California emerged as an early COVID-19 hotspot when the coronavirus first emerged in the U.S., and for skilled nursing facilities in the Golden State, the pandemic hit particularly hard.
As a result, local health officials at both the state and county levels were looking for ways to combat the anticipated need — and they turned to a major SNF operator in the state to help.
Rockport Healthcare Services operates 77 SNFs, almost entirely in California, and provides a variety of services ranging from accounting to purchasing to clinical consulting.
The operator ended up overseeing dedicated COVID-19 facilities in six different counties, starting in Los Angeles, and worked closely with officials throughout the state — while also coming under media scrutiny in the process, particularly over patient discharges.
As the pandemic shows no signs of slowing down, Skilled Nursing News caught up with Rockport CEO Dr. David Silver on December 1 to talk about how Rockport came to operate COVID-19 facilities, how it’s working with the state, and the lessons learned from the early months of the pandemic.
Can you go into the work you’ve done with COVID-19, specifically in terms of facilities that became COVID-19 facilities? What does that designation entail?
We were hearing already in March and April, [during] the preparation for the so-called surge, that there was an anticipation that there was going to be an overwhelmed hospital setting, and that there was going to be a need for destinations for COVID residents to go — as well as standard skilled nursing residents, because the hospitals were concerned about this surge that would lead to them becoming overwhelmed.
This was in discussions with state and county officials very early on; we were on almost daily phone calls with the California Department of Public Health, some of the major counties like Los Angeles County, et cetera, who were highly concerned about the surge of patients [that was] going to be coming and how that was going to impact the acute care system — and then ultimately, how we could help be a solution.
So early on, we were entering into discussions on how we could do that. We recognized early on in our work — not only with state and county officials, but [also] our health care partners — we thought there was a need for additional resources to care for COVID-positive patients. We also felt that the best way to do this, in our discussions, was to establish specialty centers where we could provide additional services to those residents that would be specialized for their care, and additional respiratory care services — because obviously respiratory problems were the biggest thing leading to morbidity and mortality in this population.
Working with county and state officials towards the end of April, we developed our first COVID treatment facility, COVID-specialty facility. We actually had ambulance on standby 24/7 — basically a lot of different additional services and obviously a heavier concentration of PPE [personal protective equipment]. We were fortunate we were one of the organizations who didn’t … run into some of the same PPE shortages that a lot of companies did. But obviously, there was an increased concentration, the need to get those kind of resources available.
We also took on consultants from various aspects, including the physician who headed the COVID response team at Cedars-Sinai, the largest teaching hospital west of the Mississippi, and other specialists as well to develop a program we thought could optimize the care of COVID residents.
By concentrating COVID residents in treatment facilities, then we could hopefully help [keep it] from spreading within a facility. We can isolate and transfer patients from facilities that are not COVID-specialty facilities to COVID-specialized facilities. We could help improve the quality of treatment, but also hopefully, if we saw an early outbreak in a facility, get those residents out, and allow them to not infect other residents in the facility — which we did find was successful to a certain degree.
We established the first facilities in the state of California with a focus on what kind of resources and equipment those residents needed, with the hopes of preventing them from needing to be hospitalized — all along recognizing that some residents were going to deteriorate, because obviously treatment options are, and were, and still are somewhere significantly limited.
But at least we can then also recognize the signs early on that this patient requires a higher level of care, and get them to the acute-care setting before, hopefully, they would need to be intubated or other more aggressive treatments would be needed.
It was an evolution over a period of six weeks. In conjunction with the state, when we were concerned about the surge, we were actually in discussions with them on reopening some shuttered facilities and even taking over a couple of developmental centers within the state to open.
We actually got to a point where we were ready to order the equipment, and within about a week and a half of opening the Porterville Developmental Center — which had been mostly shuttered over the last 10 to 15 years — to be able to take skilled nursing residents.
Ultimately, that surge didn’t happen to the degree they thought, so we didn’t have to do that. But we were talking about opening several other facilities across the state.
What were some of the factors that went into the selection of facilities for this work?
