Response to a chat room thread this morning

Actually, I believe all of us are convinced that the government doesn't know more about this than we do, neither do the trade associations.  Both groups "talk" about caring for older adults in nursing homes and assisted livings.  Both groups "tell" nursing homes and assisted living facilities to "take care of the residents."  That is something called "plausible deniability."  Politicians, government officials and nursing home and assisted living ownership are very good at this.  How many Federal, State, or Local government officials have actually allowed AMDA members "in the room" to advise them on what actions to take during this pandemic?  Very few, is the answer.  Why? Arrogance, ignorance, ego, and money.  It's really that simple, or that complex, depending upon how one wants to look at it.  We're at a point now where we have no choice but to keep speaking the truth to power and use all means possible to share our expertise.  Lest, another wave runs through the facilities where we care for the most vulnerable members of our society.  It's not enough to complain that there isn't PPE or testing.  It's not enough to complain that there aren't enough resources.  We must remind everyone on a daily basis that the efforts being taken aren't sufficient to protect the residents of nursing homes and assisted living facilities.  The fact that there is even one nursing home in the country (and we know that there are a lot more than that) who have countermanded the orders of our clinicians to test residents, is one too many. What are we going to do?  Instead of leaving this response with a question, I'll pose an answer.  We keep fighting tooth and nail to have our voices heard at all levels of government.  We engage families to support our efforts.  We are the experts in geriatrics and long term care medicine.  

The Rodney Dangerfield's of Medicine

Geriatricians are the Rodney Dangerfield's of Medicine. We get no respect!  Throughout my career I've heard the refrain, 'what's special about taking care of old people?'  A lot, in fact.  I've always told my patients, "if you want a doctor who prescribes lots of medications, orders lots of tests, sends you to lots of specialists and puts you in the hospital at the drop of a hat, I'm not your guy!"

Here we are, in a pandemic that is particularly lethal to older adults who live in congregate living such as assisted living and nursing facilities.  Everyone is afraid to go out. People aren't going to the doctor or the emergency room.  Many hospitals are emptier than usual.  But the danger to nursing homes lurks in the background.  Nursing homes are the typical recipients of patients from the hospital.  It's a perfect storm.

The majority of people in the hospital are older COVID19 patients needing a place to go.  There aren't expensive procedures for the hospital to profit from.  The nursing homes are primarily housing frail older adults paid for by the Medicaid program.  The nursing home receives less per day than a stay at the local Marriott.

The reimbursement weaknesses in our health care system are on full display.  How do hospitals and nursing homes make money right now?  What's best for the patients?  There's a conflict.  Nursing homes are struggling to get enough PPE (personal protective equipment) and testing to fight this scourge.  Hospitals have been the supply priority.

Hospitals want to reopen for elective surgeries.  That's how they make money.  That means sending the COVID19 patients back to nursing homes.  The nursing home industry sees that as a way of increasing revenue.   Is it the right thing to do for patients?  As hospitals return to "normal," they'll need the PPE and testing that the nursing homes need so desperately to protect the frail older adults who live there.  As COVID19 patients are returned to nursing homes, the virus threatens to overwhelm facilities that are not fully prepared to care for them, thus putting the lives of the residents at greater risk.

Which brings us to what's happening in California.  The California Hospital Association, in conjunction with the California Association of Health Facilities (representing the nursing homes) and the California Department of Public Health, convened a group to "figure out" how to make this happen.  What's missing?  What could possibly go wrong?  There was no representation from geriatrics and long term care medicine.  We're talking about health care.  We're talking about the lives of frail older adults.  We should be talking about "doing the right thing." We should be focused on delivering quality care to older adults.

Instead, this group is focused on how to reopen hospitals and how to get higher paid patients into nursing homes, regardless of the fact that it might literally kick off another surge of COVID19 in the nursing homes, putting the lives of both residents and staff at greater risk.

A New Day, A New Problem

Try as I may, I can't seem to get away from controversy.  Last night, yet again, I received information that was quite disturbing to me.  At least, on an emotional level, I feel like I handled it better than I have been for the past 7 weeks.  I've been sending the information to others who I trust to verify that I should have concerns.  That's actually what I've tried to do throughout this crisis.  It's an approach that I've always tried to follow.

The approach actually payed off.  I got good feedback from friends and colleagues and was able to determine today's course of action.  I'm literally living in the middle of a Showtime drama with some crazy experiences and stuff that literally would only be found in a television show.  Unfortunately, I'm told by politicians and experts that what I'm finding is pretty normal.  It's sad, the way our government runs.  Under normal circumstances, I guess that we all put up with it.  But this time, we've already lost more people than we did during the Vietnam war, and that number is way underreported.

Let's see what tomorrow brings.

Hospitals and Nursing Homes Working Together

Many hospitals are actually finding themselves relatively empty, no one going to the emergency room no one going to the doctor. This is a geriatricians dream in many ways. However, it's not a dream to have people inappropriately stay away from their doctor and the emergency room.  There's the catch during this pandemic.  Similarly, while we were at the tail end of the flu season, no one is transmitting influenza right now.  That virus was stopped dead in its tracks by the total shutdown of society.

Nursing homes aren't accepting new patients, and those that have been infected will have seen a greater number of their residents die.  At the same time, nursing homes are fulfilling one of my great missions in life, which is deprescribing.  Stopping all unnecessary medications, which in older nursing home residents, happen to be most of the medications that they're on.  Ironically, the might also save lives.  On the other hand, the degree to which social isolation has occurred during this pandemic might also have a negative impact on older adults.

Hospitals are less busy, nursing homes are less full. A perfect storm for hospitals and nursing homes to work together. who would have thought?

Then, an email exchange with a colleague this morning:

Great questions.

