Nursing homes increase capacity to care for residents after COVID-19 hospitalization

Older adults are among the most vulnerable populations affected by the COVID-19 pandemic, accounting for eight out of 10 deaths from the virus in the United States, according to the CDC.

Nursing homes, in particular, have experienced a high burden of COVID-19, with as many as 1 in 4 cases in the U.S. stemming from nursing home residents, according to a recent analysis of CMS data conducted by the Associated Press.

In May, New York Gov. Andrew Cuomo signed an executive order that called for hospitals to stop releasing patients to nursing homes unless they test negative for the virus.

Healio Primary Care spoke with Terry Fulmer, PhD, RN, FAAN, president of The John A. Hartford Foundation, and Swati Gaur, MD, CMD, MBA, a medical director and founder of the Palliative Care Program at Northeast Georgia Health System and a member and chair of the Infection Advisory Committee at the Society for Post-Acute and Long-Term Care Medicine, to learn more about where nursing home residents should go after COVID-19 hospitalization, and what steps facilities can take to prevent the spread of the virus.

After COVID-19 hospitalization

Fulmer said moving frail, older patients with COVID-19 from the hospital to a nursing home or alternative care facility can be safe, but should be determined on a case-by-case basis by the clinical care team.

If a nursing home resident is able to leave the hospital but unable to immediately return to the nursing home, Fulmer said “the patient and family can refuse to be discharged from hospital in the first place, until an appropriate plan is developed.”

However, patients can experience adverse health effects including delirium and pressure ulcers if they remain hospitalized too long, and long-term care facilities are better able to take care of these patients, and bring “normalcy” into their lives, according to Gaur.

Swati Gaur

“There is value to bringing stable patients into long-term care facilities to provide them with therapy and other services and bring these patients as close to the previous level of functioning as possible,” she said.

She added that some states, including New York and Pennsylvania, set up free-standing alternative care facilities for nursing home residents who were hospitalized with COVID-19 infection and could not return to their nursing homes.

Fulmer said after hospitalization, these patients could also go home with proper support, but this is not an option for many due to the amount of care they require.

“The good news is that many nursing homes are now increasing their ability to safely readmit COVID-19 patients through specially dedicated units for positive patients,” Fulmer said.

Gaur agreed that many nursing homes now have the capability to house and care for these residents separately from the general resident population.

Preventing spread in facilities

The CDC recommends that patients who are readmitted or newly admitted to a nursing home be placed in the facility’s designated COVID-19 care unit if they do not meet the criteria for discontinuing transmission-based precautions.

These criteria, according to the agency’s guidelines for symptomatic patients, include a symptom-based strategy where patients with improved respiratory symptoms are free of fever for at least 3 days without medication and have passed the 10-day mark since symptom onset, as well as a testing-based strategy where patients are free of fever without medication, have improved respiratory symptoms and test negative for SARS-CoV-2 in two samples taken at least a day apart.

For asymptomatic patients who tested positive for the novel coronavirus, the criteria for discontinuing these precautions includes a time-based strategy where 10 days had gone by since they first tested positive, and a test-based strategy where patients had negative test results from two samples taken at least a day apart.

Gaur noted that residents from her institution’s COVID-19 care unit can return to the general resident population after testing negative for the virus twice. Once there, residents remain isolated and are monitored for 7 days to ensure that they do not experience symptoms that may have been overlooked.

She said this process has worked well for the facility, and “residents are eager to go back into their previous settings.”

According to Gaur, the facility is also making efforts to reduce spread by changing personal protective equipment (PPE) after caring for each resident, including those who live in the same room. Extensive testing in staff and residents is also essential in preventing spread of COVID-19 in nursing homes, she said.

Although Gaur’s facility is not in a state where universal testing is mandated for staff, she said they decided to universally test all staff and residents after they had their first resident with COVID-19 to identify other infections. Since then, they have implemented extensive screening strategies in staff and residents using clinical screening tools twice per day in the latter, targeted testing in residents and staff, and thorough contact tracing within the facility.

If a symptomatic resident tests positive for the virus, all residents are tested again and those who test positive by nasopharyngeal PCR testing are moved to the COVID-19 care unit. Any staff members who had contact with these residents are also tested, so while testing is not universal among staff, most are tested frequently, Gaur said.

She said having testing results from the facility is “great,” but “test results are step one,” and health care providers in long-term care settings “should be urging their facility to do a root cause analysis as to why this resident has tested positive.”

Legislative efforts

To help provide support to nursing homes, Fulmer said, “government and health system leaders must prioritize nursing homes in the coronavirus response.”

“Nursing homes need sustained engagement by hospital, health system, and state and federal partners in coronavirus planning and management,” she said.

Therefore, according to Fulmer, nursing homes should be prioritized at the same level as hospitals for testing, PPE and staffing.

“Training and compensating staff must be a priority by our state and national leaders,” she said. “To improve health outcomes for residents, issues related to staff pay, benefits and training must be addressed. Staffing is the single greatest challenge for nursing homes; these individuals receive unacceptable pay for the work required.”

References:

• CDC. Discontinuation of Transmission-Based Precautions and Disposition of Patients with COVID-19 in Healthcare Settings (Interim Guidance). https://www.cdc.gov/coronavirus/2019-ncov/hcp/disposition-hospitalized-patients.html. Accessed June 22, 2020.
• New York State. Amid Ongoing COVID-19 Pandemic, Governor Cuomo Announces New York is Notifying 49 Other States of COVID-Related Illness in Children. https://www.governor.ny.gov/news/video-audio-photos-rush-transcript-amid-ongoing-covid-19-pandemic-governor-cuomo-announces-ne-1. Accessed June 19, 2020.