Advisory Council November 2020 Meeting Presentation: Coronavirus NH Commission

11/09/2020

ADVISORY COUNCIL ON ALZHEIMER'S RESEARCH, CARE, AND SERVICES

Monday, November 9, 2020

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Coronavirus Commission on Safety and Quality in Nursing Homes

Shari Ling, MD

Nursing Homes and COVID-19

  • Nursing homes and other congregate living facilities have been severely affected by COVID-19, as they most often furnish care to older people with multiple chronic conditions such as dementia, who are particularly susceptible to complications from the virus
  • To help CMS inform immediate and future actions and identify opportunities for improvement, the Commission was created to conduct an independent review and comprehensive assessment of how best to address COVID-19
  • The Commission's report contains practices that emphasize and reinforce CMS's strategies and initiatives to help ensure nursing home residents are better protected from contracting COVID-19

Creation of the Commission

  • CMS asked our contractor, MITRE, to appoint a commission of experts to address safety and quality in nursing homes in relation to the COVID-19 public health emergency (PHE)
  • The Commission was asked to use lessons learned from the pandemic and recommend future actions to improve infection prevention and control measures, and safety procedures
  • The Commission focused on nursing homes that are regulated only by CMS, which excludes nursing homes that operate under the Veterans Administration's purview

Commission Members

  • Roya Agahi, RN, MS HCM, WCC; Chief Nursing Officer, CareRite, New York
  • Lisa M. Brown, PhD, ABPP; Professor of Psychology, Palo Alto University, California
  • Mark Burket, CEO, Platte Health Center Avera, South Dakota
  • Eric M. Carlson, JD; Directing Attorney, Justice in Aging, California
  • Michelle Dionne-Vahalik, DNP, RN; Associate Commissioner, State Health and Human Services Commission, Texas
  • Debra Fournier, MSB, BSN, ANCC RN-BC, LNHA, CHC, CPHQ; COO, Veterans' Homes, Maine
  • Terry T. Fulmer, PhD, RN, FAAN; President, The John A. Hartford Foundation, New York
  • Candace S. Goehring, MN, RN; Director, State Department of Social and Health Services, Aging and Long-Term Support Administration, Washington
  • David C. Grabowski, PhD; Professor of Healthcare Policy, Harvard University, Massachusetts
  • Camille Rochelle Jordan, RN, BSN, MSN, APRN, FNP-C, CDP; Senior Vice President of Clinical Operations & Innovations, Signature Healthcare, Kentucky
  • Jessica Kalender-Rich, MD, CMD, AGSF, FAAHPM, FACP; Medical Director, Post-Acute Care, University of Kansas Health System, Kansas
  • Marshall Barry Kapp, JD, MPH; Professor Emeritus of Law, Florida State University, Florida
  • Morgan Jane Katz, MD, MHS; Assistant Professor of Medicine, Johns Hopkins University, Maryland
  • Beverley L. Laubert, MA; State Long-Term Care Ombudsman, State Department of Aging, Ohio
  • Rosie D. Lyles, MD, MHA, MSc, FACA; Director of Clinical Affairs, Medline Industries, Illinois
  • Jeannee Parker Martin, MPH, BSN; President and CEO, LeadingAge California
  • G. Adam Mayle, CHFM, CHC, CHE; Administrative Director of Facilities, Memorial Healthcare System, Florida
  • David A. Nace, MD, MPH, CMD; President, AMDA -- The Society for Post-Acute and Long-Term Care Medicine, Pennsylvania
  • Lori Porter, LNHA, CNA; CEO, National Association of Health Care Assistants, Missouri
  • Neil Pruitt, Jr., MBA, MHA, LNHA; Chairman and CEO, PruittHealth, Inc., Georgia
  • Penelope Ann Shaw, PhD; Nursing Home Resident and Advocate, Braintree Manor Healthcare, Massachusetts
  • Lori O. Smetanka, JD; Executive Director, National Consumer Voice for Quality Long-Term Care, Maryland
  • Janet Snipes, LNHA; Executive Director, Holly Heights Nursing Home, Colorado
  • Patricia W. Stone, PhD, MPH, FAAN, RN, CIC; Professor of Health Policy in Nursing, Columbia University, New York
  • Dallas Taylor, BSN, RN; Director of Nursing, Eliza Bryant Village, Ohio

