Protecting Our Staff Has Never Been More Critical<p>Our nation’s most vulnerable population has been amongst the hardest hit by the historic COVID-19 pandemic. Since day one, caregivers in nursing homes and assisted living communities have worked tirelessly to ensure the health and safety of their residents and staff, but facilities were forced to fight the virus with limited resources. <br><br>Critical resources, essential in fighting the virus, were hard to come by in almost every facility. Specifically, access to personal protective equipment (PPE) was a challenge for many facilities. Worldwide supply chain issues and soaring demand across every industry left long term care providers scrambling to acquire and afford the masks, gowns, and gloves they needed to help keep staff members safe and prevent further spread of the virus.<br><br>Many suppliers delayed or limited the size of providers’ orders, and many providers got taken by scammers pretending to have legitimate PPE.<br><br>The long term care industry made repeated calls to federal and state officials to prioritize these settings for PPE, but shortages remained. Many facilities were forced to reuse items like N-95 masks or use handmade cloth facemasks, all in accordance with guidance from the Centers for Disease Control and Prevention (CDC) on how to optimize PPE supplies.<br><br>Moreover, early on in the pandemic, public health officials focused on a symptoms-based approach even though we knew the virus was spreading through asymptomatic and pre-symptomatic carriers. The CDC did not revise its guidance to nursing home personnel to wear facemasks at all times throughout the facility until June 2020—five months into the pandemic.<br><br>While access to PPE has improved since last year, long term care providers still struggle to afford the high cost of quality equipment, and suppliers anticipate continued strain on items such as gloves. Some believe facilities should be fined or issued citations by the Occupational Safety and Health Administration (OSHA) or other regulators in an effort to enforce use of PPE. But that approach would only make the situation worse. <br><br>The health and safety of long term care staff and the residents they care for is and always should be the top priority. Facilities have taken historic steps to keep the virus out of facilities and limit its spread if it does make its way in. Their efforts have saved lives. Fining a facility for lack of PPE due to global supply shortages would help no one. We need a public and private partnership so that health care settings, including long term care facilities, have the necessary supplies to protect our health care heroes on the frontlines.<br><br>We should all be working together to ensure facilities have the resources they need, not making matters worse with fines that only draw resources away from where they should be focused&#58; on our residents and staff. <br><br><strong><a href="mailto&#58;dgifford@ahca.org">David Gifford, MD, MPH,</a></strong> is chief medical officer and senior vice president, quality and regulatory affairs, of the American Health Care Association/National Center for Assisted Living.<br>​</p>2021-03-04T05:00:00Z<img alt="" src="/PublishingImages/Headshots/DavidGifford.jpg" style="BORDER&#58;0px solid;" />COVID-19;WorkforceDavid Gifford, MD, MPHOur nation’s most vulnerable population has been amongst the hardest hit by the historic COVID-19 pandemic.
Temporary Nurse Aide Training a Huge Boon During Pandemic<p>Not far into the onslaught of the pandemic, when it became clear that COVID-19 was hitting long term and post-acute care facilities especially hard, the American Health Care Association/National Center for Assisted Living (AHCA/NCAL) advocated for special waivers that would help the sector to better meet the needs of its residents and patients.</p><p>One of these waivers allowed for temporary nurse aides (TNAs) to assist with frontline care. The federal government declared a national public health emergency, and on March 30, 2020, the Centers for Medicare &amp; Medicaid Services (CMS) issued <a href="https&#58;//www.cms.gov/files/document/summary-covid-19-emergency-declaration-waivers.pdf" target="_blank">blanket waivers</a> that allowed for the training and hiring of TNAs.</p><p>AHCA/NCAL immediately launched two free online TNA training courses, one taking eight hours and the other 16 hours. The swift and consequential response to these two courses has surpassed all expectations.</p><h2>A Needed Program</h2><p>More than 182,890 people have registered, and more than 136,300 have completed and passed these courses since their launch in April, numbers that continue to rise every day. Skilled nursing and assisted living communities around the country have hired TNAs, or similarly named positions, to alleviate the staffing challenges that already existed but were made even more significant by COVID-19.