1)  Adequate testing is definitely an issue.  At the same time, it’s a catch-22.  If you don’t test, and you don’t know and you don’t have enough PPE, it could be Kirkland again.  On the other hand, you are spot on, how often?  Specificity of testing?  I diverge:) I believe that a pandemic is the time that we need our government to help. Unfortunately, that hasn’t happened, in fact, it’s been almost the opposite.  If the government had engaged and done this right, they’d have payed attention to Italy and Spain and started testing all staff in nursing homes, provided full PPE to all nursing homes (btw, and ALFs), and we’d probably had a bit of a leg up (a bit, I say).  If we don’t have enough testing, what do we do?  Kiss our grandparents goodbye? We can’t even do that:(.  Stellar Infection Control and abundant PPE will only go so far, but is better than neither.

2)  We may have to find a “sweet spot” for testing.  Every week has been suggested? Do we test everyone? A sampling?  What’s the number? To your numbers, if you test 20%, will you find 2? What’s the confidence interval around that? 0-4?  What do you do with the ones you find?  On the other hand, test everyone every week (are there enough tests?), every 2-4 weeks?  

Here’s where the concept of “viral load” (which I am still intrigued by and for which there was a Lancet study in March that supported the concept).  If this concept is true, then we don’t need to test all staff every day, we just need to find that “sweet spot” for testing that keeps the “viral load” in the facility down to a reasonable level. At the very least, there’s a study idea in this concept.

Immunity appears potentially problematic.  Just not enough data at this point in time.  We don’t know about weather.  We don’t know about mutations of the virus.  The CDC should be comparing the genetics of this virus from around the country right now and answering the mutation question.  Who knows what they’re doing?  

3)  Don’t get me started on $$$.  The first stimulus package was a boon for every lobbyist in the country.  The Democrats and the Republicans came to feed at the trough.  Utterly ridiculous.  The unfortunate truth is that if my calculations are correct, when the dust settles, there will be 250,000 fewer older adults in the United States.  They will be amongst the highest cost Medicare beneficiaries.  Most of them will have died without going to a hospital and  utilizing excessive resources.  Many of them will have been Medicaid paid nursing home residents.  It’s real money, though not near the scale of the stimulus.  My personal view is that the government overreacted on this, where they should have been overreacting to “lock down” NHs and ALFs.  I’m a capitalist.  However, we could have just “taken a break” from capitalism for a few months, and we might have been fine.  The fits and starts are going to be so complex.  When the government tells restaurants and movie theaters that they can open, will they? Will anyone go? Will enough people go to make the business worthwhile.  That’s a whole other topic for another day.

4) A good chunk of the nursing home industry is based on its real estate.  The owners of that real estate will ultimately have a decision to make.  Do they stay in the NH business?  Do they convert their property into apartments? Dormitories?  Youth hostels?  Who knows?  

Another Crazy Day

Made contact with Los Angeles County Department of Public Health, which led to a two hour phone call.  Sent outreach letters to every County Department of Public Health in the State, offering support.  Wrote some emails bringing us into the middle of some things we've been left out of.  Took Raishel to her apartment to pick up some stuff.  Where did the day go?

Getting Some Rest

Today was spent resting.  That's my blog.

I Was on The Rachel Maddow Show!

In 2012, I actually taped a video saying that I wanted to be on The Rachel Maddow Show.  Today I was.  A pandemic makes everything happen.

Another Day to Prepare

Tomorrow is an important day.  I'll have my chance to once more pass our recommendations on to the California Department of Public Health. I expect them to reject our proposals.  I'm relieved.  They know not what they're doing.  They're incompetent.  But that's not my fault an it's not my problem.  So, tomorrow is the opportunity to demonstrate that we've done everything that we can.  And now, the California government can "own" its own incompetence.

I realized tonight that I'm actually playing a game of chess.  Our move tomorrow is to offer a solution.  The government, if they accept our proposal, would actually allow us to do something that I believe will work.  That would be idea.  However, the ego and arrogance of the government will prevent that from happening.  They'll demonstrate their incompetence by rejecting our proposal. Most likely they'll say that they're not going to reject it, but that they'll somehow incorporate our ideas into their own.  It's rhetoric, but that's to be expected.

One of my mentors has suggested that we not actually put ourselves in a position to be held responsible for anything. The government doesn't actually want to be held responsible for its actions and would rather blame others.  If we don't accept the premise, then we can't be blamed.  And so I prepare.

Today, I Start Educating, and Stop Fighting

When I resigned my position as CEO of the largest nursing home chain in California on November 6, 2018, the first thought that I had was that I was done fighting. I felt that for a reason.  I don't like fighting.  It doesn't feel good, and it's not healthy.  My wife has been getting more and more worried about me over the past six weeks, as I've felt the need to fight for older adults throughout the country.

I started this blog in the morning.  It was actually after I was quoted on a local news station regarding an issue I've been fighting for.  Ironically, by the time the day was over, we'd won the battle.  But, I was already onto other battles, with the caveat that I'm not planning to do anymore of the fighting.  I'll let others fight for me.  My job is definitely to educate.  Knowledge is the best way to win a battle.

That's why, today, I start educating, and stop fighting.

Today's email

I woke up and had to write this email:

I’ve gotten some really good feedback on my email about testing all staff and I’d like to make some points very clear.

1.  Geriatricians, advance practice nurses, geriatric pharmacists and post acute and long term care physicians around the country care about one thing. To care for and protect older adults.

2.  There has not been readily available testing for the post acute and long term care continuum.

3.  There has not been sufficient PPE available for the post acute and long term care continuum.

4.  Once the virus has gotten into a nursing home or assisted living facility, without adequate PPE, frail and vulnerable older adults will die.

5.  In communities where the virus hasn’t reached a certain prevalence, widespread testing of staff, if available, coupled with sufficient PPE, will save lives.

6.  Everyone is at a different place along the curve, and we can’t allow that to be used against us as we make the case for doing the right thing.

7.  Very few people seem to understand supply chain dynamics during a pandemic, and because of this many older adults will die.

