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BY DOUGLAS R. EKEREN, MHA

There is no question that the COVID-19 pandemic has taken a hard toll on all Americans, but staff in long-term care facilities have carried a particularly high burden. They experienced the loss of residents they cared for, sometimes staff members they worked with, and had the constant threat of taking the virus home to their families. And yet most stayed on out of a sense of commitment to the residents they serve. They did so while earning low wages, uncertain personal protective equipment (PPE), and a shortage of staff and supplies. We are indebted to the many women and men who have cared for residents during the pandemic and continue to do so. They have paid a price physically, emotionally and sometimes spiritually.

I would like to share the experiences that Avera Health long-term care facilities have gone through since March 2020. Avera has 22 owned, leased and managed long-term care facilities. Many of these facilities also have assisted and independent living as part of their operations.

Prior to the pandemic, Avera's long-term care business unit, working with other departments at Avera, supported these facilities by monitoring financial and quality indicators, including measures of resident and staff satisfaction. Assistance and education are provided, when needed, as part of this monitoring. The greatest operational challenge we typically faced was in staffing facilities in rural areas.

Then, our first COVID cases in South Dakota occurred in early March 2020. Based on what we knew from what had happened at long-term care facilities in the northwestern parts of the United States, Avera had activated its system-wide incident command system, based in Sioux Falls. We knew that we needed to prepare quickly for what was likely to impact our facilities.

Initially, we did not have adequate PPE for our facilities, nor were staff trained in how to appropriately use most PPE. It was a significant undertaking to ramp up the supply chain to ensure we had needed supplies. We also began to educate staff on how to "don and doff," and I think that was the first time that we began to hear concerns from staff. They were concerned about doing their work while wearing PPE. Would it protect them, would they take home the virus to their families? We had a few employees near retirement who decided to leave earlier than planned so they were not subjected to the risks of working in an environment that might have a COVID-positive resident. Education about the virus and about PPE became an immediate focus. Fortunately, as an integrated health care delivery system, Avera was able to rely on its infectious disease physicians, infection prevention nurses, educators and others to assist with this work.

We communicated with workers in a variety of ways, including printed materials, video links and instances where those with experience could visit on-site for "learn and do" sessions. Those were helpful in that experienced staff could demonstrate safety procedures, invite staff to do them, and check that the teachings were taking hold.

We also initiated a weekly newsletter, the LTC Green Line, to provide information on policy changes, resource availability and regulatory changes as they rolled out. We instituted weekly phone calls for long-term care facilities, inviting those within Avera or others outside our system who might be interested to participate. As knowledge of the virus changed quickly, we focused on sharing of best practices and recommendations about how to implement new policies or practices.

Staff told us that the restrictions placed on visitors, communal dining and activities were having a very negative influence on residents. Residents couldn't see their family members or interact with their friends in the facility. It was heartbreaking for many of the staff to see residents impacted in this way. Staff also had to deal with the frustrations of some family members who couldn't see their loved ones. Occasionally those frustrations were unfortunately taken out on the very people who were caring for their family member. Staff expressed frustration over this, but they could understand why people were upset.

We implemented outdoor visits, visitation booths, and hugging walls to try to provide options for increased interaction following the initial shutdowns. Local administrators and maintenance crews got very creative. A hugging wall, for instance, could be constructed using plastic that was flexible and strong, allowing a resident and loved one to hug through it. The wall could be sanitized for safety. Facilities shared their best ideas and plans with each other.

This seemed to help everyone, including staff, as at least there could be some level of visitation. We also began to allow families to choose an essential caregiver, a representative provided with some training so they could safely come into the facilities, which also aided in improving the overall atmosphere. While all of these efforts have helped, they certainly do not replace the normal interactions that are so important for residents and families.

Point of care testing became available starting around September, allowing us to test staff and residents. This was appreciated by some, but other staff didn't like being tested so frequently.

Information, and frequently misinformation, were among our greatest challenges. We decided early on that we wanted to be transparent with what was happening in our buildings. Along with the new newsletter and phone conferences, we also helped facilities implement video visits with families and encouraged administrators to have town hall meetings with family members to update them on COVID in the facility, whether among the residents or the staff. Staff were encouraged to participate in these sessions.

Our staff let us know when they or their colleagues were having difficulty coping with the day-to-day challenges of caring for residents, particularly when there was a COVID outbreak in their facility. Witnessing the loneliness of the residents, the incidence of positive COVID cases and the deaths that followed were very challenging. Front-line staff in a long-term care setting spend more time with residents than most family members do, even prior to the pandemic. Long-term care residents are like family to many of our staff, and to watch them deal with the symptoms of COVID and, in some cases, pass away, pushed some of our people to the breaking point.

We called again upon the strength of our system to help us provide assistance to staff. We enlisted behavioral health experts from our Employee Assistance Program to develop presentations geared specifically for caregivers in long-term care. They focused on the effects of working in an environment structured to keep COVID out of our facilities and to minimize the impact if it did enter. The sessions were recorded and made available to every one of our facilities to use for staff meetings or on facility web pages so individual staff members could access them at their convenience. Many staffers were grateful for these resources.

We also had staff express frustration with people who didn't work in health care and were not taking the pandemic seriously. One employee talked about having to leave her Facebook group as they were constantly posting pictures about outings to restaurants or bars, without masks or ignoring social distancing. Some staff explained that after spending the week in PPE and watching residents pass away, they simply couldn't handle the denial from some members of the public who wouldn't acknowledge how COVID was truly taking a toll on their communities.

The arrival of new treatments like monoclonal antibody treatments brought some hope to staff at our facilities. They could see that we were doing more to treat residents who tested positive. Avera was quick to implement this in long-term care settings, both our own and to other long-term care settings through our long-term care pharmacy. This undoubtedly saved lives not only among the residents who received the treatments, but also among people in the community who could be admitted to limited hospital ICUs because we could care for and keep our residents in their home settings. This did not go unnoticed by staff. The arrival of the vaccine is bringing an even greater sense of relief to all, knowing that there is at last the potential of an end to the pandemic.

We have recently seen a downward shift in the number of positive cases in our long-term care facilities as well as in our hospitals. We are hopeful that will continue, despite the fact that many parts of the U.S. were at a peak number of cases in early 2021.

Given the duration of this pandemic, I am sure there will be more that we will need to do to assist staff who continue to work in this environment. The long-term impact of working constantly in PPE and seeing people pass on when a short time ago they were fine simply isn't known yet. We must be ready and willing to support our staff who are answering the call to care for people who desperately need our services. We have been fortunate. We have not seen staff abandon their long-term care jobs and the residents they are caring for. It is certain that some individuals have left rather than deal with the issues the current environment presents, but nothing different than what we experienced previously. We also have had staff who have answered the call to work in long-term care, ensuring that those in need would receive the care they deserve.

DOUGLAS EKEREN is regional president and CEO of Avera Sacred Heart Hospital in Yankton, South Dakota, and Avera Queen of Peace Hospital in Mitchell, South Dakota, and he leads Avera's Long-Term Care Strategic Business Unit.