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The Outsized Impact of COVID in Nursing Homes & in Dementia: Guests Kathleen Unroe & Ellen Kaehr



Many of you listened to our prior podcast with Jim Wright and David Grabowski about COVID in long term and post acute care settings.  In this follow up podcast, we talk about the situation in long term and post acute care in Indiana with Kathleen Unroe, Associate Professor at Indiana University, a scientist at the Regenstrief Institute, and a PI of Optimistic and founder of Probari, and Ellen Kaehr, Assistant Professor of Clinical Medicine at Indiana University and geriatrician and medical director of a nursing home.  A few highlights to wet your appetite:
  • About 2/3 of the Ellen's nursing home is COVID positive.  This has led to so many challenges - how did this happen? (asymptomatic staff).  How to cohort?  Issues with PPE, with transitions to the hospital, with visitors.
  • We talked about the unique impact of COVID on people with dementia.  For example, mobile persons with dementia wander, which has negative aspects, but does keep them functional/mobile.  Now they're confined to their rooms and at much higher risk for debility/decline.  They're also noticing a loss of orientation due to lack of structured activities.  
  • We talk about the impact on Assisted Living Facilities, something that Kathleen has been thinking about increasingly from a policy perspective.  There are twice as many people living in assisted living facilities as nursing homes.  And yet assisted living facilities have received scant attention in this epidemic. 
  • Impact on providers.  This has been so hard.  And clinicians and staff are working so hard to meet this challenge.  How can we support each other during this difficult time?
And they chose an AWESOME song, Paradise by the late great singer songwriter John Prine, who sadly died of COVID related illness.  I couldn't help but overlay a few harmonies on the vocal track.  Sing along!

-@AlexSmithMD



  


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TRANSCRIPT

Eric: Welcome to the GeriPal Podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: And Alex, we are continuing our COVID podcasts, and we have two very special guests with us today.

Alex: We have two special guests from the great state of Indiana. We have Kathleen Unroe, who is associate professor at Indiana University School of Medicine and a scientist at the Regenstrief Institute. Welcome to the GeriPal podcast, Kathleen.

Kathleen: Thank you.

Alex: And we have Ellen Care, who is assistant professor of clinical medicine at Indiana University School of Medicine. She is a geriatrician, who's working in post acute care and long-term care where she also serves as medical director. Welcome to the GeriPal Podcast, Ellen.

Ellen: Thank you for having me.

Eric: So we're going to be talking about what does COVID look like right now in Indiana in particular? We're going to be diving into COVID in nursing home populations as well. But before we go into those topics, we'd like to have a song request for Alex. Do either of you have a song request for Alex?

Kathleen: Yes. I'd like to request Paradise by John Prine.

Alex: And can you tell us why?

Kathleen: Well, I think ... well, first of all, John Prine is one of the more high profile victims of COVID-19, but also this song, it sounds kind of like a eulogy, and we're grappling a lot in palliative care with how to help families say goodbye to their loved ones right now, and then even after people pass away, we're not able to do memorials and funerals, and have families and friends gather together to say goodbye. So, that issue of how to say goodbye, I think, is captured in that song.

Alex: Thank you. Terrific choice. If you're listening, feel free to sing along with the harmonies.

Alex: (singing)

Kathleen: Thank you Alex.

Alex: Thank you.

Eric: So maybe we can start with a big picture overview. We've heard a lot about COVID in New York City, and in Washington. What's it like right now in Indiana?

Kathleen: Well, we're certainly suffering here as well. A lot of similar challenges. So we have about 6.7 million people in the state of Indiana. Indianapolis is about two and a half, three hours from Chicago, just to orient people who aren't in this area. As of data from this week, from 4/21, we've had 12,438 total positive cases, and 661 deaths recorded from COVID-19, so it's certainly hitting different parts of the state differently. Concentration of cases certainly in the urban area of Indianapolis, but there's a positive case in every county in the state.

Eric: Now I was just reading something on the news today about Indiana and COVID where I read about a quarter of all deaths in Indiana are nursing home deaths. Does that sound about right?

