Courtesy of/Knollwood Life Plan Community
Staff at Knollwood perform a test on another staff member arriving for work.
Courtesy of/Knollwood Life Plan Community
Col. Paul Bricker approaches dealing with COVID-19 at the Knollwood Life Plan retirement community in D.C. much like his military service in Afghanistan and Iraq: with clear communication, a command structure and a careful eye on logistics.
"You can't wait for other people to do things you know must happen," says Bricker, the community's chief operating officer.
Knollwood is home to about 300 residents, all retired service members and their families. Currently, six residents and three staff have COVID-19, and 14 residents and 24 staff have recovered from the disease. Nine skilled nursing residents and two staff have died of the disease.
Knollwood is one of the 18 facilities in the District with resident and staff cases of the coronavirus within its walls. As coronavirus cases continue to spread in long-term care and nursing home facilities, calls from local and national officials have increased for expanding testing to all residents and staff.
In mid-April, Bricker and the Knollwood leadership team got a phone call from the D.C. medical examiner's office: A Knollwood skilled nursing resident who was hospitalized and later died, ended up testing positive for the virus after their death.
That was a wake-up call, says Tina Sandri, Knollwood's administrator.
"If you have one [case], you know you have more than one," Sandri says.
The Knollwood team decided in April to test all residents and staff in its skilled nursing facility. But D.C. public health guidelines on testing at the time restricted tests to only people who were showing symptoms. (On May 7, the District designated long-term care facility residents and workers as "high priority" if they showed symptoms or had prolonged contact with a person who tested positive for the coronavirus.)
Knollwood ultimately found a workaround in April, contracting with a private company LabCorp to test nearly 50 skilled nursing residents and 200 staff. Knollwood also has independent living and assisted living units, but prioritized testing for skilled nursing units first given that's where the first known case originated.
The results of those tests, says Bricker, were eye-opening. Several residents and nearly a dozen staff had the virus but were asymptomatic — information the facility wouldn't have known without testing everybody.
"It really shattered us because we immediately saw to what extent the virus had gotten into our skilled nursing area," Bricker recalls. "We were literally chasing employees down and asking them to go home because 80% of the folks ... had no symptoms at all."
Since then, Knollwood has conducted more than 800 tests on residents and staff throughout its community, often testing multiple times to make sure coronavirus patients have recovered. The results have informed the way the facility structures its response to the disease, grouping patients who are positive away from those who are negative, sending employees home to heal from the virus, and bolstering its stocks of protective equipment for staff.
"It's almost like flying an airplane in the fog," Bricker says. "The results of our testing were literally like a pathway through the fog to help us make informed decisions."
Local and national public health officials say universal COVID-19 testing — which, as at Knollwood, often unearths asymptomatic residents and staff — is a key tool to stop the spread of the disease, especially in congregate settings where social distancing can be difficult.
Baseline testing for all nursing home residents and staff, as well as capacity for weekly testing until all tests come up negative, are two of the factors that states should examine in making decisions about relaxing nursing home lockdowns during reopening, according to guidance from the U.S. Dept. of Health and Human Services' Centers for Medicare and Medicaid.
But universal testing is easier said than done. Accessing the tests, trained staff and protective gear necessary to conduct widespread testing in a single nursing home is still a significant logistical challenge.
"Long-term care communities need enough tests on hand to be able to test residents and staff on-site on an ongoing basis. Having a lab at-the-ready to pick up the tests and return results right away is crucial for containment," says Ilana Xuman, the executive director of LeadingAge DC, a group which represents elder care providers in the District.
Where The Region Stands
The White House urged governors in early May to complete universal testing in all nursing homes within two weeks. Maryland and Virginia leaders have also called for expanded testing — though universal testing is voluntary.
But progress toward the goal of universal testing in nursing homes in the Washington region is mixed, even as the eyes reopening in phases. Long-term care settings in the D.C. area have been hit especially hard by the coronavirus.
Maryland health officials say they expect to complete universal testing in all 227 of the state's nursing homes by the end of this week (that number does not include assisted living facilities). A spokeswoman for the Montgomery County Health Department wrote in an email that the county expects all 34 of its nursing homes will be tested by the end of the week.
The wave of testing, the spokeswoman wrote, does not include local assisted living facilities.
In Virginia, the state says it identified a list of 100 skilled nursing and assisted living facilities to prioritize for point prevalence surveys, where all residents and staff are tested in a single day by teams of public health workers and the Virginia National Guard. As of May 24, the state had completed point prevalence surveys at nearly 60 facilities. Almost 200 long-term care facilities in Virginia have outbreaks.
The Virginia Department of Health recommends that facilities with outbreaks request initial universal testing from state authorities. But beyond that, it says facilities may need to look elsewhere — like to private labs — for help conducting repeat testing on residents or staff that are recovering.
But if a facility doesn't want to arrange for testing, it doesn't have to. In Alexandria, a spokeswoman for the health department noted that one nursing home "hasn't expressed interest" in a point prevalence survey, or conducting one on their own.
DC Health did not provide information on the number of facilities who have completed universal testing. Alison Reeves, a spokeswoman for DC Health, told DCist in an email that the information was "not readily available." The department said it informed skilled nursing facilities "to screen all residents and test for COVID-19 as soon as practicable and to proceed to engage in testing of all employees and residents for COVID-19 within two weeks from the date of the notification," according to the email.