</p><p>In addition, while many people around the country were losing their jobs—in retail or the food service industry for example—the TNA program has provided a way for them to receive free training, find work quickly, and begin new careers in long term care while making a significant contribution.</p><p>“The impact of having the TNA program available to use during the public health emergency has been huge,” says Julie Adair, vice president of home care and sector support at the Iowa Health Care Association. More than 1,500 Iowans have completed the TNA course, making it possible for them to gain valuable skills and experience working at a long term care facility. </p><p><a href="/Topics/Guest-Columns/Pages/2021/What-People-are-Saying-About-the-TNA-Program.aspx" target="_blank">What-People-are-Saying-About-the-TNA-Program.aspx</a><br></p><h2>How the Program Works</h2><p>TNAs work side-by-side with and receive supervision from certified nurse assistants (CNAs), registered nurses, and other staff. Tasks include helping with activities of daily living, infection control and prevention, positioning, moving and restorative care, nutrition and elimination, and comfort care </p><p>Students are introduced to the skills and procedures required for the job in the online TNA courses, then gain skills competency training on the job. The videos and other materials used in the online courses are adapted from AHCA’s well-known training curriculum, How To Be a Nurse Assistant. <a href="http&#58;//cnaonline.com/" target="_blank">CNAonline.com</a>, an AHCA partner that offers one of the few hybrid CNA trainings available, sponsored the TNA courses and assisted in getting the material prepared for a quick launch. </p><p>In a <a href="/Topics/Guest-Columns/Pages/2021/Temp-Nurse-Aide-Training-Follow-Up-Survey.aspx" target="_blank">recent survey</a>* of those who completed the TNA course, 54 percent said they had found a job as a TNA, and 48.6 percent said they took the TNA course because they wanted to begin a new career in health care.</p><p>Katherine Midgette completed the online TNA course in November and then began working at a center in Salisbury, Md. She is currently in a CNA training class and will continue her new health career in the years to come. “I plan to be a travelling RN,” she explains.</p><p>James Benson of Michigan felt that the training prepared him and helped him feel more confident on the job. “It really expanded my scope of practice and helped me with proper use of PPE [personal protective equipment] and end-of-life care,” he says. Benson will begin school for a nursing degree this spring.</p><h2>Future Needs</h2><p>Workforce shortages already posed a major challenge to the sector prior to the pandemic, but the added stresses that COVID-19 created brought the workforce crisis to a whole new level. Staffing shortages were so severe over the past several months that states like Minnesota, California, Pennsylvania, and Indiana called in the National Guard for help. </p><p>The question of what will happen when the waivers expire looms large. As of Jan. 21, 2021, the U.S. Department of Health and Human Services extended the public health emergency until April 21, allowing for the continued use of TNAs for 90 more days and giving the long term and post-acute care sector more time to figure out how best to tackle this problem.</p><p>Once the waivers expire, providers could be faced with even more dire staff shortages, and the thousands of people who just joined the health care workforce could lose their jobs, unless they get the additional training needed to become a CNA. </p><p>Making things even more challenging, many in-person training programs and state testing sites remain closed or are operating at reduced capacity due to COVID-19. </p><p>Online nurse assistant training serves as an excellent option, and more and more, providers are stepping up to take advantage of that opportunity. </p><h2>Genesis Takes Next Step</h2><p>Genesis HealthCare, which has post-acute care companies and skilled nursing and assisted living communities in 24 states across the country, has been working with <a href="http&#58;//cnaonline.com/">CNAonline.com</a> to train and certify CNAs for the past two years. Genesis immediately began training newly hired TNAs in its buildings through CNAonline.com so that it would be in a position to hold onto and grow its workforce even after the COVID-19 health crisis has passed. </p><p>“Genesis’ goal from the start was to transition temporary nurse aides that were committed and dedicated to a career pathway toward certification and licensure,” explains Debbie Rowe, vice president of nursing workforce development.</p><p>“CNAonline.com has been very positive. It offers hybrid nurse aide training that complies with state and federal requirements and limits students’ and residents’ exposure in a pandemic environment.”</p><p>Currently, Genesis utilizes CNAonline.com to offer classes in Colorado, Massachusetts, Vermont, and West Virginia and plans to expand to more states.