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Telehealth a Silver Lining in Pandemic<p><span></span>Since the pandemic began, telehealth services—specifically meeting with physicians online—have been a time saver for&#160;one Massachusetts provider.&#160;In &quot;The Telehealth Phenomenon,&quot; learn how providers have made changes to protect residents and keep care running smoothly, learning lessons and seeing benefits along the way.&#160;To read more, go to <em>Provider's </em>just<em> </em>released first digital issue <a href="https&#58;//pagepro.mydigitalpublication.com/publication/?m=63330&amp;i=687740&amp;p=1">here.</a></p><p></p>2021-01-12T05:00:00Z<img alt="" src="/Monthly-Issue/2021/January/PublishingImages/telehealth-0121.jpg" style="BORDER&#58;0px solid;" />COVID-19;CaregivingAmy MendozaIn its first ever digital issue, Provider reports on how COVID-19 has changed the supply and demand of telehealth services in long term and post-acute care.
A Family Like None Other<p>In a year like none other, the holiday season can be especially hard in long term and post-acute care centers, where elderly residents and those with disabilities are limited from seeing loved ones in person due to COVID-19. Luckily, dedicated and supportive nurses and caregivers, many of whom have known and cared for the residents for years, naturally fall into the role of daughter, son, or friend.</p><p><img class="ms-rtePosition-1" alt="Brenda Kincaid" src="/Breaking-News/PublishingImages/BrendaKincaid.jpg" style="margin&#58;5px;" />Brenda Kincaid is a licensed practical nurse (LPN) with Virginia Health Services, based in Newport News, Va. At The Huntington, an assisted living community, and The Newport, a rehabilitation center, she’s formed a number of bonds with residents over the years, who treat her as family.</p><p>“It’s a very close relationship, especially with restrictions that we’ve had this year with visitors coming in,” says Kincaid. “And, they rely on us. We’re sort of filling in for their family right now. We are like a big family.”</p><p>It’s a natural fit for someone who chooses a career in caring for others. Kincaid stresses that the center is home for many residents, especially those receiving long term care.</p><p>“We’re really dedicated to treating them as a whole person,” she says. “That’s not a patient. It’s a resident. You know, this is their home, and we’re coming into it. And we want to bring good things into that.”</p><p>Kim Randolph, a fellow LPN at Virginia Health Services who works at Northampton Convalescent and Rehab Center in Hampton, Va., couldn’t agree more. She originally planned to only work in long term care for a year, but because of one resident, she stayed for close to 20 years.</p><p>“You become that family for them,” says Randolph. “You have your own family that you take care of at home, but then when you leave home in the morning, you have another family that you have to take care of. And just like you leave your family at home, you leave them for the night, and you come back in the morning to take care of them.”&#160; </p><p><img class="ms-rtePosition-2" alt="Kim Rudolph" src="/Breaking-News/PublishingImages/KimRudolph.jpg" style="margin&#58;5px;" />There’s usually one or more people in a family that everyone counts on to give a helping hand or nudge in the right direction. In long term care, the story is no different. </p><p>“We provide them with, you know, that little love and that passion, you know, that little laugh,” says Randolph. “And, even sometimes those that are here just for rehab. We also provide that push for them. ‘Hey, you can do this. You can.’ And sometimes they need to hear that.”</p><p>Kincaid’s and Randolph’s stories are front and center of an advertising campaign from the American Health Care Association/National Center for Assisted Living (AHCA/NCAL), the nation’s largest association of long term and post-acute care providers.