The past six months tend to blur together as Sean Cannone, DO, looks back on the dozens of instances when his team from University Hospitals in Cleveland worked with nursing homes in northeast Ohio to prevent and fight COVID-19 outbreaks.
But one occasion stands out.
A facility in a rural county experienced a particularly devastating COVID-19 outbreak in mid-April. It was staggered by a high mortality rate, with staff members falling sick and patients dying alone.
Cannone, the medical director for post-acute and home care, deployed an “intercept team,” using a model he crafted at the beginning of the pandemic to send help to those in the community who were most vulnerable to the effects of COVID-19: the elderly and disabled living in congregate care settings.
The team provided infection control guidance, staffing help, personal protective equipment, remote monitoring technology, and COVID-19 testing support to the struggling facility.
Months later, even as the team has worked with about 200 other facilities in Ohio, Cannone still remembers his feeling of relief when he received the email declaring that the rural facility — after six weeks of battling the outbreak — was COVID-19-free.
“It was just amazing … to see our team from University Hospitals running into this nursing home in the midst of such a significant outbreak, and then to see [the nursing home] all the way through to recovery,” Cannone says. “There were significant risks and challenges, and tireless effort along the way, but it was worth it to help the people there.”
University Hospitals Cleveland Medical Center is one of several academic medical centers across the United States that have developed partnerships with nursing homes and other long-term care facilities in their communities to lend their resources and expertise to mitigate the impact of COVID-19 in these settings where the virus is disproportionately serious or fatal.
“It was just amazing … to see our team from University Hospitals running into this nursing home in the midst of such a significant outbreak, and then to see [the nursing home] all the way through to recovery. There were significant risks and challenges, and tireless effort along the way, but it was worth it to help the people there.”
Sean Cannone, DO
Medical director for post-acute and home care at University Hospitals
Academic medical centers — as home institutions for experts in infection prevention and control, specialists on top of cutting edge research, and leaders in community and public health — are uniquely positioned to extend these resources to congregate care settings in crisis, according to AAMC (Association of American Medical Colleges) Chief Health Care Officer Janis Orlowski, MD.
“We need to think about health care not just as, ‘You get sick, you go to the hospital, and then you leave,’ but rather to be part of the continuum of care from preventive health to ambulatory care through acute care to post-acute care,” Orlowski says. “It’s important for an academic medical center to be part of the community. Part of that is listening to the community, understanding the needs of the community, and then adjusting what you do to meet those needs.”
A perfect storm
Earlier this year, before most regions in the United States were aware of COVID-19 infections in their communities, the country watched in horror as one of its first, deadly outbreaks devastated Life Care Center of Kirkland, a nursing home near Seattle, Washington, killing dozens of residents.
Several months into the pandemic, similar scenes have played out in congregate care facilities across the nation. The Centers for Medicare & Medicaid Services (CMS) began tracking COVID-19 cases and deaths in long-term care facilities — which the agency is responsible for regulating — in May and reports a total of 51,700 COVID-19 deaths as of Aug. 23.
However, that may be an undercount. A Kaiser Family Foundation analysis of data from 45 states reports that there have been 70,649 COVID-19 deaths in long-term care facilities as of Aug. 20, accounting for more than 40% of reported COVID-19 deaths in those states.
Since March 4, the CMS has levied fines of more than $15 million on 3,400 nursing facilities for noncompliance with infection control protocols and failure to report COVID-19 data.
Part of the disproportionate impact on nursing homes comes inherently with the patient populations they serve, says Marcio Soares, MD, chief of the Division of Geriatric and Palliative Medicine at the University of Miami Leonard M. Miller School of Medicine in Florida.
“It’s almost a perfect storm for [a deadly outbreak], unfortunately,” he explains. “They house and care for the frailest of the population … they have a high number of comorbidities, multiple disease processes, [and they’re] progressing in life … They’re in an environment where their possibility of co-mingling is higher.”
Another challenge is that poorly compensated nursing home staff frequently work at multiple facilities to make ends meet, Soares says. This creates the opportunity for a staff member to unwittingly transfer the virus from one home to another, fueling outbreaks.
The CMS announced on Aug. 25 that it would require nursing homes to routinely test staff for COVID-19 infection and that noncompliance could result in a fine.
States like New York, New Jersey, and Pennsylvania — which were hit hardest by the first surge in the United States — have reported the highest nursing home death tolls so far. But a recent analysis of CMS data by the American Health Care Association (AHCA) and the National Center for Assisted Living (NCAL), which together represent 14,000 long-term care facilities in the United States, found that there were more COVID-19 cases in nursing homes in mid-August than during the previous peak on May 31. According to the report, the latest surge is mostly driven by nursing homes in Sun Belt states, which have been seeing higher rates of community spread.
