Taking Healthcare by Storm: Industry Insights with Benjamin Canter (Part 2)

In this second installment of Taking Healthcare by Storm, continuing our previous conversation, delve into the world of expert insights as Quality Insights Medical Director Dr. Jean Storm engages in a thought-provoking and informative discussion with Benjamin Canter, OTD and PhD student from the Center for Psychiatric Rehabilitation Department of Occupational Therapy at Boston University.

Benjamin discusses research on the impact of COVID-19 on rehabilitation in nursing homes, highlighting disparities in access to rehabilitation between post-acute and long-term care patients. He also reviews challenges faced by skilled nursing facilities during the pandemic and emphasizes the importance of evidence-based policies and person-centered care.

If you have any topics or guests you'd like to see on future episodes, reach out to us on our website.

Publication number QI-050225-GK

Transcript

Welcome to "Taking Healthcare by Storm: Industry Insights," the podcast that delves into the captivating intersection of innovation, science, compassion, and care. 

In each episode, Quality Insights’ Medical Director Dr. Jean Storm will have the privilege of engaging with leading experts across diverse fields, including dieticians, pharmacists, and brave patients navigating their own healthcare journeys. 

Our mission is to bring you the best healthcare insights, drawing from the expertise of professionals across West Virginia, Pennsylvania and the nation.

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Hello, everyone, and welcome to another episode of Taking Healthcare by Storm. I am Dr. Jean Storm, the Medical Director of Quality Insights. And today, we have a part two of an episode. We're again joined by Benjamin Cantor. He's a doctor of occupational therapy. and researcher who's been instrumental in exploring the impact of COVID 19 on nursing home care.

His work spans COVID 19 prevention, mitigation, treatment, and rehabilitation. And last week we discussed two of his really important research papers that he's published. And I was, Really, we were both really involved in the conversation, so we thought we'd do a part two for two more of his papers discussing occupational therapy, speech therapy, physical therapy challenges involved in COVID 19 and skilled nursing facilities.

So we're just going to finish up and discuss two more of his papers today. Ben, welcome back. Thank you so much for joining us again. Yeah, it's good to be back. Great. So, the third paper we're going to discuss is titled Characteristics of Physical Occupational and Speech Therapy Received by COVID 19 Patients in a Skilled Nursing Facility A retrospective cohort study, and again, I will just say I'm going to try not to say too much, but I think that this topic is really interesting around what therapies that COVID 19 patients receive in nursing facilities.

You know, around the COVID pandemic, I think they were impacted significantly. I don't know how much they're impacted now, but it's a really I think it's an interesting topic. So your study found that post acute patients were more likely to receive  rehabilitation than long term patients, which appears to reflect different referral processes.

So super interesting if you think about. Skilled patients versus long term patients in a nursing facility. Skilled patients are typically ones that are kind of coming into a facility following a hospitalization, and they're there using their Medicare stays to hopefully get stronger and go home. And then we have long term care patients in a facility who are there for a longer period of time, perhaps forever.

For the rest of their lives. So how do you think these differences in rehabilitation access and prescription? Impact the overall recovery and outcomes for COVID 19 patients and nursing homes and what can be done to address these? Differences. Yeah, so it's a good question. Thanks for having me back. I think that You know, the first thing to take into context for this study is the time frame of when the data was collected, which was early in the pandemic 2020 2021 period of kind of time is what I kind of consider to be early pandemic.

And then 2022 2023 is kind of like mid pandemic. And now we're kind of in the late stages, almost in an endemic stage now. And we knew a lot less back then. And people were going to nursing homes because the hospitals were, overflowing. People were being discharged to nursing homes in New York state where this was done.

This nursing home had a COVID 19 unit at the time they were able to set aside  their  post acute unit and it was just COVID 19 there. And so a lot of these individuals are coming for COVID 19 rehabilitation, but others are individuals who got COVID 19 in the facility, right? And this is important because while the post acute patients might be more of a hodgepodge, right?

