At Every Stage of COVID-19 Spread, Nursing Homes Face Difficult Cohorting Decisions

At too many nursing facilities across the country, COVID-19 has already swept through the resident population with deadly efficiency.

But others remain untouched by the novel coronavirus, and in some cases, facilities are beginning to discharge former COVID-19 patients back into the community.

No matter where a given facility may be along the COVID-19 trajectory, leaders face incredibly difficult decisions when working to comply with a federal imperative to keep residents who test positive for the virus away from others, in a process known as “cohorting.”

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Widespread lack of test kits and personal protective equipment (PPE) aside, operators must contend with a variety of potential roadblocks, from keeping staffers separate to aging physical plants that cannot easily accommodate the social distance required to stop the spread.

SNN this week spoke with Colleen O’Rourke, vice president of clinical operations at care solutions company naviHealth, to learn some detailed strategies for proper cohorting of post-acute and long-term care residents — regardless of the number of COVID-19 cases in a given facility.

What are the primary considerations for someone exploring a cohorting strategy?

I think the number-one suggestion out there is: Test before you move. I happen to live in the Northeast — I’m from Massachusetts — and a facility not far from us, very early on, looked at doing some cohorting within their own facility to set up a COVID wing.

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Patients can be positive and asymptomatic, and if you’re moving a positive asymptomatic patient, you may be unknowingly spreading the disease from one unit to another. What we’re seeing now is the strong recommendation, rather than to start playing “bed bingo” with the residents, to really make sure that we’re testing before we’re moving, and ensuring that the unit that we’re setting up as COVID-free is truly that.

I spoke to a chief medical officer last week who told me that her facilities routinely receive half of the tests they ask for, forcing leaders to decide who gets tests and who doesn’t. How do operators navigate this process if they don’t even have testing they need?

That’s a tough one. I’m not a physician; I don’t want to over-expand upon my own skill set. I think it absolutely is a medical-director call to make determinations about who to use the testing on when your tests are limited.

To the extent possible, providers may think about moving in shifts as tests become available, so cohorting a portion of a unit and then expanding that as there’s more opportunity to do that testing. That’s probably the best advice that I could give.

Speaking of Massachusetts, officials there have placed some of the blame for the death toll on aging nursing home infrastructure — particularly the proliferation of buildings with non-private rooms. What can operators do if they simply don’t have the room to isolate and quarantine residents?

I think first and foremost, many industry experts have stated that for patients in acute care that are needing some type of a convalescent service, skilled nursing facilities may not be the number-one choice for COVID-positive patients — which is why we’ve seen alternative sites of care develop, commandeering hotels or conference centers.

To keep those hospital patients recovering in a cohorted basis makes better sense than potentially infiltrating a skilled nursing facility, because of the highly social nature that’s there — because of the limited testing, all of the things we’ve already talked about.

But for skilled nursing facilities that organically have developed the disease — whether visitors brought it in before visitor restrictions happened or a caregiver inadvertently brought it in — once you’ve got it sort of growing organically in your facility, the recommendation is really to keep the patients that is diagnosed in an infectious isolation situation, alone in a room.

If that patient has a roommate, and that patient has been exposed, [be] really, really careful about moving that patient — especially into a room with another roommate.

If you’re able to move that exposed patient to their own private room, that makes good sense. But if you’re not, because of capacity issues, et cetera, that’s when we think about PPE, masking the roommate, keeping the curtain drawn, all of those kinds of things that will help keep the patients isolated.

But certainly the recommendation is that if a patient is positive, the best setting for them is alone in a room — and that could be alone in a semi-private or even larger, based on some of the old architecture in the facility.

I do hope the pandemic prompts governments and investors to encourage the development of nursing homes designed with those kinds of infection-control problems in mind — the Massachusetts health secretary noted that regulations requiring single-occupancy rooms have been on the books there since the early 2000s, but there hasn’t been enough new construction to replace the old buildings that were grandfathered in.

Many of them don’t even meet the square-footage standard of today’s requirements. Every time they have a survey, they’re having to submit a waiver.

I think the flip side to that is, pandemic aside, as the baby boomers age into requiring this type of care, there’s going to be a huge demand for private rooms where there hadn’t been before.

When you start to think about more youthful, 70-year-olds, 75-year-olds coming into skilled nursing facilities even for short-term care, their expectations are going to be very different — and likely that will include a private room. So I do think it makes really good sense to think about those modifications now.

I spoke with a post-acute operator last week who talked about how his company’s facilities have actually begun to discharge people who have recovered from COVID-19 back home. Are there any considerations that providers have to navigate when considering this very positive outcome — such as re-infection concerns?

I think that’s a really good question. We don’t know a lot about re-infection. We don’t know a lot about antibodies even being protective at this point.

I think we always need to practice that abundance of caution. I think that how we approach patient care in general, whether it be inpatient or [elsewhere] in health care, our approach is going to be different because of this health care crisis.

I think that when we talk about home care and home care services, the way we deliver home health will be different. The PPE demands, I think, will continue to stay high through this crisis, to make sure that these fragile folks, regardless of where they’re recovering, stay protected and stay safe — even after having the disease.

Is there anything else that providers need to know about cohorting that we haven’t covered?

I know this is difficult from an operator perspective, especially if you’re a provider that has both short-stay beds as well as long-term care beds — which most of the providers out there do. If a provider chooses to become a center of excellence for COVID-19, I think there’s some caution around making that public and announcing that — and rightly so. I think providers may be cautious, because family members and patients on the long-term care side of things would have some areas of concern or worry.

But I do think it’s important that if a provider undertakes the effort to become a center of excellence, that they share that information with their referral sites, they share that information with folks like naviHealth that do care coordination, because we do want to make sure that where we’re placing our patients in the right settings that have the right level of care and service to ensure a stable recovery. I think the transparency requirements by CMS make good sense, so that we have a better understanding of where cases are. I think that that’s only going to help us better take care of these seniors.

We’ve seen a lot of frustration from both family members and operators about the lack of information and planning around cohorting transfers — people sent to different facilities without their relatives knowing, for example, or operators in New York fighting a mandate to take COVID-19 cases when they didn’t think it was safe.

The Department of Public Health statement from New York was pretty controversial when it came out, because we know as operators of skilled nursing facilities, when we say we’ll take a patient, we’re saying we can meet all of the needs of that patient while protecting all of the others, right? That could be incredibly difficult in a mandated situation. So I’m glad I’m not an operator in New York.

On a personal level, I couldn’t figure out the logic behind that order when it came down, and we were covering the announcement for SNN.

I’d like to think that hands weren’t forced. At that time, if you remember when that statement came out, alternative sites of care were still in development. The USNS Comfort was still on its way [to New York Harbor], and ended up arriving like six days early.

I do think there was some mitigation that occurred after that mandate came out that hopefully did not force their hand and take patients they inherently weren’t comfortable with.

This interview has been condensed and edited for clarity.

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