Dr. Arif Nazir, Chief Medical Officer at Signature HealthCARE
Arif Nazir, M.D., president of AMDA

When a crisis hits, besides shedding light on the system gaps, it also highlights the strengths of a community. The stresses of the novel coronavirus pandemic (COVID-19) have clearly highlighted the many positive attributes of the post-acute and long-term care (PALTC) community. As the president of AMDA, The Society of Post-Acute and Long-Term Care Medicine, I have been in awe watching several heroic stories emerge in this fight of our lifetime.

In the twilight of 2019, China announced its first COVID-19 outbreak. In a few weeks, it evolved from just an interesting story to a humanity-threatening concern for researchers, clinicians and politicians across the globe. As of now, the outbreak has reached pandemic status, prompting governments to enact emergencies and community shutdowns across the world.

No community has been impacted by COVID-19-related concerns in the US more than the PALTC setting. As an environment of care for the frailest of the frail, and with less than ideal financial support, staffing demands and inconsistent medical models, if this sector fails to receive the necessary attention and support it requires, PALTC may face dire consequences.

Over the last couple of weeks, I have observed teams in PALTC exhibit speed, resolve and agility as they initiate CMS and CDC guidelines to implement sweeping changes. This crucial reorganization in operations has occurred in admissions, staff and patient screening, use of personal protective equipment (PPE), communication flow, daily assessments, vendor partnerships, visitor policies and much more. Getting this accomplished within a couple of weeks has been an amazing feat well worth acknowledging (please access COVID-19 related resources at https://paltc.org/COVID-19).

Frontline staff accolades

My first acknowledgement and commendation is reserved for the frontline staff, including the certified aides and licensed practical and registered nurses. Like always, these staff members continue to perform around the clock, demonstrating a true commitment to their residents and families. With these residents, restricted from in- person visits with families and friends, these dedicated teams have worked tirelessly to keep residents engaged and connected with the outside world, while meeting their physical, clinical, and psychosocial needs.

Frontline advanced practitioners (PAs/NPs) and physicians, without regard to their own well-being, have also kept up with the rising wave of COVID-19 illnesses, on top of the usual chronic care needs among their residents and patients. Many practitioners and physicians are under quarantine due to exposure to the virus, but continue to engage with their teams through telecommunications and telehealth systems, even with this payment system in flux.

I am also hearing stories of partnerships between facility leaders including infection preventionists (IPs), administrators, directors of nursing and medical directors, setting new protocols, creating new tools and innovating to overcome resource shortfalls. A new library of incredible implementation tools and strategies is being created and the exceptional stories of innovation will be critical for years to come as they move the field of infection control forward beyond the pandemic.

None of this early success against the pandemic would be possible without the active collaboration among the corporate leaders of many small, medium and large skilled and senior living organizations. Executives, and chief medical and chief nursing officers, have quickly taken advantage of the power of web connectivity and social media to display the power of “co-opetition.” As a result, best practices have been shared and disseminated, producing swift action across the industry. The evidence of this historic collaboration is now documented forever on the pages of LinkedIn, Facebook and Twitter.

Professional organizations deserve praise

The key role of professional organizations, in the response to COVID-19, cannot be overemphasized. I am very proud of the truly heroic work of the AMDA Infection Advisory Subcommittee, comprised of Dr. Swati Gaur, Dr. Dave Nace, Dr. Ghinwa Dumyati and Dr. Robin Jump, among other members. This team placed their personal lives and professional jobs on hold to put forth the best available evidence to combat the COVID-19 threat. The quality, practicality and relevance of these resources have been noticed, downloaded and have already guided many. Similarly, many AMDA state chapters, particularly those in Washington (WA-PALTC) and California (CALTCM), have contributed immensely with timely webinars from the front lines of this crisis.

I would be remiss if I failed to acknowledge the contributions of leaders from other organizations including the CDC, CMS, American Health Care Association and many others, including state organizations. The high-quality learning webinars, tools and recommendations coming out of these organizations have helped our teams put forward a confident and united front to respond to the COVID-19 challenge.

Certainly, there have been gaps that have adversely affected the response to this crisis. Most notably, there is a lack of an available evidence base to manage this illness. There is also a national shortage of PPE and test kits, staffing demands, and the longstanding and egregious absence of a national database of SNF medical directors. The availability of a national medical director database would have facilitated swift communication with these key physician leaders for centralized, standardized education, training and implementation of protocols without conflicting information, and overlapping guidance. We hope that CMS will pay attention to this gap and will respond to AMDA’s years of advocacy on this issue.

Overall, AMDA is gratified by several key policy changes recently instituted by CMS and other federal government agencies. These include the lifting of the 3-day hospital stay requirement, relaxing restrictions on telehealth (although guidance is urgently needed on this!), restrictions on visitors to prevent infection transmission, focusing surveys on infection-related critical issues, and others. But, more is needed and rather quickly. We echo our partner associations’ calls for a steep increase in funds, PPE availability, and prompt testing for COVID-19. Most importantly, we demand media and public support and appreciation of our frontline teams who are fighting this fight with no immediate end in sight.

I need to highlight that, as the number of COVID-19 patients increases, there will be pressure to discharge and send these patients to skilled nursing facilities. As a geriatrician and a leader in the PALTC setting, I would highly caution against that. SNF residents who are COVID negative can not be exposed to patients who are positive. This will be a critical mistake. Instead, we should look to developing specialized COVID-19 centers to treat those in need. AMDA membership and leaders are all unanimous on this issue. AMDA’s Executive Committee has passed a resolution for educating government officials, regulators and agencies on the seriousness of the risks involved for our vulnerable population, and the urgency to provide alternative care settings. This resolution can be viewed at: https://bit.ly/393YFzB

This pandemic is still in its early days and our response to the COVID-19 threat has just started. I am happy to report that so far, the PALTC community has shown exceptional resolve, collaboration and heroism, none of which is a surprise to me. As I am privileged to have known and worked with the most passionate workforce and leaders in this setting for more than 15 years, I expected nothing less. So, even though we have a long way to go, I can confidently say, this too shall pass!

Arif Nazir, M.D., FACP, CMD, AGSF, is president of the American Medical Directors Association, The Society of Post-Acute and Long-Term Care Medicine; and chief medical officer of Signature HealthCARE.