January 12, 2023 | by Caralyn Davis

CMS and CDC Push Nursing Homes to Be More Proactive With COVID-19

In 2022, the largest spike in COVID-19 cases and deaths occurred in January and February, pointed out Chiquita Brooks-LaSure, administrator of the Centers for Medicare & Medicaid Services (CMS), during the Jan. 5, 2023 National Nursing Home Stakeholder Call. Note: CMS will post the call transcript here when available.

chiquita-brooks-lasure

Chiquita Brooks-LaSure, administrator of the Centers for Medicare & Medicaid Services (CMS)

“The country is [currently] experiencing an increase in COVID-19 infections in nursing homes, which we all know can lead to resident hospitalizations and deaths,” stressed Brooks-LaSure. “So, we want to do everything we can to avoid negative health outcomes as we enter these winter months.”

The updated (bivalent) COVID-19 vaccine is “the most important tool” available to prevent serious illness, hospitalization, and death from COVID-19, added Brooks-LaSure. “Nursing home residents, who are often particularly susceptible to severe outcomes from the virus, deserve the highest level of protection that we can offer.”

CMS requires that all nursing homes offer all COVID-19 vaccines, including the bivalent booster, to their residents and educate them on their benefits under F-tag 887 (COVID-19 Immunization), according to Quality, Safety, and Oversight (QSO) memo QSO-21-19-NH. Note: Review F888 (COVID-19 Vaccination of Facility Staff) in CMS memo QSO-23-02-ALL for guidance on staff vaccination requirements.

“While a higher percentage of nursing home residents are on average up-to-date [i.e., received a bivalent booster or completed their primary series in the last two months] on their COVID-19 vaccines compared to the U.S population over 65, the rates are still too low. They are below 50 percent—at only 48.7 percent,” said Brooks-LaSure. “Many of you have been working to increase the take-up of the new vaccine. The rates have been steadily climbing, but this number is still too low. … Getting your residents up-to-date on vaccines needs to remain your No. 1 priority.”

Officials with CMS and the Centers for Disease Control and Prevention (CDC) recommend that directors of nursing services (DNSs) and the administrative team take the following steps to address vaccination, treatment, and other issues involving COVID-19:

  1. Build vaccine confidence

“It is not just access [to vaccines that must be improved]—it is also demand for vaccines that we need to strengthen,” said Sarah Meyer, MD, MPH, chief medical officer of the CDC’s Immunization Services Division. “This is relevant not just for the residents, but also staff, as well as family members of the residents, because they are often very influential in those decisions to get the vaccine.” Note: Learn details about the CDC’s suggested tactics in the sidebar at the end of this article, “CDC: Behavioral Approaches Matter When Building Vaccine Confidence.”

“One of the most effective messages is to tell residents and their families that getting up-to-date on vaccines is the most effective way to avoid hospitalizations,” added Will Harris, a senior advisor in the Office of the Administrator at CMS. “We think that that resonates for a lot of people and their families, so we hope you might be able to use some of that messaging in a positive way to continue to encourage people to be the most protected possible against this virus. …”

  1. Consider a CDC sub-provider agreement if there is no established vaccine process

Many long-term care facilities are directly enrolled as providers in the CDC COVID-19 Vaccination Program, or they have an established way to get vaccines through on-site vaccination clinics conducted by pharmacies or health departments, said the CDC’s Meyer. For providers that don’t have access to either of these options, the CDC will allow facilities to sign a COVID-19 Vaccine Sub-Provider Agreement so that they can administer the vaccines themselves.

“A key component of this is the use of single-dose Pfizer vials,” said Meyer. “Facilities that sign a sub-provider agreement with CDC would then be able to request single-dose vials through a pharmacy partner. This was intended to help remove some of the barriers that we heard about—that storage and handling of multidose vials is more difficult, or that there are not always large groups of patients who want a vaccine at one given time.”

The sub-provider agreement also includes some data reporting flexibilities. Under the CDC COVID-19 Vaccination Program, participants must report vaccine administration data to their state or jurisdiction’s Immunization Information Systems (IIS) as soon as practicable and within 72 hours of administration. “Facilities that sign a sub-provider agreement have a 90-day temporary waiver of data reporting requirements to the IIS unless it is required by state laws,” said Meyer. “But, they would still need to report [timely] through any other required mechanisms, such as NHSN [the National Healthcare Safety Network].”

  1. Understand why COVID-19 treatment is so critical

The risk of severe outcomes with COVID-19 grows “markedly with increasing age,” said Meg Sullivan, MD, MPH, chief medical officer at the Administration for Strategic Preparedness and Research (ASPR) at the U.S. Department of Health and Human Services (HHS). “Seniors continue to have the highest risk of being hospitalized and dying because of COVID. People living in congregate care settings are also at high risk, and according to recent data, one in five recent COVID deaths were in nursing homes and other long-term care facilities, such as assisted living facilities.”

While nursing home residents are nearly all at risk for severe COVID-19 outcomes, most are also eligible for treatments, said Sullivan. “Every facility can take specific steps to act to ensure that the community of residents is aware of COVID-19 treatments and their effectiveness and to promote easy access to these lifesaving treatments.”

