The Sweet and Salty of Return to Normalcy

As the public healthcare emergency (PHE) lightens and with vaccines abundant in the U.S., many businesses are feeling a note of normalcy. Nursing homes have been given the green light to reopen, but continue to be a target of investigation, regulatory ribbon, and reduced consumer trust. This paradoxical environment highlights the sweet and salty of long-term care (LTC). Prior to the pandemic, LTC’s focus was enhancing resident’s outcomes, improving quality of care and quality of life, and fostering a home environment worthy of the residents within.  As difficult as it may have been in the moment, we now know it was truly the sweet stuff.

During the height of the PHE, regulation and policy aligned to create a salty recipe for long-term care. Reporting requirements, acquiring PPE, reduced access to care, and navigating surveys overshadowed previous focuses. Through this pandemic, we’ve learned the necessity of the salty. Salt brings balance and accountability, but when added without first testing the effectiveness of current spices, it can quickly ruin a meal. When regulation, reporting, and accountability metrics are balanced in relation to care needs, quality outcomes, and resident satisfaction, a delightful sweet and salty mix, in high demand for any consumer, is created.

As we emerge into this new era, many are fatigued, short staffed, and considering alternatives to long-term care. Let’s partner together to remember the sweet, learn from the salty, and create an enhanced recipe. Embrace each step of reopening with a dash of optimism and a cup of determination. Give a patient a hug, ignite communal dining and activities with fanfare, have a welcome party in the therapy gym, hype the benefits of group therapy, and celebrate family and friend’s visitation! Talk openly about the expectations for infection control, safety measures, and possible temporary isolation needs. This balance will help achieve a transparent trust with our residents, their loved ones, and care partners.

Don’t let the sweet get lost in the salty, share resident and facility successes with Reliant’s Model 103.0 reports. Spotlight Reliant therapists who exhibit clinical excellence by climbing the Clinical Ladder and facility team who SMILE with purpose. Never hesitate to GROW your brand. Our partnership brings the best ingredients to demonstrate your facility’s value, skill, and compassion in the community. Bon Appetit!

Coronavirus Scams, A Year Later…

This time last year, increased reports of scams and phishing attempts referencing COVID-19 captured our attention causing us to be vigilant to protect our businesses and patient information.

Fast forwarding to this year, many states have begun to lift COVID-19 restrictions, but the bad actor’s scams and phishing attempts have not let up. They continue their tactics to entice us through scams and/or phishing attempts.

Many times these attacks appear as innocent emails seeking assistance or providing information regarding the COVID-19 crisis. Bad actors are taking advantage of this crisis to prosper or do damage.  Their criminal actions are becoming increasingly sophisticated and look very official, as if coming from government agencies and health organizations.

Today and always, let us remember, it is critical to continue vigilance with all email correspondence and access to websites, but particularly those referencing COVID-19 updates, maps, donations, notifications etc.

To avoid becoming a victim, follow the guidelines below:

  • Never click on links or open attachments within unexpected emails.
  • If you receive a suspicious email appearing to come from a legitimate organization such as CDC, WHO, FEMA etc., confirm its legitimacy.  Make sure links direct you to the official site by hovering over the link.  Report suspicious email to your company’s Information Security Department.
  • If you visit a website or receive a pop-up window directing you to a phone number for support desk assistance, DO NOT call the number, instead contact your company’s Information Security Department.
  • Never share your password with anyone.

Continued trends noted to date include:

  • Malicious websites – sites referencing coronavirus or COVID-19 in the URL. Thousands of new websites have recently been registered to distribute malware when the user accesses the site.
  • Spam – emails trying to grab your attention to sell information or goods now in high demand such as masks, hand sanitizers, COVID-19 drugs, etc.
  • Phishing – emails posing to be from legitimate organizations such as the Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO), the Federal Emergency Management Agency (FEMA), etc. These emails contain malicious links, and some are collecting personal information.
  • Fake charities – emails and websites asking for donations for studies, healthcare professionals, victims, or other activities related to COVID-19.
  • Fake internal HR or IT communications such as coronavirus surveys pretending to be from your company’s HR or IT department – these sites are attempting to obtain your User ID and password or other personal information.
  • Fake notification of infection – beware of emails reporting you have been exposed to an infected individual, particularly ones asking for personal information to proceed.

