Ronda Malmberg, RN, is an administrator for CovenantCare at Home, Home Health and Hospice, based in Turlock, Calif., which provides palliative care for individuals in assisted living facilities, independent living, and in the community. 

The challenge for palliative care providers is that anyone receiving it is compromised indefinitely, so extreme precaution is a given with professionals in the field entering buildings, says Malmberg. Securing personal protective equipment (PPE) is a challenge, she says. 

“Now we have a new spike in cases, so we have another run happening on all the PPE,” she says. “If we didn’t think ahead and have a fairly good supply, we wouldn’t be in the position we are.”

That position became handy when a number of long term care facilities in Illinois became inundated with COVID patients. In response, Covenant Living Communities and Services, which operates 16 senior living and care communities in nine states, reached out to Malmberg’s team for help.

“We actually sent nurses to Illinois to help out under the CMS [Centers for Medicare & Medicaid Services] emergency provision, and with just careful use of PPE and all their hand washing, none of them got it,” she says.

While Malmberg’s staff have been healthy, she says the key has been three things. “They mask, they hand wash, and they protect their eyes,” she says. Social distancing also plays a role, and Malmberg and her team tell patients that if anyone enters their homes, both the patient and the visitor should mask.

For all patients, the precaution is screening to make sure staff are healthy. “For palliative care patients they just really need to be able to be aware and careful of who they allow in their home,” says Malmberg. “It is hard right now and it is so difficult to not have family with you, but we stress that patients have to protect themselves, especially if they are compromised.”

In her multiple roles, Jill Mendlen, RN, touches palliative care, clinical care management, and end-of-life care in a variety of ways. She is president and chief executive officer (CEO) of Family Choice of New York, based in Depew, N.Y., and president and CEO of LightBridge Hospice & Palliative Care and CEO of LightBridge Medical Associates, a palliative care specialty medical group, both based in San Diego. All of her companies provide services in both facility and home settings.

At Family Choice, Mendlen specializes in managed care, and the company operates a 1,300-plus member Institutional Special Needs Plan (ISNP). She also operates a community-based Chronic Condition Special Needs Plan for heart failure and diabetes. Both plans are through a partnership with a health plan she has been working with for the past 15 years.

COVID-19 has affected how Mendlen’s companies do business and how they deliver care to the individuals they serve. Those entering the office who are not daily staff must fill out a form that details where they have traveled, have their temperature taken, sanitize their hands, and wear a mask. In addition, her offices require social distancing. If anyone has been on a plane recently or been exposed to anyone with COVID, they are not allowed to enter the building. 

The office staff operate on a staggered schedule to avoid multiple people in the office at once, but this also presents challenges. “One thing I’m struggling with as a CEO is how do you maintain a culture remotely,” says Mendlen. “I don’t believe we are ever going to go back to 100 percent onsite operations. We have always had a large field staff, but they would come into the office for meetings on a routine basis.”

The office meetings have been discontinued in favor of online meetings, and although Mendlen says this is effective, it’s not the same as everyone being together physically. “I know we will never return to the way we used to operate,” she says. “I just don’t know how our future will look with a combination of onsite and remote work.”

Mendlen’s teams have been making use of Zoom for meetings and patient and family visits, and she is also changing education and new orientation procedures to remote, technology-based programs.

Another challenge is staying on top of what a company’s nursing and assisted living partners are doing. As hands-on caregivers, Mendlen’s staff provide palliative care and clinical services based on what a facility’s policies related to COVID are.

Some facilities will restrict the number of people on a team who can enter their building, while others will only allow a nurse practitioner or registered nurse to enter. “Every facility has made their own determination, which I totally respect and understand, so we are adjusting to that,” says Mendlen. Her teams provide hands-on care, so they partner with facilities and their physicians to provide additional support to their patients.

Team members have access to full PPE. Wearing it takes some getting used to. “We have all the PPE we need, so depending on what’s going on, my staff may need to be in face shields, N95 masks, gowns, and gloves,” says Mendlen.

A nurse recently went into a nursing home and got all of her equipment on, and she then realized the patient was upstairs. “She said, ‘Walking up stairs in full isolation equipment was quite the experience.’ It’s daily things like that that you just learn to live with and learn from.”

Another impact of the COVID pandemic in the area of palliative care has been the increased demand for medical directors to assist with treating COVID patients, while also providing expertise to support hospice companies as they respond to new state, federal, and Centers for Disease Control and Prevention (CDC) guidance, which changes frequently.

“I have one medical director who has been on—working—for almost the whole time,” says Malmberg. “I don’t think she’s taken a day off. Not having access to the regular doctor and then depending on a really overworked medical director for symptom management has been one of the things that we’ve had to deal with.”

Luckily, Malmberg’s team has not had any shortage of symptom management medication that patients require. Early on during the pandemic, however, wound care supplies were hard to come by, but that has improved, she says.

