An Open Letter to Colleen

Colleen Morley’s piece from Frontline Friday was so appreciated. As I read it, Colleen bravely understated what we as case managers, social workers, and their leadership experience during scenarios that go to an emotional level. Suddenly, we are constantly thinking about things we never thought we’d have to think about.  

Yes, Colleen, it is frustrating to get a patient, any patient, to a Skilled Nursing Facility (SNF) these days, let alone one who is recovering from or dying of COVID-19. The hoops SNFs made we case hospital managers jump through at the beginning of the pandemic are back with a vengeance, this time with a high degree of official backing: testing, retesting, “asymptomatic for (fill in the blank) days,” “waiting for an isolation bed,” “do not have isolation beds so cannot accept,” and so on. 

We cannot interact face to face with patients and families in the same way while the hospital is on visitor lockdown and PPE shortages persist. As if the job weren’t already stressful enough, with shorter lengths of stay meaning less time to put together a complex discharge plan, there are family estrangements that make decision-making laborious, the frail elder with dementia who is unrepresented, the homeless person in need of short-term rehab nobody wants, etc. (any of this sounding familiar?) Waivers aside, patients and families do not understand that we can’t offer the SNF their neighbor Mabel said had the best food, only that one her best friend Harriet said smelled like her late husband after eating a bowl of chili. 

It’s not just that transitioning COVID-19 patients to SNFs and congregated living situations has become hard, it’s why. People have died. Collectively, government agencies and hospitals alike pushed on SNFs to accept patients, supposing they had the ability to segregate and isolate, assuming there was an infection control plan and staff trained in isolation practices. 

I know some of the local nursing home leadership socially. We’ve been out to dinner and shared Christmas gifts. I heard concern bordering on panic when I called them complaining that their admissions staff were refusing to take back a long-term resident, in violation of state mandates. Even having done our best to be empathetic, lending PPE and staff training, there is still in me a nagging, unsettling sensation that too much was asked, too soon, believing too much – and now here we are. 

Looking back, it was all too easy to see. Some managed payors push for transitions to SNFs for patients who are still in an acute phase, fully convinced that a SNF can handle the acuity. By and large, my staff and I have been successful in talking medical directors out of this folly; we know the local resources and what they can handle. Suddenly, because of COVID-19, everything changed? 

All this has shown how poorly we as a community nurture our elders and fund congregate living facilities. We should not nail ourselves to the cross, as if complicit. We were uninformed, and frankly, unnerved. Now, we are not uniformed; we see the years of neglect to the so-called system.

Here in California, like many other states, the SNFs are back on the front lines, soon to be pushed to accept patients again without excuse. They have been given more money and resources with carefully delineated expectations (as if three weeks – seems like 30 – were enough to reinvent an industry).

Colleen, you and your staff are adapting to a new ways of interacting with patients and families, ways that we do not like, but know will be here for a while. You, like many of us, wonder what will happen when all the waivers and suspensions of the usual utilization management (UM) and prior authorization processes expire – but the virus hasn’t. 

We don’t have to wear PPE, but we are on the frontlines. What we all do – provide the best we can for our patients once they leave our facilities, make sure the bills get paid, talk with families about hard things like hospice, and the fact that Mom will never be the same – is hard work, and some of us are lucky enough to do it well.