Speech Language Pathology’s Role in COVID Recovery

The novel coronavirus and resulting pandemic have altered our lives in many ways. The combination of  isolation, physical and social distancing, as well as an economic crisis have all impacted our personal and professional lives. Juggling the ever-changing responsibilities during a healthcare emergency may be overwhelming. The lack of social connections with family and friends as well as in-person visits with your patients can lead clinicians to feelings of loneliness and isolation. Now consider the impact that continued social distancing and isolation may have on the residents and patients within our long-term care facilities. In some instances, isolation of residents has been ongoing for the entirety of the pandemic, entering nearly 6 months!

Prior to this healthcare emergency, a 2019 University of Michigan study on healthy aging noted that 34% of adults aged 50-80 years reported feeling lonely. This current period of social isolation will only exacerbate the number of adults feeling disconnected and lonely and disproportionately affect the elderly population, especially those whose primary social contacts were within their long-term care facility. Furthermore, according to the National Academics of Sciences, Engineering, and Medicine, “Seniors who are experiencing social isolation or loneliness may face a higher risk for mortality, heart disease, and depression.”

As experts on communication, SLPs know the value and need for social interaction for the mental health and well-being of our patients. We are a major factor in the identification of patient needs and educating patients and caregivers on appropriate and personalized techniques to improve and maintain cognitive, speech-language, and executive functioning. We can start by educating on the importance of social interaction and modeling how to achieve this safely during the pandemic.

In the absence of cognitive stimulation and routine, patients may have trouble maintaining prior levels of cognition. We can encourage and educate on the use of daily orientation techniques and maintaining daily routines – targeting problem solving, reasoning, memory, and sequencing during morning and evening self-care routines. Engage with each patient on a personal level and encourage all caregivers to do the same. Provide insight to caregivers on personal preferences that may enhance engagement.

Socialization and purpose play a critical role in feelings of self-worth and success in everyday life. Encourage the use of personal electronic devices. Provide education on increasing socialization through communication and social media. Encourage residents to write letters to family or “neighbors” within the facility. Foster conversation between residents and caregivers during meals and invite family or friends to “dine” with residents via videoconferencing.

Incorporate training on personalized “home” exercise programs to give purpose and focus to each resident’s day. Develop exercises that capitalize on the routines the resident has already established, such as oral motor exercises and/or breathing exercises during a TV commercial break.

As we evolve as professionals during a pandemic, we must continue to protect and advocate for our most vulnerable residents. With the continuation of the healthcare emergency there is a fine line between protecting those that are medically fragile from this virus while continuing to encourage and promote socialization that is vital to their well-being. As visitor restrictions are lessened we continue to be the lifeline that can bring awareness to the effects of social isolation on our residents in long-term care, and by supporting the facility and promoting each caregivers’ strengths as well as educating in areas of opportunity we are creating a more understanding and supportive environment for our residents.  

https://www.asha.org/Practice/Connecting-Audiologists-and-Speech-Language-Pathologists-With-Mental-Health-Resources/

https://time.com/5833681/loneliness-covid-19/

https://www.nationalacademies.org/news/2020/02/health-care-system-underused-in-addressing-social-isolation-loneliness-among-seniors-says-new-report

Occupational Therapy’s Role in COVID Recovery

As we all have become acutely aware of, COVID-19 and the response to the pandemic have resulted in adverse outcomes to residents of skilled nursing and long-term care facilities. These adverse outcomes range from reduced physical function, including decreased muscle strength and endurance, to cognitive and psychosocial impairments, including delirium, neurological dysfunction, depression, and occupational deprivation. In combination, these symptoms paint a clear picture for the need of occupational therapy (OT) intervention. As OT practitioners, we must identify and champion our unique role in not only the physical rehabilitation of our patients but also in their psychological well-being.

According to the American Journal of Occupational Therapy’s (AJOT) OT Practice Framework, our profession, in its fullest sense, is facilitating achieved “health, well-being, and participation in life through engagement in occupation.” We identify the areas of occupation that our residents value, consider their context, and recognize the unique performance patterns and skills that affect the individual’s ability to engage and participate. This is clearly a client-centered, holistic process—one that considers physical function, cognition, and psychosocial impairments that may be impacted. Who better to address the wide range of outcomes that have resulted with our residents in skilled nursing and long-term care facilities?

