September 13, 2020, Maggie Flynn, Skilled Nursing News - When the COVID-19 pandemic began to gather momentum in the U.S. in spring, one of the earliest strategies for combatting the virus in skilled nursing facilities was to cohort patients with the disease in designated areas — or even set up entire facilities dedicated to the care of these patients.
The Centers for Medicare & Medicaid Services (CMS) took steps in March to make it easier to transfer patients within facilities or to other locations, releasing several waivers designed to accelerate the process. It was a process that had begun at the state level, with Massachusetts one of the earliest states to start establishing dedicated COVID-19 facilities.
How this process ended up playing out varied across the country, depending on regulations and the spread of COVID-19 in any given locale. Skilled Nursing News spoke to a range of SNFs that ended up establishing units within already existing facilities, trying to factor in considerations such as physical layout and what their hospital partners needed during the height of the pandemic.
Some of the units remain active, while others eventually converted back to their former modes of operation. But for each facility, the experience provided insights in managing COVID-19, from personal protective equipment (PPE) use to staffing, as well as laying out potential roadmaps for how to handle major infectious diseases in the future.
Handling physical layout, staff
For Elderwood at Amherst, located in Amherst, N.Y., its COVID-19 unit was formed by converting a 22-bed subacute rehabilitation unit to a post-acute unit specifically dedicated to COVID-19 patients.
The facility officially opened its doors in early April, and in early August announced that it would return to its subacute COVID-19 operations.
The facility was in daily contact with Kaleida Health, a local acute care health system, as part of its preferred provider relationship, according to Warren Cole, the co-CEO and cofounder of Post Acute Partners, the corporate parent of the Elderwood operator.
It became apparent that creating a COVID-19-specific unit was the best option amid the need for hospital bed capacity and for a place to send any COVID-19 patients who were living in Elderwood’s SNFs, Cole told Skilled Nursing News in an August 20 interview.
“It was clear to us that we were going to want to create a COVID specific unit, and we determined that Amherst was the best place to do it for a number of different reasons, not the least of which was just the physical properties of that property,” Cole said.
Specifically, the layout allowed Elderwood to address some of the main considerations for SNFs when creating a COVID-19 unit: employee flow, resident flow, air handling and exchange, and other infection control issues that might extend so far as flooring.
“Like most — or all — nursing homes, you have a single kitchen that services the whole building,” Cole told SNN. “So we had to think through how to, on the one hand, use that single kitchen, but isolate the flow of people in and out of the kitchen — to isolate, again, the COVID unit versus all the other units. So we had to create two means of ingress and egress from the kitchen.”
The facility originally routed food from the subacute unit to the rest of the building, a setup not ideal for infection control, he said. So that necessitated changing exits to direct food and employees who worked in the COVID-19 unit only to that unit, while keeping food and employees at the non-COVID unit entirely separate.
Elderwood also had to create separate access to the unit, and modify its HVAC system to keep air in the COVID-19 unit isolated to that area. In fact, air exchange was one of the reasons it chose Amherst for its COVID-19 unit, since each resident room had its own wall-mounted air-conditioning unit. Flooring had to be taken up and relaid to make cleaning easier.
Overall, the cost ended up being “in the low six figures,” Cole said.
For Diakonos Group, which operates several SNFs and senior housing communities in the state of Oklahoma, setting up a COVID-19 unit was conducted in phases. The operator initially started work in late March, Alexis Batiste, the director of clinical services at the operator’s Franciscan Villa in Broken Arrow, Okla., told SNN on August 25.
At first, the unit had 11 beds, but as the pandemic continued to gather steam, that unit was shut down and another unit, with 25 beds, was opened.
That necessitated moving the negative pressure system to a greater area, Scott Pilgrim, the CEO of Diakonos, told SNN on August 25.
That unit, like the one in New York, also had to have a separate entrance, and its workforce is entirely separate from the rest of the facility. To assemble team members for the unit, Batiste spoke to each nursing staff member to discover who might be interested in working in such a unit, and Diakonos provided financial incentives for those who volunteered. The schedule is the same, but the team is kept separate from the rest of the staffers at the facility.
When it comes to personal protective equipment (PPE), Diakonos had started to pick up warning signs about the virus in January, so it directed its facilities to order three months of supplies and keep them in storage for emergency, COO Kimberly Green and Pilgrim told SNN. This only gave a bit of a head start, Pilgrim noted, especially since Diakonos had not previously ordered N95 masks — and supply availability from distributors is typically based on historic ordering volumes.
Overall, Diakonos has spent “hundreds of thousands of dollars” purchasing supplies, Pilgrim said.