If some came with COVID 19, they're there for rehab for COVID 19. Others may have had. a hip replacement or this or that. And then got COVID 19. I mean, probably not a hip replacement, but because, you know, that's often an elective procedure, but maybe they had a stroke or something. And for context, elective procedures were kind of shut down at the time.

But maybe they had a stroke, right? And they were there for that. And then they got COVID while at the facility, right? So for the post acute patients, there were both of these groups, but for long term care patients, they're not entering nursing facility because they had COVID 19 their only way of kind of getting rehab would have been if they got COVID 19 in the facility, right?

And so. Why that's relevant is. For these post acute patients, COVID 19, for some of them, that was their only issue, right? But others, most, it was more than that. And it was all, for all of the long term care patients, they have a lot of other, you know, comorbidities going on. And so, that's kind of the first thing, The second thing is the insurance for post acute patients, requires those individuals receive Rehabilitation. Whereas long term care, if you're in long term care, there's no requirement  that you receive rehabilitation to stay there. It's not like OT or PT is skilling those individuals to stay in the facility, right?

And so in terms of likelihood, that probably played a role. I also think that when we think about the way it's set up, right, and there's access, and there's prescription, like you kind of alluded to. Access individuals in post acute care are more likely to have access to rehabilitation because those insurance avenues are set up for them to receive rehabilitation for a long term care individual to get rehabilitation.

The barriers are more like they're the bar is higher for what would qualify. for rehabilitation, because they're already kind of on a decline. And so a lot of their rehabilitation, you need to kind of justify that they can be rehabilitated to a certain extent as opposed to just stable after I believe it's 10 sessions.

Insurance won't pay anymore for further rehabilitation sessions. If you come like from post acute care to, and then you move to long term care.  And so it's a lot of the technicalities like that, that can stand in the way. of being able to receive rehabilitation. And then there's the prescription of rehabilitation.

Will this person benefit from rehabilitation? And there tends to be a bias against long term care patients that. These individuals will not benefit from rehabilitation, and while they may not benefit in that they may not fully recover from COVID 19, or even partially recover, they may be able to maintain where they're at and have it not get worse.

 And so I think that, and at that time, we also didn't know a ton, and so people may have just assumed that they might have been triaging and say, okay, we've got X number of rehab staff. Let's focus on the people we know are going to get better. The post acute patients, right? Oftentimes these facilities are so strapped for rehabilitation staff and staff in general.

And. More of those rehabilitation staff go to post acute care than long term care. So, I think that there's a lot of reasons that they're more likely to receive rehabilitation. And then, there's also the amount of rehabilitation that they receive so that comes back a little bit to tolerance.

there's a difference between, you know, receiving rehabilitation and how much you can receive. And we saw that long term care patients received. lower amounts or what we would consider intensity of rehabilitation. So like the number of minutes per day of rehabilitation. And this is really poignant because it shows us that there's a disparity there in, how these individuals respond to COVID 19, but also how they respond To rehabilitation, and we knew that kind of going in right, but we also found that even the long term care patients were able to tolerate moderate levels of rehabilitation, which I personally wasn't expecting, right?

I kind of thought like, Oh, well, they'll come. They'll do it for 1520 minutes, and then they'll be done. But that's not necessarily what we saw. That's really interesting. Leading into my next question, you know, we talked last time about COVID 19 increasing risk of dehydration, functional decline.

Again, you said, just as you said that your study found that patients, most patients tolerated moderate to high amounts of rehab. So what does this suggest about the role of rehab in recovery? Like are we being too scared to really kind of give all long term end post acute, you know, long term end skilled patients?

 Are we not giving them enough, giving them the opportunity to do really high, moderate to high levels of rehab you know, or should we balance the risks of deconditioning more with the need for rehab? Yeah. So when I think about the way the study was done and how we define like intensity, right, we're defining it by the number of minutes spent in rehabilitation, right?