There were a number of factors that went into this. One of them was actually what the need in the community was, and the location of those residents were. We tried to be somewhat geographically sensitive. I’ve mentioned Cedars-Sinai; obviously in their facility alone [in Los Angeles], they had a triple-digit number of COVID residents.
And consequently, they were like: “How can you help us?”
To be blunt, we had to also be very careful, because — for very good reason — a lot of staff were scared at this point. This was all new to everybody. We had to make sure when we were talking to staff, as we looked at several centers, that they would be comfortable and competent in taking care of these residents. We wanted to make sure that we chose centers where the staff was buying into what our vision was and that they were comfortable — and with the additional training we were able to provide, would feel really confident in being able to care for these types of residents safely.
We also looked at leadership in the buildings and layout of the facilities, and then other factors as well. We were already seeing cases back in April, so [we asked] where did we have staff that had experience with these kinds of residents, be it COVID or past outbreaks?
Can you go into some of the infection control procedures, both in terms of training and staffing structure?
There was additional training for all our facilities, not just the ones that are COVID-19 treatment facilities. Early on in the pandemic, in early March, we put in overtime mandates to help people do constant deep cleaning of facilities.
When I say deep cleaning, basically on an every-shift basis, high-touch surfaces were being cleaned. Everybody, be it your administrator all the way down to your housekeeper, all were participating in this cleaning process, and obviously that was even more enhanced in our COVID facilities. Normally you did those surfaces once or twice a day, now we’re doing them three or four times a day, and in some cases we were doing them every hour or two, depending on what the need was at the facility.
Obviously there’s additional training on PPE. We were learning things on the fly, and so a lot of this, we were learning to do certain things that hadn’t been done before. Not, obviously, that we hadn’t learned how to doff and don and all these things, but doing it on basically every resident in every room was a new thing for our staff, and we were making sure they had those supplies.
We had additional nursing staff in our facilities, because these patients — they tend to be overall sicker because of the respiratory complaints, but also because of the time it took to do all these cleansing procedures, and making sure to maintain infection protocols on an entire facility, when you have effectively every patient on isolation.
There was the time it takes to do those things, and then the additional time it took to do all these procedures means you needed additional staff. So it was additional nursing staff, additional CNAs [certified nursing assistants], additional housekeeping staff that was required.
The normal staffing ratios that might be sufficient for a regular facility, we were running much higher staffing ratios in our COVID treatment facilities. That I think was the biggest change, really the staffing up of these facilities, and making sure you had your top people in a certain attitude and comfort level in caring for residents like this, so those residents would get the highest level of care.
Do you know how much the staffing ratio changed in terms of before becoming a COVID facility to after?
We typically in our centers would run staffing ratios — and I’m just trying to ballpark here — in the high threes [three skilled nursing hours per resident per day]. It would depend on the facility planning, acuity, and a lot of factors. In our COVID treatment facilities, running in the mid-to-high fours would not be unusual.
Respiratory therapists 24/7 were in the facilities. One is for monitoring … but also being able to provide respiratory treatments that were necessary. So there was a lot of additional staff that came in, in a time where staffing was becoming even more challenging.
Did you end up using a third-party service for the respiratory therapists?
Initially we did. Because we work with a company with our subacute facilities, we leaned on them a lot because they have a lot of additional respiratory therapists, so thankfully those were readily available to us.
Then there were some we had internally. We hired additional staff over the longer term, but in the short term, yes, we used a company that we have already worked with, and they were able to bring additional staff who were highly experienced and provided an excellent level of care.
Was there a target of respiratory therapists per facility?
It just depended on the need of the facility. We just wanted to make sure we had 24/7 coverage on a continuous basis. It depended on the center and the acuity of the residents, and we would flex that as needed.
What was the experience of working with local health officials, especially given California’s regulations?
It was really very collaborative. Already in March we began having these discussions with state and county officials. In L.A. County, which is obviously where our heaviest footprint is … we worked together and someone used our model for the other centers in the county that were going to be opening treatment facilities.
So it was a very collaborative effort; for all of us, this was relatively new, so we would have frequent discussions with the county, frequent discussions with the state on how we would model these centers — because they hadn’t modeled them before either, so really we leaned on each other to help each other.
