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T. L aw r en ce
• Depression among rehabilitation patients is extremely common and may involve
several factors including: medication adverse effects, medical comorbidities,
neuroendocrine imbalance, as well as a psychological reaction to disability.
• Short-term and long-term prognosis may change such that treatment goals of
rehab must be periodically revised.
Websites
• American Geriatrics Society http://www.americangeriatrics.org
• American Academy of Physical Medicine and Rehabilitation http://www.
aapmr.org
• Centers for Medicare and Medicaid Services http://www.cms.hhs.gov
• Cochrane Collaboration, Cochrane Reviews http://www.cochrane.org/reviews/
• National Institute of Neurological Disorders and Stroke, Post-Stroke
Rehabilitation Fact Sheet http://www.ninds.nih.gov/disorders/stroke/poststro-
kerehab.htm
References
1. Centers for Medicare and Medicaid. State operations manual, Appendix PP—Guidance
to surveyors for long term care facilities, Rev. 55. 2017. https://www.cms.gov/medicare/
provider- enrollment- and- certication/guidanceforlawsandregulations/downloads/appendixpp- state- operations- manual.pdf. Accessed 22 Nov 2017.
2. Kochersberger G, Hielema F, Westlund R.Rehabilitation in the nursing home: how much, why,
and with what results. Public Health Rep. 1994;109:372–6.
3. Quinn CQ, Port CL, Zimmerman S, Gurber-Baldini AL, Kasper JD, Fleshner I, etal. Shortstay nursing home rehabilitation patients: transitional care problems pose research challenges.
J Am Geriatr Soc. 2008;56:1940–5.
4. Mayer RS, Noles A, Vinh D.Determination of postacute hospitalization level of care. Med
Clin N Am. 2020;104:345–57.
5. Cruise CM, Sasson N, Lee MH.Rehabilitation outcomes in the older adult. Clin Geriatr Med.
2006;22:257–67.
6. Achterberg WP, Cameron ID, Bauer JM, Schols JM.Geriatric rehabilitation—state of the art
and future priorities. J Am Med Dir Assoc. 2019;20:396–8.
7. American Medical Directors Association. Pressure ulcers in the long-term care setting clinical
practice guideline. Columbia: AMDA; 2017.
8. The surgeon general’s call to action to prevent deep vein thrombosis and pulmonary embolism.
2008. http://www.surgeongeneral.gov/topics/deepvein/.
9. Jaffer AK, Brotman DJ.Prevention of venous thromboembolism in the geriatric patient. Clin
Geriatr Med. 2006;22:93–111.
10. Shah MV.Rehabilitation of the older adult with stroke. Clin Geriatr Med. 2006;22:469–89.
11. Zuckerman JD.Hip fracture. N Engl J Med. 1996;334:1519–25.
12. Bhandari M, Swiontkowski M. Management of acute hip fracture. N Engl J Med.
2017;377:2053–62.
13. Pomeranz B, Adler U, Shenoy N, Macaluso C, Parikh S.Prosthetics and orthotics for the older
adult with a physical disability. Clin Geriatr Med. 2006;22:377–94.
Rehabilitation andMaximizing Function inLong-Term Care
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14. Cristian A.The assessment of the older adult with a physical disability: a guide for clinicians.
Clin Geriatr Med. 2006;22:221–38.
15. Herbold JA, Bonistall K, Walsh MB. Rehabilitation following total knee replacement,
total hip replacement, and hip fracture: a case-controlled comparison. J Geriatr Phys Ther.
2011;34:155–60.
16. Leighton C, Sandel ME, Jette AM, Apelman J, Brandt DE, Cheng P, etal. Does postacute care
site matter? A longitudinal study assessing functional recovery after a stroke. Arch Phys Med
Rehabil. 2013;94:622–9.
17. Doornebosh AJ, Smaling HJA, Achterberg WP.Interprofessional collaboration in long-term
care and rehabilitation: a systematic review. J Am Med Dir Assoc. 2022;23:764–77.
COVID-19 inPost-Acute andLong-Term
Care: Challenges andOpportunities
NaushiraPandya, ElizabethHames, andPeterWinn
Introduction
The emergence of the coronavirus pandemic in early 2020 has challenged health
care systems in the USA and globally and overwhelmed US nursing and assisted
living facilities. As of midyear 2022, the SARS-Covid-2 virus has caused more than
152,000 US deaths among nursing home residents and over 2300 conrmed deaths
among nursing home staff by early 2021. Over 1.3 million conrmed cases have
occurred amid residents and staff. Weekly COVID-19 cases in US nursing facilities
peaked in late 2020 and deaths in early 2021.