</p><p>The ads, “<a href="https&#58;//www.youtube.com/watch?app=desktop&amp;v=gfJyTT4Xcgc&amp;feature=youtu.be">Family</a>” and “<a href="https&#58;//www.youtube.com/watch?app=desktop&amp;v=7uZwXoTStIE&amp;feature=youtu.be">Oath</a>,” feature caregivers from multiple Virginia Health Services (VHS) facilities talking about how long term care staff have cared for nursing home and assisted living residents in the face of what may be their most challenging circumstance yet—COVID. Their roles have become even more critical to helping those residents continue to thrive despite the obstacles, including visitor restrictions. </p><p>“We become that person for them,” says Randolph. “We become mom, we become brother. We become sister, aunt. We become all of those for them.</p><p>“It’s been rough during COVID. You know, you have the patient who cries because they can’t see their loved one. So, and then you go, and although with nursing we’re busy, but you have to stop and just pull up a chair and sit, hold a hand, and just talk. It may be about nothing, but just talking.”</p><p>The ads are currently running through the end of 2020 on select cable networks and digital platforms and are supplemented by local buys from AHCA/NCAL state affiliates.</p><p>But, no matter the season, the day-to-day dynamics and the focus remain the same. </p><p>“All shift, every day, their safety, their health, and their happiness are three things that we’re working on 24/7, every day of the year,” says Kincaid. “Holidays, whatever, every day is the same there. We know that’s our mission, and we’re focusing on that.”<br></p>2020-12-26T05:00:00Z<img alt="" src="/Breaking-News/PublishingImages/740%20x%20740/senior_woman_cane.jpg" style="BORDER&#58;0px solid;" />CaregivingAmy MendozaThe bond between caregivers and long term care residents has only deepened admidst the constraints of the pandemic.
On the Lookout for Psychiatric Distress<p>Prior to the COVID-19 pandemic, “Fred” was fairly typical of many long term care residents. With three chronic medical conditions and mild dementia, he spent his days engaged in unit activities with his fellow residents. He enjoyed the regular visits from his wife and the consistent care he received from the warm staff.<br></p><h2>Enter Pandemic</h2><p>All of that changed with COVID-19. His wife was no longer allowed to visit, activities were either eliminated or significantly altered, and his caregivers were gowned and masked.<br></p><p>Over several months, Fred’s emotional well-being declined markedly. Although he was previously prone to bouts of mild depression, he became significantly and consistently depressed, with a severe anxiety and preoccupation with both the virus and his wife’s situation.<br></p><p>Although he seemed to understand the staff’s explanations that his wife was fine, just unable to visit him due to COVID-19 restrictions, his concerns began to escalate as some of his fellow residents succumbed to the virus. Some paranoid ideation began to creep in, and Fred occasionally expressed the concern that his wife had died from COVID-19 and that staff were keeping the news from him.<br></p><p>Perhaps as a result of that idea, he became increasingly combative with staff members, and more reclusive and depressed as the pandemic lingered on. He also lost nine pounds due to frequent refusals at mealtime. His clinical decline is, unfortunately, not an isolated scenario considering the impact of COVID-19 on nursing home residents.<br></p><h2>A Perfect Storm of Emotional Stress</h2><p>Post-acute facilities have always seen high levels of psychiatric disorders, with estimates of 70 percent of residents evidencing at least one behavioral health disorder. Depression is the most prevalent. The alarming rates of depression, anxiety, and other psychiatric and emotional disorders reflect the challenges that many nursing home residents are confronted by, including chronic medical illness; loss of home, friends, pets, and hobbies; and the stress of living in a new and communal setting.