We Are PALTC is a growing collection of stories written by PALTC professionals. The stories include personal reflections, opinions on hot issues in our field, and lessons, both positive and negative, that are intended to inspire, educate and motivate the members of our profession to enact positive change in the field. The collection comprises the eponymous column in the print and online editions of Caring for the Ages as well as the online-only essays on this page. Submit your story here.

This N-95 Bruise

By Fatima Naqvi, MD, CMD, medical director, Maryland

This N-95 sitting on my nose, this metal band,
To the Health Care workers, it is the crown or garland.
Now, this mask, is this part of our face?
Is it permanent?
These warriors with profound suffering, still ever tolerant.
This metal band or crown or garland, leaves with a mark;
A bruise these days, will seed a permanent scar or a stark.
Underneath this bruise or scar lies a thousand untold stories,
Of miseries, loss, and grief; of vulnerabilities, toils and victories.
Each moment has turned into decades, each day into centuries,
This uphill journey, reflecting the last 14 months of adversaries.
The courage of facing disease, demise and fear of unknown,
So many pots were stirred, difficult conflicts resurfaced,
Discrimination, inequity and oppression that many faced.
What are we doing to care for the past generation?
Frail and old, their health care system keeps sinking!
To safeguard our past, together let’s speak up, raise our voices,
Advocate for the vulnerable and ailing.
Indeed a priceless invoice.

A rough patch does not last long

By Fatima Naqvi, MD, CMD, medical director, Maryland

What you see outside: smiles, giggles and laughter.
A COVID pandemic, 2020 brought so much disaster.
Bent back, grey hair, more wrinkles on the face,
Bruise on my nose — from N-95 — and an ongoing race.
Hands parched from washing every two minutes,
Doubled up masks and face shields, it’s hard to breathe.
Worn out and fatigued, we keep marching,
For my staff and patients, we keep moving.
Not easy! A woman leader, a wife, and mother of three,
Yet a doctor outside. From home, a source of glee.
Fueling grit and courage, like the sun always shining,
A rough patch doesn’t last long, keep marching!

Reducing Social Isolation: A Volunteer’s Perspective

By Jawad Saleem, undergraduate student, University of Kentucky

A college freshman shares an experience of volunteering at a nursing home and offers ideas for volunteering during the COVID-19 pandemic.

Continue reading.

Stress and the COVID-19 Pandemic

By Fatima Naqvi, MD, CMD, medical director, Maryland

Often, we all live in our minds, seeing what we perceive and hearing what we believe. Many times, what we hear is not as impactful as when we experience it ourselves. Today, morning seems so mystic, like a perfect day in the fantasy world. Autumn started a few weeks ago, it is neither hot nor too cold, not windy or still, and changing colors of the leaves with fog everywhere makes one feel like we are daydreaming.

The weather channel forewarned us last night that it is going to be a foggy morning with visibility of less than a foot. After I took the car out from my driveway, I realized that I needed to slow down and drive carefully since I could not discern other cars or even traffic lights. This foggy day took me to this awareness that stress does to the mind what this fog is doing to my driving abilities: It impairs our capabilities and skills to handle a given condition. Just like dark and heavy clouds can block the sunshine, stress disrupts our inner powers to comprehend and manage a given situation.

The COVID-19 pandemic has heightened the stress all over the world. The most vulnerable population is our older adults, especially those who are residing in long-term care facilities. Mental health and social isolation are major concerns. Telehealth and video calls are substitutes to minimize the isolation, though they are not the solution. PALTC staff, who are striving to maintain a work-life balance, are burning out too. They try their best to fulfill all of the expectations of residents’ loved ones, who wish to communicate via tele-visit since then cannot come in the facility because of the infection control practices. Trying to do the best yet not being able to achieve perfection is happening more often than occasionally due to the higher rate of burnout among the staff and providers.