8.  When the epidemiologists unpack this a year or two from now, I believe that the number of older adults who will have succumbed from COVID-19 will exceed 250,000. 

9.  There are still many communities throughout the country where COVID-19 infections are not prevalent enough to “storm the walls” around NHs and ALFs, but that window is closing fast.

10.If we have readily available testing and sufficient PPE, we still need stellar infection prevention, which is why we’ve held to our proposal that every nursing home in the country make sure that their already designated Infection Preventionist is full-time during this crisis.  Every other Infection Prevention resource needs to be sent out to ALFs, which have no one in this capacity.

11. Every organization, from nursing homes to government agencies need to better understand the command structure during a medical emergency.  There MUST be experts in geriatrics and post acute and long term care medicine on every incident command team in the country during the COVID-19 pandemic. There are geriatricians, advance practice nurses, geriatric pharmacists and Certified Medical Directors who stand ready to be part of local, state and federal decision making.  We’ve been the ones predicting everything that’s happened for close to two months now.  The clock is ticking and it’s time the experts were let into the room!

12. There are very few nursing homes, if any, in the country that are truly prepared to be COVID-19 facilities without a true paradigm change in how they operate.  There is considerable thought put behind the Quadruple Aim and White Paper posted on the CALTCM website (https://www.caltcm.org/assets/WHITE%20PAPER%20A%20Plan%20to%20Protect%20Our%20Nursing%20Home%20Residents%20.pdf) (https://www.caltcm.org/assets/CALTCM%20COVID19%20QUADRUPLE%20AIM%20FINAL.pdf).

We stand ready to be part of the effort to protect and save the lives of older adults across the country.

Respectfully,

Mike Wasserman, MD, CMD

President,

California Association of Long Term Care Medicine

Medical Director,

Eisenberg Village

Los Angeles Jewish Home

April 20

Every day blurs together. Some days I blog, other days I'm writing all day, but I don't blog.  I try to remember to write in my blog every day, but time has lost meaning for me during my battle with the government and the nursing home industry.  I know that I wrote a lot yesterday, and sometimes I'll just cut and paste it in. So, that's what I'll do.  Here was my email yesterday morning:

Your timing is perfect.  We are actually urging the Los Angeles County Department of Public Health to do just this.  A couple of weeks ago, a nursing home in Los Angeles had four residents test positive.  We had available testing and tested all staff, and ultimately all of the residents.  As it stands now, 90% of staff tested positive and 75% of residents have tested positive.  At this time, most of the staff and residents are still asymptomatic.  The advantage for the facility was that the knowledge allowed them to go into full PPE and isolation/containment.  There have been three deaths, all of whom were already end-of-life/hospice residents.

The bottom line is that we don’t know what we don’t know.  Many of us have found that once we test, we’re finding asymptomatic positives amongst both staff and residents.  The sooner we find this out, the sooner we can act on it and fully utilize PPE and put residents in isolation.  Thus far, in speaking to a number of clinicians on the front lines, this “might” impact outcomes  We all need data to know the answer to this.

In my opinion, how can we not be promoting full testing of nursing home staff in communities that have the virus?  At the very least, this will give us the opportunity to compare this approach with what has already been transpiring in nursing homes around the country.  This should be the highest priority for both CMS and the CDC. Not providing surveillance in the setting that has produced the highest mortality rates just doesn’t make sense. 

Here are some facts.  Asymptomatic staff can be contagious. Why wouldn’t we want to identify staff who will become the vector for transmission?  What is the downside to widespread testing of staff in nursing homes?

The Quadruple Aim put forth on CALTCMs website on Friday speaks to providing stellar infection prevention, sufficient PPE, readily available testing and that facilities be operating under their emergency preparedness plan.  Until we actually assure that all of these things are happening, how can anyone suggest not doing all of these things?

Mike

Another Op-Ed

Since the first report of the Coronavirus impacting a nursing home in Kirkland, Washington, geriatricians around the country have been concerned. For good reason, as the mortality rate at Kirkland and other subsequent outbreaks has often exceeded 30%, leaving devastation and dead bodies in its wake. The stories from Italy and Spain have already come out, and we will continue to hear such stories from around the world for weeks and months to come. 

Fortunately, the experts in geriatrics and long term care medicine, working on the front lines of this crisis, have been doing what we do best.  We make the complex simple.  We’re used to dealing with highly complex patients in congregate living environments.  Over the course of the last six weeks, a few things have become clear.

First, we don’t know what we don't know.  There are stories of nursing homes and assisted living facility owners and executives resisting efforts to test.  ‘What will we do if we find out that staff or residents are positive?’  The incomprehensible nature of this type of thinking should be clear to any rational human being.  Readily available testing is the key to identifying outbreaks before they get out of hand.  Does it make a difference?  We believe it does. 

Second, sufficient personal protective equipment (PPE) is critical to combatting this disease.  Surgical masks might help asymptomatic people (we still don’t know for sure), but N-95 masks certainly are useful in stemming the spread of the virus in staff and patients who are infectious.  Without sufficient PPE, the fight will be lost. 

Finally, without stellar infection control, the coronavirus can become overwhelming.  Strict attention to hand hygiene, avoiding coming to work if there are any signs or symptoms of infection, and proper use of PPE, is of the utmost priority.

On March 27, 2 residents at Briar Oaks skilled nursing facility had symptoms of cough and fever.  COVID-19 testing was performed on four residents, including two that were in the same room as one of the symptomatic residents.  On April 1, the tests on all four residents were reported to be positive.

Here is where the story becomes particularly important.  As soon as the facility determined that they had COVID-19 positive patients, they immediately went to full PPE for all staff and initiated isolation protocols.  But they did one other thing.  This is critical.  They immediately began testing every staff member in the facility.  While the County of Los Angeles continued to vacillate on providing testing to every nursing home in the County, and while many nursing homes did not initiate complete testing of all staff for various reasons, Briar Oaks tested everyone.  They subsequently tested all of the residents as well.  To date, 70 staff and 77 residents have tested positive.  

