Notes from a recent Q&A for Senior Care risk related to COVID-19 risk management

QUESTION: What is something you would say to Senior Care facilities that are learning now that they have positive cases? What kind of advice would you give?

MICHELLE: We have quite a few clients in this situation. And here’s what we do. We start with a little pep talk. We say: You are leader. You are in a position of leadership because you know how to be clear and decisive and to execute a plan with people reporting to you. You have a hard job but you are where you are because you’ve proven you can do hard things. Your people need you. They are depending on you. It’s shocking, I know, and everything in you wants to believe it isn’t true. I’m sure you’re angry. How the hell, after all we’ve done, did this happen? Who the heck!?!? Of course, you’ll want to blame someone. There’s the mental - emotional negotiating and bargaining that you face, they call it the stages of grief. And it’s sad. I think you have to give yourself that. It’s okay to shed some tears. But you’ll want to get through those stages in a matter of minutes or hours because what everyone is counting on you to do is to seek out realistic solutions and find a way forward. It’s time to clear your schedule and calmly switch into crisis management mode. You remember the US Airways Flight that might have crashed but the pilots, Chesley Sullenberger and Jeffrey Skiles, who were unable to reach any airports, glided the plane into the Hudson River right there in Manhattan. There were definitely some injuries but 155 lives were spared and we now call it the “Miracle on the Hudson.” A flock of geese could have taken then whole plane down. There are probably not many pilots who have experienced that before, but they know things like that can happen. So, what did those pilots do? They trusted their training and their skills. They did exactly what they had prepared in advance to do in an emergency. I’ve heard pilots say they are taught to remember: Aviate. Navigate. Communicate. Meaning, first and foremost, fly the plane. You need a pilot in the cockpit, with his or her hands on the controls. In a crisis, the Administrator or Executive Director needs to be laser focused on controlling all the crucial dials and steps. Isolate and contain the known infection. Survey the rest. Any other signs and symptoms in residents, and staff? Test what and who you can. Then protect. Do you have PPE? What supplies do you have? These are your gauges and they inform what’s next: which is Navigate. What is the safest path forward? How do we get there? What’s needed? This is where consulting your trusted inner circle of experts can be lifesaving. Don’t go it alone if you have a co-pilot or the senior care version of air traffic control. Call your clinical risk consultant and your local health department as you establish next steps. It might mean discharging/evacuating the COVID positive residents. If you have a significant outbreak, it might mean evacuating residents who test negative. It could mean moving to a contingency staffing plan, or bringing in emergency staff. Finally, and possibly one of the most important means of executing your lifesaving plan: is Communicate. What’s happening, what’s needed, who is responsible for doing what. Start with the staff and the health department. Then residents and families. Don’t forget you now have to report to the CDC as well. Make friends with the media. I suggest you manage the story as much as possible. Get in front of it. Those leaders who are able to communicate with confidence, clarity, empathy, and an ability to inspire others to be their best selves are going to have the best outcomes.

QUESTION: What separates the good, the bad, and the ugly?

MICHELLE: Culture. A facility with what we call a “Just Culture” is a setting where staff trust leadership to be fair and reasonable and supportive, even when mistakes are made. They will be in a better position to protect residents. They are also more likely to already have good relationships with residents and families going into the crisis. A Just Culture and Patient Safety go together. Those facilities and entire communities really, where people, on the other hand, are quick to point fingers, blame others, and avoid responsibility for fear of negative outcomes or shame are going to suffer. Sadly, we have plaintiff attorneys out there stoking the tendencies of people in pain to want someone blame and pay the price for their loss. And then, of course, there are those who are afraid, for good reason, that they will be shamed for things they can’t control, made out to be villains in a situation they did not create: a deadly virus with a symptomatic transmission, shortages of Personal Protective Equipment, and testing supplies.

QUESTION: What would you say to those leaders who are likely to be under public scrutiny because of things like not having enough PPE, not having enough testing, delayed treatment, or conditions outside of their control?