Despite the headway made in hospital care, COVID-19 vaccinations, the development of antivirals, and the availability of monoclonal antibodies, the continued
emergence of COVID-19 variants and subvariants that are more infectious and less
prevented by the original COVID-19 vaccine, present ongoing challenges in the
prevention and treatment of COVID-19.
Notwithstanding these challenges, opportunities have arisen. These include:
• Improved focus on resident and family-centered care and communication.
• Better readiness in infection prevention and control.
• Adoption of telehealth and telemedicine in patient care.
N. Pandya (*)
Department of Geriatrics, Kiran C.Patel College of Osteopathic Medicine, Nova
Southeastern University, Lauderdale, FL, USA
E. Hames
UnitedHealth Group, Minnetonka, MN, USA
P. Winn
Department of Family and Preventive Medicine, University of Oklahoma, College of
Medicine, Oklahoma City, OK, USA
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
P. Winn et al. (eds.), Post-Acute and Long-Term Care Medicine, Current Clinical
Practice, https://doi.org/10.1007/978-3-031-28628-5_20
383
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N. Pandya et al.
• Initiatives to address multiple medication use and overuse (polypharmacy), such
as the “Drive to Deprescribe.”
• Focused state surveys on infection control in long-term care facilities.
• Structured tools for enhanced communication and care planning related to
COVID-19 [1].
• Improved practitioners/clinician management of COVID-19 infections in
patients with comorbid cardiovascular disease, diabetes, renal failure, and respi-
ratory disease.
In late 2020 a consensus study report commissioned by the US Centers for
Medicare and Medicaid Services was released. Written by the National Academies
of Sciences, Engineering and Medicine (NASEM) it recognized and recommended
the need for vast improvements on how nursing home care is delivered, nanced,
regulated, and quality of care measured [2]. The pandemic has presented an excellent opportunity to “re-imagine” long term care [3].
This chapter will review the presentation, clinical evaluation, precautions, and
monitoring of residents with and at risk for COVID-19 infection, including a review
on the general management and supportive care and pharmacotherapy recommended for nonhospitalized patients/residents aficted with a COVID-19 infection.
In addition, CDC recommendations will be reviewed on resident visitation and
return to work criteria for healthcare workers (HCW) infected with COVID-19 at
long-term care facilities.
Demographics andthe scope ofCOVID-19 inLTC Facilities
• During the pandemic, nursing home residents had COVID-19 infection rates 14
times higher than older adults who lived in the community, accounting for 22%
of all COVID-19 cases in the Medicare population.
• Nursing home residents diagnosed with COVID-19 had 12 times the likelihood
of requiring a hospital admission as compared to adults over 65 living in the
community.
• More than 43% of nursing home residents admitted to the hospital with
COVID-19 died as compared to 22% among older adults with COVID-19 who
were living in a community setting.
• Male and female nursing home residents had nearly equal the incidence of
COVID-19 infection.
• COVID-19 infection rates among age subsets between 65 and 100years did not
show signicant difference.
• Hispanic, Black, and Asian nursing home residents had higher rates of COVID-19
infection.
• There have been more than 152,000 total COVID-19 deaths in US nursing homes
since January 2020, and over 2300 conrmed nursing home staff member deaths
due to COVID-19 since June 2020.
COVID-19 inPost-Acute andLong-Term Care: Challenges andOpportunities
385
• As of April 2022, an average of 30% of nursing homes continue to have short-
ages of direct staff, especially nurses and nurse aides.
• In the USA, over 79% of nursing home residents are now fully vaccinated and
boosted for COVID-19 (as of 2022).
• According to a report by the Ofce of Inspector General (OIG) in June 2022,
91% of nursing home staff in the USA had received the required COVID-19 vac-
cine doses, 56% of staff had received a booster dose, and 6% had received a
religious exemption.