As we continue to care for our residents who have been affected directly or indirectly by COVID-19, it is imperative that we implement this client-centered, holistic approach. How has the individual’s physical function been affected? Consider implementation of a cardiopulmonary program that includes respiratory strategies, postural control exercises, and exercise prescriptions. To address changes in cognition, complete a standardized cognitive assessment to identify specific processing skills for intervention during activities of daily living. Equally important, and even more important in some cases, are the psychosocial challenges that residents face during the pandemic. As patients are isolated to reduce transmission risks, unintended negative consequences present, including disruption of daily routines and restrictions to leisure and social participation. Recent studies suggest that isolation- associated loneliness has contributed to swift health declines in residents with dementia during the COVID-19 pandemic. Recognize and affirm residents in the challenges they face and use creative technological outlets to enhance participation in meaningful daily activities. Are there opportunities for virtual conferencing with friends or family? Are audio books, online games, or learning modules an option for leisure?

As OT practitioners, we are equipped to meet the tidal wave of challenges that COVID-19 has introduced to residents in skilled nursing and long-term care facilities. The tenets of our profession prepare us to respond to the physical, cognitive, and psychosocial changes that may occur. Though relaxed restrictions to nursing home visitation are on the horizon, the time is now to take hold of our unique, distinct role in facilitating health, well-being and participation in the lives of our residents.   

References:

American Occupational Therapy Association. (in press). Occupational therapy practice framework:

Domain and process (4th ed.). American Journal of Occupational Therapy, 74 (Supplement 2). Advance online publication.


De Biase, S., Cook, L., Skelton, D. A., Witham, M., & Ten Hove, R. (2020). The COVID-19 rehabilitation

pandemic1. Age and ageing, 49(5), 696–700. https://doi.org/10.1093/ageing/afaa118

Gitlow, L., PhD, ATP, FAOTA, OTR/L, Lee, S., OTR/L, Hemraj, R., OTR/L, Sheehan, L., OTD, OTR/L, & Ambroze, G., OTS. (2020). Occupational Therapy and Older Adults: Combating Social Isolation through Technology. PDF. American Occupational Therapy Association.

Lasek, A. (2020, September 18). Dementia mortality skyrockets since lockdowns; CMS loosens visitor restrictions – Clinical Daily News. Retrieved September 18, 2020, from https://www.mcknights.com/news/clinical-news/dementia-mortality-skyrockets-since-lockdowns-cms-loosens-visitor-restrictions/?utm_source=newsletter

Physical Therapy’s Role in COVID Recovery

For over 100 years, physical therapists have specialized in human movement using skilled interventions to maximize health and function.  During periods of critical illness, such as moderate to severe cases of COVID-19, it is common for patients to experience a loss of physical function which can lead to the development of new impairments or worsening of existing ones.

Long-term recovery from COVID-19 may be complicated by lasting effects due to deconditioning, restrictive lung disease, post intensive care syndrome, or neurological disorders. After 10 days of bed rest healthy older adults may lose up to 2.2 pounds of muscle mass from the legs with 2-5%/day loss of muscle strength.  Recovery of physical function may take an extended period of time with impairments that may persist up to 2 years post infection. 

As practitioners of movement, physical therapists are essential in early mobility during and following a critical illness in order to minimize the effects of immobility.  Through skilled interventions such as functional mobility, balance training, endurance activities, posture training, and strengthening, physical therapists are equipped to help residents achieve their optimal level of function as quickly and effectively as possible.

Along with debility, residents in nursing homes that remain quarantined during the public health emergency face another silent threat: social isolation. Even with the recent relaxation of nursing home visitor guidelines, the effects of social isolation may be long lasting.

Restricted access to family and friends may affect even those who have not contracted the virus itself and may include severe fatigue, anxiety, post-traumatic stress disorder, depression, and cognitive dysfunction. 

The effects of patients remaining in their room, the cessation of communal dining, and restricted access to common areas (i.e. the therapy gym and equipment) pose significant barriers not only to successful intervention and outcomes, but also overall resident well-being. The interdisciplinary team should assess and re-assess situations, analyze tasks, make changes, and consider a holistic plan of care to help reduce the lasting effects of social isolation and provide person-centered, specialized care which emulates Reliant’s motto of Care Matters.

References:

https://www.bsrm.org.uk/downloads/covid-19bsrmissue1-published-27-4-2020.pdf.

https://academic.oup.com/ptj/article/100/9/1458/5862054

https://www.aannet.org/initiatives/choosing-wisely/immobility-ambulation

The Impact of Isolation and New Guidance from CMS

As healthcare providers, it has been our priority to encourage and maintain as much “normalcy” as possible while following all guidelines issued to protect our residents from COVID-19 over the last 6 months. We have seen firsthand the impact these regulations have had on our residents, and have used creativity to modify the environment, teach our residents how to utilize technology to speak to their family members, and encourage continued mobility and activity. Even with exhaustive efforts to bridge family communication and daily support and love from staff, depression and loneliness among residents continues to rise.

