COVID-19 Webinar Series Session 13 – Nursing Home Care

12:00 p.m. – 12:05 p.m.     Welcome and Introductions

Rachel Nuzum, MPH

Vice President of Federal and State Health Policy, The Commonwealth Fund

@raenuzum

12:05 p.m. – 12:45 p.m.    Moderated Discussion

Richard Feifer, M.D., MPH, FACHE

Chief Medical Officer, Genesis HealthCare; President, Genesis Physician Services

@richfeifer

Vincent Mor, Ph.D.

Florence Pirce Grant University Professor, Department of Health Services, Policy & Practice, Brown University School of Public Health

@themoruknow

Terry Fulmer, Ph.D., R.N., FAAN

President, The John A. Hartford Foundation

@johnahartford

(This is an unedited transcript. For accurate quotes and presentations, please refer to the full-event video.)   0:05 Hello and welcome to our covid-19 webinar series. I am Kathy martucci director of policy and programs at the Alliance for Health policy. For those of you that are not familiar with the alliance. We are a nonpartisan resource for the policy Community dedicated to advancing knowledge and understanding of how policy issues we launched this series to provide insight into the status of the covid-19 response and shed light on remaining gaps in the system that must be addressed to limit the severity of the impact in the US. 0:36 The Alliance for Health policy gratefully acknowledges the National Institute for Healthcare Management foundation and the Commonwealth fund for supporting our series you can join today’s conversation on Twitter using the hashtag all Health Live and follow us at all Health policy. 0:55 We want you all to be active participants in today’s discussion. So please get your questions ready. Here’s how you do it. You should see a dashboard on the right side of your web browser that has a speech bubble icon with the question mark you can use that speech bubble icon to submit questions you have for the panelists at any time. We will collect these and address them during the broadcast. You can also use that icon to notify us about any technical issues. 1:19 You may be having Check out our website. I’ll Health policy dot-org for background materials including the panelists slides a recording of today’s webinar will be made available there soon. 1:33 Today are excellent panelists will discuss policy options to support high quality care for nursing home residents during the covid-19 pandemic. Now, I’m pleased to turn it over to Rachel Newsome vice president of federal and state health policy for the Commonwealth fund who is going to moderate today’s discussion. 1:52 Thank you so much Catherine good afternoon nursing home residents have been disproportionately affected by covid-19 the nature of this coronavirus which is particularly harmful to older adults and people with multiple chronic conditions has left residents vulnerable. The pandemic has also heightened existing challenges in our fragmented long-term care system today. I’m pleased to be joined by a group of distinguished panelists to help us talk through some of these issues first. We have dr. 2:22 Pfeifer who is chief medical officer of Genesis HealthCare and the president of Genesis Physician Services next. We’ll be joined by dr. Vincent Moore the Florence Pierce Grant professor of health services at Brown University School of Public Health. Finally. I’m pleased to be at least introduce. Dr. Terry Fulmer who serves as the president of the John a Hartford Foundation. Thank you all for joining us today and for Lending your expertise to this critical topic now, I’m going to turn it over to dr. Richard Cypher. 2:52 her opening remarks Thank you, Rachel. Well Genesis is the largest operator of skilled nursing facilities and nursing homes in the United States. And so we have quite a bit of experience over the last couple of months with the coronavirus pandemic. And so I’m going to share with you A View From The Trenches. I’m going to tell you a little bit about how per outbreaks happen how covid outbreaks happen in nursing homes and the mitigation strategies that can impact them. I’ll share six observations and seven. 3:23 Policy considerations before we go through other speakers and then get to QA and so let’s go to the next slide, please. 3:36 In the next slide after that. 3:38 Thank you. So this is how nursing home covid-19 outbreaks happen. The virus has to get into the facility get into the nursing home and it needs to spread and there are only four ways the virus can get into a nursing home. The first is through visitors or visitation and the good news. 3:53 There is that we all stopped allowing visitation in early March and so visitors bringing the virus and is actually not a way the virus is typically entering nursing homes right now the other three reasons, however, our new admissions from the hospital is A way the virus still gets into nursing homes, even though we screen patients before they come to the nursing home from the hospital. We screen them for symptoms or signs that may indicate coronavirus request. We request testing at the hospital so that we know coronavirus status and even once they get to a nursing home, we quarantine yet quarantine those patients and yet this is still sometimes a source of outbreaks. The Third Way, the virus gets into nursing homes is outside medical appointments, and certainly we stopped having outside. 