key: cord-1025678-4bwccera
authors: Malec, James F.; Salisbury, David B.; Anders, David; Dennis, Leanne; Groff, April R.; Johnson, Margaret; Murphy, Mary Pat; Smith, Gregory T.
title: RESPONSE TO THE COVID-19 PANDEMIC AMONG POSTHOSPITAL BRAIN INJURY REHABILITATION PROVIDERS
date: 2020-11-27
journal: Arch Phys Med Rehabil
DOI: 10.1016/j.apmr.2020.10.137
sha: 1d4b22e01a736b2308c881af3df45046d91c50a3
doc_id: 1025678
cord_uid: 4bwccera

Rehabilitation following significant acquired brain injury (ABI) to address complex independent activities of daily living and return to family and community life is offered primarily after initial hospitalization in outpatient day treatment, group home, skilled nursing, and residential settings, and in the home and community of the person served. The COVID-19 pandemic threatened access to care and the health and safety of staff, persons served, and families in these settings. This paper describes steps taken to contain this threat by seven leading posthospital ABI rehabilitation organizations. Outpatient and day treatment facilities were temporarily suspended. In other settings, procedures for isolation, transportation, cleaning, exposure control, infection control, and use of personal protective equipment (PPE) were reinforced with staff. Visitation and community activities were restricted. Staff and others required to enter facilities were screened with symptom checklists and temperature checks. Individuals showing symptoms of infection were quarantined and tested, as possible. New admissions were carefully screened for infection and often initially quarantined. Telehealth played a major role in reducing direct interpersonal contact while continuing to provide services both to outpatients and within facilities. Salary, benefits, training and managerial support were enhanced for staff. Despite early outbreaks, these procedures were generally effective with preliminary initial infections rates of only 1.1% for persons served and 2.1% for staff. Reductions in admissions, services, and unanticipated expenses (e.g., PPE, more frequent and thorough cleaning) had a major negative financial impact. Providers continue to be challenged to adapt rehabilitative approaches and to reopen services.

The novel 2019 coronavirus disease , caused by severe acute respiratory 25 syndrome coronavirus 2, can present with a wide array of symptoms and coronavirus disease 26 syndromes. Since the pandemic onset, the wealth of articles and case descriptions present a 27 picture of disease that can impact nearly all major organ systems. There is increasing attention to 28 neuroinvasive presentations as well that include a continuum of vague neurological symptoms to 29 discrete neurological syndromes. 1-3 Mao and colleagues 4 detailed subgroups of COVID-19 30 neurological manifestations centered around central nervous system, peripheral nervous system 31 and skeletal muscular injury. Estimates suggest that from a quarter to one third of individuals 32 hospitalized with COVID-19 may develop neurological symptoms with neuroinvasive 33 presentations being linked to more severe COVID-19 cases. 1, 4 The preferential impact on 34 neuroanatomical structures may include brain stem regions linked to regulatory functions, such 35 as, respiration and cardiac function, possibly exacerbating the disease course. 5, 6 More discrete 36 neurological complications can include stroke, even in persons with few if any risks factors, and 37 seizures. 1,2 Additionally, the potential for residual encephalopathy syndromes, long-term 38 hypoxic/anoxic effects and post-ICU syndrome raises concerns that the number of individuals 39 with more severe forms of COVID-19 could have significant rehabilitation needs during the 40 subacute recovery stage and even across the lifespan. 2,7 Thus the COVID-19 pandemic 41 challenges rehabilitation providers both to manage the spread of the disease among the people 42 that they presently serve and to consider the potential future rehabilitation needs of those who 43 have recovered from severe forms of the infection. 44 Over the last several decades, the duration of both acute medical and inpatient 45 rehabilitation hospital stays following significant ABI have declined markedly. In most cases, Predicting the extent of potential rehabilitation needs stemming from the COVID-19 60 pandemic is challenging. Nonetheless, consideration of potential treatment options and providers 61 to manage the complexity of the neurological and rehabilitation needs of individuals with ABI 62 who contract COVID-19 appears warranted. Given the limited length of stay for inpatient 63 rehabilitation, it is likely that any additional needs for intensive rehabilitation for these 64 individuals will be met by posthospital rehabilitation organizations.

