Medicare payment policy in skilled nursing facilities: Lessons from a history of mixed success.

The current policy environment for rehabilitation in skilled nursing facilities (SNFs) is complex and dynamic, and SNFs are facing the dual challenges of recent Medicare payment policy change that disproportionately impacts rehabilitation for older adults and the COVID-19 pandemic. This article introduces an adapted framework based on Donabedian's model for evaluating quality of care and applies it to decades of Medicare payment policy to provide a historical view of how payment policy changes have impacted rehabilitation processes and patient outcomes for Medicare beneficiaries in SNFs. This review demonstrates how SNF responses to Medicare payment policy have historically varied based on organizational factors, highlighting the importance of considering such organizational factors in monitoring policy response and patient outcomes. This historical perspective underscores the mixed success of previous Medicare policies impacting rehabilitation and patient outcomes for older adults receiving care in SNFs and can help in predicting SNF industry response to current and future Medicare policy changes.

A systematic review of long-term care facility characteristics associated with COVID-19 outcomes.

BACKGROUND/OBJECTIVES: The coronavirus disease 2019 (COVID-19) pandemic has taken a disproportionate toll on long-term care facility residents and staff. Our objective was to review the empirical evidence on facility characteristics associated with COVID-19 cases and deaths. DESIGN: Systematic review. SETTING: Long-term care facilities (nursing homes and assisted living communities). PARTICIPANTS: Thirty-six empirical studies of factors associated with COVID-19 cases and deaths in long-term care facilities published between January 1, 2020 and June 15, 2021. MEASUREMENTS: Outcomes included the probability of at least one case or death (or other defined threshold); numbers of cases and deaths, measured variably. RESULTS: Larger, more rigorous studies were fairly consistent in their assessment of risk factors for COVID-19 outcomes in long-term care facilities. Larger bed size and location in an area with high COVID-19 prevalence were the strongest and most consistent predictors of facilities having more COVID-19 cases and deaths. Outcomes varied by facility racial composition, differences that were partially explained by facility size and community COVID-19 prevalence. More staff members were associated with a higher probability of any outbreak; however, in facilities with known cases, higher staffing was associated with fewer deaths. Other characteristics, such as Nursing Home Compare 5-star ratings, ownership, and prior infection control citations, did not have consistent associations with COVID-19 outcomes. CONCLUSION: Given the importance of community COVID-19 prevalence and facility size, studies that failed to control for these factors were likely confounded. Better control of community COVID-19 spread would have been critical for mitigating much of the morbidity and mortality long-term care residents and staff experienced during the pandemic. Traditional quality measures such as Nursing Home Compare 5-Star ratings and past deficiencies were not consistent indicators of pandemic preparedness, likely because COVID-19 presented a novel problem requiring extensive adaptation by both long-term care providers and policymakers.

Improving Care of Skilled Nursing Patients: Implementation of Early Sepsis Recognition.

An aging population with underlying health conditions, such as heart disease and diabetes, is at high risk for infections, including pneumonia, influenza, and coronavirus disease 2019 (COVID-19). In particular, the number of individuals in skilled nursing and long-term care facilities is increasing and older adults are at greatest risk. Research reveals these infections can lead to sepsis, septic shock, and death unless detected early through a sepsis screening process. The current quality improvement project demonstrates the capabilities of an early sepsis recognition screening tool in a skilled nursing facility and explores process changes required to operate facilities with high quality care. [Journal of Gerontological Nursing, 47(8), 37-44.].

Implementing transitional care in skilled nursing facilities: Evaluation of a learning collaborative.

