Recommendations for a Metropolitan COVID-19 Response—Special Area of Emphasis

INTRODUCTION

Long-term care facilities, including skilled nursing facilities, nursing homes, and assisted living facilities, house some of the nation’s most at-risk populations for morbidity and mortality related to COVID-19 infection. Residents of these facilities require frequent interactions with staff such as for assistance with personal care (i.e. feeding, bathing, dressing), which increases the risk for transmission of COVID-19. Additionally, residents often have underlying medical conditions that put them at increased risk for severe complications if they become infected (1).

These facilities are often under-resourced, hindering their ability to implement some of the critical measures necessary to prevent COVID-19 transmission. Outbreaks within these congregate residential settings can progress extremely quickly, resulting in a large number of cases in a short period of time, many of which may require transfer to an acute care facility. This surge can further stress local health systems that are often already functioning at full capacity. As of April 17, at least 7000 COVID-19 deaths have been linked to nursing homes, with over 36000 residents and employees infected (2).

The US Centers for Disease Control and Prevention (CDC), health professional organizations, and state and local health departments have developed strategies and guidelines for post-acute care settings to prevent COVID-19 transmission (3-9).

To support long-term care facilities in operationalizing these guidelines and accessing needed resources, local municipalities should establish a long-term care support team. Ideally, this team would be established prior to an epidemic, and then activated as needed. Such a team could be established under the auspices of the health department and staffed by members of the health department or by other agencies, organizations, or volunteers (e.g. Medical Reserve Corps, American Red Cross). Members of the long-term care support team should include clinicians, public health practitioners, local emergency response authorities, community organizations, and others with knowledge of long-term care facility operations. Refer to Box 1 for administrative activities that the team should implement once established. The recommendations below highlight the activities that the long-term care support team should perform to support long-term care facilities during their COVID-19 preparedness and response efforts.

Recommendation 1

Improve situational awareness within the long-term care support team and long-term care facilities.

Improving awareness around state and federal guidance and resource needs (including staff and supplies) can help ensure that long-term care facilities have the tools they need to prevent the introduction and transmission of COVID-19. To help improve awareness, the long-term care support team should:

• Monitor federal agency and state and local health department websites for updates to existing guidance for long-term care facilities.
• Conduct a routine web-based survey that collects facility-specific information on the number of COVID-19 positive residents and staff, and on the status of resources such as beds, personal protective equipment (PPE), and staff. The survey should include information on any new federal, state, and local guidance and ask if the long-term care facility is following that latest guidance. The survey should be sent to the facility’s main point of contact, as frequently as daily.
• Create a resource-tracking dashboard linked to the survey results so that resource shortages within long-term care facilities can be identified and addressed as needed and tracked over time. A facility identifier should be included in the survey to ensure that each response can be linked to the facility’s previous responses.
• Convene weekly (or as frequently as needed) conference calls with long-term care facility staff to provide them with an aggregated summary of the survey results, to discuss newly released guidance that are pertinent to these facilities, and to discuss potential strategies for addressing their challenges and concerns. Staff invited to participate in the calls should have direct insight into facility operations, such as nursing or medical directors.
  • Facilitators of these calls should also attend any state-convened calls with long-term care facilities to ensure that information provided at the municipal-level is consistent with state communications and to ensure that local challenges are communicated to state officials. Facilitators should also distribute information about state-convened calls to facility points of contact to help ensure that long-term care facilities are connected to state-level resources and support.
• Convene weekly stakeholder conference calls with attendees from the long-term care support team, long-term care facilities, local hospitals, and advocacy groups to improve coordination and communication between acute and subacute levels of care.

Recommendation 2

Support long-term care facilities to ensure proper infection prevention and control.

