Sidney Greenberger runs a New Jersey-based company that operates eight nursing homes in Pennsylvania and six in New Jersey.

His buildings are filled with those most likely to die if infected with the coronavirus — the elderly and those with lots of chronic health problems. He finds the prospect “terrifying” and says the virus could make nursing homes a “death trap” for his residents.

“I’m scared s—less, and that’s the honest truth," he said.

Greenberger has plenty of company among those whose job is to protect frail seniors and disabled people who live in facilities. As the coronavirus surge builds, their fears have the potential to create logjams in hospitals that rely on nursing homes and rehab centers to take patients who are no longer sick enough to require hospital care but are not yet ready to go home.

Ashley Ritter, an expert on nursing home care at Penn Nursing, said that she has heard that some nursing homes are refusing to accept any patients, regardless of their diagnosis, from hospitals unless they’ve tested negative for the coronavirus. Yet as the need for hospital beds becomes more urgent, test kits are still scarce. Nursing homes have restricted visitors and are screening employees for symptoms, but patients who arrive from hospitals could also bring the virus inside.

“You inject risk for both the workforce and the residents who live in facilities,” Ritter said.

Ashley Ritter is a post-doctoral fellow studying healthy services at Penn Nursing. She studies post-acute care services such as nursing homes and home care.
Courtesy of Ashley Ritter
Ashley Ritter is a post-doctoral fellow studying healthy services at Penn Nursing. She studies post-acute care services such as nursing homes and home care.

The vulnerability of nursing home patients was made clear when the virus caused dozens of deaths in nursing homes in Washington state. It already has been found in nursing homes in this area. Laurel Brook Rehabilitation & Healthcare Center, a nursing home in Mount Laurel, reported Wednesday that three of its patients had died of the disease. Renaissance Healthcare & Rehabilitation Center in Philadelphia said on Thursday that one of its patients, a 73-year-old woman, had died.

David Grabowski, a professor in the department of health care policy at Harvard Medical School, said most nursing homes now only want patients they know are COVID-19 free. He thinks all new patients bound for nursing homes should test negative first. But, he said, even if nursing homes were willing to take patients who could be infectious, the country is not ready for what he’s calling the “second surge” — the wave of COVID-19 patients who are well enough to leave space-strapped hospitals but are not virus-free. “Most nursing homes don’t have the capacity to do that safely,” he said.

Grabowski, who wrote about the issue this week in the Journal of the American Medical Association, expects growing tension between hospitals and nursing homes. He said states need to retrofit dormitories and hotels to serve as nursing-home-like facilities.

He and Ritter agreed that most nursing homes are not designed to isolate infectious patients. “Most do not have a negative pressure room,” Ritter said. “Some will have the option to geographically isolate. Fewer will have staffing to dedicate to completely separate care teams."

Sidney Greenberger is CEO of AristaCare Health Services, which operates 14 nursing homes in Pennsylvania and New Jersey.
Courtesy of Sidney Greenberger
Sidney Greenberger is CEO of AristaCare Health Services, which operates 14 nursing homes in Pennsylvania and New Jersey.

Greenberger, who is not requiring testing for new patients who have not had COVID-19 and have no symptoms, knows that he may be asked to help hospitals as the number of COVID-19 patients explodes. “We see a problem with the number of hospital beds that are around, and we know that we’re going to be called upon to lighten some of the load,” he said. He may be able to create 15- to 20-bed wings for coronavirus patients in some homes, but hopes he doesn’t have to.

For now, he, like Genesis HealthCare, is not accepting patients who test positive and is insisting that any new admissions who have had the disease test negative for two days in a row.

Several area health systems did not respond to questions about discharge planning. One that did, Main Line Health, said it was not having trouble finding nursing homes for patients leaving the hospital but knows it may need to “adjust our discharge strategy.” Damien Woods, a spokesperson for Einstein Healthcare Network, said some nursing homes require negative tests for people who have had COVID-19 symptoms, leading to “manageable” delays while awaiting test results.

Officials at hospital associations in New Jersey and Pennsylvania said they were not aware of significant problems in discharging patients to nursing homes.

The American Health Care Association, which represents nursing homes and other senior facilities, released guidance to its members recommending that hospitalized patients who test positive for the coronavirus should be sent only to nursing homes that already are managing residents with the disease.

While people can spread the coronavirus before they have symptoms, the Centers for Disease Control and Prevention has told nursing homes they can safely accept patients who have no symptoms and who do not seem to have been exposed. The American Health Care Association concurs.

Greenberger said his homes keep such patients under close watch. In areas like Montgomery County, where the virus is circulating, new patients are sequestered from other residents for two weeks.

The Society for Post-Acute and Long-term Care Medicine recently issued a resolution saying that nursing homes should not be forced to accept patients who might still be infectious. It called for specialized centers of excellence to care for coronavirus patients who have left the hospital and suggested creating alternative care settings.

The organization, which represents medical professionals who work in long-term-care settings, on Thursday criticized a New York State Department of Health advisory on hospital discharges that told nursing homes they must accept “medically stable” COVID-19 patients leaving hospitals and are not allowed to require testing. In a statement, the group said that rule could have "dire, indeed fatal, consequences” for frail individuals in the nursing homes and could lead to more hospital admissions.

David A. Nace, clinical chief of geriatrics at the University of Pittsburgh and president-elect of the society, doesn’t think that all incoming nursing home patients, including those with no symptoms or history, need to be tested for the coronavirus. “That’s just not reasonable or possible or scientifically sound,” he said. “We don’t have enough tests to do that.”

He said placing patients has required more negotiation than usual recently. “We’ve managed to get everybody accepted so far,” he said. “I have to say it is taking days of work sometimes to get that done.”