The NY Times research illustrates what we have known for a few years now. A nursing home’s Care Compare 5-Star rating is both a quality measure and a financial measure. And a nursing home QAPI committee that focuses on their Care Compare rating and implements performance improvement projects based on their ratings has the spillover effect of also improving their bottom line.
In the recent JAGS article- Montoya A, Jenq G, Mills J, et al. Partnering with Local Hospitals and Public Health to Manage COVID-19 Outbreaks in Nursing Homes (J Am Geriatr 2021; 69(1):30-36), a COVID-19 outbreak investigation in Michigan skilled nursing facilities was the spark for a collaboration of interest to our members. Following the outbreak, testing was performed to determine the in-house prevalence of COVID-19. Residents testing positive for the virus were then divided into cohorts in COVID-19-dedicated units. The article shows the importance of investing in stakeholder relationships and open lines of communication. California health systems should anticipate requests for help from SNFs, and should proactively reach out in response. SNF leaders and staff have experience in providing care for medically complicated elders with functional and cognitive support needs. In turn, SNFs would greatly benefit from help provided by local health systems in terms of infectious disease experts, personal protective equipment (PPE), access to testing, and clear communication protocols during transitions to and from nursing homes. In addition, the importance of integrating nursing home data with other healthcare data is emphasized. Examples of best practices to mitigate the impact of COVID-19 on SNF residents, as described in this article, should inspire healthcare stakeholders to create meaningful, mutually beneficial relationships across settings to improve patient care.
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.
January was a record month for the greatest number of COVID Deaths in Sonoma County and 65% of those deaths were in senior congregate living facilities. Meanwhile, a large local continuing care retirement community (CCRC) didn't receive its first vaccinations until January 31. Only 20 of our 176 assisted living facilities even have a date set. Crista Nelson, our head of Senior Advocacy Services, estimated that at this rate most of our residential care facilities wouldn't be vaccinated until July. Fortunately, over the last 2 weeks, a huge collaborative effort between CDPH, Public Health, Local Pharmacies, Local hospital systems, and adjacent county providers, the situation has dramatically improved. By the end this month, most of the residents and healthcare workers who want to be vaccinated will have received at least their first vaccine injection. In addition, the Kaiser Team and a home care agency have been approved for making house calls on homebound persons and their caregivers. Prisoners are also receiving vaccines. This ramping up of the delivery of vaccines wouldn't have been possible without the heroic efforts of our public health department and the trusting relationships that have developed in this community over the course of the pandemic. At a federal level, improving production and delivery of vaccines to the states has been huge. We are now in the position of identifying which facilities need more help with staff vaccine hesitancy. I've attached an excellent presentation on the subject of vaccine hesitancy provided by UCSF's Dr. Bryn Boslett, who was able to comment on the importance of the vaccine in pregnant healthcare workers by her own experience. In Sonoma County, what once looked bleak, is now an example of what an engaged and coordinated healthcare community can achieve.
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.
On October 19, 2020, an article in the Wall Street Journal was written observing that some governors in States with surges of COVID are still insisting that masking in public settings should be a personal decision. This conflicts with the public health guidance of CDC, CDPH, and our Governor, but is still an issue in the public domain in our state where it’s common to observe people in public without a face mask, or wearing the mask under the nose or mouth. This may not only increase the risk of our health care providers (HCP) acquiring COVID, but data are emerging to suggest that those who acquire COVID while not wearing a mask have a greater dose exposure to COVID, and are likely to become sicker.
Each year, more than one in four older adults aged 65 and older will fall. Among older Americans, falls are the number one cause of injuries and death from injury (1). This represents 29 million falls, 3 million emergency department (ED) visits, 800,000 hospitalizations, and 28,000 deaths. As the leading cause of fatal and nonfatal injuries among older adults, falls will continue to soar, as America’s baby boomers grow older (2).
Deprescribing involves a systematic review of medications and identifying those medications with a high potential risk of harm and low benefit to the individual patient when incorporating the goals of care, safety, life expectancy, values, patient preferences, and level of functioning into the decision-making for discontinuing medications.1 According to Scott, et.al., an alternative definition of deprescribing includes: “Deprescribing is not about denying effective treatment to eligible patients. It is a positive, patient-centered intervention with inherent uncertainties, and requires shared decision-making, informed patient consent and close monitoring of effects.”
On September 22, 2020, the California Department of Public Health posted this all-facilities letter (AFL 20-73), available at https://www.cdph.ca.gov/Programs/CHCQ/LCP/Pages/AFL-20-78.aspx. This letter provides guidance to nursing homes about the importance of person-centered advance care planning, including ensuring that current treatment preferences in light of COVID-19 are reflected in up-to-date treatment orders.
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.
On March 9, CALTCM produced our first webinar on COVID-19. On August 31st we produced our 21stwebinar. It truly has taken a village of volunteers. Some of the webinars attracted a thousand-plus attendees. Over 200 people participated in our most recent webinar, which is a remarkable achievement in view of the abundance of information that is available online.
Please click on the link to the ABC news video and report on the letter writing project that these sisters operationalized not only for their loved one, but also for those who need loving through pandemic spawned isolation. Then click on their web site and take action.
My 10 grandchildren are all in “virtual” school for the coming year, but I do remember an advance in responsible parenting, which was applied to the care of the grandkids 10 and under. It’s a technology that has now become standard for most parents, called “baby cams.” This has allowed “never out-of-sight or sound” parenting on a 24/7 basis as long as this device is being used.
Our community is experiencing a surge of COVID in our Senior Living Facilities with the vast majority of cases traced to asymptomatic HCWs, particularly those working in multiple facilities. This problem is further compounded by delays in reporting the results of mandated HCW COVID testing as long as 10 days. Our contact tracing suggests that much of the initial infection of HCWs is occurring in the home setting where there is intergenerational living and multiple relatives living in close proximity. We have traditional sterile hygiene measures expected of HCWs going from one facility to another, but know that transmission risk during intimate care may occur through medical masks, which may be only 45-70% effective in containing the virus, versus 95+% with certified N95 masks that have been fit tested.
What do the above scenarios have in common? Under the new abuse regulations, each one must be reported and investigated as potential abuse, neglect, misappropriation of resident property or mistreatment. And if YOU hear about them, then YOU are a mandated reporter.
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.
One of the frustrating aspects of mitigating the impact of the COVID-19 pandemic on our post-acute and long-term care (PALTC) facilities has been the difficulty that each entity has had procuring adequate PPE to protect their health care workers (HCWs) and residents. As I look at my community, the acute care hospitals have had sufficient PPE to meet their needs for about the last 7 weeks, but not enough PPE to share with our PALTC providers. Our local health department (LHD) has created a real-time inventory of each facility’s PPE and has been working hard to procure sufficient PPE to direct to a facility when there is an outbreak.
