PROVIDENCE – The world of nursing homes and skilled nursing facilities has come into sharper focus in the midst of the current coronavirus pandemic, in large part because such congregant settings are the perfect Petri dish for the virus to grow and be transmitted: an aging, vulnerable population requiring round-the clock care, delivered mostly by low-wage workers now deemed “essential,” with death rates mounting here in Rhode Island and around the nation, through no fault of their own.

Most reporters “covering” the onslaught at nursing homes have had little if any direct experience with nursing homes and skilled nursing facilities. It is not a regular part of their news beat; it is unlikely that they themselves personally have ever been a “temporary” resident of such a congregant setting, except if they have had the pleasure of having to recuperate in rehabilitation from an extensive surgery.

Some reporters may have had loved ones, parents, grandparents or friends whom they have visited at nursing homes, but the sad truth is that most nursing homes exist as a world apart, far removed from the day-to-day life of reporters on deadline – as well as from many readers and viewers.

To protect nursing home residents from the potential spread of the virus, visitors have been restricted, further isolating those in nursing homes and skilled nursing facilities. Workers have now become the residents’ extended families.

Further, few reporters are conversant with the complicated financial equations governing the flow of money from health insurers, Medicaid, and Medicare that fund nursing homes, skilled nursing facilities, and assisted living enterprises. It remains an “untranslatable” arcane language of economics, governed by State House decisions often made behind closed doors at budget time, when annual mandated cost of living increases due nursing homes are deferred to keep from having to raise additional revenues.

Instead of paying now, legislative leadership has kicked the can down the road, only to have the dark consequences of such “frugality” become fully visible as the pandemic has swept through our under-resourced nursing homes.

The irony, of course, is that for most of us, unless we are extremely wealthy, are destined to spend our final days in a nursing home. The demographic trends in Rhode Island speak an irrevocable truth: we are a state with the highest percentage of “old old” residents, people 85 years of age and older, many of whom are afflicted by chronic diseases, many of whom have limited financial resources.

The unclear family
The truth is that nursing homes provide, for the most part, consistent, constant, high-quality care for many Rhode Islanders, in a supportive environment. They are an integral part of the continuum of health care in the U.S.

The coronavirus pandemic has demonstrated the severe limits of current health care policy – for hospitals, for emergency and urgent care, and for nursing homes. To invoke the Bob Dylan lyric, “Everything is broken.”

Missing from the conversation, for the most part, have been the voices of the nursing home industry, being able to share their side of the ongoing story and the mounting tragedy.

ConvergenceRI reached out to Scott Fraser, the president and CEO of the Rhode Island Health Care Association, a leader of the Rhode Island nursing home industry trade group, to provide an opportunity to share his perspective. Here is the interview:

ConvergenceRI: What are the current needs of nursing homes, from personal protective equipment to testing to staffing?
FRASER: We have many challenges and they revolve around securing a number of tools to help us keep our residents safe.

First, we need rapid testing for our workers and residents. Rapid testing is what provides our homes with the knowledge they need to keep residents and workers safe. If a resident is known to have the virus, we can move quickly to isolate them from the rest of the population.

If a worker tests positive, they know they cannot be in our facility and are sent to recover at home. The more people leave the building, the harder it is to control the environment inside the building. [Our workers leave the building to go home; medically necessary personnel such as lab technicians and ambulatory care come in and out; and our residents sometimes need to leave for kidney dialysis or other medical appointments.]

Additionally, this virus is hard to spot, as many of those infected are asymptomatic. We need rapid testing of our workers and residents regularly to ensure they are clear of the virus.

Our homes have been, for the most part, dealing with limited testing and when testing is available, it takes 3-4 days to get results. Our workers were also provided an opportunity to be tested at Twin River. This was a good temporary option for some but not a good option for others.

Many of nursing homes are coping with low staffing issues, and to send a worker to Lincoln from Newport or Westerly during their shift time is incredibly difficult – forget about doing that once a week. In the last few days, our workers have been having problems getting access to tests at Twin River.

We need frequent testing with rapid results. Fortunately, the R.I. Department of Health has heard our call and have said they are rolling out a plan. We are working with them to ensure this is done as quickly as possible.

ConvergenceRI: And getting access to PPE?
FRASER: Next, access to PPE is still of great concern. We have surgical masks and the state has helped secure these. Now, we need N95 masks and gowns. We have a person at RIHCA dedicated to finding PPE.

It is a hard thing to do and the cost is a difficult burden to bear for our homes. N95 masks, once .85 cents, are now selling for between $4-to-$7 each. We will continue to search though, as these gowns, masks, gloves and face shields keep infection under control. They are instrumental to keeping the virus from spreading and again, keeping our residents and workers safe.

Finally, in terms of staffing, we are in need of more workers in our homes. The more we have, the better we are able to fill shifts and accommodate for sick time and other staff needs.

Our partnership with Gov. Gina Raimondo and Dr. Nicole Alexander-Scott [the director of the R.I. Department of Health] and their teams has been fruitful, as just this week the Governor answered our call on two items: hazard pay for our workers and the formation of Strike Teams, including the National Guard.

Hazard pay for our workers keeps people engaged and provides them with the recognition they deserve for being on the frontlines. We spoke to the Governor on this and she let us know that she heard us. The governor’s new plan will provide a weekly bonus to those making $20/hour or less.

We will continue to work with the federal delegation, who has been supportive, to advocate for all nursing home workers to receive hazard pay, as well. Our workers are amazing human beings and committed to their work at every level of our operation.

