key: cord-1002807-xm4f2y8c authors: Bonner, Alice title: Hope Springs Eternal: Can Project ECHO Transform Nursing Homes? date: 2020-12-27 journal: J Am Med Dir Assoc DOI: 10.1016/j.jamda.2020.12.023 sha: 90a0d655c2a14ed001c60098bc872be0da3ce0fe doc_id: 1002807 cord_uid: xm4f2y8c nan There have been more than 100,000 deaths in US nursing homes attributed to COVID-19, accounting for 40% of COVID-19 deaths across the country. 1 In addition, staff turnover has increased dramatically, as many workers are afraid of becoming sick or bringing the virus home to family members, or they are simply exhausted and unable to maintain the pace required to care for so many severely ill residents. 2 Suddenly, nursing homes have been thrust into the national spotlight. Although this is not the first time advocates and others have issued an urgent call to action for nursing home reform (some readers may have worked on the Omnibus Budget and Reconciliation Act of 1987 3 or other initiatives), there may now be enough momentum and collective voice to have sustainable impact, starting with changes to infection prevention and control policies and staffing as a result of COVID-19. Researchers, care providers, and other stakeholders have written books and journal articles over the past few decades that describe poor quality and unfortunate nursing home experiences in detail. Critical issues persist, however, such as those outlined in Office of the Inspector General (OIG) investigations, 4 the 2010 Senate Commission on Aging Report, 5 and more recently the 2020 Coronavirus Commission on Safety and Quality in Nursing Homes. 6 These issues continue to exist despite years of research and compelling evidence that we are failing to adequately support and empower one another as we age. In many regions, nursing homes remain that "house on the hill," away from the center of town and a place that few people want to visit. We have not created a true "system of care." We continue to be siloed in our approach to health and social servicesdpeople working in home and community-based programs or hospitals do not know what goes on in nursing homes, and vice versa. We are not listening to the voices of older adults and their care partners, who repeatedly tell us that they do not want to live in a place where rigid schedules, high risk of infections and other adverse events drive daily routines, and hours drag on with very little happening each day. In response to the 2020 COVID-19 pandemic, the Agency for Healthcare Research and Quality (AHRQ) ECHO National Nursing Home COVID-19 Action Network (NNHCAN) was funded through the CARES Act as a partnership between AHRQ, the University of New Mexico's ECHO Institute, and the Institute for Healthcare Improvement. 7 NNHCAN provides free education, guidance, and collaboration so that nursing homes may implement evidence-based programs and services to promote quality improvement and to prevent and manage COVID-19 outbreaks in their communities and on their campuses. Groups of about 35 nursing homes work with training centers (hospitals, health systems, or academic health sciences centers) that lead weekly virtual meetings for 16 weeks. Topics include infection prevention and management, inter-professional team relationships and support, emotional and psychological impact of the pandemic on residents, care partners and staff, and quality improvement. The article by Lingum and colleagues in this month's JAMDA outlines a number of positive aspects of education and staff support provided in the ECHO model. 8 The authors describe how ECHO uses an "All TeacheAll Learn" approach, designed to avoid hierarchy and any sense that local or national experts are telling nursing homes what to do, or how to practice. Project ECHO is a multidirectional, mutually supportive approach to sharing information among nursing homes and training centers, describing best or better practices and how to address challenges and take advantage of opportunities. By designing a 16-week curriculum with 1 virtual session each week, faculty are given flexibility to tailor content and the order of presentations within the curriculum to best meet the needs of each nursing home. Although it is too soon to draw conclusions about the current NNHCAN, there are some learnings that we can report already. Those of us who were initially skeptical did not believe that half of the nursing homes in the United States (more than 7200) could be recruited and would consistently meet participation criteria (2 or more staff members attending at least 13 of the 16 sessions). Professional associations such as AMDAeThe Society for Post-Acute and Long-Term Care Medicine, LeadingAge, and AHCA (The American Health Care Association) encouraged members to consider joining Project ECHO, and nursing home leaders signed up in numbers far exceeding NNHCAN's expectations. In recruiting nursing homes, many representatives said that sessions lasting 90 minutes (the original plan) was "too long" for staff to be away from residents. Therefore, Project ECHO changed the format The ideas and opinions expressed in this editorial are those of the author and do not necessarily represent the viewpoints of the Agency for Healthcare Research and Quality (AHRQ), Project ECHO, or the Institute for Healthcare Improvement (IHI). The author declares no conflicts of interest. to 60 minutes (required) and then 30 minutes (optional) each week. This strategy enables nursing homes to have an "office hours" type arrangement, so that homes with specific issues or questions can remain on the line with local faculty and quality coaches, and other nursing homes may leave the call after the first hour. This ability to target the program to the needs of each nursing home, and to promote a sense of individual attention as well as group learning, has generated positive feedback from participants and faculty leaders. It also enables nursing home teams or individual members to express psychological or emotional aspects of their work or personal lives, to describe ways in which they have approached some of the stress, burden, and social isolation that have become part of life with COVID-19. Project ECHO and QAPI (Quality Assurance Performance Improvement) The COVID-19 pandemic revealed an absence of QAPI practices in many nursing homes, despite regulations promulgated in 2010 