Pandemic Playbook - Chapter 10
Chapter 10 - Share
Provider-Specific Guidance

Chapter Contents

Rural Issues
Affordable Housing
Hospice and Palliative Care
Home and Community-Based Services
Home Health
Adult Day Services and PACE
Skilled Nursing
Assisted Living
Life Plan Communities
Provider-Specific Reopening Guidance

By intent, the vast majority of this Pandemic Playbook addresses topics that are of interest and applicable to providers of long-term services and supports across all types and locations. The topics, issues, and lessons learned may be of value to a range of providers from home-based caregivers to hospital-based systems of health care.

Based on the guidance of our expert panelists, we have incorporated a complete chapter on provider-specific resources. Regulatory mandates and state-specific executive orders are ever-changing, so some of these resources will require periodic updating; however, these initial resources establish a baseline for reference.

Provider types covered in this chapter include, but are not limited to, adult day, affordable housing, assisted living, community services, home care, hospice, life plan communities, PACE, and skilled nursing. The resources are further organized into sub-categories of pandemic response for the ease of content navigation. There is also a section of this chapter dedicated to the unique challenges faced by rural providers of care and services.

It is well-known that rural health care providers face an array of unique challenges in serving their communities effectively and efficiently. Response to a pandemic adds a layer of hardship and complexity that is easily overwhelming.

Rural Issues

According to an Aug. 3, 2020, update from the Centers for Disease Control and Prevention (CDC), roughly 46 million Americans live in rural areas. Specifically, this CDC update cites the following common health and social inequities that place rural residents at a higher risk of serious illness and pandemic susceptibility: higher rates of cigarette smoking, high blood pressure, obesity, less access to health care, and less likelihood of having health insurance.

It is well-known that rural health care providers face an array of unique challenges in serving their communities effectively and efficiently. Response to a pandemic adds a layer of hardship and complexity that is easily overwhelming. The following resources specifically address rural providers’ pandemic-related issues, needs, and lessons learned.

Rural Member Challenges

  • Availability of testing and retesting: Local health departments and hospitals do not have enough tests available, and older adult service providers have a difficult time having staff tested unless they have 2 definitive symptoms. It is especially difficult to access rapid testing in rural areas. Providers wait for a week or more for testing and test results. This is an ever-changing variable.
  • Staff shortage: When staff resign or express a fear of working amid positive cases, there is nowhere to look for replacements. There simply are not enough bodies in rural areas to fill the volume of frontline positions that are open.
  • Financial solvency: Because of the uncertainty of a pandemic’s duration, rural providers have the potential to lose significant revenue quickly through reduced occupancy.
  • Technology: Rural communities frequently experience a digital gap in Internet accessibility and reliability that also affects availability of telehealth options.
  • Emergency staffing options: If a significant outbreak occurs or if staff tests positive or must quarantine, rural communities will have few, if any, options for temporary, supplemental agency staffing. CDC guidelines may evolve over time to allow flexibility among asymptomatic staff; however, this cannot be assumed.

Crisis Preparedness and Pandemic Needs

  • Infection control: Rural providers may lack space that can be dedicated for isolation, supplemented by a substantial amount of PPE. All but one rural community respondent had positive resident and staff cases.
  • Relationships with local hospitals: Local, critical-access hospital relationships can be strained when hospitals do not fully understand why isolation units are established in long-term care.
  • Relationships with vendors: Stand-alone care providers may lack relationships with national vendors; however, partnerships with existing service management companies (e.g., dining services) can enable these providers to access otherwise unattainable supplies. Value First vendors continuously update available resources, so rural members may consider this alternative for supply acquisition.
  • Community relationships: One rural member noted that the PPE supplies provided through its area emergency management group became a lifeline. However, the pick-up location was 90 minutes away, causing a different layer of challenge.
  • Local support: Local health departments need to be prepared. A lack of such preparedness directly impacts all providers in a county through ambiguous and sometimes conflicting guidance, as well as an extremely ineffective testing system.
  • Networking: A rural LeadingAge member suggests that LeadingAge and its state partners, CMS, state agencies, local health departments, hospitals, and nursing homes meet at least once per week to share available changes and updates.
  • Technology: Tablets enable residents to communicate with friends and family, and enable provider leadership to communicate with resident and family members via email. In concert with Zoom or other teleconference platforms, these can also be utilized for medical provider appointments.
  • Resources: Rural providers need templates for emergency plans and for communicating with individual stakeholder groups, in addition to resources for replacement staffing.

Additional Resources

Rural Lessons Learned

In the midst of an emergency as impactful as a pandemic, we must often act first and reflect later. It’s common for leaders to ask themselves retrospective questions, such as:

  • Did I act too quickly or too slowly?
  • What could I have done differently?
  • Did my approach of choice work as well as I anticipated it would?
  • How can I improve my responses if a pandemic recurs?

And then, of course, there are a lengthy series of “What ifs” that we ponder.

LeadingAge has received numerous “lessons learned” tips from members during the COVID-19 pandemic, which we are sharing at the conclusion of each related Playbook Section. In addition, a compilation of shared Lessons Learned may be referenced in the Playbook Appendix.