Sometimes these times do seem like a nightmare. You wish to wake up and be done with this horror. However, these are real times, which has bent our backs in many aspects. It has bruised many people from financial, mental, social, and even psychological perspective. What can we do to understand our situation clearly in such adverse times? How can we prevent the fog and stress that will allow us to face these challenges with patience and inner grit? A few things that work for me are

1. Accepting the reality. Let’s face it: The COVID-19 Pandemic may become endemic. Accepting the reality is like winning half the battle. When we accept our reality, the picture becomes clearer as we progress in time. The COVID-19 pandemic is not going anywhere. We have to keep moving forward in the best possible way to protect ourselves, patients and our loved ones.
2. Finding meaning within ourselves first. Introspection always brings the right outcome and peaceful mind when done for the right reasons.
3. Practicing mindfulness. It is important, especially these days, to do one thing at a time and then move on to the next. Daily mental practice of mindfulness allows the mind to find peace.
4. Keeping thoughts healthy with exercise and reading. A healthy mind can be the best companion because — guess what — you don’t need to social-distance from yourself! Embrace yourself inside out, understand, and then heal thyself first. Then move on to helping and healing others.
5. Being kind to yourself as you are kind to others. Sometimes all you need is a gentle smile from those around you. Our smiles are hiding behind our masks; but our eyes can speak and share our kindness.

Day ends in the night, one life takes to another life, and disease ends with a cure. Nothing last forever and so does this pandemic. We keep marching forward even when we are broken and bruised inside. We keep our focus at the end, with inner grit and confidence. We all are in it together! We have what it takes to work towards finding solutions and face these challenges.

Leading from the front

By Tracie E. Murray, JD, NHA, assistant administrator, California

When I entered the laundry room, the laundry staff member was paralyzed with fear. We were in the middle of a COVID outbreak early on in the pandemic. As the direction from the experts changed on a daily basis, we were never sure what we were supposed to do. I entered the laundry room, donned the required personal protective equipment and began to help with the laundry. As an administrator, I am not in the laundry room very often to work; usually I just retrieve an article of clothing for a resident. The staff member saw that I was not afraid to work with the dirty linen and soiled clothing and that I was following the instructions from the authorities, and, like magic, she was able to perform her duties. I found that during this devastating pandemic it is imperative for leaders to show that there is nothing to be afraid of when we are following appropriate precautions. We all need to work together to achieve the appropriate care for residents and to take care of our staff. Taking care of our staff goes far beyond providing PPE. It requires the emotional and psychological support to allow them to do their job without fear. It is easy for staff to let their guard down as the pandemic persists, so ongoing training and spot checking had been essential in assuring compliance with required procedures. My friend used the term, “leading from the front.” Really, there isn’t any other way to lead!

There is no place like home

By Nadia Ali, MD, CMD, medical director, and Sameer Bahl, MD, resident physician, California

DISCLAIMER: This article is not intended to be a substitute for any COVID-19 guidelines or safety precautions. This is a summary of the internal guidelines and efforts that were taken to protect our facility.

Today is the 177_th day (5.9 months) of COVID-19 precautions. Despite the initial lockdown and local attempts at sheltering in place, our city has experienced surge after surge. Whether it be the crowded intensive care units of the local hospitals, or the lower-acuity care facilities throughout the city, the rise in cases has been seemingly unavoidable. My heart filled with joy when I read the following lines in a message from the director’s desk:

“I’d especially like to recognize our Community Living Center (CLC) staff for an outstanding job on controlling the spread of COVID in the CLC! Across the nation, many health centers and nursing homes are experiencing high rates of infection. But our CLC staff is doing a great job of effectively protecting our fragile population. I’m happy to report that our CLC has had zero COVID events, and I'd like to thank the leadership and CLC staff for the exemplary care provided to our residents.”

Our Community Living Center is a 60-bed facility that has a small number of long-term care residents but predominantly serves a large cohort of veterans that come for rehabilitation. It goes without saying that most of this population care frail, older veterans, with multiple comorbid conditions. During the pandemic thus far, we have had 65 admissions and 69 discharges. Service Chief Paulette Ginier, MD, who has dedicated herself to the CLC for over 30 years, working with the rest of the interdisciplinary team, was instrumental in coordinating the various measures taken to avoid any COVID-19 events thus far.

