Editor’s Note: Charles A Crecelius, MD, PhD CMD, is the Medical Director for post-acute care at BJC Medical Group and the Project Medical Director for the Missouri Quality Initiative (MOQI). Lori L Popejoy, PhD, RN, FAAN is an Associate Dean for Innovation and Partnerships and an Associate Professor at the University of Missouri Sinclair School of Nursing. She also serves as a co-investigator on the MOQI. We discussed with them the response to the COVID-19 pandemic in long-term care facilities.
Disclaimer: This Perspective interview was conducted on June 29th and is independent of evolving laws and government recommendations regarding social distancing, masks, and nursing home resident isolation practices.
Kendall Hall: Please provide us with a brief introduction to yourselves and your areas of expertise.
Dr. Lori Popejoy: I am Lori Popejoy and I am Associate Dean for Innovation & Partnerships at the University of Missouri, and I’m also an Associate Professor. My area of research is care coordination in transitional care, my clinical specialty is geriatrics, and I have been working in nursing home systems research since the early 90s. Specifically, I work with the Quality Improvement Program of Missouri and I am a co-investigator on the Missouri Quality Initiative.
Dr. Charles Crecelius: I am Dr. Charles (I go by Chuck) Crecelius and I have been practicing (geriatric medicine) for 35 years. I have worked as the Post-Acute Medical Director for BJC Medical Group, a physician group allied with BJC Healthcare in St Louis. I’m also an Associate Clinical Professor of Geriatrics.
KH: For those not familiar with the project, please provide an overview of the Missouri Quality Initiative.
LP: The Missouri Quality Initiative is a CMS-funded innovation project. We are in the eighth year now, and the second phase of the work. In the first phase, we worked with 16 nursing facilities in Missouri with high re-hospitalization numbers. The goal was to begin to manage those re-hospitalizations and care for people living in nursing homes. We did that by situating advanced practice registered nurses [APRNs] in the facilities. They were CNSs [clinical nurse specialists, a type of APRN]; they did not write orders but worked with nursing homes to improve care delivery. We also added this very intense layer of support that included a program manager who worked with the APRNs. We improved their information technology capacity and we improved conversations about advance care planning and goals of care with social workers. The second phase of the initiative introduces a billing component. The facilities were offered the opportunity to not only take care of patients in place, but more opportunity to bill for that care.
CC: Just adding onto that, one of the foundations of the Initiative is the use of INTERACT tools as well as providing provider feedback regarding how they compare to their peers. Blinded of course, but we are trying to drive provider performance by comparison.
LP: Not just comparisons between providers, but also between facilities. They were all given their number of hospitalizations and given a target to meet. We put in friendly competition.
KH: It sounds like a lot of what you are doing are the underpinnings of a safe system. You’ve got the person and family engagement piece where you are talking about the advance care planning, you got the IT component, you have the data feedback. How did you engage the nursing home leadership at those facilities?
LP: The APRNs worked with the nursing homes. They were embedded and they became part of that team. We worked with their system to identify where the weak spots were and begin to improve the facility’s capacity overall. We had leadership meetings, initially monthly and then they dropped to quarterly, where we brought everybody together to talk about the initiative, the pros and the cons, where we were producing good outcomes, and perhaps areas where we needed to think more carefully about ways to improve those outcomes further.
CC: Some of this is driven by value-based purchasing. Nursing homes have slowly become aware that things like fee-for-service are going away and they need to become better at providing higher quality of services. They are being penalized for hospitalizations. Money drives the heart sometimes.
LP: When we first started, information technology was simply not being used. In fact, we were having to bring in fax machines and computers and just some really basic things. And they did not have any information exchange. It was not on their radar as something that they needed to be doing.
KH: Let’s talk about the culture in these nursing homes. Do you look at things like staff turnover and did that improve?
LP: We're actually writing an article right now for the results of the second phase of the Initiative. There are some nursing homes that had a lot of turnover, some not so much. Every nursing home had some turnover, but some definitely had more than others. Unfortunately, when you do nursing home research, turnover is just part of the organization. It’s leadership turnover, it’s staff turnover, it’s provider turnover, in some situations some of our APRNs turned over. You just learn to deal with it. As someone leaves, you have to have a mechanism to pull the new person in, educate them about what you're doing, the goals, and make sure that you build a relationship so everyone stays on the same page.
