In the midst of Covid-19, senior living providers are under intense pressure to prevent residents from going to the hospital or other health care settings where they risk becoming infected with the coronavirus. But it’s more difficult than ever to accomplish this goal, because senior living providers also need to limit the number of health care partners coming into their buildings.
From physicians and phlebotomists to x-ray technicians and home care aides, senior living providers usually work with a wide range of medical professionals who help keep residents’ chronic conditions in check and treat more acute issues on site. Now, senior living providers are cutting these care visits to a minimum, having recognized that they pose infection risks.
“Some of this is just anecdotal and us looking for weak points [in infection control], but some of it is also from other providers that have had earlier outbreaks and have given us great advice and been really transparent … that some of the weak points are providers who are rounding at multiple facilities and then coming into your facility,” Meredith Mills, COO of Hershey, Pennsylvania-based Country Meadows Retirement Communities, told Senior Housing News.
Mills’ point was reinforced by Fee Stubblefield, CEO of McMinnville, Oregon-based The Springs Living.
Specifically, The Springs Living believed that its home health care partners were adhering to strict infection control protocols but found this was not always the case.
“We are now reviewing and scrutinizing the relationships with all third-party essential workers,” Stubblefield told SHN in an email. Even those third-party providers that The Springs has confidence in are being asked to enhance their protocols.
Senior living operators are implementing a range of new practices in light of these challenges, not only by providing more care themselves but by increasing their use of telehealth and instituting robust precautionary measures whenever an outside health care provider does need to enter a community. And, the situation suggests that a long-term effect of Covid-19 could be increased investment in robust internal health care capabilities in senior living.
New protocols, assessing risk
To prevent Covid-19 infiltration, senior living providers across the country have been putting increasingly strict rules in place about who can enter their communities, what type of screening they must pass, and the infection control measures they must observe.
Country Meadows, which operates 12 communities in Pennsylvania and Maryland, has encouraged primary care doctors and wound care specialists to connect with residents through telehealth and is allowing technicians on site to do X-rays and blood draws if the technicians wear personal protective equipment (PPE). Therapists who visit a particularly Country Meadows building and no other health care sites are still being allowed in, Mills said.
Residents have the right to a hospice provider of their choosing. Country Meadows has an affiliated hospice provider with a service area that encompasses six of the company’s properties, and the provider is doing its best to limit the overall number of hospice agencies coming into communities.
Non-medical home care is a tricky situation, Mills said. Country Meadows is discouraging residents from having home care workers do companionship visits, but some residents do depend on home care for help with activities of daily living. Yet, home care providers are having trouble with staffing at the moment, making it difficult or impossible for them to limit caregivers to only working at a single location.
“If they need to come in, they’re going right to the resident’s room; they’re not allowed to be outside of the room with the resident,” Mills said. “We’ve been trying to discourage it as much as possible and provide the services as much as we can ourselves.”
In some situations, Country Meadows is weighing calculated risks.
For instance, the organization faced a tough choice related to an X-ray technician who failed the company’s screening questionnaire, because of likely prior exposure to Covid-19 while working in other health care facilities.
“We have to weigh the risk, is it safer for this person to come in to see our resident in full PPE, or is it safer to send [a resident] out to the emergency room where they’re even more likely to be exposed?” Mills said. “If that essential health care provision can be made on site, and if the X-ray provider is in full PPE with an N95 mask, we feel that is a safer option for our residents.”
Pleasanton, California-based HumanGood is another provider that is limiting in-person visits from outside health care providers, and is tightening up its infection control protocols for those who do enter communities.
Notably, HumanGood is requiring that outside health care providers who visit multiple facilities must change their clothes before entering any of the nonprofit provider’s 18 life plan communities. Equipment — such as stethoscopes and treatment bags — also must be disinfected.
“We don’t make them change on-site or sign an affidavit, but we do communicate the policy to them, and I don’t think we’ve had any issues with them complying,” HumanGood Vice President of Communications James Park told SHN in an email.
For their part, health care providers that work in assisted living settings are finding new ways to operate in light of Covid-19.
“It has changed almost everything,” Bluestone Physician Services Founder and CEO Todd Stivland, M.D., told SHN. Bluestone specializes in providing physician services in assisted living communities and serves more than 800 communities in Minnesota, Wisconsin and Florida.
Typically, Bluestone operates on a team-based model, in which a physician, one to three nurse practitioners, and several nurses serve a resident population of about 200 AL residents in a given geography. Now, the teams have split up so that each clinician provides in-person services to as few buildings as possible.
More dramatically, Stivland estimated that about 90% of consultations were being done via telehealth as of last week, thanks to the relaxed Medicare rules around reimbursement that were enacted as the pandemic worsened.
“Without that, I don’t know how we would have ever managed,” he said.
While telehealth reimbursement rates are generally the same as in-person rates, it’s more difficult to establish higher complexity and receive those increased payments, Stivland said. And, with fewer consults happening overall, revenue is down about 40%. The company has tapped into loan programs, and Stivland noted that other types of health care providers such as dentists are in much more dire straits.
“Patients come first, and we’ll figure all that out at the end,” he said, of the financial hit related to Covid-19.
So far, no Bluestone team members have tested positive for Covid-19.
With new protocols limiting the health care services that senior living residents receive in person on a daily basis, there are best practices to observe in order to keep hospitalizations in check — with smart, judicious use of telehealth being a top priority.
