While the COVID pandemic has changed much in post-acute and long term care, efforts to provide quality care and track outcomes, trends, and opportunities for improvement have continued unabated. Facilities didn’t swap quality measures for COVID care, they just added it to what they were already doing.

Yet the pandemic has put a spotlight on how quality is defined, measured, and reimbursed, and it has exposed what works and where changes are needed.

“It is crystal clear that our nursing home residents are a vulnerable population that should not be exposed to the risk of pandemic, either because they are sent to hospitals or emergency rooms [ERs] unnecessarily or because new patients with potential infections are allowed to come into a building that is not yet exposed to the infection,” says Rajeev Kumar, MD, CMD, FACP, chief medical officer at Symbria in Chicago.

“Hopefully, surveyors and CMS [Centers for Medicare & Medicaid Services] will work collaboratively with nursing facilities to minimize bad outcomes, rather than go on a witch hunt to find and use unfortunate outcomes to penalize nursing homes.”

Measures Matter

While nursing facilities continue to document and report on quality measures during the pandemic, the results don’t necessarily present an accurate picture of what is happening within those walls. For example, with hospitals putting moratoriums on elective surgeries such as knee and hip replacements, facilities are seeing fewer short-stay patients.

“Anecdotally, we’ve heard that falls have gone down because residents are less mobile or gone up because of muscle weakening due to being quarantined. We’ve heard that depression has risen because of isolation,” says David Gifford, MD, MPH, chief medical officer and senior vice president of quality and regulatory affairs at the American Health Care Association/National Center for Assisted Living (AHCA/NCAL).

At the same time, he notes, at least one study has suggested that weight loss may be linked to COVID, as the virus causes loss of taste and smell in some patients.

“The pandemic has spotlighted the fact that the quality metrics we use aren’t adequate,” says Michael Wasserman, MD, CMD, a geriatrician and president of the California Society for Post-Acute and Long Term Care Medicine. For instance, infection control and prevention problems are common deficiencies, even in highly rated facilities. During the pandemic, this is complicated by issues such as inadequate staffing, lack of adequate personal protective equipment (PPE), and lack of knowledge and adherence to appropriate use of PPE, he says.

While some quality measures don’t paint an accurate portrait of what has been happening in facilities during the pandemic, others have been illuminating. For instance, data about hospitalizations and ER visits can be telling. Kumar explains, “When most people are afraid to go to hospitals because of the very real risk of exposure, ER and hospital/urgent care visits need to be reduced at all costs. If there is a surge in such visits from nursing facilities, something is not right.”

Quality metrics related to vaccinations also have been worthy of attention. “Flu and pneumococcal vaccinations need to be provided in a timely manner to all vulnerable seniors. An acute respiratory illness increases the risk of hospitalization and, perhaps, a concurrent infection with COVID,” says Kumar. By having documentation regarding vaccinations, it ultimately will demonstrate to surveyors, payers, and others that the facility has made every effort to protect residents from infections and outbreaks.

Isolation and Mental Health

Pamela Truscott, MSN, RN, DNS-CT, QCP, senior manager of clinical & regulatory services for AHCA, notes, “We don’t have data, but it’s apparent that isolation has had a significant impact on behavioral and mental health issues such as increased depression, anxiety, and behaviors.” While data regarding these issues don’t necessarily reflect on quality of care, they do point to the impact of not allowing residents to have their in-person support systems during a pandemic.

“There definitely needs to be more thought about visitor restrictions. We have heard from many centers about this, and it will require some attention moving forward,” she says.

The pandemic has exposed the importance of assessing quality-of-life-related issues, something that currently isn’t optimized. “Man is a social animal. It is important to provide socialization and person-centered care for residents, even when they are isolated,” Kumar says. “We need to collaborate to make the long term care experience better for residents and staff. We need to find ways to make that happen and ways to measure the impact.”

What’s New From CMS

CMS has taken several steps to help make documentation and quality reporting easier for facilities during the pandemic. The Skilled Nursing Facility Quality Reporting Program (SNF QRP) quality measurement reporting requirement was waived from Oct. 1, 2019, through June 30, 2020, and the Value-Based Payment (VBP) program was waived for the first two quarters of 2020. Kumar says that both are likely to be extended as COVID continues to affect SNFs. At the same time, to offset additional COVID-related expenses, CMS has allocated $4.9 billion in relief to SNFs.

While CMS issued a blanket waiver related to 42 CFR 483.70(q) requiring all SNFs to submit staffing data through the Payroll-Based Journal (PBJ) system, the agency has announced its plans to end the waiver. Providers were required to submit data through PBJ for the second quarter of the year (April-June) on August 14.

According to CMS, “The blanket waiver was intended to temporarily allow the agency to concentrate efforts on combating COVID-19 and reduce administrative burden on nursing homes so they could focus on patient health and safety during this public health emergency.”

