In early June, physical therapist Alex Grimm helped a woman walk for the first time in weeks.
The woman, a resident at CommuniCare’s Burlington House Rehab and Alzheimer’s Center in Cincinnati, finally was able to sit up, and then take her first steps, after weeks of battling COVID-19. The therapy staff had been moving the woman into the prone position three to four times per day to help improve her oxygen levels.
“We have to celebrate the successes,” said Grimm, who also is the site’s therapy director.
At one point, about 75% of Burlington’s population had tested positive for COVID-19, although many were asymptomatic, Grimm said. Now, that number is down to just a few at the 106-bed facility.
As COVID-19 has spread across post-acute care facilities like Burlington, staffers have needed to care for many residents on site, instead of sending them to overwhelmed hospitals. In many cases, that means providing care for higher-acuity residents than in the past.
To do that, CommuniCare established a standard of care that it implemented across its nearly 100 post-acute care facilities, about a third of which have had COVID-19 outbreaks. The team turned to hospitals, associations, reports and journals for insight on how best to provide care and help residents recover.
“We’re not aspiring to be a hospital but we’re trying to understand what we can do,” said Dr. Matthew Wayne, an internist and geriatrician who serves as chief medical officer for CommuniCare, which has facilities in eight states. “There’s so much that can be done for the majority of these folks without them going to the hospital.”
Because there are still so many unknowns about COVID-19 and little concrete research on treatment, CommuniCare chose a variety of interventions that are low risk and have had anecdotal success in managing symptoms of the virus.
“We really are just looking at anything we think will be of benefit to our residents,” Wayne said.
The chosen treatment plan involves monitoring fluids and oxygen levels; proning; and giving residents vitamin supplements for immune support, anticoagulants to prevent blood clots and, in the case of a pilot group, amino acids to possibly reduce inflammation. Each symptomatic resident is assessed for risk before any treatments are administered and is seen by physicians three times per week, Wayne said.
CommuniCare decided to start proning residents with COVID-19 whose oxygen levels were low in order to open up their lungs. Typically, prone positioning has been used for patients in hospitals who are in respiratory distress and placed on ventilators, said Emma Powell, CommuniCare’s vice president of therapy clinical operations, but doctors in hospitals decided to try proning for COVID-19 patients to prevent the need for ventilation.
A recent study in JAMA found in small case studies that among patients who could handle periods of prone positioning, there were short-term improvements in oxygen levels and respiratory rates. However, the authors advised clinicians to monitor patients who are moved into the prone position to make sure necessary intubation is not being delayed.
“It’s one of the first times where we’ve taken something that (hospitals) have been doing on a regular basis and tried to adapt it to our population,” Powell said. “We haven’t typically seen this level of acuity of residents in nursing homes before.”
Physical therapists in post-acute settings already are trained on bed mobility and positioning and only needed to learn the protocol for the new treatment, Powell said. To train employees, CommuniCare offered a series of webinars—both on prone positioning and the other interventions—to all its facilities, even those without COVID-19 cases.
“We never know what lies ahead,” Powell said. “Even though a facility today may not have any residents with COVID-19, if tomorrow they had a resident fall ill, we wanted that team to be prepared.”
While some residents do go to the hospital, “most are doing well with a lot of close monitoring and support,” Wayne said. About 85% to 90% of the CommuniCare residents who tested positive have recovered, he said. Wayne can’t quantify that the interventions are working but said the outcomes are “definitely a step in the right direction.”