A fierce advocate for the senior care industry and its residents and employees, Frank Romano is tackling challenges facing the post-acute care environment to the best of his ability. As a combat veteran looking to start his own business after serving in Vietnam, Frank Romano opened his first skilled nursing facility in 1972 in Tewksbury, Mass. Since then, as President of the Essex Group Management Group, he has expanded into a full range of senior care services, including assisted living, adult day health programs, home care, senior transportation, and more.
As the industry bears the brunt of the pandemic, Romano is a beacon of dedication and “can-do” spirit, with many ideas of how post-acute care facilities can continue to offer services to older adults in the future. Key to the future will be having the ability and resources to attract and retain employees and residents by assuring safe conditions and low risk of infection through hand hygiene compliance, testing, contact tracing, effective quarantines, and other quality processes. The Vitalacy Blog spoke to him about the challenges facing post-acute care facilities in the wake of COVID-19.
What are the biggest challenges facing post-acute care facilities right now?
Mr. Romano: I spend probably 75 percent of my time looking at staffing issues, ways to recruit, ways to retain the workforce, and that has been the biggest single challenge. We can't raise our rates to pay higher wages other than in assisted living because that's private pay. When you're dealing with Medicare and Medicaid, you rely on a fixed state and federal government reimbursement for your labor costs.
Another problem we will face is how do we convince the elderly to come back to assisted living, skilled nursing homes, and adult day health? With the national news every morning, every evening, so inundated with the virus and how it affects older people, I'm concerned that many providers won't have the financial resources to survive the next 24 months. I hope it doesn't happen, but I think it will happen. Occupancy has dropped in skilled nursing from, in our case, the lower 90 percent down to 75 percent. In Massachusetts, I believe that close to one-third of all (post-acute care) capacity will close during this next two-year period, hopefully none of ours. There's going to have to be a lot of debt restructuring as we're starting to see in the airlines and other industries. That's been because of the coronavirus and the deaths that we've experienced.
Let's go back to January and February when the news of what was going on in China and then later Italy first broke. Did you see this coming? What were your concerns and what was your mentality during the prelude to the outbreak in America?
Mr. Romano: We were very concerned watching what happened in China. Watching people laying on the street in Wuhan, looking at that young doctor dying. I think at least our people, my clinical people, my medical directors felt that it was just a matter of time before it got to the United States. But we never thought there would be a shortage of ventilators. Never thought there would be a shortage of PPE (personal protective equipment). We misjudged by believing that the national stockpile was sufficient to get us through.
But we were getting prepared for the virus in our buildings. Because of the mandated adult day health (ADH) program closures due to the pandemic, we decided we would use the ADH program space to develop COVID units before it hit us real hard. We were able to get approved for six COVID units using our ADH space in our various buildings to be able to admit people from the community, as well as to admit residents from our buildings who became ill, temporarily relocating them to a COVID unit separate from the general area where our residents live.
The state wanted to stand up two COVID buildings in New Bedford using former nursing homes that had been closed for well over a year. With the city of New Bedford and the local hospital, we prepared to open two of these as all-COVID skilled nursing facilities. One has opened, accepting admissions from a variety of sources spanning the Commonwealth, from Beverly and Lowell, to the Cape and as far west as Worcester. Two days prior to opening the second, the state decided there was not a need for the second one, so it's right now being mothballed to stand ready should something change this fall.
What have you done to improve testing in your facilities?
Mr. Romano: We have participated in a unique program that only six skilled nursing homes in Massachusetts are involved in. It's with the Broad Institute of MIT and Harvard. They test all residents and staff in our buildings every single week. They are also doing serology (antibody testing) now in our buildings. One of the buildings had an outbreak before they started, but since they started doing this weekly testing, it has put the staff at ease. It almost was like giving them a sedative. Now, one of the buildings has no COVID. It's a 135-bed building with no COVID, and it's clearly been because of the testing. We get the results in 24 hours.
Testing is key, and ideally it should be done daily. I have ordered six testing machines for my facilities. Even with weekly testing and daily temperature checks, one of my facilities that had zero positive COVID-19 staff and residents suddenly now has several positive because we had an asymptomatic nurse.
