April 30, 2020, Maggie Flynn, Skilled Nursing News - Major skilled nursing operator PruittHealth last week announced that it was entering a partnership with a coalition of providers to expand COVID-19 testing at its facilities across Florida, Georgia, and North and South Carolina.
The partnership was about a month in the making — and it highlights the difficult timeline SNF operators have faced as they try to contain the spread of the novel coronavirus within their walls.
The U.S. has struggled to make testing for COVID-19 widely available as the number of cases surge, demand spikes, and the supplies needed — such as swabs and reagents — dry up. Laboratory capacity has also been an issue, one that the Centers for Medicare & Medicaid Services (CMS) has tried to address through increasing and expanding reimbursement for tests in nursing homes.
That’s why PruittHealth partnered with AMS Onsite, an infection prevention specialist firm, and its preferred laboratory, CoastalDx, to expand testing at its facilities. Sensiva Health, a family of companies that includes a high-volume Clinical Laboratory Improvement Amendments (CLIA)-certified medical lab, will provide COVID-19 antibody testing for staff.
In an ideal world, Pruitt would be able to secure the test kits the day that they are requested, return the swabs to the lab that day, and have the results returned within 24 hours. And that’s if it was doing facility-wide testing, PruittHealth chief clinical officer Fran Rainer told Skilled Nursing News in an April 28 interview.
In reality, the company started to see signs that there would be testing shortfalls as far back as early March — and had to start planning accordingly. That eventually led to the partnership with AMS Onsite for 118 Pruitt facilities, with the plan to eventually expand to all of its 180 SNFs.
Under that partnership, AMS will help with expanded COVID-19 testing, while also providing infection prevention help.
Pruitt has already implemented a public dashboard of its COVID-19 test results and is using donated masks to help allocate personal protective equipment (PPE) more efficiently. But the testing partnership with AMS and CoastalDx significantly bolsters its capacity to test for COVID-19, according to Rainer.
“Testing is really going to be how we’re going to control the spread of the virus,” she said.
Shortages start early
When COVID-19 was beginning to accelerate across the country, leaders at PruittHealth realized that tests for the illness from local health departments were starting to dry up.
“Early on in March is when we realized it,” Rainer told SNN on April 28. “When we first had what’s considered by definition an outbreak, with two or more positives, those tests were coming with us as a result of patients discharging to the hospital; so the hospitals were testing back then, early March.”
As Pruitt worked with the local health department in Georgia to test and cohort patients — and create isolation wings — it was able to get help for those early cases.
But as COVID-19 began to spread across the different regions in which Pruitt operates, those resources from the health department started to dwindle, with demand spreading beyond the hospitals and Pruitt, Rainer said.
To supplement those declining tests, Pruitt started to call private laboratories and testing companies. But AMS Onsite was the one to contact Pruitt in early March, after a few meetings with Pruitt and AMS’s clinical teams — including the CoastalDx team — to discuss the platform and protocols for infection prevent processes and procedures.
After that, both Real Time Medical Systems, an analytics company that captures clinical data from patient medical records, and Sensiva Health were integrated into that process to create a stronger platform, AMS Onsite executive director and CEO Patrick Britton-Harr told SNN on April 27.
The result was a contract to help Pruitt’s facilities with infection prevention protocols and provide the needed polymerase chain reaction (PCR) testing, “with respiratory as the baseline for it,” he said.
In terms of structure, AMS Onsite provides a dedicated infection preventionist to a set of nursing facilities in each group, working in collaboration with the staff to add clinical perspective and deal with some administrative functions.
The facilities, however, are in charge of choosing the protocols, process, and procedures, with AMS Onsite providing guidance.
This means AMS Onsite brings in its infection preventionists to help with sample collection.
“It can happen one of two ways,” Britton-Harr said. “We can either come in and collect the samples, or during this timeframe — where allowing outside access into homes is not necessarily going to be a positive for the facilities — we’re working in collaboration with the homes to make sure that the sample collection process is taken accordingly.”
What that means in practice is having local nursing facility staffers conduct the collections via nasopharyngeal swab; these samples are then shipped overnight to a laboratory, Dr. Chris Morgan, chief medical officer at AMS Onsite, told SNN on April 27.
The PCR test results are returned within 24 hours, and Rainer emphasized that when vetting private labs to expand Pruitt’s testing, turnaround time is one of the biggest considerations to allow for efficiently moving positive patients into isolation.
