CMS Provides Updated Guidance for Use of Waivers

CMS has updated its guidance and provided specific instructions for using the Qualified Hospital Stay (QHS) and benefit period waivers, as well as how this affects claims processing and SNF patient assessments.

  • To bill for the QHS waiver, include the DR condition code. 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 ALL admissions under the benefit period waiver (within the same spell of illness):
    • Complete a 5-day PPS Assessment. (The interrupted stay policy does not apply.)
    • Follow all SNF Patient-Driven Payment Model (PDPM) assessment rules.
    • Include the HIPPS code derived from the new 5-day assessment on the claim.
    • The variable per diem schedule begins from Day 1.
  • For ALL SNF benefit period waiver claims (within the same spell of illness), include the following:
    • Condition code DR – identifies the claims as related to the PHE
    • Condition code 57 (readmission) – this will bypass edits related to the 3-day stay being within 30 days
    • COVID 100 in the remarks – this identifies the claims as a benefit period waiver request

Note: Providers may utilize the additional 100 SNF benefit days at any time within the same spell of illness.

Claims are not required to contain the above coding for ALL benefit period waiver claims.

Example: If a benefit waiver claim was paid utilizing 70 of the additional SNF benefit days and the beneficiary either was discharged or fell below a skilled level of care for 20 days, the beneficiary may subsequently utilize the remaining 30 additional SNF benefit days as along as the resumption of SNF care occurs within 60 days (that is, within the same spell of illness).

Additional instructions can be found in the article if you previously submitted a claim for a one-time benefit period waiver that rejected for exhausted benefits.

CLICK HERE to view the MLN Matters article.

CLICK HERE for the updated list of blanket waivers available.

CMS to retire the original Compare Tools on December 1

Use Medicare.gov’s Care Compare to find and compare health care providers.

In early September, the Centers for Medicare & Medicaid Services (CMS) released Care Compare on Medicare.gov, which streamlines the eight original health care compare tools. The eight original compare tools – like Nursing Home Compare, Hospital Compare, Physician Compare – will be retired on December 1st. CMS urges consumers and providers to:

  • Use Care Compare on Medicare.gov and encourage people with Medicare and their caregivers to start using it, too. Go to Medicare.gov and choose “Find care”.
  • Update any links to the eight original care tools on your public-facing websites so they’ll direct your audiences to Care Compare.

With just one click on Care Compare, easy-to-understand information about nursing homes, hospitals, doctors, and other health care providers is available.

Information about health care providers and CMS quality data will be available on Care Compare, as well as via download from CMS publicly reported data from the Provider Data Catalog on CMS.gov.


Direct links to the tools & additional resources

Care Compare on Medicare.govhttps://www.medicare.gov/care-compare/

Provider Data Catalog on CMS.govhttps://data.cms.gov/provider-data/

Care Compare resources for consumers and partners – Medicare blog, Promotional video, Conference card  

Full Press Release: https://www.cms.gov/newsroom/press-releases/cms-care-compare-empowers-patients-when-making-important-health-care-decisions

Triumphs During Trying Times

The holiday brings with it an important time of reflection. As we gather around our proverbial table with you as part of our Reliant family, we pause to remind ourselves that despite the profuse and unique challenges of 2020, there were numerous successes for which to be grateful. While the list of obstacles at times seemed insurmountable, we continued to be a light to our patients – constantly adapting, advocating, evolving, leaning on our interdisciplinary team members, and showing up despite unsettling moments, and at times, heartbreaking losses.

Essential staff have risen as infection control heroes. We protected our residents, ourselves, and our loved ones through diligent processes as vigilance became a top priority. We met these challenges by solidifying our knowledge of infection prevention and control, provision of care for those in isolation, and proper use of personal protective equipment. The procedures and protocols developed this year will, no doubt, continue to ensure everyone’s safety in the long run.

Isolation and quarantine became a daily reality in an attempt to prevent and mitigate infection spread. Reliant clinicians continue to combat this by brainstorming and executing some impressive, heart-warming, therapeutic activities that provide much needed social interactions, safely. For example, our Sterling Oaks Rehab team built an actual lemonade stand to help the residents celebrate the end of summer, Northern Nevada Veterans Home created a resident carnival for their patients, and there were many more examples. They also incorporated daily care needs into their skilled treatment sessions to assist nursing staff. Countless other interdisciplinary teams facilitated “visits” through video calls or even through windows with patients and their families during quarantine.

