Lessons from Nursing Homes in COVID Hotspots: Secure a Lab Now — and Proceed Carefully on Visitation

With the U.S. taking steps toward reopening — at varying paces in varying states –— skilled nursing leaders from the East Coast COVID-19 hotspots of New York, New Jersey and Connecticut had several pieces of advice for their counterparts elsewhere, which all ultimately boiled down to one warning.

Be prepared.

That includes taking steps to make sure there’s laboratory capacity on hand for testing. That means reaching out to peers in other facilities for tips and best practices. And that means being very careful about reopening for visitation, according to several experts from some of the worst geographical COVID-19 hotspots in the U.S.

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“As a clinician, it makes me nervous,” Karl Dauphinais, medical director of complex care management at the health services firm Optum and the medical director of Autumn Lake Health Care in New Britain, Conn., said on a Skilled Nursing News webinar held Tuesday when asked about visitation.

The question was specifically about having families designate a specific person who’s cleared to go visit a SNF resident with proper PPE; it’s a proposal that has been floated by some resident advocates, but Dauphinais had questions about this designated visitor being able to come and go at will.

There are mitigating steps a facility can take when it comes to staff, in terms of screening and travel restrictions; employment can be contingent on following certain parameters around infection control, he explained.

It’s much more difficult to do that with a family member, who has no such tie to the SNF and who is leaving the SNF to interact with the wider world on their own terms, Dauphinais said.

“It does create a bit of a risk, if it’s completely uncontrolled,” he said. “It would have to be still screened, still monitored. It would certainly control a little better the total number [of people] coming and going, so I certainly like that part from an exposure standpoint, but it’s hard to say where that would be able to be adequately controlled.”

The question of how COVID-19 plays out in the community is another point of consideration for many SNFs — specifically if there’s a second surge of infections, according to Jon Dolan, the CEO of the Health Care Association of New Jersey.

Many states that were initially spared in the first tide of COVID-19 infection are now seeing their own so-called first waves, even as states move to reopen and spark fears of a resurgence of transmission.

For Dolan, the question for SNFs and state governments alike will be whether the lessons learned from the challenges in the first wave take root, and help SNFs improve. Long-term care was not prioritized in the first wave, he argued, with the emphasis put on hospital capacity and ventilator availability, especially in New York. That led to a lack of national response on either testing strategies or personal protective equipment (PPE), Dolan said.

“That prioritization is the number-one thing about being the second cousin of health care that we are,” he said. “They finally realized it. But will they do something different now?”

That said, it will take more than doing better in a potential second wave of COVID-19 for SNFs to overcome the reputational damage they’ve absorbed over the course of the pandemic. The choice to move into a SNF or an assisted living facility was difficult even before the pandemic; now, after media reports zeroing in on the various issues facing SNFs in the wake of COVID-19, that decision is even harder, Dolan said.

But Dauphinais strongly recommended that facilities not succumb to panic in the face of the disease.

“How do we make our homes resilient? … We get back to the basics, which are build a resilient infrastructure,” Dauphinais said on the Tuesday webinar. “First, we look to breathe, not panic. There was a lot of early on panic, because this is scary.”

That includes making sure that goals of care continue to drive practice, consulting with peers in other states on best practices, and learning from what other facilities have experienced, Dauphinais said.

SNFs were prepared for something like the flu, he explained, but the flu is much easier to contain, since those who have it are infectious for a day or two only before symptoms present. In the case of COVID-19, the unreliability of symptom screening makes it much harder to isolate and cohort residents.

“This could spread before you even know about it,” Dauphinais noted.

The lack of information and the limited preparation led to “abundant consternation” at the start of the pandemic, he added, since the lack of PPE and the slow turnaround on test results in the pandemic’s early weeks made it impossible to cohort appropriately.

The greatest lesson going forward is the the importance of the thought process, which Dauphinais explained meant deeply considering every facet of a SNF’s response.

Those SNFs that were able to ration equipment and expand their supply chain the quickest did best on PPE, he said on the webinar. Operators also have to think seriously about testing and when to conduct it, especially when it isn’t available, Dauphinais explained. That means being up-to-date on all information related to COVID-19, and who is “a big risk factor for spreading” the disease.

Testing is essential, but also one of the most challenging aspects of responding to COVID-19, according to Stuart Almer, the CEO of the SNF Gurwin Jewish Nursing & Rehabilitation.

His facility, located in in the suburbs of New York City, has faced a range of challenges in responding to COVID, including a March mandate from the state of New York to take in coronavirus patients without COVID-19 testing and the shortages of PPE that plagued much of the country.

When it comes to testing, meeting New York’s mandates has led to thousands in extra costs: Testing staff for COVID-19 once a week costs Gurwin Jewish approximately $120,000, and it’s still not clear whether the testing will be covered by insurance, Almer said.

And as states increasingly establish mandates around staff and resident testing, that means SNFs need to be proactive about setting up their own testing infrastructure.

“My guidance to all of you would be right now to secure a lab, get contracts in place,” Almer advised. “Because it was just a mad crush of lab testing going on throughout New York. We all had difficulty finding a lab that could service us — a lab that we might be able to afford.”

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