In the event of a pandemic that involves a highly contagious infectious disease, resuming “normal” operations for an aging services provider will greatly depend on reliable testing, contact tracing, workforce availability, and vaccination availability/acceptance.
The COVID-19 pandemic, in particular, drew significant focus on the aging services sector for an extended period of time. This much-neglected and underfunded sector faced unimaginable challenges with commitment to those served and with sustained resilience.
LeadingAge is seizing this moment to launch “Opening Doors to Aging Services,” a multi-year initiative to expand consumer awareness, understanding, and support for providers of older adult care and services as well as the millions of Americans they serve every day with dignity and compassion.
We have learned that reopening is not a moment, but an extended period in which we adapt and modify to keep residents, visitors, and staff as safe as possible.
Scientific study, research, and evidence of transmission mitigation will drive management decisions regarding the timing and parameters around “safe” reopening. Executive decisions will require a well-informed and thoughtful process, including a comprehensive understanding about the disease itself, and how it can be transmitted, detected, and contained.
Organizations will need to identify reliable sources of infectious disease information/data and will need to collaborate closely with state and local health agencies to ascertain the appropriate methods for testing/contact tracing and vaccine administration.
Testing and Contact Tracing
Many aspects of testing must be considered and provided: testing methodology, testing supplies, labs for test processing, reliability, speed and accuracy of testing results, frequency of testing, stakeholder groups that will be required or requested to participate in testing, and reporting of test results, to mention a few. The question of what entities will bear the burden of immediate and ongoing testing costs must be negotiated. Organizations should expect to work closely with their trade associations and advocacy groups to ensure that their needs and expenses are well represented to regulatory and legislative bodies with decision-making authority.
Contact tracing will also be of key concern to individuals, organizations, and state and local agencies. Aging services providers will need to be prepared to participate in and report on individuals’ contacts with others, should an exposure to a highly contagious, infectious disease occur within their stakeholder groups. State and local health departments will likely request this information, and providers of care and services will need to be prepared to monitor and protect such information accordingly.
- Coronavirus Testing Basics (FDA)
- Contact Tracing (CDC)
- Case Investigation and Contact Tracing: Part of a Multipronged Approach to Fight the COVID-19 Pandemic (CDC)
- Contact Tracing: A Critical Component in Combatting COVID-19 (Lippincott NursingCenter Blog)
- Texas senior living facilities using wearable tech for COVID-19 contact tracing (KXAN News, Austin, TX)
- Testing Guidelines for Nursing Homes (CDC)
- From swabs to antibodies: How to understand your coronavirus test results (Washington Post)
- Table of Testing, Visitation, and other LTC COVID Considerations by State (National Governors Association)
- HHS to Send Rapid Point-of-Care Testing to Nursing Homes (LeadingAge)
- Diagnostic Testing Support for Affordable Housing Communities (LeadingAge)
- Infection control policies for reopening: FAQs from AMDA
- LeadingAge audio interviews:
- April 23, 2020: Dr. Nicole Lurie of CEPI Offers Facts and Cautions About COVID-19 Testing. (Article based on the interview: Expert Insight from Dr. Nicole Lurie: The State of COVID-19 Testing)
- May 29, 2020: Minnesota Testing Spotlight with Sharon Zehe of the Mayo Clinic and Karen Martin and Diane Rydryc of MN Dept. of Health
- June 10, 2020: Gus Keach-Longo of The Towers at Tower Lane on Testing, Tracing, and a “Soft Opening” in Elder Housing.
- Template Letter for Communities Who Are Testing for COVID-19 (Word document)
- Template Letter for Communities With a Positive COVID-19 Case in Resident or Employee (Word document)
- Editable sample documents based on forms by Hebrew Home at Riverdale:
Alignment of Federal and State Guidelines
Organizations may find that guidelines for resuming their operations will differ between federal and state agencies; multi-state organizations may discover that guidelines are marginally or markedly different between states. Navigating these differences may present a considerable challenge, and organizations should be prepared to allot significant time and resources to distilling these guidelines down to the essential requirements that must be met to ensure compliance with regulatory bodies such as CMS, OSHA, Life Safety codes, and others. Beyond those compliance-driven requirements, organizations will need to navigate guidelines that leave their implementation to the discretion of organizations themselves.
