The COVID-19 Impact on Custodial Admissions

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Original story posted on: April 15, 2020

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The pandemic is driving a shortage of hospital beds.

Patients presenting to hospitals via the emergency department due to an inability to care for themselves (or other’s ability to care for them) is not new. But the COVID-19 pandemic has added a slew of new concerns and obstacles for hospitals across the country.

As discussed in my two other articles about this topic, these patients don’t have medical conditions that require hospitalization. But there is a need for assistance with ambulation, activities of daily living, and perhaps overall supervision and monitoring for safety.

When alternative options can’t be arranged within a few hours, while the patient is in the emergency department, there’s no option other than hospitalization.  This means there is one less bed for a patient who truly requires medical attention. This not only exacerbates the strain on facilities that are already overrun with patients presenting with and being hospitalized for suspected or confirmed COVID-19, but it also poses a more grave threat to those patients hospitalized for custodial care. Hospitals were dangerous places before, but the danger is even greater in the face of such an infectious agent.

The Centers for Medicare & Medicaid Services’ (CMS’s) temporary hold on the three-midnight rule was a terrific development for patients and those planning their discharges. With CMS agreeing to pay for Skilled Nursing Facility (SNF) care without three hospital midnights in inpatient status, it should be much simpler for case management and social work staff to transfer qualified patients out of the hospital. But guidelines from the Centers for Disease Control and Prevention (CDC) on transfer of patients from a hospital to another skilled care facility have complicated matters. Many case managers have found that even if the patient admitted for custodial care is not suspected to have SARS-CoV-2, the virus causing COVID-19, a single report of elevated temperature, intermittent cough, or rhinorrhea can throw a wrench into the works.

The CDC recommends a test-based strategy and a non-test-based strategy for determining when a patient can be transferred to another facility from the hospital. For those health systems that continue to have limited testing capabilities, the non-test-based strategy leads to at least a 72-hour wait time, and possibly as long as one week. That’s 3-7 days a patient admitted for custodial care might remain hospitalized – putting the patient at risk for nosocomial infection, and resulting in fewer beds being available for those who need hospital care.

Previously, I detailed the manner in which patients covered by Medicare Fee-For-Service (FFS), and possibly also managed Medicare plans, can be given an Advanced Beneficiary Notice (ABN) or Hospital-Issued Notice of Non-Coverage (HINN). These CMS forms notify the patient that they will be responsible for the cost of services provided during the custodial admission. But what if an elderly and frail patient’s sole caregiver is sick with COVID-19? What if there are no accepting facilities, due to issues with virus containment? These scenarios might lead your hospital leadership to think twice about using the notices, so I advise you to double-check and make sure.

Juliet B. Ugarte Hopkins, MD, CHCQM-PHYADV

Juliet B. Ugarte Hopkins, MD, CHCQM-PHYADV, practiced as a pediatric hospitalist and now serves as Physician Advisor for Case Management, Hospital Utilization, and Clinical Documentation for ProHealth Care, Inc. in Wisconsin. She is Vice President of the American College of Physician Advisors.

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