PROVIDENCE – The learning curve when it comes to how the health care delivery system has responded to the challenges of the coronavirus pandemic has been steep.

It resembles, in many ways, the proverbial “hockey stick” that venture capitalists always deride when they view the first estimated revenue projections prepared by a new startup enterprise.

But the truth is: everything has changed dramatically about health – and health care. And, it will continue to change rapidly.

• Telehealth has become a necessity.

• What happens in a future “office visit” may never be the same.

• Regulation around medication-assisted treatment for substance use disorders has been radically altered, putting more trust in the patients.

• The pandemic has made more explicit what should have already been known – the brutal racial inequities and health disparities that the state’s most vulnerable communities face.

• Investments in public health – and not just hospital infrastructure – will require more thoughtful approach on the Congressional and state legislative fronts. Money alone will not cure what ails us.

One of the biggest areas of ongoing concern is what has happened in skilled nursing facilities, where residents succumbed to the coronavirus at an alarming rate. What caused the increased fatalities is still a matter of intense political debate. The good news is that the advent of vaccines being administered to residents appears to have dropped the rate of deaths in nursing homes in Rhode Island, according to Dr. Nicole Alexander-Scott, director of the R.I. Department of Health.

The questions that still remain to be answered, however, are these: What kinds of changes need to be made in the future of care at skilled nursing homes? Who gets to participate in those discussions? And, how prepared will nursing homes be for the next pandemic?

Peer learning collaborative
In an effort to provide some guidance, a new virtual learning collaborative has been deployed, led by a partnership that includes Healthcentric Advisors, in collaboration with the federal Agency for Healthcare Research and Quality, deploying what is known as the “AHRQ ECHO National Nursing Home COVID-19 Action Network,” with an emphasis on peer mentoring and support.

The collaboration will provide those “working on the frontline in nearly 100 nursing homes in Rhode Island and from across New England with a learning opportunity to improve the knowledge, skills, and confidence to implement best-practice safety measures to protect residents, staff and visitors from the infection and spread of the virus.”

ConvergenceRI recently sent a series of questions to Healthcentric Advisors to delve more deeply into the peer-learning program. Here are the revealing answers provided by Marguerite McLaughlin, Senior Program Administrator at Healthcentric Advisors.

ConvergenceRI: What are the questions that nursing homes ask most frequently on the ECHO sessions? Can you give a few examples?
McLAUGHLIN: The questions asked by providers change within the context of new regulatory guidance, the incidences of COVID in their settings, and the campaigns in which they are currently involved.

Questions over the past weeks have focused on vaccination issues. These include:

• How will I get new staff and newly admitted residents vaccinations after the Centers for Disease Control and Prevention’s Long-Term Care Pharmacy Partnership is done?

• What strategies will encourage staff to accept vaccinations?

• How long will the vaccine protect staff and residents, and are there signs I should be watching for that indicate it is no longer effective?

• How long will protective equipment be necessary?

• How can we gently coax isolated residents out of their rooms as many seem quite traumatized and what therapies will assist with re-engaging them?

ConvergenceRI: Given the number of nursing home residents in Rhode Island who have died as a result of the coronavirus, what questions related to grief counseling for staff have emerged? And, what are the opportunities for mental health and stress-related sessions for staff?
McLAUGHLIN: Staff have been deeply traumatized by the death of residents, and many openly express their grief and sadness about those losses. Sessions on trauma have provided tips to leaders, focusing on the best ways to support staff [and residents].

Additionally, homes have used various forums to share their experience and find validation among staff members. Many homes connect with Employee Assistance Programs [EAP].

The health department has posted several support contacts on their site. Since COVID-19, Lifespan is providing mental health support specifically to health care workers statewide.

[The number to call for that is: 401-606-6000 and can be dialed Monday through Saturday, from 8 a.m. to 8 p.m. Once contacted, callers will be immediately offered an appointment for support, free of charge, with an individual health care provider.]

The Requirements for Participation [regulations issued by Centers for Medicare & Medicaid Services that nursing homes are required to follow to operate and receive payment] were refreshed in 2019, and they require homes to integrate trauma-informed care into their operation’s education curriculum line-up.

ConvergenceRI: Have all workers in the nursing homes you are collaborating with been vaccinated?
McLAUGHLIN: No. Workers can opt-in or out. Tremendous effort is placed on educating staff, encouraging, and incentivizing vaccination acceptance. Many ask why is it not mandatory? Though CMS has mandated many things during the crisis, vaccination has not been one of them.