</p><p>TNAs have gotten tremendous clinical practice and hands-on experience while under supervision from more experienced and qualified staff. Having TNAs has also allowed providers to ensure quality of care for residents.</p><p>“Working side by side with a CNA, [TNAs] gave the residents additional attention in meeting their needs,” says Kimberly Gerst, Center nurse executive at the Willows Center in Parkersburg, W.Va. “It really supported the personal touch, which was particularly important during the holidays.” </p><h2>Providers Assess Staffing Needs</h2><p>Many providers have taken an all-hands-on-deck approach and asked their current staff to take the TNA course so they could help out in caring for residents.</p><p>This approach to dealing with staffing shortages may continue even after the current health crisis is over. “We believe that all provider facilities will enhance their professional workforces by adapting a universal caregiver model,” says John Reinhart, president and chief operating officer of CNAonline.com. “By utilizing online technology for CNA training and licensing of their entire team, facilities will have enhanced flexibility for staffing.</p><p>“We work with individual facilities who want to have their own facility-based program,” he says. “This gives them the ability to take more control over their clinical workforce.”</p><p><span><span><img src="/Topics/Guest-Columns/PublishingImages/DanielleLevitan.jpg" alt="Danielle Levitan" class="ms-rtePosition-2" style="margin&#58;5px;width&#58;185px;" /></span></span>The impact that the TNA program has had on the sector during the pandemic offers hope and fresh excitement. People have come together, stepped up, and even found their calling at a critical time, people like Rachael Loretan in Pennsylvania who has loved being a TNA.</p><p><span></span>“This experience really opened my eyes to the nursing field, and I loved working directly with the residents. They made such an impact on me, and it deepened my desire to enter the nursing profession,” she says. “My experience was nothing but amazing!”</p><p><em><a href="mailto&#58;dlevitan@ahca.org" target="_blank">Danielle Levitan</a> is senior director, marketing, with the American Health Care Association.</em></p><p>&#160;</p><p><span class="ms-rteFontSize-1">*Survey of those who have successfully completed the TNA courses with 7,477 respondents. Conducted by AHCA from December 11, 2020 – January 8, 2021.</span></p> 2021-02-10T05:00:00Z<img alt="" src="/Breaking-News/PublishingImages/740%20x%20740/nurse_computers.jpg" width="398" style="BORDER&#58;0px solid;" />Workforce;COVID-19Danielle LevitanTens of thousands of applicants have registered to date, and of those, 75 percent so far have passed their courses.
Using Payroll-Based Journal Data to Compute Nursing Hours<p>Starting in spring 2018, the Centers for Medicare &amp; Medicaid Services (CMS) began using Payroll-Based Journal (PBJ) data to determine each nursing facility's staffing levels for the Nursing Home Compare tool used in the agency's Five-Star Quality Rating System.&#160; Accurate reporting is essential to a fair rating.</p><h2>How PBJ Works</h2><p>The PBJ system provides the reported staffing hours for each quarter. These data, based on Minimum Data Set (MDS) assessments, are used for CMS staffing calculations and are the basis for a nursing facility's Five-Star Rating. There is an added complexity, since CMS adjusts the reported staffing hours before calculating the ratings.</p><p>The adjusted hours <img src="file&#58;/////Users/shevonajohnson/Library/Group%20Containers/UBF8T346G9.Office/TemporaryItems/msohtmlclip/clip_image002.jpg" alt="" style="width&#58;1px;margin&#58;5px;" />H<sub>a</sub> for each staff type are given by using the formula&#58; <img src="file&#58;/////Users/shevonajohnson/Library/Group%20Containers/UBF8T346G9.Office/TemporaryItems/msohtmlclip/clip_image004.jpg" alt="" style="width&#58;1px;margin&#58;5px;" /><img src="/Topics/Guest-Columns/PublishingImages/2020/Formulas3.png" alt="" style="margin&#58;5px;" /> where H<sub>r</sub> <img src="file&#58;/////Users/shevonajohnson/Library/Group%20Containers/UBF8T346G9.Office/TemporaryItems/msohtmlclip/clip_image006.jpg" alt="" style="width&#58;1px;margin&#58;5px;" />represents the reported hours. The adjustment is based on <em>h</em><img src="file&#58;/////Users/shevonajohnson/Library/Group%20Containers/UBF8T346G9.Office/TemporaryItems/msohtmlclip/clip_image008.jpg" alt="" style="width&#58;1px;margin&#58;5px;" />, the case-mix or expected nurse staffing hours per resident per day and the national mean <em>m</em> <img src="file&#58;/////Users/shevonajohnson/Library/Group%20Containers/UBF8T346G9.Office/TemporaryItems/msohtmlclip/clip_image010.jpg" alt="" style="width&#58;1px;margin&#58;5px;" />of case-mix hours for all facilities. </p><p>The case-mix values are derived from STRIVE, which is a CMS Staff Time Resource Intensity Verification Study (2006-2007) that measured the average hours per resident per day for each staff type&#58; RN (registered nurse), LPN (licensed practical nurse) and CNA (certified nurse assistant) based on the associated Resource Utilization Group (RUG-IV) 66.