<br></p><p>It’s crucial that residents receive the psychiatric and psychological care they need, as these impairments are responsible for much of the overall distress residents experience. Additionally, these psychiatric disorders have a major impact on the effectiveness of medical care.<br></p><p>Depression, for example, the most common form of mental distress in post-acute care, has a negative impact on compliance with medical and rehabilitation treatments and on clinical outcomes, even when the medical care is excellent.<br></p><p>Despite a widespread awareness of—and efforts to expand attention to—the emotional well-being of residents, skilled nursing facilities (SNFs) are still medically oriented care settings, and the collective response to COVID-19 has focused primarily on preventing resident infections. But well-intended regulations and practices around infection control have taken a severe emotional toll on resident populations.<br></p><h2>Isolating Factors</h2><p>As their fellow residents succumb to the virus, personal protective equipment (PPE) has literally put barriers between residents and their staff caregivers. Prohibitions around family visitation have disconnected residents from the people who care for them most, in addition to limiting personal care providers, clergy, and other visitors.<br></p><p>Some facilities have actually had to restrict in-person care from the mental health workers who treat depression, anxieties, and other psychiatric issues, making psychiatric providers “nonessential” in the face of the greatest threat to residents’ emotional well-being in their lifetime. <br></p><p>Nationally, researchers have identified increases in depression and anxiety in community-based populations. While data on residents of SNFs are less clear, it’s safe to assume that a population with extremely high pre-existing levels of psychiatric stress and faced with arguably the most difficult pandemic-related changes will demonstrate commensurate increases in psychiatric disorders. <br></p><h2>Time to Act</h2><p>The Centers for Disease Control and Prevention argues that our “public health response to the COVID-19 pandemic should increase intervention and prevention efforts to address related mental health conditions.”<br></p><p>Fortunately, there is already a road map that SNFs can follow to mitigate the deleterious impacts of the COVID-19 pandemic on residents. SNFs are required by the Centers for Medicare &amp; Medicaid Services to deliver care that supports residents’ “whole emotional and mental well-being.” <br></p><p>That mandate places the emotional functioning of residents on an equal level with medical disorders, at least theoretically. Here are some suggestions for getting there.<br></p><h2>Depression</h2><p>Facilities are required to screen all residents for depression using the Patient Health Questionnaire-9. When residents screen positive for depression, either at admission or during their stay, facilities should take aggressive action. Make sure that there is a follow-up evaluation by a mental health professional and that treatment, if indicated, is initiated in a robust fashion.<br></p><p>The identification of depression, by itself, can lead to increased reimbursement to facilities, so that is an incentive for facilities to aggressively identify and treat depression. <br></p><p>SNFs are now required to provide “trauma informed care” to those residents who need it. Many residents have pre-existing trauma histories that were never identified or treated, others may have been traumatized by the events leading to their SNF admission, and still others may have experienced trauma connected to COVID-19 and its impacts.