The impact of COVID-19 has been felt by all of us, from significant changes in healthcare delivery to how we do our grocery shopping. With the surge in the number of cases throughout the nation, on March 13 the Centers for Medicare & Medicaid Services (CMS) promoted temporary regulatory changes to ease the burden to the healthcare industry. Some examples include: withholding the 3-day hospitalization requirement to obtain Medicare coverage of a skilled nursing facility (SNF) stay; easing the limits of 25 beds and 96-hour lengths of stay (LOS) for critical access hospitals; and allowing acute care patients to be cared for in Excluded Distinct Part units.1 These measures were taken to free up acute care beds to accommodate the anticipated flood of COVID-19 patients who will require hospitalization.
Along with these new regulations, hospitals experienced a serious shortage of personal protective equipment and ventilators, which threatened the delivery of patient care. Despite these challenges and threats, hospitals are still accountable to provide quality care and to ensure positive outcomes. Smooth transitioning of patients through the healthcare continuum is essential to restoring health whether the patient is discharged to a post-acute provider or to their home.
When moving a patient from acute care to a skilled nursing facility (SNF), relaying current, clear and concise information to the receiving facility is key to the success of the transfer. Electronic health records are typically sent with the patient. Unfortunately, many times this packet of information has numerous pages and is not well organized, making it difficult for the receiving nurse to meet the immediate needs of the patient when they arrive at the facility. The SNF needs a summary of the hospitalization including a clear picture of the patient’s status for the past 8-24 hours in the hospital. The summary should identify what nursing measures the SNF needs to provide to deliver quality and safe care to the patient for the first 8-16 hours they are a resident in the facility. Essential information includes but may not be limited to:
- Vital signs
- Pain level
- Lung status
- Last dose of pain or diabetic medication
- Sites of any skin break
This information should reflect the status just prior to the transfer, not an assessment completed hours before the actual move. When discharge orders are written in the morning and the transfer is delayed due to transportation issues, changes in the patient’s condition can occur. Having a current report at the time of transfer provides the SNF with important information to ensure a smooth transfer to the facility. A verbal nurse-to-nurse report at the time of transfer allows for a dialogue to occur so questions can be asked to clarify any unclear orders or care plan activity.
Accurate exchange of information is even more critical during the COVID-19 pandemic. There is a great deal of fear and anxiety when a facility is charged with the care of a patient recovering from the virus. Having the appropriate accommodations to handle these patients is critical for the safety of the identified patient, the staff and other residents in the facility. Physician orders outlining any measures to be taken in caring for the resident must be specific and clear regarding the need to use transmission-based precautions.
Discharging a patient to their home presents different challenges. Providing a patient and their family or caregiver with copies of the medical record upon discharge presents similar issues as those experienced by the SNF. The discharge packets often have multiple pages, and it is difficult for the patient to find the critical information they need to know, such as what medications to take, what previous medications to stop and what signs and symptoms they need to look for that herald a worsening of their condition. Based on the most current Hospital Compare survey of patient experiences, 87% indicated they were given information about what to do during their recovery at home, yet only 53% strongly agreed that they understood their care when they left the hospital. The dilemma is two-fold: the timing and the content of the discharge instruction.
Medicare Conditions of Participation (CoP) required hospitals to evaluate patients early in their hospitalization to determine their needs and to develop a plan with the patient and family to ensure their progress toward achieving their healthcare goals. Providing discharge instructions the day of discharge does not meet the standards. When a patient and family are anxious to go home, their ability to absorb any instructions is significantly hampered by the desire to get home. Discharge planning must start on admission and should continue throughout the hospitalization to be effective.
content of the instructions is also an important factor. The Centers for Disease Control and Prevention (CDC) states that when organizations or people create or give others health information that is too difficult for them to understand, we create a health literacy problem. Even people who read well can face literacy issues when they aren’t familiar with medical terms or how their bodies work.2 Patients need instructions they can understand so they can make sound decisions during their recovery. Simple tools like the “Zone” or “Stop Light” sheets provide disease-specific instructions about symptoms and when to contact their physicians before they require emergency care.3
These best practices work well in everyday practice. Now with the COVID-19 pandemic, consistent implementation of best practices is critical to the recovery of affected patients. Transfer information to SNFs must be meticulously relayed. We must be sure the SNF is staffed and knowledgeable to manage the transfer and that it has the proper equipment. Patients must be closely monitored in the event of any transfer delay as these patients can have a relapse and may require continued acute care. According to the CDC, the decision to discontinue transmission-based precautions can be made using a test-based strategy or a non-test-based strategy.4 Meeting the criteria to discontinue transmission-based precautions is not necessarily a pre-requisite for discharge, although the testing-based strategy is preferred for patients being discharged to long-term care or assisted living facilities.
Patients being discharged to home require intensive instruction for symptom management and for prevention of any spread of the virus to the community. If isolation is required post-discharge, case managers are faced with not only the patient’s physical needs but their socio-economic situation. There needs to be a plan for an arrival to a safe and clean environment and a supply of food. The CDC recommends the decision to send a patient home should be made collaboratively with the patient’s clinical care team and the local or state public health departments. The patient must be evaluated for their ability to adhere to home isolation recommendations. The residential setting must also be assessed for suitability. Consideration for care at home include patient stability, available able caregivers, separate care without sharing space with others, access to food and other necessities and access to gloves and face masks.5
Dealing with COVID-19 positive patients is a challenge since its impact has been so widespread and it is such a new virus. With no vaccine and only experimental treatments, mortality rates will be high. As the healthcare community strives to conquer this virus, consistent use of proven best practices will enhance the transitioning of patients through their journey to recovery. Since changes in regulations and care recommendations are rapidly occurring, the best resources for updates are the websites for the Centers for Medicare & Medicaid Services (CMS), www.cms.gov, and the Centers for Disease Control and Prevention (CDC), https://www.cdc.gov/coronavirus/2019-ncov/index.html.