Kathleen: I mean it sounds consistent with national data that's been reported, and nationally and internationally it may ultimately be decided to be even higher than that. We're dealing with such extreme vulnerability in this population. The state is now mandating reporting from nursing facilities and so there will be better and better data selection around that over time.

Eric: Yeah. I think one of the challenges that I hear from nursing homes, especially early on in this pandemic is that when people were looking that they were dying, they didn't want to be transferred. Nobody was testing them. They only got tested if they went to the hospital, and even for some of those folks if they looked like they were actively dying, the question was, "Why even bother with testing?" So I think these numbers are so fluid.

Kathleen: Yeah. We need to test ... and now testing is more and more available, but it's really important information. When we talk about best practices for infection control in nursing homes, it's a lot about cohorting residents and the staff who care for them, and so you have to know COVID positive versus negative. So testing is an absolutely crucial part of the approach here.

Alex: My sense is that the epidemic in the US started on the coasts, primarily Seattle first, then New York, and Boston, et cetera, and it's really moving into the middle of the country. Would you say that you're sort of on the upswing in terms of cases, or where are you in general?

Kathleen: I'm not sure. I think there's hope that we may be flattening. Our first cases were people who had been at a conference in Boston and came back to the Indianapolis area, so those were the first known, reported cases. So yes, that sounds consistent with my understanding of how it spread, but it's certainly, certainly we have community spread here, like other places.

Eric: And Ellen, what's it like for you right now? Where does it feel like it is for you?

Ellen: Thank you for asking. So, I am in four weeks of my COVID-19 journey in the nursing home setting, so we had our first case March 24, and we have had a significant amount of cases in our building. So this has very much been a journey. It's been a roller coaster. We've had highs, we've had lows. Everyone's shed tears, whether that's on the job or at home, but I will say my story and my clinical experience is surrounded by teamwork, compassion, and recovery. I've seen such incredible compassion on the floor, so thank you to all the nurses and CNAs for the hands-on care that they are giving. They are being so tender and reassuring to our residents, so thank you to them for keeping us going.

Ellen: We are very much looking towards recovery, so I currently have three wings that are quarantined. So they have all COVID positive residents, and we have two wings with COVID negative residents. We are still practicing social distancing, as all facilities in the country, but yesterday we were able to take residents outside of the building to get some sunshine in the state of Indiana, which was incredibly meaningful to staff and residents. And then I'm happy to say that we are going to get 80% of our residents through this without hospitalization. So we're able to care for these residents in place. And on Friday, we are going to start our round of testing in order to lift quarantine on some of those units. So, by CDC recommendations, we're going to test on Friday and then in greater ... we'll let 24 hours pass, and those with negative tests will be again tested on Monday, and with two negatives, we can really lift them out of isolation and quarantine, which is amazing. We will still have to social distance of course, but we're really excited because I do suspect we're going to get a batch of residents through.

Eric: What does lifting them out of quarantine look like? Is that like, they can use the dining room, or? Yeah, what does that look like in a nursing facility?

Ellen: So I think this is going to play out in phases, and it's going to take some time. We're hoping them to get back into common areas and get some activities going. Prior to being in quarantine, we had everything mapped out and everybody was six feet from each other. So if they were in the dining room, we had the designated seats to be six feet away, and if they were in activities we had it all very strategically planned. So we're at least going to get back to some socialization, which I think is going to be great for our residents' routines. A lot of people have decreased appetite because they're just not getting that stimulus to eat the way group dieting, that provides.

Eric: And can I ask, how many of your patients were actually COVID positive? Was it a significant portion, or very small?

Ellen: So I would say 65 to 70%. So we are a 114 bed facility, so I'm probably looking at about 70 cases. I'm the medical director-

Eric: Wow.

Ellen: ... yeah. I'm the medical director, but I do have another physician there, so I have about 35 to 40 cases myself.

Eric: I mean it sounds like the outcomes that you're seeing are not horrendous. Can you describe a little bit of it kind of again about the outcomes you're seeing in those 60 to 70 individuals?