Recently, the Centers for Medicare and Medicaid Services (CMS) has announced new guidance for long-term care facilities in relation to visitation stating, “we recognize that physical separation from family and other loved ones has taken a physical and emotional toll on residents. Residents may feel socially isolated, leading to increased risk for depression, anxiety, and other expressions of distress. Residents living with cognitive impairment or other disabilities may find visitor restrictions and other ongoing changes related to COVID-19 confusing or upsetting.” While allowing visitation will certainly improve resident morale, CMS has also opened the door to increased social interaction between residents throughout the day.

Deep within this guidance, CMS advises to resume communal activities and dining while adhering to infection prevention recommendations. For example, residents may eat in the same room with social distancing. Group activities may also be facilitated with social distancing among residents and use of appropriate hand hygiene and face covering. Facilities may also be able to offer a variety of activities while taking the necessary precautions. CMS further states that “facilities may not restrict visitation without a reasonable clinical or safety cause.”

The detailed memo largely outlines visitation for indoor, outdoor, and compassionate care situations. CMS advises that visitation should be person-centered, taking into consideration each resident’s physical, mental, and psychosocial well-being. Outdoor visitation is preferred and should be utilized whenever practicable as it poses a lower risk of transmission. Facilities should also accommodate and support indoor visitation as safety and risk assessment allow utilizing data from the COVID-19 county positivity rate, found on the COVID-19 Nursing Home Data website. Facilities should continue to reduce transmission risk while allowing visitation through the use of physical barriers (i.e. clear Plexiglas dividers or curtains).  Among these guidelines, CMS emphasizes the need to follow core principles of COVID-19 infection prevention and use of social distancing.

Although this is not a return to normal, the new guidelines from CMS provide hope for our residents and caregivers by allowing them to have time with their loved ones and other residents within their facility. As healthcare providers, we continue to be the lifeline that can bring awareness to the effects of social isolation on our residents in long-term care. By promoting safe interaction among residents and their families, friends, or neighbors, we are creating a more understanding and supportive environment for our residents.

The CMS guidance for visitation can be found here.

https://www.nationalacademies.org/news/2020/02/health-care-system-underused-in-addressing-social-isolation-loneliness-among-seniors-says-new-report

MDS Updates: Sept. 2020

Beginning, October 1, 2020, MDS version 1.17.2 will be instituted. Updates include assessment changes that will support the calculation of PDPM payment codes for state Medicaid programs and on OBRA assessments when not combined with the 5-day SNF PPS assessment.

  • This will specifically affect the OBRA comprehensive (NC) and OBRA quarterly (NQ) assessment item sets, which was not possible with item set version 1.17.1.
  • Sections GG, I, and J

The updated item sets will not have a revised RAI manual released. As of 9/18/2020, AANAC is reporting 31 states have indicated they will be gathering PDPM data for state Medicaid programs and on OBRA assessments.

Section GG

Items GG0130 and GG0170 headers updated to read “Start of SNF stay or State PDPM”

  • Completion instructions include: If state requires completion with an OBRA assessment, the assessment period is the ARD plus 2 previous days. Complete only column 1.

Section I

Item I0020 instructions for completion are revised: Complete only if A0310B=01 or if state requires completion with an OBRA assessment.

Section J

Item J2100 instructions for completion are revised: Complete only if A0310B=01 or if state requires completion with an OBRA assessment.

Contact your state’s RAI coordinator for item set questions.

CLICK HERE to view the MDS 3.0 Technical Information page.

CMS Issues New Guidance on Nursing Home Visitation

The Centers for Medicare & Medicaid Services (CMS) issued new guidance for visitation in nursing homes during the COVID-19 public health emergency. The guidance below provides reasonable ways a nursing home can safely facilitate in-person visitation to address the psychosocial needs of residents.

Visitation can be conducted through different means based on a facility’s structure and residents’ needs, such as in resident rooms, dedicated visitation spaces, outdoors, and for circumstances beyond compassionate care situations.

