Proactivity and Partnership Pay Off for Nursing Homes in a Pandemic

Advance planning, universal testing and connection with a medical center kept COVID-19 activity low in three facilities in new study.

8:21 AM

Author | Kara Gavin

nursing home close to hospital
Graphic: Stephanie King

Seven months ago, the nation first heard of a surge of COVID-19 deaths in a Washington nursing home – an early warning sign of how the coronavirus could rip through such facilities. Since that time, more than 40% of the Americans killed by the pandemic have lived in nursing homes.

Now, a new study details how three Michigan nursing homes limited the spread of the coronavirus within their walls after the first cases were diagnosed in that early peak state.

The findings, published in the Journal of the American Geriatrics Society, could inform the ongoing effort to protect nursing home residents regionally and nationwide.

All three nursing homes in the study went into the pandemic with a proactive, partnership-based approach to general infection prevention, and response plans already in place that paved the way for effective COVID-19 containment.

This was made possible in part by their formal connections pre-COVID with Michigan Medicine, the academic medical center of the University of Michigan. This includes embedded U-M geriatric physicians and nurse practitioners, regular meetings among clinical and administrative team members from the institutions, and a long history of involvement in U-M research. The nursing homes also connected proactively with the county health department.

Rapid action and testing

Having these plans and connections in place meant that when coronavirus cases started popping up in Michigan in mid-March, the three facilities could immediately spring into action.

One of the linchpins in their response: COVID-19 viral DNA testing offered through Michigan Medicine's in-house diagnostic laboratory, with results available within 24 hours, or at the most two days.

SEE ALSO: Nursing Homes Prepared for Pandemics, but COVID-19 Reveals Gaps

Proactive testing of symptomatic and asymptomatic residents, and timely test results, played a crucial role in containing the outbreak of COVID-19 in these facilities, the authors say. The in-house laboratory prioritized samples from the nursing homes, so the results came much faster than they had with the commercial laboratories that had been used at first.

"As soon as we heard of cases in the Washington nursing homes, we teamed up to devise a point-prevalence testing effort that would test asymptomatic residents, in addition to testing those with symptoms, in an effort to mitigate transmission," says Ana Montoya, M.D., M.P.H., the medical director for sub-acute care at Michigan Medicine and first author of the new paper. "The results drove a tremendous effort by nursing home staff to prevent further spread to uninfected residents."

Such proactive testing recently became a federal requirement, with the frequency depending on the level of COVID-19 activity in the surrounding community. Nursing homes are also subject to reporting requirements and potential fines if they don't report testing results. But in recent weeks, the government has sent nursing homes rapid-testing machines that are less sensitive than the "gold standard"  viral DNA tests used in the study. Further research will be needed on the impact of this approach, the researchers say.

"While rapid-testing machines allow facilities to do their own testing, most facilities are still struggling with how to best utilize the machines," says Grace Jenq, M.D., the study's first author, a geriatrics specialist and associate chief clinical officer for post-acute care at Michigan Medicine. "These rapid-testing machines most likely will be used for testing symptomatic residents and staff. Test results are available within minutes, so then they can be rapidly isolated and PPE can be deployed to staff caring for the individual. Negative tests will still need to be repeated using the more sensitive PCR tests."

Testing to stop spread

In all, 29 of the 215 residents in the three Michigan nursing homes in the study were diagnosed with COVID-19 between mid-March and late April. About half required hospitalization, and six died within 14 days of diagnosis.

Sixteen of the cases were caught by testing residents who showed symptoms between March 23 and early April.

As soon as we heard of cases in the Washington nursing homes, we teamed up to devise a point-prevalence testing effort that would test asymptomatic residents, in addition to testing those with symptoms, in an effort to mitigate transmission.
Ana Montoya, M.D., M.P.H.

But after a proactive testing blitz of asymptomatic residents in early April, only one case of symptomatic COVID-19 was identified through April 23 in each of the nursing homes in the study.

SEE ALSO: Seeking Medical Care During COVID-19

That blitz was important because it detected 10 residents who were infected but didn't have symptoms – which could mean they were asymptomatic or pre-symptomatic. This represents a full 4.7% of all residents.

Six of the 10 residents went on to develop symptoms within a few days of their test, which means they were likely to have spread the virus to other residents and staff if their infection hadn't been detected. None of them needed hospital care.

The "blitz" of testing was carried out in a single day at each facility in early April – a time when testing people without symptoms was very unusual. It allowed the nursing homes to move infected but asymptomatic residents away from others in designated COVID-19 sections of the facility.

SEE ALSO: Nursing Homes Cut UTIs in Half Through a Focused Effort on Catheter Care

More than 600 staff were also tested; 3.8% tested positive and were told to stay home until their risk of transmitting the virus had gone down.

While the new study does not include longer-term patterns of infection, the authors note that infection numbers in the three nursing homes have continued to be low. A fourth nursing home also affiliated with Michigan Medicine reported no COVID-19 cases in the peak months of March and April.

Implementing existing plans

As soon as symptoms were diagnosed or a COVID test came back positive, the nursing homes followed their plan to move COVID-19 positive residents into a dedicated wing staffed by teams that only cared for COVID-positive residents. 

The creation of the COVID-19 wings took a collective effort among all nursing home staff, even those not usually involved in direct resident care and cleaning. Administrative staff helped move furniture, and more.