Proctor's Framework for Implementation Research describes the role of implementation strategies and outcomes in the pathway from evidence-based interventions to service and client outcomes. This report describes the evaluation of a learning collaborative to implement a transitional care intervention in skilled nursing facilities (SNF). The collaborative protocol included implementation strategies to promote uptake of a transitional care intervention in SNFs. Using RE-AIM to evaluate outcomes, the main findings were intervention reach to 550 SNF patients, adoption in three of four SNFs that expressed interest in participation, and high fidelity to the implementation strategies. Fidelity to the transitional care intervention was moderate to high; SNF staff provided the five key components of the transitional care intervention for 64-93% of eligible patients. The evaluation was completed during the COVID-19 pandemic, which suggests the protocol was valued by staff and feasible to use amid serious internal and external challenges.

Implications and Experiences in Postacute Care-Rehabilitation, Long-Term Acute Care, and Skilled Nursing.

Postacute care is a term used to describe a group of health care providers, caring for patients outside of traditional acute care. The populations served and measures of outcomes are similar, but the services provided may vary by type of setting and individual provider. Managing through the coronavirus disease-2019 (COVID-19) pandemic has been both a challenge and an opportunity to demonstrate the vital role of postacute providers in the health care continuum. National media outlets have highlighted emergency departments, critical care areas, and start-up COVID units in acute care hospitals treating critically ill patients battling COVID-19. Stories of nursing homes in crisis over the rapid spread of COVID-19 have saddened readers of newspapers and social media alike. Postacute providers have experienced the pandemic alongside the acute care hospitals in ways that have highlighted the flexibility of postacute care, challenged leaders to lead with intensity, and demonstrated their importance in the continuum of care. Through a series of interviews with postacute care leaders, this article explores the response to the pandemic from the perspective of providers in postacute care settings.

Early COVID-19 First-Dose Vaccination Coverage Among Residents and Staff Members of Skilled Nursing Facilities Participating in the Pharmacy Partnership for Long-Term Care Program - United States, December 2020-January 2021.

Residents and staff members of long-term care facilities (LTCFs), because they live and work in congregate settings, are at increased risk for infection with SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19) (1,2). In particular, skilled nursing facilities (SNFs), LTCFs that provide skilled nursing care and rehabilitation services for persons with complex medical needs, have been documented settings of COVID-19 outbreaks (3). In addition, residents of LTCFs might be at increased risk for severe outcomes because of their advanced age or the presence of underlying chronic medical conditions (4). As a result, the Advisory Committee on Immunization Practices has recommended that residents and staff members of LTCFs be offered vaccination in the initial COVID-19 vaccine allocation phase (Phase 1a) in the United States (5). In December 2020, CDC launched the Pharmacy Partnership for Long-Term Care Program* to facilitate on-site vaccination of residents and staff members at enrolled LTCFs. To evaluate early receipt of vaccine during the first month of the program, the number of eligible residents and staff members in enrolled SNFs was estimated using resident census data from the National Healthcare Safety Network (NHSN†) and staffing data from the Centers for Medicare & Medicaid Services (CMS) Payroll-Based Journal.§ Among 11,460 SNFs with at least one vaccination clinic during the first month of the program (December 18, 2020-January 17, 2021), an estimated median of 77.8% of residents (interquartile range [IQR] = 61.3%- 93.1%) and a median of 37.5% (IQR = 23.2%- 56.8%) of staff members per facility received ≥1 dose of COVID-19 vaccine through the Pharmacy Partnership for Long-Term Care Program. The program achieved moderately high coverage among residents; however, continued development and implementation of focused communication and outreach strategies are needed to improve vaccination coverage among staff members in SNFs and other long-term care settings.

Community Coronavirus Disease 2019 Activity Level and Nursing Home Staff Testing for Active Severe Acute Respiratory Syndrome Coronavirus 2 Infection in Indiana.

