key: cord-1004365-13sr3wey
authors: Mills, William R.; Buccola, Janet M.; Sender, Susan; Lichtefeld, Joseph; Romano, Nicholas; Reynolds, Karen; Price, Melissa; Phipps, Jennifer; White, Leigh; Howard, DHA Shauen
title: Home-Based Primary Care Led-Outbreak Mitigation in Assisted Living Facilities in the First One Hundred Days of COVID-19
date: 2020-06-11
journal: J Am Med Dir Assoc
DOI: 10.1016/j.jamda.2020.06.014
sha: 08ce3e4795ed95891d91a4569cbc23ce588c9c79
doc_id: 1004365
cord_uid: 13sr3wey

Abstract Residents of congregate care settings have been severely impacted by the current COVID-19 pandemic. In this report, we describe the methods our home-based primary care (HBPC) practice has developed to mitigate the spread of COVID-19 in assisted living facilities (ALFs) and we present an initial evaluation of this innovation. Shortly after the first COVID-19 case was reported in the U.S., our organization assembled an outbreak committee, designed to support the 1,794 ALF residents and the 101 communities in which they reside. The committee led the development and deployment of a comprehensive COVID-19 prevention and suppression strategy. The average age of the cohort was 83 + 11 years and 74% were female. Seven individuals (0.4% of census) tested positive for SARS-CoV-2. The positive individuals were located in three ALFs, representing 3% of our total number of ALFs. There has been one death. HBPC-led outbreak mitigation may be an enabler to suppress COVID-19 in ALFs.

Residents of congregate care settings have been severely impacted by the current 2 COVID-19 pandemic. In this report, we describe the methods our home-based primary care 3 (HBPC) practice has developed to mitigate the spread of COVID-19 in assisted living facilities 4 (ALFs) and we present an initial evaluation of this innovation. Shortly after the first COVID-19 5 case was reported in the U.S., our organization assembled an outbreak committee, designed to 6 support the 1,794 ALF residents and the 101 communities in which they reside. The committee 7 led the development and deployment of a comprehensive COVID-19 prevention and 8 suppression strategy. The average age of the cohort was 83 + 11 years and 74% were female. 9

Seven individuals (0.4% of census) tested positive for SARS-CoV-2. The positive individuals were 10 located in three ALFs, representing 3% of our total number of ALFs. There has been one death. 11 HBPC-led outbreak mitigation may be an enabler to suppress COVID-19 in ALFs. and suppression strategy, with a primary objective of protecting our patients and the communities in which they live. In this report, we describe the methods our organization has 23 developed to mitigate the spread of COVID-19 in ALFs and we present an initial evaluation of 24 this innovation. 25

The ALFs in which our group provided care are owned by a variety of entities, including 27 sole or family owners of a single home, local chains, regional operators and national ALF 28 organizations. Of the approximately 5,000 residents in these 101 facilities, our group's average 29 penetrance rate (practice census / total census) is 60% in mature facilities (ALFs where we have 30 had a presence for one year or greater). However, in facilities where we more recently started 31 serving the ALF, we only provided care for a few patients at the time of this study. The ALF 32 residents in all facilities maintained provider choice, and each ALF typically has a mix of 33 providers who provide medical care for its residents. Some residents go out to office-based 34 practitioners, and some are served by our group, as well as by other visiting practitioners. In 35 buildings where we have a significant percentage of the census, the ALF leadership typically 36 utilizes our group for assistance with care policies, staff education, seminars and medical 37 oversight. Our practice's model is to provide on-site access to care for ALF residents by having 38 a practitioner visit once or twice per week, depending on census. These resources are available at: https://www.brightspringhealth.com/covid19/. We made all 65 COVID-19 materials available to all ALF partners, and we provided both formal and informal education and ongoing COVID-19 mitigation guidance throughout the study period. No specific 67 ALF approval was needed for our group to provide this freely accessible resources. 68

In order to prevent employees from coming to work sick, we developed a cloud-based, 69 mobile-enabled, symptom-screening application. For self-screening, all employees were asked 70 to record their temperature daily and answer simple screening questions using the mobile app. 71

Symptomatic employees were isolated at home, and tested for COVID-19 where testing was 72 available. We isolated the employee at home until they met the CDC's return to work criteria 73 for healthcare workers. 5 74

