June 25, 2020

Supporting Skilled Nursing Facilities During COVID-19

Skilled nursing facilities (SNFs), often called nursing homes, are residential facilities that provide on-site medical and 24-hour nursing care. People who are cared for at SNFs are usually unable to care for themselves at home because of physical or cognitive reasons—for conditions like advanced frailty, dementia or Parkinson’s syndrome. Others are there for short term, rehabilitation stays following a hospitalization for things like pneumonia or recovery from a surgery or a stroke. As hospitals have become more expensive, SNFs are relied heavily on as an auxiliary extension of the hospital. Although there is one SNF owned and operated by our system, Mass General Brigham works closely with a number of unaffiliated SNFs in the community through our Skilled Nursing Collaborative.

During the COVID-19 crisis, SNFs have played an important role in caring for patients who do not need intensive care, but are still too sick to care for themselves at home. This could either be patients with less severe symptoms, or patients recovering from long hospital stays in need of continued care and rehabilitation.

“The COVID-19 pandemic hit SNFs extraordinarily hard; yet, never was their value and heroic contribution more showcased and appreciated than during our pandemic response that required unprecedented levels of deep cross-organizational collaboration,” says Chuck Pu, MD, Medical Director of Care Continuum Programs for Population Health as well as one of the co-leads for the Care Continuum/Post-Acute Incident Command Teams at Mass General Brigham.

Streamlining Patient Movement

Since inpatient hospital beds have become a limited resource during the COVID-19 crisis, it has been critical to get beds for lower-acuity patients with the appropriate level of care. Under normal conditions, this idea of routing patients who are less sick to Skilled Nursing Facilities falls under a philosophy called the “Care Continuum.” The idea is that patients should get the right level of care of the right time. There are many logistical tools that help accomplish this task, but the SNF three-day waiver is one of the most useful. The waiver allows Mass General Brigham to forgo the requirement that a patient must stay three days in the hospital before the Centers for Medicare and Medicaid (CMS) will cover the cost of a Skilled Nursing Facility stay.

During the emergency declaration, the Care Continuum team was able to replace the normal SNF three-day waiver with a temporary emergency waiver called 1135. This allows hospitals and SNFs more flexibility to re-route patients from the hospital to skilled nursing facilities to free up beds for sicker patients while still being eligible for CMS payments. The 1135 emergency waiver has been an important resource for moving patients to the right level of care more quickly.

The Care Continuum team has also leveraged data, such as an internally developed referral tool called 4next, to create several reports detailing patients’ COVID-19 status at SNFs. These reports help our teams understand patient outflow issues. This gives our teams the ability to identify problems to fix—for example, a patient stuck at an acute facility because of limited discharge options—and to find ways to mitigate these problems for future patients.


Another major effort to support skilled nursing facilities in our communities has centered around the sharing of PPE resources. While all clinical facilities have struggled with obtaining proper PPE, skilled nursing facilities have been hit particularly hard by the shortages. Mass General Brigham has been working with the central donations team to help source appropriate PPE items for both skilled nursing facilities and hospices across the state. The Population Health Care Continuum team has helped to keep track of urgent needs from SNFs in the community to try to match requests with donations received whenever possible. Team members have also taken on sorting through boxes, liaising with the SNFs for pick up, and overcoming logistical challenges. As a system, we’ve given out over well over 60,000 PPE items to over 41 SNF and hospices.

Partners Educational Resources

Mass General Brigham has shared many educational resources with our SNF colleagues, including training videos. The MGH disparities website has been used to provide educational resources to SNFs in multiple languages about a range of topics including handwashing and doffing / donning. Through a “PPE train the trainer” session developed by MGH and Spaulding Cambridge, our system was able to offer 10 SNFs a remote learning educational session run by an MGH Complex Care Nurse Practitioner. SNFs were able to watch our videos, practice donning and doffing, and ask questions while we were able to offer some best practices along the way.


Groups from Population Health and HR have been working with SNFs to help source agency personnel to help fill staffing gaps. SNFs have been heavily reliant on agency staffing throughout the COVID-19 crisis. Central teams at Mass General Brigham were able to take some of the burden off SNFs by helping to source staff and take on administrative tasks like reviewing resumes. To tap into a larger labor pool, our system was also able to provide applicants from alternate agencies that our SNFs don’t usually work with. In just a few months, about 25 agency staff members have been placed. The SNFs supported by this staffing effort include Alliance at Rosewood, Hunt Rehab, CareOne Peabody, CareOne Brookline, Chetwynde, and Advinia Wilmington.

SNF Trauma and Bereavement

Working with Partners EAP, we were able to extend some EAP resources to colleagues working within our SNF Collaborative. Additionally, we have created dedicated SNF virtual support groups to help process the grief and stressful clinical situations related to COVID-19 care. These virtual groups are run by MGH clinicians specifically for our SNF colleagues.

This list of activities is by no means exhaustive. The depth and breadth of Mass General Brigham SNF support during the COVID-19-19 outbreak extends far beyond administrative support—from sharing meal donations for frontline workers with our SNF colleagues, to offering 1:1 infection control guidance from our MGB leadership, as well as helping to implement telehealth solutions. Although the Skilled Nursing Facilities in our communities may not necessarily be owned by our network, they are a vital part of the healthcare ecosystem that helps support our patients.

If you’re interested in learning more about our SNF collaborative network,  read this article for a deeper dive (note: written pre-COVID-19).


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