Since the beginning of the pandemic, the office of Veteran’s Affairs has been sharing several memoranda on proper precautions to minimize possible exposure to the virus and how to properly utilize personal protective equipment. In addition to following these precautions, we have instituted several policies to further protect the residents and staff here.

First and foremost, polices on hand washing, face mask use, and social distancing were strictly enforced with frequent compliance monitoring. All new admissions to the center require 14 days of isolation, and staff are instructed to use a separate mask and face shield that would have to be kept in individual brown paper bags. Our nursing staff check the residents for COVID-19 symptoms every shift and record them in the electronic medical record. Rapid testing of patients with concerning symptoms or abnormal vitals has been readily available.

Other measures have been undertaken to minimize possible exposures. Facility access has been limited to allow for organized screening of symptoms and temperature of staff daily. Access to the facility is only granted if screening is negative, otherwise the staff member must undergo testing and a period of isolation. Our own nursing staff has provided all phlebotomy services for laboratory studies. We have also taken measures to limit and control deliveries of supplies, linens, and all meals. Much time and care has gone into arranging for tele-visits with consultants or other outpatient providers that the residents need to see. Imaging studies have been limited, and, if deemed necessary, are typically arranged for the early morning, which is a generally less busy time. A no-visitor policy was instituted, though we have allowed limited entry for the family members of residents nearing the end of their life to visit with protective gear during inactive hours.

We hope that with these ongoing efforts and precautions we can continue to report zero COVID-19 events at our facility for the remainder of this pandemic.

Take this job, and love it

By Melvin Hector, MD, FAAFP, CAQ Geriatrics, CMD, geriatrician, Arizona

Mr. Davis (Comes up, face mask around neck.)

Hey Stella! Wait up!

Stella (Nurse aide just going into the nursing home.)

Yeah, Mr. Davis? Hi. Oops, face mask!

Mr. Davis (Replaces mask.)

Oh. Thanks. You taking care of Alice today?

Stella

I’m supposed to be. I haven’t actually seen the days’ assignment sheets, though. I could be working anywhere in the building.

Mr. Davis (Hands her a bag.)

Would you give her this? It’s her birthday!

Continue reading.

I’m Hurting, Too

By Paige Hector, LMSW, social worker, Arizona

Standing at her mom’s window, her palm pressed against the glass, mirroring her mom’s gesture on the other side, Janine’s tears slowly begin to trickle down her face. She had resolved that she wouldn’t cry in front of her mom, but the pressure has been building and the dam is showing signs of cracking. The “I love you” sign in bright colors that she has been holding up on every visit for months seems so heavy. In unison, the mother’s and daughter’s heads gravitate towards each other like so many times before when they could share a hug and a kiss on the cheek with an “I love you” whispered softly to one another. From opposite sides of the double-paned glass, they rest their heads together. The sign, succumbing to gravity’s pull, topples from the daughter’s hand as the dam bursts and the months of fear, frustration, anger, confusion, and grief barrel from her soul, the sobs racking her exhausted body. The sign falls to the ground, face down. Gravity pulls Janine to the folding chair placed next to the window, as the torrent of tears and emotions buckle her legs. Her handprint still visible on the window.

Continue reading.

A Silent Hero

By Barbara Resnick, PhD, CRNP, nurse practitioner, Maryland

Through the pandemic, there have been many acknowledged heroes in nursing and in medicine. We have all had to turn to our medical directors to help collate the large volume of changing "research" and findings related to COVID-19, the regulations and most importantly, the management of very complex patients with a disease that we are barely coming to understand. Some medical directors, particularly those in states that were hit early in the pandemic, spoke to us all about their experiences and many received well deserved accolades, and wrote wonderful pieces supporting long term care in local newspapers. Others were silent heroes. Hilary I. Don, MD, is the epitome of a silent hero.