And when you think about like exercise,

There's a difference between like number of minutes a day and the rigor of the exercise, right? So like I could walk for three hours Or I could run for 30 minutes and all those two things are different intensities in terms of like the type of exercise you're doing, but there are also different amounts of time you're doing them, right?

And I might be able to walk really far, but if you asked me to run, I might not be able to do that. And so that's something that we weren't able to really account for, right? It was how much physical exertion are the therapists actually asking these people to do. And so. In my mind, the fact that there were moderate intensities tolerated by everyone means that the therapy was done well and no one was getting too exhausted too quick, 

so if I had seen in the study that long term care patients were getting low amounts or low intensities,  like per day intensity of therapy. To me, that would indicate that they're getting really exhausted really quickly and are unable to continue, or they're being asked to do things at an intensity exercise intensity that is beyond what they're capable of.

And so. In a way, it shows that they're receiving proper rehabilitation for their skill level. We can't necessarily say that, controlling for the type of activity, they would have been able to do it. But in terms of the amount of time spent, they were able to stay there and participate, I kind of think about there's participation, and then there's like the content of the participation, and we didn't really look too much at the content.

We really just looked at the numbers, right? But from a clinical perspective, if you tailor your intervention to that person in front of you and say, okay, this person's getting a little tired. Let's, take a five minute break and let's continue again. Right? Okay. How are you feeling now? Let's check in.

Okay. Maybe we should go from a high intensity activity to a low intensity activity to a high intensity activity. things like that can really change. the tolerance of the resident and what that individual patient is capable of in terms of the amount of time that they can participate for.

And so that's really what this study is getting at is that just because somebody is weaker or has less endurance or is in long term care doesn't mean that they A, deserve or B, are not capable of spending the same amount of time Doing exercise or doing rehabilitation related tasks. We can't say for certain whether it would be at that same level of intensity, but that's where patient centered care comes in, right?

And goal concordant care. And that's what we as OTs and PTs and speech therapists specialize in is figuring out. What is specifically needed for this patient? What can they tolerate? And how can we make sure that they're participating for long enough to get a benefit? Because When you really enter this smaller amounts of rehabilitation and you tire the patient out too quickly, clinically, that's not good.

They're not actually going to benefit from that as much as a lower exercise intensity. for a more moderate to high ish amount of time. And so it's really important that we be careful and start slow, but not that we don't necessarily need to say, okay, we're going to start with 10 minutes and then work up to 15 the next day.

We can just say that we're going to check in with them as they go. We're going to make sure that they're participating as they can, tailor the intervention to them. And then they'll be able to do a moderate amount of rehabilitation and really get benefit.  Because if you're doing less than, you know, 20, 20 minutes, 15, 20 minutes, you're not less than a unit.

You're not really getting, first of all  there's not a lot of reimbursement there. Right. But also the patient isn't going to be getting anything out of that make sense. Do you want to make sure the patient benefits? Yeah. And in terms of the other part about functional decline and dehydration, you know, I think that the relationship between what we talked about last week and COVID 19 symptoms, potentially increasing risk of dehydration and functional decline.

and most patients tolerating moderate to high amounts. Of rehabilitation, you know, rehabilitation is the solution to functional decline often. And so when we tailor that approach, that's how we can prevent functional decline. And, but  if it isn't patient centered, especially for something like COVID 19, which has so many different clinical presentations, you know, it's not going to happen.

We're not going to be able to prevent it. Patient centered, bottom line. So, the last article we're going to talk about is, this might be a little bit of a controversial one, but Measures to Prevent and Control COVID 19 in Skilled Nursing Facilities, a Scoping Review, and a lot of people have a lot to say about what happened in skilled nursing facilities during the pandemic, and I was in  nursing homes as medical director and attending physician treating patients during the pandemic.

And I think we have a lot to learn because I think we will have another pandemic and similar different who knows, but I think we can learn a lot about what happened. So you highlighted the challenges skilled nursing facilities face during the COVID pandemic, PPE shortages, staff shortages that we still have adoption of various preventative measures.