As organizations plan to resume operations, they may find it necessary to help residents, persons served, staff, and other stakeholders grieve the loss of life precipitated by the pandemic. Funerals, celebrations of life, and other customary memorial events that may be initially postponed due to the pandemic may now be possible as services and supports return to normal.
Organizations will need to be aware and considerate of these changes, and ensure they are prepared to implement whatever transitional supports or requirements are necessary in End-of-Life situations.
- Advanced Care Planning, Grief, and Serious Illness Communication Resources (LeadingAge)
- Audio interview: April 17, 2020, Dr. Danielle Doberman on Advance Care Planning and Coronavirus
- Visitor Decision Flowchart for End-of-Life (LeadingAge)
- Special Visitor and Infection Control Guidance for Hospice (LeadingAge)
Organizations may find that guidelines for resuming their operations will differ between federal and state agencies; multi-state organizations may discover that guidelines are marginally or markedly different between states.
If a pandemic involves a highly contagious, infectious disease, admission of visitors and the general public to aging services providers may be completely restricted or permitted only in end-of-life or compassionate care circumstances. When the time comes to resume visitation, organizations should plan to do so in phases that ensure the safety of all involved, and minimize the risk of disease transmission. Policies and protocols must be developed that thoroughly prepare staff, persons served and family members for the visitation experience. Organizations should refer to their state and local health agencies and governing bodies for guidelines on how to permit safe visitation.
- Screening Tips for Nursing Homes (LeadingAge)
- CMS Updates Guidance on Healthcare Worker and Visitor Entry (LeadingAge)
- ‘Thoughtful approach’ to reopening necessary to balance risks, benefits (McKnight’s Senior Living): Taking a measured approach to resuming visitation and group activities, advocating for COVID-19 vaccines, continuing visitor screenings, and requiring masking and social distancing are among the recommendations that AMDA is making to long-term care facilities as operators consider lessening restrictions that in many places have been in effect for almost a year.
- Verified Vaccinated Visitors program allows unrestricted access in senior living (McKnight’s Senior Living): Weighing the risks versus benefits of loosening up restrictions in the independent living part of its life plan community, one New Hampshire long-term care provider is launching a new visitation program for vaccinated individuals.
- Interim Recommendations for Communal Activities and Visitation in Post-Acute and Long-Term Care Facilities (AMDA PDF): This guidance covers the need for continued masking, physical distancing, and use of other essential infection control precautions, and discusses risks from vaccine hesitancy, continued community outbreaks, and more.
Congregate Dining Programs
To reduce the risk of disease transmission, aging services organizations may elect to pause, alter or reconfigure dining services programs in the event of a pandemic. Congregate meal programs may change significantly or be temporarily halted.
Undertaking the resumption of dining services and/or a congregate meal program will require careful planning and coordination. Organizations that plan to do so should seek guidance from state or local health departments, governing bodies, the Food and Drug Administration, the Centers for Disease Control and Prevention, and other agencies as appropriate.
- The Food System Can’t Survive this Crisis, but a Better System Can Be Built (Ideo)
- Preparing to Resume Dining Services (LeadingAge QuickCast)
- Seniors COVID-19 Guide for Reopening Dining Rooms (Sodexo)
- Reimagining European Restaurants for the Next Normal (McKinsey & Co.)