that require each nursing home to have a comprehensive QAPI strategic plan. Because the concept of QAPI is not familiar to some organizations or nursing home surveyors, QAPI is often not cited as a deficiency even when absent on annual inspection surveys. COVID-19 provides an opportunity to strengthen quality improvement systems across nursing homesdbut it needs to be emphasized. This is one reason why Project ECHO may be more effective than previous effortsdit weaves QAPI throughout the entire curriculum and builds on what nursing homes are already doing to focus on systems that support resident goals and preferences, and promote quality of life and quality of care. Project ECHO also builds in time for open and honest discussion and brainstorming among nursing home and training center staff. Project ECHO creates data that can be compared across nursing homes and states using the iECHO technology platform. Training centers collect standardized information about program participants, attendance, and sessions. All data are entered into a centralized, Webbased data system called iECHO. These data are aggregated and combined with other data sources to allow Project ECHO to track and report individual site and national data. In order to provide meaningful changes to the typical nursing home lifestyle, we must figure out how to measure what is truly important (what matters) to residents and staff members; these data may or may not be captured in the Minimum Data Set (MDS), the Centers for Medicare & Medicaid Services (CMS) Five Star Quality Rating System, or other current data sets. We cannot continue to measure what we have available merely because it is easy to do so. We must measure what truly matters and use those data to drive national and state policy. Historically, academic health science centers and large health systems have not always been closely connected with nursing homes and other post-acute and long-term care organizations. Project ECHO creates a model that promotes and strengthens those relationships, even when they did not previously exist. Having a solid understanding of what nursing homes can and cannot do is vital to making decisions about resident transfers or care in the place where they live. Old beliefs can be hard to change; we need to reflect the actual, objective characteristics of today's nursing homes. A recent JAMDA article presented such a collaborative model and may be a helpful resource. 9 Project ECHO recognizes the skills, knowledge, and experience of nursing home teams and has helped to defray some of the negative impact of media pieces that "blame" nursing homes for outcomes such as resident and staff deaths and hospitalizations resulting from the rapid spread of COVID-19. Although hospital workers are often hailed as "health care heroes," nursing home staff are rarely recognized as such. Nursing home leaders, many of whom also work at the point of care, must be recognized for the long hours and dedication that they bring to this work. We have tolerated workforce weaknesses for decades. Low wages and minimal benefits, limited hours, absence of career ladders and lattices, and a lack of supervision are frequently cited by certified nursing assistants as factors that increase their intent to leave. Programs like Project ECHO have content focused on staff well-being and how to mitigate the stress and trauma that the pandemic has created for workers. Project ECHO builds a peer network and professional support among participating nursing homes. What can each of us continue or start doing tomorrow? Here are 3 ideas: 1. Become a nursing home advocate and speak publicly about morbidity and mortality from COVID-19 in nursing homes. We need stronger nursing home advocates, and we need more of them now. 2. Reach out to municipal and state leaders to talk about COVID-19 in nursing homes. Tell them what we believe to be true, and what the top 2 to 3 priorities are that we must address immediately. 3. Determine if a statewide effort to connect individuals looking for work with nursing homes seeking direct care and other workers can be implemented more consistently and reliably and rapidly scaled across states. There is currently no logical, comprehensive system of care for older adults. It is time to listen to what matters to nursing home residents, and how we can change the model of nursing home care to deliver what people say they want as they agedthoughtful, caring, smart, and knowledgeable teams that respect and value how residents wish to direct their own care. Right now, that includes nursing home teams that know how to prevent the spread of COVID-19, how to manage COVID-19 cases, communicate with residents and care partners, and how to keep nursing homes as a vital and integral part of our communities. We must continue to advocate for state, federal, and other funding to support nursing home teams and meet the care needs of residents. Although the focus right now may be on COVID-19 infection prevention and management, the principles that we are learning to apply can lead to broader, sustainable systems that will better support all of us as we age. We must work together for change now. Large numbers of nursing home residents and staff are dying from COVID-19 infections. The Project ECHO model has promise and may support large-scale transformationdnot just in nursing homes, but across health systems and community settings. We must create a sustainable continuum of care and services. Sodwhat will each of us start doing tomorrow? 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 COVID-19: Long-term care facilities COVID-19 intensifies nursing home workforce challenges Thirty-year trends in nursing home composition and quality since the passage of the Omnibus Reconciliation Act Adverse events in skilled nursing facilities: national incidence among Medicare beneficiaries Nursing homes: Some improvement seen in understatement of serious deficiencies, but implications for the longer-term trend are unclear Coronavirus Commission for Safety and Quality in Nursing Homes: Commission Final Report Nursing Home COVID-19 Action Network. Content last reviewed Building long-term care staff capacity during COVID-19 through just-in-time learning: evaluation of a modified ECHO model COVID-19 collaborative model for an academic hospital and long-term care facilities