Over the last few weeks, the concept of “cohorting” nursing home residents has emerged as a key, but potentially fraught, strategy for blunting the spread of COVID-19.
In theory, the concept makes complete sense: If providers and health officials can separate residents who test positive from those without COVID-19, they can provide safe, uninterrupted care without fear of passing the disease to more people in the institutional setting.
But in practice, cohorting comes with a pile of challenges — chief among them a lack of access to testing and personal protective equipment (PPE). Simply put, nursing homes can’t separate COVID-19 cases they can’t confirm, and they can’t protect their residents and workers without enough masks and gowns.
Massachusetts, for example, was forced to abandon a statewide plan to cohort nursing home residents by emptying out existing facilities after testing revealed a wider number of cases than officials realized; the Bay State has since pivoted to a model that focuses on reopening recently closed SNFs, which present a much lower risk of cross-contamination.
Still, the federal government has waived a host of rules around transfers and discharges in order to facilitate cohorting, and with the right formula and precautions, leaders across the country believe that the plan can work.
One of those leaders is Dr. Emily Downing, a geriatrician and medical director at the Minneapolis-based health system Allina Health.
Allina recently built on its existing partnership with Presbyterian Homes & Services, a St. Paul-based provider of senior living and care, to create a COVID-19 cohort in a 50-bed transitional skilled nursing facility connected to an Allina hospital.
The plan provides benefits to both the hospital and the senior care provider, Downing explained, as the entities look to fight back the COVID-19 tide in the Twin Cities and beyond.
SNN spoke with Downing on Tuesday, April 14 to learn more about the Allina-Presbyterian cohorting plan, and to see if the Minnesota providers had any lessons to share with operators across the country considering similar actions.
Editor’s Note: After this interview was initially published, Presbyterian Homes provided an update on the conversion plan, with a spokesperson indicating that the building was on track to begin receiving residents on April 20. The additional insight is presented throughout this interview in italics.
Walk me through how this partnership came about.
Allina and Presbyterian Homes have been partners for about the last 10 years. We co-own two skilled nursing facilities, that are branded as Interlude, that are both very close to services that Allina offers. One is next to our Mercy Hospital campus, and the other one is in Plymouth, Minn., and connected to one of our major health complexes over there. So we have a long history with them; we also co-own a medical practice that practices in long-term care facilities in a joint-venture structure as well, called Genevive.
So it’s very easy to build on a very strong partnership that we already had with Presbyterian Homes. The idea rose out of the circumstances at hand, dealing with a number of congregate living facility issues around COVID.
One of the needs driving this was really that need — Presbyterian Homes has 37 communities across Minnesota, so a place that Presbyterian Homes could use to cohort COVID-positive patients to reduce exposure to other residents, as well as preserve PPE and provide a safer environment for their employees to care for COVID patients.
On the Allina side, our need is more around having a place for step-down from the hospital for patients who may need rehabilitation, and even higher-acuity rehabilitation. Our Interlude skilled nursing facilities have been rehabilitation sites, but they haven’t been this type of rehab — they’ve been more focused on post-joints, lower-acuity, high-turnover rehab. It really is a shift for our Interlude sites to say: “We’re going to have more higher-acuity respiratory rehab patients, so that our hospitals have a place to discharge COVID patients across the community.”
Skilled nursing facilities are struggling to get ready to accept COVID patients. As many COVID patients as we can not put into a skilled nursing facility — that puts all the rest of the residents at risk — the better. The more we can put them into a place where they can be cohorted, the better for our skilled nursing facility community, and patients, and employees.
That’s the “why” of why we did it, those two use cases: post-hospital discharges, and the ability for Presbyterian Homes to transfer COVID-positive patients from their communities to this facility.
Presbyterian Homes additionally indicated that the partnership was inspired in part by a decline in elective surgeries throughout Minnesota, which in turn lessened demand for post-acute transitional care.
“The health systems took these measures to increase capacity for a likely surge in coronavirus infections which will also mean a greater need for post-acute treatment beds for COVID-19 cases to support acute-care hospitals,” the spokesperson noted. “As a short-term rehab center, Interlude is well positioned and now available to respond to this changing need.”
How do you go about prepping a facility to accept COVID-19 residents? Massachusetts, for instance, halted its plan to convert existing facilities into COVID-specific centers due to problems with testing and concerns about spreading the virus.
We’re doing it floor-by-floor at Interlude. We were able to really segregate the two floors, so that there’s not going to be any staff crossover. We’re going to convert one floor to COVID only. We’re already starting to empty out the second floor, so it would be COVID only as well.
The good thing about these Interlude sites is they only do skilled nursing. They have no long-term care residents, so that makes it really easy — a lot easier to be able to do that. I think that’s fairly unique: We just have a handful in our community that are only skilled nursing facilities, and don’t have long-term care residents, which is one of the reasons we chose this site.
As of April 17, all residents have been transferred out of the facility in anticipation of accepting COVID-19 residents on April 20, with all 50 beds reserved for coronavirus care. Allina and Presbyterian Homes will not admit any general post-acute residents to the facility during its use as a COVID-19 center.
How has access to testing been in the Minnesota market? Persistent shortages of testing kits have been a major roadblock to cohorting in other states.
It’s a challenge, definitely. I think we are challenged in the same way as other states are currently challenged. When we look at the two use cases, we think more are going to come from the hospital discharge than from moving from another long-term care facility.
Our hospital test turnaround time has improved dramatically — our tests are coming back within 24 to 48 hours. From that perspective, we feel we’re able to consistently cohort.
The long-term care ones, the turnaround is slower; the ones coming from congregate living, the turnaround is slower, and there are limited tests for testing every patient that has potential symptoms.
Fortunately in Minnesota, we haven’t had what I would call large facility outbreaks yet; you know, you can argue maybe that’s due to lack of tests, but I think they are doing testing.
How long do you project this cohorting process to take?
We think we’re going to be ready next week. So we’re moving quickly. The key things that we’re doing to prepare: We’re doing changes to the ventilation, to provide better airflow through the facility; adding hand-washing devices and stations; and doing the proper infection prevention training, and getting all the PPE supplies ready.
Has PPE been difficult to acquire?
It’s been a challenge. We have not run out. I would say our situation is not as dire as some other areas that have been broadcast on the news.
I would say while we are challenged, it’s moderately challenged. It’s more to ensure we have enough supplies going forward — and like many other places, we have some reuse policies in place that are safer-use policies. But I think we’re in the moderately challenged category. We don’t anticipate that affecting our ability to start providing care next week, our PPE supplies.
Presbyterian Homes emphasized its PPE preparedness. According to the spokesperson: “We are well equipped to sustain the health and safety of all residents and staff. Opening Interlude Fridley as a place for residents who test positive or present symptoms may go for treatment and recovery adds to our readiness and effectiveness in stopping the spread of the disease.”
Any closing advice for operators considering similar moves?
It’s a big decision to make a change like this. I would just say: Don’t let the unknown hold you back from making a decision, and making a change — and trying.