COVID-19 Collaborative Model for an Academic Hospital and Long-Term Care Facilities

Problem and Significance

The COVID-19 pandemic is devastating for many post-acute and long-term care (PA/LTC) facilities, given the threat of quick and overwhelming spread of outbreaks.1, 2, 3, 4, 5 With implementation of social distancing orders, many communities have slowed the spread of infection. However, outbreaks remain dangerous where social distancing is not possible.6, 7, 8 As geriatricians who practice in PA/LTC and a regional academic medical center, we created the Geriatric Engagement and Resource Integration in Post-Acute and Long-Term Care Facilities (GERI-PaL) program to support optimal care to residents in post-acute and long-term care facilities during the COVID-19 pandemic.

Innovation

The GERI-PaL arms are detailed in Figure 1 . The prevention arm cultivates dialogue among an interprofessional academic clinical team (Geriatrics, Pulmonary, and Nursing), local government agencies including our local health department and emergency management, and local organizations related to prevention and treatment of COVID-19 in patients in PA/TLC facilities. The program includes the following components: a daily community collaborative rounds (“Project ECHO COVID-19 in Nursing Homes”), nursing liaisons, infection advisory consultation, telemedicine consultation, and resident phone calls to provide social contact remote connections (Table 1 ).⁹

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

Implementation

GERI-PaL began on March 13, 2020, with facility-based Infection Advisory Consultation meetings. These meetings were quickly transitioned to web-based teleconferencing as the pandemic threat emerged. We met individually with 8 local facilities to provide general guidance on infection control policies, as recommended by AMDA, CDC, and CMS.10, 11, 12 The GERI-PaL team listened to facility-specific infection control concerns, staffing concerns, cohorting concerns, and challenges with ordering PPE from their standard suppliers. The attendees included a facility administrator, a facility director of nursing, an infection control practitioner, a medical director, and an all-facility licensed independent practitioner (LIP), whereas other meetings were attended by only a facility medical director or LIP.

Parallel to these meetings, on March 16, 2020, a “telementoring” series was rapidly instituted using the Project ECHO model that leverages learning, training, and practice support to build a collaboration for health professionals.^{13 , 14} The Project ECHO team included a nurse practitioner, geriatrician, pulmonologist, clinical nurse leader, and nurse educator. The goal of the virtual meetings was to connect long-term care facility administrators and directors of nursing to assess facility needs for COVID-19 preparedness. In the response arm, we provided updated COVID-19 information, testing and treatment guidelines, and best practices in infection control. Participants in Project ECHO sessions shared their experiences and sought input from a network of peers and insight from experts on managing COVID-19–positive patients in the PA/LTC setting. Other frequent community participants include local county fire and rescue representation and regional long-term care ombudsman. These sessions were daily focused discussions and needs assessments regarding clinical information, PPE preparedness, and infection control, as well as education-based discussions. Four days a week this program was driven by facility needs (in a question and answer format similar to academic office hours). One session each week the program was a more formal didactic session given by an academic content expert on a topic of interest determined by the group.

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

In addition, a facility telemedicine consult service was established to provide academic pulmonary and critical care clinical support and recommendations for testing, monitoring, and treatment-in-place, and to facilitate hospital transfer to and return from the hospital as need arises. The telemedicine consultant communicates with a hospital medical communications center to directly admit acute patients, as well as to ensure key aspects of care coordination, such as transfer of accurate medication lists, code status documentation, and demographic information faxed to a centralized number for ease of facility-based staff. An allied geriatric consultation service, including Geriatric and Palliative care specialists, provides a parallel telemedicine consult service that supports complex medical conditions, goals of care discussions, and assistance with comfort care treatment when needed.

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

Evaluation

For our Project ECHO daily discussions, our nurse liaison invited all 28 of our local facilities, as well as an additional 49 regional facilities. We connected with up to 25 facilities each week for needs assessment and education. Table 1 provides outcomes information and lessons learned for each of the prevention components as related to feasibility and adoption. Because of our collaboration with local emergency management and health department, we focused these discussion based on these localities instead of the large catchment area of our hospital. Of the local facilities with initial COVID-19 infection, 2 of the 3 facilities had participated in our prevention program and none of these facilities had sustained transmission or outbreak. The response outcomes and feasibility are listed in Table 2 based on our response to the 2 local facilities with outbreaks in which we have implemented our program. The mortality rate of each of these outbreaks was 12% and 19%, lower than the published mortality rate of 28%.²

Comment

We implemented our GERI-PaL program to support a collaborative care community between an academic medical center and local PA/LTC facilities. We present this as a practical approach intended to improve outcomes of COVID-19 in PA/LTC facilities. Components were well received among the participating facilities. The telemedicine consultation service was an integral component of our response arm and increased direct subspecialty care. In addition, our response daily huddle with all stakeholders in outbreak facilities streamlined communication for clinical and facility-based needs to activate response. A key innovation of the GERI-PaL model is our inter-professional team—including physicians, nurses, emergency response, and public health. The combined multidisciplinary expertise of this team has allowed us to more fully assess and adapt the program to meet real-time facility needs. Early intervention for facility outbreak is vital, especially to ensure appropriate planning and support before a facility point prevalence survey. Therefore, for other centers who may implement this program, we would recommend broad and ongoing outreach to facilities to expand impact and sustain facility involvement.