AHCA has expressed appreciation for the reporting flexibility CMS has afforded but emphasized that the fight against the virus is far from over and that practitioners need continued support from the federal government.

For instance, Kumar notes, “PBJ is a challenge with staffing shortages nationwide. Anxiety and depression will likely be higher, and functional improvement is more difficult to achieve with reduction in therapy services to minimize the spread of infection.”

Not New But Still Notable

While efforts to address COVID-19 are and must be a top priority, other acute and chronic conditions continue to require attention. While some conditions are being monitored via telemedicine, “fewer encounters are happening via telemedicine as they were early on in the pandemic,” says Steven Buslovich, MD, CMD, MSHCPM, a New York-based geriatrician and frailty expert. For instance, he says, facilities still have rehab staff in the building, and they are providing services in traditional safe ways.

In terms of other issues such as wound care, Buslovich says, it is difficult to cover them remotely. “You can perform some triage virtually and watch to ensure dressing changes and wound cleaning are being done appropriately. But for the most part, wound care still persists the way it was handled previously.”

Nonetheless, despite best efforts, he says, “From a quality perspective, wound data are likely to take a hit. Wound quality is likely to trigger because of confinement and isolation that lead to less activity and pressure wounds developing. At the same time, most residents who get sick with COVID are bedridden until they recover, and this can contribute to pressure ulcer development.”

It will be essential to document what is being done to prevent wounds and manage existing injuries. When quality data and quality of care don’t match up, this documentation will be key to showing the unavoidable impact of the pandemic on wounds.

Group Like Patients

As for other specialized care, Buslovich says, an effort to group COVID patients separately so that practitioners and staff can focus on other issues seems to be an effective strategy. For instance, he notes that one of his facilities has pediatrics and ventilation units, both of which at press time had remained COVID-free.

“The most important thing we need to keep in mind is that while the focus is on COVID, there are other problems we need to address, and we need to have adequate nursing staff to care for these patients,” he says.

Nonetheless, it is important to realize that there has been an undeniable impact of COVID on chronic conditions, says David Smith, MD, CMD, president of Geriatric Consultants in Brownwood, Texas. “The bar on the quality of care has moved. It is impossible to deliver the same care in the COVID era as in the pre-COVID world,” he says. “The definition of quality—the equation of benefit and risk—has shifted. COVID has impacted everything.”

As facilities slowly reopen, they will need to develop ways to measure quality in the new normal. This may include assessing frailty in residents, identifying those at high risk for falls and other problems, providing enhanced resources, and maximizing access to telemedicine and other technologies.

Making Long Term Care a Priority

Throughout the pandemic, hospitals have often been praised for their heroic efforts while nursing facilities have been vilified, as the media and others often attributed the high rate of COVID-related illnesses and deaths in them to poor quality.

“When this pandemic started, it was demonstrated early on that long term care was not a top priority, even though we heard repeatedly that the older population was at higher risk with more morbidity and mortality,” says Gifford. “All of the attention was on hospitals; long term care wasn’t a priority. We’ve been asking to be put at the top of the list for a COVID vaccine when it’s available, but I’m worried that we will find ourselves No. 2 on the list as we did for testing and PPE.”

Truscott says, “One thing is that there has been a considerable amount of underfunding for long term care centers. If we are to provide adequate care to this most vulnerable population, we need adequate funding and reimbursement.”

John Bowblis, PhD, professor of economics in the Farmer School of Business and research fellow with the Scripps Gerontology Center at the Miami University of Ohio, agrees, noting, “When facilities don’t have the resources to invest in things they need—such as PPE and testing—they can only do so much.”

PPE and Quality

“Nothing matters more than PPE. If you don’t have PPE, you can’t fight this virus. I don’t care how good you are. Abundant PPE trumps everything,” says Wasserman.

The impact of limited availability of PPE on quality has been undeniable. “Our state and federal governments need to do more to provide ready access to PPE and testing capabilities to assure residents’ safety. They need to partner with nursing facilities, rather than increasing scrutiny and penalizing minor or imaginary breaches,” he says.

In June, David Grabowski, PhD, professor of health care policy, Department of Health Care Policy of Harvard University Medical School, gave testimony before congressional committees and spoke explicitly about PPE. He called for nationalizing the production of equipment and for the government to take responsibility for testing.

In his written testimony, he said, “The federal government should implement and order universal testing of staff and residents in all U.S. nursing homes. And this can’t be a one-off. We need a surveillance program that regularly tests staff and residents in order to identify new cases as they emerge.”

At these hearings, frontline workers spoke of their desperate need for PPE. Melinda Haschak, a licensed practical nurse at a Connecticut nursing facility, says, “While I appreciate the donations of food and the occasional pizza party we receive, my co-workers and I don’t need a pizza party—we need PPE.”

Will There Be Survey Surprises?

