key: cord-0682544-viz37rzv
authors: Archbald-Pannone, Laurie R.; Harris, Drew A.; Albero, Kimberly; Steele, Rebecca L.; Pannone, Aaron F.; Mutter, Justin B.
title: COVID-19 collaborative model for an academic hospital and long-term care facilities
date: 2020-05-25
journal: J Am Med Dir Assoc
DOI: 10.1016/j.jamda.2020.05.044
sha: 81be24edeef5fa10ede6281a61e5612a06461c76
doc_id: 682544
cord_uid: viz37rzv

Abstract The COVID-19 pandemic is devastating post-acute and long-term care (PA/LTC). As geriatricians practicing in PA/LTC and a regional academic medical center, we created this program for collaboration between academic medical centers and regional PA/LTC facilities. The mission of the geriatric engagement and resource integration in post-acute and long-term care facilities (GERI-PaL) program is to support optimal care of residents in PA/LTC facilities during the COVID-19 pandemic. There are 5 main components of our program: (1) Project ECHO; (2) Nursing liaisons; (3) Infection advisory consultation; (4) Telemedicine consultation; and (5) Resident social contact remote connections. Implementation of this program has had positive response from our local PA/LTC facilities. A key component of our program is our inter-professional team, which includes physicians, nursing, emergency response, and public health experts. With diverse professional backgrounds, our team have created a new model for academic medical centers to collaborate with local PA/LTC facilities.

The GERI-PaL arms are detailed in the Figure. The prevention arm cultivates dialogue among an inter-23 professional academic clinical team (Geriatrics, Pulmonary, and Nursing), local government agencies 24 including our local health department and emergency management, and local organizations related to 25 prevention and treatment of COVID-19 in patients in PA/TLC facilities. The program includes the 26 following components: a daily community collaborative rounds ("Project ECHO COVID-19 in Nursing 27

Homes"); nursing liaisons; infection advisory consultation; telemedicine consultation; and resident 28 phone calls to provide social contact remote connections (Table 1 ). 9 29

The response arm includes all components of prevention, as well as targeted rapid response as detailed 30

in Table 2 . These include an expansion of nursing liaisons and rapid implementation of telemedicine 31 consult service with daily clinical rounds and team huddle. The response arm is activated for facilities 32 experiencing an outbreak, in need of point-prevalence survey, or deemed high-risk (through self-33 identification or determined by local health department). The response team assesses facility needs to 34 determine the best path for collaboration within 24 hours. The GERI-PaL team is available to assist the 35 facility care team with daily discussions with stakeholders including facility clinical staff, facility 36 administration, and corporate leadership, and to provide clinical consultative care. In these daily 37 huddles, the team also assesses staffing and personal protective equipment (PPE) to ensure appropriate 38 staffing to facilitate hospital transfers, on-site care, and can connect facility with local PPE resources as 39

Implementation 41 GERI-PaL began on March 13, 2020 with facility-based Infection Advisory Consultation meetings. These 42 meetings were quickly transitioned to web-based teleconferencing as the pandemic threat emerged. We 43 met individually with 8 local facilities-to provide general guidance on infection control policies, as 44 recommended by AMDA, CDC, and CMS. 10-12 The GERI-PaL team listened to facility-specific infection 45 control concerns, staffing concerns, cohorting concerns, and challenges with ordering PPE from their control practitioner, medical director, and all facility licensed independent practitioner (LIP), while other 48 meetings were attended by only a facility medical director or LIP. 49

Parallel to these meetings, on March 16th 2020, a "telementoring" series was rapidly instituted using 50 the Project ECHO model which leverages learning, training, and practice support to build a 51 collaborations for health professionals. 13, 14 The Project ECHO team included a nurse practitioner, 52 geriatrician, pulmonologist, clinical nurse leader, and nurse educator. The goal of the virtual meetings 53 was to connect long-term care facility administrators and directors of nursing to assess facility needs for 54 COVID-19 preparedness. In the response arm, we provided updated COVID-19 information, testing and 55 treatment guidelines, and best practices in infection control. Participants in Project ECHO sessions 56 shared their experiences and sought input from a network of peers and insight from experts on 57 managing COVID-19 positive patients in the PA/LTC setting. Other frequent community participants 58 include local county fire and rescue representation and regional long-term care ombudsman. These 59 sessions were daily focused discussions and needs assessments regarding clinical information, PPE 60 preparedness and infection control, as well as education based discussions. Four days a week this 61 program was driven by facility needs (in a question and answer format similar to academic office hours). 62

One session each week the program was a more formal didactic session given by an academic content 63 expert on a topic of interest determined by the group. 64

From the relationships established via Project ECHO, academic nursing educators actively cultivated 65 relationships with local PA/LTC nursing leaders to determine facility needs for assistance with PPE, 66 improve care coordination between inpatient medical teams and facilities, and provide support to 67 optimize telemedicine consultation processes. 68

In addition, a facility telemedicine consult service was established to provide academic pulmonary/ 69 critical care clinical support and recommendations for testing/monitoring/treatment-in-place and to 70 communicates with a hospital medical communications center to directly admit acute patients, as well 72 as to ensure key aspects of care coordination, such as transfer of accurate medication lists, code status 73 documentation, and demographic information faxed to centralized number for ease of facility-based 74

staff. An allied geriatric consultation service, including Geriatric and Palliative care specialists, provides a 75 parallel telemedicine consult service that supports complex medical conditions, goals of care 76 discussions, and assistance with comfort care treatment when needed. 77

Through this program, our academic medical center is providing support for local facilities and staff and 78 increasing collaboration and communication with local health departments and other agencies. We also 79 paired local medical student volunteers with facility residents for phone calls to connect socially and 80 help combat social isolation. 81

Evaluation 82

For our Project ECHO daily discussions, our nurse liaison invited all 28 of our local facilities, as well as an 83 additional 49 regional facilities. We connected with up to 25 facilities each week for needs assessment 84 and education. Table 1 provides outcomes information and lessons learned for each of the prevention 85 components as related to feasibility and adoption. Due to our collaboration with local emergency 86 management and health department, we focused these discussion based on these localities instead of 87 the large catchment area of our hospital. Of the local facilities with initial COVID-19 infection, 2 of the 3 88 facilities had participated in our prevention program and none of these facilities had sustained 89 transmission or outbreak. The response outcomes and feasibility are listed in Table 2 

Severe Outcomes Among Patients with Coronavirus Disease 2019 (COVID-19) -United States

COVID-19 in a Long-Term Care Facility -King County

DOI

Infections in Residents of a Long-Term Care Skilled Nursing Facility

DOI

They're Death Pits': Virus Claims at Least 7,000 Lives

The New York Times

Epidemiology of Covid-19 in a Long-Term Care Facility in King County

Long-Term Care Facilities and the Coronavirus Epidemic: Practical Guidelines 131 for a Population at Highest Risk

State Reporting of Cases and Deaths Due to COVID-19 in Long-Term Care