Associations Request Supplies, Data and Inclusion for Hospital Discharges to LTC to Succeed

Associations Request Supplies, Data and Inclusion for Hospital Discharges to LTC to Succeed

Vice Admiral Raquel C. Bono

Office of the Governor

RE: Hospital Discharges and Admissions to Nursing Homes During the COVID-19 Emergency

Dear Vice Admiral Bono:

LeadingAge Washington, Washington Health Care Association, Adult Family Home Council, and Washington State Hospital Association collectively represent nearly the entire acute care, post-acute, and long term care licensed settings in the state.  This includes hospitals, skilled nursing centers, assisted living communities, and adult family homes.  We, the undersigned, are writing to share with you our written concerns, recommendations regarding hospital to long term care discharge, and proposed next steps to advance and improve our state’s response to the COVID-19 pandemic.

As we discussed last week, the state must take an active role to address COVID-19 management in long term care facilities. This requires increased testing capacity, increased access to PPE for long term care facilities (including those without confirmed COVID-19 positive patients), and better data collection.

Specific Requests

  • Add a Long-Term Care Representative(s) to VADM Bono’s Team: We request the addition of an individual with long term care knowledge and expertise to participate with Vice Admiral Bono on a daily basis. This individual or individuals would raise awareness of ongoing long term care challenges and inconsistent guidance from various agencies, and work to identify practical solutions.
  • Prioritize PPE for Long Term Care Facilities: Work together to get the necessary PPE to nursing homes, assisted living, and adult family homes so they can accept hospital discharges. This includes PPE to facilities that do not have a confirmed COVID-19 positive patient.
  • Prioritize Testing for Long Term Care Facilities: Make testing a priority among nursing homes, assisted living, and adult family home staff and residents. Because COVID-19 disproportionally impacts the elderly with an increasing mortality rate by age, asymptomatic and pre-symptomatic staff and others may be spreading this deadly virus among residents. Long term care facilities need testing to properly identify cases, and then implement proper infection control procedures. Anything that can be done to prioritize tests for long term care residents, staff, and independent contractors will save lives.
  • Coordinate Data Collection: This is critically important and lacking; where it does exist, it is fragmented and inconsistent.  We all need a better understanding of long term care centers’, particularly skilled nursing facilities’, ability to accept and properly care for those residents who are either COVID-19 positive or COVID-19 negative, and those whose status is undetermined. Absent this information, our ability to cohort different populations is hampered. We must have centrally collected data to identify:
    • Where COVID-19 cases exist by each long term care setting;
    • Numbers of residents and staff in each setting that have either positive or suspected COVID-19 cases;
    • Number of COVID-19 related deaths and number of hospitalizations in or from each setting;
    • PPE inventory and projected PPE needs;
    • Location and number of beds available in dedicated wings, floors, or units of long term care facilities; and
    • Number of beds and location of any stand-alone COVID-19 facilities.

Request for State Leadership on Alignment with Recommended Discharge Guidelines

In addition to the federal guidance on screening patients through testing, we request the state’s leadership in taking the steps necessary to establish the following criteria to guide discharge decisions, which is in accordance with recent CMS and CDC guidance and reports. However, most of these options are not going to be possible without increased access to testing, PPE, staffing, and data.

  • Designated alternative care sites for long term care for COVID-19 positive/symptomatic patients: For hospital patients with COVID-19 positive tests or who are symptomatic, who are ready to be discharged from the hospital, the state needs to establish alternate care sites dedicated to caring for COVID-19 positive and symptomatic patients. These could be temporary facilities until the person has recovered and can move to long term care.
  • Create specialized capacity within long term care for COVID positive/symptomatic patients: If an alternate care site is not available, the next option should be admission of COVID-19 positive or symptomatic patients to a nursing home, assisted living, or adult family home with: a) a separate wing, unit, or floor; and b) enough staff to keep dedicated caregivers in the designated wing, unit, or floor. The facility must also have enough PPE to manage COVID-19 positive residents.
  • Cohorting for COVID positive/symptomatic patients: If a separate wing, unit or floor for COVID-19 positive or symptomatic residents is not available, the next step should be admission to a nursing home, assisted living, or adult family home with single occupancy rooms or the ability to cohort in rooms with similar residents, whether for COVID-19 positive or symptomatic residents. Again, these facilities must have adequate staff and PPE to manage COVID-19 positive residents.
  • Untested patients treated in the same manner as COVID positive/symptomatic patients: When there is a lack of testing available, hospital patients who are asymptomatic with an unknown COVID-19 status must be assumed COVID-19 positive and the above steps applied.
  • Hospital patients with a known COVID-19 negative test result can be admitted to a nursing home, assisted living, or adult family home, but it should assume COVID-19 positive and treat placement of such patients in an alternate care site dedicated to quarantining patients with an unknown COVID-19 status. Efforts should be made to cohort them in rooms or wings/units/floors with similar residents. They should also be monitored, have no contact with other residents, and have limited contact with staff that interact with other residents.


