COVID-19 and Long-Term Care: A Troubling Combination

Providers nationwide are seeking to identify ways to mitigate the uncontrolled spread of the virus amid vulnerable populations.

Since the first American case of COVID-19 was reported in January, approximately 80,000 people have died, and one-third of those deaths have been patients living in nursing facilities.

The index facility, LifeCare Center in Kirkland, Wash., served as an ominous warning of the devastating results of uncontrolled infection in this vulnerable population. Several groups in Washington State began to form “drop teams” to assist in the post-acute space. The teams have been deployed in other states as well, most notably Maryland, with varied results.

The primary source for the drop team concept is unclear. Documents from the Washington Department of Health describe similar teams. The University of Washington developed teams that went to at least one facility, and was one of the first entities to report that transmission can occur in asymptomatic individuals. This was featured in a Centers for Disease Control and Prevention (CDC) morbidity and mortality article, and changed how skilled nursing facilities (SNFs) responded to hospital discharges. Our own colleagues from Multicare formed drop teams in the Tacoma area and brought the idea to Spokane; however, the focus was mainly within our Accountable Care Organization (ACO) partner facilities.

Because of the outbreak in Kirkland and Seattle, we watched things unfold in real time as we developed our own plans. Modeling at the time showed a significant strain on our local healthcare system, and senior leadership from our provider organization held daily strategy meetings with clinic leaders. By quickly scaling down clinic operations and transitioning to virtual visits, clinical space was freed up, and dedicated respiratory testing centers formed. Hospital surge planning and labor pools were formed. The group was concerned about several issues involving post-acute care. First, the vulnerability of this population is unmatched. Second, there was fear of introducing infection in the facilities; discharge from the hospital to a SNF was becoming increasingly difficult, and likely to worsen if a surge occurred.

As in any city with multiple healthcare systems, in the event of a surge, disaster incident command would distribute patients to hospitals based on capacity. The problem would be regional, and so the solution needed to fit the scope of the problem. As mentioned above, drop teams had been formed in several communities, with somewhat of a narrow scope. Our drop team plan only involved six facilities in the Spokane region. I and other leaders felt this was inadequate, and the solution needed to fit the scope of the problem. Our goal was to provide medical coverage and assistance to all 16 facilities in the region, and to do this, we needed to engage all of the region’s provider organizations.

The idea was pitched to the Regional Health Department Director, who helped us partner with the State Department of Health. Retrospectively, this partnership made the most difference, and it became clear to us that creating something of this magnitude without their assistance would have been very difficult. Using their backing, we presented the idea to all three provider organizations and obtained project buy-in. We pitched the idea via a large virtual presentation with 30 PAC/LTC facilities and leaders from the three organizations. I can’t say that everyone was excited and on board. We had pushback from number of facilities, but we offered assistance and pressed on. All 16 of the primary SNFs were divided between the three hospital/provider organizations, and each was tasked with reaching out to obtain an inventory of their needs, including PPE supply, staffing issues, beds available, ability to treat COVID-19 patients, and others. This information was loaded into a spreadsheet that was updated daily by case management. Assistance with infection prevention and education was provided to staff at those facilities that requested it. We also began working with medical directors from the facilities, and more so with the regional director for their parent company. A regional task force was developed, and weekly meetings were held with project leaders from each organization and the Department of Health. This was all accomplished before our first COVID-19 case in a nursing facility presented.

Our drop team consisted of an infection preventionist, social worker, and several PCPs rotating on a call schedule. Instead of furloughing, physicians were divided into SNF or hospitalist surge teams. Outpatient leaders assisted with operational planning, resource allocation, and call schedules. Other providers continued virtual visits. We also engaged four PM&R physicians to offer rehab services in SNFs to hasten discharge home and open up beds, although no facilities took us up on this. Like other cities, we were preparing to be overwhelmed, and our goal was to support these facilities in concert with their medical directors. It turned out that a large surge never happened, so we pivoted from disaster management to large-scale prevention. We expanded to cover assisted and independent living homes. This was easy, since regional relationships and personnel were already in place.

We were always mobilized by the Department of Health. By back-tracking infections, we were even able to deploy to facilities that did not have any known infections, but had either infected or exposed employees. Our goal was to stamp out the virus like a brush fire. We have been deployed to a total of seven facilities over 11 separate visits, as some facilities needed second and third visits for ongoing recommendations. The project has been hugely successful, with only six reported deaths attributed to post-acute care and a total of 87 infections in a region of more than half a million people. What is even more impressive is that only 26 positive cases and no deaths were reported, outside of a single facility that had difficulty containing an outbreak. A smaller city in southeastern Washington had comparable total deaths to Spokane, but in contrast, 37 of 50 were residents of LTC facilities, and nearly a third of their total infections were from the same population. We have found that symptomatic staff that continue to work and asymptomatic infected staff are major contributors to outbreaks. In each outbreak situation, staff testing has been critical to source control, and standard screening mechanisms for symptoms has not been adequate.

The difference with this drop team has been the regional approach. In a post-surge planning phase, we continue to utilize the regional task force, and are developing operations for staffing as individuals resume their normal work. Our goal is to continue to provide this service through the summer, and plans will be made for what we expect to be a second surge in the fall. As hospitals resume elective surgeries, we are also finding that each facility has criteria for testing prior to discharge. Often, these do not follow federal or state guidance. The regional task force is also deciding on standardized criteria, which we will again present to all the facilities via conference call, organized and backed by the Department of Health. The goal is that our case managers will not need to keep a spreadsheet of testing or clearance needs prior to discharge. This will be essential in reducing length of stay and maintaining throughput as we resume normal operations.

The pandemic has been a catastrophic tragedy for much of America. Things will likely never be the same. We have found new and efficient ways to provide healthcare, but also laid bare the inefficiencies of a fragmented, competitive, fee-for-service model. My hope is that the partnerships and collaboration we developed in response to COVID- 19 continue to benefit our region in the years to come.

Programming Note: Listen to Dr. Kartchner report this story live during a special 60-minute edition of Monitor Mondays, May 18, 10-11 a.m. EST.