<br></p><p>Anyone who has experienced trauma deserves adequate assessment and response. A good place to start would be by administering the PC-PTSD-5 (Primary Care-Post Traumatic Stress Disorder-5), an extremely brief screening tool for trauma that, for most residents, will consist of just one question. Residents who need it should receive follow-up behavioral health care, and all residents will benefit when facilities increase their knowledge about the best ways to treat residents with trauma histories.<br></p><h2>Antipsychotic Medications</h2><p>The burdens of the pandemic, combined with the fact that some residents lost access to behavioral health clinicians, may have contributed to an increase in the use of psychotropics in general, and antipsychotics in particular.<br></p><p>Clinicians should be vigilant about Gradual Dosage Reductions. As behavioral health clinicians are permitted to return to in-person treatment, psychiatric and psychological clinicians should work diligently to increase the use of nonpharmacological interventions such as psychotherapy and behavior management. <br></p><p>At the same time, the use of all psychotropics, particularly any antipsychotics, should be carefully assessed, especially any that may have been prescribed recently due to exacerbations of unwanted behaviors.<br></p><h2>Staff Support and Training</h2><p>Nursing home staff, even prior to the pandemic, are often overwhelmed by the need to care for a rising number of residents with psychiatric impairments. The pandemic and its emotional stress on residents will only exacerbate the problem.<br></p><p>On top of that, staff members are struggling with what is likely the most challenging moment of their careers. Surrounded by death and dying, grappling with PPE and new practices at work, these workers return home with anxiety about their own health and the risk of transmitting the virus to their loved ones.<br></p><p>It’s counterintuitive to believe that providers can improve the psychological well-being of their residents without a commensurate effort to support the people who are caring for them. <br></p><p>Staff members need enhanced training regarding best practices for managing psychiatric impairment, but they also need to receive the support that will help them emotionally navigate the pandemic themselves.<br></p><h2>Outside Support Groups</h2><p>Facilities are encouraged to discuss staff support programs with their behavioral health teams, as well as with community-based organizations that can provide such services. </p><p>Post-acute facilities and providers have been impacted more than most by the COVID-19 pandemic. They’ve lost thousands of residents to the virus. At work, residents are struggling along with staff, and at home staff have the same concerns and uncertainty as others.</p><p>The challenge is to be sure to provide optimal care during the pandemic, and to learn from it in order to gain strength and knowledge that can be put into practice post-pandemic. <br></p><p>To achieve that, providers will need a robust and thorough strategy that provides every resident the chance to obtain their best level of mental health and emotional well-being, despite the challenges they face. <br><br><em>Richard Juman, PsyD, is TeamHealth national director of psychological services and co-chair of the TeamHealth Clinician Resiliency Work Group. A licensed clinical psychologist working in the field of behavioral health and substance use services for more than 25 years, he coordinates TeamHealth’s psychological services in hundreds of contracted facilities in multiple states. He can be reached at <a href="mailto&#58;Richard_Juman@teamhealth.com">Richard_Juman@teamhealth.com</a>.​</em></p>2020-12-01T05:00:00Z<img alt="" src="/Monthly-Issue/2020/December/PublishingImages/1220_caregiving.jpg" style="BORDER&#58;0px solid;" />Caregiving;COVID-19Richard Juman, PsyDPost-acute facilities have always seen high levels of psychiatric disorders, with estimates of 70 percent of residents evidencing at least one behavioral health disorder.