Regardless of how visits are conducted, certain Core Principles of Infection Control must be maintained:

  • Screen all who enter the facility for signs and symptoms of COVID-19 (e.g., temperature checks, questions or observations about signs or symptoms), and denial of entry of those with signs or symptoms
  • Hand hygiene (use of alcohol-based hand rub is preferred)
  • Face covering or mask
  • Social distancing at least six feet between persons
  • Instructional signage throughout the facility and proper visitor education on COVID-19 signs and symptoms, infection control precautions, other applicable facility practices (e.g., use of face covering or mask, specified entries, exits and routes to designated areas, hand hygiene)
  • Clean and disinfect high frequency touched surfaces in the facility often, and designate visitation areas after each visit
  • Appropriate staff use of Personal Protective Equipment (PPE)
  • Effective cohorting of residents (e.g., separate areas dedicated to COVID-19 care)
  • Resident and staff testing conducted as required in 42 CFR 483.80(h)

Guidance is provided for indoor, outdoor, and compassionate care situations.

Outdoor Visitation

Outdoor visits pose a lower risk of transmission due to increased space and airflow. Therefore, outdoor visitation is preferred, and all visits should be held outdoors whenever practicable.

Indoor Visitation

Should be accommodated and supported based on the following guidelines:

  • No new onset of COVID-19 cases in the last 14 days and the facility is not currently conducting outbreak testing;
  • Visitors adhere to the core principles and staff adherence;
  • Limit the number of visitors per resident at one time and limit the total number of visitors in the facility at one time (based on the size of the building and physical space);
  • Consider scheduling visits for a specified length of time to help ensure all residents are able to receive visitors; and
  • Limit movement in the facility.

Facilities should use the COVID-19 county positivity rate, found on the COVID-19 Nursing Home Data site to determine how to facilitate indoor visitation:

Communal Activities and Dining

  • While adhering to the core principles of COVID-19 infection prevention, communal activities and dining may occur.
  • Residents may eat in the same room with social distancing (e.g., limited number of people at each table and with at least six feet between each person). 
  • Facilities should consider additional limitations based on status of COVID-19 infections in the facility.
  • Additionally, group activities may also be facilitated (for residents who have fully recovered from COVID-19, and for those not in isolation for observation, or with suspected or confirmed COVID-19 status) with social distancing among residents, appropriate hand hygiene, and use of a face covering.
  • Facilities may be able to offer a variety of activities while also taking necessary precautions.
    • For example, book clubs, crafts, movies, exercise, and bingo are all activities that can be facilitated with alterations to adhere to the guidelines for preventing transmission.

For additional guidance concerning compassionate care visitations, refer to the full article here.

CLICK HERE to view the press release from CMS.

CLICK HERE to view the nursing home visitation guidance.

Take CARE with Infection Control

With frequently updated guidance from federal and state agencies, we are continuously hearing the most current information on how to protect our residents from COVID-19 with best practice infection control. Keeping all members of the team informed of the most recent processes may appear to be a daunting task; however, with the uptick in COVID-19 cases in nursing homes and CMS administrator Seema Verma stating concern, it’s a great time to review how we can keep our residents, staff, and selves safe.

Reliant has created a 4-step approach to Take CARE with Infection Control:

When considering implementation, identify appropriate hand hygiene frequency, PPE based on type of precautions, and items and equipment that need routine cleaning and disinfection.  Be attentive to sequenced steps and processes for hand hygiene, donning and doffing PPE, and cleaning.  In order to ensure reliability, commit to self and peer accountability and implementing PPE peers using return demonstration. To monitor effectiveness of implementation, assess and adjust processes as necessary.

Download and review CMS’ latest Infection Control Survey Guidance (released 8/26/2020) as a guide.

By working together as an interdisciplinary team and holding each other accountable for best practice infection control practices, we can minimize the spread of COVID-19 within our facilities.  Practice extreme diligence and caution with infection control and prevention processes.

CLICK HERE for more information on Reliant’s Take CARE with Infection Control initiative.

COVID-19 Waiver Claims Review

Providers have begun receiving non-medical additional document requests for claims utilizing the benefit period waiver in response to the COVID-19 public health emergency. These reviewers are being flagged with a “7COVD” code and have primarily been reported under Wisconsin Physician Services (WPS).

These suspended claims may be the result of a billing issue. As such, review the proper guidelines below for how claims involving the waiver for the 60-day wellness period should be billed.