Three residents have died, and all three were either nearing the end of life or on hospice subsequent to COVID-19.  Eleven residents have been hospitalized.  

On April 1, the Los Angeles Jewish Home (LAJH) began testing its asymptomatic staff that had possible contact with its first two COVID-19 residents.  We were given 500 kits by the city of Los Angeles.  The mayor’s office asked us to share kits with other organizations.  250 of those kits were given to Briar Oaks on Sunset.  To date, together with Briar Oaks, we have done nearly 500 tests.  The LAJH has contacted dozens of other organizations that would like to join us in this program and test their asymptomatic staff.  We have offered to facilitate this program for the county, but continue to wait for further test kits to implement our plan.

Without readily available testing, Briar Oaks would not have known that most of their staff and residents were positive.  They would have been on a path towards replicating the Kirkland experience, and other facilities that have been in the news.  In fact, they have received kudos from the Los Angeles County Department of Public Health (LACDPH) for their efforts to contain and mitigate the impact of COVID-19.  

What is frustrating to us is that the LACDPH appears to have had the means and wherewithal to provide testing for every nursing home in the County for over two weeks.  Every nursing home should have all of their staff tested immediately.  They must also test all symptomatic residents and any of their roommates.  Not to make this testing readily available puts the lives of more residents and staff at risk.  We have been urging the LACDPH to do this for over two weeks, but have not been given a response.  Symptomatic staff know that they should stay home.  Asymptomatic staff come to work and become the vector of infection to the most vulnerable members of our community.  The mission of the LACDPH is “To protect health, prevent disease and promote health and well-being across the life span through targeted population-based interventions and service operations that improve health and quality of life, and reduce health disparities.”  We look forward to Dr. Ferrer, Director of LACDPH, immediately announcing a specific program to assure that testing is done in every nursing home in the County.  This is an opportunity for the LACDPH to fulfill its mission when it comes to housed older adults.

Dr. Noah Marco is the Chief Medical Officer for the Los Angeles Jewish Home.  Dr. Michael Wasserman is President of the California Association of Long Term Care Medicine.

Letter to the Editor--We'll See What Happens

I am copying Anna Mathews, whom I've been working with for nearly a month.  Feel free to verify that my predictions have been spot on over the past month. I hope that you'll give consideration to my Letter to the Editor.  I'm also sharing the original Op-Ed that I sent in on March 3.  I had another Op-Ed rejected over a week ago that I've subsequently published on Medium (https://medium.com/@jzucker_46471/is-there-a-geriatrician-in-the-room-e5599859e11).  Geriatricians like myself are being shut out because we don't have the clout to get our opinions published, at least so far.  We've been six weeks ahead of everyone else in understanding what was going to happen.  I'd be happy to write another Op-Ed if you're interested.

Michael R. Wasserman, MD, CMD

President, California Association of Long Term Care Medicine

To the Editors:

Gerard Baker ("A Murky Crisis Meets all-too-certain pundits, April 18) need look no further than the Journal to find the lack of "patience, balance and reasoned judgement" he speaks of.  On February 29, with the report from the Kirkland, Washington, nursing home, geriatricians across the country, with clinical judgement honed by years of experience, knew what the coronavirus would do to older adults in congregate living settings such as group homes, assisted living facilities and nursing homes.  

On March 3, I sent an Op-Ed piece to the Journal, titled, "Coronavirus Unmasks Nursing Home Industry Issues." It was rejected.  Within a few weeks, the Journal first reported that some nursing homes were being hit hard by the COVID-19 infection.  Over the past six weeks I've tried sharing our expert predictions through various avenues.  I've written articles and have been quoted in both print and television media.  On March 25, CBS National News interviewed me and I told them that "nursing homes would become our killing fields."  This was aired on March 31.  While some have listened, few seem to have heard the cries of experts in geriatrics and long term care medicine who've dedicated their lives to serving older adults.

It wasn't until last weekend that the reports of further tragedies in nursing homes came to light.  A second Op-Ed detailing the critical need to fully engage and hear the voices of the real experts was rejected by various editorial boards, including the Journal.  The stories have mounted, while reporters write stories of government efforts to protect nursing home residents.  These stories have been factually correct, but comprehensibly wrong.  On April 17, a letter to the editor from the "American Seniors Housing Association" ("Assisted Living: After Option for Older Folks") stated the utterly incomprehensible, that "assisted-living residents are much safer living in our communities than they would be living by themselves..."  

While there are such communities where this is true (I'm associated with one), for the majority of assisted living facilities and nursing homes this is factually incorrect.  It demonstrates both the ignorance and arrogance of a long term care industry driven primarily by the real estate interests that I wrote about in my March 3rd Op-Ed.  

The Coronavirus can be devastating to older adults in congregate living settings.  In order to even begin to protect older adults in these settings, three things are required:  Stellar infection prevention, an abundance of personal protective equipment (PPE), and really available testing.  This knowledge is within the purview of experts in geriatrics and long term care medicine.  We're the ones with the "patience, balanced and reasoned judgement."  It's time that the media, local, state and and federal government officials listen to us.

Michael Wasserman, MD, CMD, is a Board Certified Geriatrician, a Certified Medical Director, and President of the California Association of Long Term Care Medicine.

-----Original Message-----
From: MICHAEL WASSERMAN
To: edit.features
Sent: Tue, Mar 3, 2020 6:25 pm
Subject: Op Ed-Coronavirus Unmasks Nursing Home Industry Issues

The Coronavirus is shining a spotlight on the vulnerability of people living in nursing homes.  I am not only a board certified geriatrician and certified nursing home medical director, but I’ve been the CEO of an organization overseeing the largest nursing home chain in California (I left that position 15 months ago).  As more nursing home residents die from the Coronavirus, the underlying faults in the nursing home industry will become increasingly relevant.  I hope that you give consideration to my Op Ed.

