As Admission Holds Loom, Skilled Nursing Facilities and Hospitals Must Stay in Constant COVID-19 Contact

The residents and patients at skilled nursing facilities are uniquely imperiled by COVID-19, the disease caused by the novel coronavirus that’s rapidly altering the routines of everyday life worldwide. As a result, SNFs across the country have gone into lockdown, with the federal government on Friday issuing a blanket ban of non-essential visits.

Their hospital partners have also had to adopt drastic measures related to the virus. But the juncture between SNFs and hospitals is a crucial one, and patients still will need to move from one care setting to the other.

During the coronavirus outbreak, which has worked its way across the U.S. in rapid order, that makes following infection control measures essential — and open communication lines between hospitals and SNFs of critical importance, according to Angie Roberson, the president of the American Case Management Association and the director of case management at the Spartanburg Regional Healthcare System in Spartanburg, S.C.

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Case managers help patients move through the entire health care system, guiding them to the next level of care, and Roberson said the role can range from connecting patients who go home to primary care providers to navigating the transfer of a patient with multiple comorbidities to the SNF setting.

She joined Skilled Nursing News’s “Rethink” podcast to talk about what SNFs and hospitals need to do as they work together on the transfer of patients most vulnerable to COVID-19, particularly as nursing homes — as they have in the past amid localized flu outbreaks — may begin suspending admissions of residents amid positive coronavirus cases.

Please note that this interview was recorded on March 10, so some of the advice on screening visitors does not reflect the most up-to-date blanket ban on all non-essential nursing home visits.

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Excerpts of that conversation, edited for length and clarity, are below. And if you like what you read, check out the episode on SoundCloud, iTunes, or Google Play — and subscribe wherever you listen to podcasts.

Can you talk about what you and your members have been seeing at the point of transition to the SNF setting? Is anything different due to the coronavirus outbreak, given how dangerous it is for people with underlying conditions and for older adults?

It’s always our intent to hand off appropriate information to the next provider, and in particular, when we’re referring folks to a SNF, we have our standard information that covers a patient’s medical history, the test and treatments that they’ve had, the tests and treatments that they need to continue. Because we always want that patient to move to a facility who has the ability to provide the need and the treatment that they need for their continuing care — and then to transition them, oftentimes, back on into the community.

So currently, as we’re all dealing with the COVID-19, our nursing facilities are currently responding in a manner to attempt to protect their residents. Locally, our facilities have have implemented some screening for visitors that are coming to visit the residents of the facility.

From a hospital perspective so far, in our region that I actually work, we’ve not had any restrictions on transferring patients to facilities at this point. Obviously, we are continuing to communicate with with facilities that we transfer our patients to most frequently.

And I expect that if I talk to any of my colleagues across the country, that would be the message: that the hospital case management teams are in communication with the SNFs in their community that they’re routinely transitioning folks to, and that you are working together to ensure that we’re identifying the right patients for their facility — as we would always do, but also making sure that on the facility has all the information they need about that patient.

Again, I’ll stress and emphasize that I think it’s going to be on a regional level and a local level for hospitals and facilities to be in communication about what’s going on in that in the particular facilities, and what their response is at that time. I’m currently aware of the facilities screening visitors that are coming in to their buildings, upon recommendations from CMS. But as of today, I’ve not gotten the information locally of any facilities that are having to hold and decline to take new residents at this time.

Clearly, sometimes that happens. We’ve had situations with the flu or other types of infectious diseases that have had outbreaks, where facilities have had to have a period of pause, where they quarantine the building, and they don’t admit new residents for a period of time. And so we’re anticipating that we will see some of that same types of things if necessary.

But my biggest piece of advice is to keep those lines of communication open with the facilities that you do business with most often. Make sure you’re communicating and you’re staying in touch, that each of you knows what the other is working with and dealing with on a daily basis.

Compared with the flu, is there anything different about how hospitals are now handling patient discharges?

No, on the hospital side, many of the same protective mechanisms that we have in place when a person presents to our facility, that initial screening when someone comes in to either an emergency department or a physician’s office, when you walk in at the door, the very first thing is there’s a sign: If you have the symptoms, please put a mask on. And so the very same things, the very same practices are being employed when folks present into the hospital emergency departments or into our primary care locations.

