MODERATOR: Welcome to Mayo Clinic COVID-19 Expert Insights and Strategies. The following activity is supported in part by an independent medical education grant from Pfizer Inc. and is in accordance with ACCME guidelines. COVID 19 Expert Insights and Strategies is a comprehensive curriculum from the Mayo Clinic for healthcare personnel worldwide.

This presentation covers transitions of care for the COVID patient, evolution of care coordination in a pandemic, and is accredited by the ANCC for 0.5 contact hours. It's important to note that there are no relevant disclosures for all those involved in this presentation.

Our panel of experts for this presentation include Sarah Blakemore, a licensed social worker with Mayo Clinic who is part of the critical care COVID cohort; Patti-Jo Dixon, a registered nurse and accredited case manager with Mayo Clinic who is part of the med/surg COVID cohort; Stacy Hunter, a registered nurse, accredited case manager, and an RN case management liaison with Mayo Clinic; and Diane Kittle, who is an RN, certified case manager, and operates as a manager for RN case managers within Mayo Clinic. Diane, would you like to get started?

DIANE KITTLE: Thank you for joining us today for this course. Our learning objectives today are to identify differences in transition planning based upon the patient's acuity, critical care versus a med/surg level of care, address the psychosocial impact of the pandemic, the isolation of patient and family, impact of socioeconomic factors in determining a safe transition plan, the heightened anxiety from patients and caregivers related to post-acute care, and then summarize how to effectively utilize and access post-acute resources for COVID-positive patients. Sarah and Patti-Jo, how do critical care and med/surg differ in meeting the psychosocial needs of our patients and families?

PATTI-JO DIXON: Psychosocial needs, one of the biggest challenges is the isolation. Patients are no longer allowed visitors, and without the support of family, friends, patients can become frustrated, depressed, lonely, and anxious. If they come in with mild dementia they can become more confused and restless as time goes on.

The health care team is tasked to provide increased emotional support for patients and families to help calm fears and provide frequent updates. Communication has become more labor intensive. Due to the no-visitor policy there's an increased importance for reaching out to families more often, which is time consuming, but very important.

No more face-to-face communication. The intimate connection with patients and families that once occurred has gone away and there's a loss of connection with family and patients. Patients and families often express fear returning home due to infecting family members that have not tested positive for COVID.

Families are concerned about how they're going to care for their ill loved ones. Increased education is a huge part of health care providers and is crucial so that families can feel as safe as possible when reuniting with their families. And then also the-- when loved ones are transferred out of state or miles away from their home for higher level of care, this adds another layer of anxiety and concern for families.

Even though no-visitor policy is in effect for families living locally or far, being far from home physically takes a toll on them. The patients are eager to get closer to home. Family members want them closer to home.

And Sarah, do you have anything to add?

SARAH BLAKEMORE: The psychosocial concerns we are seeing in our communities, and nation as a whole, are magnified when facing a medical emergency within a patient supportive nucleus. As the critical care social worker, I'm seeing most frequently patients and families in prolonged stages of crisis.

For example, inability to visit worsens the situation as a whole. And patients who are too sick or unable to communicate have to rely solely on staff to keep family informed. Over the course of a patient's hospitalization we are continuously assessing psychosocial needs which can often be quite fluid.

We are getting to know families to a greater level than ever before, and at times supporting them through traumatic events. It is not uncommon to have patients with family members diagnosed, struggling, and losing their lives due to COVID.

DIANE KITTLE: Sarah, how has the COVID-19 the pandemic changed how you communicate with our patients and families?

SARAH BLAKEMORE: As I just mentioned, there are new challenges in communication. Due to isolation precautions we are now restricted from patient rooms and unable to complete in-person, face-to-face assessments. The care team utilizes technology and bedside tablets to communicate with patients, especially on med/surg floors.

There is an increase in updates being provided via phone by all members of the interdisciplinary team. In the ICU our critical care team spends the majority of the time in communication directly with family. If alert and oriented, our patients are often too sick to complete a full assessment and our primary priority is to identify a surrogate decision maker, or determine if a patient has completed a health care directive.