COVID Outbreak in Nursing Homes Worst Since April<p>The American Health Care Association/National Center for Assisted Living (AHCA/NCAL) released an updated&#160;<a href="http&#58;//links.ahca.org/u/click?_t=3abc5280edfa42b5905fbea7c0fff5c2&amp;_m=cd581d0b5c3c43aca3428b4dca259e76&amp;_e=xqBXemj_ArK8HlrFFuvkCBgqUQ03JTCRLskAopKuT8MfEK_ij0ZmCIM8g6L-sarsx1TE5m_uV9Wyw6xcvr-xa-m9RxtUD2XkEzt3wX48NB2YPWVUhJTcORd14kJbOWjxs0dwY6eDTFqtlS7xfO6dGxRBMoVdAQ0s16AgVMSt6llthBR71zTgM8syGMzMYcRaAR3IIVOWmAAgVrLQEtqNt5TQaXaxIFJr-H7SalQdkfSSOC8OMJVEonThzNDLr2A5kkt1_j5AhiDT5ccWMJjHzMAYS1AdOaURXTsPRY3zYxWqrWtnPVpuUEp_Yv6JwSk0lxoOmXDe0sk4lTXVgOu9WlmSJgyt3jqhdbKVOi6y9yyMERPUUZy4oPkihCYNaFb2bzjAWPGFaS-4K0sZh15QaA%3D%3D" target="_blank">report</a>&#160;on Dec. 1 showing nursing homes in the United States have now experienced the worst outbreak of weekly new cases since last spring due to the community spread among the general population, surpassing previous peaks since the Centers for Medicare &amp; Medicaid Services (CMS) started tracking cases in nursing homes.<br> </p><p><span><img src="/Breaking-News/PublishingImages/12120.png" class="ms-rtePosition-1" alt="" style="margin&#58;5px 20px;width&#58;758px;height&#58;427px;" /></span>AHCA/NCAL said recent data released by Johns Hopkins University and the Centers for Medicare &amp; Medicaid Services (CMS) show that with the recent spike in new COVID cases in the general U.S. population, weekly nursing home cases are also on the rise. </p><p>According to Johns Hopkins University, weekly new COVID cases in the general U.S. population rose by 330 percent to 1,043,040 new cases the week of Nov. 15. A correlating uptick in new cases in nursing homes occurred when cases in the surrounding community started rising in mid-September.</p><p>As&#160;<a href="http&#58;//links.ahca.org/u/click?_t=3abc5280edfa42b5905fbea7c0fff5c2&amp;_m=cd581d0b5c3c43aca3428b4dca259e76&amp;_e=xqBXemj_ArK8HlrFFuvkCBgqUQ03JTCRLskAopKuT8MfEK_ij0ZmCIM8g6L-sarsx1TE5m_uV9Wyw6xcvr-xa-m9RxtUD2XkEzt3wX48NB1y-vZO9ovC-V37MuoQXJDMlvVhmFYh-u9Jejf2tbLn8JmMw19Nu9VNnjjE_VOcy4633Br65eespR9sY4dLtmFhfU4CzcKYZLHAGc1lhVY2ADqCIfPbTUUBxoP99X3VWbg5YYzzMmSbwiSYGidDy3NDNFf2lMPCTeQlEbiEZ0NTfuU76VbrTLp-pl02BLnbZm4Yz69w1wO3O9U56Wcoy9FgKLvsfCOmlnvJzyOgxWq2NhVvv3o1k26Tw_SVF6xYyzMLc54nGhjCUcdNO7jHTO7tuSEGiX_Z16zZJ2EorsObBw%3D%3D" target="_blank">experts</a>&#160;have noted, COVID-19 cases in a surrounding community is a top factor in outbreaks in nursing homes. University of Chicago's Tamara Konetzka, a nationally recognized expert on long term care, recently&#160;<a href="http&#58;//links.ahca.org/u/click?_t=3abc5280edfa42b5905fbea7c0fff5c2&amp;_m=cd581d0b5c3c43aca3428b4dca259e76&amp;_e=xqBXemj_ArK8HlrFFuvkCIdbRKvFTRx4Hya9AHdyrOTtP2HfFlm_wMHLUNxVzLN2rTPkm-IJxIQRWc1uIoOKdrUe8ZtcO_IExOyb-9e1ihHGvZ7klBwGPda2MNFu1Z9nvtF7UAxRECR2DxZ9z8a0lc7VKrjRzTvEzv3AlAipSOir2x2BLe730m7Vdm0seF5UClbdaroKbWseXZ4DPKOJXmLgQ5uEoQ6-90TCbJqtH2M65h4wI0QSC8P0dYcNwQCI1UFtfSE07tdjs9oTfB4DGMi1An4bDycFJoGzFlzsAbYVl_UfCBbuPqx5E-MWBPXU1Taib_PhzbuI-FmXUbF_Zi1fIlL4kOCUqpQ-GoiEEABiBuJenJjNmXR2jbp0diqb" target="_blank">said</a>, “Trying to protect nursing home residents without controlling community spread is a losing battle.” <br> </p><p>“Our worst fears have come true as COVID runs rampant among the general population, and long term care facilities are powerless to fully prevent it from entering due to its asymptomatic and pre-symptomatic spread,” said AHCA/NCAL President and Chief Executive Officer Mark Parkinson. </p><p>“Our health care heroes are doing everything they can to prevent it from spreading further, but this level of COVID nationwide puts serious strain on our workforce, supplies, and testing capacity. Given the fact that our elderly population is the most vulnerable and the rising level of COVID across the U.S. shows no signs of stopping, it is paramount that the Centers for Disease Control and Prevention [CDC] provide the highest priority for the vaccine distribution to long term care residents and staff.”