There is concern from public health officials and long-term care leaders mandating the vaccine may encourage this already overextended workforce to find jobs elsewhere, leaving an industry with already critical short-staffing issues facing a far direr situation.

Ultimately, vaccine confidence is a highly complex issue, and public health and long-term care administrators are leading with the belief that staff’s decision to vaccinate is a personal, cultural, and individual choice.

The vaccination rates among the Rhode Island long-term care continuum [which includes assisted living, skilled nursing facilities, adult day programs, and memory care units] as of the week of March 7, 2021, show that within that continuum, 49,420 vaccines have been administered, 30,441 workers and residents have had one dose, and 18,791 workers and residents are fully vaccinated, according to the R.I. Department of Health.

Across the U.S., from late December to early February, new cases [for COVID-19] among nursing home residents fell by more than 80 percent, nearly double the rate of improvement in the general population. The trend line for deaths is even more striking: Even as fatalities spiked this winter, deaths inside the facilities have decreased by more than 65 percent.

ConvergenceRI: Are there any demographics available regarding patients in skilled nursing facilities in Rhode Island?
McLAUGHLIN: According to data analyzed by the Kaiser Family Foundation, about 7,600 people [were living] in nursing homes in Rhode Island as of 2019, though we are aware that census has decreased amid COVID-19. In Rhode Island. Medicaid pays for about 65 percent of Rhode Island nursing home residents.

As of March 2020, nursing and residential care facilities in Rhode Island employed about 17,800 workers, according to the R.I. Department of Labor and Training. Rhode Island has approximately 15,000 certified nursing assistants [CNAs] licensed to practice in the state. But only about 9,300, or 60 percent, were working in the state, as of May 2019.

In 2019, the median wage of nursing assistants working in Rhode Island nursing homes was $14.25 an hour, according to the U.S. Bureau of Labor Statistics.

ConvergenceRI: Are hospitals still transferring patients to skilled nursing facilities for rehabilitation? How does your program interact with those patients and rehabilitation staff?
McLAUGHLIN: Yes. Hospitals discharge to nursing homes. Many of the state’s nursing homes rely on Healthcentric Advisor’s education programs for insights and quality improvement support.

But while we do not directly interact with residents, we work with staff to improve care.

ConvergenceRI: What are the biggest misconceptions regarding care in skilled nursing facilities that staff see themselves having to confront?
McLAUGHLIN: The media has viciously maligned nursing home’s skills, quality, and response during the pandemic contributing to, among other things, depression and hopelessness in staff, decreasing census, and an overall sense of victimization.

Little has been said about the heroics and bravery, the resilience, extra shifts, the innovation, and constant reinvention of their systems to respond to new guidance and ever-increasing numbers of people with COVID-19 in their facilities.

The degree to which COVID-19 impacted nursing homes was directly proportionate to the community spread where the nursing home was located. There is no connection between star rating [a designation given by the Centers for Medicare & Medicaid Services] and COVID-19; all homes were impacted regardless of star-rating.

Staff often pick up shifts in multiple homes; however, this common practice is dangerous because it could spread COVID-19. Organizations recognized this issue and started asking workers to work at only one, giving them extra shifts to compensate for shifts lost by going to the other settings.

Staffing issues were a massive problem in long-term care well before COVID-19, and sadly the pandemic has now exacerbated those challenges.

ConvergenceRI: What kind of peer support is available through this program? Can you give an example of how such peer support works?
McLAUGHLIN: The design of the ECHO program is so that peer-to-peer learning and support can take place. A short didactic session is presented, and then peers share based on their experience, prompting those with less experience to ask questions. It is remarkably collaborative, stimulating, and resource-filled.

Some things providers share include strategies they use for helping to encourage staff to get vaccinated. They share ways they were helping to combat loneliness and isolation by introducing hallway games and activities. They discuss ways to use technology to keep families informed and apps that help with symptom screening upon entry into the facility.

ConvergenceRI: Can the training you are providing be applied for “credits” for career advancement for staff?
McLAUGHLIN: Yes, CEUs [continuing education units] are available, depending on role of the staff member.

ConvergenceRI: What questions haven’t I asked, should I have asked, that you would like to talk about?
McLAUGHLIN: We want to stress how hard these homes have worked to protect their residents while also caring for them both physically and mentally, day in and day out. They face enormous challenges with access to PPE, sufficient staffing, cohorting [a practice designed to prevent spread by clustering residents with COVID-19 in one area, residents who are suspected of COVD-19 but not testing positive in another area, and residents with no symptoms and testing negative in another area, and funding.

Yet these dedicated people work tirelessly amid a deadly pandemic, doing the best they can for Rhode Island’s most fragile seniors.