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 Making it Work: Caregiving During a Pandemic

As COVID-19 swept across the planet, providers geared up to protect the most vulnerable population of all.

 

At the time this cover story was written, the nation had just entered into its second month of a federal and state lockdown of skilled nursing and assisted living facilities, along with intermediate care facilities for individuals with intellectual disabilities and many other aspects of life in America, in order to stem the spread of the highly contagious and deadly coronavirus (COVID-19). This article will not attempt to be the latest news on what has been the rapid evolution of a virus that has ravaged much of the world. Since first being reported as a significant health problem in late 2019 in Wuhan, China, COVID-19 has since spread in every direction, leading the World Health Organization to officially label the incurable virus a pandemic in March 2020.
 
Instead, Provider will present a series of real-life snapshots from the front lines of the fight to save Americans from

COVID-19 infection. Affecting the elderly and immunocompromised the most, the virus has put long term and post-acute care (LT/PAC) providers on a war footing for months now, with no real end in sight.

Facilities are in lockdown, open only to the staff and essential personnel needed to care for residents and safely operate the buildings. Even families and friends are banned from the communities housing the very people most prone to not only get the infection, but also to see serious health consequences if COVID-19
strikes.

The following is a chronicling of what providers have done to save lives, build hope, and conduct themselves as professionals with a special mission under the most trying of circumstances.

Residents Come First

Deborah Meade, chief executive officer (CEO) of Health Management, based in Warner Robins, Ga., is seeing the COVID-19 pandemic from different perspectives as the leader of her company, an acting administrator in a facility, and chair of the American Health Care Association (AHCA). As all providers interviewed pointed out, resident safety is No. 1, and all work is choreographed around that.

Debbie Meade“Our priority is always to keep the environment for residents and staff safe,” says Meade. “Everything we’ve done with implementing different policies has been focused on that goal.”

Policies and guidance from the federal government for LT/PAC providers have changed almost daily, putting new demands on providers to not only stay on top of them but implement them with little notice. 

Ongoing communication is not only critical but essential to help those on the front lines feel connected, says Meade. “I think the more that we can report, and educate, and talk about it helps,” she says. “It’s not easier, but maybe makes people feel better.”

The newest form of guidance to enhance resident safety when Meade spoke with Provider on March 15 was guidance from the Centers for Disease Control and Prevention (CDC) to restrict visitors.

“Sometimes we say the right decision can be the most difficult decision to make, and keeping residents from seeing their families and families from seeing the residents is extremely hard,” says Meade. “We’ve done a little of everything to help keep families connected.”

A little of everything means going beyond traditional phone calls, and Meade says her center now has a Facebook page that staff are using to post updates and photos. “Those pictures help put families at ease and show that yes, we’re still letting the residents have fun and keep some joy in the day when it can be quite frightening to them.”

At press time, by far the biggest challenge for Meade and her staff was restricting visitors. “It’s heartbreaking to tell someone that they can’t come in to see their loved one,” she says. “I have been very honest and very transparent—this is not a time that we hide and sugarcoat.”

The staff, she says, have been engaged as always, helping out where needed. “My staff have been wonderful; they’re always asking what else they can do and figuring out how they can best do it,” she says. “They are pulling together as always.”

Disaster Preparedness Lessons

Meade and others agree that while nothing could truly prepare them for the enormity of COVID-19 and its daily changing nature, disaster preparedness certainly helped. “I’ve been a part of hurricane evacuations at a facility in Savannah, and the one thing you will always learn is any best laid plan is never going to go perfectly, so it’s good to have back-up measures in place,” Meade says. “The staff always pull together to work together, and their compassion for residents and each other means more now than ever before.” 

Meade says there is a shortage of personal protective equipment (PPE), and that is a real concern. However, work is being done to address the shortage, with AHCA and the National Center for Assisted Living (NCAL) working together with the Centers for Medicare & Medicaid Services (CMS) and CDC to communicate needs.

Early Steps

Even before it was made federal regulation, Meade says she instructed staff to begin restricting visitors. How she did it successfully had much to do with early and consistent communication. 

“We pulled everybody together and met with all key personnel,” she says. Education on the decision to restrict visitors and why it was decided was crucial. “And then we had to make sure we were all saying the same thing; no one needed to give any different stories. Everyone has to say and give the same truthful story and be transparent and honest about the restrictions, which is always the best policy.”