But as supply lines started to rebound, the state was able to help in some ways, ensuring Franciscan Villa was well-supplied because of how many patients the unit was taking in — the unit had had about 100 admissions as of August 25. The state would call the unit weekly to see if there was any additional need for PPE, Marla Heckman, executive director at Franciscan Villa, said in that same August 25 interview.
Communication with hospitals and regulators critical
That communication, whether with state authorities or local hospitals, is critical to the success of a COVID-19 unit. Elderwood, for its part, had to submit an application to the New York Department of Health to begin accepting COVID-19 positive patients directly to the hospitals.
For Bridgemoor Transitional Care, which has four locations in Round Rock, Fort Worth, San Antonio and Webster, Texas, this entailed working closely with the Texas Health and Human Services Commission (THHS) and local health departments to be sure that the operator was following correct procedures, Mark Fritz, Bridgemoor’s president, told SNN on September 9.
This process could vary between regions, but since all of the standard life safety code rules still applied, accounting for those factors took the most time, Fritz said. The local health departments wanted to help with adding partitions, areas for donning and doffing PPE, and areas of ingress and egress, but sometimes the physical layout would get in the way; those plans might have entailed blocking exits in ways that were dangerous for emergency evacuation purposes, for example.
“We did have to work through and be creative, in taking some patient rooms and converting them to break rooms and donning and doffing areas and putting up some plastic walls, so that we could still stay in compliance with THHS,” Fritz told SNN.
In New York, Elderwood had to go through a similar process, both at the start of the planning for the COVID-19 unit and afterward, Paul Shields, Elderwood at Amherst’s medical director, told SNN on August 20. In the early days of March, Elderwood ran into some resistance from regulators and payers wary of patient movement across facilities, said Shields, who also is vice president for post-acute care at General Physician, PC, and a member of the COVID-19 Task Force at Kaleida Health.
But in mid-to-late March, CMS issued the waivers to facilitate patient transfers, helping build momentum for establishing the COVID-19 unit. And after the unit was established, that close support and communication continued, with both hospitals and regulators.
“Early on in this, we were able to coordinate, with the local county health department, town-hall calls that brought all of the skilled nursing operators onto a call,” Shields told SNN. “There was the ability to share best practices, there was the ability to problem-solve. We worked with other platform operators in the community, and were able to take patients from their facilities to our facility to cohort and manage. It was a community effort, truly.”
Both Shields and Fritz emphasized how the COVID-19 pandemic ended up bringing together providers across the care continuum. Both operators, despite their wildly different bases of operation, found themselves communicating far more closely with their hospital partners and other care providers in their work to establish COVID-19 units than was typical.
And though Bridgemoor ended up downsizing its COVID-19 units — at the time of the September 2 interview, Bridgemoor’s final unit was in the process of winding down operations – Fritz was optimistic about that newfound communication’s effects.
“This whole COVID thing — if nothing else, I think it’s brought the post-acute provider, the hospital systems, the health departments and THHS, all together, really collaborating and working together to try to make sure we’re headed in the right direction, to meet the current crisis” Fritz told SNN.
That current crisis may on some level be abating in certain parts of the country, but the coming influenza season could be a crisis unto itself, coming as it is on top of the COVID-19 pandemic — which has proven capable of roaring back in a community with surprising force. For as Shields pointed out, “there’s nothing to say that you can’t have COVID and influenza.”
When it comes to PPE use in the flu season, Bridgemoor, Diakonos, and Elderwood all noted that the pandemic has been a crash course in the appropriate use of the equipment, with correct donning and doffing procedures more deeply ingrained. That will come in handy for flu season, as will some of the screening procedures for temperature, Green of Diakonos noted.
The pandemic has also normalized isolation units in long-term care, and that’s something that will also be useful during flu season — and it might become normal to simply send any new admissions there, Batiste added.
But for patients already in the facility, it may not be so simple.
“The challenge is going to be in how we cohort patients appropriately,” Shields said. “When we were dealing with COVID on round one, you were able to pretty much rule out that it was influenza, because influenza wasn’t prevalent at the time that we were really dealing with this. In the fall, the challenge is going to be: How do you rapidly identify what that respiratory illness is, whether they’re febrile or not febrile, and then how do you appropriately cohort those patients? Because a red unit for COVID can’t necessarily be a red unit for influenza.”
“A lot of the current availability in the testing devices allows you to rapidly run influenza A and B, RSV [respiratory syncytial virus], and COVID on the analyzer,” he explained. “I think that that we will develop a testing strategy for patients who present with respiratory illness, so that we can identify and appropriately cohort on that basis. But it will add a little bit of a logistical hurdle in the fact that that you could have multiple presenting illnesses.”