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.
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