Proper infection prevention and control (IPC) measures are paramount to preventing the introduction and spread of COVID-19 within long-term care facilities. To help ensure that staff can implement IPC measures, the long-term care support team should:

• Review federal, state, and local IPC guidance with long-term care facility staff during the regular teleconferences.
• Assist long-term care facilities in creating an internal communication plan on proper hand hygiene and on the importance of maintaining physical distancing measures for staff and residents. Health professional organizations can often provide materials, such as signage or patient letters, tailored to the needs of a post-acute setting. Some of these resources can be found on the Society for Post-acute and Long-term Medicine’s website (9).
• Identify within the long-term care support team (or other partners, such as local hospitals) those with training in IPC (including PPE selection, donning and doffing; hand hygiene; cleaning and disinfection) who can be deployed to these facilities to provide additional IPC training, if requested.
• Develop plans to help long-term care facilities access supplies necessary to support proper IPC. This might include PPE, soap and hand sanitizer, and hospital-grade cleaning solutions, among others. These plans should include identifying state or local health department resources and methods for requesting these supplies.
• Advocate for policies at the state and local level that prioritize PPE access within long-term care facilities (e.g., in the event of resource shortages).

Recommendation 3

Support long-term care facilities with maintaining adequate staffing levels.

Adequate staffing levels are needed by long-term care facilities to safely meet residents’ needs. To help support appropriate staffing levels, the long-term care support team should:

• Monitor the dashboard data populated by the facility surveys to identify facilities that are experiencing staffing shortages.
• Help long-term care facilities identify alternative staffing strategies, particularly in the coming days and months as staff absenteeism will likely increase due to illness. These strategies might include developing partnerships with the Medical Reserve Corps or other volunteer sources that have medical and public health expertise or sharing of local hospital staff (if available).
• Disseminate information and Centers for Medicare and Medicaid Services (CMS) guidance about how to employ telehealth for long-term care facilities’ providers and residents, reducing the need for non-urgent resident transfers (10).

Recommendation 4

Support long-term care facilities with screening and testing of residents and staff.

Screening residents for symptoms of infection and testing those with symptoms or known exposure should be a priority for long-term care facilities so that the introduction and transmission of COVID-19 can be prevented. To support screening and testing amongst residents, the long-term care support team should:

• Encourage each long-term care facility to review and follow current CDC guidance on evaluating and managing residents with symptoms of respiratory infection and for collecting and handling specimens from persons with COVID-19 (4,11). Any residents that have symptoms of infection should be immediately placed on Standard, Contact, and Droplet precautions.
• Assist long-term care facilities to create guidelines on what to do if a resident develops COVID-19 related symptoms. This includes how to get the resident and exposed staff members tested, IPC measures that should be implemented within the facility, and when/how to report to the health department.
• Identify ways for residents to gain priority access to COVID-19 testing. This would likely be done in collaboration with the local health department and area hospitals and can help ensure timely diagnosis and identification of potential transmission chains within these high-risk environments.
• Recommend that long-term care facilities conduct broad testing of all residents and staff if a resident develops symptoms and/or tests positive for COVID-19 to assess whether infection has spread within the facility.
• If a long-term care facility is experiencing an outbreak, help connect the facility to an available state or federal testing and control response groups (e.g., National Guard). There may also be local hospital or health department teams that are available to assist with testing and rapid triage of facilities within their catchment area (for example, The Johns Hopkins Go Team (12)).

Screening staff members for symptoms of infection and testing those with symptoms or known exposure should be a priority for long-term care facilities so that the introduction and transmission of COVID-19 can be prevented. To support screening and testing amongst staff, the long-term care support team should:

• Encourage each facility to review and follow the current CDC guidance on screening healthcare staff (4). Staff who have symptoms of infection should be instructed to put on a surgical mask and leave the workplace immediately.
• Assist long-term care facilities to create mechanisms for how to evaluate and monitor symptomatic staff and identify when they can return to work based on CDC guidance (5).
• Identify strategies for prioritizing access to COVID-19 testing for long-term care facility staff. This can help ensure timely diagnosis and identification of potential transmission chains within these high-risk environments and may be achieved through local health department screening or partnerships with area hospitals.
• Encourage long-term care facility chains to minimize transfer of staff across various facilities to reduce the opportunity for spreading COVID-19. This is particularly important when a facility has transitioned from a COVID-19 naive to a COVID-19 positive facility, even if staff are asymptomatic.
• Encourage long-term care facilities to institute a policy of asking all staff whether they are working in other facilities or communities that may increase the risk of transmission (e.g., if they are employed by other long-term care facilities).
• Recommend that long-term care facilities conduct broad testing of all residents and staff if a staff member develops symptoms and/or tests positive for COVID-19 to assess whether infection has spread within the facility.

Recommendation 5

Support long-term care facilities with isolating sick and quarantining exposed residents.