This year, thousands of long-term care providers and therapists banded together to make their voices heard. Our respective, discipline-specific associations and The National Association for the Support of Long Term Care (NASL) enabled a multitude of health care providers to voice their concerns creating a powerful advocacy force and gateway to facilitate action. Advocacy measures impacted bipartisan legislation to continue to fight against cuts that would affect service provision for those who need it the most, proving that advocacy does matter!

As vaccine and treatment options appear imminent, even on the cusp of again increasing cases, we can go forward with knowledge, confidence, and determination to continue to protect and fight for our residents.  So this year, as we sit around our “Reliant table” and share feelings of gratitude with and for one another, despite having to hold each other’s gloved hands and speak through masks, we hope you feel and sense accomplishment and gratitude, and that you are smiling under those masks, knowing that we stood together on the precipice of the unknown and found resilience, meeting daily demands with continued hope beyond the present circumstances. 

The Top 7 Health Benefits of Gratitude

It’s been said that the two most powerful words in the English language are “Thank You.” But did you know that adopting an attitude of gratitude also can have a tangible, positive impact on your health? Here are some ways being grateful can boost your spirit and contribute to your overall quality of life.

  1. Lower Blood Pressure. In a 2007 study, researchers found that people were instructed to “count their blessings” once a week showed a significant decrease in their systolic blood pressure.
  2. Lower Risk of Depression. According to Sanam Hafeez, M.D., gratitude reminds us that not everything in our lives is bad and can give us motivation and a sense of hope that can protect us from feelings of depression.
  3. Better Sleep. In a research project of 65 people with chronic pain, those who were assigned a daily gratitude journal assignment reported a half an hour more sleep than those who were not. In other studies, the discipline of gratitude has caused people to report a faster time to sleep, improved sleep quality and more alertness during the day.
  4. Reduces Stress. Because gratitude activates the parasympathetic nervous system, it can stave off stress which has very well-known destructive health implications.
  5. Increased Energy. Multiple studies have correlated vitality and gratitude, and because gratitude increases physical and mental well-being, it can lead to increased energy levels.
  6. Improved Self Care. Grateful people are more likely to exercise and take care of their health according to a 2012 study. They are more likely to have regular check-ups and take precautions to improve their health.
  7. Boost Mental Strength. For people who have experienced traumatic events, gratitude has been shown to help buffer the long-term impact of that trauma and can lead to much greater resilience.

Celebrating a Diabetic-Friendly Thanksgiving

November is American Diabetes Month, and this week, we may have an opportunity to see loved ones either in person or virtually to celebrate the Thanksgiving holiday. We’ve put together a few diabetic-friendly Thanksgiving recipes in a downloadable cookbook that you can use this week for you.

While many patients and residents may have a clinical diagnosis for Type II Diabetes, there are some clinical presentation characteristics that can help us identify those who may be undiagnosed.

•          Increased thirst

•          Frequent urination

•          Extreme hunger

•          Blurred vision

•          Fatigue

•          Unexplained weight loss

•          Slow-healing sores

•          Tingling, burning, or numbness in feet and hands

•          Pain in joints or muscles

•          Frequent infections

•          Diabetic ketoacidosis

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)

Care Matters Spotlight October 2020

Mr. Borden admitted to Holzer Senior Care Center with the ultimate goal of returning home with his wife. Upon admission, Mr. Borden required the use of a feeding tube for nutrition and a mechanical lift to complete transfers. At first, returning home with his wife seemed like a lofty task due to the amount of assistance Mr. Borden needed.  He soon became unmotivated and thought this goal was impossible due to apparently insurmountable tasks.  Both he and his wife thought that he would be staying at the facility forever.

In the midst of this, Mr. Borden had a brief readmittance to the hospital and then returned to Holzer Senior Care Center with a new outlook and motivation.  After putting his all into and excelling in an aggressive therapy program tailored to meet his needs, Mr. Borden began eating regular food and was able to walk out of Holzer Senior Care following his intensive program.  What a great testament not only to Mr. Borden, but also to the excellent therapists and staff at Holzer Senior Care Center!