 Always Think Before You Click.

With Them for the Long Haul

According to Harvard Health Blog, recent studies indicate that 50-80% of patients recovered from COVID-19 continue to have at least one adverse symptom three months after the onset, even if the patient no longer tests positive for the virus.  This emerging condition has been described using a variety of terms including: “Post-Covid-19 Syndrome”, “Long COVID”, “Post-Acute Sequelae of SARS-COV2 infection (PASC)”, and “Long-Haulers”.  As healthcare providers to the most vulnerable population, it is our duty to monitor the evolving evidence in this area and adapt for timely identification and intervention of needs.  

Though what predisposes an individual to developing “Long COVID” is still unknown, a number of those with even mild symptoms have continued to experience lingering effects. Some of the troublesome symptoms that have been observed with “Long COVID” include many of the same musculoskeletal, cardiopulmonary, oral/respiratory, neurological, and psychological dysfunctions that are seen with active COVID-19. Furthermore, it has been noted that some individuals recovering from COVID-19 develop new conditions or complications of pre-existing conditions as a result of the illness.

Rehabilitation’s distinct role in COVID recovery and “Long COVID” is clear. Therapy can intervene to assist “Long Hauler” patients by maximizing their participation and performance in daily function with the use of the following:

  • Referral to the IDT when changes in clinical presentation emerge
  • Patient-specific musculoskeletal and neurological re-training
  • Individualized cardiopulmonary programming
  • Dysphagia analysis and treatment
  • Compensatory strategies to assist with cognitive re-training
  • Environmental modifications to facilitate increased participation and decreased risk of injury
  • Trauma-informed approaches to care when addressing the psychological effects of prolonged isolation
  • Patient and caregiver training on adaptive techniques and equipment
  • Patient education to promote health literacy

Reliant is actively engaged with the therapists in the field by developing resources such as Reliant’s Post COVID Clinical Considerations in order to equip the care team to positively impact patients and residents. Evidence continues to emerge, but the tools and knowledge do exist to address the physical, cognitive, and psychosocial needs that COVID-19 has introduced. Whether newly diagnosed as COVID positive, challenged by long-term effects of “Long COVID”, or facing an entirely new condition as a result of COVID-19, a patient or resident will never feel alone as they can rest assured that we’re with them for the long haul.

References:

Anthony Komaroff, MD. “The Tragedy of Long COVID.” Harvard Health Blog, 1 Mar. 2021, www.health.harvard.edu/blog/the-tragedy-of-the-post-covid-long-haulers-2020101521173.

AOTA. “Research: Occupational Therapy and Physical Therapy Provide Significant Rehabilitative Value in Post-Acute Care.” American Occupational Therapy Association, 5 Apr. 2021, www.aota.org/Advocacy-Policy/Federal-Reg-Affairs/Therapy-Outcomes-Post-Acute-Settings.aspx.

Cutter, Matthew. “COVID Long-Haulers: An End in Sight?” ASHAWire, 5 Mar. 2021, leader.pubs.asha.org/do/10.1044/leader.FTR1.26032021.42/full/.

Royal College of Occupational Therapists. “A Quick Guide for Occupational Therapists: Rehabilitation for People Recovering from COVID-19.” Rcot.co.uk, Apr. 2020, www.rcot.co.uk/files/guidance-quick-guide-occupational-therapists-rehabilitation-people-recovering-covid-19-2020.

WHO. “COVID-19 Clinical Management: Living Guidance.” World Health Organization, World Health Organization, 25 Jan. 2021, www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1.