CC: Part of this whole project is to promote the use of the Clinical Nurse Assistant (CNA) and the value of the CNA. That’s critical. If you don’t put value in the CNA the project is dead in the water. Leadership turnover is sometimes viewed as the biggest catastrophe. I think the worst is actually that slow, insidious CNA turnover and that's hard to address. COVID-19 has blown it out of the water, but that’s a whole other matter.
LP: The CNAs understand the residents. They see them every day and they notice something very subtly, or not so subtly, different, and they have a way of telling the registered nurse or the LPN, who can then pull in the physician provider or nurse provider to analyze and assess what's happening with that resident. It is vital that the people who are right at the bedside understand what that person looks like on a day-to-day, moment-to-moment, basis.
KH: When I was talking about staff turnover, I was specifically thinking of the CNAs and it sounds like providing recognition of their importance in this complex delivery system is critical. So, would you say that improved?
LP: CNA turnovers are actually hard to figure out. It does not seem like it should be hard, it seems like that should be pretty simple, but when we first started, facilities weren’t really thinking about turnover at all. When we started giving them their turnover numbers, particularly their nurse turnover numbers, it was fairly startling to them how much turnover they had and it began to click that they had a bigger problem than they thought they did.
KH: What about impact on other safety concerns? In putting all of this in place, did you see reductions in harms like pressure injuries, resident falls and those types of events? Were you looking at other pieces besides hospital admissions?
CC: We looked at certain quality measures but they were not impacted as much as I had hoped or expected. It was not the focus of the study. In some homes with good uptake we saw a good quality indicator. What was the one that improved the most consistently?
LP: It was the falls. When the APRN really was focused on a specific quality indicator, which they were asked to do, we saw some improvement. For example, they were asked to use a post-acute transfer tool and to closely analyze each transfer and decide on the avoidability of that transfer. Were there any upstream things that happened that made the transfer potentially preventable? Falls is a really easy one to apply that thinking to. For example, maybe a resident was hospitalized because they had a broken hip as a result of a preventable fall. If the fall was prevented, that broken hip wouldn't have happened and the hospitalization would have been avoided. The advance practice nurses started looking intensely at those transfers and really figuring out where to tighten the safety procedures. Are they falling because the environment is unsafe, or are they falling because they're on too many medications? Are they falling because they're not well hydrated and it's 98 degrees outside and the ambient temperature is too high? Or maybe they have diarrhea, some sort of virus, and they need better hydration? You start to shore up some of basic systems of care such as strengthening, ambulation, walking, making sure people are hydrated. You put in a system of delivery of fluids for patients. You start to think about these things and you don't wait for residents to ask, you try to anticipate and get ahead of the problems that may develop.
KH: It's doing the root cause analysis and tackling the root causes before they actually lead to an admission.
LP: It’s like root cause analysis on steroids. We have something like 3000 root cause analysis tools in Phase 1 and 3500 in Phase 2.
CC: One of the simplest things we did was put hydration stations at each nursing station. We provided a big container of a flavored liquid that was easy for the CNAs to serve. I'm embarrassed to say that didn't happen until about a year or two into the project. Why didn't we think of that sooner? Sometimes the obvious solutions aren’t always so obvious.
KH: I see that you got great results. You reduced your admission rate by 30%? Which is fantastic. Do you want to start talking about how the COVID-19 response and the work of the Initiative have intersected? I'd like to talk about the person and family perspective and some of the unique concerns that all of this has brought up for you and how you're addressing them.
LP: This actually leads on nicely from what we were just talking about. Nursing homes are based on group care activities, such as communal dining and other activities that are communal in nature. Then, all of the sudden, you're putting people in their rooms and simple things like a hydration station at the nurse’s station suddenly became less impactful because people are isolated in their rooms. You have to now go to their rooms, interact with them, make sure they have fluids, make sure they are ambulating. All of these things become much more labor-intensive to achieve within the nursing home. And you have to remember that nursing homes are not staffed like hospitals.
We are actually developing a study right now to look at the long-term impacts of required social isolation. By keeping residents safe from the COVID-19 virus and isolating them in their rooms, there are negative physical and emotional impacts. Especially if you add in dementia and people not be able to being able to interpret their environment directly and people with masks on or face shields. They don't understand having to stay isolated or to wear a mask. They want to get out of their rooms, and they want to ambulate. They don't want to stay in that enforced isolation. It became, I think, very complex.
