| How a COVID Advisory Council Improved Infection Prevention Overall | <p><img src="/Topics/Guest-Columns/PublishingImages/2022/TomGrape.jpg" alt="Tom Grape" class="ms-rtePosition-2" style="margin:5px;width:200px;height:200px;" />Protector is a role we accept as parents, spouses and partners, employers, and leaders, among other roles in our lives. It’s daunting, even on the good days. Introduce the unknown and this commitment to others becomes nothing short of frightening. <br></p><p>That’s how I felt when the pandemic turned the world upside down in 2020. How can I help Benchmark protect its 13,000 residents and employees? It kept me up at night.  <br></p><p>The initial action steps were clear: Find supplies (masks, gloves, gowns, etc.), train staff, track cases, and create policy. The nagging question, however, was whether the execution of these steps would be effective. Constantly changing—and often contradictory—local, state, and federal guidelines only contributed to my uncertainty. </p><p>I wanted a guide. Thus, the <a href="https://www.benchmarkseniorliving.com/news-article/benchmark-coronavirus-advisory-council/">Benchmark Coronavirus Advisory Council </a>was born. </p><p>At an absolute minimum, the council members would help ensure that the infectious disease prevention and containment protocols that we developed would be consistent with leading-edge thinking on COVID-19. </p><h3>National Health Leaders  </h3><p>In the fall of 2020, Benchmark asked several long-time, trusted medical advisors to help us recruit a team of medical and scientific experts to provide ongoing advice in responding to COVID-19. Soon after, nine esteemed members were in place:<br></p><ul><li>Alice Bonner, PhD, GNP, RN, FAAN, former Massachusetts Secretary of the Executive Office of Elder Affairs</li><li>Richard Carmona, MD, MPH, FAC, former U.S. Surgeon General</li><li>Brent P. Forester, MD, MSc, chief of the division of geriatric psychiatry, McLean Hospital, and past president of the American Association for Geriatric Psychiatry</li><li>David Ives, MD, the medical director of a large primary care practice serving skilled nursing facilities in Massachusetts</li><li>Michael R. Jaff, DO, chief medical officer at an international medical device manufacturer and former CEO of Newton-Wellesley Hospital</li><li>Timothy Johnson, MD, MPH, former medical editor for ABC News and a resident of a Benchmark community</li><li>Dr. Roger Schutt, DO, veteran geriatrician and executive lead for post-acute care at Beth Israel Lahey Health</li><li>Steve Schweon, RN, MPH, MSN, CIC, FSHEA, FAPIC, board-certified infection preventionist </li><li>David Shulkin, MD, former Secretary of the U.S. Department of Veterans Affairs<br></li></ul><p>It didn’t take long for lively and insightful conversations, as well as debate, to ensue among the group during our first virtual meeting. Issues have since ranged from COVID’s short- and long-term impact on seniors, advances in treatment and testing, and general health care—physical and mental—related to our workforce, to vaccine policies, COVID-19 subvariants, and the future of the virus and vaccines. </p><h3>Getting to Know Us</h3><p>Before our experts could help, they needed to understand assisted living, particularly how the business differs from nursing homes, where a higher level of medical care takes place. </p><p>They needed to understand that prior to the pandemic, assisted living was focused on the benefits of socialization and providing fine dining, beautiful grounds, and engaging programming. Infection control was not what it is today.</p><p>Benchmark’s leadership and clinical teams, who ultimately created and implemented COVID-19 policy in our 64 communities, credit the advisory council for giving us a roadmap for creating a comprehensive infection prevention program. </p><p>Today, Benchmark has a robust structure that is better prepared to identify and curb the spread of not only COVID-19, but also other infections such as norovirus, flu, and respiratory infections. </p><p>We expanded our infection prevention expertise by hiring an epidemiologist to serve as corporate director of infection prevention. This person provides community support and education, as well as helps update protocols based on regional and national trends. </p><p>We also added a vice president of quality resident services and nearly doubled the size of that team, with each member certified in infection prevention. Many of our regional nurses are also infection prevention-certified, while community nurses, and even some plant operations associates, participated in an infection prevention boot camp. Validating Concerns, Creating Solutions</p><p>The kneejerk decision to “lock down” residential care settings nationally at the onset of COVID-19 had a well-documented negative impact on the physical and mental health of seniors across the country. </p><p>The advisory committee acts as a sounding board for our concerns in this area, as well. They help fuel innovations made in our communities to better engage our residents, whether by using technology or by employing creative methods to keep residents connected to family, friends, and neighbors. </p><p>In fact, mental health dominates many of our council meeting conversations, including the impact stress and anxiety has on our employees. During the height of COVID, these dedicated professionals worked long hours caring for beloved residents who were getting sick and, in some cases, dying. Employees were also getting sick or overwhelmed with the fear of getting COVID-19 and bringing it home to loved ones. Many of these COVID challenges remain for frontline employees.