So what do you think? So that the skilled nursing facilities can learn from these experience to better for future infectious disease outbreaks, future pandemics, particularly if we're in a place where we're balancing the use of limited resources.

Yeah I think that when it comes to, first of all, I guess let's start with staffing. Right. Because I think it's kind of the most obvious explanation, right? Like there was low staffing prior to COVID 19. That was only exacerbated, and we're only now, in the last year or so, really beginning to get closer to pre pandemic staffing levels.

And we're still not fully there yet. But that was already a problem, right? And the PPE shortages and other preventive measures adopted In a way came together to what the paper really said was all these things kind of came together in this perfect storm of let's do everything we can, even though we don't really have the resources to pull any of it off.

And as a result, very few of those non pharmacological measures worked. There's no evidence, or at least there's no evidence to actively support that they worked. So, for instance the visitation closings, right?  Not allowing visitors at the facilities was detrimental to quality of life for both residents and their loved ones.

And our study found that overall, there's not really any empirical evidence to support those. Visitation closings. It didn't reduce the risk of patients getting COVID 19 or outbreaks. And that's kind of upsetting when you think about it. It's really sad because there was a huge sacrifice in quality of life to implement those policies in hopes that it would save lives.

And there's no evidence to really demonstrate that, so, from that, I take two, two main lessons. First of all, we shouldn't implement things without evidence. And second, we shouldn't implement things that we don't have the resources to pull off when it comes to infection control. If it's at the expense of quality of life.

So, for instance, with a PPE shortage, obviously you're going to use whatever PPE you have available and kind of hope for the best. Ideally. We'll get to a place where we can be prepared for another pandemic. We can kind of not stockpile, but, you know, preserve some of those resources over time.  If you know, like that there's a facility.

nearby that's had some kind of outbreak and you think there's a chance of a pandemic kind of coming to nursing homes again. We hear kind of early chatter of that. That's when we need to be advocating for earlier PPE before it's really an issue in the entire world  is looking for it. We need to advocate politically.

To make sure that nursing homes get those resources  obviously. But when it comes to creating a policy to, like, remove visitors or something like that, we don't benefit from policies that we don't know work. And so Policy changes, they require more staff, they require trainings, they require, you know, a sacrifice in quality of life in the case of the visitation policy.

So policy changes really need to be evidence based and if, they're not, they're often not worth it. If it sacrifices quality of life, that's kind of the biggest takeaway I got from the article in terms of limited resources is if there's some, if there's a chance that resident quality of life could be lowered.

And we don't have evidence for something, we probably shouldn't implement that thing and justify it by saying it could save lives.  I agree. It's hard. It's a hard lesson. But I, I would agree if it sacrifices resident quality of life, it's going to probably sacrifice resident lifespan. So  I would agree.

So you talked about non pharmacologic measures, visitation restrictions, cohortings. And as you said, limited evidence on their effectiveness, but we do have vaccination. We do have antiviral treatments. So do you feel based on your findings that skilled nursing facilities should prioritize evidence based measures like vaccination, antiviral treatments moving forward?

You know, during,  the next pandemic, so just focus on those evidence based measures, whether they be, whatever they may be. So facilities, yes, should focus on evidence based measures, but the bigger picture I think is a little bit more complicated than that. And I think it does kind of come back to I'm a researcher, so I'm a little biased, but I think that without good research, it's really hard to know what those evidence based practices are because there's no evidence, right?

So we saw this a little bit with monoclonal antibodies, for instance, or, and also with visitor restrictions and the reopening of that. It's not that there is. evidence saying it actively doesn't work, or in the case of monoclonal antibodies that it actively works, we just don't have any evidence beyond one or two studies to really go off of.