</p><h2>Rating Methodologies</h2><p>The Rating Methodology Rules shown below in Table 1 (taken from Table 4) of the July 2020 CMS Technical Users Guide, “Design for Nursing Home Compare Five-Star Quality Rating System.&quot;&#160; <br></p><p><br></p><p style="text-align&#58;center;"><img src="/Topics/Guest-Columns/PublishingImages/2020/Table1.png" alt="" style="margin&#58;5px;" />&#160;</p><p style="text-align&#58;center;"><br></p><h2>Nursing Levels Categorized</h2><p>It is important to note that two separate staffing level ratings are published by CMS. </p><p>One rating is for RN Staffing, and the other is the Overall Staffing. As illustrated in the table above, RN hours greater or equal to 1.049 will result in a Five-Star RN Rating. The combined sum of RN + LPN + CNA greater than or equal to 4.038 will give an Overall Five-Star Rating.&#160; The combination of adjusted values that result in 5, 4, and 3 stars, respectively, are summarized in Table 2 below.</p><p><br></p><p style="text-align&#58;center;">&#160;<img src="/Topics/Guest-Columns/PublishingImages/2020/Table2.png" alt="" style="margin&#58;5px;" /></p><p style="text-align&#58;center;"><br></p><p>Harmony Healthcare International (HHI) has developed three simple algorithms to estimate the staffing levels necessary for a given Star Status. In the equations below, R, C, and L represent the RN, CNA , and LPN reportable nurse staffing hours per resident per day needed to guarantee a given Star Ratings Level. </p><p>The case mix hours symbol h is the expected hours per patient per day based on the composite of RUG-IV values over a quarterly time period. The quantity h is indirectly related to case-mix indices in a nonlinear manner and is distinct for each SNF. The symbol m is the mean of case-mix hours averaged over all SNFs.</p><p style="text-align&#58;center;"><img src="/Topics/Guest-Columns/PublishingImages/2020/Formulas1.png" alt="" style="margin&#58;5px;" /><br></p><p><img src="file&#58;/////Users/shevonajohnson/Library/Group%20Containers/UBF8T346G9.Office/TemporaryItems/msohtmlclip/clip_image017.jpg" alt="" style="width&#58;1px;margin&#58;5px;" />Previous statistical data suggest that case-mix indices and adjustment factors vary very slowly over time for most facilities. Therefore, it is reasonable to assume that the values assigned in a given time period can be used to estimate the reported values in a subsequent time period to gain the desired star status. </p><p>As an example, consider the case-mix values for a given facility shown in Table 3 taken from the CMS Medicare Nursing Home Compare Website. </p><p><br></p><p style="text-align&#58;center;">&#160;<img src="/Topics/Guest-Columns/PublishingImages/2020/Table3.png" alt="" style="margin&#58;5px;" /></p><p>The calculations to attain a Five-Star rating for the case-mix data listed in Table 3 are as follows&#58;</p><p style="text-align&#58;center;"><img src="/Topics/Guest-Columns/PublishingImages/2020/Formulas2.png" alt="" style="margin&#58;5px;" /><br></p><p>The same technique can be used to determine the reportable hours per patient per day for 4- or 3-Star Ratings.</p><p><em>Kris Mastrangelo, OTR/L, LNHA, MBA, is chief executive officer and president of Harmony Healthcare International. She can be reached at </em><a href="mailto&#58;Kmastrangelo@harmony-healthcare.com" target="_blank"><em>Kmastrangelo@harmony-healthcare.com</em></a><em>. James E. Smerczynski has been with Harmony Healthcare since retiring from Raytheon in 2012. He has an extensive background in integrated weapon system engineering that includes the Patriot Air Defense System, Advanced Lightweight Torpedo, and Hawk Missile System. Smercznynski has considerable experience in applied mathematics that directly applies to the probability and statistics analytics of the health care industry. He also does analytics for the startup software company Hopforce.</em></p><p>​</p>2020-12-14T05:00:00Z<img alt="James Smerczynski, Kris Mastrangelo" src="/Topics/Guest-Columns/PublishingImages/2020/SmerczynskiMastrangelo.JPG" style="BORDER&#58;0px solid;" />Quality;CMSSmerczynski, MastrangeloStarting in spring 2018, CMS began using Payroll-Based Journal data to determine each nursing facility's staffing levels for the Nursing Home Compare tool used in the agency's Five-Star Quality Rating System.
