key: cord-1048723-ms07rhwd authors: Levitt, Alan F.; Ling, Shari M. title: COVID‐19 IN THE LONG‐TERM CARE SETTING: THE CMS PERSPECTIVE date: 2020-05-13 journal: J Am Geriatr Soc DOI: 10.1111/jgs.16562 sha: e756e5d5dde183721fc40738953b6723eb58974e doc_id: 1048723 cord_uid: ms07rhwd ABSTRACT Safeguarding the health and promoting the wellbeing and quality of life of the most vulnerable and fragile citizens is a top priority for the Centers for Medicare & Medicaid Services (CMS). In response to the COVID‐19 pandemic, numerous regulatory policies and 1135 waivers of federal requirements have been implemented by CMS to give long‐term care providers and professionals flexibilities to meet to the demands of resident and patient care needs during this public health emergency. Goals for these policies and waivers include to increase capacity, enhance workforce and capability, improve oversight and transparency, prevent COVID‐19 transmission and reduce provider burden. This article is protected by copyright. All rights reserved. As the largest payer for healthcare services, the Centers for Medicare & Medicaid Services (CMS) sets quality and safety standards for all participating healthcare facilities, and has been facilitating the healthcare system transformation to focus on value-based care. Geriatricians are critical to these efforts, providing high value care to older adults that aligns with their personal and healthcare goals. The COVID-19 pandemic has created enormous demands across all healthcare settings, including skilled nursing facilities (SNF)/long-term care (LTC) facilities, challenging us and threatening the health and safety of older adults, who are our beneficiaries and your patients. In response to the public health emergency, CMS has implemented numerous regulatory policies and 1135 waivers of federal requirements 1 to give healthcare facilities and professionals flexibilities to respond to surge demands (please see Table 1 for a summary of the CMS response to the COVID-19 pandemic). This includes the "Hospital without Walls" initiative, under which hospitals can deliver care in temporary expansion sites. 2, 3 As part of this initiative, LTC facilities can be repurposed as expansion sites, including being designated as a COVID-19 patient care facility. The creation of COVID-19 patient care facilities can achieve population separation and transmission mitigation. Based on need and with approval of the states, CMS is waiving requirements to allow for the opening or use of non-SNF buildings for unmet COVID-19 isolation and treatment. 4 CMS has eased several requirements to allow resident transfer to different rooms and also between facilities, as well as temporarily use rooms in the facilities, such as activity rooms, meeting/conference rooms, or dining rooms, for resident care to expand surge capacity and for purposes of cohorting and infection control. This article is protected by copyright. All rights reserved. With the CMS expansion of telehealth options for professionals, it is now feasible to provide higher levels of care in the LTC setting, including specialty care. With the appropriate staffing, a ventilator-capable SNF may provide a realistic alternative for COVID-19 patients stabilized during hospitalization for continued convalescence and recovery. We believe telehealth brings new opportunity to enhance healthcare quality in LTC that includes specialty consultations, where appropriate. As such, CMS is waiving some requirements for physicians and non-physician practitioners to perform in-person LTC resident visits. Instead, CMS will allow such visits to be furnished, as appropriate, via telehealth options, which we describe in the Long-Term Care Nursing Homes Telehealth and Telemedicine ToolKit. 5 To further enhance and broaden workforce capacity during the COVID-19 pandemic, CMS now allows for physician delegation of tasks or required visits to a physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS). 3,4,6 CMS is also waiving the requirements that a LTC facility may not employ a nurse aide for longer than four months unless the nursing aide met certain training and certification requirements to expand workforce capacity. Some of the best practices that healthcare organizations are using to improve physician workforce capacity include redeployment of employed physicians, utilization of available trainee staff, and recruitment of community and retired physicians. Other workforce flexibilities and resources are provided below. CMS has urged state and local leaders to consider the needs of LTC facilities with respect to supplies of PPE and COVID-19 tests. 12 CMS has additionally increased payment for high throughput technologies COVID-19 testing in LTC facilities, 13,14 and also will provide payment for sample collection. 15 Finally, to improve transparency, CMS will be requiring LTC facilities to inform residents and families of all COVID-19 cases and to report confirmed COVID-19 cases directly to the CDC. 16,17,18 CMS will begin posting data from the CDC National Healthcare Safety Network (NHSN) for viewing by facilities, stakeholders, or the general public. The COVID-19 public use file will be available on https://data.cms.gov/. 19 Finally, we must not lose sight of the care needs of residents who do not have COVID-19, but are at risk of transmission. LTC facilities are expected to provide the most appropriate care for all residents -regardless of COVID-19 status. CMS is expanding availability of renal dialysis service to LTC residents by temporarily waiving the requirement that dialysis facilities This article is protected by copyright. All rights reserved. Accepted Article provide these services directly on its main premises. 