Roll Up, Reliant!

We all hope to see, sometime in the near future, a resumption of normalcy where we can walk in and out of our facilities without masks and PPE, where we can visit with family members freely and give our elderly loved ones tight hugs and pecks on the cheek.  With the COVID-19 vaccine rollout, this hope is that much closer to becoming a reality.

Even though we have this glimmer of hope with the production of the vaccine, that is only the first step.  It is now a matter of distributing, administering, and educating.  There is fear, anxiety, and uncertainty regarding the vaccine, therefore, educating our healthcare professionals and residents on the safety and benefits of the COVID-19 vaccine is paramount.  

Our long-term care residents and healthcare frontline workers are among the first to have the opportunity to be vaccinated. While the latest statistics show a very high participation rate among residents, they also show that a large number of healthcare workers are shying away from rolling up their sleeve.  As healthcare workers, we are some of the most trusted individuals and often provide a sense of comfort to everyone else looking for guidance in such a time of unknown.  Getting vaccinated may not only protect you, but your loved ones, and those at high risk, including our beloved long-term care residents.

Reliant has been proactive in vaccination awareness for our therapists. This includes sharing peer vaccination stories and posting a series of videos by Dr. David Gifford, AHCA/CCAL, addressing important questions about the COVID-19 vaccine.  If you have not had a chance to watch them and want to hear some pressing questions answered, take a few minutes and click on the links below.

 Why Should I Get the COVID-19 Vaccine?

Does the COVID-19 Vaccine Cause Allergic Reactions?

What are the Side Effects of the COVID-19 Vaccine?

​​How Was the COVID-19 Vaccine Developed So Quickly?

Will the COVID-19 Vaccine Cause Infertility​?

Why Should I Get the COVID-19 Vaccine Now When I Can Wait to See What Happens? ​

Get informed and let’s ROLL UP, Reliant!

COVID-19 Vaccine Resources

With the increasing availability of COVID-19 vaccinations on the horizon and updated information being released almost daily, organizing the pertinent material into a concise usable format can be daunting. Below are the most up-to-date resources from the CDC, CMS, and FDA regarding the COVID-19 vaccine.

CDC Vaccine Resources

CMS Vaccine Resources

FDA Vaccine Resources

Core Principles of COVID-19 Infection Prevention

  • Screening of 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 (covering mouth and nose)
  • 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)
  • Cleaning and disinfecting high frequency touched surfaces in the facility often, and designated visitation areas after each visit
  • Appropriate staff use of Personal Protective Equipment (PPE)
  • Effective cohorting of residents (e.g., separate areas dedicated COVID-19 care)
  • Resident and staff testing conducted as required at 42 CFR 483.80(h) (see QSO-20- 38-NH)

Moving Forward: Safe and Successful Reintegration

In September, the Centers for Medicare and Medicaid Services (CMS) released exciting news for the advancement of safe visitation and resumption of group activities and communal dining in nursing homes (see QSO-20-39-NH). As the effects of isolation have taken a tremendous toll on our elderly population, care teams and residents are ready to implement safe steps to social reintegration.  Facilities, including therapy departments, can now offer a variety of group activities while also taking the necessary precautions.

CMS provides Core Principles of COVID-19 Infection Prevention which should be incorporated as best practice to reduce the risk of COVID-19 transmission in order to resume visitation and group activities. It is indicated that 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 cloth face coverings or facemasks. CMS’ examples of group activities include book clubs, crafts, movies, exercise and bingo.