Michael R. Wasserman, MD, CMD

President, California Association of Long Term Care Medicine

Coronavirus Unmasks Nursing Home Industry Issues

The significant death rate in a Washington nursing home is a stark reminder of the vulnerability of nursing home residents.  It also shines a spotlight on two competing forces in the nursing home industry.  The first are the incredible human beings that work on the front lines of nursing homes, certified nursing assistants, who don’t earn a living wage.  What are these remarkable people supposed to do if they’re feeling under the weather?  Do they stay home? Can they afford to remain out of work for two weeks, or longer?  The second force to be reckoned with are the nursing home owners, whose wealth is primarily built on their real estate assets.  I believe that many of them could care less about the lives of the residents or the staff in their facilities.  For them, the real estate is immune to the Coronavirus.  The same can not be said for the remarkable human beings that care for the vulnerable older adults that live in nursing homes.  We will see more residents die because we haven’t addressed the real issues impacting quality care in the nursing home industry.

Nursing homes came into existence because frail older adults needed a place to live.  The industry was founded on real estate concepts.  Whether privately owned, or owned by a REIT, the main financial value of a nursing home is actually its real estate.  The owner of the real estate receives rental income, and has an asset that appreciates.  The asset itself can be used as collateral to borrow additional cash.  That cash can be used to buy more real estate, or  invest in other businesses.  Real estate dynamics, such as rent increases, create financial pressures on the operations of nursing homes.  This pressure pervades the entire industry and severely hampers opportunities to improve the quality of care. Any nursing home administrator will tell you of the pressures they are under to make ends meet.  The substantial value of the real estate should offer opportunities to take this pressure off, rather than increase it.  But most of the owners of the real estate just don’t care.

CNA’s are the heart and soul of nursing homes.  They perform work that few people want to do, for low wages, in a highly regulated and stressful environment.  Many of these caregivers absolutely love their jobs!  They are the most caring and compassionate individuals I have ever met.  In many ways they are the wealthiest people I know.  The currency with which they are wealthy is compassion. The LVN’s and RN’s who provide care, as well as other nursing home staff such as housekeepers, laundry personnel, social services, therapists, and maintenance are also chock full of the currency of compassion.  Nursing homes are filled with people who care.  Those people are to be applauded and cherished.  They need to know that they are appreciated.  My favorite question to ask CNA’s who’ve worked in a home for 30 years was how they sleep at night.  Most of them have told me that they sleep like babies.  I know nursing home owners who have all the financial security in the world who can’t say this.  Unfortunately, while the currency of compassion helps CNA’s sleep at night, it doesn’t put food on their tables or a roof over their heads.  If they are forced to miss over two weeks of work due to the Coronavirus, what will they do?  We need to take a long hard look at the value these incredible individuals provide in one of the most complex working environments around.  We need to reexamine the business model of nursing homes and determine the most effective and fair way to utilize our limited resources.

The Coronavirus is about to put the nursing home industry to the test.  As the frontline nursing home staff develop early symptoms, they will be forced with a difficult decision.  Do they go to work, or do they call in sick?  From a public health perspective, there is no question as to what we need them to do.  Furthermore, from what we know about the incubation period of the virus, they will need to stay home for at least two weeks.  It is highly unlikely that they will have an adequate amount of vacation or sick leave to do this.  What is the nursing home industry prepared to do about that?  There are already huge workforce pressures in the industry that will make finding replacement staff next to impossible.  Staffing is a key element to delivering adequate care in nursing homes.  How will the industry respond to a sudden lack of adequate numbers of frontline staff?

Which brings me back to the impact of real estate on nursing homes.  Real estate owners exert extraordinary financial pressure on nursing facilities.  In large organizations, the real estate holdings are of significant value.  Operational profitability actually pales in comparison to the financial value of leveraging the real estate.  This severely hampers efforts to improve clinical quality.  The real estate owners cry that they have nothing to do with clinical care or operations. Nothing could be further from the truth!  In order to effectively address the issues that are about to become front and center in nursing homes, we must shift the financial focus from real estate to supporting the compassionate caregivers that comprise the heart and soul of the industry.  How about leveraging the real estate to improve the lives of the staff that is needed to provide the care?

As nursing homes confront the Coronavirus, we must recognize and appreciate that the front line staff are our greatest asset.  Most of them truly enjoy their jobs, and they are metaphorically rich in the currency of compassion.  However, we must evaluate the fairness of a system where the Coronavirus will bring these incredible people to financial ruin.  It’s time that we all take a long hard look at the financial priorities of the nursing home industry.  Real estate should not be the financial driver.  Notably, when a nursing home is found to have deficiencies, the operations are penalized financially, but the real estate goes unscathed.  How do we expect nursing homes to solve their operational problems while taking morale deflating punishment and financial penalties?  At the same time, the real estate appreciates, and the leveraged value of the real estate continues to bring relatively “free money” into the pockets of the owners.  As the Federal Reserve lowers interest rates in the wake of the Coronavirus, the leveraged owners of the real estate benefit, while staff are burdened financially and residents die.  What would happen if the owners of the property, or the REIT’s, were held responsible for the quality of care in the facility?  In the spirit of capitalism, perhaps they would have a greater incentive to see effective change occur!  Let’s hope that something good can come out of the Coronavirus outbreak.  This can be our impetus to unmask the real issues behind the challenge of bringing quality care to the nursing home industry.

Michael Wasserman, MD, CMD, is a Board Certified Geriatrician, a Certified Medical Director, and President of the California Association of Long Term Care Medicine.

Working Out, or Not

Six week ago, I was still giving thought to doing another Ironman.  I literally haven't had such thoughts since.  It's even a challenge to get myself to do the requisite pushups and squats that I'd come to both enjoy and value.  For some reason, they just haven't seemed important.  In fact, the only thing that's seemed important to me over the past six weeks is helping others.

