July 2022
Unprecedented challenges: Evolving support for long-term care facilities during COVID-19

By Larry W. Spector, DO, Temple University Hospital — Jeanes Campus
Thinking back to early 2020 when the first COVID-19 cases to hit the U.S. occurred in long-term care facilities (LTCF), I remember the shudder that went through me as a healthcare provider. I’m sure, many of you reading this do as well.
No one was immune. There was no vaccination to protect anyone yet. And, we hadn’t had to deal with such an infectious, unpredictable and serious disease in a very long time. Plus, many of the people we cared for in these facilities already had underlying health issues, making them very vulnerable to hospitalization, long-term problems, and even death.
When someone has a health emergency, we as healthcare professionals spring into action. When a whole nation has a health emergency, it’s no different.
Pennsylvania health officials recognized the threat and established a new program in July 2020 called the Regional Response Health Collaborative (RRHC). This was a partnership of various health organizations, including the Pennsylvania Department of Human Services (DHS), Department of Health (DOH), Pennsylvania Emergency Management Agency (PEMA) and 7 health systems.
The purpose of RRHC was to provide clinical and operational supports and an educational platform for skilled nursing, assisted living and personal care home facilities as they responded to the COVID-19 pandemic. A benefit of RRHC was it allowed LTCFs to get a handle on pandemic challenges. This was particularly true for smaller facilities that didn’t have the on-site clinical expertise.
Education, PPE and Support
RRHC issued grants to regional health systems so they could create teams to provide LTCFs with a variety of supports, including infection control guidance (handwashing, disinfection, quarantining strategies, testing, etc.), personal protection equipment (PPE), and even technology such as tablets to help quarantined care residents communicate with loved ones.
Two health systems in southeast Pennsylvania – Temple Health and Penn Medicine — were given responsibility for responding whenever a long-term care facility in Philadelphia and surrounding counties had a COVID-19 outbreak. Our team included nurses and social workers who could respond quickly and effectively when there were infections in a facility.
As the pandemic evolved, so too did the program. In December 2020, RRHC became the Regional Congregate Care Assistance Teams (RCAT). This was a more limited version of the RRHC that still served the same facilities.
The latest version of the program is the Resource Information and Services Enterprise (RISE-PA), which began on Jan. 1, 2022.
It is a collaborative effort between multiple state agencies, counties, and local non-profits and community organizations, health care, and social services providers. The interactive online platform’s goal is to serve as a care coordination system for healthcare and social services organizations. As a closed loop referral system, it allows for reporting on the outcomes of the referrals. And, it provides Pennsylvanians with a way to find and access the services they need to achieve overall well-being and improve health outcomes.
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As a result, the RISE program continues to work with facilities, to help manage COVID outbreaks and to meet with local county health departments. 
The Penn/Temple RISE program works with its regional facilities, helping with infection control and antibiotic stewardship programs. We also have partnered with companies to help with staffing and life safety issues in the facilities.
Lessons learned
Beyond infection control, building trust with staff at these facilities was our greatest challenge at first. Everyone was completely overwhelmed in both their professional and personal capacities, and outside help wasn’t always embraced. But we persisted, reaching out multiple times to explain our role and how we could help. While a very small number of facilities never responded, many did. They found our onsite support invaluable in controlling outbreaks according to best recommended practices from the Pennsylvania Department of Health and the CDC.
Today, the Temple Health and Penn Medicine team members enjoy a strong relationship with area LTCFs. And, we are the helpful eyes and ears for infection control for health authorities. We remain an ongoing resource for providing aid for future infectious incidents.
It has been a tough two years for us all, both professionally and personally. But the work we did was tremendously important. During this unprecedented time with so many evolving challenges, we served our patients and our communities well, learning valuable insights along the way. It’s been my honor to be the physician lead for this effort.
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Larry W. Spector, DO, is the physician chair for the Temple Post-Acute Care Network and serves as medical director for several skilled nursing facilities in the Philadelphia area.
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.

Gary Bernett, MD, CMD

For the last year or so, in my “semi-retirement,” I have gone back to my origins and taken on the role exclusively as a primary care physician in a SNF. While this type of work is not foreign to me, the environment and work experience has really changed quite a bit, and not necessarily for the better. The emphasis on documentation both by physicians and facility staff has increased exponentially, both for the benefit of the patient and sometimes their detriment. While communication is paramount to good care, the time spent accomplishing and completing the required tasks subtracts from the time spent caring for patients, both by the staff and clinicians. While EMR was supposed to enhance our ability to care for patients, anyone who has attempted to document a monthly encounter and avoid the appearance of cloning or heaven forbid, cutting and pasting, knows that this is time not well spent. The voluminous records received upon a transfer from the hospital, rarely include a cogent, well written discharge summary. Rather they are endless electronic pages, sometimes paper, of the same notes and results repeated over and over again. The skill now required is collating and trying to find those details that have been included but not made apparent. More time is spent hunting for details than hands on with the patient. Yes, we can now bill with time codes, and get paid for our administrative time, but billing is an art that must be mastered, along with the subtleties of coding, a journey that never reaches mastery.