The governor also heard our call for Strike Teams to supplement our staffing needs in a crisis. We supplied a detailed plan to the state for these teams and we look forward to working with the state on their formation to ensure they meet our needs. Having replacements at the ready, to step in if too many workers are out ill or for other reasons, will further protect the lives of our residents.

ConvergenceRI: In terms of the state, what does the Governor and the Legislature need to do to increase the resources for nursing homes?
FRASER: As stated above, the continued pursuit of PPE and support around staffing is of immediate importance to our nursing homes. We also have asked the Governor to provide additional funding to meet the huge increase in expenses our homes are facing due to COVID-19.

We are meeting with her team on this issue this week and hope to have good news to report to our members. In the long term, adequate funding for Medicaid and other expenses such as additional cleaning supplies, overtime and more, will have to be part of the conversation.

We communicate our needs weekly to all of the general officers and to the leaders of the R.I. General Assembly. All have been supportive of the efforts of our homes and our workers and our needs.

ConvergenceRI: What kinds of emotional and mental health support do workers in nursing homes need?
FRASER: This is a difficult time for all our workers. We have about 7,000 residents presently in our homes and our nursing home workers are incredibly close to them.

Our residents are in our homes, in many cases for years, and our workers are like their second grandchildren, nieces or nephews and serve as friends to them and their families.

Seeing a resident pass is very emotional and a big loss for the direct caretakers and all the staff in the building.

Our teams are extraordinary people and they are resilient. In many cases they have each other as support, but it is also important they have access to outside support systems, as well.

Many of our homes offer access through health plans and we are grateful to the R.I. Department of Health for providing resources on their COVID-19 website that allow our employees to reach out directly for assistance during this time.

ConvergenceRI: What questions should be asked about the R.I. Medicaid office in terms of oversight and accountability?
FRASER: RIHCA has always worked with, and will continue to work with, the Medicaid office and R.I. EOHHS. For years, our members have spoken out about the need for adequate funding to continue to provide the best services for our residents. Given the financial challenges created by this pandemic, we will continue to work together to provide proper reimbursement for the 24-hour daily care provided by our members.

ConvergenceRI: What other questions that you think are important in framing the discussion moving forward?
FRASER: Richard, thank you for the opportunity to add in other thoughts here. I think one of the key points people should know is that nursing homes are certainly on the front lines and these are serious times with more difficult challenges than ever before.

We communicate regularly about what is happening – both good news and hard news – inside the homes to family members and caretakers.

With that said, I also want people to know that there are still smiles happening in our homes every day. The key word in nursing home is home. We are home to our residents and to the family and friends who would come to visit [if they could]. Our staff is committed to creating a sense of belonging for each resident.

This time has been so heartbreaking for family and friends as this virus has paused visits and group activities for now. Yet, as committed as we are to keeping our residents healthy, we are equally committed to keeping them smiling.

Our residents and workers share stories, they tell jokes, they do individual activities like coloring or painting or singing a song, we celebrate birthdays and anniversaries, and residents Facetime with their family members so they can give virtual hugs to their children, grandchildren and friends.

Our population is most vulnerable to the virus here and across the world. We know this. And we are working day and night to be sure the exposure of our residents is limited by advocating for their needs. Thank you for the opportunity.

"Contract" tracing
One of the important tasks that Gov. Gina Raimondo and her team keep stressing at the daily briefings is the importance of developing a daily log of activities so that it can be become a critical component of contact tracing if you, or a member of your family, were to become stricken by the virus.

A similar kind of exercise is required to understand the full extent of financial stresses visited upon the nursing home industry – let’s call it "contract" tracing.

When it comes to the annual state budget, the money spent on “long-term support and services” under Medicaid, roughly two-thirds of the more than $2 billion in Medicaid expenses covered by state and federal funds, remains one of the biggest nuts to pay out.

During the last decade, there have been a number of attempts in Rhode Island to “reform” the way that the state pays for the delivery of services to nursing homes, all coalescing around the wishful thinking that if you can keep aging folks at home longer and out of nursing homes, you can somehow save money.

• Rhody Health Options, an initiative launched in 2013 that transferred the management of dually eligible nursing home residents from the state to a private contractor, Neighborhood Health Plan of Rhode Island, proved to be a dismal failure, with the R.I. General Assembly finally pulling the plug in 2018 after five years and the loss of tens of millions of dollars.

• Under the Reinvention of Medicaid, considered one of the “signature” accomplishments of the Gov. Gina Raimondo’s first term, the fact remains that despite the 2015 law enacted by the R.I. General Assembly mandating the creation of accountable entities, there is no “accountable entity” for managed care of Medicaid patients receiving long-term supports and services, responsible for two-thirds of the state’s annual Medicaid costs.

• Of course, the botched 2016 launch of the Unified Health Infrastructure Project, or UHIP, the problematic software system built by Deloitte, proved to be a debacle for many nursing homes and skilled nursing facilities, resulting in a backlog of eligibility applications for Medicaid. The financial crisis forced the state to make interim payments to nursing homes to keep them out of bankruptcy. Still, four years later, the backlog has not been resolved, with hundreds of eligibility applications still pending longer than 90 days, in apparent contravention of state law.

With Rhody Health Options, with the Reinvention of Medicaid, with UHIP, the health policy wonks had prevailed, with disastrous results. In the wake of the coronavirus pandemic, the business model for nursing homes will have to be re-imagined and re-invented, hopefully with an emphasis on the value of human services, not technological prowess.