Clinical considerations when the census is low

COVID-19 has negatively affected the ability of many long-term care facilities to maintain a full census. Less frequent elective surgeries, fewer rehab cases and more empty beds make it harder to be selective about which patients are admitted, impacting not just the financial case mix, but also the clinical mix.

A low census leads to the challenge of balancing the urgency of filling the beds with the risks of admitting residents that the team is clinically unable to manage.

During low-census periods over the years, I’ve observed nursing homes more routinely admit residents with increased medical acuity, illnesses unfamiliar to most staff members (for example, multiple sclerosis or HIV), and individuals with mental health and substance abuse problems. Residents admitted during low-census times are often younger than the typical nursing home resident.

Without forethought and planning to provide sufficient care for these new residents, organizations may increase their exposure to liability and regulatory risks.1

Impact on staff

An important consideration in making admissions decisions is whether the team will be able to manage care complexities. Under normal circumstances, workers can adapt relatively easily, especially with additional training regarding new medical needs and procedures. The pandemic, though, has already necessitated that workers make significant changes in how they function.

In a short span of time, teams have had to adapt to the need to work in a very high-risk setting, constantly wear PPE, isolate residents, restrict nonessential visitors, get regular COVID-19 testing and manage with reduced staff due to positive test results and increased worker shortages. Workers in facilities with COVID-19 losses are grieving not only the demise of their former nursing home culture, but also the deaths of residents and perhaps even coworkers.

Facilities should take into account that their teams are likely to have reduced emotional reserves to manage changes in the resident mix without more support and training than usual. They also may need assistance in coping with the psychological aftermath of the coronavirus.

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