Dr. Don is an internal medicine specialist in Baltimore, Maryland, with more than 36 years of diverse experience. Despite balancing house call visits, the responsibilities of an attending physician, and even some acute care, Dr. Don embraced the role of medical director and all that it can and is meant to be. As challenging situations occur, Dr. Don spends a large amount of time personally to find and review the facts and address the situation with calm, full disclosure, and appropriate solutions when needed. In addition to her education and support of our clinical team, Dr. Don is one of the kindest, most caring, and thoughtful individuals I have ever known.

In the face of COVID-19, Dr. Don went over and above the role of the medical director in that she took on the role of an attending physician as well. Dr. Don also worked very closely with the other members of the long-term care team within a continuing care retirement community to interface with the State Department of Health, assure we met all regulations and that we kept the residents and the staff as safe as possible. This required plans and decisions related to care across multiple levels (nursing home, assisted living and independent living settings). Dr. Don advocated for policies when she deemed them necessary and addressed resident and family concerns as those arose related to medical issues. She kept all of the other members of the clinical care team informed and apprised of changes and plans.

Beyond this leadership role, Dr. Don was the sole primary provider for every resident that was positive for COVID-19. She sat with residents and families for compassionate care visits when no other staff was available to do so. She helped us navigate the complicated and challenging cases of COVID-19, was available 24 hours a day to address resident changes in condition and support or provide alternative plans for treatment as needed. Further, Dr. Don always reached out to other experts to help us obtain additional medical specialty information or regulatory guidance to assure we were providing the best possible care for our residents.

Dr. Don is not well known to members of AMDA – The Society for Post-Acute and Long-Term Care Medicine. She is a silent hero and one, I believe, who deserves to be recognized.

Positivity and Joy in Lockdown

By Lauren Ackerman, director of life enrichment, Nebraska

One of my goals, as a director of life enrichment, and that of my counterparts within our organization, Azria Health, is to create a happy and homelike environment for our residents, to create moments of joy for everyone within our health care family. This has become particularly important during this challenging time. Since the start of the COVID-19 pandemic, we have been looking for creative ways to do just that for our residents and communities.

One project born out of this goal was Azria Cards for COVID, where residents at each Azria Health facility write letters to local COVID patients, who are undergoing treatment and recovering. Not only did this help spread some much-needed cheer, it also helped keep the residents engaged and connected to their communities and loved ones. In their first week, they wrote and sent more than 200 cards to patients in local hospitals!

The facilities have also hosted events, such as drive-by parades and hallway dance parties. The local communities came out to support the residents with some great signs and enthusiastic honking. It was fun and inspiring for both residents and caregivers alike. At Azria Health Montclair in Omaha, Nebraska, caregivers dressed in wacky costumes while dancing down the halls as the residents watched from the doorway of their rooms. In this facility the only thing contagious was laughter. The event was even featured on the local news station, WOWT 6 News.

In order to ensure that the activities selected are exciting and stimulating for the residents, we encourage the residents to propose the activities they would like to do. Every month, the caregivers and residents discuss what kind of activities interest them, and then the Activities Department plans accordingly. This creates engagement and allows for the residents to do the things that they truly enjoy. Some residents are not able to articulate their preferred activity, so the caregivers will often contact their families to find out their interests. As an example, one of the residents, was unable to communicate with her caregivers due to end-stage dementia. From speaking with her family, the Activities Department found out that she loved to paint. They set up a wheelchair-friendly painting station with adaptive paintbrushes and paint holders, allowing her to do what she loved. The resident was extremely excited to be painting again and painted nearly every day.

Positivity for a better tomorrow is what everyone needs right now. Take care of the residents, take care of one another, and remember to spread the joy of life!

