State and county public health departments across the country became acutely aware of how little they knew about the long-term care continuum in March 2020.  

The challenges linked to the coordination of medical care in that unique setting with frail and vulnerable patients at the onset of the pandemic continue to this day. That is why it is so critical to fully engage the experts in geriatrics and long-term care medicine in policy decision-making. It also highlights the essential role of a competent and engaged nursing home medical director during a crisis.

As a physician adhering to the Geriatrics Approach to Care, our complex clinical decisions are made by utilizing often limited medical research and skillfully combining our knowledge with known patient wishes and goals. This intricate balance of managing multiple comorbidities while centering our approach around individual patient priorities has often led to confusion and bewilderment among policymakers.

I was the medical director of a not-for-profit nursing home in California in March 2020. I am proud of the team of professionals who responded to a novel virus that had already devastated a Washington state nursing home. 

During that first week, we met regularly to share ideas and develop plans to protect the residents. It quickly became apparent that there was a likely airborne component. In-person daily meetings became virtual. We shared data and information daily and collaborated with colleagues across the country. We didn’t know what we didn’t know. Until we did. 

On March 9, 2020, the California state chapter of the Post-Acute and Long-Term Care Medical Association (PALTmed) put on a webinar focused on infection prevention and control in nursing homes. Our experts had quickly identified many of the key issues. 

Within a month, we had formulated a “long-term care quadruple aim for COVID response.” It embodied four key principles that have withstood the test of time: 

  • Stellar infection control, including a full-time Infection Preventionist (IP)
  • Access to sufficient personal protective equipment (PPE) 
  • Readily available testing of all staff and residents
  • Operating under emergency preparedness policy and procedure and functioning in an incident command mode 

‘Painfully clear’ need for informed policy

More recently, PALTmed has spearheaded an effort to improve nursing home staff and vaccination rates through a CDC-funded grant. It has been painfully clear that COVID-19 is still with us. 

The need to incorporate expert guidance with effective communication is essential as we deal with complex and sometimes counterintuitive information. I was a contributor to a recent study based on computer simulation modeling conducted by researchers at the Public Health Informatics, Computational, and Operations Research (PHICOR) at the City University of New York Graduate School of Public Health and Health Policy (CUNY SPH). 

We found that sending nursing staff home who are mildly ill with COVID-19 could worsen preexisting understaffing and lead to more missed care tasks, hospitalizations, deaths and costs. During the COVID-19 pandemic, the national guidance was to send staff testing positive for COVID-19 home for up to 10 days to reduce virus spread. While this clearly made sense earlier in the pandemic, when the risks from COVID-19 were dramatic, this new modeling study showed that sending staff home could worsen understaffing. The model demonstrated the clinical risks of understaffing, with 4.3 additional hospitalizations and 0.66 deaths due to staff being sent home for a 100-bed nursing home. 

An alternative to sending staff home is to have only those with mild symptoms work while wearing N95 respirators, which averts understaffing, increases the number of completed resident care tasks, lessens hospitalizations and deaths, and reduces costs. For example, the study showed that when 75% of mildly ill staff worked while wearing N95 respirators, there were five more resident COVID-19 cases but no additional COVID-related hospitalizations. 

Highlighting the complexity of policymaking in the long-term care setting, our modeling study predicts that allowing mildly ill staff to work while wearing N95 respirators alleviates understaffing caused by COVID-19 furloughs and potentially reduces unnecessary harm to residents. 

Nevertheless, infectious disease and long-term care medicine experts would not want to encourage staff to work while sick and contagious, and ideally, the impact of understaffing could be mitigated by other means. 

Determining appropriate and effective policy that can inform operational decisions during a crisis requires the collaboration of expertise in post-acute and long-term care medicine. 

Policymakers at the county, state and federal levels need to keep this in mind, not only in dealing with COVID-19, but for all issues facing vulnerable older adults in this unique care setting.

Michael Wasserman, MD, CMD, is a geriatrician and member of the Post-Acute and Long-Term Care Medical Association (PALTmed) Board of Directors. The opinions shared here are his own.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

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