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Advancing Policies That Support Real Workforce Solutions
<p><img src="/Issues/2023/Summer/PublishingImages/sum23_workforce.jpg" class="ms-rtePosition-2" alt="" style="margin:5px;width:200px;height:200px;" />Nursing homes are currently grappling with a historic labor crisis. Over the course of the pandemic, nursing homes lost more than 200,000 caregivers, or about 15 percent of the workforce. This job loss is worse than the losses incurred by any other health care sector, and, at the current pace, it is not expected to rebound until 2027. Workforce challenges in long term care existed prior to the outbreak of COVID-19, and the pandemic exacerbated them into a full-blown crisis. Caregivers are burned out after fighting the virus for more than two years, and nursing homes lack the resources to compete for workers due to chronic government underfunding.<br></p><p>As a result of these labor shortages, more than half of nursing homes are limiting new admissions, and nearly two-thirds are concerned their facility may have to close due to the staffing crisis. More than 450 nursing homes have closed over the course of the pandemic—many due to staffing shortages—and hundreds more may soon close. <br></p><p>The domino effect on seniors, their families, and our entire health care system is troubling. Seniors wait for days or weeks in hospitals for a space at a facility, and families are having to travel farther to visit their loved ones in long term care. Many hospitals are overwhelmed with patients who are ready to be discharged to receive post-acute care, but nearby skilled nursing centers cannot admit them. </p><h3>The Challenges of a Staffing Minimum</h3><p>Nursing homes would love to hire more nurses and nurse aides but are currently grappling with a historic labor crisis, and the workers are not there. Increasing staffing requirements at a time when facilities can’t find the people to fill open positions is poor public policy. Nearly every nursing home in the country is having trouble hiring staff due to a lack of interested or qualified candidates. Providers have dedicated numerous resources to recruiting and retaining caregivers, including increasing wages and offering bonuses. But nursing homes still struggle to compete with hospitals, other health care providers, and private businesses for qualified workers. Chronic underfunding by Medicaid causes current soaring labor costs to be unsustainable. Complying with an unfunded federal staffing mandate would be impossible under current conditions. <br></p><p>Increasing staffing minimums will make it harder for seniors to find the long term care they need. Ultimately, setting minimum staffing ratios without corresponding resources will further limit access to care for seniors. Nursing homes will have to continue to reduce the number of patients they can serve in order to meet ratio requirements, or close entirely. Hundreds of thousands of residents could be at risk for displacement as facilities would be forced to reduce their census to meet staffing ratios or close entirely.</p><h3>Advocating for Solutions</h3><p>A federal staffing mandate requires a significant, ongoing investment in our front-line caregivers. An analysis found that staffing minimums would require billions of dollars to hire nearly 200,000 additional nurses and nurse aides. These proposals need to be fully funded, and with proper resources, nursing homes can offer front-line caregivers more competitive wages and benefits.<br></p><p>However, the long term care industry also needs a comprehensive approach to recruit and retain long term caregivers. An enforcement approach will simply not solve this long term care labor crisis. Meaningful solutions that address the root causes of these chronic staffing challenges are needed. <br></p><p>The American Health Care Association/National Center for Assisted Living (AHCA/NCAL) encourages long term care professionals to advocate for direct aid and policies that will help us build a pipeline of dedicated caregivers. AHCA’s Care for Our Seniors Act includes thoughtful workforce policies that will help address nationwide nursing shortages, attract more caregivers to the profession, and support care professionals in developing a career in long term care. It includes proposals such as loan forgiveness, tax credits, affordable housing, child care assistance, and immigration reform.<br></p><p>Additionally, there needs to be a comprehensive approach to staffing beyond numbers. Every resident and nursing home is different, and a one-size-fits-all approach is not the solution. Nursing homes need to be able to assess the appropriate staffing levels based on their number of residents and specific needs. <br></p><p>Moreover, providers must advocate for policies that invest in full-time, dedicated caregivers, not just increase the use of costly agency or temporary staff in order to fill quotas.</p><h3>Building a Pipeline of Caregivers</h3><p>One proposal supporting a more comprehensive approach and our caregivers is the Building America’s Health Care Workforce Act (H.R. 468). This bill provides an extension in the time allowed for temporary nurse aides (TNAs) to become certified nurse assistants (CNAs). <br></p><p>During the pandemic, the 1135 waiver on training and certification of nurse aides allowed vital support to critical staffing needs for care of residents in nursing homes. Hundreds of thousands of individuals answered the call to serve our seniors in their hour of need and supported them with nonclinical tasks, such as helping with activities of daily living; delivering meals; assisting with dining, ambulation, and range of motion; and offering companionship to help residents stay connected and engaged. <br></p><p>The TNA role has attracted individuals who have wanted to serve in direct care capacities but might not have had a pathway previously. The TNA role also supports our nation’s refugees and immigrants in receiving vital training to enter the long term care field.<br></p><p>Over the course of the pandemic, TNAs have gained thousands of hours of on-the-job, supervised training and experience in providing critical services and support to residents in nursing homes and assisted living communities. The 1135 waiver ended June 6, 2022, and only four months were given for TNAs to become CNAs or they would not be able to continue working in long term care communities. <br></p><p>State capacities were not sufficient to accommodate the training and testing needs of thousands of TNAs in this short time frame. H.R. 468 would extend the time to 24 months for TNAs to train and test to become CNAs. </p><h3>Take Action</h3><p>Advocating for meaningful, supportive solutions to the workforce challenges facing long term care facilities is critical. Let’s rebuild and strengthen the long term care workforce and protect seniors’ access to care. <br></p><p>1. Tell key decision-makers (i.e., the Centers for Medicare & Medicaid Services and the Biden administration) that an unfunded nursing home staffing minimum requirement won’t solve the long term care labor crisis and will only threaten access to critical long term care for our nation’s seniors. Recommend AHCA’s Care for Our Seniors Act as a better policy for our industry. <br></p><p>2. Advocate for the passage of H.R. 468 to allow time for TNAs to train and test to become CNAs, a vital part of the caregiver workforce. <br></p><p>For more information on AHCA/NCAL advocacy efforts and how you can help, go to <a href="http://www.ahcancal.org/Advocacy" target="_blank">www.ahcancal.org/Advocacy</a>.<br></p>
<img alt="" src="/Issues/2023/Summer/PublishingImages/sum23_workforce.jpg" style="BORDER:0px solid;" />
An unfunded staffing minimum would place a heavy burden on long term care providers. But there are other options to help build the workforce.