Clinical Presentation ofCOVID-19 inOlder Adults
Older adults are particularly vulnerable to severe COVID-19 infection, with
advanced age being the strongest risk factor for critical illness. There is a wide range
in clinical presentation, from asymptomatic to fulminant disease. Clinical presentation of SARS-CoV-2 is often atypical, and may not include common signs and
symptoms such as respiratory distress and fever. Older adults undergo many physiologic changes with aging including immunosenescence. This predisposes to dysfunction of the immune system that can proceed to a cytokine storm, a multisystem
inammatory syndrome (MIS) and multiple organ failure, especially respiratory or
renal failure and sepsis. Residents with COVID-19 more commonly present with
fatigue, myalgias, headache, nasal congestion, shortness of breath (12% for patients
>60years versus 3% for patients <60years), sore throat, loss of taste and/or smell,
dizziness, nausea, vomiting, or diarrhea. Others may present with reduced mobility,
falls, delirium (up to 28% in one multicenter study), and dysregulation of glycemic
control. Falls may be a presenting symptom of COVID-19 infection in 23–32% of
persons over 65years. Anorexia has been identied as a frequent symptom that
contributes to dehydration and failure to thrive, particularly in persons with advanced
frailty. Studies of older adults have shown that a sore throat, new onset congestion,
nausea, vomiting, or diarrhea can be more reliable diagnostic criteria than fatigue
and body aches. Up to 37% lack the classic COVID-19 symptoms of fever or short-
ness of breath. In those with known pulmonary or cardiac disease, it can be difcult
to determine whether a worsening cough or dyspnea is related to either COVID-19
infection or an exacerbation of pulmonary or cardiac disease or coinfection with
inuenza, Human respiratory syncytial virus illnes RSV, or a common cold.
Older adults with an infection may not present with fever, as the mean body temperature decreases with age and the febrile response blunted. A fever of 38.3°C
(101°F) or higher requires prompt intervention as it can be associated with a severe
infection. The Infectious Disease Society of America (IDSA) denes fever in older
adults as a single oral temperature above 100°F, repeat readings over 99°F oral, or
an elevation of 2°F above baseline temperature. Fever may not be a reliable symptom to diagnose COVID-19, especially among frail and vulnerable residents in postacute, long-term care and assisted living facilities. (Delirium already mentioned
above) NPandya. COVID-19 may be difcult to differentiate between various
386
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Table 1 Presenting symptoms of Covid-19, inuenza, and the common cold
Covid-19 Inuenza Common cold
e.g., Adenovirus,
SARS-COV-2 Inuenza A, B
Onset Gradual Sudden Gradual
Fever 100 and above,
2–7days
Chills Common Common Uncommon
Headache Common Prominent Rare
Cough Dry, often severe Dry +/− severe Mild
Sore throat Prominent, common Sometimes Common
Runny nose Common Sometimes Common
SHOB Common, severe Sometimes Uncommon, rare
Myalgia Common Usual, often severe Slight
Fatigue Common Early, prominent Sometimes
Diarrhea Sometimes Sometimes Rarely
V/N Sometimes Sometimes Rarely
Loss taste/
smell
Wheezing Sometimes Rare No
Web Sources:
1. Health Partners: “What is RSV, Symptoms, Treatment and Tips for Preventions”
2. CDC “What is the Difference Between A Cold and Flu”?
3. CDC “Flu Symptoms and Complications”
(Accessed 9 Sept 2022)
Common Uncommon No
100 and above,
3–4days
Rhinovirus
Rare
N. Pandya et al.
respiratory illnesses, such as inuenza, bacterial pneumonia, aspiration pneumonia,
and non-COVID-19 viral respiratory infections. Therefore, early testing for
COVID-19 and inuenza and other viruses is recommended, so that proper infection
prevention, management, and control can be instituted.
Given the asymptomatic period of COVID-19 infection being 2–14days (versus
1–2days with the u) and its nonspecic clinical presentation of age-related decline
of taste and smell, as well as co-morbidities, geriatric syndromes of frailty, cognitive decline, falls, and polypharmacy warrant close monitoring for the emergence of
COVID-19. Table1 reviews common signs and symptoms that may help differentiate COVID-19 from inuenza and the common cold.
Symptoms ofCOVID-19 Versus Other Viral Infections
Symptoms of COVID-19 usually occur within 5–6days (and up to 14days) after
exposure and last up to a few days to a few weeks; while symptoms of inuenza
occur within 2days of exposure and usually lasts 3–7days; and symptoms of the
common cold occur within 1–3 days after exposure and resolve within 10 days.
Though these time frames may help differentiate one viral illness from the other it
COVID-19 inPost-Acute andLong-Term Care: Challenges andOpportunities
is not uncommon to be coinfected with COVID-19 and inuenza or another virus
that causes the common cold (adenovirus, rhinovirus, enterovirus, non-COVID-19
coronavirus or RSV). Coinfection with inuenza or RSV can result in a more severe
respiratory illness and the need for hospitalization and mechanical ventilation and
increased in-hospital mortality. It is not uncommon for persons with COVID-19 to
be misdiagnosed as having a common cold or worsened allergies. A comparison of
symptoms of COVID-19, inuenza, and the common cold are shown in Table1.