Ellen: Yeah, absolutely. So, the most common presentation I've seen, and the most common clinical course, is low grade fevers in the 99s for several days, fatigue, and loss of appetite. So it's been extremely non-specific. We have been looking for respiratory symptoms, cough, shortness of breath, and I've seen that in more of the minority of our residents. Again, we are keeping our residents in house as long as they're stable to do so, and that's consistent with their goals of care. Those residents who have been hospitalized, that decision has been made after multiple conversations with families, and we, the residents becoming unstable despite our interventions, and they need urgent and diagnostic intervention. So that's when we're transferring residents.

Alex: I want to ask about ... well there's so many questions, but maybe first I want to ask about when you say, "We're practicing social distancing," of course in a nursing home, the reason people are in the nursing home is because they need assistance with things like feeding and bathing in toileting, and you can't do that from six feet away. So what is social distancing mean for these residents who need so much assistance with daily activities.

Ellen: So that's a great point. They can't social distance from staff who are providing care, and they do need a lot of that hands-on care, but we are social distancing them from each other.

Alex: Mm-hmm (affirmative). Yeah. And when, and I wonder about adequacy of PPE and testing. Do you have PPE for all staff, and what's that journey been like? Has it always been this way? Or has it changed over time?

Ellen: Well when we started out, we were hurting for PPE just like every clinic and hospital and nursing home. So, a few things happened along the way with the PPE. So when we got our first cases, we received more resources, so and we also were getting more instruction and guidance on how to preserve PPE. So right now, we're doing okay with masks. We have reusable goggles, and we have gloves, but the shortage is gowns. So reusable gowns, washable gowns is a wonderful resource, we just can't get our hands on those. So we're hurting for gowns right now.

Alex: Mm-hmm (affirmative).

Kathleen: Well, the PPE is one of the biggest issues. We can't keep people in facilities and take care of them unless we have adequate PPE, and so it's a huge issue for nursing homes. But assisted living facilities had even less of these materials on hand. And so a lot of the supplies have gone towards hospitals, so nursing homes and assisted living facilities are rising higher on the radar for everyone, which is incredibly important. The gowns all echo that. That's been the issue in my facility as well. Some people are using patient gowns, but those of course have the short sleeves, so people are sewing sleeves onto the gowns, just trying to think of any creative solutions we can. But that's, it's a major issue to being able to care for people in place and protect our healthcare workers.

Eric: Now I can imagine for a lot of nursing facilities, assisted living facilities, the question when they have the first positive patient, or the first positives, is just, "Get them out of my nursing facility so they won't infect others," and then trying to keep a COVID negative nursing home by getting those individuals out. We hear that a fair amount from nursing facilities. I think part of it is also recognizing that if you have two positives you likely have at least two positives that you don't know you have because they're asymptomatic. How do you guys think about this in your facilities, and maybe on a grander scale, too, Kathleen? In Indiana?

Kathleen: Well, Ellen, why don't you go ahead and go first talking about your facility.

Ellen: Sure. So, our index case was a resident who had a negative workup, and she was becoming unstable. She was crashing before my eyes, and so we sent her out 911, and I called her daughter, and I said, "I'm concerned about COVID." And so she was tested, and that test came back quickly, less than 12 hours, and she was COVID positive. So that's how we learned that we had COVID in our community.

Ellen: So, this was concerning to us, because she was a long-term care resident, and we had restricted visitors for weeks prior to this case, and she hadn't been out to any appointments. So there is COVID in our facility. We're screening staff, we're checking for temperatures, we're checking for respiratory symptoms, we're not letting any symptomatic staff work, but yet we know that this disease can transmit from asymptomatic and presymptomatic hosts, and I believe that's how we're getting it in our long-term care facilities. And we were struggling for PPE at that time, and we have to be meticulous when we reuse it. So it comes into our facilities via those asymptomatic spreaders.

Ellen: So I knew I had to kind of do a pretty wide look trying to test as much as I could in that wing, testing the roommate, testing those with a shared bathroom, and testing staff that have had contact with the resident in the last 14 days, and we did have three asymptomatic nursing staff that were caring for residents. So then we knew it was going to be widespread throughout our building, just because our nurses had it. And so then the state department of health did come out and do testing and help us with cohorting. Ultimately we partnered with the state department of health and a private lab to get all the testing we needed. So throughout maybe two weeks we did get the whole building tested.