MICHELLE: Keep a diary. No, not a personal feelings diary, though that is great self-care, and you need to take care of your own well-being right now. I have a prayer journal that anchors me in times like this. What I mean really is a journal of what you are doing. In other words, document. Are you short on PPE? Of course you are. Everyone is. But don’t expect that to be a good enough reason when the time comes to defend your facility. Use the CDC’s PPE burn rate calculator to determine #s: How many masks, gloves, gowns, and face shields are needed? Document it. That tool wasn’t available when you did your pandemic preparedness plan. Now it is. Count what you have. Document it. Protect what you have. Document what you did. You are now using the Contingency PPE Plan issued by the CDC. Document that. Call your supplier every day. Document it. Call the health department every day and report shortages and needs. If they say they can’t help you and everyone is in the same situation. Document it. Seek out alternative supplies. Document it. You completed the CDC Preparedness Checklist. Document each step. You are following the CMS guidance that comes out or changes almost daily. Document your response to each new step. I know you don’t have established policies and procedures and documentation tools for all this. Things are changing daily. Don’t wait until you have the perfect log, form or tool to capture all that you are doing. Start where you are and write it down as you go.

QUESTION: For those who have not yet had positive cases, what’s the number #1 thing senior care organizations can do to prevent COVID-19 from entering their building?

MICHELLE: First, they can cease admissions until the patient or resident to be admitted tests negative. This is difficult because there are not enough tests and the hospitals are pushing for transfers to free up beds. Most facilities need to maintain a good relationship with their primary referral sources (which are the hospitals) but at the same time, those hospitals are where some of these residents with COVID originate. It’s a hard call. You have to think that through. Those hospitals that push you to admit now may not be quick or even able really to support you if you have an outbreak. Some governors are issuing orders that patients must be tested before transfer to long term care. On April 2nd, the White House and CMS urged state and local leaders to identify facilities they could designate specifically for COVID care and isolation, in order to keep COVID out of the senior care settings. Unfortunately, not enough of our state and local leaders have taken action. It may be up to those in senior care; the nursing facility administrators, and assisted living managers to step up and lead that effort, when their local officials and elected leaders have failed them. Otherwise, they will end up with COVID in their buildings and as we have seen time and again, it can be one resident that tests positive on one day, and dozens a few days later. Both the staff and the residents in long term care are extremely vulnerable. Reach out to your local leaders. Is there a surgery center that is under-utilized, a long term acute care hospital, a hotel, even? Anywhere is a better place for COVID patients than in a facility filled with elderly people. There are sometimes, on the other hand, that a nursing facility decides to keep their residents that are COVID positive and they want to care for COVID patients transferred from the hospital. Let’s applaud them. It’s a courageous move. We need COVID designated facilities and separate units, but only if they can transfer their other vulnerable residents elsewhere. You have to avoid shared staff, shared supplies, anything where one small misstep gives this invisible enemy a foothold. That brings me to staff. The next thing facilities need to do to keep COVID out, is screen employees’ (which is required) but I would say take it a step further - ask employees to agree to infection containment strategies which would mean not working for other nursing homes or assisted living facilities which is one of the most common ways it has spread. Some of our LTC clients have had employees sign agreements that they will not go anywhere (other than the facility) where there are more than 10 people, they will social distance, avoid public transportation when possible, use extreme caution when going to grocery or pharmacy, etc. Not sure how employment lawyers feel about that level of scrutiny, but it’s really to protect staff and residents. We don’t hear enough about the vulnerabilities of staff. Non healthcare workers often have the option of physical distancing and plexiglass barriers to protect themselves. A nursing assistant cannot very well bathe or transfer or feed a dependent resident without putting themselves at risk of being exposed to whatever that resident has. Especially with the shortage of PPE and asymptomatic transmission.

QUESTION: What’s the biggest mistake you’ve seen skilled facilities make?

MICHELLE: They don’t prepare. Or rather, they think they are more prepared than they really are. A prepared facility has done so much more than required. They have a solid plan for where to send COVID positive residents. They have a place for those who have not yet tested positive but have symptoms and need isolation. They’ve cleared out a wing with a separate entrance, or they’ve converted other parts of their building, even activities and maintenance rooms, to serve as designated COVID pending triage areas. They’ve turned as many semi-private rooms into private rooms as they can. All this is done BEFORE they need it. They’ve educated staff and already have nurses, nursing assistants, and housekeeping staff members who have agreed in advance to care for these patients exclusively. They’ve involved the community to help them get PPE. They’ve set up systems to communicate daily with families about what their status is. And, they’ve already thought out and written a press release JUST IN CASE it’s needed.

Where can people get a hold of you or find your services? OmniSure.com is our main website. There’s a link to our resource page for COVID-19. Clients access us through our helpline which is answered live 24 hours a day / 7 days a week. I think many healthcare facilities have a helpline offered by their carrier. If you’re hearing this and you’re not sure, email us: [email protected]. We’ll check with your insurance partners and help out however we can.