Assisted Living Providers Sort Through Confusing Messages About Creating Covid-19 Units

As testing ramps up and the number of positive Covid-19 cases and deaths related to the disease continue to climb, senior living providers are considering how to best care for people stricken with the virus.

One solution that has gained traction in recent weeks is cohorting, or establishing a designated wing in long-term care communities — separating those who test positive for Covid-19 from the healthy census and allowing for unimpeded and safe care without fear of further transmission. Industry associations have recommended that providers consider this approach, and it has been addressed — sometimes confusingly — by officials in some states.

For example, the American Health Care Association/National Center for Assisted Living (AHCA/NCAL) on April 4 issued a guide to cohorting that stated: “Cohorting is imperative to increase the change of controlling the spread of the virus. If possible, nursing homes and assisted living facilities should also begin preparing wings, units or floors as ‘isolation units’.

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But there is no one-size-fits-all approach to cohorting in senior living, AHCA Senior Vice President of Quality and Regulatory Affairs Dr. David Gifford emphasized to SHN.

What we’ve learned during this is, ‘Think before you move.’

naviHealth Senior Vice President of Clinical and Network Solutions Colleen O’Rourke

Up to this point, the Covid-19 cohort concept has gained traction particularly among segments of the long-term care continuum such as rehabilitation facilities and nursing homes. Providers that offer the full care continuum are beginning to adapt their higher-acuity settings for this purpose. One example is RiverSpring Health, a New York City life plan community. Another example is St. Paul, Minnesota-based Presbyterian Homes & Services, which offers independent living, assisted living, memory care, home health, skilled nursing and transitional care.

Last week, Presbyterian Homes and Services and its health system partner, Allina Health, opened a Covid-19 cohort at Interlude Restorative Suites, a 50-unit transitional skilled nursing facility connected to an Allina hospital in Fridley, Minnesota.

This is one of four “Covid support centers” in the Gopher State, and another seven are in development, LeadingAge Minnesota President and CEO Gayle Kvenvold told Senior Housing News.

Assisted living facilities are under growing pressure in some cases to establish Covid-19 cohorts, but this in some cases has led to confusion. For instance, the governor of Michigan issued an executive order that has since been put on pause, while language around cohorting expectations is clarified.

Providers that are exploring cohorting must be mindful of the added pressures this will place on operations, as well as the morale of residents and staff.

Guidance varies by community

With regard to the cohorting guidance issued in early April, AHCA’s Gifford stressed that this is a framework and that implementation will not be uniform, given the fluid nature of the pandemic, layouts of long-term care facilities and the extent of a cluster outbreak in a facility.

“It’s important to remember not to get caught up with the details of a specific sort of guidance, to understand the purpose and intent behind them, because a one shoe fits all approach is not going to work now. When it comes to cohorting, the issue here really is how do you prevent people who have been infected from interacting with other people who don’t have the infection?” he said.

Assisted living providers considering cohorting can learn a lot from their skilled nursing counterparts, naviHealth Senior Vice President of Clinical and Network Solutions Colleen O’Rourke told SHN. Headquartered in Brentwood, Tennessee, naviHealth provides health care solutions for providers across the care continuum, from home-based medical care to post-acute care.

Skilled nursing providers have been quick to cohort healthy residents in order to free up wings in their facilities when others fall ill. Knowing that coronavirus can be transmitted from asymptomatic carriers to healthier people, providers are acting deliberately when cohorting.

“What we’ve learned during this is, ‘Think before you move,’” O’Rourke said.

The physical plant must also be considered when cohorting. Presbyterian and Allina Health set up its Covid-19 suites with negative room pressure to accommodate stronger methods of removing airborne particles from the room. Suites are equipped with internet technology using a smart TV that provides patient education videos and information about their care to help them participate in their recovery. This also provides access to the internet, streaming video entertainment and keeping connected with family and friends online, Presbyterian Homes and Services Vice President of Operations Duane Larson told SHN.