OBJECTIVES: To assess whether using coronavirus disease 2019 (COVID-19) community activity level can accurately inform strategies for routine testing of facility staff for active severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. DESIGN: Cross-sectional study. SETTING AND PARTICIPANTS: In total, 59,930 nursing home staff tested for active SARS-CoV-2 infection in Indiana. MEASURES: Receiver operator characteristic curves and the area under the curve to compare the sensitivity and specificity of identifying positive cases of staff within facilities based on community COVID-19 activity level including county positivity rate and county cases per 10,000. RESULTS: The detection of any infected staff within a facility using county cases per 10,000 population or county positivity rate resulted in an area under the curve of 0.648 (95% confidence interval 0.601‒0.696) and 0.649 (95% confidence interval 0.601‒0.696), respectively. Of staff tested, 28.0% were certified nursing assistants, yet accounted for 36.9% of all staff testing positive. Similarly, licensed practical nurses were 1.4% of staff, but 4.7% of positive cases. CONCLUSIONS AND IMPLICATIONS: We failed to observe a meaningful threshold of community COVID-19 activity for the purpose of predicting nursing homes with any positive staff. Guidance issued by the Centers for Medicare and Medicaid Services in August 2020 sets the minimum frequency of routine testing for nursing home staff based on county positivity rates. Using the recommended 5% county positivity rate to require weekly testing may miss asymptomatic infections among nursing home staff. Further data on results of all-staff testing efforts, particularly with the implementation of new widespread strategies such as point-of-care testing, is needed to guide policy to protect high-risk nursing home residents and staff. If the goal is to identify all asymptomatic SARS-Cov-2 infected nursing home staff, comprehensive repeat testing may be needed regardless of community level activity.

Cross-Sectional Prevalence of SARS-CoV-2 Among Skilled Nursing Facility Employees and Residents Across Facilities in Seattle.

BACKGROUND: Skilled nursing facilities (SNFs) are high-risk settings for SARS-CoV-2 transmission. Infection rates among employees are infrequently described. OBJECTIVE: To describe SARS-CoV-2 rates among SNF employees and residents during a non-outbreak time period, we measured cross-sectional SARS-CoV-2 prevalence across multiple sites in the Seattle area. DESIGN: SARS-CoV-2 testing was performed for SNF employees and residents using quantitative real-time reverse transcription polymerase chain reaction. A subset of employees completed a sociodemographic and symptom questionnaire. PARTICIPANTS: Between March 29 and May 13, 2020, we tested 1583 employees and 1208 residents at 16 SNFs for SARS-CoV-2. MAIN MEASURE: SARS-CoV-2 testing results and symptom report among employees and residents. KEY RESULTS: Eleven of the 16 SNFs had one or more resident or employee test positive. Overall, 46 (2.9%) employees had positive or inconclusive testing for SARS-CoV-2, and among those who completed surveys, most were asymptomatic and involved in direct patient care. The majority of employees tested were female (934, 73%), and most employees were Asian (392, 30%), Black (360, 28%), or white (360, 28%). Among the 1208 residents tested, 110 (9.1%) had positive or inconclusive results. There was no association between the presence of positive residents and positive employees within a SNF (p = 0.62, McNemar's test). CONCLUSIONS: In the largest study of SNFs to date, SARS-CoV-2 infections were detected among both employees and residents. Employees testing positive were often asymptomatic and involved in direct patient care. Surveillance testing is needed for SNF employees and residents during the pandemic response.

Modelling resource requirements and physician staffing to provide virtual urgent medical care for residents of long-term care homes: a cross-sectional study.