It's ironic, but I had been fighting with myself for the past year when it came to this issue.  I've felt a strong need and desire to help others my entire life.  That need and desire has literally consumed me for the past six weeks.  To the point that nothing else matters.  Even working out.  Fortunately, I've been able to do a ton of walking.  I can walk when I'm on the phone, and I've even taken some walks when I'm not on the phone, although that is rare.  I have to be helping others, don't I?

Six weeks should be enough time to focus on everyone but myself.  If I continue down this path, I know that there are unhealthy aspects to it.  In fact, I've begun thinking about life after COVID-19.  All I can visualize is a life of peace and quiet.  I don't want to battle politicians or government bureaucrats.  I don't want to "play the game," or have to figure out something new every day.  I just want peace and quiet.  There was a time, not long ago, that peace and quiet was associated with working out.  Right now, I've lost that.  I need to get it back for a few reasons, not the least of which is my own sanity.  It's also healthy.  It's also something I had come not only to enjoy but to cherish.  My time in Kona, albeit complicated by illness, was an amazing time to just reflect and revel in the appreciation of my own self.

I started today with a set of 20 pushups and 20 squats.  I'll go do another now.  We'll see how the day goes.  Can I push these few minutes of exercise into the front of my brain and make them matter?  We'll see. Working out, or not?

Letter to LA County Department of Public Health

Zach,

I’m reaching out to see what is happening about the multitude of test kits that were supposed to be sent to the LA Jewish Home that were then to be used to test nursing homes throughout the city and county?  The LAJH simplified a complex process and a system was set up.  We have already had initial success in identifying a couple of outbreaks, from the first set of testing kits received, which have allowed those facilities to react accordingly.  The LAJH must receive an adequate number of test kits so that they can assist in carrying out everyone’s collective goal of testing every nursing home in the city and county.  I, and others, have been warning about the rapid escalation of outbreaks for some time.  We need to do this testing in order to respond appropriately.

I’d also like to take this opportunity to reiterate some of the key points that I’ve been making to State and Local officials for the last 5-6 weeks. Like Dr. Marco, I’m tired of getting the run around.  People are dying and the experts in geriatrics and long term care medicine are being “listened” to, but we’re not being “heard.”  We need to be “in the room” going forward, starting today.  Nursing homes can not function as they do traditionally and expect different results.  There are four things that form the base of the pyramid for fighting this scourge.  To make this clear, CALTCM has developed the COVID-19 Long Term Care Quadruple Aim:

1.  Stellar infection control is an absolute requirement.  In order to achieve this, every nursing home must make their already designated Infection Preventionist (IP) full-time. It is beyond difficult for a traditional nursing home to provide stellar infection control without a full-time IP.  We’ve been trying to get the Governor to mandate this for the State, however, there’s no reason that LACDPH can’t mandate it for the County! Once this is done, CALTCM and HSAG (the QIN-QIO for CA) will willingly collaborate to provide ongoing education and training for the IPs in conjunction with state and county efforts.

2.  Abundant personal protective equipment (PPE) is critical in order to battle COVID-19.  We can not depend on facilities to provide this.  This takes the full resources of the government to make sure that every nursing home, assisted living facility and group home has an abundant supply of PPE. There shouldn’t be questions about how to get PPE.  There can’t be delays in assuring that the long term care continuum is completely supplied with this literally life saving equipment.  I have already reached out earlier this week with an opportunity from a trusted and reliable source to bring 10 million units of PPE to the State or County within 10-14 days.  I wish I could pay for it, but at least we can help the County access this important equipment quickly.  I’ve yet to hear back. PPE is essential to put a “moat” around our nursing homes, assisted living facilities and group homes. We can’t wait for it any longer.

3.  Readily available testing is very important to know what you’re dealing with.  All staff in a nursing home must be tested in order to know what the facility is up against.  Residents must be tested if anyone is suspected of having the COVID-19 infection. Hence, our request to let the LAJH do the job it was tasked to do and ready and willing to carry out!  Please do everything in your power to get us the test kits to disseminate!

4.  Finally, every nursing home in the county MUST be operating under an incident command structure.  They all have the emergency preparedness policy and procedure that tells them how to do this, but only a very few are actually operating under this model. We advise that they all watch the webinar that CALTCM had on March 25th (https://vimeo.com/400847523/dcff9a483e)

Also, you MUST immediately stop any plans to designate COVID-19 positive SNFs, and immediately forbid interfacility transfers.  It is time that the experts in Geriatrics and Long Term Care Medicine be consulted before any such decision is made.  The wrong decision in this regard will cost many more lives than necessary. I’m attaching the final version of a White Paper that we've been developing over the last three weeks with experts around the country.  We plan to post it on the CALTCM website later tomorrow, but I feel it’s important enough to share here, so that you can have a full appreciation of the amount of thought and work that has gone into everything that I’ve put into this email.

Finally, I’ll repeat this one more time, Please get the LAJH enough test kits for us to disseminate those kits to every nursing home in the city and county of Los Angeles. Time is of the essence.  We have already wasted enough time.  The window is closing on our opportunity to stem the tide of this virus here in Los Angeles.  We don’t have to be New York and New Jersey.  We don’t have to be Italy and Spain. We are better than that!