According to this Medicare Learning Network memo, to bill for the benefit period waiver:

  • Submit a final discharge claim on day 101 with patient status 01, discharge to home
  • Readmit the beneficiary to start the benefit period waiver

For admission under the benefit period waiver:

  • Complete a 5-day PPS Assessment. (the interrupted stay policy does not apply.)
  • Follow all SNF PDPM assessment rules.
  • Include the HIPPS code derived from the new 5-day assessment on the claim.
  • The variable per diem schedules begins from day 1.

For SNF benefit period waiver claims, include the following:

  • Condition code DR- identifies the claim as related to the PHE
  • Condition code 57 (readmission) – this will bypass edits related to the 3-day stay being within 30 days
  • COVID100 in the remarks – this identifies the claim as a benefit period waiver request

What’s GG Got to Do With It?

Despite the many adaptations and additional considerations that have been adopted in the battle against COVID-19, healthcare providers in skilled nursing facilities (SNFs) maintain their primary focus of quality patient rehabilitation and care. In the midst of planning and delivering care in a pandemic, some may ask, Does data collection really matter right now?  What’s GG got to do with it? The answers are Yes and everything!

CMS has indicated the value of data collection of our patient’s functional abilities (i.e. Section GG) by signaling it as a key comparison of quality across post-acute settings, an indicator of resource use impacting reimbursement, and critical to guiding patient-centered care planning. Although CMS stated exceptions and extensions were granted because data collection may be greatly impacted by the response to COVID-19, beginning July 1, SNFs are expected to report their quality data to meet the SNF QRP requirements for the third quarter of 2020. (Download CMS’ SNF QRP Tip Sheet)

Knowing this data eventually will be publicly posted, the question now becomes Does it reflect our exhausting efforts to deliver care during this public health emergency? That answer is yet to be determined, but it is never too late for a review and refresh of Section GG content as well as considerations for coding and patient identification in the current environment.

Accuracy of Section GG coding depends not only upon the healthcare professional’s familiarity with the objective scales, but also with each item’s definition, intent and parameters for coding. For example, walking items may be completed within separate sessions. A single walking item may include a brief rest, as long as the resident does not sit down. These considerations may assist in completing a thorough assessment in isolation. CMS provides training videos on the SNF QRP Training webpage for instructional purposes.

Facilities can use Section GG data to capture potential changes in function that may require skilled intervention by completing interim assessments. It is the role of the interdisciplinary team to identify potential impacts of isolation on a patient’s biopsychosocial wellbeing and intervene as appropriate.

Finally, review the submission requirements for the SNF-QRP, so a technicality does not overshadow the successful outcomes your teams are creating. Avoid dashes, utilize the activity not attempted codes as necessary, incorporate at least one goal into the patient’s care plan and submit the completed data for at least 80% of your Medicare A claims.

The interdisciplinary team should champion the role of data collection, even in a pandemic, to ensure that we are facilitating the appropriate plan of care, capturing the true picture of the resident’s needs and maintaining the highest quality of rehabilitation and care. Our patients are counting on us!

CMS Releases Enhanced Enforcement Actions Based on Nursing Home COVID-19 Data and Inspection Results

CMS released a memorandum addressing COVID-19 survey activities, enhanced enforcement, and engagement of Quality Improvement Organizations (QIOs).  CMS also released a state-by-state report on COVID-19 cases for residents and staff along with numbers of infection control focused surveys completed. The memorandum includes guidance related to

  • Focused Infection Control Nursing Home Surveys and CARES Act Supplemental Funding 
    • States that have not completed focused infection control surveys in 100% of their state’s nursing homes by July 31, 2020 will be required to submit a corrective action plan outlining the strategy for completion of these surveys within 30 days. 
    • Access to CARES Act allocations will be impacted by state performance on completing the nursing home infection control focused surveys. 
  • COVID-19 Survey Activities 
    • Requiring states to implement the following COVID-19 survey activities. States that fail to perform these survey activities timely and completely could forfeit up to 5% of their CARES Act allocation, annually. 
  • Expanded Survey Activities 
    • Emphasizes Nursing Homes Re-opening Recommendations, which indicates that once a state has entered Phase 3 of the reopening process, states may use their discretion as to whether and how they decide to expand survey activity beyond the current survey prioritization.
  • Enhanced Enforcement for Infection Control Deficiencies 
    • For all infection control deficiencies at a scope and severity of D or above, CMS will impose a directed plan of correction that will include the use of root cause analysis. 
  • Support From Quality Improvement Organizations (QIOs) 
    • Nursing homes can take advantage of weekly National Nursing Home Training that focuses on infection control, prevention and management to help prevent the transmission of COVID-19.Nursing homes can locate the QIO responsible for their state here

Read the memo from CMS here.