BACKGROUND: The coronavirus disease 2019 (COVID-19) outbreak increases the importance of strategies to enhance urgent medical care delivery in long-term care (LTC) facilities that could potentially reduce transfers to emergency departments. The study objective was to model resource requirements to deliver virtual urgent medical care in LTC facilities. METHODS: We used data from all general medicine inpatient admissions at 7 hospitals in the Greater Toronto Area, Ontario, Canada, over a 7.5-year period (Apr. 1, 2010, to Oct. 31, 2017) to estimate historical patterns of hospital resource use by LTC residents. We estimated an upper bound of potentially avoidable transfers by combining data on short admissions (≤ 72 h) with historical data on the proportion of transfers from LTC facilities for which patients were discharged from the emergency department without admission. Regression models were used to extrapolate future resource requirements, and queuing models were used to estimate physician staffing requirements to perform virtual assessments. RESULTS: There were 235 375 admissions to general medicine wards, and residents of LTC facilities (age 16 yr or older) accounted for 9.3% (n = 21 948) of these admissions. Among the admissions of residents of LTC facilities, short admissions constituted 24.1% (n = 5297), and for 99.8% (n = 5284) of these admissions, the patient received laboratory testing, for 86.9% (n = 4604) the patient received plain radiography, for 41.5% (n = 2197) the patient received computed tomography and for 81.2% (n = 4300) the patient received intravenous medications. If all patients who have short admissions and are transferred from the emergency department were diverted to outpatient care, the average weekly demand for outpatient imaging per hospital would be 2.6 ultrasounds, 11.9 computed tomographic scans and 23.9 radiographs per week. The average daily volume of urgent medical virtual assessments would range from 2.0 to 5.8 per hospital. A single centralized virtual assessment centre staffed by 2 or 3 physicians would provide services similar in efficiency (measured by waiting time for physician assessment) to 7 separate centres staffed by 1 physician each. INTERPRETATION: The provision of acute medical care to LTC residents at their facility would probably require rapid access to outpatient diagnostic imaging, within-facility access to laboratory services and intravenous medication and virtual consultations with physicians. The results of this study can inform efforts to deliver urgent medical care in LTC facilities in light of a potential surge in COVID-19 cases.

Pflege in Zeiten von COVID-19: Onlinebefragung von Leitungskräften zu Herausforderungen, Belastungen und Bewältigungsstrategien.

Nursing care in times of COVID-19: Online survey of leaders on challenges, burdens, and coping strategies Abstract. Aim: In light of the dynamic developments and consequences of the COVID-19 pandemic for the care of people in need of long-term care the following questions arise: How do leaders of care facilities perceive the challenges, how burdened are they and how do they cope with these? METHODS: Leaders from outpatient and inpatient nursing and hospice care facilities were contacted by e-mail to participate in an online survey. Closed questions were analysed descriptively, open information was analysed by content analysis. RESULTS: From of 4,333 nursing facilities contacted, usable information was available from 525 persons. The greatest pandemic-related, interdependent challenges include concern about infections of patients and employees, procurement of protective equipment, compliance with hygiene regulations, inconsistency and lack of transparency of information and guidelines that are important for work, and loss of income and lead to a cascade of burdens. Around 40 % of respondents are uncertain whether they can cope with these. According to the respondents, the well-being and presenteeism of the leaders surveyed has deteriorated in the course of the pandemic outbreak and they appeared to be more often ill at work. Financial and structural measures, the strengthening of social cohesion and explanation were mentioned as coping strategies. CONCLUSIONS: The results show an increase in challenges and illustrate interdependent pandemic-related burdens. These are mainly met by overtime and additional effort, especially on the part of leaders. It remains unclear what long-term consequences are to be expected from the burden situation.

Policy Recommendations Regarding Skilled Nursing Facility Management of Coronavirus 19 (COVID-19): Lessons from New York State.

To provide policy recommendations for managing Coronavirus 19 (COVID-19) in skilled nursing facilities, a group of certified medical directors from several facilities in New York state with experience managing the disease used e-mail, phone, and video conferencing to develop consensus recommendations. The resulting document provides recommendations on screening, protection of staff, screening of residents, management of Coronavirus 19 positive and presumed positive cases, communication during an outbreak, management of admissions and readmissions, and providing emotional support for staff. These consensus guidelines have been endorsed by the Executive Board of the New York Medical Directors Association and the Board of the Metropolitan Area Geriatrics Society.

Variation in SARS-CoV-2 Prevalence in U.S. Skilled Nursing Facilities.

