Strategies for Successful Nursing Facility Operations in the COVID-19 Crisis
Nursing facility administrators across the nation are facing extraordinary operational pressures as they deal with the SARS-CoV-2 virus and incidence of COVID-19 affecting virtually everyone, both in the workplace and at home. Nursing facilities play an essential role in managing the health of the elderly and other vulnerable individuals, which reflects an increased risk to residents and staff for severe illness related to COVID-19. We recognize the focus is on maintaining resident and staff health, providing adequate staffing levels and procuring enough supplies and resources to keep operations running as smoothly as possible.
CMS, the Centers for Disease Control and Prevention (CDC), state and local health departments and other agencies have issued copious regulatory guidance and information on an almost daily basis to assist facilities in addressing daily operational challenges during this emergency. In addition, CMS and other agencies have created tools to help facilities self-assess and improve their preparedness efforts in developing a comprehensive COVID-19 response plan. It’s critical that facilities implement operational protocols to address these challenges on a day-to-day basis.
Examples of Strategies Employed to Address Clinical, Operational & Financial Challenges
Infection Control & Prevention Survey Readiness
CMS recently released infection control guidance, which includes a self-assessment tool based on the protocol that surveyors will be employing to implement focused infection control surveys in the upcoming weeks. CMS has stated the focused surveys will be conducted in communities with high COVID-19 incidence and not for facilities reporting a high volume of COVID-19 positive cases. CMS expects facilities to implement either the CMS LTC Facility Self-Assessment Tool or the CDC Infection Prevention and Control Assessment Tool and expects facilities to provide the assessment results at the time of the survey. The CMS self-assessment document includes a review of the scope of policies and procedures as well as staff and physical plant observation, referred to as “tracers.” The self-assessment tracers address:
- Standard Precautions
- Hand Hygiene
- Transmission-Based Precautions
- Injection Practices
- Point-of-Care Devices
- Central Lines
- Urinary Catheters
- Respiratory Therapy
- Wound Management
While it may seem overwhelming to redirect staff to complete the self-assessment, reviewing your infection control and prevention program can help you fine-tune your operational strategy to manage and control COVID-19 challenges.
Workforce Communication & Recognition
Workforce challenges appear to be the major issue facing facilities as this crisis continues to affect employees both at home and in the workplace. The stresses of managing school-age children and older parents while maintaining workplace commitments are particularly challenging. Facilities are increasingly eliminating routine face-to-face staff and leadership meetings to reduce the risk of exposure. Some strategies being employed to both maintain the flow of communication and reassure staff include:
- Daily rounds in resident areas conducted by leadership to “take the pulse” of the staff and understand issues affecting staff at home and at work
- Establishing routine written communication to staff posted on the units or in departments to provide updates and address any potential concerns
- Use of electronic media such as Zoom or Skype to conduct virtual meetings and provide a forum for questions and relay input for solutions
- Providing a break room for staff to relax and regroup. This could be a room that’s typically used for resident group activities available during this time of communal restrictions
- Supplying nutritious snacks or a means for staff to easily access meals during shifts
- Providing staff with a list of available community resources for child care, food and other services based on the individual staff need
- Providing information on available support services to assist with emotional stress associated with this crisis. The Disaster Distress Helpline is a national hotline available 24/7 that provides immediate crisis counseling. This helpline can be reached directly at 800.985.5990
With the closure of some programs and services, organizations should review and assess nursing, medical and social work professionals’ qualifications and consider potentially redeploying staff where their skills are most required to address potential shortages. In addition, with the announced delays in reporting and submission deadlines, additional capacity is potentially available to assist in essential service areas. While providers should be cognizant of any state-specific guidance concerning the use of healthcare workers across programs or facilities, all staff roles should be reviewed. There may be an opportunity to redeploy some direct or nondirect care staff whose usual responsibilities are on hold or less urgent to assist nursing staff in providing resident services. It’s important to recognize that all redeployed staff must be trained in using personal protective equipment.
Examples of redeployments include:
- Therapy staff who can assist with resident transfers and ambulation programs
- Assistance with meal delivery and setup that’s challenging for residents sequestered in their rooms
- Assistance with water and snack delivery
- Assistance with in-room friendly visits and coordinating audio or video calls with family members
- Stocking supplies
- Responding to call lights and triaging to appropriate personnel
Maintaining Social Connections, Activities & Programs
Given the strict visitation and social distancing policies recently imposed on nursing facilities, residents are isolated from their families and loved ones, as well as each other. Many facilities have been working hard to develop and implement workable and creative solutions to help residents stay connected. Social distancing requirements have created additional challenges related to planning activities for residents.
Examples of proactive strategies that some facilities have implemented to help residents stay in touch and participate in activities include:
- Video chats and FaceTime sessions with family
- Having residents write messages on whiteboards that can be photographed and posted on family members’ Facebook or Instagram pages
- Scheduling group activities, such as hallway bingo or trivia, that permit residents to remain in their rooms or at the doorway and still participate
- Implementing an “Activities Room Service Request Form” for residents to identify specific requests for individual activities, including:
- Adult coloring books and crayons/pencils
- Crossword puzzles
- Playing cards
- Providing access to online programming such as:
- Religious activities, particularly during the upcoming holidays
- All-day programming, such as Enrichment on Demand
Maintaining residents’ morale during isolation can prevent behavioral issues that could create an additional burden to the care staff, who are already overwhelmed during this crisis.
With the spotlight on care delivery in facilities and resources and attention diverted to maintaining essential services, it’s imperative that the organization’s accounting and financial functions are maintained. The normal business flow of the cash management, interim and financial reporting continues. In addition, with the potential for financial relief and supplemental funding as a result of COVID-19, meticulous documentation will be critical. Isolating the associated costs and identifying utilization trends will help build the framework for future appeals.
Key areas of focus should include:
- Maintaining a detailed accounting of incurred expenses (labor, supplies, equipment) related to COVID-19 activities, particularly for future documentation requirements for potential federal and state reimbursement
- Identifying opportunities to obtain grants to cover increased expenditures, and being prepared to address funding requirements and meet application timelines
- Stepping up cash flow analyses, moving to almost daily monitoring
- Reaching out to your lenders to identify any relaxation of current debt payments, deferred payments or availability of additional credit lines
- Focusing on revenue cycle management, including billing and receivables and opportunities for Medicare accelerated advanced payments
- Remaining connected with line managers (billing, payroll, AP, etc.) during these times when employees may be working remotely
- Assessing the ability to recover lost revenues as a result of program closures and decreased census (business interruption insurance, CARES Act, etc.)
- Reviewing your procedures for permitting residents to access their funds during this time of social distancing and facilitating the process when necessary
- Educating billing staff on the effect of the CARES Act stimulus checks that your residents may be receiving, and how those funds can be used
We’re actively monitoring the wide-ranging and rapidly evolving changes to help facilities mitigate the short- and long-term effects of this healthcare crisis. Our goal is to help you focus on strategies that can help navigate the challenges you currently face and provide ways to address them.
As with most topics related to COVID-19, changes are being made rapidly. Please note that this information is current as of the date of publication.
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