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Pictured: This photo was taken prior to the mandatory mask requirement in Hawaii. Arcadia Resident Helen Paris celebrated her 100th birthday with friends and family with respect to social distancing. Photo courtesy of Arcadia Family of Companies.

via Paula Bender, UH Med Now

May 13, 2020 — Observing the rate that COVID-19 has afflicted the globe, Hawaii government officials put in place stringent controls to protect its residents from the rapidly spreading virus. It has flattened the curve, but staying flat depends on keeping distance rules in place, especially in senior living facilities and nursing facilities. 

As COVID-19 swept through mainland cities, it appeared that the senior population was especially vulnerable to the virus. When news about the Life Care Center in Kirkland, Wash., continued to update, it was hard to ignore that 81, or two-thirds of its residents, and 47 of its staff members, were struck by the virus. Thirty-five of them died. 

Medical doctors pay attention when something infectious is happening in the world. Patricia Blanchette, MD, MPH, founder of John A. Burns School of Medicine’s (JABSOM) Geriatric Medicine department, sensed that coronavirus could sweep through Hawaii’s senior facilities if there was any hesitation in executing protective measures.

Thirteen of Hawaii’s nursing facilities and senior living facilities, as well as two hospices, are where JABSOM and its faculty practice organization, University Health Partners (UHP), have placed geriatricians to serve as medical directors and associate directors. They are teachers for the department’s Teaching Nursing Home (TNH) program wherein they train medical students, residents, and fellows in geriatrics medicine. 

“I recommended in early March that these medical facilities close to family, casual visitors, and volunteers. Also, at entry into the facility nursing facility should screen employees, doctors, nurse practitioners and therapists before allowing them into the facility. We recommended wearing of masks, taking everyone’s temperature at the door, and not allowing anyone to enter if they had traveled out of state over the past 14 days or had symptoms know to be associated with COVID-19 As Dr. Blanchette said. “This was the imposition of an early quarantine.” A lot of other facilities followed suit. 

So far, not one of the residents in these JABSOM/UHP medical director facilities have come down with COVID-19. Statewide, it is believed that only one senior contracted the virus. It is to Hawaii’s credit that its seniors are protected so well.

Although swiftly executed, it wasn’t easy to wind down any of these facilities. There is a constant flow of people entering and leaving: three shifts of registered nurses, licenced practical nurses, and certified nursing assistants; therapists; laboratory and radiology techs admin, kitchen and cleaning staff; doctors and nurse practitioners and physician assistants; and people delivering food and supplies. 

For a lot of the facilities’ residents it was and remains a confusing time. Many of them noticed that there were no more visitors, and some thought that their loved oneshad died. 

“It’s particularly hard for patients with dementia because they don’t remember what they’ve been told,” said Dr. Kamal Masaki, professor and chair of JABSOM’s Department of Geriatric Medicine. 

Frustration wasn’t limited to inside the facilities. Dr. Blanchette says, “It was so hard on the staff when a few family members were shouting at them as they were denied entrance to the facility. Staff had a thankless job at first.”

“Some families were angry or resistant but they were in the minority,” Dr. Pia Lorenzo said. “For my experience, most were grateful and cooperative. And when the news started talking about deaths in mainland nursing homes , the attitude changed to overwhelming support and gratitude from the families.” 

Dr Lorenzo is an assistant professor at JABSOM’s Department of Geriatric Medicine and a geriatrician at UHP, the medical director at both Nuuanu Hale and 15-Craigside Retirement Community; and an associate medical director at Hi’Olani at Kahala Nui. She said that her colleagues and Dr. Blanchette were already preparing patients and families about a potential COVID-19 lockdown since February. 

Officially, lockdown for Hawaii’s nursing homes started on March 14, 2020. Only essential staff members were approved to enter the facilities. This was primarily the nurses, LPNs, and the CNAs who were there to keep patients healthy, clean, and fed. Deliveries were received at a single point, usually at the beginning of a driveway. 

