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The United States is taking lessons from the COVID-19 pandemic. Among those is what may work best for elder care.

Statewide in Missouri, all hands were on deck to find best practices as the pandemic deepened during 2020.

Public health workers felt like they had a grasp of what it would take to get through a pandemic early in the year.

That was before the COVID-19 pandemic broke out in February.

Most plans centered around a 30- to 60-day crisis, said Steve Bollin, Missouri Department of Health and Senior Services director of licensing and regulation.

Bollin, who had been in emergency management for communities for 15 years before arriving at licensing and regulation in October, said the 2014 U.S. Ebola outbreak strengthened confidence a pandemic could be contained in a short period of time.

Ebola was first detected in the United States on Sept. 30, 2014, when a man who traveled to West Africa came down with the disease in Dallas. He died Oct. 8, 2014. Two health care workers who treated him tested positive for the disease. On Oct. 23, 2014, a medical aid who volunteered in Guinea was hospitalized in New York with the disease. Seven other people exposed to the disease in West Africa came down with it and were treated in the United States. However, strict prevention and control practices prevented it from spreading more, and the disease was contained within about 30 days.

“Pandemic was one area where you just never knew how long things were going to last,” Bollin said. “I think (COVID-19) went much farther — technically we’re still in it — but it went much farther than anybody anticipated.”

Questions arose every day. One day, the answer was “no.” The next day, the answer for the same question was “yes,” he said. It could be “no” the following day.

“Things were changing so fast — it was literally a day-to-day-to-day situation … from April 2020 through December,” he said. “When the vaccines started showing up was really when we felt that we had turned a corner — and really started to make some progress.”

That was when things started turning around in nursing homes as well.

The Commonwealth Fund, which supports independent research on health care issues and provides grants to promote better access and health outcomes, looked at challenges to improving nursing home residents’ outcomes and experiences following the pandemic.

Nursing homes were already in crisis before the pandemic, according to the Commonwealth Fund report, “Strengthening Nursing Home Policy for the Post-pandemic World: How Can We Improve Residents’ Health Outcomes and Experiences?”

Many nursing facilities faced low quality of care, a broken payment model, ineffective regulation and a lack of transparency for patients’ outcomes, according to the report.

Residents are primarily Medicare or Medicaid beneficiaries, according to the report. While Medicare is “generous” as a payer, the report says, Medicaid oftentimes pays below the cost needed to care for individuals. So many facilities rely on admittance of enough short-term Medicare patients to “cross-subsidize” longer-term Medicaid patients.

And low wages prevent nursing facilities from being able to hire and retain qualified care givers.

To align costs, the report suggests the federal government contribute more to Medicaid so the program can pay higher rates to meet costs of long-term care. The report encourages policies that require more on-site clinicians. And it suggests raising wages for caregivers.

Another challenge to overcome is provision of enough nurses and nurse aides to meet residents’ needs.

Data show, as of Friday, according to the Centers for Medicare and Medicaid Services, there had been 655,623 cases of COVID-19 in patients in nursing homes nationwide, with 132,703 deaths. Additionally, 584,596 staff members at homes had been diagnosed with COVID-19 and 1,934 had died.

We still have a long way to go before the pandemic is over, but over the past few months there have been reassuring signs of a return to something that resembles pre-pandemic normal, officials said.

COVID-19 in nursing homes has made for a challenging year for state health officials, said Shelly Williamson, administrator for the DHSS section for long-term care regulation.

“We’ve done a lot of work with homes — supporting them with their outbreaks,” Williamson said. “Just making sure they’ve got all their resources and everything they needed.”

Her section offers the guidance nursing facilities need to manage their outbreaks.

That’s been its primary focus over the last year, she continued, but it has been able to continue some of its normal activities, such as conducting inspections and investigations at nursing homes, she said.

The state didn’t have a good plan for the pandemic before it struck, but each pandemic is different, so it would have been near impossible to anticipate each correct mitigation step, Bollin said.

Nursing homes have to report to the section when they have COVID-19 outbreaks (one case is an outbreak), Williamson said. Once that occurred, the section contacted the facilities and assisted them with testing and with how to order personal protective equipment. It made certain administrators understood the guidelines for quarantine, and isolation and “cohorting” — separating people who have tested positive for the virus from others in the homes.

And it tried to make sure facilities had sufficient staffing.

“Just providing them with different information and resources so they could best manage that outbreak,” she said.

Missouri even contracted with a national temporary staffing agency to assure it always had a resource for nurses, registered nurses, therapists and even housekeepers, Bollin said.

So the state worked with facilities to optimize the staff they had.

Staffing was an issue before the pandemic for a lot of the facilities, he said.

“Nursing has been a challenge for a number of years in hospitals and long-term care facilities. So this was an ongoing conversation,” he said.

The state used Coronavirus Aid, Relief, and Economic Security Act funding to provide some support for hospitals, which were running at 110 percent capacity and trying to manage COVID-19 patients.

The other side of the coin, Bollin said, was that long-term care facilities were viewed as safety-relief valves to get patients who required a lower level of care out of hospitals, making room for more COVID-19 patients.

Lesson number one, Bollin said, is to continue planning and keep working on the pandemic, and wait for the next issue to occur. Nursing homes were a good place to send patients, creating capacity in hospitals.

But they had to have more staffing. And officials had to transport patients.

“We actually developed a map that showed where hospitals are and where long-term care facilities are around them, so that they could relocate patients where appropriate, fairly close to where their families were,” he said. “So, if their families wanted to go see their loved ones, they didn’t have to drive five hours to do that.”

That doesn’t mean there weren’t patients whom hospitals transported four or five hours away because there was just nowhere else for them to go. That did occur.

“We learned a lot about case management in a crisis situation like this that is going to help us in our future endeavors,” Bollin said. “We also made a lot of transitions and improved a lot of our processes and made ourselves more efficient. Most importantly, we learned that we have got to partner better intra-departmentally, from department-to-department-to-department across the state. We also need to be much closer with our local health care partner agencies — the local providers that are out there.

“Because it is truly an all-hands-on-deck situation.”

In its report, “Reimagining Nursing Homes in the Wake of COVID-19,” the National Academy of Medicine finds opportunities for improvements to the facilities.

It calls for the physical layout and operations to allow for more patient isolation, social distancing and reductions in cycling of staff members.

The report calls for people with “matching” needs be located in similar care sites — putting hospice care patients with similar patients or placing relatively healthy patients who have “pure memory impairment” in “memory centers,” designed to manage their specific needs.

It suggests long-stay patients with multiple co-morbitities could be better served in smaller facilities, such as Green Houses, which offer home-like care environments and are limited to only 18 beds, where each resident has a private bedroom and bathroom.

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