Our nurses have taken responsibility for facilitating video calls at bedside so families can see their loved one. We have made visitor exceptions for goals of care meetings on withdrawal of care or for end of life. As a unique way for families to feel a connection to their loved one, I have asked families to email photos to be hung up in the patient's room.

Also we have utilized a gift that historically was used for patients nearing end of life as a way to connect patients with their young children. This was initially a program that was taken, or adopted, from our palliative care team. This gift is a heart module that the nurses are able to record the patient's heartbeat on. And we give the modules to families to put in a stuffed animal or other keepsake.

DIANE KITTLE: Patti-Jo and Sarah, what additional challenges do the patients and families endure when a loved one is hospitalized with COVID?

PATTI-JO DIXON: Well, many challenges emotionally that can include despair, loneliness, fear, and depression. Some or all of these emotions are present in all of COVID-positive patients and families due to the unknown changes in medical status, but mostly because of the isolation and lack of in-room support from family and other loved ones.

When patients that are elderly come into the hospital, the longer the hospital stay, the more emotional support patients and families need to cope with illness and the isolation. And if a patient comes in with mild dementia and becomes more confused, that person who was once fully functional to live at home with their spouse is no longer able to return home. And that takes a toll on the families, as well.

When a patient can go home and can return to the family without any other needs other than PPE, they have concerns about obtaining and paying for the needed PPE in order to follow guidelines to prevent infected family members. They may expect the hospital to provide PPE, which is not a viable option. Assisting patients with this discharge need can be time consuming, and at one time was not possible at all.

If families are given a choice and they're able to bring their loved one home, most of them would choose that option. But due to lack of resources many families do not have that option. And they are in a position to have their loved one discharged to a skilled nursing facility that may have a lower CMS rating. And then that causes more emotional stress because that decision is not the one that they would choose if they were in a different situation.

Sarah, would you like to add?

SARAH BLAKEMORE: Sure. Like Patti-Jo had said, we've seen both patients and families struggle with isolation, despair, loneliness, fear, and depression, among other emotions. Patients, often those who are elderly, stay in the hospital longer due to comorbidities and complex discharge needs. There's a visual or even tangible correlation between not having family visit and the emotional and physical toll that it not only creates for the patient and their family, but also for staff.

In addition, on both med/surg and critical care units, we have seen extensive financial challenges. On med/surg we have seen patients struggle to afford medication and pay for transportation home. In both units we've seen the struggles families face when the primary breadwinner is hospitalized.

Social work has assisted in connecting families with community resources and completing financial assessments to determine eligibility for charity funds through the hospital or national organizations.

DIANE KITTLE: Sarah, can you tell us why an advance directive is important for our COVID patients?

SARAH BLAKEMORE: Yes. On both med/surg and critical care units, our team offers patients who are alert and oriented the opportunity to complete a health care directive. We provide education on advance directives and guidance on how to complete the document. Patients who are not interested are informed of who their surrogate decision maker would be, per state statute, in the event that the patient becomes incapacitated during the course of their hospitalization.

On the critical care unit one of the toughest challenges I'm facing is identifying a decision maker. Many times I'm racing to complete a health care directive with a patient within a few hours of the patient being intubated. If a patient is not alert and oriented, I'm calling their emergency contact to obtain as much information as possible and identify a surrogate decision maker, and contacting that individual to determine whether or not they are willing to serve in that role. The medical team is notified as soon as a decision maker is identified.

DIANE KITTLE: Patti-Jo, what are some of the socioeconomic challenges that COVID presents?

PATTI-JO DIXON: Patients and families faced with lack of financial resources are faced with more stress at time of discharge because they're not able to make the choices that they would normally make if they did have the resources. Not only do patients want to return to their own homes, families want them at home, as well.

But if the patient is too weak and becoming deconditioned this may not be an option. If the patient does not have 24/7 care given by another family member and they're unable to afford private caregivers they're put in a position to choose a discharge plan that is less than desirable. This can be a barrier to discharge and takes a lot of the health care staff to work on creating and making them feel as well as possible with the decision that they make for their loved one.