It wasn’t like you had the state or county saying: This is how you’re going to do it. We gave them feedback, they gave us feedback to make sure we could work together on establishing the highest quality care for our residents at these centers.
Do you have any sense of how many patients have been treated at your COVID-19 centers?
It’s certainly in the several hundred, but I’d be only ballparking because obviously residents come within a period of seven to 14 days, they’re clearly stable and are able to move on. And some, based on where their level of care was before, require longer stays.
There were some weeks — if you can imagine a facility a facility with 99 beds getting 25 admissions in a week, that’s obviously a huge burden. There was times where there were [non-Rockport] facilities that had to be evacuated; the state had to come in because of inadequate care being provided, and there was one time where we, in one 12-hour period, had to take approximately 60 residents from another facility that needed to be evacuated.
The call came in and the state said, “We have to close the facility,” and that was at 4 in the afternoon. And by 4 in the morning, we had accepted all those residents.
When it comes to the movement of patients, this is something I did want to ask about. The Department of Health and Human Services Office of Inspector General has added improper discharges from nursing homes to its formal work plan, citing media reports, and the New York Times did a piece over the summer discussing this that did mention Rockport. Obviously in COVID units, patients will not be staying forever, but I did want to ask about this. How did assessing patient discharges change for Rockport over the course of COVID-19, given the environment and the state of emergency?
I’ll say from the beginning, and one of the things we’ve worked with — specifically in L.A. County — was we reached out to the to the county ombudsman’s office on: How do we improve this process? How do we make sure we’re meeting the needs of our residents?
The 60-person facility that I talked about, it was actually the regional ombudsman who reached out to me and said: We need your help. Can you help us?
It’s a lot of coordination with that office, understanding that if that resident gets COVID, we don’t have 30 days to figure out how we’re going to get that resident treated. We need to make a decision immediately. It’s making sure, if the person’s not competent themselves — because obviously a lot of our residents are not — who was the contact person?
Make sure that we’re in touch with families, that we’re in touch with conservators, that we have that information readily at hand so we’re keeping a constant line of communication with families, with conservators, obviously with residents.
We basically have strike teams that would come in that were really experts in doing this — obviously heavily involving our social services department — to be able to counsel and explain what the process was.
And we hate to say it, but we got very good at making sure that we explained to the residents, made them understand what was going on, help them to understand the process and understand this was temporary. The goal was how do we provide the highest level of care and how do we protect other residents from getting this virus?
Any time we had one of these situations, we’d be in immediate contact with the ombudsman’s office, we’d be in contact with the district office for the state, so that everyone knew what was going on.
What are some of the lessons you’ve learned about that kind of communication over the course of the pandemic?
One of the things we learned and one of the challenges …. is that obviously for a significant portion [of residents] because they have dementia and other issues, we have to communicate with their families. There’s some families who are very actively involved with their loved ones, and it’s easy to identify those.
Unfortunately, there are others where their families are less involved, and sometimes we don’t have updated information. So one of the first things is make sure: Who is the person who’s responsible? Who is the next person? Who is the person that we can communicate with if there are issues, concerns, problems?
Normally if it took a couple days to figure out, that was not necessarily a big problem. But now, during times like COVID, you sometimes have to make very quick decisions, and if you don’t have the right person to contact, that can be problematic. So updating all of our contact information and making sure we have the right people.
Nobody’s perfect, and when all of a sudden you have to move 10 or 15 people because you have an outbreak in the facility, obviously first and foremost your concern is caring for those residents. That is always your North Star — and as best as you do, there are times where you’re going to say: I wasn’t able to get in touch with this person, I had the wrong phone number, someone moved and didn’t update their contact information.
So obviously making sure that we have that information updated, and we do things on our websites on a daily basis. Multiple times, we’ve notified residents and families: If you ever have a question, our websites are updated. Every facility has their own website that’s updated on a daily basis so they can get information on what’s going on with COVID or anything else going on in the building.
So if you can’t immediately reach someone, they have another resource. But I think learning how to better communicate is something we can always work on.
This interview has been condensed and edited for clarity.