You know, there is no monoclonal antibody randomized controlled trial in nursing home residents in America, I believe. I mean, I could, I don't have the paper in front of me, but I believe. And when we think about that, we're generalizing from a general older adult, or maybe even a young, healthy adult study, assuming it'll work for nursing home residents, right?

When the visitation restriction came about, it was generalized based on this public health kind of knowledge that if you quarantine someone at home and they don't want to get sick, if you stay in your house, you're less likely to get sick, right? And so they're like, great, we'll implement that at nursing homes.

But what happened? Well, nurses went in and out. And we saw that nurses who actually worked part time at multiple facilities, the more facilities had those nurses, The more likely those facilities experienced outbreaks because those nurses were bringing COVID 19 between the facilities. Cause so there were staff still going in and out.

So it didn't matter that residents. weren't seeing their loved ones. It didn't make a difference in terms of infection control. And so that's really where it comes from is we need evidence based policies, and we need to focus on those. But we also need evidence. If there was a study prior to the pandemic showing that shutting down everything wouldn't work, no one would have done it.

We had to draw conclusions based off of the way public health works in the community space, right? And that's what led to that visitor restriction. Policy that was implemented nationwide. Yeah. And it, I, well, you know, as you look back, right, it makes sense. You have nurses coming in and out. Right. But so I think that's the issue is that you can't apply.

public health measures on a whole to nursing homes every single time. It just doesn't work. It's a different environment. It's a different setting. So, yeah, I would agree. It's a tough lesson, but maybe we can learn for the next. So in the last very, you know, few minutes, maybe you can just briefly just  if you have any best practices that occupational therapists can maybe share with staff or maybe just the therapy department around treating patients with COVID infection and maybe mitigating long term risks of ADL decline if there are, if they are needed at all.

So I think that really it's important to monitor. These individuals before, during, and after they get COVID, right? If we're monitoring properly and providing proper care, hopefully individuals don't get COVID if they're already in the facility. When they have COVID 19, we need to prevent dehydration. We need to prevent You know functional decline and we can do that by making sure that these individuals as much as possible are still getting up Still active right a lot of times, Rehabilitation clinicians will get a list of ten maybe even like twelve patients that they have to see that day in like post acute care and we'll say, okay, we're going to prioritize these people.

This person has COVID. So they're probably not going to want to work with me today. So I'll put them at the bottom of my list. I saw this when I worked in a facility, you know, I'll put this at the bottom of my list. And if I get to them, great. And if not, they're probably going to be too tired anyway, or we get, I get there and they're tired and I don't really push them like, okay, they're sick, well, that sickness is exactly why we want to encourage them to get out of bed, right?

Because that's, what's going to help prevent their functional decline. And I think that really emphasize, I just really want to emphasize that these individuals are capable of rehabilitation. At, you know, maybe not the same level of vigor that they would be,

should they be fully healthy without COVID 19, but alas, right, like they have COVID 19 and we can still try to help them. So I think that not shying away from pushing people to engage in rehabilitation during COVID 19 is really important or after. So monitoring. engaging residents in participation of rehabilitation during and after, and lastly, relying on the evidence that's out there.

So we talked about four different studies that I've published, but there's way more out there too. And really trying to rely on the evidence for The nursing home population whenever possible. Yeah, those are my tips. Those are great tips. Oh, and person centered care. Don't want to forget that.  Let's close out with that.

Cause that is my favorite term. Forever is person centered care. Benjamin Cantor. This is really interesting. I hope that individuals out there listening in nursing homes or interested in nursing home care Really gained a lot and we're gonna use the information in how they approach their patients. Ben, Thank you very much for joining us.

Thank you for tuning in to Taking Healthcare by Storm: Industry Insights with Quality Insights Medical Director Dr. Jean Storm. We hope that you enjoyed this episode. If you found value in what you heard, please consider subscribing to our podcast on your favorite platform.

If you have any topics or guests you'd like to see on future episodes, you can reach out to us on our website. We would love to hear from you.

So, until next time, stay curious, stay compassionate, and keep taking healthcare by storm.