Innovative Training Program Open to Help Caregivers Combat COVID<p>​<br></p> <p><img src="/Topics/Guest-Columns/PublishingImages/1120_JaneDavis.jpg" alt="Jane Davis " class="ms-rtePosition-1" style="margin&#58;5px;width&#58;270px;height&#58;347px;" />I had little idea what I was getting into when I agreed to participate in an innovative pilot program to help nursing home administrators and frontline staff combat the spread of COVID-19.</p><p>But I was willing to try almost anything to prevent another wave of sickness, suffering, stress, and uncertainty like the one that hit our facility in April and May.</p><h2>All Are Welcome to Join</h2><p>Now that effort’s gone national. The AHRQ [Agency for Healthcare Research and Quality] ECHO National Nursing Home COVID-19 Action Network launched this month with training centers and nursing homes around the country joining new virtual communities of practice.</p><p>And, after participating in the pilot program, I’ve signed up again, because what the COVID-19 Action Network offers—not only education but mentoring and a peer community—is that valuable right now.</p><p>Working at nursing homes during this pandemic, so many of us feel like we’re carrying the weight of the world on our shoulders, with hardly any support. The stress takes a terrible toll. Even worse, because there’s so much still unknown about this virus, we worry that we’re missing things—things that could help keep our residents safe. </p><h2>Support and Mutual Respect</h2><p>Participating in the COVID-19 Action Network brought me to a new place—a place where I could share my perspective and experiences, where I could learn from the experiences of my peers, where I could hear new ideas and think differently. It was a place of collaboration and mutual respect where I didn’t just passively receive wisdom and best practices from the experts. I contributed my own, and it was valued.</p><p>And, perhaps most of all, it was a place where I felt supported. My staff and I were not alone—far from it. Being in the Network reinforced that we truly are all in this fight together.</p><h2>A Collaborative Approach</h2><p>The Network is led by three organizations&#58; the federal AHRQ, the Institute for Healthcare Improvement (IHI), and Project ECHO. Together, they created the initiative to prevent and reduce COVID-19 in nursing homes—not through regulation or compulsory programs but through voluntary, collaborative learning.</p><p>Here’s how it works&#58; Training centers across the country—mainly academic medical centers or large health systems—run virtual communities of practice on Zoom that are staffed by experts in infection control and gerontology. Staff from up to 35 nursing homes participate in these communities of practice.</p><p>Each Zoom session (there are 16) kicks off with a quick lecture on a topic like Personal Protective Equipment (PPE) use and then moves on to real-life case presentations that spark a lot of hands-on discussion and problem solving.</p><p>Everyone participates in the sessions. Everyone’s experience, observations, and questions are honored and valued. That’s what made it so different. We weren’t just there to learn. We were there to share with each other, and even teach each other—as well as the experts, who wanted to know about our on-the-ground experiences to inform their own perspectives.</p><h2>More Than Worth It</h2><p>After only one or two sessions, I was hooked. I didn’t want to miss a single session because of what I was learning, the support I was receiving, and the relationships I was building. After the 16-session program ended, I found myself missing it.</p><p>People sometimes ask me what it was like when the pandemic peaked this spring. I tell them I never experienced anything like it before and never want to again.</p><p>That’s why I “re-upped.” As a nursing home administrator, I want to do everything in my power to beat this scourge and protect our residents and our staff. I’ve learned that when we come together to learn with and from each other, we can create something powerful&#58; the knowledge and support to move forward and succeed.</p><p>We are not alone—and we shouldn’t be. I urge others to join the COVID-19 Action Network now.</p><p>To learn more about the AHRQ ECHO National Nursing Home COVID-19 Action Network, visit&#160;<a href="https&#58;//hsc.unm.edu/echo/institute-programs/nursing-home/pages/nursing-home-info.html" target="_blank">https&#58;//hsc.unm.edu/echo/institute-programs/nursing-home/pages/nursing-home-info.html</a>.&#160;</p><p><em>Jane Davis is administrator for Hyatt Family Facilities at Landmark Care &amp; Rehabilitation in Yakima, Wash. Starting out in assisted living in 1993, Davis has been a licensed nursing home administrator since 1998 with licenses in six states.&#160;She has practiced in Washington state, Texas, and South Carolina during her career. She can be reached at </em><a href="mailto&#58;Jane@hyattff.com" target="_blank"><em>Jane@hyattff.com</em></a><em>.</em></p>2020-11-23T05:00:00Z<img alt="" src="/Breaking-News/PublishingImages/740%20x%20740/nurse_computers.jpg" style="BORDER&#58;0px solid;" />Technology;COVID-19Jane DavisThe AHRQ ECHO National Nursing Home COVID-19 Action Network launched this month with training centers and nursing homes around the country joining new virtual communities of practice.