As facilities implement these principles and activities, it is important to remember, early in the pandemic, resident-centered care plans were adapted for isolation considerations. These care plans should now be reviewed, especially in the light of infection control prevention, trauma-informed care, cognitive changes and fall prevention. It should not be assumed that residents will function at the same level as they did pre-pandemic; therefore, consider the increased risks associated with the possible secondary effects of the pandemic and isolation precautions:

  • Infection Prevention and Control: Review the resident’s ability to safely wear cloth face coverings and understanding of or cueing needed for social distancing. Identify assistance and reminders needed to perform hand hygiene.
  • Trauma-Informed Care (TIC): Consider whether the resident is suffering from anxiety associated with infection risk or recovery and provide a facility plan for safe reopening. Ensure staff buy-in to the plan and implementation in order to set good examples and provide TIC support. Be sensitive to the effects of a busy, potentially noisy, environment following a period of social isolation.
  • Cognitive changes: As social interaction increases and the physical environment changes, be aware of behavioral responses and signs or symptoms of confusion. Assess behaviors as a form of communicative response to the environment and adapt as appropriate.
  • Fall prevention: Consider that as the resident’s access to the facility and grounds expands, their environment is now exponentially larger. Review their ability to safely ambulate throughout the facility as this may place the resident at increased risk of falls and wayfinding confusion.

Protecting residents from COVID-19 highlights the struggle between keeping residents healthy and providing beneficial, daily experiences that can impact quality of life. Nursing, therapy, and facility staff must work as a team to implement creative means to facilitate safety during group activities and social reintegration to allow our residents to safely flourish in light of the challenges they encounter.

Updated NHSN Pathway Reporting Mandatory for Point of Care Testing in Skilled Nursing Facilities

The Centers for Disease Control & Prevention (CDC) and the Centers for Medicare & Medicaid Services (CMS) are now requiring nursing facilities to utilize the CDC’s National Healthcare Safety Network (NHSN) as the required reporting pathway for the COVID -19 testing results that nursing facilities are generating from point of care (POC) testing devices which were provided by the Department of Health & Human Services (HHS). 

Data collected via NHSN is pushed to the AIMS platform, which is hosted by the Association of Public Health Laboratories, every two hours. The AIMS platform then shares this data with state and local health departments as well as with HHS.

Currently, entry of data into NHSN is manual and entered one patient at a time. The CDC indicated that it plans to make accepting a CSV file, for multiple persons and test results at one time, possible in the future.  

CLICK HERE for more information from HHS on reporting requirements.


Incentive Payments to Nursing Homes Curbing COVID-19

The U.S. Department of Health and Human Services (HHS) announced it will distribute approximately $333 million in first-round performance payments to over 10,000 nursing homes. These nursing homes are being recognized for demonstrating significant reductions in COVID-19 related infections and deaths between August and September.

Nursing Home Performance-Based Results

HHS announced that in the first round of the incentive program, 10,631 of the 13,795 eligible nursing homes met the infection control criteria. Overall, these nursing homes contributed to 5,000 fewer COVID-19 infections in nursing homes in September than there were in August. Against both the infection control and mortality criteria, 10,501 nursing homes qualified for payments and contributed to 1,200 fewer COVID-19 related nursing home deaths between August and September.

Nursing homes will receive September quality incentive payments next week and will have four more opportunities to receive additional incentive payments.

CLICK HERE for a state-by-state breakdown on incentive payments from this first cycle.

CLICK HERE for more information on the Provider Relief Program.

CLICK HERE to read the full press release from HHS.

HHS Provides Update for Provider Relief Fund Reporting Requirements

On Oct. 22, The Department of Health and Human Services (HHS) released a memo stating that they are no longer limiting providers’ use of Provider Relief Funds for covering lost revenue due to the coronavirus. HHS announced that it will go back to allowing providers to calculate their lost revenue based on the difference between their 2019 and 2020 actual patient- care revenue, and eliminate limits on how much Provider Relief Fund (PRF) payments can be applied to that lost revenue.

HHS added that the amended reporting instructions should allow providers to fully apply PRF distributions to lost revenues. 

CLICK HERE to read the full memo.

