Variability of COVID-19 Practices Among Skilled Nursing Facilities in a Health System Post-Acute Care Collaborative

Coronavirus 2019 (COVID-19) has been a profound concern for skilled nursing facilities (SNFs) caring for older adult residents.¹ COVID-19 has emerged as a deadly pandemic with extensive community migration leading to challenges in isolating, testing, and treating.^2-4 There is a critical need for close coordination between hospitals, SNFs, and public health authorities to ensure proper care of patients, as well as the need for rapid dissemination of clinical information related to the care of patients with COVID-19.^5,6 

Initial public health strategies for minimizing COVID-19 did not prioritize SNFs. Thus, many SNFs had to make decisions and create facility policies relying on the knowledge base of their medical directors and administrator team.⁷ A conduit for patient care coordination between hospitals and SNFs can occur through clinically integrated post-acute networks or collaboratives. Post-acute care collaboratives (PACCs) facilitate collaboration between hospital-based health systems and post-acute care facilities such as SNFs, long-term acute care hospitals, and home health agencies (HHAs) around quality improvement initiatives such as reducing readmissions and improving transitions of care. Thus, during the COVID-19 outbreak, leveraging PACCs to support SNF patient care practices and coordinate safe transitions of care may help minimize spread of COVID-19 and improve patient outcomes.  

A PACC network survey was deployed at the start of the COVID-19 pandemic to support proactive coordination of care among facilities. We report the results from the SNF cohort of the sample, surveying their admission and infection prevention and control (IPC) policies for patients with COVID-19. 

This study is a qualitative analysis of results from a survey conducted within a large academic health system’s PACC in Illinois, focusing only on responses from SNFs in the network. All 51 SNFs within the PACC were invited to participate. This project was deemed exempt from review by the Northwestern University Institutional Review Board. 

Survey

The COVID-19 care processes survey was developed by PACC leadership. This short survey posed questions to identify SNF processes being used for admission and IPC processes during COVID-19 pandemic (Box 1).

Surveys were emailed to PACC participating SNFs in mid-March 2020, when the state of Illinois, in which the PACC operated, had under 100 COVID-19 cases and no deaths attributed to COVID-19 at the time. 

Data Collection and Analysis

Survey responses from SNFs were emailed to PACC staff members who transcribed and aggregated the data into Excel files made available for hospital discharge planning teams across the health system. After permission to use survey responses for research purposes was granted, data was supplied to the research team. Using a grounded theory approach and constant comparative techniques, research team coders (TA, AL, LL) analyzed the responses for each survey question.^8,9 Each coder independently assessed SNF responses (open coding), attaching codes to blocks of text to develop a preliminary codebook. The coders then compared and compiled findings, discussing and refining identified codes from their perspectives.⁸ Coders then identified connections between the previously identified themes forming higher level categories.¹⁰ Using multiple coders to develop themes controls for each coder’s subjective bias.¹¹ Any discrepancies were resolved through discussion; consensus was reached among coders. 

Of the surveys emailed to the 51 SNF members of the PACC, 46 surveys (90%) were returned. SNF members participating in the PACC have an average Centers for Medicare & Medicaid star rating of 3.75 stars (range 2-5), 126 beds (range 20-316), and were located in urban/suburban settings (36% and 64%, respectively).   

COVID-19 Admissions Policy

Among 46 responses, 32 SNFs (63%) were not accepting patients who tested positive for COVID-19; one (2%) was uncertain; and five (10%) were planning to accept patients who tested positive for COVID-19 at the time of initial outreach. Qualitative analysis of admission protocols and barriers to accepting COVID-19 positive patients resulted in six themes. The themes were then organized into two larger categories: Structural and Patient-Focused.

Structural Barriers

Several structural barriers to admitting COVID-19 patients were identified. 

Insufficient personal protective equipment (PPE). Lack of PPE for staff was a common reason why SNFs did not feel prepared to accept COVID-19-positive patients to their facilities. One facility commented: “PPE remains a barrier for taking any patients who require isolation or are COVID-19 positive.”

Insufficient isolation rooms/developing isolation space. Facilities cited they were unable to take patients testing positive for COVID-19 due to lack of isolation rooms, while others were working on creating separate spaces for COVID-19-positive patients. One facility mentioned they were “creating a step down/isolation unit for patients coming in from the hospital,” but did not have any availability at the time of the survey. 

Capacity concerns. Potential staffing shortages during the COVID-19 outbreak was another barrier to accepting patients with COVID-19. Additionally, bed shortage, particularly for SNFs with double-bed rooms, was identified as a major barrier because of isolation issues. One facility commented a major challenge was “bed availability, 2-week isolation for all new admissions.”

Patient-Focused Barriers

Several patient-related barriers to admitting COVID-19 patients were also identified. 

General non-acceptance of patients with COVID-19. Several facilities stated upfront that they would not accept COVID-19-positive patients. There were no reasons given. Other facilities were willing to take active or recovered COVID-19 positive patient without restriction. One facility commented they “will not accept active COVID-19 patients, no plans to accept.” Others commented they would “accept patients recovered from COVID-19” but did not elaborate on how recovery would be defined. 

Patients with respiratory symptoms. There was variability in admission requirements when it came to patient symptoms. One was not willing to accept patients with respiratory symptoms. Others were willing to take patients only if they had tested negative for COVID-19, eg: “Will consider patients with pulmonary symptoms with negative COVID-19 test.” Many facilities were requiring additional clinical history before planning to admit, eg: “Requires detailed information on any patient presenting with respiratory infection so appropriate precautions can be taken.”