Making sure the right message gets across all levels of staff is a key part in Meade’s facility’s daily meeting. “And we continue to talk during the day about those messages. At the daily meetings we also give everyone an opportunity to talk about what came up yesterday, what came out today, and we revisit it collectively to put the communication plan in place.”

A Whirlwind

Tiffany Adams, RN, is staff development coordinator and infection preventionist at Hyden Health and Rehabilitation Center in Hyden, Ky., a role she has worked in since February. She had been a part of Hyden for years as a nurse assistant, then registered nurse, working on the floor. 

She says things have been a whirlwind with new guidance to follow and implement, and everything has been focused on keeping residents safe and healthy. Restricting visitors means screening people outside, taking temperatures, and asking a series of questions on symptoms if present and exposure to individuals with COVID-19. 

Adams and her team monitor residents on a regular basis, and they also monitor staff. “Every shift that comes in we ask questions and we take their temperatures,” she says. “When we get another shift in, we go ahead and take everyone’s temperature to make sure that we’re assessing for any respiratory issues.”

In terms of PPE, Adams says the staff assess equipment all the time. “We are trying to make the most of it, and we keep an eye on our supply, and we haven’t run into an issue yet,” she says. “It’s kind of real scary right now watching the news and everything that I’ve seen, but we’re trying to make sure that we are being cautious and making sure that we are not unnecessarily using the PPE when we don’t need it.”

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Staff Education

Rosemary Oldham, RN, minimum data set coordinator at Hyden, is Adams’ predecessor, and she currently assists Adams with education of staff. The fast flow of all the changes has pushed Oldham and her colleagues into overdrive for processing the changes and turning around to provide education to staff. 

Rosemary OldhamShe points out that even a small change in existing regulations and guidance from CDC, CMS, and other federal agencies, for example, is a big deal, and changes occur daily. “It’s coming from all different areas, and we have to put it all together and in what should be the best plan for our building,” she says.

Oldham has been flexible with her workload and put noncritical items to the side in order to allocate more time and resources to COVID-19. “Right now, we are really focused on our PPE and the N95 masks,” she says. “I’ve had to put some of my other work aside to really focus on this and to help educate the staff on all the changes.”

In terms of keeping staff updated and educated, Adams says she is learning while teaching. “I’m learning something new every day while I teach staff, too,” she says. “And other staff pitch in their time and help get everyone trained.” 

Adams says she has even reached out by phone to some employees to ask them and make sure they understand what is being taught. “What’s also helpful is that we have the knowledge of what we must do if someone does become infected as far as quarantining and care for that person and others,” she says. “So, following up with staff on their understanding of all that’s happening and the daily changes is important.”

Hyden staff have reached out to other experts for help. “We’ve reached out to the local fire department, and the local emergency management service has been good about sharing information with us and helping us screen people,” she says. 

The overall state of mind in staff is good, Adams says. “Everyone is doing really well with it, although there is a little bit of uneasiness because it’s something new that’s really scary. Everybody’s pitching in doing what we’ve got to do to take care of the residents.” 

The morale of residents is also termed good, with many of them talking to friends or family via shared iPhones from staff and iPads at the facility. “FaceTime and Skype have become very popular around here,” says Adams.

Companywide Communication

The Evangelical Lutheran Good Samaritan Society, based in Sioux Falls, S.D., keeps its staff abreast of COVID-19 changes in a multitude of ways, one being via daily calls companywide across its 270 facilities in 10 regions from its incident command center. 

Randy Bury“This is the time for as much open transparent communication that we can have,” says Randy Bury, Good Samaritan president. “America’s history is all about handling challenges and different sorts of emergencies and disasters, so we are handling this to the best of our ability.”

The incident command center is located at the organization’s headquarters, and participants include each of the organization’s regional vice presidents as well as other key support staff like nursing and quality consultants. The calls are held at the beginning and ending of each day.

About Access

Daily calls are especially important not only to receive federal updates but also to discuss logistical issues like resident medications or supplies such as hand sanitizers. For Good Samaritan, being a part of a health system has helped facilitate access. 

“It works very well for us that we are part of a large acute care health system—Sanford Health—because once a day we also have phone calls, and we are able to express news that we have relative to supplies and equipment,” says Bury. “Also, if we have clinical questions, we can make one phone call and speak directly to a medical clinical professional.”

In mid March, Good Samaritan had no coronavirus cases, but it had begun preparing for the event that someone would become infected, Bury says.