20 To enable clinicians to better focus on the care needs of residents during this public health emergency and as a continuation of the "Patients Over Paperwork" initiative, CMS has temporarily given LTC providers relief from many paperwork, reporting and audit requirements. 21 For example, CMS announced it is granting exceptions from reporting requirements and extensions for clinicians and providers participating in Medicare quality reporting programs (QRPs) with respect to upcoming measure reporting and data submission for those programs. Additionally, CMS is temporarily relaxing the timeframe requirements for Minimum Data Set (MDS) assessments and transmission and providing relief for submitting staffing data through the Payroll-Based Journal (PBJ) system. Star Quality Rating System reported on Nursing Home Compare will temporarily be held constant to ensure the rating system reflects fair information for consumers. 22 CMS most recently announced the independent Coronavirus Commission for Safety and Quality in Nursing Homes that will conduct a comprehensive assessment and provide independent recommendations to help inform immediate and future responses to COVID-19 in LTC facilities. 23 The Commission will include residents, families, resident/patient advocates, leading industry experts, clinicians, medical ethicists, administrators, academicians, infection control and prevention professionals, state and local authorities, and other experts selected through a nomination process. We are ever mindful that the care LTC residents need is so much more than the delivery of healthcare services. Ingenuity and innovation can arise during austere times such as these. This article is protected by copyright. All rights reserved. Geriatricians and other Geriatric Health Professionals, we applaud you for your commitment, and express our deepest gratitude for your service. For the latest information about COVID-19 prevention, symptoms, and answers to common questions, please go to https://www.cdc.gov/coronavirus/2019-ncov/index.html. The full CDC guidance to prepare LTC facilities and nursing homes for COVID- 19 This article is protected by copyright. All rights reserved. Conflict of Interest: The authors have no financial or personal conflicts of interest to report. Author Contributions: Both authors contributed in the preparation of this document. This article is protected by copyright. All rights reserved. Waiver or Modification of Requirements Under Section 1135 of the Social Security Act (online) Healthcare System Address COVID-19 Patient Surge (online) Long Term Care Facilities (Skilled Nursing Facilities and/or Nursing Facilities): CMS Flexibilities to Fight COVID-19 (online) COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers (online) Long-Term Care Nursing Homes Telehealth and Telemedicine Tool Kit (online) Interim final rule with comment period: Medicare and Medicaid Programs; Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency (online) This article is protected by copyright. All rights reserved trump-administration-issues-key-recommendations-nursing-homes-state-andlocal-governments Guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in Nursing Homes (REVISED) (online) COVID-19 Long-Term Care Facility Guidance Strategies to Optimize the Supply of PPE and Equipment (online) CARES Act Financial Guidance to State Survey Agencies (online) COVID-19 Long-Term Care Facility Guidance (online) This article is protected by copyright. All rights reserved Press Release: CMS Increases Medicare Payment for High-Production Coronavirus Lab Tests (online) Payment under Medicare Supplementary Medical Insurance (Part B) for clinical diagnostic laboratory tests for the detection of SARS-CoV-2 or the diagnosis of the virus that causes COVID-19 making use of high throughput technologies (online) Available at Transparency Effort (online) Memorandum: Upcoming Requirements for Notification of Confirmed COVID-19 (or COVID-19 Persons under Investigation) Among Residents and Staff in Nursing Homes (online) Basic Health Program, and Exchanges; Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency and Delay of Certain Reporting Requirements for the Skilled Nursing Facility Quality Reporting Program (online) Memorandum Summary: Interim Final Rule Updating Requirements for Notification of Confirmed and Suspected COVID-19 Cases Among Residents and Staff in Nursing Homes (online) End Stage Renal Disease (ESRD) Facilities: CMS Flexibilities to Fight COVID-19 (online) Memorandum: Nursing Home Five Star Quality Rating System updates, Nursing Home Staff Counts, and Frequently Asked Questions (online) Coronavirus Commission for Safety and Quality in Nursing Homes (online)  Waive physical environment requirements ("Hospital without Walls")  Waive transfer requirements for cohorting or separation purposes  Waive coverage requirements (3- https://www.cms.gov/newsroom/pressreleases/cms-announces-relief-cliniciansproviders-hospitals-and-facilities-participatingquality-reporting https://www.cms.gov/files/document/covidlong-term-care-facilities.pdf https://www.cms.gov/medicareproviderenrollment-andcertificationsurveycertificationgeninfopolicy-andmemos-states-and/nursing-home-five-starquality-rating-system-updates-nursing-homestaff-counts-and-frequently-asked