Utah Targeted Recommendations in Support of Long-term Care Facilities During the COVID-19 Pandemic (as submitted to Gov. Gary Herbert on 05/18/20)

Authors: Corinna Trujillo Tanner PhD, MSN, RN; Linda S. Edelman PhD, MPhil, RN; Nanci McLeskey DNP, MCG, MDiv, RN-BC, CHPN, FNGNA

The SARS COV 2 virus creates the potential for the perfect storm in Long Term Care facilities (LTC) where groups of vulnerable people live in congregant settings and a highly transmissible virus that can spread asymptomatically between residents and staff caregivers, collide. Atypical presentation of symptoms among LTC residents is common and makes surveillance and identification of new cases of COVID-19 difficult (1-3). A failure to aggressively address these issues now could result in high costs related to COVID-19 treatment and management, and LTC facilities could become a reservoir of SARS COV-2 which could accelerate a second wave of the pandemic. As nurses with clinical, educational and research expertise in gerontology, we are aware of the need for ongoing resources to support LTC facilities at this time, and are extremely concerned about the long term physical, psychological and emotional  impact of the pandemic on LTC residents.

We are advocating for enhanced support for LTC facilities so that they can fully meet the demands of the pandemic, provide person-centered care for all residents and compassionate care for those at end of life (EOL).

 We respectfully submit recommendations in the following areas:

1. Social Isolation, Dignity, and End of Life Care

LTC facilities differ from other health care settings in that complex medical care is provided in a congregant setting that is also the resident’s home. The current physical distancing policies banning visitors affect all LTC residents, with or without COVID-19. This has created an environment in which residents, many of whom have cognitive deficits, can no longer visit their loved ones face to face, and compounds all of the risks and suffering commonly known to be associated with social isolation, including loneliness, grief, anxiety, depression, declining health and mortality. For those in LTC for rehabilitation, a connection with their prior life is often key to their recovery. Addressing social isolation and access to supportive resources is just as critical at the End of Life (EOL). We must act decisively to abate these negative outcomes and human suffering among LTC residents.

Our Recommendations:

All residents:

  • While maintaining restrictions, LTC staff should assist residents, and families with communicating virtually, or at a window, and create individualized care plans that focus on addressing in-person visits and comfort measures.  
  • Provide residents with support and technology to communicate with each other and with family members.

Residents at EOL

  • Hospice team members (nurses, social workers, chaplains) should oversee the care of dying residents.  This essential care will greatly reduce the caregiving demands on LTC staff during the COVID-19 pandemic response.
  • For many LTC residents and especially those at EOL, COVID-19 testing is often not compatible with their goals of care. Once COVID-19 becomes widespread within a LTC facility, these individuals, can choose to receive palliative care, and testing can be delayed until after death.
  • Patients with a terminal prognosis of 6-months or less should continue to be offered a referral to hospice care or receive an individualized plan of care to address EOL symptom management, social and spiritual support and compassionate comfort care. Encourage LTC facilities to follow the recommendations in the attached article for EOL care planning, comfort care and adequate staffing support to deal with respiratory failure and other symptoms and complications at EOL (4) https://www.healthaffairs.org/do/10.1377/hblog20200330.141866/full/
  • Provide individualized comfort care to all residents who choose not to be transferred to the hospital and remain in their facility.
  • When possible, assist in transferring terminally ill and dying residents through a hospice referral to receive care at home

2. Testing

Current Centers for Medicare & Medicaid Services (CMS) guidelines require LTC to report positive COVID-19 cases to the state, Centers for Disease Control (CDC), residents and family (4). The CDC has established four key principles regarding test-based prevention: 1) Testing should be in addition to infection prevention and control measures; 2) Testing should be used when results will lead to infection control and prevention actions; 3) A point-prevalence survey of all residents and health care providers in the facility should be the first step.  Currently, the Utah Department of Health is testing all staff for COVID-19. However, there are delays and significant under-testing of nursing home residents, particularly in rural areas. Some LTC are electing not to engage in widespread testing, leading to underreporting and this has contributed to the undetected spread of the disease in some facilities.

Our Recommendations:

  • Require, and provide, testing kits, PPE, and staff to prioritize comprehensive, widespread and frequent testing of direct care staff and nursing home residents.
  • Provide comprehensive contact tracing of all positive nursing home cases.
  • Prioritize antibody testing for nursing home staff as it becomes available.
  • Prioritize rapid COVID-19 testing for nursing home staff as it becomes available

3. Infection Prevention

Infection prevention is the single most protective measure a facility can provide its residents. A robust infection prevention program is imperative for NH facilities. COVID-19 infection prevention guidelines require that nursing home staff wear masks the entire time they are in the facility and that residents wear masks in the presence of staff. Full PPE including face mask, face shield, gowns and gloves is required for all staff when working with any residents in a LTC facility where COVID-19 is present. Further, full PPE including face mask, face shield, gowns and gloves should be utilized during all invasive procedures including replacement of tracheotomy or nasogastric tubes. Nursing homes continue to struggle to access sufficient PPE, including N95 masks and gowns. State support is needed both in the procurement and distribution of essential supplies.

