Post-Acute Rehabilitation Provider Responds to the Coronavirus Pandemic

By Mary Pat Murphy, MSN, CRRN, CBIST, ReMed

As a post-acute rehabilitation, long term care, and outpatient provider for individuals with brain injury, we find ourselves very quickly learning new standards of care and implementing best practices for the virulent COVID-19 virus. Without the benefit of a crystal ball, we not-very-methodically implemented a four-phase approach. I say “not methodically” because at the beginning of March, not realizing that there would be more than one phase, we implemented Phase One:

• Refreshing staff skills related to infection control and universal precautions
• Training on PPE skills to include how to preserve the PPE and education on droplet transmission
• Designing a number of videos and competency checklists to ensure staff’s follow through of universal precautions practices
• Implementing symptom and temperature checks for staff and clients
• Revising and restricting visitor and delivery protocols to include having temperatures taken at the door and signing an attestation related to travel and symptoms
• Informing staff and families via letter about our processes

These procedures are probably universal within the post-acute communities.

Literally three days later, our community-based programming came to halt. Phase Two became the “lock down” phase. The edict included no outings, no visitors, only essential physician appointments and ER visits. The day programming in the community center ended; group programming was implemented in the homes with the challenge of social distancing. Outpatient and therapy services were closely evaluated and telehealth and telemedicine became the best practice. And, we began the effortful mission of sourcing PPE.

This is now the beginning of May. We watch for the “curve of COVID-19” carefully in all of our regions. Our programs are located in “hotspots” – Philadelphia, North New Jersey and New Orleans – meaning community spread is occurring, and despite vigilant attempts to spot the carrier, many people do not have symptoms. At this point, what we know is the clients have not been in the community for almost two months. The staff will likely be the cause of transmission to co-workers and clients.

Critical to Phase Two was designing settings for isolation in each of our regions – the “Recovery House.” In the event a client tests positive, removing him or her from the setting is critical to minimize the spread. The challenge of staffing the setting and training staff remains a daunting task. Staff fear working with COVID-19-positive clients. Designing procedures for care that provides client support and safety for staff is key.

Phase Three, the implementation of isolation, was initiated a little over two weeks ago. Our first client was admitted to a Recovery House and will be returning home this week. What we recognize is that individuals with brain injury have difficulty appreciating the need for quarantine and, even more so, isolation. What we also realize is that social distancing for both staff and clients is difficult.

Entering Phase Four – the key questions:

• How do we open up?
• How do we maintain the safety of clients and staff while ensuring the integrity of clinical programming?

Like all businesses, we are re-designing our settings and looking at work place rules, admissions procedures, and group therapies.

And finally, testing! Having clients and staff tested was impossible in the beginning of March. In the early weeks, tests were available for individuals with symptoms only. Eventually, using key words like “staff exposed to presumptive clients in congregate setting” on a staff prescription became effective. The key strategies for Phase Four will be:

• Obtaining PPE 
• Social distancing 
• Developing of a testing strategy 

Testing staff and clients on a routine basis is likely to become the standard.It is simply too late to test when the emergence of symptoms is evident.

Phase Five – as we anticipate this phase and as we see states begin to ease restrictions and businesses open, we know the coronavirus will recur.As a post-acute program, we know that it is necessary to redesign marketing, admissions, care delivery, and community access. Discussion and planning has for all of these already begun.