Cracks in the System

Long-term care providers, payers and society can learn from the mistakes of COVID-19

By Mark Thill

Editor’s note: The report of the Coronavirus Commission for Safety and Quality in Nursing Homes can be accessed here.

Ask Dallas Taylor, RN, “Why are there so many COVID-19-related deaths in nursing homes and long-term-care facilities?” and she’ll ask you right back, “What do you know about long-term care?”

Taylor is director of nursing at the Village of St. Edward Community in Fairlawn, Ohio, and was a member of the federal government’s Coronavirus Commission for Safety and Quality in Nursing Homes. She acknowledges the challenges nursing homes face, and the “cracks in the system” that the pandemic exposed. But after working in the field for 20 years, she wouldn’t work anywhere else. And she believes that COVID-19 can bring about long-term improvements in nursing home care.

Ever since its appearance, COVID-19 has jeopardized the health and well-being of nursing home residents and staff. By the end of the first week of December, almost 82,000 nursing-home residents and 1,200 staff had died due to COVID-19, reported the Centers for Disease Control and Prevention.

Recognizing the problem, the Centers for Medicare & Medicaid Services in May convened a commission of experts to draw lessons learned from the early days of the pandemic and develop recommendations for future actions to improve infection prevention and control measures, safety procedures, and the quality of life of residents in nursing homes. A call went out for people to participate in the Coronavirus Commission for Safety and Quality in Nursing Homes. Taylor heard about it and submitted an application. Ultimately, she was one of 25 people selected for the months-long task, which culminated with the publication of a 36-page report in September.

The Commission issued 27 recommendations and accompanying action steps organized into 10 themes. But its members also issued this caveat: “Unless accompanied by sustainable, systems-level change addressing the issues discussed in the report, these recommendations will likely be inadequate to enable nursing homes to prevent the next crisis.” The question is, will systems-level change take place?

‘We weren’t designed for this’

“I wasn’t expecting to be selected,” says Taylor, who was director of nursing at Eliza Bryant Village in Cleveland, Ohio, when she submitted her application to be a member of the Commission. “Once you get involved in something like that, you realize that everybody – whether they’re in Nebraska, Texas or California – is going through the same things you’re going through in Ohio.”

“When I got into long-term care, hospitals kept patients for weeks; we wouldn’t get them until they were stable,” she says. “Now, they may come three, four or five days after heart surgery. They have more complex illnesses. They require more care. We have people who can’t breathe, people with diabetes who have to be monitored on a routine basis. Nursing homes weren’t designed for this.”

Funding hasn’t kept pace with these new demands, says Taylor. “Nursing homes do not have the resources, funding or financial stability to allow one person to focus on one task,” she says. “For instance, I am the director of nursing and the infection preventionist. The assistant DONs, in addition to their regular duties, also handle wounds and manage other programs, such as restorative care and staff development.

“We weren’t designed to handle a pandemic. We didn’t have ventilators; we didn’t have the necessary medicine on hand.” Nor did they have adequate PPE.

“What has been so different with COVID-19 is the constant use of PPE. Before, you may have had an outbreak of flu for a couple of weeks, twice a year. But when the whole building gets sick, that’s something we couldn’t accommodate.” And because COVID-19 affected every area of the United States, nursing homes such as Eliza Bryant had nowhere to turn for relief. “We thought that because nursing homes are funded by CMS, we would not have a problem getting the supplies we needed. We never dreamed it would be such a struggle.” What’s more, prior to COVID-19, the reuse or decontamination of single-use PPE was unheard of, she says.

Game-changer

In the pandemic’s early days, Holly Heights Nursing Home in Denver received N95 respirators, isolation gowns and face shields from a local construction company, says Executive Director Janet Snipes, LNHA, another member of the Coronavirus Commission. “Once we received these items, it was a game-changer in containing the spread of the virus.

“Now we have the ability to test our residents and staff; we have more PPE than we did when the pandemic started; and we understand that general community spread [of the coronavirus] leads to nursing-home spread,” she says.

Staffing remains a challenge. “It’s one of the things I think a lot about,” says Snipes. The industry lacks sufficient numbers of RNs, LPNs and CNAs. “People have to be incentivized to go to school to learn these skills and then to work in nursing homes.”

Fulfilling one of the Commission’s recommendations – hiring an infection preventionist – remains a struggle for nursing homes across the nation, she adds. “When the pandemic began, our community had two full-time infection preventionists.” But one had to remove herself from work because of comorbidities, and the other was diagnosed with COVID and had to isolate for 14 days. “Infection preventionists are so valuable in our day-to-day operations. We need a program that will help us obtain both IPs and nursing staff in general.”

Given the emotional trauma of treating residents with COVID-19, long-term-care facilities have found it more difficult than ever to retain staff, says Snipes. “You hear a lot about PTSD; it’s very real. We’ve had staff who say they’ll never work in healthcare again. And to this day, some continue to seek counseling to help them cope.”

But she looks forward to a different – and better – future for long-term care. The Holly Heights team is working on strategic planning now. “I see more private rooms in the future,” which will help slow the spread of infectious diseases, she says. And the facility has made changes to its physical plant, such as installing HEPA air filters, air-purifying units and ultraviolet lighting to disinfect rooms.

