“We Are Alone in This Battle”: A Framework for a Coordinated Response to COVID-19 in Nursing Homes

Abstract

As of May 2020, nursing home residents account for a staggering one-third of the more than 80,000 deaths due to COVID-19 in the U.S. This pandemic has resulted in unprecedented threats to achieving and sustaining care quality even in the best nursing homes, requiring active engagement of nursing home leaders in developing solutions responsive to the unprecedented threats to quality standards of care delivery during the pandemic. This perspective offers a framework, designed with input of nursing home leaders, to facilitate internal and external decision making and collective action to address these threats. Policy options focus on assuring a shared understanding among nursing home leaders and government agencies of changes in the operational status of nursing homes throughout the crisis, improving access to additional essential resources needed to mitigate the crisis’ impact, and promoting shared accountability for consistently achieving accepted standards in core quality domains.

As of May 2020, nursing home residents account for a staggering one-third of the more than 80,000 deaths due to COVID-19 in the U.S. This pandemic has resulted in unprecedented threats to achieving and sustaining quality of care even in the best nursing homes. Nursing homes are required to implement effective, data driven quality assurance and performance improvement (QAPI) programs that are systematically focused on improving the care and lives of their residents (Center for Medicare and Medicaid Services (CMS), 2016). During this crisis, QAPI requirements have been narrowed to center on two quality domains, adverse events and infection control (CMS, 2020a). Under normal circumstances nursing homes rely on established standards and guidelines to operationalize QAPI programs (Zale & Selvan, 2010). However, a key response to the devastating impact of COVID-19 on residents has been the massive amount of new guidance nursing homes continually receive from multiple federal, state, and local (e.g., public health department) governmental agencies related to these core domains. This top-down, poorly coordinated communication strategy is highly ineffective, often confusing, and enormously stressful to nursing home leaders who, in the best of times, have limited capacity to process and act on information from numerous sources (D’Adamo, Yoshikawa, & Ouslander, 2020).

Under normal circumstances, most nursing homes are stretched to provide essential care to residents coping with complex physical, functional and cognitive needs (White, Aiken, & McHugh, 2019). This pandemic has created a crisis situation due to the challenging needs of residents with COVID-19 and the unparalleled growth in demands for quality data from multiple agencies. Even more troubling is the fact that these homes lack essential resources required to protect their residents and staff. One nursing home leader stated, “we are alone in this battle”, reflecting the sense of abandonment that is shared by many in the industry as they work tirelessly, but not collectively, to respond to unparalleled threats (J. Duffey, personal communication, April 20, 2020).

Immediate solutions are critically needed to position nursing home leaders to maximize available resources, rapidly communicate major gaps in these resources, and be assured of timely assistance from governmental agencies to prevent major interruptions in the delivery of established standards of care quality that all residents deserve. A framework, designed by the authors and critically reviewed by nursing home leaders, provides a path forward to better position nursing home leaders and their teams to achieve these goals. This perspective describes this framework and offers ideas for its use by decision-makers, both internal to nursing homes (e.g., nursing home administrators, directors of nursing), and external to nursing homes (e.g., county health departments, policy makers at all levels). It also suggests policy opportunities to advance widespread use of this roadmap to assure acceptable levels of care quality throughout and beyond COVID-19.

Framework to guide quality assurance

A framework to guide operational decision-making during this crisis, “Nursing Home Capacity to Provide Quality Care During COVID-19 Pandemic” was designed, independently reviewed by six leaders from four Philadelphia nursing homes and refined based on their input. The “Ethical Framework for Health Care Institutions Responding to Novel Coronavirus SARS-CoV-2” (Berlinger et al., 2020) was developed to assist health systems and community centers associated with hospitals to discuss, review, and update institutional policies concerning care of patients during times of diminishing resources such as the COVID-19 pandemic. While its full adoption in these settings is unclear, health system leaders have acknowledged its utility in addressing ethical issues raised by the COVID-19 pandemic (Meagher et al., 2020). In recognition of the complexities associated with balancing person-centered care with public health demands in the nursing home settings, this source framework (Berlinger et al., 2020) was adapted to characterize four stages of operations: Standard, Contingency, Crisis, and Catastrophic. “Standard Operations” reflects a capacity to deliver care to residents that meets accepted quality standards. “Contingency Operations” represents a moderate decrease in this capacity, leading to interference with the consistent delivery of established levels of quality. “Crisis Operations” suggests a significant decline in capacity that results in substantial and ongoing interference with achieving quality standards. “Catastrophic Operations” represents a sentinel failure, where delivery of care consistent with established standards is not possible.

Consistent with federal and state guidelines, categories of resources essential to mitigate COVID-19 represented in this framework include: Testing, Personal Protective Equipment (PPE), Bed Availability, Staff, Leadership, Registered Nurse Infection Preventionist, Culture of Care, and Physical Environment (CMS, 2020a; 2020b; Commonwealth of Pennsylvania Department of Health, 2020a; 2020b; Wright, 2020). Figure 1 depicts the dynamic and interdependent relationships between these categories and stages of operations. For example, limited access to testing and PPE in one nursing home contributes to increased infections among staff which, in turn, reduces availability of requisite staff to deliver care consistent with accepted standards. The net effect is a facility in “Crisis Operations”. If reductions in staff are protracted and a high proportion of residents are subsequently diagnosed with COVID-19, the situation in this nursing home converts to “Catastrophic Operations”. Alternatively, adequate access to testing and PPE enables another nursing home to maintain accepted levels of quality and, thus, this facility remains in the “Standard Operations” stage.