- LeadingAge Member Ideas and Inspiration stories:
- Meals Delivery, Grab-and-Go, and Grocery Delivery for Residents
- A Partnership to Ensure Food for Affordable Housing Residents
- Staff Stepping Up to Ensure Passover Meal Deliveries
- Pop-Up Groceries Allow Residents to Stay Home
- In-House Grocery, Frozen Meal Services Instituted
- A Large Meals Program Ramps Up Dramatically
Recovery from a pandemic can create a perfect storm of low occupancy, high/unbudgeted expenses, and staffing challenges—all of which may seem insurmountable. For some providers of long-term services and supports, their operations will ultimately be unsustainable. For others, there may be a period of widespread expense reduction, use of staffing agencies to supplement employees and repurposing of resident rooms. Above all, a post-COVID environment prioritizes protecting assets, implementing operational efficiencies, and supporting staff.
The intense financial pressure, uptick in merger/acquisition activity, and marketplace volatility has placed long-term services and support providers in one of the most challenging periods of our time—even worse than the 2008 market collapse. For the majority, who have begun to rebound from a stretch of unforeseen and unimaginable financial stress, a return to stability will be slow, yet steady.
Long-Term Services and Supports
- Opening Doors to Aging Services is a multi-year LeadingAge initiative to introduce the wide range of aging services and care available to older adults and their families. Data from the initiative is part of the care economy debate that includes significant and much-needed federal investment in care and services for older adults. The foundational research (completed in summer 2021) is available now, and strategies and tools for members will be available in the fall.
- Long-Term Care Policy after Covid-19—Solving the Nursing Home Crisis (New England Journal of Medicine): Nursing homes have been caught in the crosshairs of the coronavirus pandemic.
- Post-vaccine: The future of senior living (McKnight’s Senior Living): Even though millions of Americans are now vaccinated, however, particularly for those of us who serve elders in communal living, we will not be automatically reverting to how things were before the pandemic.
- Preparing to thrive after the COVID-19 storm (PDF, from McKnight’s Executive Power Panel): Industry leaders home in on specific ways long-term care providers can succeed, despite the ongoing pressures of the pandemic. They offered strategies and opinions on where operators should be concentrating. Topics included improving staffing levels and retention, digital workflow, infection control practices, rehab processes and more.
- Long-Term Care and Care Facilities Post-COVID-19 Pandemic (Health Management Associates): A team of experts with expertise across the continuum of long-term care reflect on the initial pandemic response and share insights about the crisis, the response, and how to move forward.
- Social Care COVID Recovery & Resilience (International Long-term Care Policy Network): Learning lessons from international responses to the COVID-19 pandemic in long-term care systems.
- Pandemic Paralysis (McKnight’s Senior Living): Recovery efforts for leaders in long-term care likely won’t be talked about or publicized, but recovering from this paralysis is real and will take time.
- What Happens When Americans Can Finally Exhale (The Atlantic): The pandemic’s mental wounds are still wide open.
- Why ‘getting back to normal’ may actually feel terrifying (National Geographic): After a year of anxiety, anger, and burnout, many people are struggling with returning to pre-pandemic behaviors. Experts weigh in on ways to work through the trauma.
- AMDA recognizes that surviving COVID requires “Healing Together”: We just passed the one-year mark of what many health care professionals describe as the most difficult year of their careers. Importantly, most of us are suffering from emotional and psychological trauma.
- Navigating the stress of the long COVID-19 journey (McKnight’s Senior Living): With the rise of the Delta variant of COVID-19 and the increase of individuals being infected by the virus, the potential increases for reinstating measures to stem the spread of the disease. The uncertainty of the future clearly increases the anxiety for all.
There’s a recurrent question of whether a pandemic can have a silver lining, and the response can be positive. Though a devastating disruptor in many ways, it’s been said that the COVID-19 pandemic pushed innovation forward 10-15 years out of sheer necessity. From virtual medical examinations to international, epidemiological think-tanks conferring over Zoom, to robots serving dinners to long-term care residents to limit human contact—it all happened at warp speed.
The following revelations, learnings, and processes have already emerged following the COVID-19 experience:
- The pandemic cast an unfavorable light on the health care disparities long endured by minority populations in America.