To enable employees to have access to the most current information, policies and 75 training materials, we developed and deployed over one hundred twenty COVID-19 prevention 76 and action resource materials. This resource library (the same material provided in the link 77 above) was posted to our organizational intranet, and updates were also communicated by 78 email to the organization three times per week. 79

All HBPC practitioners and support staff reviewed the resource library documents and 81 participated in the educational sessions that the outbreak committee and practice medical 82 director developed. In the one hundred day period between January 20, 2020 and April 30, 83 2020, we provided HBPC to 1,794 ALF residents in 101 ALFs in Ohio. The average age of the 84 cohort was 83 + 11 years and 74% were female. 35 ALF residents were classified as PUIs for 85 COVID-19. Seven individuals in our facilities (0.4% of census) tested positive for SARS-CoV-2 by 86 nucleic acid test (Table 1) , with an average age of 82. The positive individuals were located in 87 three ALFs, representing 3% of our total number of ALFs. Of the seven cases, four were from one ALF, two were from another, and one ALF has had a single case. For each positive case, the 89 ALF notified the health department, and any additional guidance was implemented in 90 collaboration with our group. 91

Three COVID-19 positive individuals were hospitalized. As of April 30, two of the 92 individuals hospitalized have been discharged and are recovering. There has been one death. 93

The patient who died was a 77 year-old woman with a history of Parkinson's disease, dementia, 94 atrial fibrillation, hypertension, hypothyroidism and morbid obesity. She presented to the ALF 95 nurse with change in mental status and sore throat, and upon evaluation, was found to have 96 fever and hypoxemia. Our on-call practitioner admitted her to the hospital where she tested 97 positive for COVID-19. For several days, she maintained clinical stability on four liters of oxygen 98 by nasal cannula. Ten days into the hospitalization, she acutely desaturated and was placed on 99 a 100% non-rebreather mask in the intensive care unit. She was initially treated with 100 hydroxychloroquine and azithromycin, but she did not improve and her family honored her 101 wishes to avoid intubation and mechanical ventilation. She elected the hospice benefit, and she 102 died two weeks into the hospitalization. 

A Novel Coronavirus from Patients with Pneumonia in 125

An interactive web-based dashboard to track COVID-19 in real 127 time

The Need to Include Assisted Living in 130 Responding to the COVID-19 Pandemic

Infection Control Guidance for Healthcare 132 Professionals about Coronavirus (COVID-19)

Criteria for Return to Work for Healthcare 136 Personnel with Suspected or Confirmed COVID-19

Our patients are dropping like flies' USA Today

The authors wish to express our most sincere gratitude to the caregivers, nurses and administrative leadership of our country's assisted living and nursing facilities, who continue to do their very best as they courageously face the COVID-19 pandemic.

In the U.S., at least 5,700 (12.8%) of the approximately 44,500 nursing homes and ALFs 105 have reported a COVID-19 case. 6 To date, 3% of ALFs where our group provides HBPC have had 106 at least one COVID-19 positive case. We report seven positive cases in the first one hundred 107 days of the U.S. COVID-19 outbreak across our ALF population of 1,794, for a prevalence of 108 0.4% of census. COVID-19 positive ALF residents who did not require hospitalization were able 109 to isolate in their room, and recover with symptomatic support. 110 A highly coordinated and frequently communicated approach to infection control, 111 employee screening and visitor management may enable suppression of COVID-19 in ALFs. We 112 have also begun regular diagnostic testing of all visiting practitioners, using a "two-pronged" 113 approach that includes nasopharyngeal swab for SARS-CoV-2 nucleic acid to diagnose acute 114 infection for those who are acutely symptomatic and a rapid POC test for asymptomatic 115 employees for IgM and IgG antibodies against SARS-CoV-2 to determine recent or past 116 infection. At the time of this report, all visiting practitioners have tested negative, and we have 117 begun a regular monthly antibody testing cadence. 118In the first one hundred days of the COVID-19 outbreak in the U.S., we observed that 119 HBPC-led outbreak mitigation may be an enabler to suppress COVID-19 infection rates in ALF 120 residents. All congregate living settings pose challenges for infection control COVID-19, 121 however, vigilant infection control procedures, case and exposure documentation, and real-122 time data analysis can be enablers of an optimal response. 123