Montoya notes that clinical teams worked together creatively to reduce unneeded interaction between staff and patients infected with the virus.

This included changing the frequency of medication dosing, procedures that could aerosolize the virus, and temporary reduction in routine blood draws and other testing. The nursing homes implemented alternative bathing options if the resident's temporary room had no shower, and arranged to bring services to them instead of having them leave their room for therapy or meals.

Staff who worked at more than one nursing home, including those not in the Michigan Medicine-linked facilities, were asked to pick one and work there exclusively, to avoid carrying the virus between facilities.

SEE ALSO: Keeping Our Patients Safe During COVID-19

Importantly, staff received hazard pay, meals and in one nursing home, even a dedicated space to stay overnight to avoid taking the virus home to their families. Special break areas were created in areas formerly used for communal resident activities, to allow staff a space to decompress and eat during a stressful time.

The facility's leadership communicated about testing and results with residents, healthcare professionals, and families; and embarked on intensive cleaning as well as re-education efforts for staff about personal protective equipment use. The companies that own the nursing homes also made special efforts to obtain enough PPE for staff when it was in shortage.

Montoya's co-authors include Lona Mody, M.D., M.Sc., who has studied infection transmission and prevention in nursing homes for more than a decade and was senior author of a paper published in April about pandemic preparedness among Michigan nursing homes at the start of COVID-19.  She also served as a consultant to the Center for Health and Research Transformation on its independent report about Michigan nursing homes and COVID-19. 

"We were particularly happy to see various teams come together in a moment of crisis with a shared purpose," says Mody. "We knew that even a little delay would have enormous consequences. Our experience shows the incredible value of research, collaboration and connections. We hope that our work informs state-level and national actions to limit devastating consequences from COVID-19."

Montoya, Jenq and Mody are all faculty in the Division of Geriatric and Palliative Care Medicine at the U-M Medical School. In addition to them, the study's authors are John P. Mills, MD, Jennifer Beal, DO, Erin Diviney Chun, MD, Duane Newton, PhD, Kristen Gibson, MPH, Julia Mantey, MPH, MUP, Kristen Hurst, BA, and Karen Jones, RN, MPH, CIC.

Montoya has a joint paid position at one of the nursing homes involved in the study, as part of Michigan Medicine's partnership agreement.

Paper cited: "Partnering with Local Hospitals and Public Health to Manage COVID‐19 Outbreaks in Nursing Homes," Journal of the American Geriatrics Society. DOI: 10.1111/jgs.16869

More Articles About: Industry DX Nursing Homes Covid-19 Work Safety Geriatrics
Health Lab word mark overlaying blue cells
Health Lab

Explore a variety of healthcare news & stories by visiting the Health Lab home page for more articles.

Media Contact Public Relations

Department of Communication at Michigan Medicine

[email protected]


Stay Informed

Want top health & research news weekly? Sign up for Health Lab’s newsletters today!

Featured News & Stories Minding Memory with a microphone and a shadow of a microphone on a blue background
Minding Memory
The Intersection of Artificial Intelligence & Alzheimer’s Disease and Related Dementias
In this episode, Matt and Donovan talk with Dr. Jason H. Moore, Director of the Center for Artificial Intelligence Research and Education (CAIRE) and Chair of the Department of Computational Biomedicine at Cedars-Sinai Medical Center. Jason discusses the coming impact of artificial intelligence on a spectrum of Alzheimer’s disease and related dementia (ADRD) issues. We discuss how tools such as AI-powered chatbots may improve quality of life for people living with dementia (and their caregivers) and how AI may contribute in the future to diagnosis and treatment.
Provider takes a pulse oximetry reading from a patient's finger
Health Lab
Inaccurate pulse oximeter readings could limit transplants, heart pumps for Black patients with heart failure
Racially biased readings of oxygen levels in the blood using pulse oximeters may further limit opportunities for Black patients with heart failure to receive potentially lifesaving treatments, such as heart pumps and transplants
Minding Memory with a microphone and a shadow of a microphone on a blue background
Minding Memory
The Professional Workforce of People Who Provide Dementia Care
In this episode of Minding Memory, Matt & Donovan speak with Dr. Joanne Spetz, the Brenda and Jeffrey L. Kang Presidential Chair in Healthcare Finance and Director of the Philip R. Lee Institute for Health Policy Studies at the University of California, San Francisco (UCSF). Joanne talks with Matt & Donovan about who makes up the professional workforce of people who provide dementia care and how these individuals play a critical role in the delivery of services. Joanne also discusses how different professional roles interact across setting of care. Lastly, Joanne introduces a new study she is working on with Donovan called the National Dementia Workforce Study (NDWS) that will be surveying a large group of clinicians who provide care for people living with dementia.
Woman sleeping on a couch holds her stomach, as if in pain
Health Lab
Long COVID-19 is linked to chronic pain conditions
Therapies for pain conditions like fibromyalgia provide clues for helping those with long COVID-19
Older woman listening to music with headphones as she lays on a couch.
Health Lab
Music may bring health benefits for older adults
Making music by singing or playing an instrument, or listening to music, brings health and wellbeing benefits to many older adults.
Surgeon's tray with gloved hand reaching into wallet
Health Lab
Worries about costs, time off work and COVID-19 kept some older adults from having surgery
Elective surgery study shows older adults have concerns about what it will cost them, how much work they’ll miss and whether they’ll catch COVID-19.