The Covid-19 epidemic has led to an unprecedented shift in patient volumes across settings. Some hospitals have had to operate at well over 100% capacity, while others have experienced rapid declines due to patients avoiding care. But hospitals aren't the only care settings seeing this type of shift: Many post-acute providers have realized similar decreases in volumes due to outbreaks in their facilities and cancelled elective procedures. 

The missing piece of your Covid-19 capacity strategy: Post-acute care

Health systems that own post-acute facilities are in a unique position to leverage those assets to rebalance capacity across the system. Below, we explain how two health systems did just that with their inpatient rehabilitation facilities (IRF).

Strategy 1: Convert underutilized post-acute space into a Covid-19 SNF

Early data on Covid-19 patient needs suggest that many require intensive therapy after discharge from a hospital—often in a skilled nursing facility (SNF). However, because so many SNFs have experienced significant outbreaks in their facilities, most are unable to accept new patients until after they have tested negative for Covid-19 multiple times.

This policy protects current SNF patients and staff from exposure to the virus, but inadvertently results in patients getting held up at the hospital. This not only strains hospital capacity, but also prevents patients from accessing much-needed therapy services.

To solve this problem, Ochsner Health, an 11-hospital system based in New Orleans converted one floor of its inpatient rehabilitation facility (IRF) into a Covid-19 SNF, which was in use from mid-March through mid-May. Ochsner took three steps to repurpose the space in just five days:

1. Identified underutilized space that could be used to fill specific system needs. Ochsner chose to convert the IRF space because it had a low census due to canceled elective surgeries and patients avoiding care for serious illnesses or injuries. Instead of using it for general overflow space, Ochsner chose to use it specifically for Covid-19 patients to meet that need for the health system, and because they already had the expertise to manage SNF-level patients in the facility.
2. Prepared the unit to minimize the risk of infection spread. The first thing Ochsner had to do was clear the floor of IRF patients so they could dedicate the entire unit to Covid-19. They were able to do this by transferring some patients to the other floor of the IRF, and discharging the rest home with additional support. Then, they made physical changes to the unit, such as creating separate space for staff to don and doff PPE.
3. Phased in admissions to give staff time to adjust to new demands. Lastly, Ochsner sourced staff for the unit from recently closed down outpatient clinics and other post-acute settings that had excess staff capacity due to reduced volumes. They capped the unit capacity at 15 patients for the first five days to allow staff time to complete additional training, shadow more advanced staff, and learn how to care for Covid-19 patients.

In just 10 days, the unit was operating at full capacity, allowing Ochsner to clear out an entire med-surg unit at the hospital. By May 13, they were able to convert the unit back to rehabilitation services full-time.

Strategy 2: Convert underutilized post-acute space into a med-surg unit

Even outside of patients requiring SNF care, many hospitals have found that their inpatient surge predictions are so high that their med-surg capacity still isn't big enough. While some systems have turned to non-health care facilities or outpatient clinics to expand capacity in these scenarios, low-volume post-acute facilities already have the space and structure to manage patients who would otherwise be in the hospital.

WellSpan Health's predictive models projected that their flagship hospital, WellSpan York Hospital, would need an additional 120 inpatient beds at the peak of the surge. To create this additional capacity, they converted their combined IRF and surgery center, the WellSpan Surgery and Rehabilitation Hospital (WSRH) into additional med-surg beds. A multidisciplinary team from across the health system convened twice a day for two weeks to plan the transition. The transition followed four steps:

1. Equip and redesign the unit for acute care patients. Wellspan took several measures to prepare the unit for acute patients: they discharged existing patients to an enhanced home health program, converted peri-operative spaces into additional rooms for patients, and designated an isolation area for patients suspected of Covid-19.
2. Designate admission criteria in accordance with legal requirements. WellSpan considered their system’s surge projections, WSRH's current clinical capabilities, and recent regulatory changes when deciding how to use the space. Based on these factors, they decided to reserve the space for non-Covid med-surg patients, and created an extensive list of patient admission criteria for admission staff to reference.
3. Prepare staff to treat new patient types. To ensure WSRH would be able to safely deliver care to their new patient population, WellSpan brought in additional staff from their closed ambulatory surgery centers, and performed a capability assessment for all staff to inform their scheduling and training process.
4. Provide on-demand advanced clinical support. To add an additional layer of support for WSRH staff and patients, WellSpan set up telemetry units so that WSRH patients and staff could consult with York Hospital physicians. They also set up a rapid response team made up of Wellspan anesthesiologists that is responsible for managing patient escalations.

By preparing WSRH to treat med-surg patients, WellSpan was preparing for the worst. Luckily, Pennsylvania was able to flatten its curve with social distancing measures. Because of this, WSRH has not yet had to admit any overflow med-surg patients. However, the hospital remains prepared if the need arises. More importantly, the two-week process forced them to get creative with the way they provided care and interacted with the health system. They plan to keep many of those measures, including the telehealth system, as permanent features at WSRH.

Additional support for acute/post-acute partnership strategy during Covid-19

Over the coming weeks, the Post-Acute Care Collaborative will be publishing more research answering key questions for hospitals about Covid-19 discharge strategy, including how hospitals can discharge more patients to home health, bypassing the need for additional facility-based care.

To read more of our current work on the topic, review:

• 7 lessons on discharge planning during Covid-19 from UW Medicine
• 4 steps nursing homes can take to prepare for COVID-19 positive patients
• The missing piece of your Covid-19 capacity strategy: Post-acute care
• How 5 hospitals are helping nursing homes control Covid-19