“We were as well prepared as we could have been based on what we knew. We followed all the recommendations and diligently conducted employee and resident screenings. We completed a series of tabletop exercises and conducted weekly in-services [and] education. We performed infection control competencies and randomly conducted infection control surveillance for staff members. We adopted COVID-specific policies and procedures.

“You can get hit very hard, very fast, and you have to make decisions quickly. We lost 45 of 83 employees over 3 days due to testing positive, contact tracing, or they were fearful and just quit. Every single department manager except dietary was out, including the MDS nurse, the assessment nurse, and the director of nursing. None of the employees had symptoms prior to baseline testing and more than 90% of them never had any symptoms after testing positive. We did everything correctly and diligently to try to keep COVID out of our facility, but COVID found its way in anyway. Access to PPE is in limited supply. The financial impact is going to hurt LTSS providers in the present and future.”

– Billy Johnson, campus director, Baptist Village of Hugo, Hugo, OK

More lessons learned:

Affordable Housing

In a pandemic, affordable housing providers face the unique challenges of navigating HUD and CDC guidelines for resident safety and infection control with a very limited staffing model and tight budgets. Pressing needs for funding, meal service coordination, resident education and communication, cleaning and disinfecting properties, and other issues must be carefully managed and balanced.

LeadingAge resources:

Ensuring that hospice and palliative care professionals are able to maintain contact with and access to clients must be a priority. Grief support for all those experiencing loss can be offered by a hospice provider and give much-needed resources to community members.

Hospice and Palliative Care

An essential care and support service in any circumstance, hospice and palliative care can be even more vitally important in the event of a pandemic. Ensuring that hospice and palliative care professionals are able to maintain contact with and access to clients must be a priority. Grief support for all those experiencing loss can be offered by a hospice provider and give much-needed resources to community members.

LeadingAge resources:

Home and Community-Based Services

Home and community-based services (HCBS) can be a lifeline for older adults living in community during a pandemic. Caregivers with dependent family members will need additional support in caring for their loved ones, and working together with other aging services providers, legislators, and regulators can be key to ensuring some of the HCBS remain available.

LeadingAge LTSS Center @UMass Boston research reports:

Home Health

Successful recovery at home—whether in the community or in a retirement setting—may be heavily dependent on home health providers, especially during a pandemic. Maintaining access to critical therapies, medical oversight, and a visiting nurse is fundamental to the healing process for older adults, and a pandemic may make it immensely challenging to continue services. Home health providers need support and guidance from public health authorities and state and federal regulatory agencies to deliver services safely and reliably for both clients and employees.

In a pandemic, adult day and PACE programs may be some of the first to discontinue services to older adults, depending on the method and intensity of the disease’s spread. The absence of these essential services may create a great strain on the families and caregivers that are dependent on their day-to-day operations.

Adult Day Services and PACE

In a pandemic, adult day and PACE programs may be some of the first to discontinue services to older adults, depending on the method and intensity of the disease’s spread. The absence of these essential services may create a great strain on the families and caregivers that are dependent on their day-to-day operations. Maintaining robust and frequent dialog with all persons-served, families, and with state and federal regulators can foster crucial understanding of needs and hopefully hasten the resumption of services, albeit perhaps in an alternative form.

LeadingAge resources:

Skilled Nursing

Already the most highly regulated area of aging services, skilled nursing providers will face a multitude of challenges on all fronts in the event of a pandemic. Staying on-pace with rapidly changing guidance and regulations, keeping residents safe and protected, implementing intensified infection control measures, training and retaining staff, managing staff shortages, and balancing the social needs of families and residents will be just a few of the core competences that nursing home leaders must practice. Working closely with, and providing a steady stream of information to, legislators and regulators as well as the press can make an immense difference in the success of a SNF’s pandemic mitigation.

LeadingAge LTSS Center @UMass Boston research reports:

LeadingAge resources:

Other resources:

Assisted Living

Although not as highly regulated as skilled nursing facilities, assisted living communities face nearly the same challenges in a pandemic. Issues include keeping up with rapidly changing guidance (if issued by the state), working to protect residents while honoring the socialization needs of being with family, intensifying infection control, maintaining open lines of communication with all stakeholders, and managing myriad workforce issues. The challenge for assisted living communities is to divine from limited federal guidance, and in some cases limited state guidance, a clear path forward for daily operations.

Life plan communities […] may find themselves balancing the regulatory challenges of skilled nursing, the potential void of guidance for assisted living, and the interpretative adaptations needed of [HCBS] and hospice. In addition, LPCs must determine how to handle safety, movement, and autonomy of a large independent living population that may or may not comply with community infection control measures.

Life Plan Communities

Housing many aging services provider types within one dynamic umbrella, life plan communities/continuing care retirement communities (LPCs or CCRCs) may find themselves balancing the regulatory challenges of skilled nursing, the potential void of guidance for assisted living, and the interpretative adaptations needed of home and community based services and hospice. In addition, LPCs must determine how to handle safety, movement, and autonomy of a large independent living population that may or may not comply with community infection control measures. As with all providers, LPCs will face a difficult financial balancing act to ensure much-needed supplies, staff, and equipment are available for an indeterminate duration.

LeadingAge resources:

Provider-Specific Reopening Guidance

LeadingAge resources:

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