Commission Objectives

  • Identify best practices for facilities to enable rapid and effective identification and mitigation COVID-19 transmission (and other infectious diseases) in nursing homes
  • Recommend best practices as exemplars of rigorous infection control practices and facility resiliency that serve as a framework for enhanced oversight and quality monitoring activities
  • Identify best practices for improved care delivery and responsiveness to the needs of nursing home residents in preparation for, during, and following an emergency
  • Leverage new data sources to improve upon existing infection control policies, and enable coordinated actions across federal surveyors and contractors (as well as state and local entities) to mitigate the effects of COVID-19 and future emergencies

Principal Recommendations

  • Theme 1: Securing Testing & Screening Capabilities
    • With federal, state, local, territorial, and tribal (SLTT) partners, immediately develop and execute a national strategy for testing and delivering rapid turnaround of results (i.e., results in less than 24 hours) in nursing homes, in combination with CDC recommended screening protocols. Allow nursing homes to tailor the strategy in partnership with federal and SLTT authorities
  • Theme 2: Increasing PPE Supply and Use
    • Take responsibility for a collaborative process with federal and SLTT partners to ensure nursing homes can procure and sustain a three-month supply of high-quality supplies of Personal Protective Equipment (PPE) and essential equipment
    • Work with federal partners, including CDC and FDA, to create specific guidance on the use, decontamination, and reuse of PPE and essential equipment
    • Collaborate with federal and SLTT partners to provide guidance on training to all staff on proper use of PPE and equipment
  • Theme 3: Rethinking Cohorting Practices
    • Update cohorting guidance to balance resident and staff psychological safety and well-being with infection prevention and control
    • Update cohorting guidance to address differences in nursing home resources for cohorting
  • Theme 4: Prioritizing Visitation Activities
    • Emphasize that visitation is a vital resident right. Update and release consolidated, evidence-based guidance on safely increasing controlled, in-person visitation prior to Phase 3 reopenings
      • Update and release consolidated, evidence-based guidance on effectively planning for and implementing virtual visitation tools and techniques
      • Provide resources to help nursing homes assess and improve the mental health and psychosocial well-being of residents during and after the pandemic
      • Assess, streamline, and increase the accessibility of COVID-19-related directives, guidance, and resources on visitation into a single source
  • Theme 5: Supporting Nursing Home Communications with Residents and Families
    • Increase specificity and expand breadth of guidance on communications between nursing homes, residents, and families
  • Theme 6: Strengthening the Workforce Ecosystem
    • Address nursing home workforce hazard pay; assess and leverage emergency nursing home surge support options; and emphasize minimum care standards
    • Issue guidance for on-the-job certified nursing assistant (CNA) training, testing, and licensure; track all CNAs via a central registry; and catalyze interest in the CNA profession through diverse recruitment vehicles
    • Provide guidance grounded in maximizing equity and preventing employee burnout that allows nursing home workforce members to continue to work in multiple nursing homes while adhering to infection prevention and control practices
    • Require a Registered Nurse (RN) to be present around-the-clock in a nursing home when 10% or more of residents test positive for COVID-19
    • Identify and immediately leverage certified infection preventionists who can support nursing homes' infection prevention needs
    • Professionalize infection prevention positions in nursing homes by updating regulations at 42 CFR § 483.80 so more fully qualified infection preventionists are available to serve in nursing homes
    • Require nursing homes to employ infection preventionist(s) with specific educator duties (1.0FTE < 30 resident beds; 2.0FTE > 30 resident beds)
    • Convene a Long-Term Care Workforce Commission and/or Advisory Board to assess, advise on, and provide independent oversight for modernization of workforce ecosystem
    • Work with federal, state, local, public, private, and academic partners to catalyze overhaul of workforce ecosystem.
  • Theme 7: Catalyzing Technical Assistance and Quality Improvement
    • Identify and work to achieve funding mechanisms for -- or reprioritize activities of -- technical assistance and other contractors to increase the availability of collaborative, on-site, data-driven support prior to, during, and after a COVID-19 outbreak
  • Theme 8: Enhancing Facility Design
    • Identify and share with nursing homes short-term facility design enhancements to address immediate pandemic-related risks that can be implemented at minimal cost
    • Establish a collaborative national forum to identify and share best practices and recommendations; facilitate real-time learning on how to best use existing physical spaces
    • Collaboratively establish long-term priorities​ and seek appropriate funding streams for nursing homes to redesign and/or strengthen facilities against infectious diseases
  • Theme 9: Making Data More Actionable
    • Improve COVID-19 data element standardization and data collection while identifying specific actions that CMS and federal partners will take in response to changes in key COVID-19 data indicators based on data reported by nursing homes
    • Develop a single, bidirectional application to serve as a central interface for nursing home data collection and information dissemination that includes essential COVID-19 guidance, statistics, and outcomes
    • Enhance health information technology (HIT) interoperability to facilitate better communication, improve quality measurement standards, and coordinate integration of nursing home data with data from other health organizations