Ensuring Resident Coverage During the Medicaid Unwinding
<p><img src="/Issues/2023/Summer/PublishingImages/sum23_unwinding.jpg" class="ms-rtePosition-1" alt="" style="margin:5px;width:200px;height:200px;" />Since March 2020, states have been prohibited from disenrolling any Medicaid beneficiaries from the Medicaid program. The freeze on redeterminations and prohibition on disenrollment were based on federal statutory requirements states had to meet to receive the increased federal Medicaid funding of 6.2 percent over the course of the pandemic. Now, with the public health emergency ended, states are returning to “regular” Medicaid redetermination schedules. <br></p><p>State Medicaid agencies have over 87 million redeterminations to conduct before May 2024. Most states have not conducted redeterminations in over three years. During that time, beneficiary information (contact information, financial information, etc.) might have become out of date  and state agencies have had significant staff turnover and shortages. In many states, state and/or county eligibility units may have few or no staff members with redetermination expertise. Despite Centers for Medicare & Medicaid Services’ guidance and support, this could result in notable breaks in Medicaid coverage.<br></p><p>If a beneficiary loses Medicaid eligibility, Medicaid payments stop, and beneficiaries have very clear federal protections for when these breaks occur despite the loss of Medicaid payments. For example, beneficiaries must be given 30 days’ notice before discharge steps are taken, families and beneficiaries may not be billed for care, and a clear discharge plan must be explained and shared in writing. Failure to follow these steps can result in survey deficiencies and may make providers vulnerable to legal action. <br></p><p>At first glance, waves of nursing facility (NF) and assisted living (AL) Medicaid redeterminations may seem of little concern. However, they are cause for concern if staff turnover in NF and AL business offices has resulted in workplaces staffed with personnel who have little to no Medicaid redetermination experience. While older adults’ and persons with disabilities’ functional criteria to meet Medicaid levels of care are unlikely to change, the people involved with managing residents’ finances likely have changed. </p><h3>AHCA/NCAL Resources</h3><p>The American Health Care Association/National Center for Assisted Living (AHCA/NCAL) has prepared an array of resources aimed at supporting NFs and AL facilities to manage significant numbers of Medicaid redeterminations. Working with partner organizations, AHCA/NCAL has developed three modules and related tools. Many members have used these resources to educate admissions and business office staff on unwinding and to provide refreshers on financial care planning, as well as the basics of Medicaid eligibility determination. These AHCA/NCAL members-only resources are available at <a href="https://educate.ahcancal.org/" target="_blank">https://educate.ahcancal.org/. </a>Search for Medicaid unwinding or visit <a href="https://educate.ahcancal.org/products/medicaid-unwinding-return-to-regular-medicaid-redetermination-ensuring-resident-medicaid-coverage" target="_blank">https://educate.ahcancal.org/products/medicaid-unwinding-return-to-regular-medicaid-redetermination-ensuring-resident-medicaid-coverage</a>.<br></p><p>For state-specific Medicaid eligibility requirements and processes, members should work with their state affiliates, since those policies and features are state specific. </p>
<img alt="" src="/Issues/2023/Summer/PublishingImages/sum23_unwinding.jpg" style="BORDER:0px solid;" />
Since March 2020, states have been prohibited from disenrolling any Medicaid beneficiaries from the Medicaid program.