Figure 1.

Operational Framework to Guide Decision Making During the COVID-19 Pandemic*

Par Level = pre-determined quantity of a resource item that a nursing home should always have, PPE=personal protective equipment, RN=registered nurse, DOH=department of health, COVID=COVID-19 or coronavirus.

*Adapted from the “Ethical Framework for Health Care Institutions Responding to Novel Coronavirus SARS-CoV-2” (Berlinger et al., 2020).

Use of framework for internal decision making

The proposed framework provides a path for nursing home leaders to anticipate and continuously monitor critical resource categories during the COVID-19 pandemic and to use findings to both plan for operational changes or initiate interventions in response to new operational threats. Using data on variables identified under each resource category (see Figure 1), QAPI team members could develop plans responsive to threats likely to contribute to adverse events and infection control. For example, in a preparedness exercise a nursing home might assume that 50% of residents and staff are infected and PPE is in short supply. With these data, they would then conclude that they are in “Crisis Operations”. Their goal, in turn, would be to improve operations to the “Contingency” level. Guided by the resource categories defined in the framework, they might decide to halt all new admissions (Bed Availability) until all residents and staff suspected to have COVID-19 are tested (Testing Kits), resources are secured for all staff to receive a ration of PPE for daily use (PPE), external staff support is enlisted from external agencies or pools to meet minimum state hours (Staffing), and leadership reaches out to external experts for leadership support (Leadership). A communication strategy could be designed to continually update family members and staff on progress in mitigating risks (Culture of Care). Additionally, the plan might include offering staff assigned to COVID-19 residents alternative housing, emotional support and additional remuneration (Culture of Care). Finally, the plan might include cleaning and disinfecting all surfaces prior to clustering infected residents in one area (Physical Environment). Any set of circumstances that moves a nursing home from “Standard Operations” to another level should trigger implementation of plans to return to a higher level of operations.

Use of framework for external support

While leaders may be able to implement some dimensions of proposed contingency plans, most will not be able to do so without external support. Support from county, state, and federal leaders is critical to enable nursing homes to acquire and maintain the additional resources needed to mitigate COVID-19 risks (D’Adamo, Yoshikawa, Ouslander, 2020). The proposed framework can be used to facilitate effective collaboration and coordination among nursing home leaders, governmental agencies and other key stakeholders, with attention to communication of timely and accurate data (McClelland et al., 2017). Nursing home leaders who provided input in the design of this framework (Figure 1) suggested that a streamlined set of core data relevant to each of the resource categories be reported daily to local, state and federal agencies. The use of a standardized format is essential to assure that consistent and reliable information is shared with these agencies and burden on an overwhelmed nursing home staff is minimized. In turn, this data could trigger targeted and more immediate responses. For example, if one or more nursing homes in a community are determined to be in “Crisis Operations”, an external team of quality experts might be enlisted to focus on the needs of specific facilities. Through collaborations with local academia and state government, Missouri has implemented such a state-wide program to support local QAPI teams (Rantz et al., 2009). Nursing homes that have successfully mitigated the impact of COVID-19 can be identified from these data; then, strategies employed by them to maintain or return to “Standard Operations” can be shared with others. Overall, the operations’ trajectories and lessons learned can inform the development of policies that will better position nursing homes for future crises.

To assure nursing homes are positioned to deliver accepted standards of care quality to residents in the core quality domains of adverse events and infection control, immediate action on the following federal and state policies is needed:

• Implement a single, standardized mechanism for routine communication by nursing homes of changes in operational status during COVID-19 to local, state and federal agencies;

• Fill immediate gaps in essential resources (e.g., testing, PPE, additional staffing, RN infection control nurse) to nursing homes in “Contingency” or “Crisis” stages of operations;

• Provide emergency support (e.g., interim management team, staff from local staffing core or national guard) to nursing homes in “Catastrophic” stage of operation;

• Enact legislation modeled on the state of Missouri to provide external support to nursing homes in “Contingency” or “Crisis” stages of operations; and

• Assure public reporting of responses by local, state and federal agencies to nursing homes in “Crisis” or “Catastrophic” stages of operations.

Conclusion

Active engagement of nursing home leaders in developing solutions responsive to the unprecedented threats to care quality posed by COVID-19 is imperative. This perspective offers a framework designed with input of nursing home leaders to facilitate internal and external decision making and collective action to address these threats. Policy options focused on assuring a shared understanding of changes in the operational status of nursing homes throughout this crisis, improving access to additional essential resources needed to mitigate the impact of this crisis, and promoting shared accountability for consistently achieving accepted standards in core quality domains are identified. Nursing home residents are arguably the most vulnerable population to the human devastation wrought by this pandemic. Nursing home leaders cannot be left “…alone in this battle” in providing residents with the quality of care they need and deserve.

Key Points:

• The needs of nursing home residents during the COVID-19 pandemic demand a coordinated response among nursing home leaders and government agencies.

• Consistent use of an operational framework during a coordinate response can inform decisions related to quality.

• A standardized strategy to communicate resource needs to governmental agencies is essential.

• Accountability for care quality needs to be shared among internal and external stakeholders.