Key information that nursing home staff, residents, families, and physicians and nonphysician practitioners need to understand about treatment options include the following:

  • COVID-19 treatments are safe and effective. “There is now strong scientific evidence that antiviral treatment of outpatients at risk for severe COVID-19 reduces their risk of hospitalization and death,” said Sullivan. “This includes clinical trial data that led to authorization or approval of these treatments, as well as real-world evidence data that points to their effectiveness.” Note: In this context, outpatients include any patients who are not hospitalized, including nursing home residents.

“Based on preliminary analyses, these treatments are expected to be active against all current circulating variants,” added Sullivan. “This is something that we continue to monitor closely.”

  • Anyone (1) over the age of 50 or (2) with a high-risk health condition should be counseled on and potentially prescribed COVID-19 treatments as clinically appropriate. “Even if vaccinated, patients are more likely than others to get very sick from COVID if they are age 50 or older (with risk increasing with age); they have one or more health issues, such as heart, lung, or kidney disease, being overweight, diabetes, severe asthma, some types of disabilities, or other health conditions that are linked on the CDC website; or they have a compromised or weakened immune system.”

Unfortunately, underutilization of COVID-19 therapeutics is common, said Sullivan. “In a recent CDC study, most people eligible for one of the [preferred] treatments—in every age group, including those aged over 65—did not receive a prescription for this medication.”

  • COVID-19 treatments must be started early, even if symptoms are mild. “Treatments must be started within five days of symptom onset for the oral medications and seven days of symptom onset for the IV medication,” pointed out Sullivan. There are currently two preferred first-line treatments and one alternate second-line treatment for eligible patients, according to the Dec. 20, 2022 CDC Health Area Network Health Update “Important Updates on COVID-19 Therapeutics for Treatment and Prevention”.
  • Ritonavir-boosted nirmatrelvir(Paxlovid). This oral antiviral pill is taken twice daily for five days, said Sullivan. It is not recommended in patients with severe renal impairment, and clinicians need to consider renal dosage adjustment for moderate renal impairment. “For all eligible patients, drug interactions need to be assessed, and certain medications may need dose adjustments.” Note: Visit ASPR’s Paxlovid page for more information, including fact sheets, frequently asked questions (FAQs), and a Paxlovid Patient Eligibility Screening Checklist Tool for Prescriber that addresses potential drug-to-drug interactions.
  • Remdesivir(Veklury). This IV antiviral medication, which is used once a day, is a preferred treatment for patients “for whom Paxlovid is not appropriate,” said Sullivan. Note: Visit ASPR’s Veklury page for prescribing guidance and other resources.

Note: For more insights, review ASPR’s Information Sheet – COVID-19 Treatments: Key Messages for Long-Term Care Facilities. In addition, the CMS Quality Improvement (QI) Voices: Improving COVID-19 Outcomes in Nursing Homes Across America is a three-episode audio series with experts from CMS, the CDC, and the U.S. Food and Drug Administration (FDA) that covers (in 15 minutes or less) the following topics: (1) the safety and efficacy of the bivalent COVID-19 vaccine, (2) long-term care treatment options for COVID-19, and (3) CDC Programs for COVID-19 infection prevention and vaccination in nursing homes. Find all three episodes, as well as related tools and resources, here.

  1. Create resident-specific COVID-19 action plans

Nursing homes should consider working with each resident, their family, and their physician to create COVID-19 action plans in case the resident gets sick with COVID-19, suggested Sullivan. This plan should include the resident’s “optimal treatment choice if they are eligible and how to quickly access that medication.”

Doing a COVID-19 action plan in advance of sickness to find out each resident’s tolerance level for Paxlovid or the other medications is worth the effort, added Jean Moody-Williams, RN, MPP, deputy director of the Center for Clinical Standards and Quality at CMS. “It is hard to make those decisions if you are in the midst of it. We really are encouraging that those discussions be held with residents and their families as appropriate so that when the time comes, those decisions have at least been given some thought.” 

  1. Pre-position treatment medications directly at the facility

Currently, no supply constraints are limiting access to approved or authorized treatments, said Sullivan. “Long-term care facilities should ensure timely access to effective COVID-19 treatments for all eligible patients. … The U.S. government is currently distributing the two oral antivirals at no cost, and facilities can contact their long-term care pharmacy or e-mail COVID19Therapeutics@hhs.gov for access.”

One way to help ensure that residents receive treatment timely is to pre-position the oral antivirals within the facility following local regulations, suggested Sullivan. That’s allowed “as long as they are only dispensed to patients once a prescription is entered,” she added. “We encourage you to reach out with questions.”

  1. Bring the medical director and prescribers on board

“We have moved into a place where really it is those dedicated individuals in nursing facilities who are driving the bulk of the care right now to prevent COVID-19 illness and to ensure response,” said Suzanne Gillespie, MD, RD, CMD, president of AMDA, the Society for Post-Acute and Long-Term Care Medicine in Columbia, MD. “Many facilities are reflecting on their practice and whether they are engaged fully in efforts to test, vaccinate, and treat.”