Holding Both

By Paige Hector, LMSW, social worker, Arizona

My husband, a long-term care physician, said to me one recent afternoon, “I had another patient with COVID die today.”
Big exhale from me with, “I’m so sorry. This is really hard.”
“The mortuaries are all full and the nursing home has no where to send the body.”
There was just no response to that except to be present with him, in the sadness of the situation.
That evening our 14-year old son was begging me to let him have a friend over, “Please, please Mom. I miss my friends so much.”
Anyone with kids can relate to the angst that we feel as parents, the fierce desire to protect our children, to keep them as safe as we possibly can while struggling to find creative ways to connect with friends and maintain any shred of “normalcy”.
As a family, we talk about the virus and certainly our son knows that his parents are dealing with it each day in their work. We talk about the risks, financial and business aspects, social distancing, how our lives have changed, what might come next, school, friends and more. We have adopted and adapted to (well, mostly, and not without some irritation and anger) altered cleaning and disinfecting habits and finding a new way to be present in this new world.
But, that night as I held the two experiences simultaneously, the grief of another death, and, my son’s pleadings for connection with a friend, I felt immobilized with fear and protectiveness, of wanting to shield my son from the sadness that his dad and I see and hear about daily. And, appreciating how desperately I wanted to allow my son to have a friend over, to hear the teenaged laughter spilling out of his room, to witness the rummaging for snacks in the pantry and see the joy on his face.
For now, I will focus on holding both the pain, and the promise for joy to come and allow both to have space.

Together

By Christian R. Amoroso, MD, retired physician

We are never ever alone.
Our Spirits fill both time and space.
United they form the bond,
That holds our universe in place.
More than separate lonely runners,
Together we are the race.
We are never ever alone.

Always Connected

By Scott Janssen, LCSW, hospice social worker, North Carolina

Agnes’s voice trembles as we speak by phone. In the weeks preceding her mother’s death she’d been unable to visit due to COVID-19 restrictions implemented by the nursing home where her mother had lived.

In addition to grief and sadness Agnes is struggling with guilt and self-recrimination – “She was always there for me but when she needed me, I wasn’t there for her.”

She’s struggling with anger – “Why did they lock me out? They stole that precious time from me and my mom.”

She’s struggling with shame and moral pain – “What kind of person let’s their mom die all alone? I’ll have to live with this for the rest of my life.”

As her mother’s hospice social worker, I fish about for ways to help Agnes find perspective and access self-compassion. She’s having none of it. At least until she tells me about how she found out her mother was dead.

“I knew it was them calling that morning to tell me she was gone.” she says.

“How’d you know,” I ask.

“I was cleaning the kitchen and I saw her.”

“What do you mean by saw her?”

“I saw her walk across the living room and into the kitchen just as clear as you or me.”

“What did she do?” I ask.

“She smiled at me and touched her heart with one of her hands.”

Working with dying patients I know that there’s a wide range of paranormal events that may occur around death. Things like out-of-body and/or near death experiences, deathbed visions (in which a dying person sees deceased loved ones or helpful beings), after death communication (in which a grieving person senses the presence or experiences a visit from a deceased loved one) and, as in the case of Agnes, deathbed synchronicities (which encompass a range of phenomena coinciding with the time of death).

Unfortunately, some professionals are quick to explain away such phenomena as physiological effects associated with dying, heavy medication or psychiatric effects such as dissociation or depersonalization. Doing so can be insensitive and hurtful. Research has failed to prove any of these hypotheses, but it has been shown that such experiences, when not greeted with dismissal or ridicule, can become sources of meaning and comfort for those who experience or witness them. These events can also bring healing to those who grieve.

After inviting Agnes to recount the story of her mother’s visit in more detail I ask her what message she thinks her mother wanted to send when she touched her heart.

Agnes’s tears are audible over the phone. There is silence as she formulates her thoughts.

"She wanted me to know that it’s okay. We are always connected whether we can be with each other or not."

“How does that knowledge, straight from your mother’s heart to yours, change the way you understand what happened the day she died?” I ask.

I hear more tears then laughter. “She’s not mad at me. She understands. I didn’t let her down, I guess. I did the best I could, and she knows that.”