“It was a real coordinated effort with all nursing homes, the leadership, and the administrations,” said Dr. Cody Takenaka, assistant professor of Geriatric Medicine, a JABSOM 2009 grad, and a geriatrician at UHP. “We worked hard to collectively share information from the CDC and the American Medical Directors Association. The recommendations in what to do to control and prevent infection changed almost every day. So we used our network to keep doctors informed and as many homes as we could, in line with the recommendations. We wanted to enable all doctors at other facilities to be aware of what to do in terms of watching out for signs of the disease.”

Dr. Takenaka is the associate medical director at Avalon Nursing Home. The mainland based Avalon Health Care company on March 11 advised its facilities to close the door to visitors, and to screen essential employees and healthcare professionals. 

“As soon as I saw this order I asked what are we doing on the patient and family end,” Dr. Takenaka said. “No policy. Unprecedented. With an influenza outbreak there is more warning.” 

Between the administrator, the director of nursing, and Dr. Takenaka, they split up to call the families. To be proactive, she called all the different programs at Kaiser Permanente, Healthcare Association of Hawaii, and private practices, so their messages would be unified. At the same time, the three of them looked at other moving parts. 

“I called every dialysis center for all the doctors to find out if anyone had been tested or under investigation so we could increase precautions for these high risk patients,” Dr. Takenaka said. “At all dialysis centers there is a community of specific patients, doctors and healthcare professionals. That communication was really important.” 

There were also patients who had to visit doctors outside the facilities, riding in a Handi-Van, sitting at length in waiting rooms. Each segment of the trip is an opportunity to contract the virus. So we set out to limit these as much as possible. 

Because of the COVID-19 pandemic, Medicare issued waivers to temporarily approve telemedicine visits between doctors and senior facility patients. Each patient in a nursing home has an attending physician, and each doctor might have multiple patients in different homes. 

“We would go to three or four, sometimes more nursing homes a week in our practice,” said Dr. Lorenzo. “This was making us possibly the worst vector for our patients.” 

Telemedicine has been a key element in protecting Hawaii’s seniors from COVID-19. Because reimbursement for telemedicine for this sector of patients may only be temporary, many hope that CMS (Medicare and Medicaid) will see its benefits to establish it as a permanent reimbursable. Dr. Blanchette worked with UHP’s general counsel, compliance officer, and director of IT and its Central Billing Office to set up consent and other forms. Dr. Lorenzo talked to UHP’s billers and coders, and she and her colleagues coordinated with IT experts in their respective sites to assure that the launch of virtual visits would be smooth. 

Neither Dr. Lorenzo nor Dr. Takenaka had incorporated telemedicine into their practices before the pandemic, because there was no CMS Medicare approval for reimbursement. CMS Medicare always required doctors and patients to meet face to face. Now virtual visits are a regular part of doctors’ daily schedules. The doctors are true believers for several valid reasons. One was for saving personal protective equipment (PPE). Each time they visited a facility they would don PPE. If they went to a different floor or wing, they would doff PPE and then don new PPE. And this was while PPE was scarce. 

The second reason is because through telemedicine, nurses are now getting an opportunity to learn about their patients from the doctors. They are directed to position the iPad or phone in certain ways so a doctor can talk to the patient and see how they are doing. It’s all a learning experience, and requires a heavy commitment on the nurses’ time. An advantage is that a rapport has developed between the nurse and the doctor, as well as the nurse and the patient. These nurses are gaining a better understanding of what their patients need because of these doctor-nurse-patient visits.

A number of physicians who serve as attending physicians work collaboratively with nurse practitioners or physician assistants. They are also actively participating in telemedicine visits. 

“We are lucky that in Hawaii nursing homes, the nurses are so dedicated. They don’t get paid as much as nurses in hospitals, so we put in an effort to take care of them,” Dr Takenaka said. “These nurses are less likely to abandon our patients like we saw happen on the mainland.” 

In hindsight, Dr. Takenaka said that she wishes they had put even more energy educating the nursing staff. She said it was difficult when the recommendations were changing every day. 

“We stopped waiting for official guidelines, some of which were changing two or three times a day. We had to initiate the safest possible actions. We had staff check-ins to talk about what we are doing now, or how the masks work, and so they could ask questions about their safety, their patients’ safety, all via email or six-feet apart,” Dr. Takenaka said. “Then we used Zoom so we could test our Zoom capabilities. We wanted to assure our nurses know that we are doing everything we can do to keep them safe.”

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