Improve Engagement and Retention with Employee Stock Ownership Plans
<p></p><p><img src="/Articles/PublishingImages/740%20x%20740/stock.jpg" class="ms-rtePosition-2" alt="" style="margin:5px;width:200px;height:200px;" />With many health care companies facing hiring and retention challenges, the idea of creating an employee stock ownership plan (ESOP) has proven to be an effective management and ownership method that prioritizes employees and provides quality care to residents.</p><p>One such company is Bridges Health, headquartered in Oklahoma City, Okla., where Brett Coble, CEO, said his operational ESOP exists today because the family-owned business grew over time to build a legacy where people and generosity were always at the forefront of the family's mind.</p><p>Those key values are why Bridges Health's ESOP is unique in Oklahoma as the only 100 percent employee-owned company in the skilled nursing and long term care sector.</p><p>There are approximately 6,500 ESOPs in the United States with approximately 13.9 million participants collectively, according to 2020 data from the National Center for Employee Ownership. ESOPs represent a variety of industries including finance, retail, construction, and technology services. About 2 percent of those are in the health care sector.</p><p>“Our mission of serving others with compassion and dignity strongly aligns with the idea of employee ownership," Coble said. “Being an employee-owned company certainly benefits employees, but it's much more than just a financial benefit. Locations that are part of the Bridges Health ESOP have implemented programs to further develop a workplace culture of ownership."</p><p>Michael Moore, CEO of North American Health Services (NAHS), transitioned to an ESOP in 2018. Its owner at that time saw an opportunity to turn the company over to the employees in what could be viewed as a type of ownership succession plan, Moore said.</p><p>“He felt this was a way to give back to the employees and provide them with an opportunity to contribute to their future," Moore said. “I think he made the right choice."</p><h3>ESOPs Create Pride and Ownership</h3><p>Moore said there's a direct connection between employee engagement and those who have a sense of belonging and value. “Every business wants an employee base that performs with a sense of pride and ownership and an ESOP allows just that," said Moore.</p><p>“By practicing what we preach, we prioritize our employee-owners through inclusion and involvement," Moore continued. “We rely on their input and lean on their expertise to help us shape policy and procedure with an emphasis on continuous improvement. Our employee-owners are the greatest process improvement resource we have. The more we rely on them, the more they contribute to making us better."</p><p>The Bridges Health ESOP has an Employee Communications Committee comprised of employees who work at various locations in diverse roles. The Committee creates monthly activities to promote and educate their peers and local community service providers about the ESOP.</p><h3>Making Your Company the Best Place to Work</h3><p>ESOPs can help companies recruit and retain staff, Moore said, “but only if your employees feel like owners. The most important emphasis for an ESOP is company culture. If we're not sincerely prioritizing making our company the best place to work, it won't matter what our share value is or how much our employees are paid."</p><p>“Committing to continuous improvement as an operator and an employer is the surest way to creating and nurturing an exceptional work environment in which employees feel seen, heard, and valued," said Moore. “Our culture is our reputation, and we have to be honest about how that impacts retention and recruitment, and we have to be willing to do the work that makes us better."</p><p>At Bridges Health, the ESOP is introduced early to applicants through social media channels to help candidates better understand what it means to be part of a 100 percent employee-owned company.</p><p>“As an applicant, when you have the potential opportunity to work with individuals who are learning about how to be employee-owners, that's attractive and unique," Coble said. “It has the potential to transform the work environments."</p><p>Like other ESOPs, the Bridges Health ESOP has a vesting schedule that encourages employee retention. “When employees see their first statement, there's a certain level of interest and curiosity particularly in the early stages of vesting," Coble said. “There's excitement about receiving a statement each year."</p><p>At NAHS, the structure depends on how long an employee has been with the company. Employees aged 21 or older who work at least 1,000 hours per year are eligible to participate in the ESOP. Employees begin vesting after one year, which increases each year thereafter until they are fully vested after 6 years.</p><p>Coble said that many ESOPs utilize formulas to determine the calculation of shares employees receive after they enter the ESOP and meet certain eligibility requirements such as hours of service and years of service. The value of those shares is determined annually by an independent valuation firm.</p><h3>Sharing Company Profitability</h3><p>Coble said employee ownership requires a consistent communication strategy to ensure employees understand the value of what it means to be a 100 percent employee-owned company.</p><p>The Bridges Health ESOP prioritized creating communication tools for employees to think about what it means to be part of a 100 percent employee-owned company that provides a service to people.</p><p>Moore said that buy-in and consistent commitment to behaving like an ESOP is a primary challenge.</p><p>“The idea of sharing company profitability can be uncomfortable for some and the process of setting up an ESOP structure is labor intensive," he added. “However, like any other meaningful endeavor, the investment of time and effort required is ultimately worth it."<br></p><p>There are several professional service groups exclusively operating in the ESOP development space, and Coble said they can assist in evaluating whether a particular business could be a good candidate to become an ESOP.</p><p>There are also several advocacy organizations that provide education surrounding a variety of ESOP topics from employee ownership culture to technical questions.</p><h3>Employee-Centric Benefits of an ESOP</h3><p>Operating as an ESOP requires due diligence and an examination of how much you want to invest in the ESOP, according to Moore. Considerations need to be made about whether the company wants to be 100 percent employee-owned or 70 percent, for example.</p><p>“Regardless of which approach anyone chooses, the conceptual benefits of an ESOP are hard to argue with," Moore said. “Investing in a business model that is employee-centric while sharing the benefits of company growth with the very employees that created that growth seems suitable for any business.</p><p><img src="/PublishingImages/Headshots/PaulBergeron.jpg" class="ms-rtePosition-1" alt="Paul Bergeron" style="margin:5px;width:175px;height:175px;" />“Most of the time, when publicly traded companies share their growth with shareholders, it is more transactional," said Moore. “Whereas for ESOP shareholders, it's very personal. They are employee-owners who invest physically, mentally, and emotionally in the growth and progress of the company. I would rather be accountable to our employee shareholders who contribute to our success than to those who don't."</p><p><em>Paul Bergeron is a freelance writer based in Herndon, Va. </em></p>
<img alt="" src="/Articles/PublishingImages/740%20x%20740/stock.jpg" style="BORDER:0px solid;" />
The idea of creating an employee stock ownership plan has proven to be an effective management and ownership method.
