“Now is not the time for additional ‘studies’ to assess the importance of appropriate staffing levels. The combination of inadequate staffing and disparities can only lead to more tragic situations and outcomes, such as those recently seen during the latest hurricane in Louisiana.”  Thus begins CALTCM’s “White Paper on Nursing Home Staffing.”  CALTCM is the medical voice for long term care in California.  Our public policy committee developed this White Paper with the intention of making recommendations based on evidence-based literature.  It was not our intention to debate the financial impact of our recommendations or where nursing staff will come from, given the current huge workforce shortage issues.  We stand for quality care in nursing homes. We absolutely understand many of the issues that have put nursing home care in the precarious state that the COVID-19 pandemic has tragically highlighted. Those issues need to be debated and those problems addressed, but that does not change the existing evidence.  Our White Paper presents the evidence. We’re ready and willing to have a debate over the evidence, though we think it’s more important to have a vigorous discussion on how to finance these recommendations and find the nurses and nursing assistants needed to fulfill these requirements. 

Dr. Dan Osterweil recently received a Lifetime Achievement Award from CALTCM.  During the same week, Governor Newsom signed AB 749, which was authored by Assembly member Adrin Nazarian (D-Van Nuys), Chair of the California State Assembly Aging and Long-Term Care Committee. That these two events occurred together was a poetic coincidence.  For many years Dr. Osterweil has championed the concept of a “medical director utility.” He regularly encouraged many of us to advocate more vociferously for medical directors.  This became the inspiration behind CALTCM’s effort to enhance the role of the nursing home medical director.

ALERT: Requirement for Patient Representative is delayed 12 more months for 1418.8 (Epple) decision-making.

In April, a special article appeared in JAMDA (Journal of the American Medical Directors Association) titled, “Addressing Systemic Racism in Nursing Homes:  A time for Action”.  While this article is copyrighted, it may be worth purchasing if you are not already a subscriber.  Table 1 outlines the Structural/Institutional, Cultural, and Interpersonal manifestations of racism in our facilities.  Figure 2 outlines how these factors have operated at a policy and operational level.  

CALTCM’s Public Policy Committee has been quite busy over the past several months, advocating for our members and the residents we provide care for. We are the proud sponsors of AB 749, a bill that requires nursing home medical directors in California to be certified by the American Board of Post-Acute and Long Term Care Medicine. In the early days of the pandemic, some of us were faced with pressure to admit COVID patients to our facilities. CALTCM members warned that “if you send us five, we’ll send you back 20 within a week.” Sadly, we were prophetically right. Many of us also advocated testing of all staff in order to identify outbreaks early. Because of our training, we knew what to do, and we had varying levels of success in limiting outbreaks at our facilities. Our actions saved lives.

I wanted to start this year with a grateful word of thanks to all of our CALTCM members. Our CALTCM friends and family are leaders in medicine, nursing, administration, pharmacy, social services, ombudsman, and more who believe in quality and safety in post-acute and long-term care.  Your efforts help CALTCM serve as the medical voice of long-term care in California.  Your work through the pandemic has been heroic and the sacrifices have been many.  

When COVID-19 exploded last March, my community went to work attempting to keep COVID out of our facilities.  We developed county-wide virtual learning collaboratives for Assisted Living (AL) communities and for SNFs, which met on a weekly basis.  By the end of June, we had done well with no outbreaks and only 4 deaths in the county.  Unfortunately, last summer’s surge in COVID prevalence shattered the myth that we had done enough to contain it.  Like the rest of our state, we pivoted to follow guidance focused more on infection control and early recognition of outbreaks.  By the end of October, we seemed to be back in the driver’s seat with much better facility COVID metrics.  However, with the winter surge, we are stretched thin on staff, resources, and again wondering when the bad news will end.  In my county, we have now have had 196 deaths, and 70% of them have occurred in senior congregate living facilities.  

Since the SARS CoV-2 virus arrived in the USA last winter, our lives have been disrupted in many ways.  We are currently in a Winter Surge that has locked down most of the state.  The latest statistics on COVID activity show a doubling or tripling of cases in most of California in the month of December, which greatly increases the risk of outbreaks in our post-acute and long-term care settings.  As of 12/10, the USA had 15.6 million confirmed cases and 294,000 deaths.  Though only 6% of the cases have been in post-acute and long-term care (PALTC), including skilled nursing facilities (SNFs) and assisted living communities (AL), our residents have had a hugely disproportionate 34% of the deaths.  As of Friday, December 11, over 100,000 persons with COVID in the USA were hospitalized and 21,000 were in ICU beds. In California, we had 33.500 new cases reported over the preceding day.  

Prior to the pandemic, most of the SNFs in Sonoma County had applied for waivers, because they weren’t able to staff CNAs at the required 2.4 FTE state standard.  I heard one administrator comment that the website “Indeed.com” had become a main source for attracting CNAs from other SNFs.  In our area, we do have a training program for CNAs through partnerships of facilities with the Red Cross and the local community college, but the number of CNAs attracted to this track has been small.  Since the COVID pandemic, our CNA shortage has been aggravated by concern for personal safety, complicated sick leave policies, inconsistent work hours, and the realization that those working in multiple facilities had a much higher risk of transmitting COVID.  

The 9 page (AFL-20-53 ) update should be studied by management in the SNF and hospital setting since it sets expectations for testing during care transitions, dialysis care, and outbreaks.  In addition, it creates a new expectation that all HCP will be tested weekly, even when in surveillance mode.  The guidance allows for routine use of Antigen testing rather than exclusive use of RT-PCR testing.  This should allow facilities to have immediate test results.  The tracking and reporting requirements for testing results in symptomatic and asymptomatic persons are also addressed.  