The COVID-19 pandemic challenged these organizations to develop innovative methods 66 for continuing to provide services while protecting the health and safety of persons served, their 67 families, and staff and managing financial budgets based on pre-pandemic planning. Individuals 

Adapting services and assuring safety for persons served and families 89 Organizations uniformly instituted a number of practice and environmental changes (see 90   Table 1 ) following guidance from the Center for Disease Control and Prevention (CDC) and 91 state/local regulatory agencies when available. Practice changes were initiated immediately 92 J o u r n a l P r e -p r o o f following awareness of the pandemic threat (although, as noted below, major practice 93 realignments, e.g., transition to telehealth, took more time to fully implement) and continue to be 94 regularly reviewed and updated as new guidance emerges from the CDC and state agencies.

Rehabilitation therapies continued to be provided in residential settings for individuals deemed to 96 be unsafe to return to community settings or when such a transition would greatly impact their 97 recovery potential. In-person services also continued in most group home and H&C settings with 98 recommended protections. Residential facilities designated a specific area of the facility for 99 persons served who were identified as COVID positive to prevent the spread of infection. As 100 testing became more available, one organization with a number of group homes designated one 101 home as a "Recovery House" in each geographical area served for those who were recovering 102 from a COVID infection, and other homes for those without symptoms or with negative testing.

Insert Table 1 New evaluations were also limited and modified as described in Table 2 . Although 107 COVID testing was generally conducted in cases screened as suspicious for infection, this varied 108 by locale. Early on when testing was scarcer, some states prohibited long-term care facilities 109 from using COVID testing as a requirement for admission and advised preadmission temperature 110 tracking and symptom monitoring followed by 14-day quarantine. In other cases, admission was family and social support to aid in service, and resistance to video telehealth.

Assuring the health, well-being, and safety of staff 152 The potential for spread of infection applies not only to persons served but to the staff 153 who serve them. Managing staff exposure was critical as many organizations quickly learned 154 how a single positive case could temporarily deplete a treatment team or support staff group.

Many of the practice modifications (Table 1) to protect participants from infection also protect 156 staff. Additional interventions specific to staff are listed in Table 3 . Obtaining PPE and testing is 157 challenging in some locales and requires diligence and creativity in managing the systems 158 controlling these resources. Programs have also needed to be vigilant regarding CDC updates for 159 PPE, particularly around the asymptomatic spread of COVID-19. Staff showing symptoms or 160 testing positive were instructed to self-quarantine; however, some with minimal or mild 161 symptoms continued to deliver therapy using telehealth.

Insert Table 3 about 

Formal and informal staff feedback during the pandemic revealed an elevated level of 166 stress regarding personal safety and the overall uncertainty of how COVID will impact job 167 security as well as concern about long term organizational viability. Initiatives to address 168 increased stress among staff and to enhance staff appreciation and support were implemented days (e,g., wear favorite football team shirt) and staff appreciation days; organizing external 179 volunteers to sew masks and gowns for staff; dedicated space for staff to decompress and relax; 180 videoconference and text groups for decompression and support.

Effectiveness of interventions to reduce spread of COVID-19 183 As Table 4 illustrates, implementation of the procedures and processes previously Table 4 are not mutually exclusive; for example, a person 190 identified as COVID positive may also have been hospitalized and required ICU treatment. The 191 pandemic continues and estimates are limited by a lack of widely available testing and well-192 established diagnostic procedures. As such these estimates, although based on the best available 193 data at the time this paper is being written, must be considered preliminary.

Insert Table 4 -197 198 Financial impact and other costs 199 The early financial impact of practice changes (see Table 5 ) required to respond to the 

Insert Table 5 Environmental changes include visual cues to encourage social distancing and more frequent and 256 thorough facility cleaning. In H&C settings, therapists have always been encouraged to decline 257 to provide service in a residential setting in which they feel unsafe and this policy also extends to 258 potential COVID-19 exposure. With greater access to testing and more rapid and accurate 259 results, programs should be better able to make decisions around quarantining. Telehealth also makes pre-admission screenings and family conferences more accessible to those 282 served and opens access to services to those who may have difficulty journeying to a care center 283 J o u r n a l P r e -p r o o f due to distance or other obstacles to transportation. Working with persons served in their living 284 environments increases both the value and the probability that the changes will be 285 lasting. Working in a virtual environment also facilitates access to other interdisciplinary team 286 members to address issues in real time through texting or teleconferencing.

As mentioned previously, a few barriers to telehealth have been encountered. Continued 288 mainstream telehealth use is expected to allow providers to learn to minimize these modifiable 289 barriers. Such efforts may include cost reductions or other financial supports to assist consumers 290 in purchasing necessary technology, identifying staff and/or family support persons who can 291 provide needed training and technology assistance to persons served, and including other parties 292 (e.g., translators, case managers) in therapeutic interactions as in in-person therapy. Although 293 security issues may be a concern, applications like FaceTime can be used if a smartphone is 294 available but a computer is not. If more advanced technology is not available, traditional 295 handouts and therapy guides can be sent through the mail with telephone follow-up.