<br> </p><p>During the week of Nov. 15, nearly half (49 percent) of new COVID cases in nursing homes were from Midwest states, with major spikes in community spread in the upper parts of the region. As a result, the Midwest region saw more than a 400 percent increase in weekly COVID cases in nursing homes since mid-September.</p><p>After seven weeks of declining cases in nursing homes through mid-September, nursing home cases began to increase as nearly all 50 states started to see significant rising levels of COVID cases. New weekly cases in nursing homes grew by more than 177 percent nationwide between mid-September and the week of Nov. 15.</p><p>The report also showed COVID-related deaths in nursing homes are starting to rise, crossing more than 2,000 residents lost the week of Nov. 15—the first time since early June. Nursing home residents are typically older adults with multiple chronic conditions, making them highly vulnerable to COVID-19. Residents of long term care facilities account for only 7 percent of the nation’s cases, yet 40 percent of its deaths. </p><p>“With millions of Americans failing to heed advice from public health experts and traveling during Thanksgiving, we are extremely concerned that this situation will only get much worse,” Parkinson said. </p><p>“At this point, long term care facilities desperately need public health officials at every level to take emergency steps to get control of the community spread and ensure our facilities have the resources they need, as well as for CDC to make our residents and caregivers the top priority in distributing the vaccine in order to save thousands of lives.”<br> </p><p>With record new COVID cases across the country, Parkinson said Congress must also prioritize frontline health care workers and long term care residents during the lame-duck session. Last week, AHCA/NCAL released a&#160;<a href="http&#58;//links.ahca.org/u/click?_t=3abc5280edfa42b5905fbea7c0fff5c2&amp;_m=cd581d0b5c3c43aca3428b4dca259e76&amp;_e=xqBXemj_ArK8HlrFFuvkCBgqUQ03JTCRLskAopKuT8MfEK_ij0ZmCIM8g6L-sarsx1TE5m_uV9Wyw6xcvr-xa-m9RxtUD2XkEzt3wX48NB2oo2PWHg35qXHcb-OvfoKS__w4YhpeA3jTY6x_vvQKYlSuYbiZYtKTuPeOiAk9W9_qUoBQjjjWJ7xtN3MC083cnMxlD3XpZh_VDqG_Ugo_dkvNoxHHunceXKefuoHQ2-hyV_wgU7cMuGAV9FBh8lf9P9KXDhVwZ73_6o1Mb1AC1Qwq5WsMWtQGz98CKqFElRjmz8fQMJSTcQfksMk5JJU8-sMpt-ntyekUM8DJWVRfo9h9XgJH7f-_ILe-2yekZqs%3D" target="_blank">list of actions</a>&#160;that Congress should urgently take to help nursing homes and assisted living communities respond to the uptick in new cases.<br> </p><p>“Congress must fulfill its duty,” Parkinson said. “Without adequate funding and resources, the U.S. is repeating the same mistakes made during the initial outbreak last spring and the major spike over the summer. We need Congress to prioritize our vulnerable seniors and their caregivers in long term care facilities, by passing another COVID relief package during the lame duck session on Congress.”<br> </p><p>For more information, please visit&#160;<a href="http&#58;//links.ahca.org/u/click?_t=3abc5280edfa42b5905fbea7c0fff5c2&amp;_m=cd581d0b5c3c43aca3428b4dca259e76&amp;_e=CZr5Uh7p1PxyJca5sa504ZajmmBRGq3xBn46eVzA9qFdbgymGGjAeUk5U1ImU9YqLQIzXnElOjcO8Ac8d9nD6JPLpaP1DjuF10KFiPAahWKR00kW4e4jBHmT174qzXPGliaCS6oxIXsnhWhFBA3ANO_pONJQMNJBLGQSGsQaH2fl3JNLr2MnUNb8bNccWJ_3fvHxjPV7iQGE8jaiHQNVwj1EIaQbtG6QxBbVZYqslq_0CNVUrWsOnq9oRqgDgcaRgiUUg99d6p0sRZSA9EIcmnIMAcLHZfGIfcE2EWD1XlA%3D" target="_blank">www.ahcancal.org/coronavirus</a>.</p>2020-12-01T05:00:00Z<img alt="" src="/Breaking-News/PublishingImages/740%20x%20740/0920_News1.jpg" style="BORDER&#58;0px solid;" />Caregiving;COVID-19Patrick Connole​A new report shows U.S. nursing homes are now experiencing the worst outbreak of weekly new cases since last spring due to community spread among the general population.