4:38 Medical appointments that were discretionary early on in this condemned Akin early March but some visits are still essential like dialysis. And so when a patient goes out for a day offices, they wear a mask and their cohorted into dialysis units for those who are positive or negative and there’s there’s much attention to cleaning and yet despite that. We still see nursing home outbreaks caused by patients catching the virus at appointments like that and the fourth is Staff bringing the virus in from the outside staff people who work in nursing. 5:08 Ons providers doctors nurse practitioners and others we screen them all everyone upon entry to these facilities take their temperature ask if they have symptoms or doing more and more testing of staff to see if they might be carrying the virus and then when they’re there they’re following strict hand hygiene. They’re wearing masks all the time and yet in spite of those strategies staff are a source of virus entry. So once the virus gets inside a nursing home, then it can only spread one of three ways contaminated service and surfaces and objects. 5:37 And of course Mental services and cleaning. That’s one way of mitigating that second is Patient to Patient spread. Well, that’s limited significantly by the fact that patients have been largely isolated to their rooms since the start of this pandemic and if they need to leave their room, they wear masks, but of course in many nursing homes patients don’t have private rooms and so they might have roommates and so that is a source of spread and the third is patient to staff to patient that that chain of transmission that can occur sometimes on on gowns. 6:07 I see In gallons that that should be limiting the spread but because of the shortage of personal protective equipment, it’s not always perfect. I’ll get into that in a moment. So let’s get to the next slide. 6:20 Six observations the first which is a dreadful one, but it’s real the case fatality rate the percent of patients who are infected who died in nursing homes approaches 20 percent to more than half of infected patients in nursing homes are contagious, but they’re asymptomatic. They have no symptoms. So we don’t know who they are unless we test for them three. There is a high risk of outbreaks in nursing homes, despite the mitigation strategies that I listed on the previous. 6:50 Slide they are helpful, but they’re imperfect for outbreaks can still happen despite outstanding infection control. We have many examples of nursing homes with outstanding quality ratings with no infection control findings are citations in the past, but very experienced staff and infection preventionist and outbreaks happen. 7:10 Anyway, we’ll talk about some of the reasons why five lack of broad access to accurate and fast testing is costing lives because we can’t tell as contagious as well as we need two and six the greatest risk we see is for the most debilitated patients with comorbidities multiple medical conditions and those with dementia where the risk of spread is so high so, let me turn to the last slide and share with you seven policy considerations that might spur further conversation during our qa1 PPE personal protective equipment availability is still inadequate to support pre-pandemic practices, like changing a gown after Patient whose asymptomatic and the costs of PPE are three times to seven times higher than pre-pandemic levels, but we still need to incur those costs to testing prioritization nursing homes were not at the highest Federal priority for far too long during this pandemic and still asymptomatic patients are not at the top tier swabs and testing supplies are still inadequate in many states turnaround time for the test results, which had been up to 11 days. 8:20 Days is now down to 24 to 48 hours in many cases. But what we really need urgently is point of Care Rapid testing for the virus. Not the antibody 3 the cares act and financial support the cost of PPE hero pay other expenses plus the dramatic reductions in census or placing an already precarious industry at risk and the cares act allocations, very important to nursing homes have been less than one-quarter of what’s necessary to fill the void. 8:49 Or quality improvement in litigation quality oversight processes need to be more efficient relevant and impactful rather than leaving it up to the courts through private litigation during this completely unprecedented crisis 5 collaboration across the healthcare industry now more than ever hospitals and skilled nursing facilities need to work together to establish safe places to care for covid positive and covid negative patients without increasing transmission risk such as the creation of debt. 9:18 dedicated facilities for covid recovery And the next to fall into the same category the same fundamental political structure on which our country was founded. The federal-state balance of power has made for a fractured response to this pandemic in a national crisis like this a centralized response is what’s needed. 9:37 So 6 a patchwork of state regulations and support wide variability exists at State and County levels pertaining to critical issues like the availability of diagnostic testing and policies around cohorting of patients within nursing homes. Now more than ever. We need to align around Medical Science and standardized practices as much as possible and finally 7 federal state and local reporting a while all would agree with transparency in reporting the number of cases and the number of covid related deaths inconsistent definitions and duplication of effort, which is occurring today and will occur more as federal reporting kicks in in a couple of weeks that pulls attention. 