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.  

CALTCM has been advocating for a strategy involving State-led PPE procurement as part of our Quadruple Aim for combating the COVID-19 pandemic. 

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.