April 2020
Mitigating the Spread of COVID-19 in the Post-Acute and Long-Term Care Facilities
Dillard Elmore, DO, CMD, MBA

As post-acute and long-term care organizations prepare for a potentially significant increase in COVID-19 cases, it strikes me that our industry has a few major handicaps.
 
Our population appears to be much more vulnerable to COVID-19 than the general population. From reports, we know that approximately 80% of the confirmed COVID-19 cases are mild, whereas 20% are severe. We also know that individuals with multiple comorbidities are at the highest risk of experiencing severe illness. Beginning with age 60, we see the death rate start to increase significantly, with the highest death rates occurring for individuals older than 80. Based on CDC data, 90% of the individuals living in long-term care are 65 years and older with almost half of them being 85 years old and older. Eight out of 10 deaths reported in the U.S. have been in adults 65 years old and older (1).
 
Among adults with confirmed COVID-19 reported in the U.S. (1):
 
  • Estimated percent requiring hospitalization
  • 31-70% of adults 85 years old and older
  • 31-59% of adults 65-84 years old
  • Estimated percent requiring admission to intensive care unit
  • 6-29% of adults 85 years old and older
  • 11-31% of adults 65-84 years old
  • Estimated percent who died
  • 10-27% of adults 85 years old and older
  • 4-11% of adults 65-84 years old
 
CDC guidelines for screening individuals who may have COVID-19 do not take into account reports that asymptomatic individuals may have higher viral loads than those who are symptomatic (4). Can it be inferred that these asymptomatic individuals are more contagious than symptomatic individuals? The spread of COVID-19 between multiple post-acute and long-term care facilities in Washington State was linked to workers who were employed by more than one facility. It is conceivable that these individuals did not have any symptoms and unknowingly infected several residents. Even if the facilities in Washington were…
 
1.    Closed to visitors
2.    Actively screening each employee for symptoms (fever, cough, and shortness of breath)
3.    Documenting outside employment for each team member
 
… they likely would have still missed a significant portion of the infected employees.
 
The Pennsylvania Department of Health’s guidance for health-care workers is reasonable and should help to avoid serious human resource constraints (2). Our mild winter has led to a confluence of several conditions that can mimic COVID-19. Is the resident with a cough suffering from seasonal allergies, influenza or COVID-19? However, wearing a facemask for 14 days after returning from diagnosed COVID-19 may not be long enough. There are reports that individuals can shed virus for up to 37 days.
 
Therefore, a nurse who is diagnosed with COVID-19 on day 0 and becomes symptom-free by day 3 can potentially return to work after day 7. That person would then have to wear a mask for 14 days and avoid all high-risk residents (e.g., transplant, hematology-oncology). After day 21, she or he could then care for residents as they did prior to being absent from work. A key point is this scenario, if you subscribe to the theory that an infected individual can shed the virus for an extended period of time, may result in that employee being contagious for an additional 16 days...with obvious ramifications.
 
One way to decrease the chance of spreading COVID-19 to and within the post-acute and long-term care communities is to increase the availability of screening for health-care workers. As noted above, a significant portion of the PALTC workforce is shared. As noted above, healthy individuals may be asymptomatic while spreading COVID-19.
 
Screening all PALTC workers with nasopharyngeal swabs could prove beneficial. We would be able to exclude these team members from working while contagious and thus decrease the chance of them further infecting our population. This could have the downstream effect of decreasing the burden on acute hospitals. The employee would then return to work after being symptom-free and having negative nasopharyngeal swabs. This method is limited by the 3- to 7-day turnaround with commercial labs.
 
Making rapid antibody test kit widely available may prove transformational. The test can be performed like a bedside blood-glucose check with results in minutes, not days. Nasopharyngeal swabs only inform you that people are actively ill. You do not know if an asymptomatic person already cleared the infection and now has immunity. Kits that show the presence of IgG may have added value for health-care workers.
 
Studies comparing the production of IgM/IgG and the viral shedding from nasopharyngeal swabs could prove important for PALTC. If the studies find that there is a precipitous decline in viral shedding once IgM is produced and that there is zero shedding by the time IgG is produced, then it is possible to identify workers who are no longer a risk to spread disease to our residents.
 
Further studies would be needed to see if individuals who are producing IgG for COVID-19 can be re-infected. If they are no longer susceptible to COVID-19, they may no longer need PPE. They can also be the team members selected to care for COVID-19 residents. In my opinion making these kits available to healthcare workers should be a major priority. 