So in many, many ways, some of the practices that we’re employing are very similar to the same types of infection prevention strategies that are used to prevent the spread of the flu from patient to health care worker, with the exception of: We don’t have a vaccine.

We’re not handling a patient any differently; if there was a patient who was a COVID-19 patient, obviously that would be in their medical record, and we clearly would not transition that patient to a SNF during their infectious period, because we would not want to risk the outbreak at another facility. So really and truthfully, basic infection prevention principles and communication about a patient and their history. But that really is routine. So we have not stepped outside our normal assessment and referral processes from that perspective.

As of today, I’m not hearing reports that facilities are asking us any new or different questions either. I would suspect that they are probably scrutinizing when we send a referral; a referral comes with history and physical information. So if I were on the skilled nursing side, I probably would be taking a little closer look to see what was documented there and to ensure that, you know, I’m not bringing folks in that are potential risk.

We all recognize 100% that our skilled nursing facilities are on high alert, and are taking precautions to prevent the spread to their residents due to the high risk on nature of their residents.

So our processes are the same. But again, the communication and the extra thought around the infection prevention piece of it is certainly an item that that I’m sure that facilities are taking a closer look at. And our team, our case managers are ensuring that our referrals are complete and accurate when we’re sending those referrals to those facilities.

Have you heard anything from case managers in areas where there’s an outbreak? Is there anything additional they’d do in such cases?

Obviously, it’s a two-way street between the hospital and the skilled nursing facility. And clearly if a facility has the virus identified in their facility, my experience tells me with flu, that those facilities are going to be in a in a quarantine status, and so they’re not going to be accepting new patients. So that’s going to be off the table. From a transfer perspective, of patients in acute care, any patient in acute care who is presumed to be infectious, obviously there would not be an introduction of that patient into a SNF population.

From a case management perspective, we would be working with our infection prevention staff and those teams of physicians to ensure that our patients are being isolated appropriately in care, the care and treatment that they’re being provided, and that we’re not moving them until they’re no longer a threat to the other community or if they are being moved, they’re being moved in a manner that’s appropriate for them to continue to be isolated.

I’ve talked to a nursing home administrator yesterday, and he was sharing with me that they’ve been given guidance that they should screen visitors, but there’s not a lot of detail behind the guidance. So they’re doing their very best to limit the visitors that are coming into their building. And the ones that do come in they’re screening, to make sure that they’re not potentially exposing those residents unnecessarily or when they could potentially on the risk to those residents.

As a case manager in the hospital, when we’re going to transition somebody to a facility, we can reassure patients and families, that this facility is taking the steps in following infection prevention standards.

Do you have any advice for SNFs in terms of how they deal with hospitals in this situation?

I think we know our practices. I think our skilled nursing facilities know what they do, and they know what they do well. I think it’s important that we’re communicating between hospital and skilled nursing facility, and that we’re keeping each other in the loop and abreast on what’s going on in each of our buildings, that we’re following our standard processes and procedures, and we’re following infection prevention strategies that are in place and that we already know exist.

Then of course, we’re all watching what comes out from CDC and our local departments of health and environmental controls putting information out about our local areas. I think it’s important that we stay abreast and we say knowledgeable about what’s going on, and that we contribute as health care professionals, reminding the public that we should wash our hands, we should stay home when we’re sick. You know, if we followed those things all the time, we would cut down on the spread of infections every day — but certainly, right now those are the things that that we’re all hearing and we’re all being told.

And as far as hospitals and skilled nursing facilities, keep your lines of communication open in your networks and in your regions. Talk to each other, share information back and forth, so that you know what’s going on. The hospital case managers certainly can help prepare patients and their loved one for what to expect when they get to the facility, when we know that the facility has some additional screenings in place right now, things like that.

And we certainly want to know if our facilities are experiencing situations that are going to cause them to to have to go into a quarantine status and not accept patients. We want to know that so that we’re not bombarding them with additional work of reviewing patients, that’s not appropriate — things like that. So I think the open communication is pretty critical for us right now.

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