CC: I don't think we were prepared for COVID-19. In our study, we had urban, suburban, and rural homes. Select homes got hit in all three areas, and some had wide-spread outbreaks. We had to admit with our project that the general infection control processes that we use for the flu from year-to-year were not enough. COVID-19 is very different from the flu. There were some homes that were hit pretty badly. Basic PPE [personal protective equipment] was in very short supply for a while, and in some homes, there was no hope of properly managing COVID-19.
Something that has been particularly devastating to a lot of homes is a rise in non-COVID-19 deaths. In one of the homes where I am the Medical Director, we’ve had one COVID-19 death but have had six deaths attributed to social isolation. A resident whose spouse came in every day to feed them before this, there’s no chance for that person to survive. All these people probably had two years of life left, but isolation has caused premature deaths in people who are psychologically disadvantaged and are highly dependent on their family. Nobody really talks about that very much. CMS recently announced that they are trying to come up with some ways to allow visitation in a safe manner, but it’s been a generally unrecognized problem.
LP: When we went into lockdown, we thought, it is going to slow down, we are going to come out of it; but, we're really still in it. They're not opening up and there's a balancing act to all of it. COVID-19 didn't stay out of the buildings because staff were coming in and out and asymptomatic spread was a problem. When all the facilities started to be tested, we were identifying that about 25% of staff and 25% of residents were asymptomatic positive.
CC: Missouri only requires widespread testing if you had a COVID-19 case. So if you haven't recognized that you have a COVID-19 case, you're not doing mass testing and therefore you're susceptible to undetected exposure. We are required to do mass testing until we go two weeks with no new cases. My home would have been scot-free this Thursday but somebody popped up positive. 240 patients and almost equal number of staff that I have to test every week for two more weeks. It's a $50,000 proposition each time. It's really expensive, but you have to keep it up because one staff member brought it in. The concept of social distancing is pretty foreign to staff and many don’t know how to safely have a life outside of the nursing home.
LP: CNAs in particular are quitting because they don’t want to be continuously tested because the process is uncomfortable. Residents have adverse effects like nosebleeds and other problems associated with constantly being tested. They hate it. The other thing is that it's almost playing out as a moral discussion. “Oh, you haven't had COVID-19, you must be doing a really good job of keeping it out”, or maybe you’ve had COVID-19 and therefore you are the opposite, you haven't done a good job. People don't even know they're sick and they bring it in.
CC: It’s not a question of who has had COVID-19 in the building, it’s a question of if you can contain it. Except for two of our buildings, they’ve all done a good job of containing it. For one of the homes, it was March and early in the pandemic and no one knew what to do with it. But now we contact trace, we isolate, we’re much better at containing it in the building. Unfortunately, if you have just one case it shuts you down for 28 days to loved ones. We’re going to see more deaths from isolation than COVID-19.
KH: Should we be treating every resident as if they have COVID-19 – is that the way we need be acting? And at the same time, is there a way to work with families to ensure that the residents do get interaction with their families?
CC: We've gotten quite a bit of money to buy iPads for FaceTime. Many of our buildings are one-story so they are able to do window visits from outside. For people with reduced mental capacity, they still don't understand it. That window is still a prison, I am still locked away.
LP: Not every resident can tolerate wearing a mask. They don’t understand it, they are afraid of it. Particularly if they have dementia. I am wondering if you could limit the number of family members but frankly, any family member coming in is a risk.
CC: Phase 1 of the COVID-19 response basically entailed nobody visiting except under compassionate situations. You get to Phase 2 and you have to have 28 days with no COVID-19 cases and then you can have visits outdoor only, both parties wearing mask, 6 feet apart. However, we are talking to the county Department of Health to better define compassion. Is that when somebody loses weight? When somebody can't sleep at night and is crying? Isn't that compassion?
LP: I’ve thought about this a lot. When nursing facilities who are not a part of a corporation start to have an outbreak, they have to make very complex decisions very quickly. They've never done this before, they may not have an infectious diseases specialist in their building. When things happen and they need help, they need expert help and there really isn't anybody to call. It’s really unfortunate, but there is not a whole lot of capacity in the system to give them the assistance they need.
The infection preventionist within the nursing home is often an LPN and, as good as they are, they are not trained with the critical thinking capacity to do that job in a pandemic. I think it’s unfair to put that level of responsibility on somebody who’s been trained via the internet on infectious disease principles.