- The impact of a pandemic on the physical and mental health of residents and staff cannot be underestimated—despite outward resilience, pandemic impact deserves focused attention and a coordinated response.
- We witnessed a willingness among international scientists to share new ideas and data—both immediately and transparently.
- Daily news reports of untimely and voluminous deaths and emotional interviews of grieving families have inspired genuine human empathy.
- Vigilant use and appropriately placed masks provide protection from pre-symptomatic and asymptomatic COVID-19 transmission, while also reducing the annual flu season impact.
- Technology will have an ongoing role in the future of infection control, compliance, preparedness, telemedicine, and virtual visitation among residents and family members.
As we process these takeaways, it’s an advantageous time to reflect upon how to reimagine the delivery of care and services to older Americans. For example:
- The Mayer-Rothschild Foundation Designation of Excellence in Person-Centered Long-Term Care Project is developing a first-of-its-kind national standard of excellence for person-centered care in long-term care and assisted living settings.
- According to the LTSS Center at UMASS Boston, a number of initiatives have been introduced to elevate the standing of CNAs within the care team, such as including CNAs in care plan meetings, teaching CNAs to identify early signs of illness onset, and offering CNAs instruction in methods that help to prevent resident decline.
- Expanding the development and influence of technology-based learning collaboratives will positively impact long-term services and supports.
Reimagining Long-Term Services and Supports
- Designing a National Designation of Excellence in Person-Centered Long-Term Care: The Mayer-Rothschild Foundation Designation of Excellence in Person-Centered Long-Term Care Project is developing a first-of-its-kind national standard of excellence for person-centered care in long-term care and assisted living settings. A partnership of The Mayer-Rothschild Foundation; The Cedars, a LeadingAge-member provider in Portland, ME; and The University of Maine Center on Aging.
- Post-Pandemic: CNAs Can Help Improve Nursing Home Care (The Research Institute on Aging at The New Jewish Home): We should learn from the expertise of CNAs and think of ways their experience can be used to improve care for older adults and to support CNAs in the workforce.
- Showcasing Community-Based Organization’s Innovative Response to COVID-19 with Evidence Based Programs (NCOA): In the wake of the pandemic, health care and community-based organizations have become creative in providing consumer-centric services that offer high value, based on changing needs.
- By modifying Area Agency on Aging approaches to social engagement programming, older adults can continue to stay safely engaged (The National Resource Center for Engaging Older Adults): To help promote safe connections during COVID-19, AAAs and other community-based organizations have quickly updated their programming and found new ways to offer much-needed resources and services to older adults.
- New senior living demands: Interactive, custom tech (McKnight’s Senior Living): The world of senior living has gone through an accelerated transformation with the events of the past year. As we begin to look forward, it’s clear that residents’ expectations have not just changed but have significantly leapt forward in certain areas, especially in technology.
- Long-term care should use more tech-based learning collaboratives (McKnight’s Senior Living): Article about a session, Panel IV- Technology Innovations for Crisis Management, at the 2021 Collaborative Care & Health IT Innovations Summit): Technology-based learning collaboratives are an underutilized resource within long-term care and may be a great tool to help the field develop a pandemic preparation plan for the future.
- Pandemic Disruption Spurred Innovation in Aging Services (Next Avenue): Groups share their success stories and some lessons for the future.
- The future of long-term care requires investment in both facility- and home-based services (Nature): If there is a silver lining to COVID-19 and long-term care, the pandemic will hopefully accelerate the decades-long push towards expanding HCBS while also causing a reconceptualization of nursing home care.
- Senior living design: Post-COVID trends and innovations (Building Design + Construction): Two senior living design experts discuss the latest trends and innovations in the senior living building sector.
- A Fresh Look at Your Organization Can Turn Challenge Into Opportunities (CLA resource): The COVID-19 pandemic has rattled many organizations, but with the right approach, you can turn challenges into opportunity. Taking a fresh look can help you adapt, grow, and improve your financial health. You’ll gain valuable insights and data to set goals and create an action plan.
