One of the most important weapons for fighting the novel coronavirus outbreak in the U.S. is also one of the most glaring gaps in the country’s health system: a lack of rapid, widespread testing for COVID-19.

Nowhere does the testing shortage have as much destructive potential as in the skilled nursing setting, where the virus can run rampant even while undetected — with devastating effects.

In Washington state, a report from the Centers for Disease Control and Prevention (CDC) found that the outbreak at the Life Care Center of Kirkland led to a death toll of 27.2% of residents — as of March, 9 one week after the first positive COVID-19 test at the facility.

The testing shortage has also thrown a wrench into the typical admission procedure for SNFs, as several states have called on SNFs to admit patients suspected or confirmed to have COVID-19. While facilities have been focused on cohorting patients as best they can to comply with new federal guidance, and some states have worked to set up entire SNFs dedicated to taking in COVID-19 patients, the testing problem remains — and simply put, nursing homes can’t fight what they can’t see.

The Centers for Medicare & Medicaid Services (CMS) seemed to have its eye on this problem when it expanded testing coverage, allowing lab companies to receive reimbursements for tests performed at nursing homes or in individual Medicare beneficiaries’ homes.

But as welcome as that may be, it won’t be as simple as lab companies deploying personnel in new ways. The process of collecting samples for laboratory testing from nursing homes has logistical considerations that become especially acute in the age of COVID-1 — considerations that range from the nationwide shortage of personal protective equipment (PPE) to a shortfall of essential testing supplies.

Skilled Nursing News spoke with Christopher Martin, CEO of American Health Associates, to talk about how the clinical lab is obtaining tests from nursing home residents, and what the company is doing to help SNFs combat the rising tide of COVID-19 cases.

The Miramar, Fla.-based American Health Associates has a presence in 22 states with 14 regional labs, servicing more than 3,000 SNFs and more than 1,000 assisted living facilities, among other clients.

This interview, which took place on April 7, reflects the COVID-19 situation at the time. It has been edited for length and clarity.

Can you start by giving me the background of your company, and the typical procedure of collecting lab specimens from nursing home residents?

A good way to think about nursing home labs in general is: We are both a logistics company, and a more traditional clinical lab that you would think of, not unlike a LabCorp or Quest, or one of the big industrial labs.

The component that’s a little bit different for us is the logistics component — not that the large industrial labs don’t do logistics. But what we do is acquire specimens at the bedside. Most of the patients that we serve are actually not mobile. They’re not able to be transported for blood draws and other specimen collection. And so what we do is we actually travel to the facility to acquire those specimens.

That’s what I mean by a logistics company. We have over 1,000 phlebotomists who, every day, travel to facilities in 22 states, and they collect those specimens and then transport them back to a lab to be analyzed. And then we return those results the same day.

That’s a dramatic shift, operationally, from most other clinical labs, or traditional clinical labs that receives specimens — and, I would say, return results over a longer period of time.

A lot of that has changed over the last, let’s say, 10 to 15 years; the typical patient in a nursing home is much sicker today than they were 15, 20, 25 years ago. And a lot of that has to do with the way that hospitals are discharging patients more quickly. The patients today, many are actively rehabilitating from inpatient stays in hospitals.

So we’ve had to — from the nursing home side and as the ancillary service provider — catch those more sick patients, with the result that we’ve almost had to act like mini-hospitals. [While] hospitals have labs within them, a lot of nursing homes, obviously — well, no nursing home that I know of has a lab in it. Because of that turnaround time need, we almost have to function as if when we were in the four walls of that facility. We provide between four and five hour turnaround time on staff — so, effectively, tests ordered outside of the routine window, we can return those results within four or five hours.

That demands a vast logistics network, and acumen in that space around resulting is really important. Every business, I think, organizes its logistics a little bit differently, but I would say it’s similar among most nursing home labs: We have our phlebotomist draw between three and five facilities on their routine route, which sees them go into the facility, draw the patients that have orders for that day, and then the next facility to do the same thing, to the next facilities to do the same thing. Then the phlebotomist foreseeably would either themselves transport those specimens back to a lab, one of our regional testing facilities, or we would have them basically driven by courier.

So how has that procedure had to change in the COVID-19 situation — or perhaps a better question is: How is that procedure changing?

Yeah, that’s a really important qualification. We serve our clients, and so we have spent a lot of time listening to what the clients are being told by CDC, by CMS, by the different agencies, because they really have a lot of guidance coming to them. We’re all kind of looking to understand, and synthesize from those materials, best practices that will keep these patients safe and insulate them from this really terrible virus.

So what does that mean, where the rubber meets the road? What it means is that we are actively sourcing PPE, we are actively working with facilities as they quarantine patients and create special wings within facilities as to who can draw in those facilities and those parts of facilities. There are questionnaires that our phlebotomists fill out each time they visit a facility; there are temperature readings being taken of all of our phlebotomists at all the facilities that they visit.

We’re all doing a lot of that at the facilities, but then our company specifically is spending a lot of time with our team understanding what their insight is, making sure that they understand if they feel unwell, they’re not going to work — so there’s support for that. If they’ve been around a COVID-positive patient, then we need to figure out: When was it? Is the patient truly COVID-positive?

We’re working with the facility to share that information back and forth in an effort to understand, for infection control purposes, tracking COVID-positive patients, and then working with our staff to make sure that they understand who may be COVID-positive.