Many families declined the recommendation given to them at discharge because they're put in a position to choose a skilled nursing facility that has a low CMS rating, as these are the only ones available and accepting patients who are COVID-positive. They feel hopeless because they are concerned about poor care, not being able to check to make sure their loved ones are OK and receiving adequate care. Again, more stress to the family and the patient.

When patients are not close to their home and they're transferred over because they need a higher level of care, when they return to their homes they may not have the resources in the area that they need. For example, they may not have home health because they're in a rural area that it's just not possible. This creates added responsibility and concerns for the family.

How are they going to bring their loved one home? How are they going to get the loved one to outpatient therapy? So there is a lot of working with patients, families, and supporting a discharge plan that can work for them to get to their home. And that's not always easy.

There's also just social issues caused and complicated by the pandemic by uprooting families, especially the low economic population. Lack of resources have forced patients to move in with their children or other family members. Families have had to rearrange their lifestyles to care for loved ones that once were independent and had their own lives.

As you can see, again, more stressors, more psychosocial issues, and we are very thankful for the social workers that help us deal and support our families and their patients.

DIANE KITTLE: Stacey, how has COVID-19 displaced patients from their residential facilities?

STACEY HUNTER: So residential facilities include assisted living and group homes and really everything in between, and they've been hit hard by this pandemic. So what we're running into is patients coming into the hospital because they have a COVID diagnosis, and their place of residence is declining to take them back into the home.

So then we're faced with a patient who is temporarily without a home. Now what we need to do in this situation is to work with these homes to determine, is there a way that we can help them take their resident back. Also, we need to explore skilled nursing facilities that will accept somebody who has COVID.

We need to work with families and identify any resources that they might have. Are they able to take their loved one home with them? Are they able to hire caregivers? So we really have to get creative in this situation.

And it's also very important to be aware of the local policies. For example, in our area we had an executive order that said that these facilities need to have a plan to take their residents back. So when we run into this issue we simply remind these facilities of the executive order and also work closely with them to make this safe.

Is it education that they need? Do they need resources for finding PPE? There have been some shops identified that will sell to really anyone. So it's just working closely, thinking outside of the box, and identifying different-- whether it's temporary or long term placement for these patients, and always having a backup plan.

DIANE KITTLE: Stacey, what are some additional challenges that exist in obtaining these resources due to COVID?

STACEY HUNTER: So limited providers is definitely a reality for us. I think that this is something that case managers struggled with before a pandemic, and now we're faced with understanding who will accept somebody who has COVID currently, who will accept somebody who is considered COVID-recovered, and actually identifying what definition of those are they using.

So there's many facilities that have specific testing criteria, timing criteria, all sorts of things that different providers are following. And again, we need to work closely with them to follow those and get patients safely discharged.

There's also limited staffing in the post-acute setting due to exposures. There are limited beds, limited chairs. There's COVID units available, but those beds fill up. The outpatient dialysis chairs in a COVID unit can fill up as well, and we've also experienced this with inpatient hospice units.

So sometimes it's a waiting game, sometimes it's working on a backup for these patients to get them where they need to be sooner rather than later. Oxygen is a very common need for COVID patients upon discharge and we've had to change some of those workflows, as well. So due to limited visitors being allowed in the hospital and also the sustainability of having somebody come in and do education on all of these patients, we had to come up with something new.

So our bedside nurses learned how to educate patients on this equipment so that we could quickly get these patients home so that they can rest and recover with oxygen without waiting on somebody to come in and educate them and make that delivery. Transportation has been quite a challenge, and this is a matter of reaching out to identify who will take these patients, what they require.

For a while we had to explore is an ambulance the only option, because they're the only company willing to transport somebody who has COVID. But then eventually there are more providers willing to do this. And it's just working closely with them to identify those resources.

DIANE KITTLE: So Stacey, what about patients who are discharged into a post-acute facility?