Once a long-term care facility resident develops symptoms of infection, they must be immediately isolated to prevent further disease transmission. To help ensure proper isolation and quarantine of sick or exposed residents, the long-term care support team should:

• Encourage each long-term care facility to review and follow current CDC guidance on infection prevention and control for COVID-19 patients in healthcare settings (6).
• Review internal plans and procedures (and update them if necessary) for isolating sick residents within long-term care facilities. This includes identifying existing isolation capacity within each facility, such as converting shared rooms to private rooms, designating separate units or wings to be isolation only, or cohorting infected residents.
• Encourage long-term care facilities to cohort residents in COVID-19 positive and negative facilities, if possible. CMS has issued transfer scenarios that allow certified long-term care facilities to transfer or discharge residents between themselves for cohorting purposes (13).

Recommendation 6

Support long-term care facilities to reduce the risk of staff and resident exposure.

Long-term care facilities should attempt to reduce all potential COVID-19 exposure opportunities to prevent disease introduction into its resident population. To do so, the long-term care support team should:

• Encourage long-term care facilities to restrict all visitors per CDC guidance (4).

  • Assist facilities in identifying ways to support maintenance of residents’ personal relationships (e.g., through Facetime or Zoom) due to visitor restrictions.
• Encourage all long-term care facilities to create specific teams that are designated to care only for COVID-19 positive residents in a designated area or COVID-19 positive only facility. This team should include clinical and support staff (e.g., environmental, dining). Special attention should be paid to educating this select group of individuals on proper IPC measures.
• Encourage all long-term care facilities to limit the number of nonessential staff who enter the premises.
  • Assist facilities in identifying ways to support teleworking for those employees deemed nonessential.
  • Assist facilities in identifying no-entry or minimal-entry methods for supply delivery and vendor visits.
• Encourage all long-term care facilities to cancel group activities, including congregate meals.
  • Assist facilities in identifying alternate ways to entertain and engage residents due to group activity cancellations. This is particularly important to reduce the incidence of agitation among those with dementia or cognitive impairment. Such activities may also reduce the incidence of delirium.
• Encourage long-term care facilities to employ telemedicine for routine healthcare visits and specialist visits for residents to limit unnecessary transfers out or provider visits to the facility.
  • Assist facilities in providing PPE for residents to use when leaving for essential medical appointments or Emergency Department visits that cannot be delayed or completed via telemedicine.
• Develop contact mechanisms between the long-term care facilities and area Emergency Departments. Facilities should notify Emergency Departments before any transfer in order to allow the hospital to prepare for the resident’s arrival.
• Develop plans for how to monitor for and mitigate the mental health impacts of the COVID-19 outbreak on residents. Some strategies can be found on the website of The Society for Post-Acute and Long-term Care Medicine (14).

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References

1. US CDC. Coronavirus Disease 2019 (COVID-19) People Who are at High Risk. Last reviewed April 15, 2020. Accessed April 15, 2020.
2. Stockman F, Richtel M, Ivory D & Smith M. ‘They’re Death Pits’: Virus Claims at Least 7,000 Lives in U.S. Nursing Homes. The New York Times. April 17, 2020. Accessed April 20, 2020.
3. US CDC. Key Strategies to Prepare for COVID-19 in Long-term Care Facilities (LTCFs). Last reviewed April 15, 2020. Accessed April 20, 2020.
4. US CDC. Preparing for COVID-19: Long-term Care Facilities, Nursing Homes. Last reviewed April 15, 2020. Accessed April 20, 2020.
5. US CDC. Return to Work for Healthcare Personnel with Confirmed or Suspected COVID-19. Last reviewed April 13, 2020. Accessed April 20, 2020.
6. US CDC. Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings. Last reviewed April 13, 2020. Accessed April 20, 2020.
7. American Geriatric Society. AGS Coronavirus Disease 2019 (COVID-19) Information Hub. Accessed April 20, 2020.
8. American Health Care Association. Coronavirus. Accessed April 20, 2020.
9. The Society for Post-Acute and Long-Term Medicine. AMDA Update on COVID-19. Accessed April 20, 2020.
10. Centers for Medicare and Medicaid Services. Long-Term Care Nursing Homes Telehealth and Telemedicine Tool Kit. March 27, 2020. Accessed April 20, 2020.
11. US CDC. Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens from Persons for Coronavirus Disease 2019 (COVID-19). Updated April 14, 2020.
12. Johns Hopkins Office of Critical Event Preparedness and Response. The Johns Hopkins Go Team. Accessed April 21, 2020.
13. Centers for Medicare and Medicaid Services. 2019 Novel Coronavirus (COVID-19) Long-Term Care Facility Transfer Scenarios. Updated April 13, 2020. Accessed April 20, 2020.
14. The Society for Post-Acute and Long-Term Care Medicine. Strategies for Mitigating the Emotional Impact of COVID-19. Updated March 15, 2020. Accessed April 20, 2020.