10:21 From the bedside where it belongs, so we really need to simplify those processes. And with that. I’ll conclude my prepared remarks and turn it over to our next speaker and look forward to your questions. Thank you so much. Dr. Pfeiffer now, I’ll turn it over to dr. Moore High man the next slide, please. 10:40 and the next slide so this is Vince more. I’m a professor at Brown University and the work I’m presenting is actually been done in collaboration with Rich and his colleagues at Genesis HealthCare. 10:57 It’s an example of a wonderful collaborative relationship something that he talked about sort of at at the end of his remarks and our analyst analyst groups graduate students postdoctoral fellows and faculty and staff have been working closely with I’m trying to look at their data to understand the phenomenon of what’s going on in this covid environment to turn their frantic and hectic life of responding to crises into some signals that we can actually see for systemic systematic review and we’ve learned a huge amount and I’m hoping they had because we’ve been trying to use our skills to try to answer basically very pragmatic questions that will be important in terms. 11:43 Terms of their making operational definitions. So just to get in this my work is also been funded by the National Institute on Aging. This is a this work we’re doing with Genesis is actually part of a supplement to a large program project looking at the future of nursing home care in America. So I’ve been doing this kind of work for some time. So just what’s important to recognize is that there’s been this late recognition. 12:13 Nursing homes are in some sense. The epicenter of the consequences of the pandemic nursing homes. Did cause this pandemic they’re the people however who bear the brunt of the the phenomenon Nursing Home in other Residential Care settings have been sort of the biggest losers in many respects with the most concentrated in that adverse effects associated with this pandemic. So as a society, we’ve been kind of surprised and looking for someone to blame. 12:42 Lame and unfortunately nursing homes have a long history of being blamed sometimes because there are bad apples as it were but I’m hoping I can convince you in the next few minutes that this is not the issue of bad apples. This is actually a where where you are not who you are. So this is from the Kaiser Family Foundation. 13:03 There are a very high proportion of all deaths in the states where covid has been as been visited most aggressively that are People who died in nursing homes. So in New York state actually just sort of discovered another sixteen hundred deaths from from the from the epidemic people complain think this is terrible. 13:24 This is all due to the fact that the nursing home, but if I could have the next slide Next slide please. This is the same phenomenon that’s happening in Australia and Singapore Norway Israel, France a high proportion of all deaths due to covid are associated with people living in residential and Elder Care settings. So this is not a unique American phenomenon that we have to worry about. This is something that’s broader next slide, please. 13:57 So we combined we looked at this is data from the Genesis facilities. And we looked at what are the factors that differentiate facilities that do have a positive covid case and those that don’t have awesome covid case and the most important factors are the size and if you look at the bottom of this slide is basically the number of cases per hundred thousand in the county where the nursing home is located. 14:24 So where the pain Chemical is Broad. The nursing homes are much higher risk of becoming becoming poke covid positive and a bigger nursing home is has more more risk than a smaller one. So it’s all about the traffic and weather the traffic that is the people who come in and out of the nursing home whether the traffic has a high risk of catching covid or the virus in the community because most people who carry the virus are asymptomatic in the community. 14:55 That’s why it’s Sufficiently next slide, please. 15:00 So here’s the same thing. We see that this is a very strong relationship across the entire country where they number of cases per cow per hundred thousand in the county is high. The number of sniff beds. The number of cases in the skilled nursing facilities is also High that’s just the relationship of where you are next slide, please. 15:23 For all the things we’ve looked at we’ve done actually regression analyses through some of these data we found that basically it’s unrelated to Quality rankings. Even in the states where Kaiser says there has been this relationship. It is actually not related to that when you properly control for the number of people in the county who have have the condition, so it’s basically large Urban facilities with more minority residents in counties with many Urban. 15:52 Covid cases. Those are the epicenter those the Target and that’s the places that really need the help next slide. 16:02 So it’s about the traffic the bigger the building the more people will enter if you’re in a county with many cases more the traffic will be infected. So it’s most asymptomatic. So it’s not about the facility, but it’s about the virus. So nursing homes. In order to Grapple with this issue is exactly as Rich suggested any testing and Rapid testing in order to make operational decisions about how to mitigate they need PPE because mostly it’s the people who come into the building. 