Collaboration Is Key to Effective Pain Management
<p><br></p><p><img src="/Articles/PublishingImages/740%20x%20740/senior_woman_nurse_3.jpg" class="ms-rtePosition-2" alt="" style="margin:5px;width:255px;height:179px;" />Recent estimates indicate more than <a href="https://pubmed.ncbi.nlm.nih.gov/36162443/" target="_blank">half of residents</a> in nursing homes suffer from chronic pain. Yet multiple studies over the years show it remains largely undertreated.</p><p>That's not suprising, given the challenges of pain management across the population generally. There's simply no clear way to measure pain. And identifying the source can be just as tricky.</p><p>In senior communities, particularly in nursing homes, there are additional complexities—from residents living with cognitive impairments and communication limitations to access to diagnostic and specialty services.</p><p>Making sure pain is being properly evaluated and treated requires a coordinated and personalized approach involving the residents' doctors, specialists, therapists, nursing center staff, and families.</p><h3>Step 1: Identifying the Pain, Understanding the Individual</h3><p>The first step is recognizing if a resident is experiencing pain, to what degree, and why.</p><p>Many seniors, especially in nursing homes, have trouble describing or communicating their pain. So it's important to really get to know patients. Sometimes the sign that someone's having pain is simply that they're more easily agitated or more aggressive.</p><p>Determining the level of pain is another challenge. You may have someone who barely bumps themselves and claims how much pain they are in. Then you could have someone who's had a major surgical procedure shrugging it off, saying, “I'm not too bad," even if they are in excruciating pain.<br></p><h3>Step 2: Determining the Appropriate Treatment Plan</h3><p>After pain is diagnosed, it's important to develop the right treatment plan. There is no one-size-fits-all approach. Options can involve a variety of things, from topical medications to therapeutic modalities like ice, heat, diathermy, and therapeutic exercises; splints; compression; oral or injectable medication; and therapeutic injections directly to the site of pain.</p><p>Choosing the best pain treatments for nursing home residents, however, can be complicated by the fact that many struggle with multiple chronic conditions.</p><p>Again, that is why it is so important to really understand the individual, their unique health challenges, and personal care goals—even getting down to the cultural basis that may influence how this individual sees their treatment and how they express their pain.</p><p>When medication is part of the plan, it's critical to carefully consider all the side effects and how any new medication may interact with the resident's other prescriptions to avoid any adverse interactions.</p><h3>The Last, But Not Always a Bad Step: Opioids</h3><p>The increased scrutiny on opioid prescriptions has increased hesitancy to prescribe these pain-blocking medications. It has also led to an unfortunate belief by some that all opioids are bad.</p><p>While opioids aren't the first, second, or even the third line of treatment, they can play an important role in pain management when symptoms can't otherwise be controlled.</p><p>Of course, there are risks, such as lethargy, confusion, falls—even respiratory depression and death. Understanding that balance of when it's important to use opioids can be challenging.</p><p>It's also important to discuss the resident's pain and potential benefits and risks of using opoids, all while staying up-to-date on how the drugs are regulated.</p><h3>Teamwork Is Key to Effective, Personalized Pain Management</h3><p>Unfortunately, chronic pain doesn't just go away. It needs to be constantly monitored and treatment options revisited when necessary to ensure the best possible quality of life for residents.</p><img src="/Articles/PublishingImages/2023/KarlDauphinais.jpg" alt="Karl Dauphinais" class="ms-rtePosition-2" style="margin:5px;width:0px;" /><p><img src="/Articles/PublishingImages/2023/KarlDauphinais2.jpg" class="ms-rtePosition-1" alt="" style="margin:5px;" />And that requires a team approach. For example, clinicians can work closely with on-site therapists, nurses, and nurses aides to help them decipher whether changes in patient behavior—from moaning to needing more support in a wheelchair to suddenly needing more assistance with transfers—is the result of a new condition or worsening pain.</p><p>Then all the caregivers work together to get the right care for the individual. Coordination and communication are at the heart of effective pain management programs.</p><p><em>Karl Dauphinais, MD, MSS, FACP, CMD, is the Connecticut and Rhode Island medical director for Optum's Complex Care Management division. He also serves as medical director at Autumn Lake Healthcare of New Britain, a 280-bed skilled nursing facility.</em></p>
<img alt="" src="/Articles/PublishingImages/740%20x%20740/senior_woman_nurse_3.jpg" style="BORDER:0px solid;" />
Making sure pain is being properly evaluated and treated requires a coordinated and personalized approach involving the residents’ doctors, specialists, therapists, nursing center staff, and families.