Deadline to Sign Up for Vaccine Program Extended

On Oct. 16, the U.S. Department of Health and Human Services (HHS) and Department of Defense (DOD) began offering sign-ups for agreements with CVS and Walgreens to provide and administer COVID-19 vaccines to residents of long-term care facilities (LTCF) nationwide with no out-of-pocket costs. LTCF residents are anticipated to be part of the prioritized groups for initial COVID-19 vaccination efforts until there are enough doses available for every American who wishes to be vaccinated.

LTCFs will now have UNTIL NOVEMBER 6 to opt in and indicate which pharmacy partner their facility prefers to have on-site. LTCFs are not mandated to participate in this program and can request to use their current pharmacy contracts to support COVID-19 vaccination.

Nursing homes can sign up via the National Healthcare Safety Network (NHSN) and assisted living facilities can sign up via an online survey

The CDC is offering an overview and FAQs, updated as of 10/23/20, to help further explain the program and AHCA/NCAL also are offering an overview.

CMS Updates Methodology for Calculating COVID-19 Testing by Nursing Facilities

The Centers for Medicare & Medicaid Services (CMS) announced a change in its methodology for calculating county-level community infection rates for COVID-19. Facilities are expected to use the county-level color coded rating (green, yellow, or red) to determine the frequency for testing facility staff and residents in accordance with CMS guidance.

The earlier guidance and methodology required facilities to test staff once monthly if the county in which the facility is located had a positivity rate of less than five percent (< 5%); testing frequency increased to once each week for county positivity rates between five and 10 percent (5 – 10%) and twice weekly for county positivity rates that exceeded 10 percent (>10%). The shift in methodology will mean a change in the color-coding rates. For example, CMS’ new methodology classifies counties with both fewer than 500 tests and fewer than 2,000 tests per 100,000 residents, along with a positivity rate greater than 10 percent over 14 days as “yellow” whereas the earlier methodology would have put these counties in the red zone.

CLICK HERE to read CMS’ press release about the change in methodology.

CLICK HERE for the latest county positivity rates. 

CMS Changes Medicare Payment to Support Faster COVID-19 Diagnostic Testing

The Centers for Medicare & Medicaid Services (CMS) announced new actions to pay for expedited COVID-19 test results. CMS announced that starting January 1, 2021, Medicare will pay $100 only to laboratories that complete COVID-19 diagnostic tests within two calendar days of the specimen being collected. 

Also, effective January 1, 2021, for laboratories that take longer than two days to complete these tests, Medicare will pay a rate of $75. CMS reports they are working to ensure that patients who test positive for the virus are alerted quickly so they can self-isolate and receive medical treatment.

CLICK HERE to review the full press release from CMS.

CMS Announces New Repayment Terms for Medicare Loans Made to Providers During COVID-19

The Centers for Medicare & Medicaid Services (CMS) announced amended terms for payments issued under the Accelerated and Advance Payment (AAP) Program.  Under the Continuing Appropriations Act, 2021 and Other Extensions Act, repayment will now begin one year from the issuance date of each provider or supplier’s accelerated or advance payment.  

Providers were required to make payments starting in August of this year, but repayment will be delayed until one year after payment was issued.  After that first year, Medicare will automatically recoup 25 percent of Medicare payments otherwise owed to the provider or supplier for eleven months.  At the end of the eleven-month period, recoupment will increase to 50 percent for another six months.  If the provider or supplier is unable to repay the total amount of the AAP during this time-period (a total of 29 months), CMS will issue letters requiring repayment of any outstanding balance, subject to an interest rate of four percent.

Guidance is also provided on how to request an Extended Repayment Schedule (ERS) for providers and suppliers who are experiencing financial hardships.  An ERS is a debt installment payment plan that allows a provider or supplier to pay debts over the course of three years or up to five years in the case of extreme hardship.  Providers and suppliers are encouraged to contact their Medicare Administrative Contractor (MAC) for information on how to request an ERS. 

CLICK HERE to read the full press release from CMS.

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.