No one could have imagined the changes we have experienced over the past eight months due to a heretofore unknown viral pathogen. The COVID-19 pandemic has upended all of our lives, many in a profound way. This pathogen’s impact on how we live and work has been highlighted so extensively in the media it requires no further explication. What is possibly less appreciated is the impact COVID-19 has had on long term care (LTC).
As an internist-geriatrician I have dedicated my career to the care of individuals living in nursing homes (NH) and assisted living facilities (ALF). I appreciate the complexities of caring for people who are typically frail and have extensive comorbidity, and I also understand the resource constraints that typify the majority of NHs and ALFs.
Medical Director Position Needed in Assisted Living
While the COVID-19 pandemic has laid bare multiple infrastructure issues that have long plagued LTC, such as inadequate staffing and limited infection control resources, it also has highlighted the critical role of NHs and ALFs within the healthcare continuum, as well as ongoing challenges. In the paragraphs that follow, I briefly describe some of these challenges, particularly regarding medical care, in the hopes of stimulating a much-needed dialogue.
The medical complexity of residents living in ALFs has clearly increased over the past several years, blurring the distinction between NH and ALF residents. Some observers fear that these trends may lead to a “medicalization” of ALFs and detract from the social model of care that has long been their guidepost. Many also fear that the increasing medical care needs in ALFs may lead to regulations similar to those in NHs, ultimately leading to a more rigid institutional environment.
As the battle between the social and medical models of care continues, what is clear is that we need greater physician involvement and leadership in ALFs. I have long argued for dedicated medical staffs in NHs who possess the necessary experience and skill set to effectively manage patients who are increasingly frail and functionally impaired.
In addition, I believe that a position akin to a NH medical director needs to be defined and mandated for ALFs nationally. Templates for such a position already exist and can be applied to accommodate demographic differences at regional and state levels. Without a dedicated medical staff and physician leadership, the challenge of dealing with a COVID-19 outbreak can quickly become magnified.
'If nothing else, we have learned we must act as a team.'
For example, what does a facility do when their attending physicians get sick, fail to make the rounds on their COVID-19 positive patients or are unable to accommodate their patient’s acute medical needs? Who does the executive director in the AL turn to for help with the multitude of policy decisions around infection control, therapeutic standards for COVID-19–infected patients or transfers to and from the hospital?
While NHs clearly have similar issues, their existing infrastructure and regulatory mandates have left them in a better position to respond to emergencies.
Nursing workforce differences also are a major factor to consider given that nurse staffing in ALF varies significantly between states and LPNs, rather than RNs, predominate. Given these challenges I have been incredibly impressed by the resourcefulness of the administrative and nursing staff at the NH and ALFs where I practice. Under intense time and resource pressures, both of these organizations were able to create separate wings for COVID-19–positive patients, acquire the necessary personal protective equipment, establish infection control protocols and maintain safe staffing levels. The commitment to patient care and self-sacrifice that I have observed has been truly amazing.
Acute Care Misconceptions and Communication Concerns
Another issue exposed by COVID-19 concerns the centrality of the “acute care hospital” within the healthcare continuum, despite the fact that at least 40 percent of all COVID deaths in the United States have occurred in LTC facilities. No one, of course, can dispute the hospitals’ essential role in treating the sickest of our patients infected with COVID-19.
Unfortunately, I have noted a lack of understanding on the part of our acute care colleagues concerning the realities facing the LTC sector. I have seen hospital-based case managers subtly threaten the NH or ALF if they refused to readmit patients, suggesting that they would redirect future admissions elsewhere. Both acute care–based administrators and physicians alike continue to base discharge decisions on assumptions about staffing and resources that often don’t apply in LTC. While there is no simple fix to these perception issues, giving LTC leaders a seat at the table is a necessary and vitally important first step.
Communication also is a critical element when it comes to guidance from the department of health or state regulatory agencies responsible for NH and ALF care. While intentions are always good, I have been impressed by the lack of physician involvement at both the policy level and regarding implementation strategies. While much of this issue stems from a lack of identifiable physician leadership in LTC, some relates to a lack of appreciation for the role, both real and potential, of medical providers practicing in NHs and ALFs. Until all stakeholders are meaningfully engaged in determining how to best deliver care in the context of COVID, we will fall short of optimum care.
Hopefully, the lessons learned from the COVID-19 pandemic will lead to better LTC practices at all levels. If nothing else, we have learned that we must act as a team. The John A. Hartford Foundation’s “Rapid Response Network for Nursing Homes,” in concert with the Institute for Healthcare Improvement, is an excellent example of how to engage diverse stakeholders and apply innovative solutions to the challenges of COVID-19.
Paul R. Katz, MD, CMD, is professor and chair of the Department of Geriatrics in the College of Medicine at Florida State University in Tallahassee, Fla.