“Unfortunately patients that are palliative tend to have a lot of wounds, so that’s been a charge—to really make sure that you have plenty of wound care supplies,” says Malmberg.

With regard to telehealth and conducting televisits, Mendlen says it’s a process to see what works and what does not. And because there are differing needs and systems between provider partners and palliative care providers, a single technology solution doesn’t really exist. 

“I don’t think we’re going to end up selecting just one solution because our environments are diverse, and, depending on where we’re trying to serve our patients, we will need different approaches. I believe we will end up implementing at least a couple of different technology approaches,” she says. Mendlen’s teams can bill for some of the services they provide, which is currently helpful, but they will need to track billing regulation changes in the future.

“One of the challenges of doing telehealth and televisits in a facility setting when you are the external party is when you’re trying to see your patients,” says Mendlen. “Many of the patients we serve are frail and very ill, and it’s not easy for them to sit and hold an iPad or hold a phone for a televisit.”

Facilities are working hard, and staff may be stretched thin, making it difficult for them to take time to coordinate and assist with a televisit. Mendlen’s teams continue to explore different solutions to tailor telehealth and televisits to patients’ needs and ensure they go smoothly. For example, telehealth and televisits in a community setting with a young population are very different from those in a complex, fragile population, says Mendlen.

Malmberg, like many palliative care providers, is looking at all of what has transpired with COVID as “the new normal,” noting that even if the virus abates or a new vaccine appears, the impacts of the virus will be lasting.

One of those impacts is the use and stocking of PPE. “I expect my PPE usage to be at an active level—at least very close to this level for the next year or two,” says Malmberg. “So we need to take that into consideration. And I also need to make sure that I’m very vigilant in understanding how fast we are using it for this population.”

Without sufficient supplies, Malmberg’s team cannot take on new patients. This would be a hard blow to the local community since CovenantCare at Home, Home Health and Hospice is one of the only palliative care programs in the local area.

To assess PPE, Malmberg looks at how much PPE the team is using on a weekly basis. “I look at what my population is right now, I look at what my census is and how much am I using on a weekly basis of masks, gloves, gowns, etc.,” she says. “So for example let’s say I’m using 50 gowns a week, then I know that for the next four weeks I’m going to need 200 gowns, and I may only have 50 in stock. And we also need to [account for] increases in demand.” 

Access to PPE is spotty at best. From the beginning of the COVID pandemic, Malmberg’s vendor partner has been able to provide only small quantities at a time, so she has reached out to multiple suppliers.

“Amazon has been one of my greatest resources in just getting supplies,” she says. “But sometimes the supplies are kind of funky and weird—you order it and then when it arrives you realize it’s not exactly what you wanted. You’ve just got to be several steps ahead as much as you can.”

Surgical masks and gowns have gotten easier to acquire as of late, she says, and face shields have hit a new high in demand and are difficult to get a hold of. “Whenever the CDC releases information on products that are good to have, those products disappear quickly, and I believe that’s what’s happened to face shields,” says Malmberg.

Another impact of the pandemic has to do with staff. Family members of staff have been coming down with the coronavirus, so staff have been taking leave to take care of them, or because they have been exposed to COVID through an infected family member, they have to self-quarantine. 

“You have to have a back-up plan for staffing in order to take care of the patients you have and in order to take on new patients,” says Malmberg. Initially there were a lot of people who were worried about contracting the virus and didn’t want anyone to enter their home, “so several patients asked us to not come or they asked to be discharged,” she says.

But now hospitals are full of patients, and they also are discharging patients either home or to a long term care facility. “So we have to manage that new influx with more staff than before and be sure we are on top of the staffing,” she says.

This means caring for nurses emotionally and making sure they are staying healthy. It also means that staff know that Malmberg has their back as a leader. “It’s whatever I ask the staff to do, I’m ready to talk it through with them because sometimes they do feel insecure,” she says. “It’s very important as a leader to be accessible to the staff and not shut yourself away. Make sure you are there to support your staff so that they can do what they need to do to keep your community safe.”

Mendlen agrees. The key for leaders is to try to remain flexible and support their teams as much as possible. “Our leaders are tired, and even though they are dealing with COVID on a daily basis, they still have all of the usual legal, regulatory, and operational demands. COVID adds an additional layer of challenge and complexity none of us has seen before,” she says. “I would like to say that COVID is behind us, but it’s not.” 

The challenge for all providers is trying to figure out how to support staff emotionally and how to clinically respond to help patients in the midst of this crisis.

“The nursing home of today is having to deal with the death of residents who they love many times like family at a frequency they have never experienced,” says Mendlen. “While the pandemic has created challenges and opportunities in ways we have never thought of, we are trying to figure out where this journey is taking us and what we are going to look like when we emerge from this,” she says.

“The one thing I am sure of is we just have to weather it together.” ■