key: cord-1034719-0afdww8c authors: Chen, Angela T.; Ryskina, Kira L.; Jung, Hye-Young title: Long-Term Care, Residential Facilities, and COVID-19: An Overview of Federal and State Policy Responses date: 2020-07-04 journal: J Am Med Dir Assoc DOI: 10.1016/j.jamda.2020.07.001 sha: e41dce7d868ef3d6cad29b5788830aee3a145e0b doc_id: 1034719 cord_uid: 0afdww8c Abstract The COVID-19 pandemic has disproportionately affected residents and staff at long-term care (LTC) and other residential facilities in the US. The high morbidity and mortality at these facilities has been attributed to a combination of a particularly vulnerable population and a lack of resources to mitigate the risk. During the first wave of the pandemic, the federal and state governments received urgent calls for help from LTC and residential care facilities; between March and early June of 2020, policymakers responded with dozens of regulatory and policy changes. In this article, we provide an overview of these responses by first summarizing federal regulatory changes, and then reviewing state-level executive orders. The policy and regulatory changes implemented at the federal and state levels can be categorized into the following four classes: 1) preventing virus transmission, which includes policies relating to visitation restrictions, personal protective equipment (PPE) guidance, and testing requirements; 2) expanding facilities’ capacities, which includes both the expansion of physical space for isolation purposes and the expansion of workforce to combat COVID-19; 3) relaxing administrative requirements, which includes measures enacted to shift the attention of caretakers and administrators from administrative requirements to residents’ care; and 4) reporting COVID-19 data, which includes the reporting of cases and deaths to residents, families, and administrative bodies (such as state health departments). These policies represent a snapshot of the initial efforts to mitigate damage inflicted by the pandemic. Looking ahead, empirical evaluation of the consequences of these policies – including potential unintended effects – is urgently needed. The recent availability of publicly reported COVID-19 LTC data can be used to inform the development of evidence-based regulations, though there are concerns of reporting inaccuracies. Importantly, these data should also be used to systematically identify hot spots and help direct resources to struggling facilities. Importantly, these data should also be used to systematically identify hot spots and help direct 23 resources to struggling facilities. The COVID-19 pandemic has surfaced many of the ways in which our health care system fails to 26 protect vulnerable older adults and their caregivers. Residents and staff of nursing homes, 27 assisted living facilities, and other long-term care facilities have contracted the disease at high 28 rates; although nursing home residents comprise less than 1% of the U.S. population, they 29 account for over 40% of In addition to a vulnerable patient population, the 30 high morbidity and mortality associated with the COVID-19 pandemic in long-term care 31 facilities has been attributed to poor access to personal protective equipment (PPE), staffing 32 shortages, and poor infection control practices. 2 During the first wave of the pandemic, federal 33 and state governments responded to urgent calls for help from facilities with several policies and 34 regulatory changes. Understanding those changes is an integral first step toward developing a 35 comprehensive policy framework to address the long-term care needs of older adults and their 36 caregivers. In this piece, we review federal and state regulations implemented between March 4 th 37 and June 12 th , place those in the context of existing empirical evidence, and make 38 recommendations for the future. Expanding facilities' capacities: CMS put forth numerous regulatory waivers to expand both the 58 physical capacity and the workforce available to combat To increase capacity to 59 isolate long-term residents and relieve acute hospital bed shortage, non-nursing facilities can 60 temporarily be certified for use as nursing homes. Additionally, LTC facilities can transfer 61 residents to other locations without a formal discharge, thus enabling facilities to cohort affected 62 residents in separate locations from those who test negative. Training and certification requirements have been modified to bolster the workforce available to 64 care for LTC residents. Nurse aides can now postpone the deadline for completing a required 12-65 hour annual training until COVID-19 is no longer deemed a public health emergency. Physicians 66 have more leeway to delegate tasks -including physician visits -to other licensed staff members 67 (such as nurse practitioners). Minimum training hours for paid feeding assistants have been 68 reduced from 8 to 1. Of note, physician visits are still required to occur at the same frequency as before and feeding assistants still must work under the supervision of a registered nurse (RN) or for LTC facilities to submit data on facility staffing, and suspending requirements for pre-75 admission assessments at nursing homes. CMS has also advised its billing contractors to allow 76 extensions for filing appeals and to relax requirements relating to timeliness and completion of 77 requests for appeals. Reporting COVID-19 data: On April 19th, CMS began requiring nursing homes to report 79 COVID-19 positive cases and deaths to residents, families, and the CDC on a weekly basis; these 80 data were published on Nursing Home Compare on June 4 th . 83 We used Executive Orders compiled by the Council of State Governments, a nonpartisan 84 organization that serves as a resource for state governments, to identify state-level policy 85 changes. 