Kathleen: Yes. And in our facility our first case had come directly from the emergency department, had been quarantined, and then developed respiratory symptoms after arriving so it was clear. And then we learned his son also got sick that very day, was hospitalized and in the ICU with COVID. So it was a very clear exposure story for that resident. We did then more recently have a long-term care resident test positive, and it's the same story. Had not been out of the building, had not had any family visitors, and so did wide testing throughout the building, and we also have staff who are positive, housekeeping staff, activities staff, so.

Eric: And can I ask, early data from Washington suggested that a lot of individuals, nursing home residents, were asymptomatic, but then like a week later most of them developed symptoms. Are you seeing the same thing? Or are people staying asymptomatic?

Ellen: I'm seeing a large portion of asymptomatic, and so in a couple weeks I'll probably be able to confirm my suspicion of about 20 to 30% are going to be asymptomatic. Now, our residents have communication deficits and cognitive impairment, so they may have mild symptoms, they may have body aches, they may have some chest discomfort, headaches, that I don't know about, because they can't communicate. So are they truly asymptomatic, or do they have symptoms that they're not expressing to us? So the ones I'm alerted to are those elevated temperatures or those change in pulse ox, which unfortunately that means their disease has been going on for several days.

Eric: I also imagine that both with those individuals [inaudible 00:18:47] documented COVID positivity and those were ... pretty much all of your individuals are high risk. Ellen, you experience this on daily basis, Kathleen I know you've done a lot of work around advanced care planning and having these discussions with patients. How are you guys approaching these discussions with patients or family members?

Kathleen: Well, it's certainly ... I think you've had this as a topic of a few of your podcasts, it's not advanced care planning as usual. It's advanced care planning in a crisis. And sometimes it's not advanced, it's just medical decision making for what's going on right now. So, I think that one of the first things we heard is, "We have to do advanced care planning for all nursing home residents," and many of us working in the space were like, "Yes. Yes, you do. That has always, always been true." Because nursing home residents, even absent of COVID-19 are at risk for all kinds of acute illnesses, and falls, and fractures, and so these issues just come up. Well now, they're really coming up with this new threat.

Kathleen: So, Dr. Susan Hickman and I worked on a 12 minute webinar, it's a free webinar on advanced care planning in a crisis targeted to nursing facility staff who are being asked to call and review goals of care with residents. So it's very urgent that we are doing this right now in this environment, but we need to try and do it well. We need to use, have a script in front of us and try not to frighten families, but talk very frankly and honestly. And the other thing is I just said families, and many of our residents have a significant cognitive impairment, and it is families who are the decision makers. But since we've lost the ability to sit down in person with the resident and the family member, we also need to be careful we're not cutting residents out of these conversations and making sure that this truly reflect resident goals of care or their surrogate decision maker with the residents unable to do this.

Kathleen: So, incredibly important issue, high on the radar, but just trying to guide people towards best practice. There's been all kinds of good tools that have been put out. In our webinar we refer to some of the vital talk tools and scripts that are out there.

Alex: That's terrific. I wonder if you want to say something more about your work on Project Optimistic and your company Probari, and how they fit into this epidemic.

Kathleen: Sure. So, I'm the project director and actually Ellen is the associate medical director of Optimistic, which is a CMS clinical demonstration project. It's a $33.3 million project designed to reduce avoidable hospital transfers of long-stay nursing facility residents, and it started in 2012 and is ongoing through fall of this year. And as part of Optimistic, we've embedded additional staff into several nursing homes in central Indiana, and had very exciting results over the years in terms of being able to partner with nursing facilities, implement this evidence based clinical care model, and reduce overall hospital transfers. Based on the success of the Optimistic clinical care model, I founded Probari, a healthcare startup, two years ago, whose mission, whose goal, is to work with nursing facilities to implement this clinical care model. And so it's a novel nurse role that's supported by evidence based protocols, workflows, and software, and we have contracts to do this in Michigan, and in Ohio, and we were actively working on these when COVID-19 happened. These last months our team became very focused on what can we do to meet the immediate need, especially in our state around us?

