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Nursing Homes Anxiously Look Toward the Future With the End of PHE

Analysis  |  By Jasmyne Ray  
   May 31, 2023

Nursing homes were the most heavily affected sector of healthcare during the pandemic, relying on many of the PHE waivers and flexibilities to sustain operations.

When the public health emergency (PHE) declaration for the COVID-19 pandemic ended May 11, along with it went flexibilities and waivers on which many providers had come to rely.

For skilled nursing facilities in particular, the end of the PHE means the expiration of the three-day waiver, which waived the three-day inpatient hospital stay requirement prior to a Medicare-covered, post-hospital, extended care service.

Due to lack of staff at the acute setting, potential residents will now be subject to shorter hospital stays and risk being discharged before they're ready or truly well enough to leave, according to Allison Salopeck, president and CEO of northeastern Ohio's Jennings Center for Older Adults.

"The fact that they [implemented the wavier] was because the hospitals needed to make sure that they had room for other, particularly COVID-positive, patients," she explained. "And so, they recognized that if they made that three-day waiver go away, they would reduce the pressure on the hospitals and have those folks continue their care needs in skilled nursing."

While hospitals no longer have an overabundance of COVID-positive patients, they—much like skilled nursing facilities—are under pressure from not having enough staff to keep all their beds open, Salopeck said.

In the days after the PHE expiration, aging service providers like Jennings Center are attempting to transition operations back to normal. The greatest concern, Salopeck said, has been Medicaid enrollment and reauthorization.

"Everybody gets redetermined at the same time," she explained. "But as that rolls through, I am concerned about people's care potentially being interrupted by something that may have happened during the course of that time with their eligibility."

The center took advantage of the flexibilities for telemedicine, using iPads for residents’ remote psychological treatment when face-to-face appointments weren't feasible due to social distancing requirements.

"We know that particularly people who have dementia do much better face to face as opposed to the strangeness of looking at a screen," Salopeck said. "Otherwise, it has been extremely helpful, I think, especially around mental health."

One waiver the Jennings Center didn't take advantage of was the use of temporary nurse aides, which allowed nursing assistants to work prior to certification and have those hours apply to their training. The waiver was a point of contention for some facilities, regarding the use of untrained aides to work with vulnerable residents.

Skilled nursing facilities were the most negatively affected sector of healthcare over the duration of the pandemic, because of media scrutiny, high numbers of resident deaths, and the highest loss of employees. Now, with low reimbursement rates not covering the full cost of care, which means nursing homes are unable to offer wages to compete with larger providers, they are struggling to rebolster their workforce.

Providers and advocates alike have begun championing nursing homes and their workers, calling for providers to reevaluate the reimbursement model so that facilities will be able to offer wages that will attract workers.

Recently, Salopeck met with state legislators in Ohio to discuss the issue as they begin developing the state's budget.

"They've heard the pressures, they know that this is about taking care of Ohio's elders," she said. "I think if they ignore that, we're going to be in a lot of trouble."

"There's not a lot of adjustment other than closing down [facilities] and unfortunately, in some cases, entire communities, that we can do."

“There's not a lot of adjustment other than closing down [facilities] and unfortunately, in some cases, entire communities, that we can do.”

Jasmyne Ray is the contributing editor for revenue cycle at HealthLeaders. 


Medicaid enrollment and reauthorization are the greatest areas of concern for skilled nursing facilities now that the PHE has ended.

Now providers and workers are advocating for legislative change, like reevaluating reimbursement rates, to help rebolster the skilled nursing workforce.

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