Nursing Home Quality & Safety

Earlier this month, the Coronavirus Commission for Safety and Quality in Nursing Homes issued their final report for the Centers for Medicare & Medicaid Services (CMS). The task of the Commission was “to solicit lessons learned from the early days of the pandemic and recommendations for future actions [in both the current and future pandemics] to improve infection prevention and control measures, safety procedures, and the quality of life of residents within nursing home.” According to the report, “The intent is that CMS would implement each principal recommendation in conjunction with its
associated action steps to understand and realize the Commission’s vision.”

The Commission came up with 27 recommendations with hundreds of associated action steps divided into the following 10 theme areas: Testing and Screening, Equipment and PPE, Cohorting, Visitation, Communication, Workforce Ecosystem: Resident Safety, Workforce Ecosystem: Strategic Reinforcement, Technical Assistance and Quality Improvement, Facilities, and Nursing Home Data.

Vaccines: CDC Covid-19 Vaccination Program Interim Playbook

Last week, the Centers for Disease Control issued its Covid-19 Vaccination Program Interim Playbook. The document is directed toward “state, territorial…, and local public health programs and their partners on how to plan and operationalize a vaccination response to COVID-19 within their jurisdictions.” According to the playbook (emphasis mine):

Centers for Disease Control and Prevention (CDC) Immunization and Vaccines for Children Cooperative Agreement funding recipients (i.e., “awardees”) should use this document to develop their COVID-19 vaccination plans. Within their vaccination plans, awardees must address all requirements outlined in the playbook and clearly describe their responsibility for ensuring activities are implemented. Awardees should submit their plans to their CDC project officer by October 16, 2020.

While most of the entities listed above undertook planning efforts in 2009 to distribute the H1N1 influenza vaccine, and may wish to build upon these plans as well as those used for annual influenza vaccination campaigns, it is expected that the scope and complexity of the COVID-19 epidemic will demand additional planning efforts to successfully meet the health needs of the public.

The playbook outlines steps these entities should take, including but not limited to: the conduct of Public Health Preparedness Planning, Engagement of Partners, Establishment of a Phased Approach to Vaccination of the Public, Identification of Critical Populations, Recruitment of Vaccination Providers, Assess Capacity to Conduct All Stages of Vaccination Supply, Storage, Distribution and Administration, and conduct Vaccination Communication Efforts.

What populations might states prioritize for access to the limited number of vaccines available in the period immediately following the vaccine’s approval? In the last few weeks several government- and non-government expert groups have examined this issue, including the National Academies of Science, Engineering and Medicine, the Advisory Committee on Immunization Practices, and the Johns Hopkins Center for Health Security. The CDC suggests considering the following groups:

• Critical infrastructure workforce, including
  • Paid and unpaid healthcare personnel working in healthcare settings, including not only physicians, nurses, PAs, etc., but also vaccinators, pharmacy staff, ancillary staff, school nurses, and EMS personnel.
  • Other essential workers, as might be characterized under standards from the Cybersecurity and Infrastructure Security Agency [CISA]
• Those at increased COVID-19 risk severity, including
  • LTCF residents (i.e., nursing home, assisted living, independent living facility residents)
  • People with underlying medical conditions that are risk factors for severe COVID-19 illness People 65 years of age and older
• People at increased risk of acquiring or transmitting COVID-19, including
  • People from racial and ethnic minority groups
  • People from tribal communities
  • People who are incarcerated/detained in correctional facilities
  • People experiencing homelessness/living in shelters
  • People attending colleges/universities
  • People who work in educational settings (e.g., early learning centers, schools, and colleges/universities)
  • People living and working in other congregate settings
• Those with limited access to routine vaccination services, including
  • People living in rural communities
  • People with disabilities
  • People who are under- or uninsured

Health Insurance Loss – Hispanic Populations Disproportionately Affected

A new Urban Institute report estimates that between April and July 2020, more than 3.3 million non-elderly adults lost their employer-sponsored health insurance (ESI). Of this population, more than 1.9 million became newly uninsured. According to the report:

Nearly half of those who lost ESI (1.6 million) were Hispanic adults, adding to earlier evidence that suggests Hispanic adults are disproportionately feeling the impact of the pandemic-related recession more than other racial and ethnic groups. Younger adults (2.2 million), men (3.0 million) and adults who did not attend college (2.1 million) made up the majority of ESI losses.

Domestic Violence

From March through June 2020, the Indiana Coalition Against Domestic Violence saw an 86% increase in domestic homicides compared to the same period in 2019, according to an article in the Indiana Lawyer. Other area agencies and organizations addressing intimate partner violence also report concerning rises in violent attacks, stalking and harassment. The CEO of the ICADV attributes this rise in violent behavior to the pandemic. According to the article, “Triggers and factors in domestic homicide include unemployment, access to firearms and increased alcohol consumption, Berry said. Being socially isolated at home with less access to supportive services is another contributing factor that has lead to the increase.”

Federal Judge Strikes Down PA Covid-19 Executive Orders

A federal judge in Pittsburgh declared unconstitutional the Covid-19-related Executive Orders issued by Pennsylvania’s governor that restricted outdoor gatherings, imposed state-at-home orders, and kept “non-life-sustaining” businesses closed during the early stages of the pandemic. While these orders all expired months ago, the fact that the judge declared them unconstitutional raises questions about what social distancing and other public health efforts would be permissible to use to contain future widespread, highly infectious, dangerous disease outbreaks when no tests or treatments exist.  Other federal courts have critically reviewed state executive orders; however, this decision diverges significantly from most federal court reviews of state Covid-19 emergency orders (including those made by the U.S. Supreme Court), which have given significantly more deference to state executives as to how to respond to the pandemic. The Governor is expected to appeal this decision to the Third Circuit Court of Appeals.

Workers’ Rights

The California Governor recently signed two laws expanding Covid-19 protections to workers in the state. Under these laws, employers would be required to inform employees and subcontractors when individuals at their worksite have either tested positive or been ordered to self-isolate, and unless employers can prove otherwise, the state, for workers’ compensation purposes, will presume employees sick with Covid-19 caught the illness at their work.