Kathleen: And we have, Probari has partnered with the Indiana State Department of Health to support statewide efforts to do education and outreach to nursing facilities and assisted living facilities. So Probari nurses are working alongside Indiana State Department of Health nurses to call nursing facilities and assisted living facilities with both their test results, but also how do you cohort residents? What is best practice infection control mean in this setting? If it's a positive case, what are we going to do now? What are the immediate next steps, and what happens next? And if it's a negative case, how do we prepare? What do you need to have in place now in case you do have a positive case in the future?

Kathleen: So we've been doing that work. I think it's been three weeks now, it's been a very busy time, but just very grateful to have these local resources that we were able to quickly connect with state government.

Alex: Right.

Eric: And any big lessons learned in the last three weeks while you're doing this and what your nurses are learning from doing that consultation and that boots on the ground work?

Kathleen: Well, I think we're all learning here. I mean, it just, it's been amazing on the clinical side as a physician, on Monday something is best practice; by Friday, it's not, and that's the same everywhere. So the state regulators are putting out new guidance as we understand what best practice looks like in this setting, and nursing facilities are working very hard to respond to that. But it's a changing landscape, and so that's why having more people and more FTE, more workforce to be supporting nursing facilities and trying to understand what the regulations are, what best practices is necessary, because it's not static.

Eric: Yeah. Can I ask another question? I think we talk a lot about dementia, but we talk about how it affects decision making, and I can only imagine in a nursing facility if you have trouble understanding what's going on in the world, and now you're quarantined in a room, you guys must be facing particular issues around this population of patients with cognitive impairment and dementia. Do you want to describe anything that you're seeing out there and what you're experiencing with this population?

Ellen: Yeah, I'd love to talk about that. There's a lot of morbidity related with COVID-19. There's morbidity related to the illness itself, and then the measures that we're taking to protect our residents and to decrease its transmission. So for our dementia residents, they are having a lot of restlessness, because their routines have been disrupted. Again, since we're not doing group dining, I believe kind of their internal clock is also being disrupted. They don't have that stimulus and that routine in their day. So I'm seeing restlessness, I'm seeing falls, I'm seeing decreased ability. So a lot of our dementia residents struggle to get their nutrition, they struggle to feed themselves every day. So now they have this new routine and a febrile illness, and a lot of our residents are losing the ability to feed themselves, which is devastating. I was in the nursing home today, and a CNA was putting chocolate milk into a spoon and putting it in the resident's mouth because the resident was unable to manipulate a straw, and that's something that they usually can do. So it is going to take an extreme recovery to get our residents back where they were prior to COVID-19.

Eric: Yeah, some of the behaviors that we see in dementia, like wandering, on one hand we talk about it as a problematic behavior. On the other hand, they're walking. They're being functional, and I can imagine in the quarantine, they're stuck in this small little room. Is that right?

Ellen: That's correct. Yeah. We don't want people wandering or pacing and touching all the rails as they do so. So I do have a memory care unit, and I will say there's 98% disease on that unit, because these are people who ambulate, and pace, and they just aren't practicing that hygiene of cover your cough anymore, so it's going to spread very easily on memory care units.

Eric: How about you Kathleen? What are you seeing?

Kathleen: I mean I'll just echo what Ellen says. I mean, the wandering, it's walking, but it's so much more than walking. It's touching, it's picking things up and putting them in your mouth ... and it is not a behavior that you should stop. And best practice dementia care is not just telling them to stop and sit still, but we are restricting mobility because of infection control, and even if someone can move within a wing, the doors are closed and they can't go in a lap around the facility like they could. And so their space is smaller and they can't understand, and will continue to keep trying to open that door. And it's incredibly challenging. And in assisted living, it's just magnified. I mean these are peoples' apartments, peoples' homes, and it's even more difficult to think about how you could move and separate people in that setting.

Alex: Sticking with the assisted living for a moment, I know that you were part of a task force with AGS that's publishing a paper on guidelines for assisted livings in the setting of COVID, Kathleen. Is there anything else that you want to say about assisted livings and what's needed there? Because as you said earlier, people who are getting the attention the earliest and the most were hospitals, right? And then now we're starting to see more attention paid to nursing homes, they're really getting second shrift. And then assisted living facilities have been nowhere on the radar until just recently, and they are probably the last to get PPE and testing. What do we need to do there? What's the situation in assisted living facilities?

