Targeted Recommendations for State of Connecticut Nursing Homes
As healthcare experts working in the field, we are aware that there is significant underreporting and under-testing of COIVD-19 positive nursing home residents and staff. While nursing homes are required to immediately report COVID-19 cases to the Department of Health, and many have been transparent, others have failed to do so. Some facilities lack the capacity to test adequately, some are electing not to engage in widespread testing. This has led to underreporting and has contributed to the silent spread of the disease in some facilities. Family members, staff, residents and the public have the right to know the scope of challenges faced by nursing homes in order to make informed decisions.
The State of Connecticut must immediately require, and provide testing kits, PPE, and staffing to preform comprehensive, widespread testing of all nursing home residents, direct care staff and impacted visitors.
Report tests to county and state health departments, the state medical examiner, CMS, CDC, residents, staff members, ombudsmen and the public, protecting the identities of individual residents and staff.
Provide comprehensive contact tracing of all positive nursing home cases.
Prioritize antibody testing for nursing home staff as it become available.
PPE and Nurse Safety
Nursing homes continue to struggle to access sufficient PPE, including N95 masks and gowns. Suppliers and distributors are charging premiums of up to $8 per mask, a cost that many nursing homes are not able to afford. State support is needed both in the procurement and distribution of essential supplies. Lack of PPE has already contributed to the death of two Connecticut nursing home nurses (https://www.ctpost.com/news/coronavirus/article/Union-chief-lashes-out-after-2nd-nursing-home-15209366.php). Therefore, Connecticut must immediately:
Give the highest priority to nursing homes and assisted living facilities when distributing PPE and supplies.
Provide support including Fit testing kits and fit testing staff to nursing homes to ensure proper Fit testing of all nursing home employees per OSHA standards.
Establish COVID-19 support teams, focusing on facilities that have a history of deficiencies in the area of infection control. These facilities should be carefully monitored.
Hire a full-time RN infection control nurse to work in consultation with nursing homes to provide guidance on best policies for specific nursing homes.
Dignity at the End-of-life: Spiritual Care and Emotional Support
Nursing home residents with COVID-19 are suffering from loneliness and depression due to the visitation restrictions in place. While initially intended to prevent transmission of COVID-19 to this exceptionally vulnerable population, once a nursing home or any assisted living facility is affected by COVID-19, the strategy needs to shift to allow visitation at the end of life.
Because the care requirements associated with providing physical care are time-intensive, family members and chaplains can be a valuable resource to provide for both physical care, spiritual care, emotional support for nursing home residents dying from COVID-19. In order for these interactions to be carried out safely, nursing homes need to be in a position to provide PPE for these visitors.
COVID-19 testing is not compatible with the goals of palliative care. Once COVID-19 is widespread within a nursing home, it can be treated with the focus on palliative care, and testing can be delayed until after death. Given the surge in sudden deaths due to COVID-19 the Office of the Chief Medical Examiner requires additional support for staffing.
Facilitate visitation at the end of life for family members and chaplains, ensuring access to adequate PPE.
Advise all LTC facilities to follow the recommendations in the attached article for end-of-life care planning, comfort care and adequate staffing support to deal with respiratory failure at end of life. See: https://www.healthaffairs.org/do/10.1377/hblog20200330.141866/full/
Provide Intensive Individualized Comfort Care to residents who will not benefit from being transferred to the hospital and to those who prefer to remain in their nursing homes. See attachment.
Ensure access to adequate post-mortem care and facilities by establishing a statewide overflow morgue.
Increase staffing at the coroner’s office to allow for post-mortem care, including post-mortem testing as needed.
Minimum state staffing levels are insufficient to provide adequate care for COVID-19 positive nursing home residents. Each resident requires extra time for bathing, feeding and social support exceeding usual care standards. Compounding the stress of the need for increased care, nursing homes are experiencing high levels of absenteeism due to illness. Even with tremendous wage incentives of up to $50/hr for CNAs and $100/hr for licensed staff, facilities have been unable to achieve sufficient staffing. Therefore additional actions must be taken to support staffing adequacy in nursing homes, including the use of nursing students and pre-licensure RN’s. Strike force teams should be assembled with the goal of providing immediate support to nursing homes requiring additional staffing as has been done in other states (https://www.washingtonpost.com/local/virginia-politics/maryland-forms-strike-teams-to-combat-nursing-home-coronavirus-outbreaks-in/2020/04/07/0792b312-78f5-11ea-a130-df573469f094_story.html). Targeted recommendations include:
Require all nursing homes to meet minimum state mandated staffing levels on a daily basis, and ensure minimum staffing levels are adhered to through comprehensive monitoring.
Halt admissions to all nursing homes failing to meet minimum state staffing guidelines.
Establish a state-wide strike team of physicians, dietitians, National Guard and other experts ready to support staffing needs of affected facilities.
Explore options for families to serve as paid caregivers in home or in collaboration with adult day health or PACE programs.
Permit undergraduate student nurses from accredited programs who have completed 40 hours of direct patient care experience to function as Certified Nursing Assistants in Nursing Homes
Permit graduating senior nursing seniors to function as Licensed Staff in Nursing Homes while awaiting NCLEX licensure.
Support for Nursing Home Staff
Support for nurses has largely been focused on acute care hospitals. Focus needs to shift to long-term care as the majority of Connecticut deaths will likely occur in nursing homes. Connecticut must:
Provide housing and/or transportation options that enable nursing home staff to self-isolate from family members. Establish a state fund to support this effort.
Provide school/child-care options for nursing home staff on the front lines.
Establish a fund for unexpected expenses related to care of COVID-19 patients including housing costs and other expenses.
Resources needed to provide COVID-19 care will quickly exhaust the financial means of many long term care providers, as nursing homes who previously were supported by short-term Medicare rehabilitation money will be nearly exclusively dependent on Medicaid funding.
Establish a fund for unexpected expenses related to COVID-19 response efforts for Nursing Homes
Provide state support for sick leave for 14 days for all nursing home staff.
Post-Acute Care Facilities
Hospitals need to be able to discharge COVID-19 positive older adults into long term care institutions. Establishing post-acute care facilities that are attractive places of residence to both patients and their families will relieve the burden on Connecticut hospitals. In short:
High quality post-acute care facilities are in desperate need across the state. Nursing homes currently do not have the capacity or training to ensure safe care of these residents. COVID-19 positive hospital discharges to nursing homes will propagate the spread of COVID-19 in nursing homes, and put residents and staff at risk.