"DC healthcare facilities are working towards this goal and communicating needs to DC Health to work towards accomplishing this goal," the email reads. It did not specify a particular timeline.
The D.C. Department of Forensic Sciences lab has provided results for close to 1,400 tests from long-term care settings, according to Director Dr. Jenifer Smith. That doesn't count results from facilities that are using private labs to expand testing, like Knollwood.
Smith says the District's new mobile testing unit has improved testing capacity in nursing homes, though for facilities that need more than 50 test results done, she recommends bringing in a medical team to collect samples and send them to the department for processing. The District is encouraging nursing home staff to visit public testing sites for screening.
'Like A Field Operation From The Military'
Even with public health officials emphasizing widespread testing in nursing homes, tests and the people and protective gear to administer them are often still in short supply.
"It's not something that can just happen overnight. You know, some things would just need to be aligned," says Dana Parsons, the vice president at LeadingAge Virginia, a group representing nonprofit elder care providers.
Knollwood contracted with LabCorp for the testing kits, and they had a stock of protective gear for staff to use in testing. The facility hired a medical team from Capital Caring Health to conduct the initial testing in April, and teach Knollwood staff how to do it in future. Staff from the Centers for Disease Control and Prevention were also there to help on testing day.
Keeping staff and residents safe during widespread testing requires complex choreography — and a lot of personal protective equipment.
"The full PPE burn rate was two outfits of gowns and gloves per test kit," Knollwood administrator Tina Sandri wrote in an article she published detailing the community's approach. "Testing teams wore goggles, N-95s and face shields, which were not touched throughout the testing process with residents and did not need to be changed until all testing was done."
Dr. Eric De Jonge, the head of geriatrics at Capital Caring Health, who led the group administering the tests at Knollwood, says his team and Knollwood staff split into teams of two to perform tests. It was a 21-step process for each patient, from when the team entered the patient's room to when they left.
"Col. Bricker and his team had prepared this like a field operation from the military, actually," De Jonge says. "They had all the supplies, all the logistics, all the carts with all the PPE and the hand sanitizer and the kits."
Bricker and Sandri told DCist that the staff rehearsed the steps before the actual test day.
De Jonge, who has advised a handful of other nursing homes in the region on testing practices, says Knollwood stands out for the commitment of its staff under pressure — and also the ability to find the supplies, protective equipment and test kits to perform widespread testing.
"They had kind of a lot of resources with which to do it," he says. "So that's why it worked."
Sandri recognizes that.
"It was a matter of having the financial and access to the resources, i.e. test kits and PPE, to make it happen," she says.
Many facilities in the District do not have those resources, according to Ilana Xuman, the director of LeadingAge D.C.
"DC long-term care communities need: adequate funding to cover the cost of regular, rapid-results testing; additional dollars to account for the strain on staffing that testing requires; and enough PPE to administer the tests safely," she wrote in an email on May 28. "As of today, most of our providers do not have enough tests on hand, funding or PPE to administer tests safely on an ongoing basis."
The testing process is expensive. According to the American Health Care Association, it could cost more than 26 million dollars to test each resident and staffer at such facilities in D.C., Maryland and Virginia.
Some of the testing and protective gear costs are borne by state health departments, Medicare and private insurers. But some costs aren't covered, and others are ambiguous.
Bricker says that Knollwood started its testing regimen without confirmation that the facility would be reimbursed, which he said was a "huge risk." And while Bricker says Medicare and Kaiser Permanente, a private insurance company, are chipping in to pay for the testing itself, there are other related costs to consider, too. The facility is paying staff a lot of overtime, and they're keeping staff who have tested positive on the payroll. Bricker estimates that is costing $40,000 per week, which is being partially covered by a paycheck protection loan.
Dana Parsons of LeadingAge Virginia notes that pandemic-related costs are especially complicated for residents in assisted living, where services are often not paid for by Medicare or Medicaid. In Virginia, an auxiliary grant program helps fill in the gaps, but Parsons hopes to see more funds from the Coronavirus Aid, Relief and Economic Security Act diverted to the program during the pandemic.
"What we've proposed is additional funding for testing, support for nursing homes and assisted livings and especially for those assisted livings that have auxiliary grant recipients," Parsons says.
Knollwood continues to test regularly, and they recently received a donation of an Abbott ID testing machine, which can give rapid results on site. Knollwood reports no new positive test results have come back since a private duty aide tested positive more than three weeks ago.
Xuman of LeadingAge D.C. says that level of testing will be critical moving forward, as the region looks towards reopening.
"With the country — and soon the District — beginning to reopen, staff will be at a greater risk of exposure to the coronavirus as they go back and forth between home and work," she wrote in an email. "In order to prevent the spread of COVID-19 among our country's most vulnerable — our elders — long-term care communities need enough tests on hand to be able to test residents and staff on-site on an ongoing basis."
Bricker and Sandri are buckling in for constant testing in future.
"We think this is steady-state moving forward," Bricker says. "Until we have a credible and reliable vaccine, we're going to be screening nonstop."