COVID-19 Data and Inspection Results Available on Nursing Home Compare

The Centers for Medicare and Medicaid Services (CMS) initiated posts of COVID-19 nursing home data which will be updated weekly.

In addition, results of targeted inspection surveys and reports are available on Nursing Home Compare. CMS plans to post the results of the inspections monthly as they are completed.

Available Links

Medicare COVID-19 Testing for Nursing Home Residents and Patients

The Centers for Medicare & Medicaid Services (CMS) instructed Medicare Administrative Contactors and notified Medicare Advantage plans to cover coronavirus disease 2019 (COVID-19) laboratory tests for nursing home residents and patients. This instruction follows the Centers for Disease Control and Prevention’s (CDC) recent update of COVID-19 testing guidelines for nursing homes that provides recommendations for testing of nursing home residents and patients with symptoms consistent with COVID-19 as well as for asymptomatic residents and patients who have been exposed to COVID-like symptoms in an outbreak.

Medicare Advantage plans must continue not to charge cost sharing (including deductibles, copayments, and coinsurance) or apply prior authorization or other utilization management requirements for COVID-19 tests and testing-related services.

For the full Medicare Learning Network article, CLICK HERE.

CMS Releases FAQs on Nursing Home Visitation

The Centers for Medicare and Medicaid Services (CMS) issued a Frequently Asked Questions document on visitation for nursing home residents that provides clarifications and considerations including:

Visitation for compassionate care situations

  • CMS clarifies compassionate care situations are not exclusive to end-of-life situations.   An example is provided explaining a resident who was living with their family prior to being admitted to the nursing home may experience trauma due to the change in their environment and sudden lack of family.  Therefore, this may qualify as a compassionate care situation.

Outside visits

  • CMS encourages creative means of connecting residents and families including visitation outside of the facility while ensuring all actions for preventing COVID-19 transmission are followed.

Communal activities

  • Residents (without COVID-19 symptoms) may eat in the same room with social distancing.
  • Group activities may be facilitated (for residents who have fully recovered from COVID-19, and for those not in isolation for observation, suspected or confirmed COVID-19 status) with social distancing among residents, appropriate hand hygiene, and use of a cloth face covering or facemask.

Steps for reopening to visitors

  • Nursing homes should continue to follow CMS and CDC guidance for preventing the transmission of COVID-19 and follow state and local direction.
  • CMS does not recommend reopening facilities to visitors (except for compassionate care situations) until phase three when the following criteria are met:
    • No new onset of COVID-19 in the nursing home for 38 days
    • No staff shortages
    • Adequate supplies of PPE and essential cleaning and disinfection supplies
    • Adequate access to testing for COVID-19
    • Referral hospitals have bed capacity on wards and ICUs

Factors to consider regarding visitation

  • CMS encourages that any decisions to relax requirements or conduct creative alternatives within nursing homes be made in coordination with state and local officials after a careful review of facility-level, community, and state factors/orders.

To access the complete FAQs document from CMS’ Current Emergencies webpage, CLICK HERE.

Recovery and Rehabilitation Following COVID-19

As research and data collection regarding the recovery from COVID-19 grows, valuable information from research studies identifying correlations between contracting the virus and other acute medical complications, as well as the increased risk of readmission to the hospital, is clear. Current data suggests that patients hospitalized for COVID-19 are at increased risk for blood clots, strokes, heart and lung damage, speech and swallowing difficulties due to prolonged intubation, and neurological impairments.  It is our job to have a heightened awareness of potential complications associated with COVID-19 and communicate any findings to the interdisciplinary team (IDT).  With proper notification of subtle observed symptoms, the IDT can work together to minimize the side effects of COVID-19 and decrease the need for rehospitalization, consequently avoiding delayed recovery, increased potential for exposure to other contagions, and development of further complications.

Recovery is not only needed for those who have survived COVID-19; recovery, although different, is also needed for those who did not contract the virus but find themselves dealing with side effects from the modification of routines and activities in an effort to combat the spread of COVID-19. Current data shows that older adults who have not contracted the virus are seeing physical and psychosocial effects due to social distancing that result in deconditioning, increased effects of chronic disease, and reduced functional capacity. Facilities can provide ways to keep residents active while still maintaining social distancing guidelines. To thwart the effects of isolation and inability to see family, facility staff can provide technology, such as Facetime, to allow for residents to check in with their loved ones. Another consideration would be to reach out to family members and encourage them to send pictures and care packages to brighten the residents’ day.  We must ensure minimal impact to those who have made the skilled nursing facility their home by increasing opportunities for social and physical activities while maintaining precautions and social distancing during the COVID-19 pandemic.