387
Infection Prevention andControl Strategies inLTC Facilities
Quarantine
The CDC has previously recommended quarantine for all residents being admitted
to a long-term care facility. This included residents with a known exposure to the
SARS-CoV-2 virus and those who are not up to date with COVID-19 vaccination.
However, quarantine is no longer needed for asymptomatic residents who have been
fully vaccinated and received the COVID-19 booster or who have acquired natural
immunity following infection with SARS-CoV-2 that occurred in the last 3months.
Infection Control Program (ICP) Recommendations
forLTC Facilities
The CDC recommends a robust infection control program (ICP) for long-term care
facilities with ongoing surveillance and testing of residents and staff. Infection control measures such as source control and COVID-19 screening tests are dependent
upon the COVID-19 community transmission level. The CDC’s COVID-19 Data
Tracker has two indicators that (1) determine the county level of SARS-CoV-2 for
each long-term care facility, and (2) the higher level by the CDC indicator being
selected as to the current transmission level (low, moderate, high).
Facilities with 100 or more residents, and facilities that provide ventilator care or
on-site hemodialysis must employ a full-time infection control preventionist. The
CDC has developed training courses on infection control and program management.
Adequate personal protective equipment (PPE) needs to be provided to staff members as well as FDA-approved hand sanitizer (60–95% alcohol) and be available in
all resident rooms and facility common areas. Training and education sessions
should be provided for staff members, including health care personnel (HCP) and
consultative staff such as therapists, podiatrists, hairdressers, and volunteers.
Residents and family members should also attend education sessions and receive
written materials on use of PPE, protocols for social distancing, and instructions on
correct hand hygiene.
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N. Pandya et al.
According to CDC guidelines, the facility should notify the local health department under the following circumstances:
• ≥1 residents or HCP with suspected or conrmed SARS-CoV-2 infection.
• Residents with severe respiratory infection resulting in hospitalization or death.
• ≥ 3 residents or HCP with illness compatible with COVID-19 with onset
within 72-h.
SARS-CoV-2 infections, facility stafng, and point of care testing data needs to
be reported to the CDC’s National Healthcare Safety Network (NHSN) Long-term
Care Facility (LTCF) COVID-19 Module every week. Facilities are given a secure
online platform to track infections and prevention process measures. Weekly reporting to the NHSN LTCF COVID-19 Module satises the CMS COVID-19 reporting
requirement.
All persons in a healthcare setting are recommended to use source control and
practice physical distancing necessary during the provision of care. Source control
(in contrast to PPE) refers to wearing well-tting masks and respirators to prevent
transmission of viral particles. PPE (masks, respirators, face shields, gowns, gloves,
etc.) protects the wearer from being exposed to viral particles. This is especially
important for individuals (1) not up to date with COVID-19 vaccination, (2) with
current signs or symptoms of COVID-19, (3) with close contact or exposure within
10days to a person with COVID-19, or (4) immunocompromised. Facility staff who
are up to date with COVID-19 vaccination in counties with low to moderate COVID
transmission rates, may choose to use source control in facility areas that have
restricted patient access but should continue to wear source control in other areas
that patients may frequent.
Visitation
Patient visitation recommendations from the CDC state that the safest option is
wearing source control and physical distancing during indoor visitation. If the resident and visitor are both up to date with COVID vaccination, they can choose
whether to wear source control or not, and whether to have physical contact or not.
Visitors should wear source control when they are in areas with health care personnel or other residents, even if they are up to date with all COVID vaccinations.
During outdoor visitation, CDC facility guidelines for source control are based on
COVID-19 incidence levels in the region. During COVID-19 outbreak conditions,
facilities should follow guidance from the Centers for Medicare and Medicaid
Services (CMS) on visitation and encourage the use of PPE during outdoor
visitation.
Consideration should be given to the fact that long-term care facilities are the
“home” for long-stay residents. Specialty societies and the CDC emphasize balancing the risk of COVID-19 transmission and quality of life. Residents who are not at
increased risk for severe COVID, who are up to date with COVID vaccination, and
COVID-19 inPost-Acute andLong-Term Care: Challenges andOpportunities
living in areas with low to moderate levels of COVID-19 infection may be allowed
to not use source control in communal areas of the facility. High risk residents
should continue to use source control and physical distancing. Following CDC
guidelines can be confusing so request clarication from the facility staff (director
of nursing, administrator, or infection preventionist) or the state survey agency.