</p><p>Advisory council member Dr. Forester, MD, MSc, the division chief of geriatric psychiatry at McLean Hospital, located outside Boston, and a Harvard Medical School adjunct professor, is passionate about this subject. He shares his expertise beyond council meetings by leading “support group” calls with our communities’ executive directors, offering advice to them and providing ideas and tools the community leaders could use to help frontline staff. </p><h3>Don’t Go It Alone</h3><p>The council helps lead us through the unknown and to navigate hurdle after hurdle, wave after wave. Their guidance reinforces that we are doing everything we can to protect our residents and the associates that care for them. </p><p>They are just one of several resources Benchmark has worked closely with throughout COVID-19. We also learn from and share advice with state and federal assisted living advocacy groups, other senior care providers, and all levels of government. </p><p>If the pandemic teaches the nation anything, I hope it’s the importance of shedding silos and facing the unknown together. It will help everyone sleep better at night. </p><p><em>Tom Grape is Founder, Chairman, and CEO of Benchmark Senior Living, a provider of senior living in the Northeast with 64 communities in seven states. </em><br></p> | 2022-09-12T04:00:00Z | <img alt="" src="/Topics/Guest-Columns/PublishingImages/2022/TomGrape.jpg" style="BORDER:0px solid;" /> | Clinical | Tom Grape | Protector is a role we accept as parents, spouses and partners, employers, and leaders, among other roles in our lives. |
| Detecting and Treating Dementia Early | <p><img src="/Breaking-News/PublishingImages/740%20x%20740/senior_woman_daughter_2.jpg" class="ms-rtePosition-1" alt="" style="margin:5px;width:256px;height:179px;" />Dementia is staggeringly common, with an <a href="https://www.alz.org/media/Documents/alzheimers-facts-and-figures.pdf" target="_blank">overall prevalence of 11 percent in people aged 65 and over</a>. This prevalence increases markedly with age, such that it affects over half of octogenarians and one in three will ultimately die in this condition. These statistics do not include mild cognitive impairment (MCI), mental changes that are measurable but not severe enough to affect daily function and are often but not always a precursor to dementia, or <a href="https://www.cdc.gov/aging/data/subjective-cognitive-decline-brief.html" target="_blank">subjective cognitive decline</a>, self-reported mental fogginess or memory depreciation that aren't able to be measured by a test.</p><h3>Detecting and Diagnosing Dementia</h3><p>Despite being widespread, official diagnosis lags behind the true prevalence, with only 3-4 percent of patients having “dementia" (let alone Alzheimer's disease or a specific type of dementia) written anywhere in their chart. This amounts to more than 3 million Americans lacking a diagnosis, a number which will double in the next decades if diagnosing doesn't catch up.</p><p>The early stages of dementia, particularly Alzheimer's disease, which most commonly manifests with short-term memory loss and difficulty navigating an environment, is not always obvious from a short interaction. Verbal abilities can be intact, and a patient can regale you with stories from their youth, masking the fact that when they are sent home from the doctor's office with instructions to take a medication once a day, they may not fully understand, remember, or have the capacity to follow instructions. Caring family members such as adult children living out of state may also take a long time to go from a subtle feeling or suspicion that something seems off or odd to the conclusion that there may be a real problem. This can obviously have catastrophic consequences—preventable adverse events and hospitalizations; missing the opportunity to reverse, slow, and mitigate disease; and treatment for symptoms that can improve quality of life and functional independence.</p><p>Improving detection and arriving at diagnosis before the onset of catastrophic events, more severe disease, and unmanageable symptoms begins with equipping clinicians on the front lines with validated tools to assess function rapidly, reliably, and comprehensively across <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5772157/" target="_blank">cognitive domains</a>. Tools must be simple enough for the non-specialist to gain comfort with and fit reasonably within their established workflows. For example, a recent peer-reviewed study in the <a href="https://aging.jmir.org/2022/2/e36825/" target="_blank"><em>Journal of Medical Internet Research (JMIR) Aging</em></a> validates the efficacy of a computerized cognitive test. Conducted in-person or remotely, this type of assessment improves accessibility to testing while providing physicians with the tools necessary to diagnose and treat patients.