CC: Staffing has been at an all-time low at nursing homes. Older workers are afraid to show up because they're older and know they’re at increased risk of contracting COVID-19. It's hard to get young workers to come when they have to wear a mask, and some of them have rejected it. Nobody's really been able to address it. If your facility is willing to admit publicly they are below minimum staffing levels, the government will send in the National Guard for support. But who wants to be on TV with the National Guard coming into the building? It’s seen as an admission of failure and your home will be branded. One of our homes in St. Louis that had an initial outbreak ended up becoming a COVID-19 home. They have done a good job taking care of people with active COVID-19 disease, but people did not want to go there because that's the home that had all the deaths.
KH: Was that home acting like an essentially short-stay or a skilled nursing facility and they just change the model for that?
CC: Right. At the very beginning, I worked with something called the Round Table and we tried to get the homes in the area to become COVID-19 homes. The hospitals were trying to move patients out, not keep them in a hospital forever. We didn’t want a New York situation, where the patients were being forced out and the homes were not prepared to take them. This model worked pretty well but hospital case managers were having real difficulty telling people they should go to these homes full of COVID-19 patients, even though they take good care of residents with COVID-19. People just didn’t want to go there. You’re stigmatized with COVID-19 but it doesn’t mean you’re a bad home.
KH: So what can we do for the nursing homes? If you have to put down some steps or some best practices of an initiative like yours, what do we do right now to help the quality of care and safety of the residents in this situation?
CC: Staffing is still a big issue because nursing homes fall apart with lack of staffing.
LP: I think it is at every level. We need more registered nurses in nursing homes. Right now, we need advanced practice nurses, NPs, and CNAs.
LP: We need people at the local level who can quickly step up and offer support for how you move patients safely between settings if a setting becomes infected. There needs to be someone offering expertise for decision-making in that situation. We can’t just direct homes to use their own policies, as we can’t be sure those policies are correct. Additionally, is there a best practice in how you cohort residents? We know it's easier to cohort in a facility at partial capacity than a full facility because there is nowhere to move patients in a full facility. How do you separate people from each other if one becomes ill and the other does not? When one needs to go into isolation and one needs to go into quarantine? Also, we need good practices about how to manage people with dementia who are COVID-19 positive.
CC: Setting firmer guidance for when you send people to the hospital. Earlier in the pandemic, homes would send people that weren’t that serious to the hospital when they had an outbreak because they didn’t think they could take care of them or because they were low on PPE.
KH: This brings us back to your initiative and its intersection with the COVID-19 response – how are you using the work and the lessons from the initiative in your approach to the pandemic?
CC: With the APRN presence, principles of infection control, early identification of change in condition, ensuring communication with family and physicians, building confidence in treating in place and in the ability to contain infections helped us get back on track with the initiative. Staffing continues to be a rate-limiting problem at times, but things are getting better since access to PPE has stabilized.
LP: We have to ensure there is a robust supply chain. If we have another big spike, is the supply chain going forward going to remain sufficient? A disruption in the PPE supply chain would be deadly. But also, people need to understand when you really need to use an N95 mask and when it may not be necessary.
CC: There are a lot of people offering best practices and I don’t know how that could have been done better. I tend to trust my own medical society. We had a chat room and a lot of good ideas were shared there. The frontline staff from New York and Washington State had some really helpful advice. I would encourage frontline staff in hard hit areas to use forums like that to share what they’ve learned.
LP: I think the ECHO hub and spoke model can be fairly effective at bringing experts to the table. You can have huge teleconference calls where people can hear case studies, hear the expertise, and ask questions.
KH: Perhaps doing that regionally would be a good solution?
CC: It is definitely easier to balance national and regional. We are not New York, so some lessons didn’t apply. We did learn a few things from Kansas and Chicago as they are more similar Midwestern cities. Those conversations were really of value to both sides.
KH: Is there anything you would like to bring up that we have not discussed?
CC: One unique thing about our industry is that we integrate with a lot of other sites and services and have a lot of stakeholders. Part of the key to success is rapid identification of all stakeholders and quick collaboration with them. It is impossible to think in a vacuum in this area. You have to find all key parties and get them to the table quickly. And the one party you forget about is the one that is going to screw you up the most.
LP: It’s crucial to understand the dearth of expertise that could be at a nursing home, particularly rural homes. They need help, not regulation. They need help to understand and to learn, so we need to figure out the balance between regulations and the need for support.