Sincerely,

Michael Wasserman, MD, CMD

President

California Association of Long Term Care Medicine

Instead of Blogging, Finalized Draft of White Paper

What Our State Can To Do To Protect Its Nursing Home Population

• COVID-19 has infected one in five nursing homes nationwide.  At least 5000 residents have lost their lives, and many more have been hospitalized.  Infection control efforts have thus far failed to reduce the spread of disease (both between and within senior congregant settings).
• Emerging data suggests that few nursing facilities have the organizational structure, training, resources (staffing, PPE, testing), physical plant, and operational capability to fully fend off COVID-19 infections.
• Key infection prevention strategies (such as cohorting patients, universal masking of patients/staff, focused ventilation, universal testing, and preventing movement of healthcare workers between facilities) are being applied inconsistently and haphazardly.
• Infrastructure and staffing efforts must effectively integrate knowledge and understanding of the nursing home industry.
• We recommend that COVID-19 positive facilities be transitioned to an incident command management structure.  This would combine state, local and facility resources to help support each nursing home with staff, training, PPE, engineering, and real-time expert driven recommendations. 
• COVID-19 Positive Post Acute Care Centers and existing COVID-19 Positive nursing homes can be more effectively overseen by a virtual centralized Support and Guidance Center that disseminates real time expert driven recommendations to the traditional organizational structure.
• Clinical and operational aspects of this proposal are based on incident command principles, allowing the Nursing Home Administrator (NHA) and Director of Nursing (DON) to focus on their leadership abilities, rather than wasting energy and time trying to manage every department in the facility.
• While this approach is aspirational, the principles delineated in this document can be used to guide policy decisions as our state works to mitigate the impact of this virus.

Why Every State Should Take This Approach

Nursing homes have struggled with all types of infection prevention historically, just given the age and health of the population they serve and the close proximity between many of the residents. Sending more COVID-19 positive patients to a facility that has a mix of infected and uninfected patients risks overrunning a facility that is already unprepared and risks increasing morbidity and mortality in that facility and in surrounding hospitals.  The New England Journal of Medicine concluded “proactive steps by …facilities to identify and exclude potentially infected staff and visitors…are needed to prevent the introduction of Covid-19.” Drs. Grabowski and Joynt also have made the case in their recent article in JAMA, “Postacute Care Preparedness for COVID-19. Hence, the concept of COVID-19 Positive Postacute Centers. This same concept is applicable to separate wings in a traditional nursing home. Furthermore, the management principles laid out in this document are also applicable and can be applied to any nursing home faced with the COVID-19 infection.

The idea of moving COVID-19 negative residents out of existing facilities in order to repurpose those facilities into COVID-19 positive facilities has significant drawbacks. First, there is literature on the impact of transfer trauma in nursing home residents. Second, there is the clear risk of introducing the virus during the transfer process. Third, there is no guarantee that the facility that they are moved to will be COVID-19 negative. There are also civil rights issues at play.  These are the “homes” to these residents. Forcibly moving them may have a variety of untoward consequences. Transitions such as these are known to introduce an increased risk of errors and potential harm.

Efforts are already underway to create alternative sites of care for COVID-19 positive patients that require a skilled nursing level of care.  Plans to create the infrastructure and to provide the staffing are moving forward. This proposal helps to effectively integrate knowledge and understanding of the industry that is vital to the successful implementation of these efforts.  It does not add to the work already going on, it just helps to insure that those efforts will not be wasted.

The COVID-19 pandemic is a medical emergency.  This calls for the utilization of an incident command approach in COVID-19 positive facilities. Traditional nursing homes are managed top to bottom by a Nursing Home Administrator (NHA).  This proposal allows the NHA to focus on their leadership abilities, rather than wasting energy and time trying to manage every department in such a facility.  Management of each department will be supported at the state level by an incident command focused structure that provides real-time expert driven direction to the department heads of COVID-19 positive facilities.  

As a simple and easily implementable start to this process, the Boards of the California Association of Long Term Care Medicine (CALTCM) and The Infectious Disease Association of California (IDAC) have resolved that the Governor require that every nursing home in California give their Infection Preventionist (IP) full-time status.  CALTCM and Health Services Advisory Group (HSAG), the Quality Improvement Networks-Quality Improvement Organizations (QIN-QIO) for California, are prepared to provide the ongoing education and training of the IPs in nursing homes throughout the state as an actionable initial step towards implementing this proposal.

The clinical guidance for addressing COVID-19 in nursing homes and the nursing home population has been led by The Society for Post Acute and Long Term Care Medicine (AMDA).  This guidance has been developed by experts on the front lines in real time and is now supported by expert panels created by The California Association of Long Term Care Medicine (CALTCM), and convened by Health Services Advisory Group (HSAG) that is prepared to disseminate information throughout the state.  This expertise will be shared with Medical Directors and Directors of Nursing.  

COVID-19 demands a well-reasoned, evidence-based approach to creating and supporting COVID-19 Positive Postacute Care Centers and separate COVID-19 Positive wings.  The resources and guidance provided by a centralized virtual support and guidance center can be utilized to stem the tide of the COVID-19 infection in all nursing homes throughout the state. This involves real-time dissemination of best practices through an incident command driven model developed specifically to stop the spread of this deadly pandemic and to limit the morbidity and mortality in the most vulnerable members of our population.

Details on How To Accomplish This Goal from a Virtual Support and Guidance Incident Command Center

Pandemics wait for no one.  Not for individuals, not for governments, not for elected officials, and certainly not for nursing homes.  Emergency situations, whether they be earthquakes, hurricanes or the COVID19 pandemic requires an Incident Command response.  Nursing homes themselves must be operating under their emergency preparedness policies and procedures, which dictate an incident command response.  The challenge is that COVID19 has never been seen before.  This places a strain on every nursing home and the systems historically set up to regulate and monitor them.  Addressing this challenge is at the core of the ICOS response.  ICOS stands for Infrastructure Clinical, Operations and Staffing.  It can quickly be put together virtually at the state level.  Its purpose is to bring real time expert support and guidance to every nursing home in the state, including COVID19 Positive Post Acute Care Centers.  It is described below.

INFRASTRUCTURE

During natural disasters, entities such as FEMA, the Army Corp of Engineers, Army Medical Corps and Regulatory bodies would coordinate the building, retrofitting, and supplying of temporary housing or health facilities for those who need it.  During this pandemic, no structures have fallen, but there is clearly a need to house COVID-19 positive older adults.  The problem is that the agencies that are ready and prepared to act on this do not have a full understanding of what is required to create skilled nursing facilities.  It is essential that these bodies effectively interact with skilled nursing facility physical plant and maintenance experts in order to create a standard template and to effectively coordinate the repurposing and creation of COVID19 positive facilities or wings.