</p><p>To better detect and diagnose dementia, physicians must go beyond patient interviews (i.e. do you feel like you are losing your memory?) and use formal assessment tools, looping in a specialist for complex cases when needed. If MCI is identified, the physician must further assess for functional impairment to arrive at a diagnosis of dementia and perform serial assessments for changes in cognitive status (improvement or decline) that could change diagnosis and management approach.</p><h3>Preventing Adverse Events and Hospitalizations</h3><p>People with dementia have much higher hospitalization rates than older adults without. According to a recent study, 40 percent of <a href="https://agsjournals.onlinelibrary.wiley.com/doi/abs/10.1111/jgs.16636" target="_blank">hospitalizations in the dementia cohort could have been preventable</a> with proper identification, education, and outpatient care. When care teams are on the same page about a person's cognitive status, the individual can be given additional supervision or support to prevent adverse events. Consistency between caregivers is essential toward preventing trips to the hospital as well as reducing uncertainty and conflict around patient care and well-being.</p><h3>Ruling Out and Addressing Reversible Causes</h3><p>Cognitive impairment does not always spell dementia. Many cases of MCI are due to reversible causes, with the most common offenders being medication adverse events, depression, sleep apnea, infection, and thyroid disease. Long COVID is another major driver, with more than 70 percent of sufferers calling out brain fog as a chief complaint.</p><p>It is for this reason that the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5772157/" target="_blank">American Academy of Neurology</a> cites ruling out and addressing reversible causes as a primary reason for performing cognitive assessment. Clinicians should perform a medical evaluation of common reversible causes.</p><h3>Addressing Risk Factors to Slow Progression</h3><p>The landmark FINGER study and subsequent <a href="https://pubmed.ncbi.nlm.nih.gov/32627328/" target="_blank">World-Wide FINGERS network</a> found that 40 percent of dementia is preventable by addressing certain modifiable risk factors. These include:<br></p><ol><li>high blood pressure,</li><li>smoking,</li><li>diabetes,</li><li>obesity,</li><li>physical inactivity,</li><li>poor diet,</li><li>high alcohol consumption,</li><li>low cognitive engagement,</li><li>depression,</li><li>traumatic brain injury,</li><li>hearing loss,</li><li>social isolation, and</li><li>air pollution.</li></ol><p></p><p>The physician is charged with the task of working with the patient and caregivers to put together a comprehensive cognitive care plan that addresses these modifiable factors in a holistic manner. By giving them the knowledge, resources, and motivation to see the patient through the long journey of cognitive change, they can slow dementia's progression and give the patient a better prognosis.</p><p>There are now few pharmaceutical options to treat dementia, with cholinesterase inhibitors showing efficacy in dementia's early stages. There are multiple medications at different stages of the drug development pipeline, and all of them depend on patients being identified as early as possible to have the best chance of success.</p><p>Behavioral and psychiatric symptoms are common in dementia, and an early and specific diagnosis enables clinicians to treat these with the best approaches available.</p><p><em>Yael Katz, Ph.D., is co-founder and CEO of BrainCheck. Katz received her Ph.D. in neuroscience from Northwestern University and conducted her postdoctoral work at Princeton University.</em><br><br></p> | 2022-06-23T04:00:00Z | <img alt="" src="/Topics/Guest-Columns/PublishingImages/2022/YaelKatz.jpg" style="BORDER:0px solid;" /> | Dementia;Clinical | Yael Katz, Ph.D. | The early stages of dementia, particularly Alzheimer’s disease, which most commonly manifests with short-term memory loss and difficulty navigating an environment, is not always obvious from a short interaction |
| Cleaning With a Vengeance Gets Results | <p></p><p>Covenant Living Communities and Services has taken a full-scale approach to infection control and prevention. With 16 communities in nine states, it is one of the largest not-for-profit retirement living organizations in the nation. Its continuing care retirement communities offer independent living plus many more levels of care, including assisted living, skilled nursing, and, often, memory care and rehabilitation.</p><p><img src="/Topics/Special-Features/PublishingImages/2021/1121/BillRabe.jpg" alt="Bill Rabe" class="ms-rtePosition-2" style="margin:5px;width:210px;height:210px;" />Cleaning and disinfection of all skilled nursing rooms happens at least twice a day as a practice the company implemented at the beginning of the COVID pandemic and continues to employ amid different COVID-19 variants. Leadership took the step of reviewing all of Covenant’s housekeeping policies in each level of care and released an organization-wide safety program known as Our Safer Home Commitment. </p><p>“This program focuses specifically on examining cleaning frequencies and practices and retraining our staff on how to properly clean and disinfect rooms and spaces that our residents visit frequently,” says Bill Rabe, senior vice president of enterprise operations at Covenant. “It also allowed us to make a fresh, new commitment to our residents and their families that their safety is our No. 1 priority.”