Strategies to Prevent Multidrug Resistant Organism Transmission in Long Term Care
<p><img src="/Articles/PublishingImages/740%20x%20740/medications_2.jpg" class="ms-rtePosition-2" alt="" style="margin:5px;width:200px;height:200px;" />Skilled nursing facility (SNF) residents <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5382184/" target="_blank">are at increased risk</a> for both colonization and infection by multidrug resistant organisms (MDROs.) The prevalence of <em>S. aureus</em> and IP colonization among residents has been estimated at higher than 50 percent, with new colonization acquisitions <a href="https://pubmed.ncbi.nlm.nih.gov/30753383/" target="_blank">occurring frequently</a>. Because standard precautions have not been effective at controlling the spread of organisms and because contact precautions are less frequently adopted in SNF settings, infection preventionists (IPs) in these settings often seek additional strategies to help stop the spread. Two such strategies are enhanced barrier precautions (EBPs) and decolonization.</p><h3>Decolonization</h3><p>Traditionally, decolonization has been used for surgical patients, especially those undergoing high-risk surgeries. As part of the Centers for Disease Control and Prevention (CDC) core strategies for preventing surgical site infections and bloodstream infections, skin antisepsis with chlorhexidine gluconate (CHG) wash or wipes and nasal decolonization with an intranasal antibiotic or antiseptic (mupirocin or at least 5 percent Iodophor) are <a href="https://www.cdc.gov/hai/prevent/staph-prevention-strategies.html" target="_blank">recommended</a>.</p><p>In more recent studies, nasal decolonization has been used as a strategy for MDRO prevention in SNF and long term care settings. The SHIELD Orange County Project recognized that patient movement between care settings was contributing to MDRO spread. They formed a regional decolonization collaborative that instituted a protocol of chlorhexidine bathing and twice-daily povidone-iodine nasal swabs in 35 facilities. At the end of the <a href="https://academic.oup.com/ofid/article/6/Supplement_2/S23/5605644" target="_blank">study</a>, they found reductions of MDRO colonization of 22 percent in nursing homes and 34 percent in long term acute care hospitals (LTACHs).</p><p>In the PROTECT study, a similar protocol was used universally, but only in nursing homes. The study assessed pre- vs. post-intervention MDRO prevalence by randomly sampling 50 residents in each facility. Decolonization was associated with a 28.8 percent decrease in MDRO prevalence, and split out by pathogen, there were 24.3 percent, 61.0 percent, and 51.9 percent decreases in methicillin-resistant <em>S. aureus</em> (MRSA), vancomycin-resistant <em>enterococci</em> (VRE), and extended spectrum <em>beta-lactamase</em> (ESBL), respectively.</p><p>Decolonization with CHG bathing and nasal decolonization with povidone-iodine can lower MDRO transmission within SNFs, as well as MDRO spread to other health care facilities.</p><h3>Enhanced Barrier Precautions</h3><p>In 2021, the Healthcare Infection Control Practices Advisory Committee (HICPAC) set forth a document entitled <a href="https://www.cdc.gov/hicpac/pdf/EnhancedBarrierPrecautions-H.pdf" target="_blank">“Consideration for Use of Enhanced Barrier Precautions in Skilled Nursing Facilities"</a> that outlined topics related to the care of nursing home populations and the implementation and scope of EBPs as requested by the CDC at the November 2019 HICPAC meeting. This document highlighted that MDRO transfer is common in skilled nursing facilities, and that EBPs can help stop the transfer from happening. EBPs can and should be applied in high-touch care activities regardless of MDRO status, in addition to transmission-based precautions used when residents are infected or colonized with an MDRO. To implement EBPs effectively, staff must be trained on personal protective equipment (PPE) use, and PPE and hand hygiene supplies must be readily available at the point of care. Staff should also be trained on why EBPs are important.</p><p>In <a href="https://www.cdc.gov/hicpac/pdf/EnhancedBarrierPrecautions-H.pdf" target="_blank">studies</a> so far, EBPs have proven to be effective in preventing acquisition, transmission, and infection by <em>S. aureus</em>.<sup> </sup>Although studies have not explicitly proven that EBPs are effective in preventing the spread of MDROs or other epidemiologically significant organisms, many of these organisms require contact precautions, so although not studied, EBP should certainly be an effective prevention strategy.</p><p>When recommending EBP as additional guidance for the long term and skilled nursing care settings, the CDC considered that standard precautions are not often successfully implemented in these settings. In addition, contact precautions are not strictly adhered to, in part due to the home-like environment of these care settings. Many residents in these care settings have MDROs that are not identified—all these things make it difficult to know exactly what the potential for organism transmission is in many cases, which makes a <a href="https://www.cdc.gov/hai/pdfs/containment/PPE-Nursing-Homes-H.pdf" target="_blank">strategy</a> like EBP more appealing.