COVID-19 has touched everyone, either directly or indirectly, and the effects of the virus may linger for an indefinite amount of time.   However, through increased communication among the IDT, we can potentially aid in speeding up the recovery process and in minimizing the risk of rehospitalization.   Additionally, through increased social and physical opportunities, our residents who have not contracted COVID-19 can explore alternative ways to stay connected and physically active.  Through the actions of a proactive interdisciplinary team, we can assist all our residents in achieving functional and quality outcomes allowing for enhanced quality of life.

Honking for Hugs #CareNotCOVID

With the restrictions on visitors, several communities across the country have gotten creative showing appreciation for patients and residents by coordinating “Honk for Hugs” events in a reverse parade fashion.

Forest Hills Care and Rehabilitation, Broken Arrow, OK

The Forest Hills Care and Rehabilitation team in Broken Arrow, OK participated in two community parades, which allowed the patients and residents to see friends and family from a safe distance.

Let’s recognize the team:

Rachel Blanchard DOR
Dianna Sunday PT
Rebecca DeVilliers OTR
Chelsea Holmes OTR
Shannon Pinson SLP
Kelsey Farragher SLP
Saundra Fite PTA
Tara Stephenson PTA
Katie Forler PTA
Candice Ertman PTA
Michelle Kellam COTA
Kimberly Luu COTA

Cottonwood Creek Healthcare Center, Richardson, TX

Cottonwood Creek Healthcare Center in Richardson, TX held a Honk for Hugs event with patients and residents. The patients and residents had so much fun!

CareCore at Westmoreland, Chillicothe, OH

CareCore at Westmoreland’s therapy team in Chillicothe, OH decorated and had patients participate in a “Honk for Hugs” event where the community showed how much they cared for the facility patients and residents.

Let’s recognize the team:

Angie Nartker PT
Kelly Davidson SLP
Crystal Steele PTA
Amanda Karr PTA
Jill Burton COTA
Penelope George PTA/DOR

When Will We Begin Seeing Medical Review Audits Following the COVID-19 PHE?

While it is still unclear at this time when we will begin to see normal audit activity resume from traditional Medicare entities, some Managed Care companies have lifted their suspensions and may have resumed normal auditing practices as early as May 15, 2020. Humana released a memo on May 14, 2020 stating the following

“Given that health system capacity is opening up and procedures are increasing steadily, we will begin to resume some of the regular processes that we suspended on April 1, 2020, to support providers with the strain on the healthcare system posed by COVID-19 at the heart of the crisis…The first of these is for medical record requests for claim reviews, which we will resume effective May 15, 2020.

  1. Resuming pre-payment medical record claims review. As of May 15, Humana may begin to request medical records from your organization prior to issuing payment, consistent with our policy in place prior to the April 1 suspension.
  2. Resuming post-payment medical record claims review. Since April 1, Humana has not requested medical records in connection with our post-payment review process. Our post­ payment claims review team will now resume making requests for medical records as required, consistent with our policy in place prior to April 1.

Humana leaders will continue to monitor service volumes as well as the progression of the COVID-19 curve and recovery and will review our policies and procedures as necessary as this crisis evolves.”

Please be prepared to start seeing these requests again in the coming days and weeks and notify your Medical Review/Appeals department as soon as possible. It is highly possible that there will still be barriers to obtaining medical records timely and extensions may need to be requested. We are all in this together and are happy to assist in any way possible.

CMS Releases Toolkit for Nursing Homes

CMS has released a toolkit to aid nursing homes, governors, states, departments of health, and other agencies who provide oversight and assistance to these facilities, with additional resources to aid in the fight against the coronavirus disease 2019 (COVID-19) pandemic within nursing homes. Access the toolkit here.

The toolkit is comprised of best practices from a variety of front line health care providers, Governors’ COVID-19 task forces, which provide a wide range of tools and guidance to states, healthcare providers and others during the public health emergency.

The toolkit is comprised of best practices from a variety of front line health care providers, governors COVID-19 task forces, associations and other organizations, and experts, and is intended to serve as a catalog of resources dedicated to addressing the specific challenges facing nursing homes as they combat COVID-19.

View the full press release from CMS here. The toolkit can be accessed here.