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Lead Authors

These recommendations were developed by:

• Diane Meyer, RN, MPH, is a Senior Analyst at the Johns Hopkins Center for Health Security and a Research Associate in the Department of Environmental Health and Engineering. Her work focuses on nursing and hospital preparedness and health systems as they relate to global health security.

• Sarah LaFave, MPH, RN is a doctoral student in the Johns Hopkins University School of Nursing and a Robert Wood Johnson Foundation Future of Nursing Scholar. Her work focuses on community-based strategies to support older adults, with a specific focus on racial and socioeconomic health equity.

• Allison A. Hart, MHA, is the Program Administrator for the Johns Hopkins Medicine Skilled Nursing Facility Collaborative, which aims to improve patient transitions between acute and post-acute care, improve quality of care, and reduce avoidable hospitalizations.
• Elena Martin, MPH, is an Analyst at the Johns Hopkins Center for Health Security and a Research Associate in the Department of Environmental Health and Engineering. Her work focuses on health systems preparedness with specific focus on how the interface of clinical medicine and public health influences outbreak preparedness, response, and recovery.
• Jennifer Nuzzo, DrPH, is an Associate Professor in the Department of Environmental Health and Engineering and is a Senior Scholar at the Johns Hopkins Center for Health Security. Dr. Nuzzo directs the Outbreak Observatory, which conducts operational research to improve outbreak preparedness and response.

Content Reviewers

• Alice Bonner, PhD, RN, FAAN is the Director of Strategic Partnerships for the CAPABLE Program and an Adjunct Faculty at the Johns Hopkins University School of Nursing. She is also a Senior Advisor in Aging for the Institute for Healthcare Improvement.

• Cynthia Boyd, MD, MPH is a Professor of Medicine at the Johns Hopkins University School of Medicine in the Department of Medicine, Division of Geriatric Medicine and Gerontology, with joint appointments in the Bloomberg School of Public Health in Epidemiology and Health Policy and Management. Dr. Boyd’s research focuses on how to improve health and health care for older adults living with multiple chronic conditions and their family/friends.

• Thomas K.M. Cudjoe, MD, MPH is an Assistant Professor of Medicine at the Johns Hopkins University School of Medicine in the Department of Medicine, Division of Geriatric Medicine and Gerontology. Dr. Cudjoe is also faculty at the Johns Hopkins Center on Aging and Health and his research is at the nexus of aging, housing, and social connections.
• Jennifer Wolff, PhD, is the Eugene and Mildred Lipitz Professor of Health Policy and Management at the Johns Hopkins Bloomberg School of Public Health. She directs the Roger C. Lipitz Center for Integrated Health Care and is jointly appointed in the Division of Geriatric Medicine and Gerontology in the Johns Hopkins University School of Medicine.

Copy Editor

• Christine Prosperi, ScM is a Research Associate at the International Vaccine Access Center in the Department of International Health.

Executive Editors

• Joshua M. Sharfstein, MD is a Professor of the Practice in Health Policy and Management, and the Vice Dean of Public Health Practice. He previously served as secretary of the Maryland Department of Health and Mental Hygiene, the principal deputy commissioner of the U.S. Food and Drug Administration, and as commissioner of health for Baltimore City.

• Melissa A. Marx, PhD, MPH is an Assistant Professor in the International Health Department. She spent nearly 15 years practicing epidemiology including responding and leading responses to outbreaks for the CDC, first as an Epidemic Intelligence Officer, later as a senior epidemiologist for the CDC at the New York City Department of Health, and then for the CDC overseas. She has responded to SARS, H1N1, Ebola, and many other outbreaks.

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