To reduce the risk of spread of the infection within staff, procedures are also being 298 implemented in office settings, such as, eliminating group workspaces, supporting social 299 distancing, requiring masks be worn in offices, and frequent intensive cleaning of these areas.

Special considerations for staff at higher risk will continue to be made. In accordance with some 301 government recommendations regarding graduated business re-opening, using the 302 25/50/75/100% capacity model or other internally developed staged protocol will be followed.

These changes both in therapeutic and nontherapeutic areas will dramatically alter these milieus Many aspects of staff role flexibility, varying schedules for patient care, and having multiple 335 methods of care delivery will undoubtedly lead to a better experience for the person served and 336 increase access to care going forward. The potential to downscale nonclinical facility space and 337 overhead for those who can work remotely allows more revenue to be dedicated to direct care 338 expenses. This is critical given the declining reimbursement and increasing insurance challenges 339 that continue to threaten postacute care viability.

Ideally current appeals to CMS and other payor sources to continue to reimburse for 341 telehealth and other care modalities employed during the pandemic will be successful. This unchanged, yet cost of care and less efficient treatment/staffing models will continue. The harsh 347 reality for posthospital rehabilitation and other healthcare providers may be that the resources 348 needed to manage future outbreaks will not be available given the monumental financial burden 349 that has been already absorbed. • Update and distribute staff policies and guidelines for isolation procedures, transportation, cleaning, exposure control, and infection control specifically targeting droplet exposure • Serial training and competency checks on these above procedures based on updated information regarding best practices • Vigilantly implement recommended protections for staff (e.g., personal protective equipment; PPE) and persons served • Discontinue community activities outside of the residential facility, group home, or participant's home • In the absence of community outings, enhance and expand in-house leisure and recreation programs (for example, increased frequency of recreational therapy; implement telehealth availability of art and music therapy and support groups including availability in evening hours; increase outdoor recreational activities and community walks that include instruction and rehearsal of safe practices for community activities) • Restrict outside visitation to facilities • Conduct daily symptom screening and temperature checks of those required to enter the facility (e.g., staff, vendors) • To reduce the possibility of cross-contamination, assign therapists who in the past served multiple facilities or group homes to a single setting and, as possible, to a small cohort of persons to treat • Increase frequency of facility cleaning routines with special attention to thorough and frequent cleaning of shared surfaces and equipment • For services in the participant's home, provide and reinforce education on infection control and prevention (for example, frequent hand washing, adhering to local shelterin-place orders, social distancing, and wearing masks or face shields) • Quarantine and, as possible, test program participants and staff showing COVID-19 symptoms; recommend seeking appropriate medical evaluation and treatment • Quarantine program participants and staff who had contact with COVID positive individuals guided by physician and regulatory agency advice • Include queries about flu and coronavirus symptoms, possible exposure, and travel history for the potential participant and others with whom they have been in contact • As allowed by state regulation and availability, obtain COVID testing prior to admission if evaluation suggests that an appropriate rehabilitation candidate is at high risk for infection • Administer COVID symptom checklist to person served and other household members at the onset of services and at least weekly thereafter Table 3 . Intervention Specific to Assuring the Health, Well-being, and Safety of Staff • Give staff option of working from home or, as possible, alternative assignment, or temporary furlough-particularly those identified as at high risk • Organization managers maintain regular telephone contact with furloughed staff to support their eventual re-engagement • Assist furloughed staff to access organization's Employee Assistance Program and resources for financial assistance and other supports, e.g., continuing education and coping videos • Develop programs for active, non-furloughed staff appreciation and provide in-themoment support • Assure flexibility in work schedules for employees with childcare, elder care and other COVID-related family challenges • Implement supportive adjustments in pay, paid-time-off, and leave-without-pay to recognize the increased risk and effort during the pandemic • Provide greater pay increases for those volunteering to provide service to COVID positive or symptomatic participants J o u r n a l P r e -p r o o f • Inconsistent telehealth reimbursement that, in many cases, is well below prior reimbursement level • Revenue reductions resulting from suspension of outpatient services, reduction in inperson therapies, and reduced and delayed admissions due to necessary additional screening and processing • Pay adjustments, increased paid time off and other expanded staff benefits and services J o u r n a l P r e -p r o o f

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The purpose of this form is to provide readers of your manuscript with information about your other interests that could influence how they receive and understand your work. The form is designed to be completed electronically and stored electronically. It contains programming that allows appropriate data display. Each author should submit a separate form and is responsible for the accuracy and completeness of the submitted information. The form is in six parts.

