their patient numbers, caused not only by deaths, but by a decrease in elective surgeries because these patients often rehabilitate in nursing homes. 

Association offers ideas, state explains why they won't work

Johnson said the best way to help nursing homes would be increasing the amount the state pays for residents covered by Medicaid by $12.55 per resident per day, instead of the additional $270 per day it is paying for positive covid-19 residents only.

“We were grateful for this funding, but we found it a little problematic,” Johnson said. “Not everybody in a facility is Medicaid eligible; a lot of them are Medicare or private pay. A lot of people went immediately out to the hospital, so it really wasn’t providing the necessary funding to arm ourselves in fighting off covid-19.”

She said the association has asked twice for the change, has been denied once and expects that the second request will also be denied, based on an Aug. 13 letter from Friedlander. 

She suggested that the payment boost could come from the 6.2% increase in Medicaid contribution that the federal government is paying states during the pandemic, since it "was intended to assist providers in fighting covid-19."

Secretary Eric Friedlander

However, Friedlander told Kentucky Health News in an interview that states got the increase to cover the cost of expanding their Medicaid populations during covid-19, not to pay providers.

Many people who have lost their jobs have become Medicaid beneficiaries, and Kentucky has led the nation in the percentage of people gaining Medicaid coverage during the pandemic, according to a July 24 report by the Kaiser Family Foundation. It found that Kentucky Medicaid, which now covers more than 1.5 million people, grew 7% from March to April.

Friedlander had another reason to oppose Johnson's request: "When you give a provider group a raise, you can't ever take it back. And then it becomes a matter of, 'Do you have the budget to support that, ongoing?' And I think we know, Kentucky's got a lot of budget challenges and so it's pretty clear that we wouldn't have that ongoing." 

In an email, Johnson offered an alternative, that the state use federal relief money to help nursing homes "acquire (and/or maintain) these important things to continue to fight covid-19," including "needed PPE, testing beyond what the state or the federal governments are willing to pay for, and to continue to pay 'heroes pay' to staff." 

That doesn't seem to be an immediate option. Some have criticized Gov. Andy Beshear for spending only about 6% of the state's relief money, but he has held firm that Kentucky and other states are stuck between "a rock and a hard place" not knowing whether Congress will provide more money to stabilize state budgets, or allow states to do that with money they already have. The way it is now, "it doesn't allow for an informed decision," Beshear said Aug. 19. 

Money from the Coronavirus Aid, Relief and Economic Security Act can be spent only on programs that directly respond to effects of the virus. In addition to the strike teams, the state has used it to finance testing and surveillance at long-term-care facilities. States are also waiting on the details around another $5 billion in federal funding that has been promised to skilled nursing facilities.

Friedlander said the state has also done other things to help nursing homes, like allowing them to hold beds longer for patients who leave temporarily, making Medicaid enrollment easier, and increasing their Medicaid payments. The inspector general's written presentation to the committee, which wasn't presented for lack of time, says this increase was 8.5%. 

Impasse in committee

Greensburg Republican David Givens, president pro tem of the Senate, said Johnson's request for state funding of PPE, testing and personnel "sounds like it is a very critical ask for them, and a very appropriate ask in use of CARES money," and asked Adam Mather, the cabinet's inspector general, to respond. 

Insp. Gen. Adam Mather

Mather said he could not speak about Medicaid, but said "large swaths" of federal money have been provided to nursing homes and that a "significant amount" of PPE has been distributed. Johnson's slides showed the federal government has provided $33.6 million to skilled nursing facilities in Kentucky, an average of $169,000 each.

Mather said the state used CARES Act money to test every long-term care facility resident and employee and is using it for testing through the end of the year. 

He said the state's universal testing was "one of the more robust programs in the country" and that its current testing is happening "at a much quicker swath and more appropriate swath than many other states." 

Givens asked, "So then why would she make the ask if the need has already been met?"