</p><p>EBP consists of adding gowns and gloves during high-touch care activities for all residents that have a wound or indwelling device, when that PPE may traditionally only have been used for residents who displayed signs and symptoms of active infection. High-risk activities specifically include <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6809310/" target="_blank">care tasks</a> where close contact is anticipated: dressing, bathing/showering, transferring, providing hygiene (showering, shaving, brushing teeth), changing linens, incontinence care/toileting, device care or use, and wound care. EBPs would not add room placement restrictions that transmission-based <a href="https://www.cdc.gov/hai/pdfs/containment/PPE-Nursing-Homes-H.pdf" target="_blank">precautions</a> may include.</p><p>These activities were chosen based on observations of activities in SNFs and evaluations of these observations to determine the risk of pathogen transfer on hands after the <a href="https://www.cdc.gov/hai/containment/faqs.html" target="_blank">activities</a> occurred.<sup> </sup>Although EBPs only address gown and glove use during these activities, other PPE may be used as required in adherence to standard precautions if any blood or body fluid exposure may be expected during any care activity taking place.</p><p>It is not currently recommended that all residents in a skilled nursing facility are immediately placed on EBPs. CDC recommends that EBPs are used for residents that have any wound or indwelling device, and any resident that is infected or colonized with an MDRO if transmission-based precautions would not otherwise apply. <a href="https://www.cdc.gov/hai/pdfs/containment/PPE-Nursing-Homes-H.pdf" target="_blank">Tips</a> to implement EBPs include clear signage indicating they are required, having PPE and hand hygiene supplies readily available, having trash receptacles in appropriate locations for proper disposal of PPE, education and PPE training for staff, and audits to monitor compliance.<br></p><h3>Considerations</h3><p>Some common objections to facility-wide implementation of additional IP strategies include cost considerations and PPE supply considerations. Although costs would be incurred for PPE, training, and additional signage as well as staff time, one study looked at the implementation of EBP in a 120-bed nursing home and found that overall, there was a cost savings. The authors found that the program would cost about $20,000 but that $54,000 in disease treatment cost would be prevented, providing an <a href="https://pubmed.ncbi.nlm.nih.gov/29489017/" target="_blank">overall cost savings</a> value of $34,000 per year to the facility when considering catheter-associated urinary tract infections alone.</p><p>Supply chain and PPE availability have been an increasingly high priority since the onset of COVID-19. Currently, PPE stock and availability has largely returned to normal. Facilities should plan for contingency and crisis standards of care, so that in the event of a shortage, a plan is in place for PPE supply preservation. (For example, residents with documented MDROs would be prioritized over those with wounds or indwelling devices.)</p><p><img src="/Articles/PublishingImages/2023/JennyBender.jpg" alt="Jenny Bender" class="ms-rtePosition-1" style="margin:5px;" />IPs across the continuum of care should be aware of the current recommendations around EBPs and how these are practically deployed. Adoption of EBPs in long term care settings has the potential to prevent infections across the continuum of care, as residents (and any potential MDROs they are harboring) are frequently transferred between care settings. EBPs are not currently recommended in settings outside SNFs, IPs in other settings like acute care or a LTACH should be able to speak to the differences in prevention strategies in different care settings to clarify any questions from patients and their family members, as well as to better understand the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6809310/" target="_blank">risk of MDRO infection and colonization</a> when patients and residents pass between their facilities.</p><p><em>Jenny Bender, MPH, BSN, RN, CIC, is clinical science liaison at PDI Northeast Region and an RN with more than 10 years' experience as an infection preventionist in community hospital, ambulatory/outpatient, academic medical center, behavioral health, and public health settings.</em></p>
<img alt="" src="/Articles/PublishingImages/740%20x%20740/medications_2.jpg" style="BORDER:0px solid;" />
Skilled nursing facility residents are at increased risk for both colonization and infection by multidrug resistant organisms.