Kathleen: Well, there are a lot more assisted living facilities than I realized, more than twice as many as there are nursing homes. There's about 16,000 nursing homes, and there's something like 36,000 assisted living facilities, and many of them are smaller. I think the key with assisted living facilities is they're not medical settings. They're designed to be social, residential settings for care. Their average age is even earlier than nursing facilities. They have even higher rates of cognitive impairments, and so many assisted living facilities have specialized memory care units. So it's over 70% have cognitive impairment in assisted living facilities, and they have less PPE on hand to start with. And so, it's enormously challenging.

Kathleen: The piece I worked on for AGS is a policy brief, and then I just was reading this morning JAMDA has an editorial about assisted living facilities. I think we're naming the problems pretty clearly, and we just need to keep talking about what are the solutions? We have to confront this, and I think also it's we want to have the same expectations in terms of infection control for an assisted living and a nursing home, but they do not have the same resources, the same physical layouts, the same regulations, and so it's just, it's incredibly challenging. But PPE, PPE and testing, mostly. We need to focus up, let's focus on those things.

Alex: Yeah.

Eric: Well, can I focus on one other thing? Because I mean I think this idea of applying the same standards to everybody, it seems like people are trying to do that, but there's some things like a visitor policy, is that what makes sense in the hospital, as you go into nursing facilities or assisted ... especially assisted living facilities, where visitors may actually be the day to day caregivers for that person in an assisted living facility? How should we be thinking about this as we quarantine these populations, as we just say "Absolute no visitors," but also recognizing that for a lot of these individuals, especially in assisted living facilities, their caregiver may no longer be able to come into that facility.

Kathleen: So, many assisted living facility residents receive home healthcare services or hospice care, and those are clearly essential workforce that need to come into the building. But I think you're thinking of family-

Eric: The informal family caregiver that goes into these facilities.

Kathleen: ... Well, I mean we have them in nursing facilities to, to a much lesser extent, but still. So, when we started the visitor restrictions, we had a couple restrictions. For example, we had a resident that is non-English speaking, and so, and has dementia. And so her husband would come in every evening until the day he showed up and he had a fever. So it's just, and then he couldn't come in anymore, but it's really challenging. Assisted living facility residents do receive a lot of visits from their family, social and I'm sure as you describe to help as well, and I think that just has to be carefully negotiated. I mean in terms of any policy around visitor restrictions, besides the sort of one-off exceptions, I have seen some and we have in Indiana around compassionate visitation at the end of life to have one or two people be able to be with people near the end of life. But I recently heard a story of an assisted living facility is their first case was after they had a situation like that, multiple family members were at the bedside, and then after that, that's how they feel they got COVID-19 into their facility. So-

Alex: Oh no.

Kathleen: ... again, naming the problems.

Kathleen: But struggling, struggling to find the solutions here. And I think though it speaks to, there has to be some flexibility and individualization at the say assisted living facility level because they have different layouts, they have different populations, they have different staff capabilities, and so they're just going to have to problem solve that. And so that's where our nurse team can help with that, that's where our state departments of health can help, the trade associations in the nursing home space have been putting out tons of guidance and technical assistance in this area, trying to support facilities through this, and communication with each other.

Alex: I want to ask about ... we've asked other people what this is, we've talked about staff have been sick, and what is this like for you, what's it like for your staff, how are you dealing with this personally? What's it like, Ellen, to come home after a day at the facility? What's this been like?

Ellen: Well, I think it's been an emotional roller coaster. We have a lot of good moments, because I am surrounded by a great team, and they are giving excellent care, and we are getting our residents through this. And so we have a lot of bright moments. There are some dark moments. When you see staff using PPE improperly, kind of due to lack of education, when you see your residents not be able to eat, or when you have a tough conversation with family, it breaks your heart, it's devastating. Even losing one resident to COVID-19 is devastating for the whole facility, the staff, for the families. So, there's a sense of loss and grief.