Everyone is wrestling with how to define and measure quality in light of the pandemic. In March, CMS announced that it was suspending survey activity for certain nonemergency state survey inspections. At the same time, the agency stressed that it would immediately focus inspections on compliance with federal infection control policies. In June, CMS released new expectations for updated inspections and surveys (including issues such as resident abuse) without offering a specific timeline for when nonemergency surveys will resume.

Also in June, the federal government unveiled increased civil monetary penalties for nursing facilities with “patterns” of infection-related deficiencies.

In a statement at the time, CMS Administrator Seema Verma said, “While many nursing homes have performed well and demonstrated that it’s entirely possible to keep nursing home patients safe, we are outlining new instructions for state survey agencies and enforcement actions for nursing homes that are not following federal safety requirements.”

Kumar says, “CMS has stated that surveys will focus on infection control as a priority. No one could have known how COVID would affect us. What are facilities to do? People are doing the best they can in a never-foreseen pandemic. We appreciate and need the support of government agencies during these difficult times. However, CMS and HHS [Department of Health and Human Services] policies have changed frequently, and it’s challenging to stay on top of these policies and prepare for surveys moving forward.”

According to Bowblis, “Useful measures of quality need to measure how care is provided over the long-term. Right now with COVID, we don’t know what is ‘good’ quality or what any particular quality measure means. And we don’t know how surveyors will interpret COVID-related quality.” Until the regulatory process gets back to normal, surveys and deficiency citations that are issued may not be reflective of the care facilities are providing, he says.

Teaching an Element

Nonetheless, there is some optimism about surveys. “I think that the survey regulatory approach has been much more targeted and focused on helping providers learn how to do things differently,” Gifford says. “On the whole, we’ve seen a shift in survey processes on providing feedback and education on how to do things better so that care teams are more confident.” He adds, “We have seen a recognition in some areas that sometimes even when you do things right, things can go wrong.”

The best way to ready a facility for surveys, Kumar suggests, is to document everything staff are doing for residents in great detail. However, even more important, he says, “Have solid best practices and policies in place.”

Elsewhere, reach out to state and local health departments and seek guidance and industry-specific information from the Centers for Disease Control and Prevention and professional organizations such as AHCA/NCAL. “Employ interdisciplinary, collaborative approaches, and use all resources available to stay on top of evolving research, policies, and guidelines related to COVID-19,” Kumar says.

“It’s important to know what areas surveyors will be targeting. Make sure you’re doing a good job in those, and document what you’ve done,” Bowblis adds. Elsewhere, he suggests, “there is a need to communicate to consumers what is occurring in the industry and to help them understand that in the context of COVID, publicly reported quality data may not be reflective of what is happening in a facility for some time.”

Leadership Matters

COVID clarified another point about quality, Wasserman says. “One thing we see is that poor leadership leads to poor outcomes. Certain staffing needs, as well as process measures that indicate strong leadership, are things we need to look at,” he says.

The industry needs good directors of nursing, administrators, and medical directors, he says. At the very least, it needs nursing leadership 24/7. “I believe that QAPI [quality assurance process improvement] when done as a team effort can help you identify where your concerns are. Then you can think, act, and work on it as a team. That is where the focus has to be for quality improvement to work and create real system and culture change.”

Looking Ahead

The future is more uncertain than ever, as the COVID pandemic continues and spikes in cases come in waves. It will be interesting to see what impact various CMS initiatives to address infections and outbreaks may have. For instance, in June, the agency announced the establishment of a Coronavirus Commission on Nursing Home Safety and Quality.

This body will conduct a comprehensive assessment of the overall response to the COVID pandemic in nursing facilities. Based on its assessments, the commission will make recommendations on actions and best practices for immediate and future actions.

The key areas of focus for the commission will include ensuring that residents are protected from COVID-19 and improving the responsiveness of care delivery to maximize quality of life. The group also will address efforts to enable rapid and effective identification and mitigation of virus transmission in nursing facilities. The commission includes members of AHCA and AMDA – The Society for Post-Acute and Long-Term Care Medicine.

Will the Changes Stick?

At the same time, Buslovich notes, “We are seeing lightning-speed revisions to regulations—such as changes regarding provision of services, infection control, and the use of telemedicine—that were impeding care and serving as disincentives to do what is right. Hopefully, moving forward we will have a greater voice in deciding what is important for our patients and our communities.”

At the same time, says Gifford, the pandemic has brought out more technology and ways to use it, and it will be interesting to see if policymakers and payers continue to support these efforts, either via funding or reimbursement. Waivers regarding technology and other issues regarding paperwork and documentation have had a mostly positive impact on care, and Gifford and others are hopeful that this will factor into regulatory changes moving forward.

“Any emergency unmasks general problems, but we don’t want to throw the baby out with the bath water,” he says.

“Quality measures in general have been driven by the tail wagging the dog approach. We need to look at the data we have and find ways to measure what is important to residents and families.”

Read more: Quality Ratings and COVID: What's the Relationship?

Joanne Kaldy is a freelance writer and communications consultant based in Harrisburg, Va.