2. PENNSYLVANIA DEPARTMENT OF HEALTH 2020 – PAHAN- 489 – 03-19-ALT
Any views or opinions presented in this article are solely those of the author and do not necessarily represent any policy or position of PAMED, PMDA, AMDA, its affiliates and members.
PMDA Awards
Daniel R. Steiner, MD, CMD-R

In an effort to recognize dedication, performance and accomplishments of its members, the Pennsylvania Society for Post-Acute and Long-Term Care Medicine, PMDA, has established two awards that are presented at the fall Annual Symposium business meeting. One, the Duncan S. MacLean Founder's Award for Distinguished Service, is named in honor of its first recipient, Duncan S. MacLean, and is awarded based on efforts for and dedication to the organization. The other, the Long-Term Care Clinician of the Year Award, is awarded to the clinician demonstrating excellence in providing and/or promoting quality clinical care in the long-term care arena. Further specifics regarding the awards are defined below.
 
 
Duncan S. MacLean Founder’s Award for Distinguished Service
The Duncan S. MacLean Founder’s Award for Distinguished Service recognizes significant contributions to building the organizational strength, image and mission of PMDA, which is “to promote Medical Direction and Physician Services in long-term care, to enhance the reputation of PMDA, and to advance goals enabling the Association to improve care delivered to patients throughout the long-term care continuum.”
 
The nominee must be:
1. A physician in good standing with the community and profession.
2. Active in the field of long-term care.
3. A PMDA member in good standing.
4. Not a current board member of PMDA.
 
Prior recipients include:
Duncan S. MacLean, MD, CMD
Daniel Haimowitz, MD, CMD, FACP
David Nace, MD, CMD
J. Kenneth Brubaker, MD, CMD
Thomas E. Lawrence, MD, CMD
 
The Long-Term Care Clinician of the Year Award recognizes those individuals whose vision, passion, leadership, knowledge, and commitment succeed in taking patient care in the facilities they serve to exceptional levels of quality, excellence, and innovation.
 
The nominee must be:
1. Nominated by NHA, DN, Medical Director or other clinicians from a facility where the nominee serves as a clinician (Physician, NP, or PA). The facility may be a SNF, ALF, or LIFE Program.
2. A PMDA member in good standing.
3. Recipient determined based on the demonstration, within the nominating letter, of the clinician’s role in any or all of the following achievements: quality improvement, annual state survey, patient satisfaction surveys, staff moral and retention, community/hospital relations and outreach, medication management, reduction in unnecessary rehospitalizations, and overall impact of his/her role as a clinician in the facility.
 
Prior recipients include:
Neelofer Sohail, MD, CMD
Tracy Polak, CRNP, MSN
Christina DeFrancisco, DNP, CRNP, FNP, CWS
 
Nominations are accepted year-round but must be submitted and received this year by September 11, 2020 . Please consider nominating a deserving individual for one or both awards, both this year and in future years. Congratulations again to all our previous recipients!
The PMDA Trainee Education Fund supports PMDA’s efforts to educate, recognize and inspire post-acute and long-term care clinicians in training in the benefits and rewards of a career in the PALTC continuum. Your contribution will allow us to continue to offer complimentary registration to the Annual Symposium for fellows, residents and students and support PMDA’s contribution to AMDA’s Futures Program. Help us invest in the future of practice in PALTC medicine.
Upcoming PMDA Events

  • Spring Board Meeting - 5/15/20 - Zoom Virtual Meeting
  • PMDA 2020 Spring Consortium - 5/16/20 - Zoom Virtual Educational Event
  • Regional Meeting - 9/15/20 - Six (6) locations and individual virtual attendance. Registration fees: $25 PMDA Members; $30 non-members.
  • Fall Board Meeting - 11/5/20 - Hotel Hershey, Hershey, PA
  • 2020 Annual Business Meeting - 11/6/20 - Hotel Hershey, Hershey, PA
  • 28th Annual Symposium - 11/6/20 - 11/7/20 - Hotel Hershey, Hershey, PA
PMDA COVID-19 (Coronavirus) Update:
PMDA is very aware of the concerns with the spread of the coronavirus. The PMDA board and staff are closely following and monitoring the situation on a daily basis. We will provide regular updates to the attendees and PMDA members. 
Breaking News: CMS Addresses Society Concerns–Makes Sweeping Changes/Additions to Telehealth Services

Since the outbreak of the COVID-19 pandemic, the Society has asked CMS to remove all barriers to providing visits in skilled nursing facilities via telehealth. On Monday, March 30, CMS did just that—essentially eliminating all barriers and adding services in other sites of care to the telehealth list. Importantly, all of these changes are backdated to March 1, 2020, so any billing that occurred prior to this release will be reimbursed.

The guidance released on March 30 by CMS suspends all face-to-face regulatory visits and allows them to be done via telehealth.

Read more in this article by Alex Bardakh, AMDA's director of public policy and advisory.
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