“Once the virus has been exposed somewhere, symptoms start to display around five to seven days after that,” she told SNN.
As a result, Pruitt aims to have enough testing capacity to last at least a week, with conversations at the beginning of each week to discuss the end of the prior week and the plan for the coming seven days.
The operator also monitors the data to get a sense of where the next hotspot location might be, she noted.
In addition to AMS Onsite and its partners, Pruitt is working with Clinical Laboratory Services in Winder, Ga., and Capstone Healthcare in Atlanta to supplement public health department testing.
That said, the capacity of public health departments does vary by state, Rainer noted. South Carolina, for instance, has not had as heavy a spread of COVID-19, and as a result, testing in that state hasn’t been a problem for Pruitt.
But if the disease worsens there, Rainer expects to see resources become strained.
That makes the private laboratory testing partnerships all the more paramount. The importance of this was highlighted by the Centers for Medicare & Medicaid Services (CMS) allowing lab companies to receive reimbursement for tests in the nursing home setting, and then increasing the reimbursement for those tests.
The increased reimbursement for the tests now lets them actually cover the cost of testing; the original reimbursement was below cost, which made it challenging to mobilize laboratories to handle the test volume, Dr. Jim Silliman, chief medical officer at CoastalDx, explained to SNN on April 27.
“We are billing Medicare rates for our tests, and the supplies and everything are costing more now because they’re in such demand and there’s not very much supply out there — because a lot of the supplies were actually made in China or some component parts of the supplies were made in China,” he said.
CoastalDx, which has no plans to expand outside the long-term care space, is focused on maintaining the capacity to test “a significant number of residents,” Silliman said.
In the era of COVID-19, that means making sure it can catch both that illness and other respiratory issues. The patients in the long-term care setting are typically immunocompromised — but most lab testing panels have been developed for the general population, he added.
In addition, CoastalDx is expecting to have “a proprietary, quantitative test on the antibodies, which will be way more specific to COVID-19,” relatively soon, which will give the staff a better sense of whether they might have immunity, as well as a better understanding of resident status.
PCR testing, which identifies the material of the SARS-CoV-2 virus that causes COVID-19, will be used early on in the testing process, Morgan told SNN. But as the technology matures, the antibody testing will be incorporated as well.
“We’re very focused on developing panels that relate specifically to the residents of long-term care facilities, which are typically immune compromised,” he explained. “We have not only the COVID testing, but we also have a full respiratory panel to test, and then we have access to the lateral flow antibody and antigen test, which will be important for the staff to see whether or not they’ve been exposed.”
Testing for COVID and beyond
But even with the increased capacity, the testing isn’t quite universal. Whenever a case of COVID-19 is identified at a Pruitt location, all of the residents at that location are tested, Rainer told SNN.
For staff members, the procedure is different. For one thing, not all staff at a given facility would necessarily have been exposed to the positive patient, she noted.
As a result, some Pruitt employees have had to use their personal physicians if they have symptoms — though some private entities such as CVS Health (NYSE: CVS) have begun to offer testing, and Pruitt does try to get some portion of swabs for employees.
In addition, the Centers for Disease Control and Prevention (CDC) has put out guidelines on how health care facilities can mitigate staffing shortages, which Pruitt used to develop protocols for testing staff.
Anyone with “high exposure, direct contact” with a positive patient would be tested, Rainer said. This high-risk level is defined as having direct, prolonged contact with a patient who tested positive while something happened that would have caused the patient to cough, sneeze, or in some way project droplets into the air.
A medium-risk exposure might be someone in the area who was not providing direct care, but also not wearing any PPE; low-risk would be someone wearing PPE who was doing direct patient contact for a long period of time, Rainer explained.
But even with the challenges, the partnership with AMS Onsite, CoastalDx, and Sensiva has bolstered Pruitt’s testing capacity by at least 25% to 30%, Rainer estimated; the other two lab partners and the National Guard testing in Georgia have also proven helpful.
For other SNFs focusing on ramping up their access to tests, Rainer recommended that they reach out to their state trade associations, which proved helpful to Pruitt in vetting the lab companies and learning about firms that would be able to take on testing.
“Understand that testing is really is going to be how we’re going to control the spread of the virus,” she advised. “Really think about communicating frequently with their public health departments, responding to vendors, because they are reaching out to different locations and trying to get their trade association to help. Just use all available resources, really, is what I would recommend.”