“With the recent major spikes of COVID cases in many states across the country, we were very concerned this trend would lead to an increase in cases in nursing homes and unfortunately it has,” Mark Parkinson, president and CEO of the AHCA and NCAL, said in an Aug. 17 press release. “This is especially troubling since many nursing homes and other long term care facilities are still unable to acquire the personal protective equipment and testing they need to fully combat the virus.”
Bringing expertise into the community
For the health care providers at University of Washington (UW) Medicine, the high death toll at the Life Care Center of Kirkland was a call to action.
“Everyone was incredibly shocked and wanted to act quickly so we could prevent that from happening throughout the region,” says Thuan Ong, MD, MPH, a geriatrician and the chief of the University of Washington School of Medicine’s post-acute care network.
“We have world-renowned researchers, world-renowned clinicians in infectious disease, a world-renowned laboratory. There is a mission to serve the population and that was what it was perceived as. We are here to fulfill that goal, and to step in when others are not able to for the time being.”
Thuan Ong, MD, MPH
Geriatrician and chief of the University of Washington School of Medicine’s post-acute care network
UW Medicine, like many academic medical centers across the country, has formal relationships with skilled nursing facilities in the community to improve the transition for patients between hospitals and these facilities. A team from UW Medicine used the existing relationships with 16 facilities in its network to develop and implement a three-phase approach to supporting facilities’ responses to COVID-19. The team’s involvement ranged from help with planning before any infections entered a building to deploying an emergency “drop team” — made up of volunteer clinicians, nurse practitioners, and an infectious disease expert — within 24 hours to a facility that was becoming overwhelmed by an outbreak.
They also provided testing for all residents and staff at facilities early on, when the world was only just becoming aware of the prevalence of asymptomatic spread, Ong says.
The result not only helped limit the extent to which the virus spread in nursing homes but also likely reduced the number of patients needing emergency services and hospitalization, freeing up resources at health systems, according to a UW Medicine report on the system’s approach.
“We have world-renowned researchers, world-renowned clinicians in infectious disease, a world-renowned laboratory,” Ong says. “There is a mission to serve the population and that was what it was perceived as. We are here to fulfill that goal, and to step in when others are not able to for the time being.”
Rethinking palliative care
In the pre-pandemic world, when a resident in a nursing home was nearing the end of life, hospice care workers would come into the facility to provide support. But with the dangers of COVID-19, even as more residents were becoming sick and dying, most facilities no longer allowed outside providers to come in.
“So many residents were infected and didn’t want to go to the hospital,” says Nina O’Connor, MD, chief of palliative care at the University of Pennsylvania Health System (Penn Medicine).
This meant that O’Connor and other palliative care experts had to rethink how to provide care and support to residents and their families.
As part of a larger collaboration with the public health department in Philadelphia, Penn Medicine created a virtual palliative care support program that connected nursing home staff, residents, and families to resources.
This included making medical center experts available to help with advance care planning, symptom management, medication recommendations, speaking with family members about treatment options, and making connections to social workers and chaplains to help residents and grieving families.
Penn Medicine also helped facilitate the donation of tablets to nursing homes so that residents could connect with loved ones and receive virtual emotional and spiritual support.
Although it wasn’t the same as being physically present, O’Connor says the virtual support could at least provide some comfort.
“Part of our mission”
Early in the pandemic, the geriatricians at UW Medicine realized that they needed to adjust the way that they thought about the residents in nursing facilities.
At most of the facilities, about 10%-20% of the residents were patients at their medical center — meaning that they would consider those residents to be “their” patients, Ong says. But with the dangers of a COVID-19 outbreak in the facility, the UW Medicine team quickly adopted the entire facility as “theirs,” he says.
O’Connor explains that it was vital for the success of the collaborations that the academic medical centers approached partnerships with long-term care facilities in a way that didn’t seem punitive and, instead, promoted a positive relationship.
“It needs to be a peer relationship,” she says. “One doesn’t go into a facility to tell them what to do, but to hear about their experience, to come alongside them and hear what they need.”
It was this sense of responsibility to the community that led the teams at University Hospitals in Cleveland, the University of Miami, and Penn Medicine to put their resources, expertise, and effort where it was needed most.
“Our desire to serve the community as an academic medical center is ingrained in our DNA and it’s part of our mission,” says Phillip Chang, MD, MBA, chief medical officer of University Hospitals Cleveland Medical Center. “That’s what’s really helped us through this crisis.”
