It is amazing that it has only been a little over a month and a half since, the World Health Organization characterized COVID-19 as a pandemic. Since this announcement, healthcare providers have received a flood of recommendations, sometimes changing daily, on how to combat the coronavirus and deal with this public health emergency. For therapists and others providing direct care to the elders in these unusual times, however, the information is often contradictory and sometimes not practical to implement with the individuals we treat.
In addition, as skilled nursing facility (SNF) healthcare providers we cannot help being concerned that our actions or inactions may escalate public scrutiny over the quality of care provided in our setting. The Centers for Disease Control and Prevention (CDC) has reported that cases of COVID-19 have been identified in long-term care facilities across all 50 states, with many having widespread community transmission. Tuning into the news, nursing homes are often vilified for their handling of the situation.
However, we continue to focus on the therapy services needed by the elders entrusted in our care.
Professional Responsibility for Therapy
Regardless of whether your facility has been directly or indirectly impacted by the coronavirus, the residents at your facility still need services during the COVID-19 pandemic. All patients who meet skilled criteria per the Medicare Benefit Policy Manual, Chapter 8, should continue to be evaluated and treated by rehabilitation services.
Eventually, skilled nursing facilities will begin to accept new admissions, and restrictions will be lifted. Remaining will be the impact to seniors who survived prolonged periods of isolation, restricted mobility, decreased strength, weight loss, potential confusion, skin breakdown, and contractures. It is our professional responsibility to be there for our elders before, during, and after the coronavirus crisis.
During this novel situation, healthcare providers are giving increased attention to options for using telehealth for therapy services. Despite the April 30 announcement from CMS allowing physical, occupational, and speech therapy practitioners to provide Medicare-covered telehealth services, clarification is still needed to determine if therapists in skilled nursing facilities who bill under the facility provider number will be included in the expansion of these services.
At this time, we can look to our professional organizations for support and clinical guidance. The American Physical Therapy Association, the American Occupational Therapy Association, and the American Speech-Language-Hearing Association have all stepped up to the challenge and provided a wealth of resources.
Understanding Standard and Transmission Precautions
Exposure to patients with various infectious diseases is not new for us as therapy clinicians. We have all been trained on standard precautions during interactions with patients, regardless of their illnesses.
Yet to better understand how we can best protect ourselves and our patients, we need to start with understanding how COVID-19 is spread. According to the CDC, COVID-19 is thought to spread mainly through close contact from person to person in respiratory droplets from someone who is infected. People who are infected often have symptoms of the illness. Some people without symptoms may also be able to spread the virus.
CDC officials caution that they are still learning about how the disease spreads and the severity of illness it causes. The CDC further states that people may become infected by touching surfaces or objects that have the virus on them and then touching their own mouths, noses, or possibly their eyes.
For people with confirmed cases of COVID-19, the CDC recommends placing the patient on contact and droplet precautions and using airborne precautions and respirators in high-risk situations. It is imperative that we work closely with nursing staff to ensure patients who have tested positive for COVID-19 or symptoms consistent with COVID have been identified.
If these patients require therapy service, we will need to strongly adhere to standard and transmission-based precautions recommended by the CDC, donning a gown, surgical mask or respirator, goggles or face shield, and gloves, in that sequence. We will need to review our treatment plans to identify how we can modify the patient’s plan of care while adhering to the precautions.
For patients who are not confirmed or suspected positive for COVID-19 based on current guidelines, we need to be just as diligent with our interactions so as not to potentially expose the patient to COVID-19 or inadvertently spread the virus. The CDC has encouraged all healthcare personnel to actively monitor patients—especially those who may fall in high-risk categories—for the presence of fever, cough, shortness of breath, sore throat, and malaise.
Preventing Spread of the Coronavirus
Currently, there is no vaccine to prevent COVID-19. The best way to prevent illness is to avoid exposure to the virus. This advice makes sense for the lay person. For those on the front lines, however, this is often not practical.
Depending on the impact of the virus at your facility, you may or may not have adequate personal protective equipment (PPE) to protect yourself and your residents from transmission. Due to shortages of PPE in many parts of the country, providers are having to ration or optimize the supply of equipment. The CDC has provided guidelines and tips to protect healthcare personnel, which include the reuse of PPE and extending the life of respirators, facemasks, and eye protection beyond a single patient.
Most recently, CMS on April 2 reversed its position on the use of facemasks, stating, “For the duration of the state of emergency in their State, all long-term care facility personnel should wear a facemask while they are in the facility.” Also, “When possible, all long-term care facility residents, whether they have COVID-19 symptoms or not, should cover their noses and mouths when staff are in their room. Residents can use tissues for this. They could also use cloth, non-medical masks when those are available. Residents should not use medical facemasks unless they are COVID-19-positive or assumed to be COVID-19-positive.”
Therapy Practice Management
In addition to following exceptional hand hygiene and using appropriate PPE, therapy professionals will need to review their therapy practices to ensure they are adhering to strong infection control techniques and incorporating social distancing protocols as much as possible.
- Prioritization of patients depending on clinical needs.
- Transitioning from treatments in gyms to one on one in-room patient sessions.
- Consistent staffing assignments when possible.
- Block scheduling for patients on same units.
- Clean all equipment, devices, and surfaces between each patient interaction.
- Discontinuing sharing gait belts between patients.
- Updating the patient’s plan of care to address declines in function related to isolation or secondary effects related to COVID-19.
- Consider the use of virtual supervisory visits for therapy assistants.
Therapists will need to be creative when developing the patient’s plan of care to accommodate these restrictions. When we have opportunities to safely ambulate or provide therapeutic activity on the unit, the recommendation is to ensure that both the resident and the healthcare provider are wearing masks.
As SNF therapists, we often have the luxury of providing therapy services in well-equipped therapy gyms and employing a wide range of modalities. Today, regardless of whether or not you have an active case of COVID-19 at your facility, the CDC is recommending that SNF residents remain in their rooms due to the high risk of unrecognized infections among other residents and potentially among healthcare personnel.
Specific Ideas for Adapting Therapy Services
SNF therapists can borrow treatment approach ideas from their home health therapist counterparts, who often provide therapy services with limited equipment or using items within the home—or in this case, within the resident’s room. Consider creating evaluation kits or treatment carts to bring to residents’ rooms, and do not forget to keep disinfecting wipes handy between patients.
This is also a great time to incorporate functional activities, such as self-care tasks, sitting balance tasks from bed, transfer training to and from various surfaces in the room, sit-to-stand activities, standing tolerance and balance tasks, pulmonary rehab focused interventions and deep breathing activities.
Therapy personnel should incorporate educating residents on how to self-monitor their vitals and to independently call for assistance using the call button system if cognitively capable. Also, therapy can work with the resident on current events and orientation, communication approaches with the resident’s loved one, how to use technology to contact family members, and how to identify leisure activities on digital devices if available.
If you have a resident who is in the process of returning home, consider working with the resident and family on virtual home visits to strategize recommendations prior to discharge home. For additional ideas, I encourage you to reference your respective professional associations’ websites for resources.
As SNF therapists, we will continue to work to protect and improve the health and functioning of the residents in our care during the COVID-19 crisis and beyond. Our expertise is vital in providing services to our elders now more than ever. Person-centered care will continue to benefit all of our residents, and trauma-informed care will capture more of our attention moving forward from this crisis.