OBJECTIVE: To identify county and facility factors associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreaks in skilled nursing facilities (SNFs). DESIGN: Cross-sectional study linking county SARS-CoV-2 prevalence data, administrative data, state reports of SNF outbreaks, and data from Genesis HealthCare, a large multistate provider of post-acute and long-term care. State data are reported as of April 21, 2020; Genesis data are reported as of May 4, 2020. SETTING AND PARTICIPANTS: The Genesis sample consisted of 341 SNFs in 25 states, including a subset of 64 SNFs that underwent universal testing of all residents. The non-Genesis sample included all other SNFs (n = 3,016) in the 12 states where Genesis operates that released the names of SNFs with outbreaks. MEASUREMENTS: For Genesis and non-Genesis SNFs: any outbreak (one or more residents testing positive for SARS-CoV-2). For Genesis SNFs only: number of confirmed cases, SNF case fatality rate, and prevalence after universal testing. RESULTS: One hundred eighteen (34.6%) Genesis SNFs and 640 (21.2%) non-Genesis SNFs had outbreaks. A difference in county prevalence of 1,000 cases per 100,000 (1%) was associated with a 33.6 percentage point (95% confidence interval (CI) = 9.6-57.7 percentage point; P = .008) difference in the probability of an outbreak for Genesis and non-Genesis SNFs combined, and a difference of 12.5 cases per facility (95% CI = 4.4-20.8 cases; P = .003) for Genesis SNFs. A 10-bed difference in facility size was associated with a 0.9 percentage point (95% CI = 0.6-1.2 percentage point; P < .001) difference in the probability of outbreak. We found no consistent relationship between Nursing Home Compare Five-Star ratings or past infection control deficiency citations and probability or severity of outbreak. CONCLUSIONS: Larger SNFs and SNFs in areas of high SARS-CoV-2 prevalence are at high risk for outbreaks and must have access to universal testing to detect cases, implement mitigation strategies, and prevent further potentially avoidable cases and related complications. J Am Geriatr Soc 68:2167-2173, 2020.

Nurse Staffing and Coronavirus Infections in California Nursing Homes.

In the United States, 1.4 million nursing home residents have been severely impacted by the COVID-19 pandemic with at least 25,923 resident and 449 staff deaths reported from the virus by June 1, 2020. The majority of residents have chronic illnesses and conditions and are vulnerable to infections and many share rooms and have congregate meals. There was evidence of inadequate registered nurse (RN) staffing levels and infection control procedures in many nursing homes prior to the outbreak of the virus. The aim of this study was to examine the relationship of nurse staffing in California nursing homes and compare homes with and without COVID-19 residents. Study data were from both the California and Los Angeles Departments of Public Health and as well as news organizations on nursing homes reporting COVID-19 infections between March and May 4, 2020. Results indicate that nursing homes with total RN staffing levels under the recommended minimum standard (0.75 hours per resident day) had a two times greater probability of having COVID-19 resident infections. Nursing homes with lower Medicare five-star ratings on total nurse and RN staffing levels (adjusted for acuity), higher total health deficiencies, and more beds had a higher probability of having COVID-19 residents. Nursing homes with low RN and total staffing levels appear to leave residents vulnerable to COVID-19 infections. Establishing minimum staffing standards at the federal and state levels could prevent this in the future.

Solving the COVID-19 Crisis in Post-Acute and Long-Term Care.

Our nation's nursing home industry has been in need of overhaul for decades-a situation made all the more evident by COVID-19. AMDA-The Society for Post-Acute and Long-Term Care Medicine is dedicated to quality in post-acute and long-term care process and outcomes. This special article presents 5 keys to solving the COVID-19 crisis in post-acute and long-term care, related to policy, collaboration, individualization, leadership, and reorganization. Taking action during this crisis may prevent sinking back into the complacency and habits of our pre-COVID-19 lives.