389
Precautions when Providing Patient Care
Healthcare workers should follow standard precautions when caring for patients
with “suspected” SARS-CoV-2 infection. Healthcare workers in areas with high
number of COVID cases should wear NIOSH-approved N95 respirator or higher
level respirator. A face shield or eye protection that covers the front and sides of the
face is currently recommended during all patient encounters. During the hiatus of
the COVID-19 pandemic the CDC recommended this due to aerosol risk to spread
COVID-19 during nebulizer treatments and that multidose inhalers be used instead.
Patient Monitoring andCOVID-19 Testing inFacilities
All residents need to be monitored on admission and daily for fever (temp.
≥100.0°F) and COVID-19 symptoms. Oxygen saturation by pulse oximetry is recommended to be included with the standard vital signs. COVID-19 viral testing
should be obtained on any resident with symptoms (including mild symptoms),
even if the resident is up to date with the COVID-19 vaccine and boosters. Any
asymptomatic resident who has had close contact with a person with SARS-CoV-2
should have two viral tests, one immediately and if negative, a second test 5–7days
after exposure. Testing is not necessary in asymptomatic persons who have recovered from COVID-19in the last 3months; however, if a test is to be performed, an
antigen test (rather than a nucleic acid amplication test (NAAT) should be obtained,
as some persons may be NAAT positive for 3months yet not infectious. Blood anti-
body tests should not be used to diagnosis on active COVID-19 infection. (www.
fda.gov April 2021 communication.)
Screening of asymptomatic healthcare workers without a known exposure is
required. However, those who are up to date with all COVID-19 vaccines may be
exempt from testing.
Pre-procedure and/or pre-admission viral testing for residents is usually decided
by the center or hospital to which the resident is being sent. The CDC states that the
overall yield of this testing is low. If a healthcare-associated transmission has
occurred, consider expanded testing of healthcare workers and residents. If
expanded testing detects additional infections, broad testing should be implemented,
and repeated every 3–7days, until no new cases are observed for 2weeks. Consult
the local health department or other public health government agency for guidance.
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Return toWork Criteria forLTC Facility Healthcare Workers
“Infected” withCOVID-19
Healthcare workers infected with COVID-19 should monitor themselves for symptoms and be evaluated by occupational health if symptoms recur or worsen. Once
returned to work, an antigen test or NAAT can be used, preferably the former. As
noted, some persons can remain NAAT-positive for an extended period of time yet
be non-infectious. Antigen tests typically provide rapid results but are less sensi-
tive than NAAT. If test supplies are low, prioritize their use to diagnose new
infections.
Facility healthcare workers with mild to moderate COVID-19 symptoms who are
not immunocompromised can either return to work in 7days since symptoms rst
appeared and with a negative antigen or NAAT within 48h of return to work OR in
10days since symptoms rst appeared if no COVID testing was performed or a
positive result was obtained on day 5–7 of symptoms—AND in either scenario, that
at least 24 h have passed since the resolution of fever without the use of feverreducing drugs, and symptoms have improved.
Facility healthcare workers with severe to critical COVID-19 who are not
immunocompromised can return to work in at least 10 to possibly 20days since
symptoms appeared, and at least 24h have passed since last fever without the
use of fever-reducing drugs, and symptoms have improved. Two consecutive
respiratory specimens collected ≥24h apart (antigen test or NAAT) need to be
negative.
Facility healthcare workers who are moderately or severely immunocompro-
mised may produce infectious SARS-CoV-2 virus more than 20days after symptoms appear. For these workers, an infectious disease or occupational health
consult is needed to determine when to be allowed to return to work. For immu-
nocompromised workers who have symptomatic COVID-19 infection, fever
must be resolved without current use of anti-fever medications, symptoms need
to be improved, and two consecutive respiratory specimens collected ≥24 h
apart (antigen test or NAAT) need to be negative. For immunocompromised
healthcare workers with asymptomatic COVID-19, return to work requires two
consecutive negative respiratory specimens collected ≥24h apart (antigen test
or NAAT).
Return toWork Criteria forHealthcare Workers “Exposed”
toConrmed COVID-19
The CDC denition of close contact is: (1) being within 6feet of a person with
conrmed SARS-CoV-2 or (2) having unprotected direct contact with infectious
body uids of a person with conrmed SARS-CoV-2. Even distances of greater
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