CMS Issues Guidance to Ensure the Safe Reopening of Nursing Homes

After President Trump revealed Guidelines for Opening Up America Again on May 18, the Centers for Medicare and Medicaid Services (CMS) announced new guidance for state and local officials to ensure the safe reopening of nursing homes across the country.  State leaders are encouraged to collaborate with the state survey agency and local health departments to develop a plan on how these criteria should be implemented.

CMS recommends that decisions on relaxing restrictions in nursing homes be made with careful review of the following facility-level, community, and state factors:

  • Case status in community
  • Case status in the nursing home(s)
  • Adequate staffing
  • Access to adequate testing
  • Universal source control
  • Access to adequate personal protective equipment (PPE) for staff
  • Local hospital capacity

Reliant’s Real Time Memo on this topic can be accessed here.

CMS’ guidance can be accessed here.

The Frequently Asked Questions (FAQ) document can be accessed here.

or questions or concerns related to this memo, please email the DNH Triage Team.

Connection Through Video Chat

As the country continues to take a proactive, preventative approach to reduce the spread of COVID-19, social distancing and visitor restrictions in long-term care challenge us to use alternative means for connecting patients, family members/responsible parties, and long-term care staff.  On March 13, 2020, the Centers for Medicare & Medicaid Services (CMS) issued Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in Nursing Homes (Revised) stating:

“In lieu of visits, facilities should consider offering alternative means of communication for people who would otherwise visit, such as virtual communications (phone, video-communication, etc.)”1

When choosing to use video communication, the US Department of Health and Human Services provides guidance regarding which video communication platforms are safe to use and which are not. For example, FaceTime and Skype* are classified as non-public facing remote communication products while TikTok, Facebook Live, and Twitch are public-facing products.  Public-facing products are not acceptable to use. 

When video chatting, be mindful of the following:

  • Obtain proper authorization for use or disclosure from the resident/patient/responsible party.
  • Make reasonable efforts to ensure others, not authorized to participate in the video chat, cannot hear the discussions.
  • Ensure other patients are not in the background of the video chat to prevent unauthorized use or disclosure of that individual.
  • Confirm the party answering the video chat is the appropriate party before proceeding with discussions.
  • Be sure when ending video chat that it successfully ends so that other conversations or videos are not accidentally seen or overheard.

*FaceTime and Skype means of communication are not supported by HIPAA regulations outside of the current healthcare emergency. The Office of Civil Rights states:

“Health care providers may use popular applications that allow for video chats, such as FaceTime and Skype, to provide telehealth without risk that OCR might seek to impose a penalty for noncompliance with the HIPAA Rules related to the good faith provision of telehealth during the COVID-19 nationwide public health emergency.” 

1 https://www.cms.gov/files/document/qso-20-14-nh-revised.pdf

2https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html

Implementation Strategies: Trauma-Informed Care During the COVID-19 Pandemic

The COVID-19 pandemic introduces unique considerations related to patient-specific care plans, the execution of trauma-informed care (TIC) and the implementation of protocols to prevent disease transmission allowing for the continued provision of quality care.  In order to incorporate TIC, each patient’s unique history, specifically those relevant to the current environmental demands, should be addressed with strategic care planning. 

Interdisciplinary teams must help alleviate the unintended consequences of social isolation and source control strategies (i.e. face mask use) while in pursuit of infection control.  Now, more than ever, we must be familiar with our residents and newly admitted patients, their histories, potential triggers and preferences in order to develop and employ patient-specific TIC successfully. 

Consider the following strategies:

  1. Determine the health literacy of each resident/patient and provide education concerning infection control and prevention at their level of understanding to the diminish potential for new trauma
  2. Adapt protocols as necessary and modify care plans accordingly to prevent re-traumatization.
  3. Provide patients reassurance as often as necessary that protocols in place are in their best interest.
  4. Address needs for a sense of normalcy by developing new routines, roles, and habits. 
  5. Mitigate the psychosocial effects of isolation through creative implementation of activities to promote socialization and engagement.
  6. Utilize technology to facilitate connections with family and friends, when possible.

There are no shortages of avenues for success with TIC, but communication is critical for them all.  At its core, TIC requires communication with the patient and their designated representative for historical knowledge and care plan updates. It takes each member of the interdisciplinary team offering specific insight resulting from their familiarity with the patient, to develop a thorough and comprehensive care plan for the individual that accomplishes preventing traumatization or re-traumatization.  Do not diminish the explicit value each member brings as their contribution may very well be the one to enable positive patient outcomes.