Our Recommendations:

  • Give the highest priority to nursing homes and assisted living facilities when distributing PPE and supplies.
  • Provide support including Fit testing kits and Fit testing staff to LTC to ensure proper Fit testing of all nursing home employees per OSHA standards.
  • Continue “train the trainer” support for fit testing, donning and doffing of PPE.
  • Establish COVID-19 strike teams, focusing on infection prevention training, especially at facilities that have a history of deficiencies in the area of infection prevention. These facilities should be carefully monitored.
  • Hire a full-time RN infection prevention nurse to work in consultation with Nursing Homes to provide guidance on best policies for specific LTC facilities.
  • Provide vigilant monitoring of staff providing care, including daily temperatures and monitoring of symptoms.

4. Staffing

Minimum state staffing levels are insufficient to provide adequate care for COVID-19 positive LTC residents. Each resident requires extra time for bathing, feeding and social support exceeding usual care standards. Additional staff are needed to meet the psychosocial needs of residents who, due to infection control precautions, are socially isolated, with no family or friend visits, little to no peer interaction, in solitary loneliness, which in itself poses tremendous health risks. Compounding the stress of the need for increased care, LTC facilities are experiencing high levels of absenteeism due to illness. Therefore, additional actions must be taken to support staffing adequacy in nursing homes. State strike force teams should be assembled with the goal of providing immediate support to nursing homes requiring additional staffing as has been done in other states (5).

Our recommendations:

  • Require all nursing homes to meet minimum state mandated staffing levels on a daily basis and ensure minimum staffing levels are adhered to through comprehensive monitoring.
  • Halt admissions to all nursing homes failing to meet minimum state staffing guidelines.
  • Establish a state-wide strike team of nurses, dietitians, advanced practice clinicians (Nurse Practitioners and Physicians Assistants), and other experts ready to support staffing needs of affected facilities.
  • Explore options for families to serve as paid caregivers in home or in collaboration with adult day health or other programs.
  • Continue to Permit individuals who have completed their education as registered nurses to function as staff in LTC while awaiting licensure.

5. Support for LTC Staff

Resources needed to provide COVID-19 care will quickly exhaust the financial means of many long term care providers, as nursing homes who previously were supported by short-term Medicare rehabilitation money will be nearly exclusively dependent on Medicaid funding.

Support for healthcare staff has largely been focused on acute care hospitals. Focus needs to shift to long-term care as nearly half of COVID-19 related deaths in Utah have occurred, and may continue to occur among LTC patients.

Our Recommendations:

  • Provide paid leave for staff who are sick.
  • Provide housing and/or transportation options that enable nursing home staff to self-isolate from family members.
  • Provide school/child-care options for nursing home staff on the front lines.
  • Provide state support for sick leave for 14 days for all nursing home staff.
  • Establish a fund for unexpected expenses related to care of COVID-19 patients including housing costs and other expenses.

6. Support Post-Acute Care Facilities care of COVID-19 patients

Hospitals need to be able to discharge COVID-19 positive adults into long term care institutions. Establishing post-acute care facilities that are able to provide complex care to COVID-19 patients will relieve the burden on Utah hospitals. In short:

  • High quality post-acute care facilities are in desperate need across the state. Nursing homes currently do not have the capacity or training to ensure safe care of these residents. COVID-19 positive hospital discharges to nursing homes will propagate the spread of COVID-19 in nursing homes and put residents and staff at risk.

*acknowledgements: We are grateful for the contributions of Robert Ence, Executive Director of Utah Commission on Aging, Mat Hansen, Executive Director of Homecare and Hospice Association of Utah; Joan Gallegos, Comagine; Amy Hartman, Solstice Hospice and Home Care; Patricia Ravert, Dean, Brigham Young University College of Nursing; Macie Howard, research assistant

References

 1.Kimball, A., Harfield, K. Arons, M. et al. (April 3, 2020). Asymptomatic and Presymtomatic SARS-CoV-2 Infections in Residents of a Long-Term Care Skilled Nursing Facility – King County, Washington, March 2020. Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report, 69(13): 377-379. Retrieved from https://www.cdc.gov/mmwr/volumes/69/wr/mm6913e1.htm?mod=article_inline

2. Keeping Nursing Home Residents and Staff Safe in the Era of COVID-19. (Webinar, April 22, 2020). Sponsored by the National Academies of Sciences, Engineering, and Medicine (NASEM). Terry Fulmer, President of The John A. Hartford Foundation, Moderator. A video of the webinar and webinar’s PowerPoint slides are archived at: https://www.nationalacademies.org/event/04-22-2020/keeping-nursing-home-residents-and-staff-safe-in-the-era-of-covid-19-a-webinar

3. Graham, J. (April 23, 2020). Seniors with Covid-19 Show Unusual Signs, Doctors Say. Kaiser Health News. Retrieved from https://www.cnn.com/2020/04/23/health/seniors-elderly-coronavirus-symptoms-wellness-partner/index.html

4. Lynn, J. (2020) Getting Ahead of COVID-19 Issues: Dying of Respiratory Failure Outside of the Hospital.  Health Affairs Blog. Retrieved from:

https://www.healthaffairs.org/do/10.1377/hblog20200330.141866/full/

5. Testing for Corona Virus (Covid-19) in Nursing Homes (2020) retrieved from:https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-testing.html

6. Strike Teams to Combat Corona Virus Outbreak (2020). Washington Post. Retrieved from:https://www.washingtonpost.com/local/virginia-politics/maryland-forms-strike-teams-to-combat-nursing-home-coronavirus-outbreaks-in/2020/04/07/0792b312-78f5-11ea-a130-df573469f094_story.html).

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