“Right now we’re doing everything we can to hold the line but also knowing that if and when that is reached we also are spending just as much time on what we are going to do to support a local facility that ends up having a case,” says Bury. “We are reviewing those communication plans and what other infection control processes we will use. Unfortunately, I think it’s more likely to be a case of when not if.”

No One Left Out

Good Samaritan also hosts weekly town hall meetings from its incident command center. The town hall meetings are designed for all facilities to participate. 

“It’s literally hundreds of individuals on that call—all sites can participate, so an administrator at a facility somewhere in West Virginia will be on that call,” says Bury. “Our chief medical officer and our head of quality were on the call last week to provide updates and answer questions.” 

While Good Samaritan commonly held town hall meetings once a month, it is now holding them once a week to help everyone stay connected on the latest updates with COVID-19. 

“I think there is the feeling that we’re all in this together, and that no one is alone,” says Bury. “Even if you’re in a small 30-bed facility in rural America, we want folks to know they are not alone, and they have a linkage back to the much larger organization that has people and resources. It is also about letting our leaders know that they have a voice, and if they have a question, we will get them an answer.”

Town Hall Topics

Supply chain issues are high on the list of topics discussed at the town hall meetings. “Everyone has the same concern on PPE, and we are monitoring our supplies very carefully, and in return we get our policies, our plans, and our communication just that much more well-oiled on these issues,” says Bury. 

Staffing concerns is a close second as a popular topic. This comes up in questions like what will the company do if staff get ill?

“We are working with temporary agencies to line up the possibilities of pulling the trigger on utilizing those services, and we’re also watching optimistically some other work that’s being done with medical licensure and allowing people to cross state lines without delay—without having to go through being relicensed within a given state,” says Bury.

Ahead of the massive virus outbreak, in early January Good Samaritan and Sanford joined forces to offer health services spanning the continuum of life, including clinics, hospitals, health insurance, and senior care services.

“As a company we have 50,000 employees, and we’ve got somewhere over 8,000 nurses in the system,” he says. “Those nurses will respond and will help us out, but it doesn’t do us any good if a given state says we cannot send them out because we have to license them and do the background check, and that’s going to take a month. A month in the current crisis is like a year.”

In February, Bury and Meade participated in a White House meeting with other providers, Vice President Mike Pence, AHCA lobbyists, and CMS Administrator Seema Verma to discuss COVID-19 and issues for caring for elderly and frail residents, including medical licensure. 

As an example of how current medical licensure requirements result in delays for care, Bury highlights Good Samaritan’s experience with Hurricane Dorian. 

“Fortunately for everyone, that hurricane took a right-hand turn, and it wasn’t as devastating for Florida as we thought it would be. But we were having to spend an awful lot of time on the phone working with the Florida Department of Health trying to work with them on the medical licensure issue,” says Bury. “There are a lot of other issues that we need to be dealing with during an emergency.”


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Concern for Each Other

Another issue that comes up in town hall meetings is the genuine concern for residents from staff, the majority of whom see residents as family, says Bury. “There is a lot of responsibility, a lot of stress involved in that, and from everything that I can see I just can’t say enough about the response from staff.” 

Several staff have been working multiple days in a row, which is not uncommon during times of disaster, but the nature of COVID-19 is much different.

“Hurricanes are more of a sprint in terms of an episodic event,” says Bury. “It’s traumatic and it’s terrible, but the sun comes out within a few days. On this, it’s a marathon, and so we’re going to have to learn how to pace ourselves and how to divide and conquer this from a leadership perspective, because it’s unrealistic to think that we can have people working 12 hours a day for the next month after month.”

On the Ground

When Jessica Toth, administrator at Good Samaritan Society–Florida Lutheran in DeLand, Fla., hears the updates from the weekly town hall meetings, she shares them with her team in daily meetings.

“Our whole team is focused on resident safety,” she says. “In our morning meetings we focus on the residents, making sure that none of them are sick. We go through their symptoms, making sure that we have everything up to date, and we follow up on any issues identified before. We also focus on employee screening. Every employee is being screened before they enter the building right now.”

Toth and her staff participate in the calls from the national campus as well as daily calls with the regional team. “That’s about an hour a day, and then we also have a weekly call as a whole campus that we participate in to make sure that we were updated,” she says. “As updates come through the day, I share them with my team via our morning and afternoon meetings.”