16:31 And since there are no family members coming into the building and it’s only clinicians and other staff were coming into the building and a few new entrance from hospital, but that’s a minority by and large. It’s mostly the staff were carrying this which means that the current right now in the state of Rhode Island. The governor is just a just said that we’re having basically Hazard pay for people working in Elder Care Homes and nursing homes for this month of for this month of May. 17:00 That’s that’s comes from the there’s act information data that money that comes from the state. And so this extra support for staff is really critical because the nursing homes need and the patients need to rely on them to not go boogying and to open the bars in the grills when they open up because they’ll catch it and they’ll bring it in because they won’t know they have it and infect the patients and that once the patient’s get it they have a very high risk of dying think that’s it for my for my part. Thank you very much for your time. 17:32 That’s implications. That’s it. Protecting alive. There are great. Thank you so much. Dr. More time and I will turn it over to Terry Fulmer. Go ahead Terry great and next slide, please. Thanks, Rich. And Vince for that, you know really important content that really tease up the some of the points that I’d like to make and I want to thank the alliance for creating these important webinars the John a Hartford foundation in New York City. 18:01 T is dedicated to improving the care of older adults and what I want to talk to the policy audience today is about the role of philanthropy and Foundations in these moments of Crisis and men in the long term. So we’re dedicated to improving care for older adults. It’s been our mission since the early 80s and her money is from A&P grocery stores. I always like to give a shout out to that wonderful Legacy store and the Hartford family. 18:28 So as we think about the work that Rich is doing day-to-day in operations and Vince’s research and partnership. What the foundation is doing. What are some of the things where our foundation has three priority areas creating age-friendly Health Systems which start at your kitchen table and should get you back to your kitchen table. 18:49 That means in the system is long-term care and nursing homes and as it’s been pointed out we failed in the systematic approach we support family caregivers, and if ever they needed it, they need it now when they’re told that they can’t come see See the people they love who are nursing homes, and we also support improving the practice of serious illness and end-of-life care. So palliative care making sure people have advanced directives all of this sounds very familiar to you as you think about what you’ve been reading in the Press about nursing homes next slide, please. 19:20 So what have we done as we saw this coming along our foundation and many others serve immediately as conveners. We can support philanthropy can partner with government. We do that all the time with the Center for Disease Control ACL HHS you name it and we try to get to them as quickly as possible so that we can be a part of the solution as riches taking care of patients. 19:49 Vince is doing important research foundations can pull together government academics professional trade Association and other experts and we can also determine where we should offer our help to advance the knowledge. And therefore the policy that has to happen to get ahead of this we can do that very rapidly. We can coalesce and get information exchange and continuing touch points for improve messaging and organization next slide. 20:19 Supporting nursing homes during covid-19 how we partnered with government in the field to support. We have a new rapid response Network and I want to particularly underscore the leadership of the institute for healthcare Improvement in Boston, which is the leadership organization that leads are age-friendly health system work the instantly turned on a dime and got ready to create daily nursing home Huddle’s that happen every day Monday. 20:49 Go through Friday 12 noon to 12:20. And in those National Huddle’s which are funded by our foundation and others are discussing joining us. We talk about one minute of policy one minute of data were joined by various team colleagues from CDC and CMS. And we also talked about clinical and Operational Support. So we welcome everybody on this call to jump on and you’ll learn a lot from watching the chat that comes in from Frontline nursing assistants from CMOS. 21:19 From families, but mostly we’re talking about the clinical facing conversation that’s going on. So in that we have an expert group, that’s our content committee Vince more and Rich both being a part of that that help us figure out what the topic should be. So the topic we started with was personal protective equipment PPE as you’ve heard about already testing capacity for both residents and staff and administrators by the way staff. 21:49 Are you know sometimes we think of staff is just the clinical people, but every administrator is the same Vector as the staff what to do about staff illness attrition and their well-being. 