Innovation in Senior Living Facilities Design
<p>The pandemic shone a light on senior living infrastructure that has leaders and staff of assisted living and skilled nursing facilities looking for progressive and innovative design concepts. As such, senior housing providers from around the world are looking to learn from the successes and challenges that various models faced at the height of the pandemic. </p><h3>Early Adopters of the Green House Model in Rochester, NY</h3><p>Founded in Rochester in 1997 by a group of forward thinkers, the Pioneer Network has since evolved through a partnership with The Green House Project (GHP) into the Center for Innovation. The new alliance focuses on supporting eldercare reform initiatives and educating and advising eldercare organizations that seek to initiate changes to the cultural, organizational, and physical structures of the traditional nursing home. </p><p>Upstate New York is home to early adopters of the Green House model, giving the region two decades of experience with a model that others are now beginning to recognize, due to exceptional outcomes during the pandemic. <br></p><h3>Design Tenets of the Green House Model</h3><p><span><img src="/Articles/PublishingImages/740%20x%20740/innovation.jpg" class="ms-rtePosition-1" alt="RPH Creekstone Memory Care Small Homes in Perinton, New York" style="margin:5px;width:200px;height:200px;" /></span>The primary objective of the Green House model is to provide a culture and environment where seniors can continue to grow and thrive in a period when they may be experiencing physical or cognitive decline. The model strives to create meaningful life and purpose for both residents and staff, leading to enhanced quality of living and improved clinical outcomes for residents, higher levels of satisfaction among residents and their family members<sup>1</sup>, and greater workplace satisfaction and lower levels of stress for frontline caregivers.<sup><a href="https://thegreenhouseproject.org/wp-content/uploads/The-Green-House-Difference.pdf" target="_blank">2</a></sup> <br></p><p>There are multiple design elements that contribute to these results, including a small-scale environment, private bedrooms with private bathrooms, living rooms and other open public spaces, communal dining areas, access to outdoor spaces, and consistent staffing.</p><h3>Green House Model Benefits</h3><p>The pandemic in particular brought more attention to the benefits of the small-house/Green House model. According to a study published in the Journal of Post-Acute and Long-Term Care Medicine, the small-scale environments of Green House and other nontraditional nursing home models proved advantageous, experiencing significantly lower levels of infections and mortality when compared to traditional nursing homes with larger bed counts.<sup><a href="https://www.jamda.com/article/S1525-8610%2821%2900120-1/fulltext" target="_blank">3</a><br></sup></p><p>In addition to better clinical outcomes for residents, the Green House model offers many other benefits, including flexibility that allows for modification of occupancies as needs change (e.g., skilled nursing, memory care, rehabilitation, hospice), more private pay residents, daily costs that are lower than the traditional nursing home model<sup><a href="http://www.greenhouseproject.org/" target="_blank">4</a></sup>, and greater staff retention. Moreover, data collected by GHP reveals that even after the pandemic, Green House homes have reported significantly lower turnover rates for CNAs, LPNs, and RNs.<sup><a href="https://thegreenhouseproject.org/wp-content/uploads/The-Green-House-Difference.pdf" target="_blank">5</a></sup> This is particularly notable as staffing continues to be a critical concern and maintaining staff with a lower turnover rate may offer a competitive advantage.</p><p><img src="/Articles/PublishingImages/2023/RobertSimonetti.jpg" alt="Robert Simonetti" class="ms-rtePosition-2" style="margin:5px;" />Green House living represents a set of design criteria that reconfigures the operations and environments of a traditional nursing facility into an “intentional community” that offers person-centered care focused on relationships and people. Data is mounting that suggests this design initiative also provides several benefits, including better quality of living for residents, lower levels of infections and mortality, lower staff turnover rates, and lower daily costs. New programs and funding opportunities may encourage, require, and facilitate these innovative models further. </p><p><em>Rob Simonetti is senior living leader at LaBella Associates. He has focused the last 15 years of his career on small house models of care for skilled nursing occupancies. </em><br><br><span class="ms-rteStyle-Normal">References</span><br class="ms-rteStyle-Normal"><span class="ms-rteStyle-Normal">1.    "Effects of Green House Nursing Homes on Residents’ Families" by Terry Y. Lum, M.S.W., Ph.D., Rosalie A. Kane, M.S.W., Ph.D., Lois J. Cutler, Ph.D., and Tzy-Chyi Yu, M.H.A., Ph.D.</span><br class="ms-rteStyle-Normal"><span class="ms-rteStyle-Normal">2.    "The Green House Difference: By The Numbers," <a href="https://thegreenhouseproject.org/wp-content/uploads/The-Green-House-Difference.pdf" target="_blank">https://thegreenhouseproject.org/wp-content/uploads/The-Green-House-Difference.pdf </a></span><br class="ms-rteStyle-Normal"><span class="ms-rteStyle-Normal">3.    "Nontraditional Small House Nursing Homes Have Fewer COVID-19 Cases and Deaths," Journal of Post-Acute and Long-Term Care Medicine, <a href="https://www.jamda.com/article/S1525-8610%2821%2900120-1/fulltext" target="_blank">https://www.jamda.com/article/S1525-8610(21)00120-1/fulltext</a></span><br class="ms-rteStyle-Normal"><span class="ms-rteStyle-Normal">4.    "Pilot Study Finds Meaningful Savings in THE GREEN HOUSE<sup>®</sup> Model for Eldercare," <a href="https://www.greenhouseproject.org/" target="_blank">www.greenhouseproject.org</a> </span><br class="ms-rteStyle-Normal"><span class="ms-rteStyle-Normal">5.    "The Green House Difference: By The Numbers," <a href="https://thegreenhouseproject.org/wp-content/uploads/The-Green-House-Difference.pdf" target="_blank">https://thegreenhouseproject.org/wp-content/uploads/The-Green-House-Difference.pdf</a> </span><br><br></p>
<img alt="" src="/Articles/PublishingImages/740%20x%20740/innovation.jpg" style="BORDER:0px solid;" />
The pandemic shone a light on senior living infrastructure that has leaders and staff of assisted living and skilled nursing facilities looking for progressive and innovative design concepts.
