The COVID-19 emergency overturned nursing home operations overnight in almost every respect, notably with regard to the provision of clinical care.
And according to a panel of physicians who work in the nursing home setting, some of those changes should stick around, even after the public health emergency finally comes to a close. Namely, they want to see collaboration between physicians and frontline staff continue, as well as for skilled nursing facility physicians to keep serving as a resource to hospital partners.
Dr. Arif Nazir, chief medical officer of the Louisville, Ky.-based Signature HealthCARE, is one such physician. He’s been pushing for better collaboration between doctors and nursing homes for years, he said during a March 26 webinar hosted by Skilled Nursing News and sponsored by MatrixCare.
“We never saw the kind of teamwork [before] that we had in nursing homes, finally,” Nazir said in a March 26 webinar hosted by Skilled Nursing News and sponsored by MatrixCare. “We would have drooled over this kind of teamwork for the past 40 years, …and I challenge doctors to really continue the behavior doctors have shown in nursing homes, which has made me so proud, finally.”
Keeping up the pace
While SNFs are required to have a medical director – a physician responsible for coordinating care at the facility – by law, the pandemic highlighted the shortcomings of that role as it presently exists. But it also shows how it could improve.
Even before COVID-19, cracks in the model were showing.
Dr. Justin DiRezze, CEO at Theoria Medical x 5-Star Telemed, pointed some of those out to Skilled Nursing News back in 2020.
“I always had the notion that the second I discharge this patient to post-acute, the physician’s there immediately, and they’re seeing the patient, and they’re doing an evaluation,” DiRezze said, speaking of his time as a hospitalist at a major acute care provider. “I had this false sense of sense of security when I was sending patients to post-acute care facilities. I never fully understood why they would come back, because how does the patient come back if there’s a physician there all the time? Well, we both know that’s not how it is in post-acute.”
The ravages of COVID-19 could be the catalyst for significant change in the role of medical director, and one CEO of a company providing medical directorships to SNFs predicted just that at the start of the year.
“For decades, physicians and SNFs have not been aligned to provide the best clinical outcomes for residents,” Dr. Jerry Wilborn, CEO of the Dallas-based GAPS Health, told SNN in a 2021 executive outlook. “SNFs have been considered an afterthought by many physicians, as it is often not their primary clinical focus. As a result of a paucity of effective physician presence across the industry, SNFs have developed their own clinical protocols without the input of physician guidance. We need to redefine this relationship.”
Some of the aspects of care provision in the pandemic provide a blueprint for how that relationship could be redefined. Dr. David Clayton, national medical director at GAPS Health, pointed out on the March 26 webinar that the partnership between nursing staff and medical directors improved drastically over the course of COVID-19.
“When we look at how much education and how much co-management took place this year, I don’t think I’ve ever seen medical directors and nursing staff work more closely and more hand-in-hand as part of an interdisciplinary team,” Clayton said during the webinar. “Quality went up, outcomes improved, and there was a lot more collegiality and teamwork happening that I saw across all of our corporate partners.”
The use of telehealth facilitated this optimism for Clayton; he witnessed how technology in the pandemic allowed for a more widespread deployment of physician resources and care, in a more efficient way. GAPS’ STATt [“surveillance, tracking, assessment, teaching and treatment”] rounds for COVID-19 patients make use of telehealth, and allowed for a 99.9% ability to treat in place, Clayton said, which he argued would have been impossible going bedside to bedside in person.
However, some wariness is needed when assessing the benefits of telehealth and technology in health care, Nazir cautioned. The collaboration between nurses and physicians that occurred during the pandemic – the cooperation he had strong praise for – could be a “confounder” in assessing how much benefit technology brings.
“There is a very good place for telehealth, but being in a room with the patient is so valuable, seeing their environment and seeing exactly what their body language is,” Nazir said. “So to me, telehealth is great; it helped Signature patients immensely. But I heard a lot from many, many physicians about how it had an aspect that was not fulfilling.”
He called for “tons of research, very, very quickly” to be able to examine the outcomes and benefits of telehealth.
Dr. Rayvelle Stallings, corporate medical officer at the Norcross, Ga.-based operator PruittHealth, also emphasized the importance of having a good grasp of metrics, noting that over the course of the pandemic, “data became huge.”
“Whether it was actually monitoring temperatures and O2 stats, we could pull up a dashboard everyday on our COVID patients,” Stallings said.
This allowed Pruitt to see opportunities to use new therapies, for example, and to see the statistics and findings across the company, and it’s something that will have benefits well beyond the pandemic, she explained.
“We were forced to use it because it really made a huge difference, and I really think continuing that type of utilization of data – and we at Pruitt utilized data from a transparency standpoint,” she noted. “We did not have patients and families coming in, and we have a dashboard so they could look at that data themselves.”
Physicians as storytellers
The need for clinical transparency also includes communications with staff, a point that Stallings emphasized with regard to vaccination efforts among front-line staff who have been hesitant about taking a COVID-19 vaccine. SNFs have not been immune from the challenges of an era of distrust of leadership and institutions, and this cannot be undone overnight, as Nazir pointed out in the webinar.
The collaborative mentality that emerged over the course of the pandemic goes outside the walls of the nursing home. When the COVID-19 emergency finally ends, one of the most critical roles for doctors who work in nursing homes will be to educate the public on the care provided in the setting. Doing so is especially important after the slew of bad press the sector has received, all the speakers on the webinar agreed.
But that education can’t stop at the general public; it has to extend to other parts of the health care continuum, Stallings pointed out.
“I would say during this pandemic, I’ve spoken to more [emergency room] physicians and hospitalists than I’ve ever spoken to in the past,” she said. “All of a sudden we became a resource, and it was a necessity to speak to us. I would like that to continue.”
Stallings also emphasized how, in an era of social media, physicians have not responded as quickly as they need to – not only to address the concerns that spring up like wildfire on those sites about the COVID-19 vaccines, but to meet people where they are for information.
For Pruitt, this meant overhauling how it communicates on those platforms and elsewhere, for everyone from certified nursing assistants (CNAs) to registered nurses (RNs)
“The health care industry, we have not been that savvy with social media,” Stalling said. “Every one of our employees, every one of our partners has a smart device. So whether it’s Twitter or Facebook or Instagram or any of those types of things that they can immediately get information, we really changed our communications platform to get everyone at every different level.”
This meant using social media and putting information on devices, but also designating “champions” for CNA education on topics ranging from vaccines to infection control processes such as donning and doffing personal protective equipment (PPE).
But Stallings also emphasized the need for physicians in long-term care to provide education not just to CNAs but to their fellow physicians and the general public about what long-term care does and provides. The need to do this is only going to grow as the population lives longer and becomes more medically complex, she explained.
“There were a lot of things that didn’t happen before, when we talk about communication and collaboration,” she said “I think there’s a huge amount of education [needed], not only among my other colleagues … that have such a skewed view of long-term care in nursing homes. I think we have a huge responsibility to be that education, not just to patients’ families, but to other colleagues.”