Other things to consider when setting up a cohort are respiratory therapies and oxygen availability. Piped oxygen, particularly, is more convenient and better to use than concentrators or personal tanks that can run into challenges in terms of amount of use and availability, O’Rourke said.

Cohorting provides staffing challenges that are easier to meet in a skilled nursing setting. Providers also need to consider local regulatory environments in exploring segmenting facilities. In Minnesota, for example, there is a wide variation on what is known as “housing with services,” of which assisted living is a subcategory.

“You can have settings that are staffed in such a way that they could provide the clinical needs that an individual might have, and others which don’t approach anywhere near that level of staffing. So even though they might be able to self isolate, you’d still have the challenge of how to manage that individual’s care in these settings if their symptoms are other than mild,” Kvenvold said.

Other states are exploring cohorting for assisted living. The Texas Department of Health and Human Services’ Covid-19 response guidance recommends assisted living facilities “use separate staffing teams for Covid-19 positive residents to the best of their ability.” The agency also suggests providers work with state and local leaders to “designate alternative facilities or units within a facility to separate COVID-19-negative residents from COVID-19-positive residents, as well as those with unknown COVID-19 status.”

Cohorting staffing should follow a one-on-one family liaison model, where a staff member works directly with and communicates with residents and their families, according to naviHealth. This model builds trust and confidence that a resident is receiving the best possible care and reduces anxiety, O’Rourke told SHN.

When it comes to cohorting, the issue here really is how do you prevent people who have been infected from interacting with other people who don’t have the infection?

AHCA Senior Vice President of Quality and Regulatory Affairs Dr. David Gifford

In Michigan, Governor Gretchen Whitmer signed an executive order last week that will eventually pave the way for assisted living providers to set up cohorts to isolate Covid-19 positive residents. But the order lacked specific guidance as to how to achieve this, LeadingAge Minnesota President and CEO David Herbel told SHN.

Michigan does not officially use the term “assisted living.” Instead, what other states define as assisted living facilities are known as “adult foster care” or “homes for the aged.” Whitmer’s executive order lumped these facilities and other long-term care properties within the requirements for nursing homes, adding layers of confusion to how the order should be implemented.

Until further guidance is issued, the Michigan Department of Public Health recommends long-term care providers to begin preparing to cohort, but to not move forward with moving Covid-19 positive residents unless required for medical purposes.

“The department is working very hard to get this clarified,” Herbel said.

Building layout challenges

Physical plant considerations should be another factor to consider for assisted living providers looking to cohort. Most of these communities are already capable of isolating residents to their living quarters to limit the spread of a viral outbreak, Gifford told SHN.

“In assisted living, this is a person’s home. Moving them around may not make sense at all. And it’s not easy because it’s not like a hospital room, where all the furniture is interchangeable. Moving someone is not just asking someone to move into a different bed. It’s really moving them completely around. That’s not an easy task, and may cause just as many problems [as restricting movement],” he said.

Cohorting can be an option for communities that have recently opened and have available space, but have had leaseups stalled due to stay-at-home orders.

You can have settings that are staffed in such a way that they could provide the clinical needs that an individual might have, and others which don’t approach anywhere near that level of staffing. So even though they might be able to self isolate, you’d still have the challenge of how to manage that individual’s care in these settings if their symptoms are other than mild.

LeadingAge Minnesota President and CEO Gayle Kvenvolc

And given the variable nature of how Covid-19 affects people, assisted living providers may in some cases have both the space and the care capabilities to not only cohort their own residents who become ill, but even to take some hospital discharges.

Earlier this month, Phoenix Senior Living announced it would work with Atlanta area health care systems to take on patients, potentially including those with Covid-19, who do not require 24-hour nursing care.

This is something that LeadingAge Minnesota has asked its member providers to consider, but it presents other obstacles.

“If you’ve got the opportunity for physical cohorting, I could see where that could work. The challenge would be having the staffing to be able to manage that, as well,” Kvenvold said.

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