The incidence of COVID-19 infection in long term care facilities continues to grow and the mortality rate for elderly residents in the long term care setting is unacceptably high. Once COVID-19 gets into a long term care facility, it spreads quickly and can have a devastating impact upon the resident population. A number of national articles this weekend have helped raise the profile of this issue. Links to two of those articles are here and here.

We are keenly aware of the role long term care plays in the health care continuum. We are also cognizant of the fact that a smooth transition of patients from hospitals to nursing homes is critical at this time.  No one wants a scenario where hospital beds and ventilators are unavailable for patients in need. Patients who need post-acute care should not be stuck in acute care hospitals. Discharging hospital patients who are well enough to be cared for elsewhere is a top priority. 

On March 30, 2020, the American Health Care Association advised long term care providers that unless a person is tested for COVID-19 and was determined negative before admitting them to the long term care setting, the long term care provider should assume the person has COVID-19.

On April 2, 2020, the federal government released guidance stating that patients and residents who enter facilities should be screened for COVID-19 through testing, if available. This was supported by recent data from the Centers for Disease Control and Prevention (CDC) that found just over half of all elderly people who tested positive for COVID-19 showed no symptoms[1] and that 6-12% of new cases are due to spread from asymptotic individuals who are infectious for at least three days before developing symptoms[2]. The CDC found that nursing home residents who tested positive were likely spreading the virus to others for up to seven days before they developed symptoms. This supports a “test before discharge” approach in hospitals, which academics also support[3]. However, lack of testing and delays in getting test results make testing all patients before discharge unlikely. We need a more workable approach.

As you aware, we need more testing capacity in our health care system. Our system does not have enough tests available to test every patient discharging to long term care. Therefore, we are told that in the absence of available testing the only solution is to transfer the patient from the hospital to the nursing home or alternative setting without a test. In these situations, the resident is presumed COVID-19 positive, and placed in isolation for 14 days with droplet precautions in place.

While we could support this approach on an interim basis (pending the ability to perform more testing), not every skilled nursing facility or alternative site has enough PPE to safely accommodate a 14-day isolation period for every patient coming out of the hospital. The lack of PPE is a particularly serious issue for facilities that currently do not have residents diagnosed with COVID-19 since, absent an active case of COVID-19, the facility is not accorded any degree of priority for receiving PPE. Yet, they are asked to accept patients from the hospital who may or may not be infected. This needs fixing.

We appreciate your consideration of our recommendations, including next steps, as we look to support you in your efforts to improve our state’s health care system readiness and response to the COVID-19 pandemic.

If you have any questions, please do not hesitate to contact us. Letter


Deb Murphy, MPA, JD, Chief Executive Officer

LeadingAge Washington


Robin Dale, JD, Chief Executive Officer

Washington Health Care Association

John Ficker, Executive Director

Adult Family Home Council

Cassie Sauer, President and Chief Executive Officer

Washington State Hospital Association

[1] CDC Morbidity and Mortality Weekly Report: Asymptomatic and Presymptomatic SARS-CoV-2 Infections in Residents of a Long-Term Care Skilled Nursing Facility – King County, Washington, March 2020

[2] CDC Morbidity and Mortality Weekly Report: Presymptomatic Transmission of SARS-CoV-2 – Singapore, January 23 – March 16, 2020

[3] Journal of the American Medical Association (JAMA): Postacute Care Preparedness for COVIV-19 – Thinking Ahead, David C. Grabowski, PhD; Karen E. Joynt Maddox, MD, MPH (March 25, 2020)


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