LAUSR

Nursing facilities are in the news often these days, with story after story describing the challenges faced by providers and staff trying to care for residents during a pandemic. Many of these pieces detail concerns about lack of equipment, staff, testing capability, and other resources, some with tragic outcomes. Kim and colleagues, from the University of Washington, describe how they actively leveraged their existing university health system infrastructure with 16 nursing facilities to provide solutions and support. Their work is an example of a meaningful partnership between acute care hospitals and nursing facilities that can support better quality of care for residents. They implemented a three-phase plan, an initial, delayed, and surge plan. The “initial phase” described multiple proactive steps they took with their nursing facility partners to deliver education around best practice infection control, establish surveillance protocols, and create the tracking infrastructure needed to monitor resource needs and disease spread. Every nursing facility in the country has been engaging in these efforts to varying degrees; the University of Washington Medicine (UWM) team’s proactive leadership allowed for standardization of these activities across their 16 skilled nursing facility system. The “delayed phase” details their support of facilities after identification of a positive case, including on-site implementation support for conserving personal protective equipment and infection control practices. Slow access to testing has hampered our national efforts to understand the spread of coronavirus disease 2019 (COVID-19) and respond to it. It is especially critical in nursing facilities to be able to test all contacts with a positive resident, including other residents and staff who may be asymptomatic carriers. The UWM team gained access for all residents of the partner nursing facilities to their health system laboratory and facilitated the collection of samples and efficient delivery of results. Overall staffing is critical to the quality of care and service delivery, yet nursing facilities have long struggled to recruit and retain staff. The continued risks and potentially modified work environments of COVID-19 may only exacerbate front-line staffing challenges. Certified nursing assistants need particular focus, as they deliver the vast majority of hands-on care for residents and are the backbone of the workforce in facilities. In addition to becoming ill or testing positive themselves, staff may have to care for school-aged children at home or care for sick family members. Additionally, staff often work at multiple facilities, which would undermine infection control efforts. Importantly, staff require effective communication and education to allay any fears and concerns of exposing themselves to the virus. Staffing is a real and urgent problem that facilities are grappling with during the pandemic, as they work to provide essential care for frail residents. Some larger chains may have more capacity to shift staff between facilities, agency staffing is being utilized, and the National Guard has even been called up to support staffing at some nursing homes. The UWM plan includes a “surge phase” for the case of an overwhelming outbreak, which involves sending a team of clinicians on-site to support nursing facility staff, including physicians, advance practice providers, registered nurses, and an infectious disease provider. As highlighted in the article, health system partners can serve as a key resource if they participate in contingency planning with nursing facilities, including a willingness to send personnel on-site to support with care. Several policy and economic drivers suggest the need for better partnerships between acute care hospitals and nursing facilities. For example, concerns over reducing readmissions from nursing facilities and recognition of problems with transitions of care have prompted many health systems to develop closer relationships with post–acute care providers. Further, payment mechanisms, such as accountable care organizations and bundled payment programs, have incentivized some health systems to tighten connections with nursing facilities over the past several years. Partnerships take different forms. Some attempts to engage post–acute care providers focus on requiring the nursing facilities to report data and track metrics prioritized by the health system. Nursing facilities may be required to adopt software or tools preferred by the health system. Health systems may send nurses or managers into facilities to audit care or follow up on a specific patient whom they discharged. Many nursing facility leaders are willing to comply with and facilitate such requests to remain in preferred provider networks with health systems and continue to receive referrals of new patients. However, examples of true partnerships and investment in the overall quality of care in nursing facilities are harder to find. DOI: 10.1111/jgs.16540