To help keep track of it all for staff, Toth is preparing a resource book onsite. “It’s going to be a huge binder that has all of our resources that have been provided to us from the national campus,” says Toth. The binder includes everything from recently asked questions to visitor guidelines, to a screening information checklist, to emergency numbers. 

“That’s also been a huge priority, making sure that all the staff are educated and have one place they can go to get this information,” she says.

Updates are also shared through email. Through the corporate office, Toth sends out information to all employees via a newsletter called Facts Over Fear, which includes daily updates. These are also printed and placed in the binder.

Drawing on Experience

Like other providers, Toth reflects on her experience with disasters to help make sense of COVID-19. The help received from inside the company with the resources of Sanford Health made a difference. “Having Sanford around as part of our team was a huge help to us because they were available and set up a command center at the corporate office,” she says. 

“They were available to anything that we needed here in Florida 24/7; we just had to send them a text or an email,” she says. 

While Hurricane Dorian helped Toth and her staff prepare, she says, there are differences. “With a hurricane situation you kind of have an idea when it’s supposed to hit and a time frame of how long you’re going to be in lockdown mode, but this is a little bit different,” she says. 

“I feel like what my team went through with Hurricane Dorian is helping us, and our teamwork is stronger because of that and because we have the dedicated support 24/7,” says Toth. 

At the time of her interview with Provider, Toth and her team had no identified cases of COVID-19 but had come up with a system for it if they did. “If people start to get sick or if we have a diagnosis of COVID-19 in our building, then we have designated people to help with that as Team A and created a Team B to help people who are not sick. That way we are not cross-contaminating,” she says.

Keeping Residents Happy, Secure

Toth says residents are very understanding about new measures in place. “It’s no doubt a scary time for them, but I think they understand that everything has been put in place to help keep them healthy and safe,” she says. Staff, she says, are also doing well with the guidance and handwashing, screening, and other safety precautions. 

“We’ve been still doing different fun things to keep the environment as happy as possible during this time, so we’ve had different treats in the break room, and we’re doing different things individually to try to make the days as positive as possible,” says Toth. 

Keeping the connections going with families and the outside world has played a big part in helping residents and staff. Families are using Good Samaritan’s Send A Note feature via its website where anyone can write a note to a resident and attach a picture. “Monday morning, we received notes to the residents, and it is fun to share them,” says Toth. “It’s something that just brightens their day knowing that their loved ones have sent them a message.”

FaceTime meetings are popular during the week. Toth’s staff sent out letters to families inviting them to FaceTime meetings with the residents. Some family members are also coming up to residents’ outside windows to visit.

Leadership Lessons

While Bury points out the benefit of working in a larger company like Good Samaritan and Sanford Health from a resources perspective, he also sees his organization’s experience with COVID-19 as a lesson. 

“This is a leadership moment for all of us,” he says. “We should all realize that this is what we get paid for. It’s easy to continue to be a leader in the good times. But in hard times like this, now is the time for all of us to step up and support the staff and the residents and each other, and we’ve got some great things to share.” 

Bury points out photos of family members in front of a facility holding up signs supporting the staff and thanking them. “Those kinds of things are what we like to be able to share as well because it kind of tells people, ‘Hey we know you’re working hard, we know there’s nothing fair about any of this, and people recognize and appreciate and thank you for what you’re doing,” he says.

“I think you have to as a leader fight against that current constantly and keep enforcing the fact that we are going to get through this. This is a marathon, but it will come to an end. We’ve encountered a lot of things over the years in this country, and this too shall pass—this is the message that I think that we need to constantly reinforce.”

Advice to other providers is all about support. “Be there to support the staff, and you can’t communicate too much,” says Bury. “You have to stay in contact. This is one of those times where my staff managers and administrators want to know that someone has their back, and you’ve got to have their back.”

Consistent Communication

Keeping families connected goes hand in hand with the restrictions, and Meade’s staff were encouraged to get creative with communication. Residents use cordless phones throughout the facility, and staff volunteer their cell phones to help residents do FaceTime calls with family and friends. The facility has also started up its own Facebook page, posting updates and photos.

 “We’re just trying to keep some form of normalcy through connections so that residents are hearing from people routinely.”

While most families have expressed concern that residents may feel forgotten, Meade says residents have been very positive and supportive in their outlook. 

“They look at me and say, ‘Debbie, I know you are keeping me safe.’ That means everything because it shows they understand what we’re doing is not being done in any punitive way, it’s in an absolutely protected way.” 

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