Staffing has been one of several concerns for SNFs with regard to exposure to the virus; have you run into that issue?

I probably shouldn’t comment on the facilities’ perspective on this, but what we’re doing is on our end — there are certainly employees of ours who have tested positive for COVID. And they are effectively quarantine; several have actually gone to the emergency room. None are actively inside of an intensive care unit. We’re getting very active updates from our human resources department and our different ops managers across the country about that.

What I would say is we’ve not seen a massive outbreak in our employee population in terms of COVID-positive. There are certainly facilities we serve that have COVID-positive patients. But what we’re doing is — to the extent possible — using the PPE that we have. We are sourcing masks. We do have gloves in limited supply, but enough so that many of our people are getting some masks, some gloves, and some face shields. We’re working to basically insource more and more and more of those, just like everybody, and we’re closely monitoring how it is that we can deploy those staff into the facilities.

Has anything changed since the outbreak in terms of who visits which facilities, and how many facilities they visit?

We are not actively reassigning facilities that one, don’t have COVID outbreaks in them, yet, or won’t foreseeably — hopefully ever. But those facilities that do have active COVID patients, we’re trying to basically have the phlebotomist only visit that facility and not others. To the extent possible, we’re working with the facility staff to understand where the outbreak is, and tracking that actively.

To the extent possible, we’re trying to limit exposure for our employees, and then having the employees be in a situation where they would have to travel from one facility with COVID to one facility without it. That’s something we’re very actively saying: No, thanks. Let’s just not do that. We’re really, really trying to understand where COVID is in the system, and actively working with facilities to monitor how to keep it from spreading from one to the other.

A big part of that is PPE because a lot of people around the country are in emergency rooms. They’re in hospitals, working with COVID-positive patients. That’s part of what the health care worker’s real mission is — it’s to effectively help these people that are sick. And to the extent possible, we’re going to try to keep our people from getting sick.

Has that led to any workforce strain for you, maybe in any particular region?

Not yet, so knock on wood. I think as an industry — and I would extend this to the clients as well – we’re all working together to share information about where we see facilities that have positive patients. We’re actively trying to confront that with information. I’m a big believer in the power of data, so I think the more testing we can do — obviously, we play a role in that. But what I would say is, there’s a reason why testing works at scale. There’s a reason why the [World Health Organization] is saying: Test, test, test.

As patients are being discharged from hospitals, with COVID-positive patients in those hospitals and going into nursing facilities, we need to know if those patients are positive themselves. We need to be able to arm clinicians with the insight that they need in order to be responsive. And so the best thing that we’ve seen at scale is to say: If a patient is positive, we need to be able to quarantine them. We need to be able, to the extent possible, to provide PPE to the people that are taking care of those people.

That’s where we’ve looked at this: How do we give clinicians the insight that they need to respond to this? And testing is a big part of that.

On that topic, the shortage of tests is a problem across the country. Have you run into issues related to supplies needed for the tests or taking the tests? If so, what shortages have you run into?

As it stands today, we are actually sending out our COVID testing to LabCorp; it’s a send-out partner of American Health, and it is for several other labs. In that case, really the onus is on the supply of swabs, and everybody across the country is having challenges with sourcing swabs. It’s not unique to us, and we’re really working as hard as we can. That’s been a challenge for sure.

But we are hopeful that we’re going to get more. We’ve heard there are several suppliers — the big ones being Puritan [Medical Products], Thermo Fisher Scientific; Becton, Dickinson and Company, and Copan— foreseeably going to be releasing more swabs into circulation so we can source them.

Have you seen any regional variations in terms of the COVID-19 tests you have to do, and has that led to any issues in terms of turnaround time?

The first part of your question: absolutely. The Northeast has been a very, very intense COVID region in terms of both the number of tests being requested and foreseeably, the number of — we think — positive cases. So this is Delaware, Pennsylvania for the company. We’re starting to get a lot of requests in those facilities for tests.

In terms of turnaround time, it had initially been — a couple of weeks ago with LabCorp — a couple of days. It went up a bit, and now it’s actually hopefully going to come back [down].

Across the country, people are — especially LabCorp — doing a great job of ramping up supply of the testing that they can do, in terms of the throughput. We’re doing the same thing. So we’re going to be bringing COVID testing in-house with several instruments from Thermo Fisher; we’re going to be doing respiratory panels, which is to say, we’ll be doing tests that rule out several of the other different kinds of viruses that indicate similarly to COVID.

What’s the timeline for the in-house testing being ready?

We should, within a limited number of weeks now, be able to do COVID in-house; that’s something that we’ve been working on for a long time.

So what does “a long time” mean when a month ago feels like a year ago?

Yeah, I should probably qualify that. We’ve been working on it for a couple of weeks. It feels like it’s a long time. But we’ve been working on it for a couple of weeks, and we should be live in a couple of weeks.

I think I think that’s a really good point, which is: When it comes to patients’ lives, minutes feel like days, and days feel like years. We’re very, very sensitive to that because we know that the results that we provide often hold a patient’s life in the balance. As a company, we treat every single specimen that we acquire, and every test we run, as if somebody’s life depended on it — because of such a high volume of the tests that we run really do hold life-altering consequences inside of those results.