Nursing homes have to be made a priority for testing. If we had that system in place when this first broke in Washington, I believe, after 48 years of this business, we would have saved half the deaths in skilled nursing.
What is your policy when an employee tests positive for COVID-19?
Mr. Romano: We pay to have them stay home for two weeks. They get full pay. We thought that was important for people who needed a paycheck. One employee showed no symptoms, and she called me because she got tested at the end and she is positive. And totally asymptomatic. No fever. No coughing. No aches. No headache. And if you're not testing, I don't see how you catch them (asymptomatic residents and employees).
What other things have changed within the environment of care in your facilities? Mr. Romano: One of the biggest things that I've observed is the emotional impact of the residents with so many people passing away at once. Obviously, we're used to people passing away in a nursing home; in a 120-bed building, we could on average have as many as two to three a month. But when you have five or six a week passing away in your building or at the hospital you sent them to, and family members not being able to be with them at end of life, our staff becomes their immediate family. Even though they're dressed in gowns and gloves and masks, providing that emotional support clearly has had a big impact on our staff.
I think getting used to the PPE, getting used to have to gown, ungown and regown, and having to make sure we have gowning rooms and degowning rooms have become an extra burden to our staff. Hospitals have that in the OR (operating room) and the ER (emergency room), but nursing homes have never had that. Now we can’t feed residents in the dining room; we have to feed them in their rooms. We have to do activities in their rooms. No common communal activities or dining.
We have a very limited amount of public events at our facilities. Prior to the pandemic, we would host events such as community bingo, which was packed every week because we provided lunch and snacks. We cannot allow people to come in and spend time with their families or meet with friends that live in our nursing homes.
You mentioned earlier that you're advocating to the state legislature and the federal government to give higher priority on getting testing equipment to nursing homes. What other key messages do you think are important to get out there? Mr. Romano: The CNAs (certified nursing assistants) who do the bulk of the work in nursing homes do not make a living wage. Most of them are just above minimum wage. To survive, they have to have two jobs. Many of them will have three. They'll work two jobs during the week, and they'll work another job on the weekend. They became the pied pipers of the disease (COVID-19), unknowingly spreading it from one building to the next. Many were asymptomatic or the symptoms did not manifest themselves yet.
It's the same with nurses. Nurses who are working for staffing agencies work in multiple buildings. I would estimate that 80 percent of all COVID-19 infections in nursing homes came through staff members who were exposed on the outside.
In my opinion, this is where the spread came. The state and federal government is going to have to realize that this is the beginning of the epidemics. We're going to see more of them, and if that's the case, then we need to also think about a living wage for our housekeepers and laundry and kitchen workers so they don't have to work in multiple nursing homes to make a living.
In addition to providing a living wage, how else can healthcare organizations assist caregivers?
Mr. Romano: We are in the process of building housing for our staff, apartments for them in safe neighborhoods. Other colleagues of mine are doing the same thing. They're buying houses, retrofitting them, and providing subsidized housing for the staff. Also, we became self-insured because I got tired of the 15-percent increases every year. Our biggest single cost is labor, and it's 75 percent of our operating cost. Now that we’re self-insured, we give all of our non-smokers at 30 percent discount. We can pay people to get better. How do you mean? If you get a yearly physical, we give you $50. Our women employees receive $50 to get a mammogram. In Massachusetts, half the women do not get them. With medications, if you have a generic, we have no copay because we want you to get your meds. It's going to cost us a lot more to have you get sick and go to the ER. Under our plan, if you go to the ER, you've got to come up with $250. However, if you go to a community health center first, you have only a $20 deductible. We’re educating our staff about their options, such as the increased expense of going to the ER for non-emergencies when you can go to a community health center first.
In that way, you drive people to begin to think about how much their health care choices cost. When the state average premium increase in Massachusetts was 10 to 12 percent, we had no increase in premiums at all. We're getting people to think about their health, and we're pushing people to be nonsmokers. We're telling people to get their yearly physicals. Get your mammogram. Get taken care of. Do not wait. It's a slow process and I'll tell you the best thing I think we ever did was go self-insured because we rolled up our sleeves and we got involved in health care like we never did before.