Ellen: I will say that when I was feeling dark, I wasn't exercising, I wasn't reading, I wasn't kind of sharing my thoughts, but I realize that's just not going to work. So, enjoying my family, picking up a fiction book that's nonmedical, has been a great support. Getting some exercise and some fresh air. My colleagues have been an awesome support. It's emotional. So, I want to make sure that ... did I think this through clearly? I'm using, I'm making the best decisions with the data I have, but we know our data, we get more every day, but it's still somewhat imperfect. So, they kind of go through my plans with me and make sure, "Yeah, I think that you're thinking about that correctly," which just gives me tremendous support and the confidence I need every day.

Ellen: So we're just going through it day by day, and we're going to recover. We're going to be at this for a long time, but we are going to get our staff and our residents through this.

Eric: Mm-hmm (affirmative). Yeah. Kathleen, how about you?

Kathleen: I agree with so many of the things that Ellen has highlighted in terms of the importance of community, talking with colleagues and self care. I am worried about our staff, who have deep and long-standing relationships with these residents, and who are in the facilities for long shifts, and it's very stressful. They're also dealing with family members who are so stressed out as well, and trying to communicate with them and keep them connected to what's happening with the residents, so I think that the staff at nursing facilities is going to need a lot of support, right now and over the long term. Their hearts are in this, and are with the residents, and like Ellen said, it used to be when you had congregate dining you could have four residents at a table and you could have an aide feeding these residents and queuing and helping them drink their drink and all of that, and now it's all room by room. And so it's a lot of work. It's really intense, and so they had to change their jobs around in ways that are really challenging. So, they need a lot of support, so you're right to highlight that.

Alex: I have two more questions, I know Eric has one. Okay, my last two questions. First is Ellen, I think you wanted to give a shoutout to the workers in the hospital who are caring for your patients. Do you want to go ahead and say something there?

Ellen: Yeah, absolutely. So we did a fair amount of advance care planning prior to hospital transfer, and when we make that transfer we make sure that their posts and all their advanced care planning documents go with them and we make sure that the ER has the contact of family, the name, and the phone number. And so my fear, as a geriatrician and a nursing home doctor was that my residents are going to become agitated, distressed, noncompliant, they're going to get unwanted treatments, and that was just absolutely a myth. That's not how it's playing out. Zero percent have been intubated, zero percent have received CPR, a large percent are getting geriatrics and palliative care consults to continue to support these residents and families. And some are offered in-patient hospice when that's appropriate.

Ellen: So, I am so thankful to my geriatricians and palliative care consultants in the hospital. Thank you for caring for our residents with such compassion.

Kathleen: And I'll add that Ellen's been having this experience, though a lot because she and the nursing facility have been so proactive in making sure those documents and those wishes make it into the hospital side. Because I have heard other stories of a nursing home resident arriving in the emergency department, becoming unstable, and getting intubated and then eight hours later, more paperwork arrives from the nursing facility or the hospital staff calls. So making sure that's with them when they hit the door of the emergency department is so critical and yes, I agree, our hospital colleagues are happy to honor those wishes and follow through with those plans of care, but we must make sure they travel across settings. In the emergency department, in usual times, often a family member would show up and be there to help give context, and now there's no family there, so they're having to make quick decisions sometimes without any other people to provide the information, and that's why that [inaudible 00:40:43] handoff, that phone call whenever we're transferring someone out, is absolutely essential. And the ER docs are grateful for it. I mean, every one that I've talked to says, "Thank you for your call." So, they are hungry for that connection so that we can provide coordinated care for this very frail population.

Alex: Okay, last question from me and then I know Eric has one more. Last question from me is, we haven't talked much about post acute care. So you have people who maybe started in your nursing home, went to the hospital, and then are coming back, or people who are in the community, who go to a hospital, become functionally disabled because they become deconditioned in the hospital, and they need, or they have another, they have a skill need for rehabilitation or other services. Whether they be COVID positive or COVID negative, are you taking these patients in your facilities? Are you only taking COVID negative patients? Where should the COVID positive patients who need post acute care go? Thoughts about post acute care, maybe starting with Ellen.

Ellen: So right now, we are not taking any admissions because we have to get our long-term care residents through this. But we are close to taking admissions again. I can very much see us taking COVID positive because we've been through it, and we know how to do it, but we just have to be extremely calculated in that. So we are not open for business yet. That's because we've got to get through this, but I see it in our future.