<br></p><h2>How Disinfection Measures Up</h2><p>With Covenant’s new commitment, leadership wanted to take the next step of ensuring the new practices really measured up. “We quickly realized we wanted feedback and a quantifiable way to assess our cleaning practices,” says Rabe. “To do that we made an investment in ATP luminometer testing, which is a way to test the cleanliness of hard surfaces by scrubbing for a molecule.” </p><p>Adenosine triphosphate (ATP) is a molecule found in all living cells that is responsible for transferring and storing energy. The effectiveness of a cleaning process can be checked by testing surfaces for ATP levels, which act as an indicator of whether an environment has been properly cleaned.</p><p>“This is a practice used in the food service industry and acute-care setting, but we find it extraordinarily valuable given the higher risk that COVID-19 puts our residents in,” says Rabe. “It helps us understand, first, how clean our facilities are overall and, second, how effective our cleaning is.”<br></p><h2>How It’s Going<br></h2><p>Staff have appreciated the clarity that Our Safer Home Commitment procedures provided, says Rabe. They also appreciate the tangible, quantifiable feedback that the ATP testing provides. </p><p>“The feedback on the results of the cleaning process is captured and tracked for accountability,” says Rabe. “This helps us identify opportunity for improvement in our cleaning and disinfecting process.”</p><p>As part of the program, Covenant also rolled out survey cards with access to an online survey tool to capture feedback on the program from guests staying in guest or resident rooms after cleaning and common areas such as dining. “So far, the feedback has been overwhelmingly positive,” says Rabe.<br></p><h2>Other Steps</h2><p>In addition to the statewide cleaning program, Covenant has taken other steps to control for infection, including updating its Minimum Efficiency Reporting Values (MERV)-rated filters in its HVAC systems to the highest filter that the system would allow.</p><p>Covenant has also started to roll out a new telemedicine program and equip all facilities with communication technology where physician visits and visitation can be done virtually and on demand as needed. “This includes utilization of iPads for FaceTime visits with family members or utilizing Microsoft Teams,” says Rabe. “In addition, we’re using the iPads for virtual telehealth consults with resident physicians.”</p><p>In addition, a new guest registration screening process with automated technology now allows Covenant to screen visitors with or without assistance from staff. “We use a product called VT Shield from Toshiba,” says Rabe. “This product allows us to ask questions that are in line with CDC [Centers for Disease Control and Prevention] requirements and take the temperature of our guests prior to entering the building.” Once passed, the system will provide a visitor pass. The data are saved within the system for auditing purposes.</p><h2>Communication at the Heart<br></h2><p>At the heart of all Covenant’s modifications is communication. “We have started to roll out a resident and family communication app to improve communication with our residents and their family members,” says Rabe. </p><p>The app is called myCovLife. In addition to keeping residents and families up to date on the latest company-wide infection control and prevention tactics, Covenant staff use the app’s basic features to send communication to the residents for a number of purposes. </p><p>“We can provide them access to key contacts in the community, a resident directory, information about the community, what’s on the menu for dining, transportation requests, and the ability to sign up for activities,” says Rabe. The app is being rolled out over a period of several months, and so far the residents have been enjoying becoming familiar with it and using it, he says. </p><h2>Looking Ahead <br></h2><p>Thinking about the future conjures up images of fine-tuning modifications for continued infection control. “This would include smaller, but more dining space options in our communities to reduce capacity, longer dining hours to reduce capacity based on the needs of individual communities, and extension of outside space area,” says Rabe. Enhancements in building air circulation are still in use, which are different based on each community.</p><p>Rabe says that the pandemic has reinforced the need for repetition in education and protocols. With that comes a heightened focus on training and education and more audits to ensure compliance. </p><p>Rabe’s advice: “Develop a process to follow and implement state and local regulations,” he says. This is even more difficult with national providers serving residents in multiple states. Requirements are different between states and local counties, and they can become very confusing.</p><p>Regular communication can help reduce that confusion, Rabe says. “Develop a robust communication plan,” and along with it, identify tools to deliver consistent messaging. </p><p>“During COVID we utilized several forms of communication to ensure we were able to keep residents and families up to date,” he says. “This communication came in the form of virtual town hall meetings delivered to our residents’ rooms, use of kiosks and information slides through our resident channel, push notifications and content delivered via our engagement application, along with updates on our website and family letters.” <br></p><p></p> | 2021-11-01T04:00:00Z | <img alt="" src="/Topics/Special-Features/PublishingImages/2021/1121/CF2.jpg" style="BORDER:0px solid;" /> | Clinical;Infection Control | Amy Mendoza | Cleaning and disinfection of all skilled nursing rooms happens at least twice a day as a practice the company implemented at the beginning of the COVID pandemic and continues to employ amid different COVID-19 variants. |