Resources to Navigate the End of the Public Health Emergency
<p><img src="/Articles/PublishingImages/740%20x%20740/0820_News1.jpg" class="ms-rtePosition-2" alt="" style="margin:5px;width:170px;height:170px;" />With the COVID-19 public health emergency (PHE) ending on May 11, providers need to be aware of the changes to regulations, requirements, and other processes. Many programs will be ending, yet some have been extended or changed. See below for an up-to-date list of articles related to the end of the PHE.</p><p><br></p><ul><li><p><strong class="ms-rteForeColor-2">NEW</strong> <a href="https://www.ahcancal.org/News-and-Communications/Blog/Pages/Post-PHE-Infection-Control-for-Transmission-Based-Precautions.aspx" target="_blank">Post PHE: Infection Control for Transmission-Based Precautions </a></p></li><li><p><span><strong class="ms-rteForeColor-2">NEW</strong></span> <a href="https://www.ahcancal.org/News-and-Communications/Blog/Pages/COVID-19-Provider-Vaccine-Mandate-Still-in-Effect.aspx" target="_blank">COVID-19 Provider Vaccine Mandate Still in Effect</a></p></li><li><p><span><strong class="ms-rteForeColor-2">NEW</strong></span> <a href="https://www.ahcancal.org/News-and-Communications/Blog/Pages/COVID-19-PHE-Policies-for-Therapy-and-Physician-Telehealth-Remain-in-Place-for-SNF-and-AL-Residents.aspx" target="_blank">COVID-19 PHE Policies for Therapy and Physician Telehealth Remain in Place for SNF and AL Residents</a></p></li><li><p><a href="https://www.ahcancal.org/News-and-Communications/Blog/Pages/Clinical-Laboratory-Improvement-Amendment-Changes-Post-PHE.aspx" target="_blank">Clinical Laboratory Improvement Amendment Changes Post-PHE</a></p></li><li><p><a href="https://www.ahcancal.org/News-and-Communications/Press-Releases/Pages/AHCANCAL-Releases-Statement-on-the-End-of-the-Public-Health-Emergency-.aspx" target="_blank">AHCA/NCAL Releases Statement on the End of the Public Health Emergency</a></p></li><li><p><a href="https://www.ahcancal.org/News-and-Communications/Blog/Pages/Post-COVID-19-PHE-Medicare-Part-B-Therapy-Telehealth-Services-Coverage-Policy-Uncertain.aspx" target="_blank">Post-COVID-19 PHE Medicare Part B Therapy Telehealth Services Coverage Policy Uncertain</a></p></li><li><p><a href="https://www.ahcancal.org/News-and-Communications/Blog/Pages/DEA%2c-SAMHSA-Extend-COVID-19-Telemedicine-Flexibilities-for-Prescribing-Controlled-Medications.aspx" target="_blank">DEA, SAMHSA Extend COVID-19 Telemedicine Flexibilities for Prescribing Controlled Medications</a></p></li><li><p><a href="https://www.ahcancal.org/News-and-Communications/Blog/Pages/CDC-and-CMS-Update-COVID-19-Guidance.aspx" target="_blank">CDC and CMS Update COVID-19 Guidance</a></p></li><li><p><a href="https://www.ahcancal.org/News-and-Communications/Blog/Pages/COVID-19-Regulatory-Relief.aspx" target="_blank">COVID-19 Regulatory Relief</a></p></li><li><p><a href="https://www.ahcancal.org/News-and-Communications/Blog/Pages/PHE-Ending-Impact-on-Emergency-Preparedness-Regulations-.aspx" target="_blank">PHE Ending Impact on Emergency Preparedness Regulations</a></p></li><li><p><a href="https://www.ahcancal.org/News-and-Communications/Blog/Pages/CMS-Announces-Ending-of-COVID-Staff-Vaccine-Requirement%2c-Other-Protocols.aspx" target="_blank">CMS Announces Ending of COVID Staff Vaccine Requirement, Other Protocols</a></p></li><li><p><a href="https://www.ahcancal.org/News-and-Communications/Blog/Pages/HHS-BinaxNOW-Program-to-Continue-After-PHE-Ends.aspx" target="_blank">HHS BinaxNOW Program to Continue After PHE Ends</a></p></li><li><p><a href="https://www.ahcancal.org/News-and-Communications/Blog/Pages/CDC-Announces-Sunset-of-COVID-Community-Transmission-Levels.aspx" target="_blank">CDC Announces Sunset of COVID Community Transmission Levels</a></p></li><li><p><a href="https://www.ahcancal.org/News-and-Communications/Blog/Pages/HHS-Announces-Expiration-of-COVID-19-PHE-HIPAA-Notifications-of-Enforcement-Discretion.aspx" target="_blank">HHS Announces Expiration of COVID-19 PHE HIPAA Notifications of Enforcement Discretion</a></p></li><li><p><a href="https://www.ahcancal.org/News-and-Communications/Blog/Pages/CMS-Corrects-Guidance-on-Billing-SNF-Part-A-Stays-for-3-Day-Waiver-Admissions.aspx" target="_blank">CMS Corrects Guidance on Billing SNF Part A Stays for 3-Day Waiver Admissions</a></p></li><li><p><a href="https://www.ahcancal.org/News-and-Communications/Blog/Pages/Public-Health-Emergency-Ending-May-11.aspx" target="_blank">Public Health Emergency Ending May 11</a></p></li></ul>
<img alt="" src="/Articles/PublishingImages/740%20x%20740/0820_News1.jpg" style="BORDER:0px solid;" />
With the COVID-19 public health emergency ending, providers need to be aware of the changes to regulations, requirements, and other processes.