Nurse Chrissie

By Melvin Hector, MD, FAAFP, CAQ Geriatrics, CMD, physician, Arizona

Nurse Chrissie got to our last patient doing tele-video visits with me on the COVID unit, refreshing her personal protective equipment for maybe the tenth time already this morning. Hot work. In our skilled nursing facility for many medical problems complicated by a hip fracture, this 38-year-old without a home — whose husband was in the ICU on a ventilator for his own health issues — was febrile last night. Transferred to the COVID unit in the wee hours, this morning her COVID test had returned as positive. She seems to feel fine, said Chrissie, as she then started sobbing. Uncontrollably. I told her to just slow down for a minute and be in her grief, and she did. I could see her face mask steamed over as she turned off the video and just quietly sobbed. Deep, soulful, uneven breaths. I heard her visor un-velcroed, the “pop” of tie strings from gowns removed, and paper gown stuffing into the hazardous waste bin, and gloves taken off. I heard hands (and probably face) being washed a little longer than two Happy Birthdays, and then silence as I imagined gowns retied, her N95 mask meant for tomorrow put in place, new visor re-velcroed, and gloves refitted. The video came back on. “Let’s go”, Chrissie said, and our patient with hypoxia treated with applied oxygen was doing okay. Somber and worried, but okay. After the visit, I thanked Chrissie for her courage and her assistance and offered help, but she said that she was all right. The next day I got to talk to her about other things, and she admitted that when she got home that night, she cried some more, but there was nothing that hugging her kids and two glasses of wine did not help. Later that afternoon, we sent our failing 38-year-old patient back to the hospital.

Note to self: I’ll need to give Chrissie a call later today.

How To Build a Ventilator in 10 Easy Steps

By Alan C. Horowitz, JD, RN, RRT, practicing attorney, Atlanta, GA

DISCLAIMER: This article is not intended to be a substitute for sound medical advice. It merely recalls how one medical center successfully dealt with a ventilator shortage. Any ventilator must be assembled and fully tested by qualified respiratory therapists before it can be considered for patient use. Each hospital will have to determine how best to meet the ventilatory needs of its patients by careful review of all options by appropriate and qualified personnel.

As we all know, many states, cities, and municipalities are scrambling for ventilators. This article describes my experience converting a simple breathing machine — the Bird Mark 7 respirator — into a functioning ventilator. We know it works because I and my team of respiratory therapists did this for literally thousands of patients, mostly open-heart surgery patients who came directly from the operating room, not fully reversed from general anesthesia, into a cardiac surgery intensive-care unit (ICU) at Hahnemann Medical College and Hospital, Philadelphia, in the 1970s and 1980s.

During my time as a supervisor of a respiratory therapy department and coordinator of a respiratory therapy care team at Hahnemann, we had about 30 critical-care ventilators, mostly used in ICUs, in stock at any one time. But, because the cardiovascular surgeons were performing about five open-heart surgeries a day, we needed additional ventilators that could be quickly assembled and turned over as soon as we weaned patients after open-heart surgery from the ventilators in the cardiothoracic surgery ICU.

To solve the problem, we converted the Bird Mark 7 respirator into a functioning ventilator. How we did it is described step by step here in a longer version of this article. It is not ideal and was not intended to be a long-term critical-care ventilator, but if a patient needs a ventilator and is going to die without one, it does the trick. At least, it did for the thousands of patients we treated that way.

Some New York hospitals, and others, have recently been experimenting with using a single ventilator to ventilate two patients simultaneously. Such a desperate practice of attempting to ventilate two patients with one ventilator, each with different requirements for oxygen levels, pressure, the prescribed tidal volume, and other parameters is difficult beyond belief. But, if someone is going to die without the support of a ventilator, then there is little to lose by attempting even extreme, Hail Mary measures. Desperate times call for desperate measures, and a converted Bird Mark 7 is an alternative worthy of consideration.