Mr. Borden’s ultimate goal was met; he was able to return home with his wife. Mr. Borden is pictured here, with his PT and OT, heading to embrace his wife after months of being separated from each other.  The staff, Mr. Borden, and his wife had a “going home” parade and sang “O Happy Day” as Mr. Borden walked to the car.  Needless to say, it was an emotional day for everyone as the Bordens hugged each other for the first time in 4 long months!

Great job Mr. Borden and awesome job, team!

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.

PHI Breaches and Breach Reporting

What is a breach of Protected Health Information (PHI)?  A breach means the impermissible acquisition, access, use, or disclosure of PHI as defined under the Health Information Portability and Accountability Act (HIPAA) Privacy Rule that compromises the security or privacy of PHI.

Whenever a breach of PHI occurs, the residents impacted must be notified along with the secretary of the United States Department of Health and Human Services (HHS).  Residents must be notified as soon as possible but no later than 60 days from discovery of the breach.  This notification deadline to the Secretary of HHS varies depending on the number of residents impacted.  If less than 500 residents are impacted, the deadline for notification to the Secretary is 60 days after the end of the calendar year in which the breach occurred.  If 500 or more residents are impacted, the deadline for notification to the Secretary is no later than 60 days from the discovery of the breach. 

Covered entities are required to report breaches to the Office of Civil Rights Breach reporting portal. The United States Department of Health and Human Services, in accordance with section 13402(e)(4) of the Health Information Technology for Economic and Clinical Health Act (HITECH), posts online a list of breaches impacting 500 or more individuals.  This breach portal is unofficially labeled the “Wall of Shame”.  CLICK HERE to visit the portal.

Interrupted Stay Policy

Under the Patient-Driven Payment Model (PDPM), there is a potential incentive for providers to discharge skilled nursing facility (SNF) patients from a covered Part A stay then readmit the patient in order to reset the variable per diem schedule. To mitigate this potential incentive, an interrupted stay policy is included within the PDPM. 

This policy combines multiple SNF stays into one single episode in situations where the patient’s discharge and readmission occur within a prescribed window. If a patient is discharged from a SNF and readmitted to the same SNF no more than three consecutive calendar days after discharge, then the subsequent stay is considered a continuation of the previous stay.  In this instance, the variable per diem schedule continues from the point just prior to discharge.

If the patient is discharged from a SNF and then readmitted more than three consecutive calendar days after discharge or admitted to a different SNF, then the subsequent stay is considered a new stay.  In this instance, the variable per diem schedule resets to day one.

CLICK HERE for more information in the PEPPER User’s Guide Update.

CMS Memo on the Resident’s Right to Vote

The Centers for Medicare & Medicaid Services (CMS) released a memo reiterating the continued right of nursing home residents to exercise their right to vote. While the COVID-19 Public Health Emergency has resulted in limitations for visitors to enter the facility to assist residents, nursing homes must still ensure residents are able to exercise their Constitutional right to vote.  A resident’s rights, including the right to vote, must not be impeded in any way by the nursing home staff. 

Nursing home personnel should have a plan to ensure residents can exercise their right to vote, whether in person, by mail, absentee, or other authorized process. For residents who are otherwise unable to cast their ballots in person, nursing home staff must ensure residents have the right to receive and send their ballots via the U.S. Postal Service or other authorized mechanism allowed by the State or locality.

CLICK HERE to read the full memo from CMS.

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 Posts Updated PDPM Grouper

The Centers for Medicare & Medicaid Services (CMS) posted an updated PDPM Grouper DLL v1.0007 to the MDS 3.0 Technical Information webpage.

CMS indicates that six ICD-10 codes were “inadvertently excluded from the NTA calculation.” The ICD-10 codes include: T8484XA, T8389XA, T8321XA, T82399A, T82392A and T83021A.

The PDPM Grouper DLL v1.0007 package notes that PDPM can be used for OBRA assessments where A0310A =[01,02,03,04,05,06] and A0310B = [99] as determined by each state. CMS also notes that FY2021 ICD-10 codes must be used for I0020B in these assessments as well as for the I8000A-J items in MDS assessments with a target date on or after October 1, 2020.
 

CLICK HERE to access the zip file.

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