22:01 We know that staff are suffering because they may have taken care of the same person for three years and that person dies and they see an empty bed the next morning and so we’re working on trying to get a dialogue around how to support those individuals and bringing in every organization that has expertise in At managing transfers to and from emergency departments and hospitals is already been mentioned, but I can’t tell you how much we have failed in doing this properly and correctly. And so that’s a moment to underscore it get the data and improve it the visitation restrictions are crucial and they are painful. We know that some people are dying alone and that their family can’t come see them. We know the good reasons why but don’t underestimate the horrific pain and suffering that goes on. 22:49 on around that next slide So the other thing that philanthropies can do and I know if you watch the news you see people like Mike Bloomberg and how group Rockefeller and Carnegie have come together with 75 million dollars to support New York city. So philanthropy and Foundations also can partner with government in the field to support Solutions and create systemic change. So we already participated in mid-april with the national academies on keeping nurse. 23:21 Mhmm, residents and staff safe and we had over a thousand people sign up for that about 700 joined. And so we’re also our foundation has already committed and begun the finalizing the statement of task for the national academies of science engineering and medicine on a nursing home quality and safety study with Tracy lustig and Cheryl Mass helping us get that organized for an 18-month study to develop a set of consensus findings and to recommend and ensure safety. 23:51 Nursing home residents and staff with a special emphasis on public health impact of pandemics in nursing home care and I’d say that our trustees had an emergency meeting to release These funds instantly and that’s what foundations can do when and we fill in the cracks when when there’s a lot to be done and a lot going on. 24:12 So the next slide we also think about how to help with the announcements that come out every day from CNS reactions so that we can push them out again get that expertise at rapid group of academics government people who are leading critical organizations in this country to understand how people feel of it feel about these press releases this morning. 24:40 We saw that Senator congresswoman Jan schakowsky has Reported out that they want to do a quality for nursing home residents workers through Act of 2020. And so a lot of the content you see in that release this morning talks about the issues that we’ve just heard laid out so clearly and what we need to do next and so we help get that information out and we also help synthesize the various points of view. So new nursing homes and transparency certainly transparencies important. 25:13 We’ve seen AARP released a set of excellent questions and by the same token, we are committed to helping nursing homes answer those questions, which can come at them in ways that seem accusatory when in fact It’s a port so we have to look at these things from both ways. And so I recommend that you look at the AARP website as well. So in closing next slide. 25:40 I want to just say that our foundation is grateful to all of you for what you’re doing in this moment, and that we are dedicated to improving care for older adults no matter where they are and to get them back to the parks and the stores where they belong. Thank you. 25:56 Fantastic, thank you to all three of our panelists for a really excellent overview of the critical issue facing nursing home residents and their families as well as those that take care of them every day. This is time to move to the questions. I will start with you. If you opening questions, and then we will turn to some from the audience just a reminder. You can do that in the question box over to the right, dr. Pfeiffer. 26:25 And dr. Moore both reference data from the Genesis system and noted how critical it is to restrict access to nursing homes. In order to protect the safety of the residents and the workers. 26:39 We also know and I think that performer referred to this as being both crucial and painful that this contributes to social isolation and a reduction in the well-being residents and the staff but it also Cuts families off from from the support and the ability to check in with their loved ones. So I like to start with each of you giving us your sense on whether or not there are models out there right now that exists that can that work to connect residents with their families with their support systems. It’s really difficult time. Are there things that have been working well and what can policymakers do to really address this this phenomenon crying really difficult time? 27:23 I’ll be glad to start. This is Rich Pfeiffer again, and it is such an important point and I’m glad you made it in Terry made it as well. It is it is not only emotionally painful for for nursing home residents and their families, but it causes actual distress and a worsening of behavioral health problems that many nursing home residents have it’s a very serious issue not one that we take lightly and not one that we can fully eliminate because ultimately we’re balancing the need for us. 27:53 Relation, which is the which is what we call social distancing in a nursing home. We’re balancing that against the case fatality rate of 20% Which is also very serious some things that we in we’ve been sure to adopt and and apply in all of our facilities include first making sure that all of our staff know that Behavioral Health Care is an essential medical service. And so we’ve been very clear with our Behavioral Health Partners and providers that we need them. 28:23 Now as much as ever whether it’s in person or via telemedicine, which is often applied so that we can support patients who have diagnosis and those who just need additional support that second is leveraging technology from the very beginning of the pandemic when we started ceasing visitation. We knew this was going to be an issue. We acquired very large numbers of iPad tablets provided them to the nursing homes not for telemedicine use that’s a whole different catch of devices solely for the purpose of keeping residents. 