| High-intensity Resistance Training in Post-Acute Care Produces Better Outcomes | <p></p><p>Results of a study by researchers from the University of Colorado Anschutz Medical Campus show that high-intensity rehabilitation training for older patients in skilled nursing facilities can safely and effectively accelerate improvements in their function, enabling them to return home sooner. The study was published in <em>Physical Therapy</em>, October 2020.<br></p><p>Skilled nursing facilities provide medical and rehabilitation services to individuals post-hospitalization to help facilitate the transition to home or the next level of care. However, research has shown the trajectory of functional recovery following hospitalization and skilled nursing stay care is generally poor, with fewer than 25 percent of patients returning to pre-hospitalization levels of function. </p><h2>How the Study Worked</h2><p>“Our study identified an impactful opportunity to improve the way we care for patients in skilled nursing facilities,” said lead author Allison Gustavson, PT, DPT, PhD, at the CU Anschutz Medical Campus. “Our findings demonstrate that high-intensity resistance training is safe, effective, and preferable in caring for medically complex older adults in skilled nursing facilities.”<br></p><p>The study split 103 participants into two nonrandomized independent groups—usual care and high-intensity care—within a single skilled nursing facility. For both groups, physical therapists administered the Short Physical Performance Battery and gait speed at evaluation and discharge.</p><h2>Results of the Study</h2><p>For the high-intensity training group, the physical therapists used the i-STRONGER program (Intensive Therapeutic Rehabilitation for Older Skilled Nursing Home Residents).<br></p><p>The patients participating in the high-intensity program benefited by increasing their functional independence, as evidenced by a significant and clinically meaningful increase in their walking speed from evaluation to discharge by 0.13 meters/second more than the usual care group. This is a critical outcome for this patient population, as improvements in walking speed greater than 0.1 meters/second are associated with reduced mortality.<br></p><p>Also, the patients’ stay at the skilled nursing facility was reduced by 3.5 days.</p><h2>Implications for Future Rehab Approaches</h2><p>Based on their findings, the researchers advocate the need to increase the intensity of rehabilitation provided to patients with medically complex conditions to promote greater value and patient experience within post-acute care. <br></p><p>“Our study shows that the quality of rehabilitation compared to the quantity drives better outcomes,” said Principal Investigator Jennifer Stevens-Lapsley, MPT, PhD, FAPTA. “These findings provide a timely solution to address rehabilitation value in the context of recent post-acute care changes by policymakers who are looking to raise the bar on the quality and efficiency of post-acute care services,” she said.<br></p><p>“We are eager to support the transition to this safer and more effective high-intensity care approach,” said Stevens-Lapsley, a professor and director of the Rehabilitation Science PhD Program at the CU Anschutz Medical Campus.<br></p><p>“We are encouraged by the results that accelerated the improvement in patient function, created positive patient and clinician experience, and resulted in less time needed for care in the skilled nursing facility,” she said.<br></p><p><img src="/Topics/Special-Features/PublishingImages/2021/1021/LaurenHinrichs.jpg" alt="Lauren Hinrichs" class="ms-rtePosition-1" style="margin:5px;width:170px;height:216px;" />The University of Colorado has partnered with the American Health Care Association to offer a CEU-credited High-intensity Resistance training program. For those interested in learning more about the research or training or for implementation support, contact Lauren Hinrichs or visit <a href="http://www.movement4everyone.org/" target="_blank">www.movement4everyone.org</a> for more information. <br><br><em>Lauren Hinrichs, PT, DPT, OCS, board-certified in orthopedics, is a Rehabilitation Science PhD student with the Department of Physical Medicine and Rehabilitation, University of Colorado School of Medicine. She can be reached at </em><a href="mailto:lauren.hinrichs@CUAnschutz.edu" target="_blank"><em>lauren.hinrichs@CUAnschutz.edu</em></a><em>.</em><br></p> | 2021-10-01T04:00:00Z | <img alt="" src="/Topics/Special-Features/PublishingImages/2021/1021/SF_intensity.jpg" style="BORDER:0px solid;" /> | Clinical;Diet | Lauren Hinrichs | Researchers advocate the need to increase the intensity of rehabilitation provided to post-acute patients to promote greater value and patient satisfaction. |