The Covid-19 pandemic has radically changed how providers deliver health care.  Realizing that in-office and in-facility clinical care risks transmission of SARS-CoV2, CMS has removed all restrictions on the adoption of Telemedicine.  Multiple organizations including CALTCM, AMDA, and AGS (American Geriatric Society) have provided helpful webinars and resources that have helped providers implement Telemedicine in their work flow.  Understandably, seniors have had difficulty embracing this technology.  Medical offices have enhanced their MA’s (Medical Assistant’s) training so they can contact patients prior to the telemedicine visit, to help them with technical issues and to gather pertinent information for that appointment.  

The NEJM Online June 3 edition reported a study from the University of Washington and United Health Group comparing the efficacy of COVID-19 testing in 530 subjects by nasopharyngeal swab vs. patient-collected anterior nasal swab, or mid-turbinate swab, or tongue swab.  This well-done study found similar sensitivity and specificity to that of our gold standard for RT-PCR testing, the  uncomfortable and universally detested nasopharyngeal swab.  An audio interview with Editor-in-Chief, Dr. Eric Rubin, and Deputy Editor, Dr. Lindsey Baden, endorsed these alternative collection sites.  Since that study, the public health departments of San Diego and Contra Costa Counties have approved the anterior nasal site as a collection option for SNF patients and staff.  PPE isn’t required for patient-collected swabs, and adherence to our mandated and recommended testing protocols will likely be better.  

SNFs are now required to report patients under investigation for COVID-19 (PUIs) and actual COVID 19 cases among their residents and HCWs (Health Care Workers).  The report is updated every working day (https://www.cdph.ca.gov/Programs/CID/DCDC/Pages/COVID-19/SNFsCOVID_19.aspx ) and indicates that over 20% of our SNFs have one or more cases associated with their facility.  

The World Health Organization has recognized what experts in geriatrics and long term care medicine have known for over two months.  Unfettered COVID-19 infections are devastating to nursing homes and assisted living facilities.  Reports are finally coming out that more than half of the reported deaths have occurred in senior congregate living settings.  It is quite likely that the number of deaths is still far underreported.  Only when the epidemiologists review all of the deaths across the U.S. and the world during this pandemic will we have the true answer.  The sad truth is that the experts in our field already know the answer.  We’re just waiting for corroboration.

The Wall Street Journal reported on April 11 that over 2100 skilled nursing and assisted living facilities in 37 states had been infected with SARS-COV2 with over 2,000 deaths occurring. In Sonoma County, we have developed 2 workgroups for coordinating, disseminating, and implementing best possible practice ideas.  One workgroup consists of Leadership from Public Health (PHD), skilled nursing facilities (SNFs), Hospitals, and Foundations. The other has leaders from the assisted living (AL), residential care facilities for the elderly (RCFE), and Senior Living Communities.  In the latter group, we were relieved to learn that our county just developed a contract with Sonoma State University to house up to 580 seniors with stable COVID disease so they can be quarantined outside their home facility, reducing the risk of COVID transmission within this high risk population. 

On February 29th, the first case of COVID-19 was announced, occurring in Washington state in the Kirkland nursing home.  Geriatricians around the country immediately knew what this meant. CALTCM went into action and had our first webinar on March 9.  It’s six weeks later and we’d like to give everyone direction. For anyone who has not watched our webinars, we will redirect you to the most important, in the order that they should be watched.  Keep in mind, if you’re already far along the curve, some of this might seem remedial. We can assure you, it’s not.   

Note: This article was prepared by Mr. Horowitz and Dr. Ferrini with special thanks to Dr. Robert Gibson PhD JD, Psychologist, for his input. 

Our country now has the distinction of having the most COVID cases in the world.  Our response as a nation is a stress test that has exposed our lack of a coordinated system of health care in this country.  In my community, there remains a shortage of naso-pharyngeal swabs, a public expectation of easy access to testing (County Public Health Department can do 100-120 tests per day), and many facilities still don’t have real-time access to adequate PPE.  Because of the lack of PPE and nasopharyngeal swabs, testing in some facilities for influenza/RSV/Other viruses is not being done. There appears to be an over-reliance on quarantine of residents with respiratory illness as well as shelter-in-place strategy to keep their facilities COVID-naïve.

Nursing homes are always “putting out fires.”  That excuse is often used to avoid addressing critical issues.  There’s a reason that the federal Requirements of Participation recognize the need to have a person in a nursing home tasked with infection control. That person is designated as the Infection Preventionist, or IP.  Who normally does that job?  It might be an RN or an LVN.  It is often the Director of Staff Development, or DSD.  Infection control is usually one task among many for the person typically designated to be the IP.  How does that work? Is it enough?

At CALTCM, we are very concerned for the welfare of our very vulnerable post-acute and long-term care (PALTC) residents, families, and staff.  Because the world in our lifetime has not experienced such a rapidly moving and serious pandemic, CALTCM presented a Webinar on the COVID-19 coronavirus last Monday which was well attended (over 900 registrants) and is currently available to the public at no charge (for a limited time only) with additional resources on the CALTCM COVID-19 webpage.  Since that time, more important tools and information have become available.  The CDC now has posters and handouts on COVID-19 available on their web page in multiple languages that could be used for staff and visitor education.