Snipes says she sees a future in which federal and state surveyors serve as partners with nursing homes to improve patient’s care and quality of life. And while infectious disease will always be a threat, COVID-19 has served as a valuable learning experience, she says. “I can’t imagine not always having a three-month supply of PPE on hand or the training for how to use it properly.”

Cautiously optimistic

Meanwhile, Dallas Taylor is cautiously optimistic about the future. “The Commission made a lot of good recommendations. But if our recommendations are pushed to the wayside, things will get worse before they get better.

“Nursing homes are expected to do things that they were never designed to do. Most of our workers are underpaid and underexperienced in dealing with a pandemic such as COVID-19, yet they have the incredible task of being responsible for someone whose life is in their hands while taking care of themselves. And the pandemic isn’t going anywhere anytime soon.

“But I am hopeful. Those of us in long-term care believe in what we’re doing, and we love it. We just need people to listen.”

Commission recommendations

In May, the Centers for Medicare & Medicaid Services convened the Coronavirus Commission for Safety and Quality in Nursing Homes to solicit lessons learned from the early days of the pandemic and develop recommendations to improve infection prevention and control measures, safety procedures, and the quality of life of residents in nursing homes.

In September, the Commission published 27 recommendations and accompanying action steps intended to respond to:

  • Ongoing supply and affordability dilemmas related to testing, screening and personal protective equipment.
  • Tension between infection control measures and quality-of-life issues associated with cohorting and visitation policies.
  • A call for transparent and accessible communications with residents, their representatives and loved ones, and the public.
  • Urgent need to train, support, protect, and respect direct-care providers.
  • Outdated infrastructure of many nursing-home facilities.
  • Opportunities to create and organize guidance to owners and administrators that is more actionable.
  • Insufficient funding for quality nursing home operations, workforce performance, and resident safety.

The report can be viewed at https://sites.mitre.org/nhcovidcomm/wp-content/uploads/sites/14/2020/09/FINAL-REPORT-of-NH-Commission-Public-Release-Case-20-2378.pdf.

Reuse of N95s en masse

COVID-19 forced providers to do things they hadn’t considered before, such as reusing single-use items. On March 28 – in the early days of the pandemic – the U.S. Food and Drug Administration issued an Emergency Use Authorization (EAU) for the use of the Battelle Critical Care Decontamination System (CCDS) for use in decontaminating compatible N95 respirators for multiple-user reuse. Shortly thereafter, Battelle got a $400 million federal contract to decontaminate N95 respirators and offer the service free to hospitals. Battelle is a nonprofit science and technology development company located in Columbus, Ohio.

Battelle had actually developed the decontamination process – which uses concentrated hydrogen peroxide vapor – in response to the 2014 Ebola outbreak, but only implemented it during the COVID-19 pandemic. At its peak, the company operated 48 decontamination facilities, but by the beginning of December, as the federal contract was winding down, that number was down to 21. At that time, the company had decontaminated more than 3 million N95s, according to a spokesperson.

For nursing homes: A moment in time

“Everybody understands nursing homes are under siege,” says Terry Fulmer, PhD, RN, FAAN, president of The John A. Hartford Foundation and a member of the federal Coronavirus Commission for Safety and Quality in Nursing Homes. “[COVID] exposed fundamental flaws in nursing homes in this country. Having the spotlight makes this a moment in time when we must act. Policymakers are paying attention, the sector is undergoing major upheaval.”

The Foundation – a private philanthropy dedicated to improving the care of older adults – has several projects in the works to facilitate change, she says. It is working with the FrameWorks Institute to reframe the narrative around nursing home care – one based on “the actual story and science of long-term care, instead of the back-and-forth headlines we see every day.”

The Foundation is also working with the Institute for Healthcare Improvement, the American Hospital Association and the Catholic Health Association of the United States to promote “Age-Friendly Health Systems,” that is, systems that focus on what matters most to older adults, and that provide care aligned with residents’ goals and preferences. The Age-Friendly approach has been adopted in 1,100 care sites, says Fulmer.

Additionally, the Foundation is the primary sponsor of an initiative by the National Academies of Sciences, Engineering and Medicine to examine how the nation delivers, regulates, finances and measures quality of nursing home care, including challenges brought to light by COVID-19.

Infection prevention training

In November, the Centers for Medicare & Medicaid Services recognized 1,092 nursing homes in which 50% or more of staff completed CMS training designed to help staff combat the spread of COVID-19. More than 125,000 individuals from 7,313 nursing homes completed the training, representing approximately 12.5% of approximately one million nursing home staff in the country.

The training modules for frontline staff include:

  • Hand hygiene and PPE.
  • Screening and surveillance.
  • Cleaning the nursing home.
  • Cohorting.
  • Caring for residents with dementia in a pandemic.

The modules for management include those topics as well as:

  • Infection prevention and control.
  • Emergency preparedness and surge capacity.
  • Addressing emotional health of residents and staff.
  • Telehealth for nursing homes.
  • Getting your vaccine delivery system ready.

The training is available on the CMS Quality, Safety & Education Portal at https://QSEP.cms.gov.