Joshua Uy, MD, an associate professor of Geriatric Medicine in the Perelman School of Medicine, serves as medical director at a West Philadelphia nursing home, where, in early March, COVID-19 ripped through the building like a hurricane. As top U.S. health officials struggled to predict how severely the novel coronavirus would impact the country, Uy was sending five of his nursing facility’s 20 infected patients to the hospital in a single week.
Fortunately, much has changed for the better since those early days of the pandemic — thanks largely to a new partnership between Penn Medicine and West Philadelphia nursing homes.
The initiative provides nursing home patients, their families, and staff with virtual palliative and hospice care, clinical management, and bereavement services. The efforts are led by Nina O’Connor, MD, chief of Palliative Care and chief medical officer of Penn Medicine at Home, and Laura Porter, executive director of Sub-Acute and Therapy Services for the health system. Penn Medicine is also helping nursing homes to develop or improve infection control practices, and the health system is now working with Philadelphia’s Department of Public Health to expand the efforts across the city.
“Penn Palliative Care has been a bright spot during one of the darkest times,” Uy said. “There is no question about that. This situation highlights that when different sites of care collaborate, it can be a win-win for everybody.”
The unprecedented challenges that nursing homes are facing during the pandemic have been well-documented: Older patients, who are particularly susceptible to the coronavirus, are living together in close quarters. Their care requires high-touch contact from staff members, many of whom may work in multiple locations. When a nursing home employee gets sick, he or she has to self-quarantine for two weeks, putting a strain on what is typically a small staff.
“Nursing homes are communities where people live, have meals, exercise, and socialize together. They are not set up to be isolation wards,” said Joan Weinryb, MD, clinical associate professor of Geriatrics and medical director at another West Philadelphia nursing home.
Moreover, nearly all nursing homes have banned visitors during the outbreak, which means that family members are having to make decisions about their loved ones’ care — or say their final goodbyes — from a distance. COVID patients who do not want aggressive care such as intubation or ICU care are still ending up in the hospital, where doctors have few options that they can provide them.
When Uy sent one of his first COVID-positive patients to the hospital, doctors said that there was not much more care that they could offer beyond what could be provided in a nursing home setting. The patient did not want life support, and her family member expressed to Uy that she would rather spend the end of her life at the skilled nursing facility. It was her home, after all.
Uy called O’Connor to discuss hospice care. However, hospice workers were already being stretched thin. In addition, it didn’t seem advisable to start sending entire teams of hospice clinicians into nursing homes amid an infectious disease outbreak, especially when nursing homes were trying to limit the number of people coming into their facility.
Kevin Fosnocht, MD, was seeing similar scenarios play out at Penn Presbyterian Medical Center, where he serves as chief medical officer. Elderly patients were either dying within nursing homes — without the proper palliative and hospice care that is intended to minimize suffering for both their patient and their family members — or they were being sent to the hospital, enduring the stress of the emergency room, without their loved ones surrounding them.
That is when O’Connor, Porter, and Fosnocht began talks with the health system to come up with a solution to the growing crisis.
“We hoped that we could partner with nursing homes to provide them with the best possible care, including avoiding emergency visits when possible,” Fosnocht said.
In response, Penn Medicine has matched Penn Palliative Care clinicians to several nursing homes in the West Philadelphia area. Those clinicians provide consultations and care — to staff, patients, and their family members — through telemedicine.
For example, when a nursing home patient tests positive for COVID-19, the patient and his or her caretakers are immediately connected by phone with the palliative care consultant. The Penn Medicine clinician explores the patient’s goals and values, including the medical treatments that would or would not be desired if the patient gets worse. If the patient does not want hospitalization, the palliative care physician explains measures that can be taken in the nursing to treat COVID-19, such as oxygen and IV fluids, as well as medications to manage any symptoms that might come up.
The patient and family members also receive virtual support from members of Penn’s psycho-social staff, such as music therapists and social workers from Penn Medicine at Home. Penn Medicine has also recently received donations of iPads, which they have distributed to the nursing homes that do not currently have them, so that families can stay more easily connected with their loved ones and nursing home staff. Patients can transition to virtual hospice care, if desired, or they can continue to stay on the palliative care program for the course of their COVID-19 illness. Families who lose loved ones receive expert bereavement services from Penn Medicine to assist them with their grief.
“The way that I see this program is that it’s about patients’ and their families’ choices,” O’Connor said. “There are many who adamantly do not want to go to the hospital and do not want life support during this pandemic. This gives nursing homes the support they need to honor those patients’ wishes.”
Additionally, O’Connor’s team has been providing bereavement services for nursing home staff, who have experienced overwhelming loss over the past two months.
“For many of them, these patients are like family, and when they pass away or are transferred to the hospital and don’t come back, that’s a huge loss. They may be used to losing patients, but not on this scale. At the same time, many of their staff are out sick, so nursing homes have even fewer resources and staff members than they usually do,” O’Connor said. “These workers are heroes. We really want to provide them with the recognition and the support they deserve.”
Now that these partnerships are in place with a group of West Philadelphia nursing homes, O’Connor and Penn Medicine have partnered with the Philadelphia Department of Public Health to identify other skilled nursing facilities across the city that are in need and provide support, including PPE supplies and testing, in addition to the telehealth consultations.