- ‘Game-changing’ wellness model takes person-centric approach to 40-year-old industry standard (Mather Institute): The idea that wellness means something different to everyone has inspired the Mather Institute to develop a Person-Centric Wellness Model meant to accommodate senior living residents’ unique wants and needs.
- Payment, regulatory and staffing reforms could emerge from effort to ‘reimagine’ care for older adults (McKnight’s Senior Living): Aging and caregiving experts are engaging in a year-long national dialogue to explore the future of long-term care, including innovative ways to expand the direct care workforce, increase home and community-based services, and reform payment models.
- Provider expands services into home care (McKnight’s Senior Living): American Baptist Homes of the Midwest has eight communities across six states: Colorado, Iowa, Minnesota, Nebraska, South Dakota, and Wisconsin. Outside the walls of those communities, caregivers will drive to local homes to provide the services individuals need.
- The good that came from COVID (McKnight’s Senior Living): The silver lining: Collaboration. Support. An understanding that we all together nurture individuals.
Reimagining Workforce Management
- Feeling Valued Because They Are Valued: A Vision for Professionalizing the Caregiving Workforce in the Field of Long-Term Services and Supports (LeadingAge LTSS Center@UMass Boston): “Despite the valuable work they do, direct care professionals are not valued by our society or its health care system. Too many of these caregivers earn low wages, receive inadequate benefits, and endure poor working conditions while carrying out an extremely labor-intensive job. Inevitable staffing shortages and workforce instability will lead to lower-quality care, lower-quality of life for consumers and their families, and unmet needs among care recipients.” This LeadingAge report also considers what a reimagined, professionalized direct care workforce would look like.
- How to Do Hybrid Right (Harvard Business Review): When designing flexible work arrangements, focus on individual human concerns, not just institutional ones.
Reimagining Health Care
- Covid pandemic should serve as ‘Chernobyl moment’ for global health reform (Stat): A report from an international panel of experts calls for swift negotiations to lift intellectual property protections for Covid vaccines—and an automatic waiver if the negotiations fail to deliver within three months.
- How COVID Changed Science (Scientific American): What is unprecedented is not just the speed and focus with which the community responded to the pandemic but also the singular willingness of scientists all over the world to share new ideas and data immediately and transparently.
- 4 innovations that found their use case during the pandemic (Medical Marketing and Media): These four innovations were in the works prior to COVID-19, but the pandemic presented the right conditions for them to connect.
- CEPI launches plan to tackle risk of future pandemics and epidemics: The Coalition for Epidemic Preparedness Innovations launched a $3.5 billion plan to dramatically reduce or even eliminate the future risk of pandemics and epidemics, potentially averting millions of deaths and trillions of dollars in economic damage.
- Life after COVID: Remote patient monitoring will be even more critical (McKnight’s Senior Living): One positive outcome that came out of the pandemic has been the expansion of telehealth capabilities. Now that patients have experienced the convenience of telehealth, most prefer it to in-person care when possible.
Lessons Learned: Reopen and Recover
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 is 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.
- 5 Ways to Reopen America Safely (LeadingAge LTSS Center research report)
- How to Think about Long Term Strategy When You can Barely See Past Tomorrow (Ideo)
- Innovating from Necessity: The Business-Building Imperative from the Current Crisis (McKinsey & Co.)
- Creating a Path Towards the Next Normal in Senior Living (International Council on Active Aging white paper)
- The Beginning of the End of the American Pandemic (The New Yorker, May 2021): The country is reopening. What does the future hold?
- Quarter of COVID patients have post-acute symptoms (white paper from FAIR Health, Inc.): An analysis of nearly two million private U.S. health care claims has found that one-fourth of people with COVID-19 develop at least one lingering post-acute condition.
