I have spent a lifetime in medicine caring and advocating for aging patients, and worrying about them. Meanwhile, medicine has changed from a profession centered on the relationship between one doctor and one patient, into a highly profitable industry centered on expensive procedures and pharmaceuticals — on technology over touch. There has been one major exception to this trend: the subspecialty area of geriatrics, notably long-term care (LTC) medicine and palliative care. Our older citizens are dying by the tens of thousands, yet who does CMS blame for the disgraceful number of COVID-19 deaths in LTC? The facilities themselves, of course.

Socializing with family and friends is essential for older adults in long-term care because it significantly reduces the depression and anxiety that may come from isolation and loneliness. Unfortunately, today socializing may also bring COVID-19 infections to one of the most at-risk populations for morbidity and mortality from this disease. It is estimated that over 40% of the COVID-19 deaths in LTC resulted from visitation, which in turn resulted in most LTC settings banning visitors. We have now gained a better understanding of how to manage the risk of COVID-19 spread while benefiting from reopening to visitation, so many LTC communities will be entering a phase of readmitting visitors.

Since the onset of the COVID-19 pandemic, the responsibilities of health care professionals practicing in long-term care settings have expanded dramatically, with self-care becoming an essential skill. Many, however, have found themselves unprepared for the change. To help providers and staff, Ithaca College and its partners have adapted for the LTC settings Stress First Aid, a self-care and peer support model developed for the military (Nash et al, “Combat and Operational Stress First Aid for Caregivers Training Manual,” U.S.

David A. Nace, MD, MPH, CMD, president of AMDA – The Society for Post-Acute and Long-Term Care Medicine, is representing the Society on the administration’s new Commission for Safety and Quality in Nursing Homes. The Commission was created to conduct a comprehensive assessment of the nursing home response to the COVID-19 pandemic. It includes leading industry experts, clinicians, medical ethicists, administrators, academicians, infection control and prevention professionals, state and local authorities, residents, families, resident/patient advocates, and other experts.

Post-acute and long-term care facilities have learned more about how to respond to outbreaks of COVID-19, as well as the consequences of ineffective responses or none at all. COVID-19 also “has exposed how fundamentally broken our approach to providing care and support to our nation’s older adults has become,” writes Christopher E. Laxton, CAE, the executive director of AMDA – The Society for Post-Acute and Long-Term Care Medicine, along with his coauthors David A. Nace, MD, MPH, CMD, and Arif Nazir, MD, FACP, CMD, AGSF, in a recent special article.

Being regarded as a hero may contribute to unrealistic expectations that may be detrimental to the health care worker. 3

Website: https://apex.paltc.org/local/catalog/view/product.php?productid=311

Editor’s note: This column was inspired by a real case, and the responses of the team members have been written by the editors of the column as an example of how the interdisciplinary team (IDT) can contribute to comprehensive, person-centered care.

Physicians, nurse practitioners (NPs), and physician assistants (PAs) often face ethical challenges while facilitating transitions of care, especially when the transitions appear unsafe for the patient. Two particularly challenging scenarios are discharges from the skilled nursing facility against medical advice (AMA) and discharges associated with cessation of insurance coverage for SNF care. Providers may wonder how to do the right thing while reducing risk to themselves, the SNF, and the patient.

Dear Dr. Jeff: Our facility is being severely criticized by families for not sharing with them information about the status of the novel coronavirus among the residents of our building and among our staff. This seems to go across the board from families of the small number of residents who died or the somewhat larger number who were sick but have recovered and to many families whose loved ones have been absolutely fine. We simply issued statements affirming that we were following CMS and CDC guidelines and doing everything that we could during a difficult time.

As the devastation of the COVID-19 pandemic continues to unfold and the death rate begins to take shape with accurate reporting and more frequent testing, David Grabowski, Ph.D., a researcher at Harvard Medical School’s Health Care Policy Department who studies nursing homes, says that when the final data are in, nursing homes will probably account for about half of all COVID-19 deaths in every state — as they already do in Massachusetts, New Jersey, and Pennsylvania, among others (New York Times, May 5, 2020, https://nyti.ms/3cwZGC5).

The 2019 novel coronavirus (COVID-19) pandemic is the defining global health crisis of our time and the greatest public health challenge we have faced since World War II. Since its emergence in Asia late last year, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has spread to every continent except Antarctica. Cases are rising daily in Africa, the Americas, and Europe (United Nations Development Programme, “COVID-19 Pandemic,” 2020, https://bit.ly/31fHqvf).

Has the advent of COVID-19 changed your life in a significant way? Has it caused a cancellation of that trip to Europe, torpedoed a lifetime dream cruise to the Far East, trashed your budget, doubled or tripled the medical director hours at your struggling facilities, or caused the death or illness of those special facility staff members or residents that you just love to see on rounds? If you answer “No” to such questions, I can only assume you are piloting an Orbiter expedition to Mars, because I know you do not live here on Earth.

More than six months after the SARS-CoV-2 virus began its spread through the United States, nursing home leaders and staff feel battered.

There’s mixed news for the diagnosis and management of epilepsy in nursing homes, where the prevalence of the disorder is estimated to be more than seven times higher than among seniors in the community.

During the session “Expert Consensus on the Use of Telemedicine in the Roles, Tasks, and Functions of the PALTC Medical Director” at the Annual Conference of AMDA – The Society for Post-Acute and Long-Term Care Medicine, Suzanne Gillespie, MD, RD, CMD, noted that the concept of virtual medicine is hardly new. Back in the 1970s, “TV physician Marcus Welby used the phone to render general care,” she pointed out. Even more telling was the scene in the 1960s cartoon The Jetsons, where Elroy tries to stay home sick from school — only to have his mother arrange a telemedicine visit.

They came on the screen — one, then two, then three, then more. At first, they exchanged pleasantries and talked about work and upcoming events. Then Timothy Holahan, DO, CMD, introduced Ghinwa Dumyati, MD, who provided an update on Monroe County, NY, COVID-19 in post-acute and long-term care, including numbers of cases, hospitalizations, and deaths.

“Surrounded by family” is a phrase often used to depict the concept of a “good” death. To die among loved ones is something we desire for ourselves and practitioners want for their patients. The COVID-19 pandemic has changed everything. “It’s hard enough to wrap your brain around death, but this is even more difficult when people have to die alone — without loved ones or even caregivers or other team members at their bedside. That, as much as anything, is making this pandemic about traumatic grief and loss,” said Carla Cheatham, MA, MDiv, PhD, TRT, author of Hospice Whispers: Stories of Life (SCIE, 2015).

Arif Hussain, DO, talks about the risk of falling after a period of isolation and how to stay safe and strong post-COVID.

Health care staff are being applauded as heroes. Signs with “Heroes Work Here” have appeared across the country in front of nursing homes and hospitals. In urban areas, people share their gratitude for health care heroes by banging on pots and pans and clapping as the workers head off to work. Everyone likes a hero story — someone who prevails against the odds and makes the world a better place. We feel uplifted and inspired, at a time when we need it most.