“Telehealth — people need to get on board,” Country Meadows’ Mills said. “I don’t know why people think it’s so hard. We’ve been doing it for two years.”
Country Meadows has mainly been using FaceTime via iPads. While that technology is straightforward, having the right policies and structures in place is important. So, Country Meadows has created scripts for nurses to use, if they are communicating with primary care providers who want to send a resident to the hospital. And, the provider has set up a telehealth hotline, which offers urgent care triage to get consultations for residents who otherwise might go to the hospital.
Bluestone’s Stivland concurs with the point that telehealth can be a simple process, particularly for assisted living settings where residents are capable of operating an iPad.
In those cases, staff members can simply give a resident a disinfected iPad, the resident can use it to have a telehealth visit in the privacy of their room, and then the staff member collects the device.
For residents that do not have the capacity to operate in iPad, a nurse might operate the tablet. But anyone in the proper protective gear is capable of helping a resident with an iPad or other device, Stivland noted. This is an important consideration given that caregiving staff are stretched thinly at the moment, and other types of workers are filling in on the fly when they are needed and the situation allows.
In the context of Covid-19, even more attention should be given to the most common causes of hospitalization, such as urinary tract infections (UTIs) and falls, Stivland said. Signs and symptoms of UTIs can be observed by senior living staff working on site or in the course of telehealth consultations and are “pretty easy to manage,” he said.
Falls are a tougher issue, and Bluestone team members have observed an increase in falls during the Covid-19 crisis. Stivland attributes this to several factors, including that residents’ family members are no longer visiting and providing extra sets of watchful eyes and helping hands.
Some senior living providers automatically send any resident who falls to the emergency room. Such policies are typically motivated by fear of being sued, in situations when a resident who falls appears to be fine but later is hospitalized or dies due to complications such as brain bleeds.
Stivland believes that these are bad policies at any time, as they eliminate resident choice while increasing health care system burdens and costs. Now, such policies are especially ill-advised. And, they might be impossible to carry out.
Stivland heard of a situation in which a resident fell, broke a hip, went to the emergency department, and was turned away because the hospital did not have the capacity to treat the injury.
“I can’t give you details on the severity of it or what the course [of treatment] has been, but I would assume they put her on pain control — and we are going to see more of that,” he said.
Stivland is also concerned that hospitalizations could spike in two to three months unless the proper precautions are being taken now for residents with chronic conditions.
With health care staff stretched thinly both within senior living communities and among the outside providers that serve these residents, there is a danger that routine check-in visits are not happening frequently enough, he believes.
“You can [reduce those check-ins] for a short period of time, but if you start doing it for two, three months — and I’ve been in that situation before — things really start to fray, and then all of a sudden you get sick people all over the place,” he said.
So, although he recognizes that they are stretched thinly and focused on Covid-19 issues, Stivland implores senior living providers not to lose sight of more routine care, such as preventing COPD exacerbations or ensuring that psychiatric medications are adjusted correctly.
It’s a concern shared by Mills.
“We work a lot as a team to look for changes in symptom exacerbation, look for changes in our residents’ normal routines, and when they’re being pulled completely out of their normal routine, how do you know what their good baseline is?” she said. “We are really trying to systematically round and take vitals on all our residents, and then using our EHR, really track and trend to see if they’re having changes.”
Senior living’s health care capabilities
One lasting effect of the Covid-19 crisis could be to spur greater investment in health care capabilities among senior living providers that have taken a lighter approach in the past, opting to rely on third-party partners that now are absent from buildings or that create risks with each in-person resident interaction.
Country Meadows has invested in a strong care infrastructure, including staffing nurses around-the-clock, seven days a week at all its campuses. The provider’s in-house expertise and capabilities, combined with extra precautions and rigid protocols, make its campuses safe places even for residents and patients with higher acuity, Mills said.
“We have two former hospital chief nursing officers that run our clinical protocol, and we train all our staff on chronic disease symptom exacerbation and ongoing management,” she said. “We have pretty strong clinical support and we also staff much higher than the state minimums because we know that if we’re going to accept that [higher] acuity, then we need to do it responsibly.”
She credits this type of high-level clinical capability with limiting active Covid-19 infections, with positive cases at four of the 38 buildings across the company’s often large campuses.
She is also grateful that Pennsylvania and Maryland allow assisted living providers to provide care to a fairly high level of acuity.
“When I talk to other states … it was shocking to hear in some states you can’t give a resident their medications or you can’t put a Band-Aid on them, because that’s considered wound care,” she said.
Those states might be compelled to rethink their limitations on assisted living, particularly if AL communities become overflow sites for hospital patients or turn into important settings for Covid-19 care — a possibility that is already taking shape.
Last week, Country Meadows was receiving calls from hospitals in their markets, alerting them to be prepared to take Covid-positive residents back into communities and to have contingency plans in place in case hospital capacity is not available. Mills is confident that Country Meadows will be able to handle these situations as they arise, and sees an opportunity to further cement already strong relationships with health system partners.
“I think the providers that kind of shut their doors and say, ‘we’re not taking that person back,’ it’s either going to really not put them in a good light with the health care system, or it’s going to cause us to look more stringently about what we expect clinically from our capabilities at this level,” Mills said. “[I see] positive possibilities for showing the health care system that we really can be part of the solution, or it’s going to look like we haven’t fulfilled that obligation in a time when we could help.”