When the time comes to resume visitation, organizations should plan to do so in phases that ensure the safety of all involved, and minimize the risk of disease transmission.
LeadingAge Member Ideas and Inspiration stories:
- A Unit to Nurse COVID-Positive Residents Back to Recovery
- A Partnership to Bring COVID-19 Testing to At-Risk Elders
- Transitional Care Center to Operate as a COVID-19 Post-Acute Care Center
- Provider Innovates in Face of Multiple Challenges
- Independent Living Meals Delivery Schedule Changes
Audio interviews from LeadingAge Daily Calls:
- April 30, 2020: Sharon Wilson-Geno of VOA on How VOA Pivots to Cope With COVID-19.
- May 4, 2020: Dr. Paul Katz of FSU College of Medicine on Containing Outbreaks, Testing, and Workforce Challenges
- May 7, 2020: Dr. Nimalie Stone of CDC on the Role of CDC and Difficulties That Face Aging Services Providers
- May 11, 2020: Neal Buddensiek, M.D., of Benedictine on a Multi-State Provider’s Pandemic Preparation, and Concerns About Testing
- May 26, 2020: Kate Shepard of Reformed Church Home on Recovered Residents, Maintaining Positivity, and Testing.
- May 28, 2020: Ami Schnauber of LeadingAge NY on the Nightmare of Coronavirus in New York
- June 17, 2020: Tina Sandri of Forest Hills of DC on Coping With COVID-19 Early, Plus Workforce and Testing Difficulties
- June 25, 2020: Kim Brooks of Hebrew SeniorLife on How HSL is Thinking Through Reopening.
- July 1, 2020: Deke Cateau of A.G. Rhodes on Morale, Testing, and Reopening.
- July 6, 2020: Nancy Evans of CSI Support and Development on How a Large Housing Provider Copes and Thinks About Reopening
- July 10, 2020: Allison Salopeck of Jennings on PPE, Testing, and Managing Outdoor Visitations.
- July 23, 2020: Dr. Noah Marco of Los Angeles Jewish Home on Letting Residents Decide Their Own Risk Tolerance; Plus Testing
- “Reopening” to Visitors: A Review of CMS and States’ Guidance to Nursing Homes (LeadingAge)
- “Reopening” to Visitors: A Review of States’ Guidance for AL (LeadingAge)
- Advice on Re-Opening from Senior Options
- Reopening Guidance for COVID-19 Available by State (HHS)
- Eldercare staff keep the good times rolling amid lockdowns (Catholic Health World)
- Succeeding Despite the 2020 Pandemic (McKnight’s Power Planning e-book; registration required)
- FEMA Exercise Starter Kit for Resuming Operations Post-COVID: Includes sample documents to conduct your own planning workshop to navigate returning to full operations during the pandemic. The Kit includes a sample facilitator guide and conduct slides designed to be adapted and customized for your own needs. Suggested discussion questions for the workshop build upon reconstitution planning principles and relevant White House guidance for employers included in the Guidelines for Opening Up America Again.
- Restart Readiness Checklist (CDC): A guide (for non-health care employers) to resuming business operations as safely and healthy as possible for you, your employees, and the public. Includes a resources section for links and QR codes to web resources.
- Considerations for Balancing Seniors Housing Residents’ Safety as Communities Reopen (American Seniors Housing Assn., fee based resource): Research and advisory services firm ATI Advisory and CEO Anne Tumlinson present the results of case studies and interviews across the industry that reveal how seniors housing operators are gradually restoring resident engagement, allowing non-essential visitors, and enabling new move-ins while taking a strategic public health approach to balance multiple competing priorities and risks.
- State Strategies for Ongoing Post-Acute and Long-Term Care Resident and Staff COVID-19 Vaccination (PDF): This guidance helps prepare for ongoing vaccination programs to cope with the usual turnover in residents and staff in a long-term care community. (On The AMDA Update on COVID-19 page, a one-stop site for a wide variety of AMDA’s pandemic resources.)