2. The work under consideration for publication. This section asks for information about the work that you have submitted for publication. The time frame for this reporting is that of the work itself, from the initial conception and planning to the present. The requested information is about resources that you received, either directly or indirectly (via your institution),to enable you to complete the work. Checking "No" means that you did the work without receiving any financial support from any third party--that is, the work was supported by funds from the same institution that pays your salary and that institution did not receive third-party funds with which to pay you. If you or your institution received funds from a third party to support the work, such as a government granting agency, charitable foundation or commercial sponsor, check "Yes." 3. Relevant financial activities outside the submitted work. This section asks about your financial relationships with entities in the bio-medical arena that could be perceived to influence, or that give the appearance of potentially influencing, what you wrote in the submitted work. You should disclose interactions with ANY entity that could be considered broadly relevant to the work. For example, if your article is about testing an epidermal growth factor receptor (EGFR) antagonist in lung cancer, you should report all associations with entities pursuing diagnostic or therapeutic strategies in cancer in general, not just in the area of EGFR or lung cancer.Report all sources of revenue paid (or promised to be paid) directly to you or your institution on your behalf over the 36 months prior to submission of the work. This should include all monies from sources with relevance to the submitted work, not just monies from the entity that sponsored the research. Please note that your interactions with the work's sponsor that are outside the submitted work should also be listed here. If there is any question, it is usually better to disclose a relationship than not to do so.For grants you have received for work outside the submitted work, you should disclose support ONLY from entities that could be perceived to be affected financially by the published work, such as drug companies, or foundations supported by entities that could be perceived to have a financial stake in the outcome. Public funding sources, such as government agencies, charitable foundations or academic institutions, need not be disclosed. For example, if a government agency sponsored a study in which you have been involved and drugs were provided by a pharmaceutical company, you need only list the pharmaceutical company.

This section asks about patents and copyrights, whether pending, issued, licensed and/or receiving royalties. 5. Relationships not covered above. Use this section to report other relationships or activities that readers could perceive to have influenced, or that give the appearance of potentially influencing, what you wrote in the submitted work.Definitions:Entity: government agency, foundation, commercial sponsor, academic institution, etc. The purpose of this form is to provide readers of your manuscript with information about your other interests that could influence how they receive and understand your work. The form is designed to be completed electronically and stored electronically. It contains programming that allows appropriate data display. Each author should submit a separate form and is responsible for the accuracy and completeness of the submitted information. The form is in six parts.

This section asks for information about the work that you have submitted for publication. The time frame for this reporting is that of the work itself, from the initial conception and planning to the present. The requested information is about resources that you received, either directly or indirectly (via your institution),to enable you to complete the work. Checking "No" means that you did the work without receiving any financial support from any third party--that is, the work was supported by funds from the same institution that pays your salary and that institution did not receive third-party funds with which to pay you. If you or your institution received funds from a third party to support the work, such as a government granting agency, charitable foundation or commercial sponsor, check "Yes." 3. Relevant financial activities outside the submitted work. This section asks about your financial relationships with entities in the bio-medical arena that could be perceived to influence, or that give the appearance of potentially influencing, what you wrote in the submitted work. You should disclose interactions with ANY entity that could be considered broadly relevant to the work. For example, if your article is about testing an epidermal growth factor receptor (EGFR) antagonist in lung cancer, you should report all associations with entities pursuing diagnostic or therapeutic strategies in cancer in general, not just in the area of EGFR or lung cancer.Report all sources of revenue paid (or promised to be paid) directly to you or your institution on your behalf over the 36 months prior to submission of the work. This should include all monies from sources with relevance to the submitted work, not just monies from the entity that sponsored the research. Please note that your interactions with the work's sponsor that are outside the submitted work should also be listed here. If there is any question, it is usually better to disclose a relationship than not to do so.For grants you have received for work outside the submitted work, you should disclose support ONLY from entities that could be perceived to be affected financially by the published work, such as drug companies, or foundations supported by entities that could be perceived to have a financial stake in the outcome. Public funding sources, such as government agencies, charitable foundations or academic institutions, need not be disclosed. For example, if a government agency sponsored a study in which you have been involved and drugs were provided by a pharmaceutical company, you need only list the pharmaceutical company.

This section asks about patents and copyrights, whether pending, issued, licensed and/or receiving royalties. 5. Relationships not covered above. Use this section to report other relationships or activities that readers could perceive to have influenced, or that give the appearance of potentially influencing, what you wrote in the submitted work.