To help providers include medical directors in that self-assessment, AMDA has outlined five collaboration strategies in “Role of the Medical Director in Effective Prevention and Treatment of COVID-19.” This tool is included in the COVID-19 Vaccination and Therapeutics in PALTC Toolkit: Resources for Clinicians, updated on Jan. 4, 2023, which AMDA created in partnership with the American Society of Consultant Pharmacists, the Gerontological Advance Practice Nurses Association, the American Association of Nurse Practitioners, and the American Academy of Physician Associates to provide bedside healthcare teams with up-to-date, easily accessible knowledge and tools to make vaccination, testing, and treatment the standard of care in nursing homes.

Other tools and resources included in the toolkit include a Paxlovid standing order template and treatment order form, a pharmacist ordering flowchart, frequently asked questions about the bivalent vaccine, and an information sheet on myths and facts about Paxlovid.

  1. Take advantage of QIO expertise and resources

The Quality Improvement Organization (QIO) program includes 12 Quality Innovation Network (QIN) QIOs that are contracted with CMS to work with nursing homes nationwide on several quality initiatives, including infection control assistance and vaccination uptake. Note: Providers can find their QIN-QIO here or by e-mailing Colleen Frey, the QIO program director, at colleen.frey@cms.hhs.gov.

CMS reviews NHSN data weekly to identify nursing homes with low up-to-date vaccination rates and then deploys the QIOs to work with those nursing homes, said Anita Monteiro, director of CMS’s Quality Improvement and Innovations Group. “For instance, in the last five weeks of last year starting Nov. 26 through Dec. 30, … the QIOs set up 150 on-site clinics across the country, resulting in over 4,000 residents being vaccinated and over 1,300 staff being vaccinated.”

However, any nursing home can reach out to the QIOs for assistance, encouraged Monteiro. For example, the QIOs can help set up on-site clinics, distribute fact sheets and other educational materials, disseminate and explain information around therapeutics, improve vaccination confidence, work with local health departments to obtain licensed vaccine administration staff to assist in nursing homes, and conduct clinic or office hours with nursing homes to answer questions that may come up with the clinicians, the residents, and the staff.

In addition, F884 (Reporting—National Health Safety Network) was the No. 1 cited F-tag nationwide in calendar year 2022, according to QCOR (Quality, Certification, and Oversight Reports) data accessed on Jan. 7, 2023. The QIOs can help nursing homes understand how to use the NHSN system and improve the accuracy of their reporting, advised Monteiro. “The QIOs have assisted several hundred nursing homes with that request.”

Note: Some QIOs recently have hosted webinars on NHSN reporting, as well as providing tools to help nursing homes develop a strong reporting process. For example, the QIO Telligen offers the NHSN Reporting Continuity Tip Sheet, the eight-minute video “LTC—NHSN: How to Add a New User,” and other resources. In addition, many of the QIOs have established NHSN groups that providers can join to share anonymized data with their QIO for quality improvement purposes.

  1. Continue to follow testing and masking guidance

To help reduce the risk of COVID-19 transmission, nursing homes still must know their county community transmission level, advised Evan Shulman, director of the Division of Nursing Homes at CMS. “As a reminder for nursing homes, you should review the county community transmission level, which is different from the community levels used for the folks in the general community, and make sure that residents, staff, visitors, and others who come to the facility are aware of the level of your county and what to do because of that level.”

Note: When obtaining county information at the COVID-19 Integrated County View page of the CDC’s COVID Data Tracker, providers must select “Community Transmission” in the Data Type section, not “COVID-19 Community Levels.”

Nursing homes also should continue to follow the testing and masking guidance from CMS and the CDC, said Shulman. “Remember, a lot of these recommendations are just the minimum that we recommend, but certainly the safer route is to go above and beyond the minimum.”

Current guidance includes the following:

  • CMS memo QSO-20-38-NH, revised on Sept. 23, 2022, provides guidance on testing residents and staff.
  • CMS memo QSO-20-39-NH, also revised on Sept. 23, 2022, provides visitation guidance, including guidance for face coverings and masks during visits.
  • CMS memo QSO-20-29-NH, issued on May 6, 2020, addresses COVID-19 reporting requirements to the NHSN, as well as to residents, their representatives, and their families.
  • The CDC COVID-19 Infection Control Guidance page provides detailed guidance on everything from personal protective equipment to testing, cohorting, and the duration of transmission-based precautions.

Note: For additional action steps, including how to improve air quality (e.g., by purchasing portable air cleaners with high-efficiency particulate air filters through CMS’s civil money penalty reinvestment program), see the White House’s Winter Playbook for Nursing Homes and Other Long-term Care Facilities to Manage COVID-19 and Protect Residents, Staff, and Visitors.

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Topics: Accountable Care Organizations (ACOs) , Clinical , Facility management , Featured Articles , Infection control , Operations , Regulatory Compliance , Resident Care