Making the best use of limited resources

By Steven Buslovich, MD, MSHCPM, physician, New York (as told to Joanne Kaldy)

As coronavirus began to spread, the focus was on hospitals in the scramble to ensure adequate staffing, beds, equipment, and resources to care for COVID-19 patients. In an ill-advised move to help address this, NY state officials announced that nursing homes couldn’t refuse patients coming from the hospital, even if they were COVID-19 positive, and we couldn’t demand testing prior to admission.

Given the limited resources our PALTC facilities have to begin with, we don’t have the capability to control a pandemic of this nature. We can quarantine patients to some degree, but it is difficult, if not impossible, to cohort residents and limit contamination. In truth, it is the worst setting to send COVID-19–positive patients to.

I was already working on a collaboration with regional medical directors and other stakeholders, and we developed an initiative to identify health care facilities in the area suitable to focus on COVID-19–positive patients. These, we determined, would need to have separate entrances, separate laundry and dietary facilities, dedicated staff who wouldn’t float to other units, with specific training and oversight, and dedicated personal protective equipment (PPE). All of this would reduce the risk of contamination and make the best use of limited equipment and other resources.

We started with a 22-bed unit, and we now have an entire 200-bed building that was decommissioned because of bankruptcy and is now supported by new owners. We are able to cohort COVID-19 patients where they can get additional support. It’s also easier to allocate PPE and staff to one unit or building, and given the current shortages of both, this is key. We’re seeing COVID-19–naïve facilities request PPE from the Department of Health/Office of Emergency Management and being provided with 2 gallons of hand sanitizer. There are no supply streams out there to support PALTC facilities.

We are hopeful (and optimistic) that we can drastically reduce the spread of this illness by cohorting patients, and we are now seeing that hospitals are less inclined to force COVID-19–naïve facilities to take patients. However, the challenges remain. We are still seeing limited testing and a lot of false negatives. We are fighting in the dark.

Looking for a light in the dark, nurses and other health care professionals who were overlooked or underappreciated before the pandemic will be the most admired people in our communities. We will cherish staff and support the training of additional nurses and physicians, so we have enough practitioners to care for our communities. We also will use efforts such as frailty assessments to identify patients at greatest risk of illnesses such as this, predict the likely prognosis and trajectory of illness, and best target our treatment strategy where it can be most effective.

Telemedicine Takes Center Stage in COVID-19 Response

By Bader Almoshelli, MD, physiatrist, Chicago, IL

"In a health crisis where medical advice boils down to 'stay at home and stay away from others' to protect us from COVID-19, telehealth is poised to become a much more significant part of care delivery," Joseph C. Kvedar, MD, wrote in The Boston Globe last week (https://bit.ly/3dZopRo), and the physicians in my practice are seeing this happening in real-time. I think one positive in situations like the one we are currently experiencing is it reveals what’s actually needed and what’s effective. Our group has been deploying telemedicine visits to our post-acute facilities to great effect during the COVID-19 crisis, and I know a lot of ambulatory care colleagues who have been using it extensively as well.

Telemedicine has enabled us to continue providing care without putting our residents at risk or having to use precious resources, such as masks and gloves. We can do more assessments quickly and efficiently and identify those patients who need to be seen in person or transferred to the hospital.

Facility staff who were previously hesitant to embrace telemedicine are starting to see the benefits. They see that these “visits” don’t require undue extra staff time and represent effective forms of assessing residents, addressing acute changes, and providing continuity of care. We also can order medications and changes to the care plan in real time. When time is of the essence and everyone already has too much on their plate, this makes a real difference. Telemedicine also makes it easier to keep patients isolated and prevent exposure on everyone’s part.

Residents like that we can see them and that they can talk to us directly about what is happening and what they’re feeling. Some of them really enjoy it; they are amused to see us on the screen. I also can speak to family members and give them prompt updates, and they are happy that I’m doing facetime to ensure ongoing clinical care, especially in this dangerous time. Many of them are videoconferencing with their loved ones, and they’re pleased that we’re using technology to keep our residents safe and comfortable.