Variability of COVID-19 testing. Multiple facilities required COVID-19 testing of patients prior to admission. There was notable variation in this requirement, with some only requiring it for patients with respiratory symptoms and others requiring two negative tests prior to accepting any patient citing: “Can take COVID-19 patients after 2 negative tests and no longer require transmission-based precautions.” Others were much more strict with respect to admitting COVID-19 patients: “No fever x 2 days without the use of any antipyretic medication (Tylenol, Advil, Aspirin, etc) with a copy of the resident’s vital signs 2 days prior to discharge.”

Care Plans for Residents Testing Positive for COVID-19

We asked participants about their care plan protocols for when a resident at the SNF tested positive for COVID-19. Four themes were identified: (1) isolation, (2) hospitalization policy, (3) personal contact, and (4) coordination.  

1. Isolation. The tactic of isolation was unsurprisingly common, considering it a standard of care during the COVID-19 epidemic. The practices of isolation responses varied between simple “isolation” to “droplet precautions” to “full droplet, contact precautions.” No facilities provided a detailed plan of isolation.  

2. Hospitalization policy. There was a wide range of hospitalization policies for SNFs with some requiring all residents with confirmed or suspected COVID-19 to be transferred: “transfer to hospital”; others did not plan on sending patients to hospitals unless required: “no plans to hospitalize unless required.” 

3. Personal contact. Contact with others included thematic variants centered on other residents and staff preparedness. There was significant variability on how SNFs were utilizing and training staff on using PPE. While some facilities kept all patients isolated, even those without COVID-19-positive patients, others stated they would only isolate COVID-19-positive residents. 

4. Coordination. Coordination with outside health care entities was a theme that included strategies such as “contact PCP” and “Notify Department of Public Health.”

Within an integrated health system’s PACC, SNFs exhibited wide variability in COVID-19 practices for both admission and for IPC practices prior to formal issuance of guidance by the Centers for Disease Control and Prevention. Most SNFs were not able to accept COVID-19-positive patients because of significant barriers related to both structural issues, such as lack of PPE, and patient-focused issues, such as lack of COVID-19 testing in symptomatic residents. Similar to other regions in the United States,¹² these results highlight challenges where many SNFs were not prepared early on in the pandemic to admit or manage patients with COVID-19. Hospital-to-SNF communication through PACC was integral to mitigating the spread of COVID-19 and to ensure safe transitions of care for COVID-19 positive patients. 

Survey results show that PACC leaders were able to identify barriers SNFs were experiencing, such as lack of PPE and testing. Acting as a central source of information for the health system, PACC leaders were also able to identify which SNFs were willing to take COVID-19 positive patients to optimize transitions of care for this unique population. By initiating communication with SNFs early on, PACC have the ability to influence decision-making that ensures patient care is the priority, for example, by supporting guidance from the Society of Post-Acute and Long Term Care Medicine to discourage mandates that facilities accept COVID-19 patients into COVID-naive facilities.”¹³ 

Additionally, as large health systems can provide expertise in infectious diseases, PACCs can disseminate vital evidence-based recommendations to SNF members to improve their IPC practices. Unifying all SNF practices may be impossible. Individual cultures, bed availability, and skill sets differ greatly between SNFs. Thus, PACCs, acting as a coordinating entity with information dissemination between and to SNFs, may be the best option for health systems.

Policymakers need to recognize both the barriers to providing optimal care in the post-acute setting during the COVID-19 pandemic and the variability driving challenges in optimal throughput through the care continuum. Not only do these challenges present issues for providers of care to some of the most vulnerable to COVID-19, they present an unpredictable variable in being able to appropriately and accurately project allocation of resources across multiple levels of care.

This study had some limitations. First, this survey was performed early on in the COVID-19 pandemic in the Unite States, and the response to COVID-19 has rapidly evolved.¹⁴ However, understanding how SNFs were limited early on and how PACCs were able to identify and support SNFs is essential, which is what this survey aimed to capture. Second, this was done within one health system capturing a small sample, thus the results may not be generalizable. Examining how SNF participants from multiple PACCs respond to similar questions about care processes would provide additional insight. Third, these data reflect one point in time, and changes in COVID-19 admission criteria and status are changing on a daily basis. Finally, these data are self-reported and were completed, most often, by the administrator in conjunction with nursing and medical directors. It is unclear if there is variability stemming from the occupations of those who completed the survey. 

By leveraging a health system’s PACC, we found significant variability in COVID-19 IPC practices in SNFs and significant barriers to accepting COVID-19 positive patients. These data can be leveraged by health systems and policymakers to support optimal transitions of care and to provide adequate IPC support to SNFs. As there remains significant uncertainty in how to best manage COVID-19, understanding areas where SNFs face variability in IPC protocols and how health system PACCs can support optimal patient care in SNFs is critical. 

The authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Authors: Theresa A Rowe, DO, MS • Anna Liggett, MD • Lee A Lindquist, MD, MPH, MBA

Affiliations: Division of General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL

Disclosures: All authors provided (a) contributions to conception and design, or acquisition of data, or analysis and interpretation of data for the article; (b) drafting of the article or reviewing it and revising it critically for important intellectual content; and (c) final approval of the version to be published.

Correspondence:

Theresa Rowe, DO, MS
Division of General Internal Medicine and Geriatrics,
Northwestern University, Feinberg School of Medicine
750 N. Lake Shore Drive, 10th floor
Chicago, IL 60611

Phone: (312) 695-4525
Email: theresa.rowe@northwestern.edu
Twitter: @theresa_rowe1 @LeeLindquistMD @Annaliggett1