Alex: And Kathleen?

Kathleen: This has been a real area of controversy across the country. It's one thing to take one of your own residents back, so readmitting a resident that you know and there's a relationship with, even if COVID positive. Facilities are working hard to accommodate that. But the larger question is new admissions. So the people you describe who are deconditioned after their hospitalization or who survived a prolonged mechanical ventilation experience and will need significant rehab. I think there's been a lot of efforts around COVID dedicated facilities, either nursing facilities that have been cleared out or new facilities that are being created, maybe that have been built but had not gotten any residents yet, that are a good solution potentially, but this is just a really difficult issue. So in Indiana, if there's a pending test, the guidance is that that person stays in the hospital until you have the test result back, and that you have a negative test before you accept a resident back, and that if you take a COVID positive patient, that you're taking them onto a COVID positive wing, where they can be cohorted, and you have appropriate PPE.

Kathleen: So, it's difficult to navigate, and I think that it has to be done, but policy around this has to be done in close collaboration with nursing facilities and hospitals about what's appropriate and possible, because some of the guidance that's come out that has said nursing facilities must take COVID positive patients just ... it isn't appropriate. It doesn't seem enforceable. We have such a vulnerable population, and our number one job is protect the people who are here right now, and then look to the post acute care. But there's going to be so much need for this as we are seeing people coming off a ventilator for, after 10, 12 days, so. It's going to continue to be an issue.

Alex: Do you think nursing homes should be incentivized with higher rates if they take COVID positive patients?

Kathleen: Yes. I mean I think there's a lot of work happening around rate setting right now, but I think there has to be some mechanism to support the increased resources that are needed to care for this population, both in terms of having appropriate supplies, and in hazard pay for the staff in these facilities so they can be appropriately staffed. New facilities that are being started for this population really need to make sure that they're working with people who are in this space and know how to care for these residents, but yes, I think that CMS and states are working on all kinds of different things in terms of incentive payments and rate setting to try and recognize the additional effort and specialization that's needed around this.

Eric: I want to thank both of you for joining us today. I am just amazed what you guys are doing. I think we hear a lot about what's happening in the hospitals and how some hospitals have 70% of their patients are COVID positive, and everything that's going on there, just hearing from Ellen too, like 70% of your patients are COVID positive, 100% in the memory ward. And just thinking about the staff who go in there, and to care for these people, and then to go home, and recognize that it doesn't end when you leave the facility. The anxiety and everything still is there. What happens when I go home, and be with my family, and this idea of hazard pay. It's real. This is hazardous. So I just want to say, again, how proud we all are of the amazing work that you're doing, and for really leading the way. Again, I also just want to, when I hear you talking, Ellen, there was no book you could open up to read how to do ... I'm guessing this was not part of your fellowship, like, "Hey, this is what you do during a pandemic." And you're really, you're writing the book for all of us, so thank you both.

Eric: And with that, Alex, do you want to maybe sing more of John Prine?

Alex: One of the greatest singer-songwriters. Heir to Bob Dylan.

Alex: (singing)

Eric: I love that song.

Alex: It's a great song.

Eric: Never heard it before. I loved it. Kathleen, thank you for joining us. It's always great to see you.

Kathleen: You too.

Eric: And Ellen, very big thank you for joining us, and thank you for all the hard work that you're doing, and everybody else in your nursing facility.

Ellen: Thanks for having me. Thank you.

Eric: To all of our listeners, thank you for everything that you're doing during this pandemic, and to Archstone Foundation for your continued support.

Alex: Thank you everybody. We'll see you next time. Bye.

Eric: Goodbye.



Comments

DocHoppy said…
One of my two facilities is all dementia, Alzheimer's, LBD, FTD etc. and my guests are non-stop, in-motion, delightful people. When the virus arrived, I arranged for everyone to be admitted to Palliative Care or Hospice, so the futility of sending them to an ER wouldn't even be an option. Care and comfort, no unnecessary suffering and the same curious clinical presentations with absolutely random, chaotic but terminal processes.
Now, the survivors are ready to resume life with dementia and they are worn out, in need of gentle physical recuperation and awaiting the company of their friends and families.
John Hopkins Dr.P.H.