Vermont team focuses on nursing homes

Published: 1/18/2021 7:52:05 PM
Modified: 1/18/2021 7:52:03 PM

Ashley Hudson, co-owner of Four Seasons Care Home, found out at 4 p.m. on Nov. 10 that a staff member had tested positive for Covid.

In less than two hours, she was on a Teams meeting bombarded with advice from half a dozen state workers — from the state lab, epidemiology, Department of Health, licensing, and aging.

The speed at which they responded “was crazy,” Hudson said.

That’s the goal, said Will Fritch, a team lead for the state’s response team for long-term care facilities, dubbed the Health Care Outbreak Prevention and Response rapid response team.

“These are serious situations and that’s why we act so promptly,” he said.

Once COVID-19 slips inside an elder care facility, it spreads like wildfire. It encompassed Burlington Health & Rehab in April. The state’s largest outbreak, at Elderwood in Burlington, had risen last week to 126 total cases among staff and residents.

To help mitigate the spread of the virus in elder care facilities, the state formed its team in early November, and has deployed it to more than two dozen outbreaks and “situations” since then.

The eight-member team, housed in the Vermont Department of Health, is a combination help-line, equipment supplier and source of moral support for facilities.

It’s on call seven days a week to respond to questions, provide volunteer workers for understaffed facilities, deliver personal protective equipment, offer COVID-19 testing, and brainstorm the nitty-gritty details of how to make sure residents have adequate bathrooms or how to communicate with families.

Their message to facilities combating the virus? “Whatever you need, we’ll figure out a way to make it happen and support you,” said Monica White, director of operations for the Department of Disabilities, Aging and Independent Living.

Partly because the state is so small, Vermont can offer one of the more comprehensive and aggressive state-led responses to nursing home outbreaks, according to federal documents.

Those involved, and nursing home officials, say it’s been successful in slowing the spread of the virus among the state’s most vulnerable.

The group aims to intervene as soon as possible, to “cut off initial potential for transmission from cases and then contain any spread if there has been any,” Fritch said.

Some of the initial steps are obvious — send the staff home or isolate the resident, make sure the facility has adequate personal protective equipment, and set up a strategy for daily testing.

Others are more complicated.

Different plans for different places

The Centers for Disease Control and Prevention recommended that facilities “cohort” people who are sick — put those who are positive together, keep those who remain negative separate, and group those who may have been exposed, but aren’t yet positive.

The health department helps decide who to move, and where. That was impossible at Four Seasons, where every resident has their own furniture and unique rooms — but they shared bathrooms, so the team put commodes in each room.

At Elderwood, workers said they moved people but had to bag up and move belongings.

When five staff members and a resident tested positive on Dec. 30 at the Vermont Veterans’ Home in Bennington, CEO Melissa Jackson and the state decided to keep the resident in place, and just assign special staff to care for the infected patient.

In the midst of staffing shortages, the Department of Disabilities, Aging and Independent Living taps staff members from area hospitals and calls on volunteer networks to fill in in everything from patient care to laundry and transportation.

This fall, it recruited volunteers through local organizations and on Front Porch Forum to help at Rutland Health & Rehab when the facility staff was decimated by the virus, said facility spokesperson Lori Mayer.

The team instituted a testing plan, either run by the state or by each facility — at least twice-a-week PCR testing and antigen testing every other day. It helps supply gloves and hand sanitizer, and manages protocol for meals and deliveries.

Sometimes, Hudson said, she didn’t even know which state workers would show up to help. Someone in uniform — a National Guard member, she guessed — dropped off additional protective equipment. When she was overwhelmed with paperwork, a state worker from the Department of Health took some of the forms home and filled them out himself, she said.

Ultimately, 30 out of 31 residents tested positive for the virus, though most were asymptomatic. One person died, though he also had other serious conditions, Hudson said. Most important to her was the reassurance from the Department of Licensing and Protection that she hadn’t failed her residents. That was “the best and most heartwarming thing,” she said.

Staff available seven days a week

The rapid response team has grown as the pandemic has progressed and COVID-19 has spread within more elder care facilities.

By the time Vermont marked its first few COVID-19 cases in March, the state knew it needed a team to respond to outbreaks, said Fritch, who previously worked in the infectious disease prevention section of the Health Department.

A barebones team — created mainly to distinguish them from the contact tracers — has added members in epidemiology and in other state departments, such as Disabilities, Aging and Independent Living, he said. They started focusing on elder care facilities this fall, he said.

Now, they have staff available seven days a week and work across agencies, he said.

Exactly how well the approach has worked is hard to tell; there’s no null hypothesis to gauge what would have happened without the team.

Vermont has seen a spike in outbreaks in long-term care facilities this fall. At the peak in December, the state had 121 cases associated with elder care outbreaks.

As of last week, 660 of 9,700 COVID-19 cases were among residents and staff long-term care facilities. But residents of elder care homes comprised a third of the state’s 162 COVID-19 deaths. That’s slightly below the U.S. average of 37%, according to the Covid Tracking Project.

“By and large, all hands on deck is a great idea. Any help nursing homes can get is great,” said Mike Wasserman, immediate past president of the California Association of Long-term Care Medicine.

But, he said, “this is an inflection point for long-term care. We have to acknowledge that we just weren’t prepared for anything like this.”

With growing death counts, “there are no laurels to rest on right now,” he said.

What’s right? No one really knows

There is no standard for responding to outbreaks in elder care facilities, said Dr. Daniel Haimowitz, a geriatrician from outside Philadelphia who has met weekly with state and clinical leaders in an effort to help protect elder care homes against the virus. “There has not been a unified, comprehensive response,” he said. That leaves states to chart their own paths.

For instance, Indiana’s response has been facilitated by a project run by Indiana University. Some states, and counties, have strike teams similar to Vermont’s approach, but they vary widely from place to place.

“What’s right? Is it a good model? No one really knows,” said Haimowitz. “It’d be nice to figure this out.”

It’s not perfect, agreed Hudson, of Four Seasons. The facility’s staff weren’t fit-tested for N-95 masks until after the outbreak occurred. They hadn’t required residents to wear masks at home before then either.

Other facilities had ongoing short-staffing; some had PPE shortages.

Still, Vermont officials say the system has worked. At Elderwood, even though the virus spread rapidly, peaking at 126 cases this week, only one resident of the rehab wing tested positive.

“That’s a success,” said Kayla Donohue, one of the rapid response team leads. She pointed to an outbreak at Berlin Meadows Nursing and Rehabilitation that was contained to a single floor.

This “enhanced intervention” approach and aggressive testing strategy were used as models for the CDC over the summer, she said. And even when the system or a facility’s response is imperfect, the goal of saving lives is always worthwhile, Donohue said.

“With case counts all over the media, I’m kind of like up in arms that each one of those numbers is a person,” she said.

For now, the number of new cases at long-term care facilities has slowed; the Health Department reported 25 new cases over the past week.

All of the residents at the state’s nursing homes and most of those at the assisted and independent living facilities have received the first round of COVID-19 vaccines; the remainder will get them soon.

But the facilities aren’t out of the woods yet, White said.

While the vaccines offer a source of optimism, the ongoing community spread, the number of people who turn down a vaccine, and the gaps in the vaccine’s effectiveness mean that outbreaks will continue to pop up at long-term care facilities for the foreseeable future.

The COVID-19 variants may also lead to a rise in cases.

“The vaccines are absolutely a light at the end of the tunnel. How long that tunnel is remains to be seen,” White said. “In terms of when we could reasonably anticipate a reduction in facility outbreaks, I think we’re still a ways away from that yet.”

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