But whining about what clinicians have to deal with is not where I intended to go, just another rabbit hole of LTC. SNF’s, particularly those that are not, shall we say high end, are faced with the direst threat to patients, and that is staffing. If there are insufficient numbers of nurses, aides, and other ancillaries to care for the residents, the best plans of care, therapeutic measures, and assistance with ADL’s will never be accomplished nor completed. Feeding, bathing, cutting nails, acts of dignity and compassion do not get done. Short staffing, paper compliance and documentation, and even as pointed out at the recent AMDA Symposium, washing hands between each patient encounter, do not allow time for goals to be met or plans completed. Frequent/daily vital signs, timely turning, medication administration, dressing changes, and sadly respect for the individual are sometimes victims of a system that is being met with financial, regulatory, and business challenges. While outsourcing, automating, and cost cutting, are good business practices, and may contribute to the facility bottom line, they may not ultimately lend benefit to patient needs. 

Well as they say, you can either be a part of the problem or a part of the solution. As long as investors are able to find a profit in “the nursing home business,” facilities other than the upscale private pay models, will continue to struggle. Infusion of governmental funds, liberalization of payment models, and partnering with agencies rather than an adversarial process, will contribute to helping to repair a broken system. As much as I wanted to not use the term, I observe that those who end up on Medicaid become warehoused, by a system that is broken. 

AMDA and PAMDA and their respective public policy representatives must strategically use their influence and voice. Be on the alert for facilities operated by private equity firms. The greater the demand for profits, the greater likelihood that patient care will suffer. The profit margin in LTC is very narrow, and any company that is enormously successful financially needs to be able to demonstrate that their outcomes are good, their residents are well cared for and there is sufficient and well trained staff doing their jobs and going the distance. As concerned clinicians we must being looking under the hood of the car and not just in the passenger seat.  
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.
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2023 Physician Fee Schedule Includes CPT Changes in Coding and Documenting For Nursing Facility Codes

On July 7, 2022, the Centers for Medicare & Medicaid Services (CMS) released the proposed rule for the 2023 Medicare physician payment schedule. While members of AMDA’s staff analyze and develop a summary of the 2,000+-page proposal, we want to make you aware of a few key issues. Notably, CMS is adopting changes to CPT coding and documenting for evaluation and management codes, including nursing facility codes. Thanks to the many members who participated in a 2019 survey of the nursing facility codes to help the RUC develop and recommend these changes to CMS. Learn More
CMS Issues Significant Updates to Improve the Safety and Quality Care for LTC Residents and Calls for Reducing Room Crowding

CMS issued updates to guidance on minimum health and safety standards that LTC facilities must meet to participate in Medicare and Medicaid. CMS also updated and developed new guidance in the State Operations Manual (SOM) to address issues that significantly affect residents of LTC facilities. The surveyors who use these resources to perform both routine and complaint-based inspections of nursing homes are responsible for determining whether facilities are complying with CMS’ requirements. Learn More
LAST CALL! Submit Proposals for PALTC23 by July 19

AMDA’s Annual Conference will be held March 9-12, 2023 in Tampa, FL. Submissions on all topics pertinent to PALTC medicine and medical direction are welcome, including:
  • Navigating the Healthcare System (effecting change, navigating the hierarchy of the system, role of PALTC in the healthcare system overall)
  • Communication (practical strategies, resolving communication gaps at all levels)
  • COVID-19 (best practices, patient management and treatment, litigation, medical director/facility liability)
  • Dementia (staff training on interacting with residents and managing PBSD behaviors)
  • Infection Control (protocols, PPE, testing, preventing future pandemics)
  • Leadership Skills (effective leadership, nurse leadership training)
  • Medical Director (role and responsibilities, contract negotiations, how to gain administration support)
  • Medication Management (deprescribing, opioids, antibiotics stewardship)
  • QAPI (meetings, implementation)
  • Staffing Issues (retention, competency, recruitment, burnout)
  • Telemedicine (implementation, billing & coding, protocols)
  • Transitions of Care (readmissions, acute care, data transfer)
  • How to apply strategies in other settings (ALF, Home Health, etc.)
  • Change culture in facility with staff and patients (bias, racism, building resilience)
  • Caring for special populations (medically complex needs, younger residents, LGBTQIA+, patients with prior substance abuse/addiction)