Modeling algorithms are being created to determine the number of stand alone facilities needed to meet the expected demand.  In the meantime, there is clearly a need to create and repurpose existing space as nursing homes literally become de facto COVID19 Positive facilities.  However, we should absolutely NOT consider facilities with significant COVID19 outbreaks to take on the role of becoming COVID-19 Positive Post Acute Care Centers, unless there are clear and scientifically based guidelines to assess the readiness of such facilities.   Sending patients to facilities that are unprepared and do not meet basic “readiness” criteria does not make sense.  The available literature and experiences suggests that policy decisions that do not effectively take “readiness” into account will not mitigate morbidity and mortality, and might actually exacerbate the loss of life.

It can not be overstated that an abundance of  PPE and other supplies and equipment are critical to a skilled nursing facility’s ability to defend against the COVID19 infection.  We also need to engage the use of technology that allows for the delivery of clinical care and finding ways to increase socialization while minimizing transmission of the virus

CLINICAL

The Clinical component of the ICOS proposal recognizes that the COVID19 infection brings with it little in the way of evidence-based research and experience.  It is thus necessary to use real time clinical experience and incorporate a modified Delphi process in order to develop an approach to care. It’s not enough to have Delphi based guidelines, however.  In order to delive true person-centered care during this pandemic means that we must also contextualize the decision making process. Our solution to this challenge is to develop expert multidisciplinary teams working with AMDA, CALTCM and other organizations.  These expert panels incorporate  feedback from clinicians in the field who are dealing with COVID-19 outbreaks.  A normal modified delphi process might take several months.  In a pandemic, that time frame must be reduced to weeks, days and sometimes hours, based on the information that becomes available. 

This type of process is already guiding decision making in the field around the country, it just has not been formalized.  There is a clear opportunity to develop guidance in real-time for medical COVID19 Positive Care.  These expert supported clinical recommendations can be developed in real time for Directors of Nursing and Medical Directors.  An example of a recommendation that has come out of this process is the need for bluetooth-enabled pulse oximetry to reduce viral transmission while monitoring COVID19 positive residents who might need acute hospitalization.

As expert clinical recommendations are developed, they will be delivered back to the COVID19 Positive Postacute Care Centers and all skilled nursing homes throughout the state utilizing the QIN-QIO to assist in the dissemination of this information.  Weekly webinars can continue to be utilized, such as the ones already developed by CALTCM.

OPERATIONS

The typical nursing home runs from the top down with a nursing home administrator (NHA) in charge.  The training of NHAs can not have prepared them for the COVID19 pandemic.  It is critical that nursing homes immediately shift into their emergency preparedness policies and procedures, which means that facilities must immediately being functioning in an incident command mode.  The idea of a “morning stand up” meeting where the NHA meets with all of the department heads no longer works.  Unfortunately, because this is a medical crisis,  the NHA and DON are ill prepared for the management decision making that are essential to effectively run a nursing home.  

In a pandemic, each department in a NH needs up to date actionable information that will not be effectively shared through the traditional chain of command structure and function.  Hence, the concept of  operational multidisciplinary teams led by experts in a virtual Support and Guidance Center that provides daily management guidance to each department in a COVID19 Positive Post Acute Care Canter.  This Center can also readily provide education and training to every nursing home in the state that is grappling with this infection.

The virtual Support and Guidance Center is set up by department, following a traditional NH organizational chart.  The departments represented are as follows: 

Incident Commander: NHA

Incident Management Team: NHA, DON, Medical Director, Infection Preventionist (IP)

Staffing

Education and Training

Physical Plant/Maintenance

Housekeeping

Dietary

Central Supply-logistics

CNA’s

Licensed Nurses

Pharmacy

Rehabilitation

Social Services & Activities

Admin/Business Office/Finance

Planning function

.

Each Department in the virtual Support and Guidance Center would develop actionable recommendations through a similar modified Delphi expert approach taken by the clinical leadership already discussed.  They would then feed this information daily back to COVID19 Positive Postacute Care Centers directly to facility department heads. This information would also be shared regularly and integrated with individual facility incident command teams on a working in conjunction with the QIN-QIO in a fashion similar to that already outlined.

It is critical to reiterate that a pandemic of the nature of COVID19 necessitates the development of incident command approaches that shift facility staff from “drinking information from a firehose,” to getting them information that they can ingest through a straw.  This approach is actually not very complicated.  Once it is set up at the state level, the daily dissemination of information will flow rather simply and easily, as well the response to questions and the need for feedback from individual facilities.  Many of the questions and concerns will be similar, so this simplifies processes that have been developed that looked more to one on one interactions.  There are just not enough people to achieve that level of support and guidance, nor is it a logical approach to developing a scalable solution to overseeing not only the COVID19 Positive Post Acute Care Centers, but the opportunity to provide expert based best practices on a daily basis to the department heads of every nursing home in the state of California.

STAFFING

A lot of people are out of work in the industries that have applicability to the nursing home workforce, e.g., housekeeping from hotels, dietary from restaurants, activities from leisure and entertainment. We also need to find and engage RNs and LVNs. It should be possible, and is probably already happening, that the state is able to engage entities such as the National Guard and Army Medical Corps. We also need more Certified Nursing Assistants (CNAs), as they are the backbone of nursing homes.  The main requirement for CNAs is that they are caring human beings.  There appear to be models occurring throughout the country that provide for on-the-job training, and these programs just need to be expanded.  Licensing regulations need to be streamlined to allow for on-the-job training, but again, this appear to be happening already. There is a clear opportunity to utilize existing education and training approaches, waiving all fees, though they may need to quickly adjust to more rapid training.  Finally, it is critical that all of these training programs fully integrate education specific to the needs of frail older adults, in particular those with cognitive dysfunction.