Key Messages From the Commission

  • CMS should act based on the below:
    • Residents and families must be able to connect in meaningful ways to ensure the physical and mental well-being of the resident and to protect against abuse and neglect and to achieve positive outcomes, CMS must ensure nursing homes address this need and residents' other conditions while prioritizing rigorous infection control
    • Nursing home staff must be kept safe and treated with respect in the workplace, which requires access to the right training and equipment, along with compensation that recognizes the risks they take, their dedication to resident safety, and the quality of the care they deliver
    • Nursing home management and staff can be more effective if provided with streamlined communications, reporting capabilities, and access to funds that will support myriad additional costs, and can reduce the trauma of some emergency measures by communicating policies in advance and providing advance notice when activated.
  • CMS should work with its partners to identify sufficient funding for each recommendation implemented
  • CMS should take steps to solve longstanding systemic issues illuminated by the pandemic including a systems focus on long-term care financing and accountability, facility design, workforce, governance/management, technology, and data to ensure nursing home safety and quality

CMS Response

  • The Administration has worked to support nursing homes financially during the pandemic, distributing over $21B to America's nursing homes -- more than $1.5M each, on average
  • To ensure nursing homes had access to supplies, the Administration shipped a 14-day supply of personal protective equipment (PPE) to more than 15,000 nursing homes in May
  • The Administration has also required facilities to report data about COVID-19 cases, deaths, and supply levels, with 99.3 percent of facilities currently reporting
  • CMS took action to help keep COVID-19 out of nursing homes by requiring them to test staff, a requirement that was paired with the distribution of 13,850 point-of-care testing devices to nursing homes
  • The Administration has also deployed federal Task Force Strike Teams in six waves in more than eighteen states to 61 facilities particularly affected by COVID-19 to share best practices and gain a deeper understanding of how the virus spreads
  • CMS also required states to conduct focused infection control inspections at their nursing homes; between June and July, states completed these inspections at 99.8 percent in Medicare and Medicaid certified nursing homes
  • CMS conducts weekly calls with nursing homes, has issued over 22 guidance documents and established a Nursing Home COVID-19 Training program focused on infection control and best practices
  • CMS is using COVID-19 data to target support to the highest risk nursing homes
  • CMS released a COVID-19 toolkit updated bi-weekly to aid nursing homes, governors, states, departments of health, and other agencies that provide oversight and assistance to nursing homes

New Nursing Home Resource Center

  • CMS recently established a Nursing Home Resource Center to provide a one-stop source for providers, partners, residents, and caregivers to find the latest information from the federal government on guidance and resources
  • The Resource Center includes a new comprehensive resource to help train nursing home staff and administrators with COVID-19 information
  • CMS also issued updated guidance in September regarding visitation in nursing homes
  • Information at: https://www.cms.gov/nursing-homes and https://www.cms.gov/files/document/qso-20-39-nh.pdf

The Report, and CMS's Response


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