Mather said he didn't know, adding that he recognized that while there is always a need for more PPE, "I don't know what to say about the ongoing testing; it is there, and available." 

"We seem to be at an impasse," Givens said.

Sen. Ralph Alvarado

Sen. Ralph Alvarado, R-Winchester, said an unnamed Lexington nursing home didn't follow the local health department's covid-19 guidelines, but did what it had found to be successful in the past to control infectious diseases, and got a much better outcome than another Lexington facility that followed the health department's guidelines.

Alvarado would not share the names of the two nursing homes with Kentucky Health News, but said he was the medical director of one and had patients in the other.

Friedlander said in the interview that many factors influence covid-19 outcomes in a facility, such as employees carpooling or socializing in the break room without PPE. "Sometimes even the best intentions, if they're not implemented fully, don't always yield the perfect results or the optimal results," he said, adding later, "We know . . . we're making sub-optimal decisions sometimes, but it's the best decision we can make." 

Alvarado asked Johnson and Mather if the state requires a "one size fits all approach" for every facility. 

Johnson said, "It's not a one-size-fits-all kind of solution. So it would be nice to have more of a listen to what we need and you all provide support rather than dictating what should happen inside that building." 

Mather, a former nursing-home executive, told a different story. He said long-term-care facilities work with state and local health departments to make an action plan to address a case of covid-19, and with a team that fights infections associated with health care and includes Dr. Kevin Spicer of the federal Centers for Disease Control and Prevention. Mather noted his experience in the industry and that of Keith Knapp, coordinator of the state's nursing-home task force.

He said the Centers for Medicare and Medicaid Services recently commended Kentucky on what a good job it's done with long-term care facilities. "It's a very robust program," he said. "It's a best-in-class, through-all-the-states program," he said.

Most covid-19 deaths are in long-term care

During her presentation, Johnson displayed a map that showed Kentucky has one of the highest covid-19 death rates in long-term care. She was using mid-July data that showed such facilities accounted for 63% of the state's covid-19 deaths. By Aug. 29, that had declined to 58.6%.

Mather said Johnson's data was outdated, and now "We're doing much better than many states around us." The most recent CMS covid-19 nursing home data webpage, using data from the week ending Aug. 16, shows Kentucky with 107.3 cases per 1,000 residents and 23.8 deaths per 1,000 residents, ranking 21st for both measures. Friedlander said the state has been ranked about 20th for several weeks.

Beshear, asked about the topic on the day of the meeting, said "I believe the amount of assistance, the amount of expertise, the amount of resources we provided to our long-term care facilities here in Kentucky battling covid rivals if not exceeds what any other state has done, and they continue to work on that."

At least 3,415 residents and 2,029 employees at 303 nursing homes have tested positive for the coronavirus, and 535 residents and five employees have died from it.

A seat at the table

Johnson said several times that the association should have been included in state decision-making about long-term care in the early days of the coronavirus, adding that she would like a dementia expert and a long-term-care expert on staff at the state health department. "There's been a serious lack of understanding of how skilled nursing facilities operate during the covid-19 pandemic," she said. 

Friedlander said in the interview that he intentionally did not include a lobbyist on the long-term-care task force, but his cabinet has been in regular communication with Johnson's association and Leadingage Kentucky, a lobby for nursing homes and assisted-living centers. 

Friedlander said the task force includes medical personnel, a member from the association that includes medical directors for long-term care, a provider, an owner, an operator, a person from the University of Kentucky and cabinet personnel.

"We think we have a really strong representations of folks who know, one, how to operate; and then, two, on the medical side," he said. "This is a medical group, it isn't a political group. So those are the representatives that we have. So we don't have any associations on there." 

Johnson replied in an e-mail, "We want to have a true collaboration – where they ask what we need, and work with us to achieve a compromise on the “asks.”

She concluded her at times emotional presentation at the meeting by saying, "I believe the toughest days are actually ahead of us."