key: cord-0894544-mj4gcff2 authors: Wong, Brian M.; Rotteau, Leahora; Feldman, Sid; Lamb, Michael; Liang, Kyle; Moser, Andrea; Mukerji, Geetha; Pariser, Pauline; Pus, Laura; Razak, Fahad; Shojania, Kaveh G.; Verma, Amol title: A Novel Collaborative Care Program to Augment Nursing Home Care During and After the COVID-19 Pandemic date: 2021-11-24 journal: J Am Med Dir Assoc DOI: 10.1016/j.jamda.2021.11.018 sha: 9a28be16a81af1662516449f2e53196393ff133a doc_id: 894544 cord_uid: mj4gcff2 The 2019 novel coronavirus (COVID-19) pandemic created an immediate need to enhance current efforts to reduce transfers of nursing home (NH) residents to acute care. Long-Term Care Plus (LTC+), a collaborative care program developed and implemented during the COVID-19 pandemic, aimed to enhance care in the NH setting while also decreasing unnecessary acute care transfers. Using a hub-and-spoke model, LTC+ was implemented in six hospitals serving as central hubs to 54 geographically associated NHs with 9,574 beds in Toronto, Canada. LTC+ provided to NHs with the following: 1) virtual general internal medicine (GIM) consultations; 2) nursing navigator support; 3) rapid access to laboratory and diagnostic imaging services; and 4) educational resources. From April 2020 to June 2021, LTC+ provided 381 GIM consultations that addressed abnormal bloodwork (15%), cardiac problems (13%) and unexplained fever (11%) as the most common reasons for consultation. Sixty-five nurse navigator calls addressed requests for non-GIM specialist consultations (34%), wound care assessments (14%) and system navigation (12%). One hundred and seventy-seven (46%; 95% CI 41-52%) consults addressed care concerns sufficiently to avoid the need for acute care transfer. All 36 primary care physicians who consulted the LTC+ program reported strong satisfaction with the advice provided. Early results demonstrate the feasibility and acceptability of an integrated care model that enhances care delivery for NH residents where they reside and has the potential to positively impact the long-term care sector by ensuring equitable and timely access to care for people living in NHs. It represents an important step towards health system integration that values the expertise within the long-term care sector. pandemic, aimed to enhance care in the NH setting while also decreasing unnecessary acute care 5 transfers. Using a hub-and-spoke model, LTC+ was implemented in six hospitals serving as 6 central hubs to 54 geographically associated NHs with 9,574 beds in Toronto, Canada. LTC+ 7 provided to NHs with the following: 1) virtual general internal medicine (GIM) consultations; 2) 8 nursing navigator support; 3) rapid access to laboratory and diagnostic imaging services; and 4) 9 educational resources. From April 2020 to June 2021, LTC+ provided 381 GIM consultations 10 that addressed abnormal bloodwork (15%), cardiac problems (13%) and unexplained fever 11 (11%) as the most common reasons for consultation. Sixty-five nurse navigator calls addressed 12 requests for non-GIM specialist consultations (34%), wound care assessments (14%) and system 13 navigation (12%). One hundred and seventy-seven (46%; 95% CI 41-52%) consults addressed 14 care concerns sufficiently to avoid the need for acute care transfer. All 36 primary care 15 physicians who consulted the LTC+ program reported strong satisfaction with the advice 16 provided. Early results demonstrate the feasibility and acceptability of an integrated care model 17 that enhances care delivery for NH residents where they reside and has the potential to positively 18 impact the long-term care sector by ensuring equitable and timely access to care for people living in 19 NHs. It represents an important step towards health system integration that values the expertise 20 within the long-term care sector. to support PCPs in 54 geographically associated NHs with 9,574 beds (www.ltcplus.ca). Although not mandated by the regional COVID-19 pandemic task force, we assigned NHs to 34 acute care hubs in part to align with provincially mandated relationships for other types of 35 pandemic support (e.g., infection control, COVID-19 testing, staffing), and also to strengthen 36 local care networks and build relationships. To access the program, PCPs in all participating NHs 37 were provided with a single phone number to call and once connected PCPs used an automated 38 phone menu to select their desired service. To inform the design of LTC+, we drew upon multiple data sources to determine the 40 services needed to enhance care delivery in NHs. These included the GEMINI database that  Data from a subset of hospital admissions in the multicenter GEMINI study of 7 acute care hospitals in Toronto and a crosssectional needs assessment survey informed the design of LTC+.  Utilization of a data dashboard that is updated weekly and reported on acute care transfer rates and delivery of program components to inform ongoing improvement activities.  Cross-sectoral partnerships from the longterm care and acute care sectors supporting the development of an integrate care model.  Range of expertise on LTC+ leadership team including long-term care, primary care, internal medicine, geriatric medicine, palliative care, quality improvement (QI), data analytics, and virtual care.  Rapid testing and refinement at three nursing homes with pre-existing relationship with a hospital-based hub, prior to full implementation.  Plan-Do-Study-Act cycles to optimize individual LTC+ components.  Supported the identification and implementation of local solutions and the ability to pivot in response to the COVID-19 pandemic.  There was a need for rapid implementation to meet the pandemic related needs of the nursing homes, meaning some components were implemented prior to full refinement.  COVID-19 outbreaks in NHs required scaling back of some engagement and implementation activities due to nursing home staffing capacity.  Visitor restrictions in NHs limited in-person stakeholder engagement.  Reliance on in-kind resources provided by acute care hospitals, nursing homes and community service providers, may be a threat to sustainability and spread.  Need for system level funding changes to ensure nursing home access to diagnostic testing and other services.  Seven high-adopter NHs accounted for 81% of all GIM consultation requests.  Many NHs did not use any LTC+ services.  Creates challenges for conducting a full evaluation of LTC+ effectiveness and impact. 1. Virtual specialist consultations: Acute care hospital hubs made virtual specialist consultation available to NHs, with GIM and palliative care specialists on-call 24/7 to field urgent request 2. Nurse navigator: Available weekdays via phone or e-mail during daytime hours to coordinate timely access to community-based services such as nursing outreach, behavioural support programs, and wound care. Coordinated with private sector laboratory and diagnostic imaging providers to expand access to these services.  Increased access to laboratory services whereby a phlebotomist was available 7 days per week to draw samples and deliver them to the lab for same day reporting of results.  Mobile diagnostic imaging service technologist traveled to NHs to perform on-site X-rays and ultrasound 4. Educational webinars: We co-designed and co-delivered a series of educational webinars with NH Medical Directors and Administrators, archived on the LTC+ website (https://ltcplus.ca/primary-care-provider/#Education-and-Webinars). Clinical experts presented care delivery topics relevant to the pandemic (e.g., Management of Residents with COVID-19 in NHs, Facing Decline and Death in the Time of COVID, Infection Prevention and Control in NHs). Long-term care facilities and the coronavirus epidemic: practical guidelines for a population at highest risk Potentially avoidable hospitalizations of dually eligible Medicare and Medicaid beneficiaries from nursing facility and home-and community-based services waiver programs COVID-19 in nursing homes: calming the perfect storm Care by design: New model of coordinated on-site primary and acute care in long-term care facilities COVID-19 collaborative model for an academic hospital and long-term care facilities Implementation of telemedicine consultation to assess unplanned transfers in rural long-term care facilities, 2012-2015: A pilot study Modelling resource requirements and physician staffing to provide virtual urgent medical care for residents of long-term care homes: a crosssectional study The improvement guide: a practical approach to enhancing organizational performance Solving the COVID-19 crisis in post-acute and long-term care