7 As of June 12 th , twenty-five state governors collectively issued nearly fifty executive 86 orders relating to the prevention of COVID-19 transmission among residential and long-term 87 care facilities (Figure 1 ). Executive orders are policy tools used by state governors without direct 88 involvement of the legislative or judicial branches; as such, they allow for swift policy responses 89 to public health problems that demand immediate attention. 8 We focused this summary of state-90 level policy changes on executive orders, though such orders alone likely do not capture all state initiatives in response to COVID-19 (for example, orders from departments of health, governor 92 proclamations, and emergency orders were excluded). We limited policies to those that 93 specifically addressed concerns of LTC and other residential facilities (such as assisted living 113 * AZ #2020-07, VT #01-20, CT #7, NH #2020-04, MI #2020-06, MT #2-2020 and 3-2020, TX #GA 08, TN #17, MS #1463, OK #2020-07, NC #120, SC #2020-15, ND #2020-22, GA #04.08.20.03 executive orders † to expand the workforce available for patient care at long-term care and These policies represent a snapshot of the initial efforts to mitigate the damage to long-term care 147 and residential facilities inflicted by the pandemic. As this wave of COVID-19 infections 148 subsides, there is an opportunity for evidence-based long-term policy development (Table 1 149 provides a summary of recommendations). Empirical evaluation of the consequences of these 150 policies, including potential unintended effects, is urgently needed. For example, despite the 151 efforts to improve resident access to providers via telemedicine or to relax scope of practice 152 regulations, COVID-era distancing policies may limit residents' access to necessary caregivers 153 and advocates. This could put residents at higher risk for other adverse outcomes, as previous 154 work has shown that patients in skilled nursing facilities without physician or advanced 155 practitioner visits were at higher risk for both hospital readmission and death. 10 Also, close proximity to visitors is associated with positive nursing home resident behaviors, such as smiling 157 and alertness. 11 Containment measures are a necessary step to prevent transmission, but many 158 patients caught in the fray of involuntary transfers and visitation restrictions may incur 159 considerable harm that they may deem worse than COVID-19. Paralleling ongoing policy evaluation, state and federal administrations should also use the 161 COVID-19 nursing home data to systematically identify and help facilities that are struggling. This may lead to deteriorating care quality or, if facilities close, many residents will lose their 188 homes. The recent release of nationwide COVID-19 data on Nursing Home Compare provides an 190 opportunity to evaluate COVID-era policy changes, but care must be taken when using these State-level executive order numbers are plotted by date and policy category. Each data point includes the state abbreviation, the 262 executive order number, and the date the order was signed. Policies were identified using orders compiled by the Council of State 263 Governments at https://web.csg.org/covid19/executive-orders/. • Evaluate COVID-era nursing home policies for those that could be both protective and unintentionally harmful in an evidence-based manner. • Ensure residents have access to necessary caregivers and advocates. • Use COVID-19 long-term care data to quickly identify and assist facilities at risk or facing an outbreak. Assistance can come in the form of COVID-specific expertise, additional personnel, equipment, or an infusion of capital. • Assess the effect of regulatory waivers granted during the COVID-19 pandemic; consider permanently waiving regulations that are outdated. • Understand the effects of public reporting of COVID-19 and related financial penalties on the quality of and access to nursing home and residential care. • Recognize and address the potential pitfalls -such as reporting inaccuracies -of using a publicly-reported COVID-19 data. Nursing Homes & Assisted Living Facilities Account for 42% of COVID-19 Deaths Nursing Homes Continue to Face Critical Supply and Staff 209 Shortages as COVID-19 Toll Has Mounted Accessed on June 8, 213 for Medicare & Medicaid Services. Prioritization of Survey Activities Enhanced Enforcement for Infection Control deficiencies, and Quality 218 Centers for Medicare & Medicaid Services. Long Term Care Facilities (Skilled Nursing 221 Facilities and/or Nursing Facilities): CMS Flexibilities to Fight The Council of State Governments Using Gubernatorial Executive Orders to Advance 227 Public Health The Office of Governor Ned Lamont. Governor Lamont Expands Financial Aid for 229 Connecticut's Nursing Homes Amid COVID-19 Pandemic, Announces Nursing Home 230 Site Visits to Extend Additional Support From State Aid-for-Connecticuts-Nursing-Homes Assessing First Visits By Physicians To 234 Medicare Patients Discharged To Skilled Nursing Facilities Effects of pet and/or people visits on nursing home residents. International 237 journal of aging & human development Waiving the three-day rule: admissions and length-239 of-stay at hospitals and skilled nursing facilities did not increase Medical staff involvement in nursing homes: 242 development of a conceptual model and research agenda Postacute care outcomes and medicare payments for 245 patients treated by physicians and advanced practitioners who specialize in nursing home 246 practice COVID-19 Deaths in Connecticut Driven to tiers: socioeconomic and racial disparities in 251 the quality of nursing home care Daily Nursing Home Staffing Levels Highly 253 Characteristics of U.S. Nursing 255 Homes with COVID-19 Cases The Importance of Long-term Care Populations in 257 Models of COVID-19 She was 259 probably able to ambulate, but I'm not sure Program in Management and Technology at the Wharton School) for assistance with policy review and proof-reading the manuscript.