28:53 In touch with their loved ones on a regular basis and and family member feedback on that has been just outstanding. I’m sure there’s more that we all need to learn how to do to make that even better, but it is a very important question. 29:09 So let me just respond. So as Rich suggested this is it’s a really terrible choice for people something like 60 or 70 percent of people in nursing homes have some form of dementia and to imagine seeing people who they otherwise would know and recognize all of a sudden walking around with masks and full gowns as if they’re walking on the moon. It must be an extraordinarily disconcerting experience. 29:38 and we do that because we’re weighing their safety from this high high mortality rate this that you can ignore with the the social interactions and the benefits of socialization and familiarity with the staff but also with family members who then come that cannot come in to see them and that’s a terrible terrible Choice I’m hoping that over time we can figure out a better way to do this but given we just don’t know enough yet about the virus the huge number of large number of people who are asymptomatic right now we’re still unsure about the adequacy of the and the sensitivity of these tests for indicating whether people have antibodies for the for the disease what even though they’re not no longer positive and whether they’re safe to come in and under what circumstances so in the time being we hope that there will be a change in our knowledge and our Need to systematically make change make changes to the our operations within within these buildings. But in the meantime safety is the appropriate first line. And so then how to basically get people connected to family members via the various tablets the various routines and zoom and other things the same thing we’ve been doing with our children and our children’s children from our own little place. 31:08 Aces and because we don’t have much interaction ourselves with people, so if it’s difficult for us, can you imagine how difficult it is for people who are in these in the nursing homes and alone? So what what’s important is to say this puts even more pressure on the nursing homes more pressure on their relationship and the add the Dual fold goal of actually providing as safe as possible environment, which is controlling the behavior of their staff. 31:38 But then also encouraging the staff to be as engaged as possible with the with the patients so that they can connect via device to their family and Big Challenge. 31:55 The only thing I could the both of those answers, I agree with and the only thing I would add is that one of the things I’m hoping will improve is our communication among and across all of us. 32:08 So staff nurses families feel enormous uncertainty about the day-to-day changes and they’re uncertain because we are but that means that we To Triple our efforts to communicate and I know people are trying. Thank you. 32:29 Thanks so much to to all three of you are next. We have a number of questions around testing. Testing has been a critical area in so many different ways during the covid pandemic and I was struck by the the data and the need for almost all three of you mentioned the need for Rapid testing of residence. 32:52 I’m wondering if you could address how why we’re not in a place where we’re Lead testing staff your data shows that they’re the ones having the most regular interactions with the residents. Is it a matter of ill Supply? Is it a matter of prioritization? Is it a is it a policy debate? What’s the what’s the solution here in are we where are we if it is a supply issue. 33:21 Where do you think we are in terms of getting enough supplies in the pipeline to be able to adequately Early tests Workforce Rich, I’ll give it to you. I have a few comments. Yeah. Well, it’s it’s all the above. It’s a supply a policy and a technology issue. So I’m going to start with the easy one. The last one the technology problem is that we don’t yet have a way of testing for the virus itself. It’s the PCR test not the antibody test. 33:53 We don’t have a way of testing for the virus itself itself at Large Scale in Seeing homes today right now. There are very limited supplies of the small rapid testing that I know you’ve all seen about they have not been directed to the nursing home space, but they’re in such short supply across the entire healthcare industry. And so we are relying upon send out test. So right now best case scenario. We’re waiting a couple of days for results in that time. Someone could be spreading the virus or they could be catching the virus. 34:26 And so we need to get th