STACEY HUNTER: We get a lot of questions from family about what that's going to look like, is that safe. We're asked often, how can you make sure that my loved one does not get COVID in that facility? And unfortunately we have to explain that we cannot guarantee that their family member will not get COVID.

Whether that's in a facility or in the home, we can only do our best to prevent spread of this disease. So we also encourage them to really work closely with these facilities to understand what they are doing to prevent the spread. Because every facility is doing something differently.

So we get the families in contact with them early on so that they can identify if they're comfortable with the measures being taken. And we can educate them as well on the CDC guidelines so that they can make an educated decision, but understanding that we certainly could not guarantee that their loved one will not get COVID.

We also like to discuss with them a communication plan. There's a lot of post-acute facilities that are allowing window visits. So they might not have seen their family member for weeks, months, because they've been in the hospital. But then when they go to a skilled nursing facility they're able to sit outside of their window and visit them.

There's also facilities that have technology to allow video chats between patients and their family or friends. So identifying the processes for the individual facility and then setting up a communication plan is very helpful for patients and families.

DIANE KITTLE: So Stacey, how do you keep track of which post-acute providers will accept COVID patients?

STACEY HUNTER: So my role as the RN care management liaison is to act as a liaison between the hospital and these outside providers. So really having one dedicated staff member to organize all of these resources is key. Frontline staff are caring for patients. They're supporting families. They're actually formulating the plans for each individual case.

They're just not able to search for all of the resources as well. So having a point person for these resources is essential. We have a shared spreadsheet of each different arena.

So whether it's a skilled nursing facility, home health, long-term care hospital-- we have a spreadsheet to keep track of the contacts for these organizations, as well as the COVID procedures that they're following. So that we know in order to send to this facility, you need to follow X, Y, Z.

So this person can also get involved with those problematic discharges. If there's a barrier between the hospital and that facility, this person can really step in as a third party and mitigate any of those issues in order to move forward with a safe discharge plan for the patient. This requires a lot of calls, a lot of emails in order to keep up-to-date on the most recent information.

Because as we know, this all changes very quickly-- from minute to minute-- as to whether or not a facility has space for a patient. Or if a home health really has the caregivers to go in for COVID patients, COVID-recovered patients, or if they're not accepting them at this time. So really having one staff member to keep track of all of these different resources is key.

DIANE KITTLE: Thank you. Patti-Jo, what has assisted you as you've worked through the discharge planning process with the COVID patients?

PATTI-JO DIXON: All righty. On our med/surg floor we have daily rounds. Collaborate with the health care team, which can include physicians, the care management team, dietary, our floor team lead and the manager, as well as therapy. And it gives us the time to discuss the possible barriers that are many.

They can include financial resources, lack of financial resources, limited choice for skilled nursing facility as Stacey just mentioned, home health. Some home healths are able to have an RN go out but not physical therapy. They're not able to return to their assisted living facilities.

Each assisted living facility seems to have their own set of criteria. Group homes may not accept them back, and then what was already talked about, transportation. And all of these can cause delays in discharge.

Leadership is also at these meetings so they have a good idea of what the med/surg team is up against to get a timely discharge. And their input is valuable-- all of the input is valuable-- to assist making this discharge happen. And then we have a remote monitoring program, because many of our patients express over and over again that they do not feel safe going home when they're still testing positive for COVID. They want to go home when they test negative, which can take quite some time.

Having the remote monitoring program available has provided them some comfort in knowing that they're not alone. That they will have nurses and physicians that will be able to monitor their progress. They're available to them at home, because they will be twice daily putting in vital signs, which includes a pulse oximeter. And then they'll be able to talk to them if they have questions.

This program has helped alleviate some of the stress for them going home knowing that they're not alone. It serves as a lifeline for the community. And any patient that tests positive for COVID that goes home will have that ordered for them. So this is a really good additional resource that helps our COVID patients.

Education, that just begins at the time of admission. Our physicians, the primary care nurses, the care management team-- all are starting to educate at the very beginning because there's many questions and fears associated with being positive for COVID. And they're educating them on safe guidelines for returning home which is practicing social distancing, masking, hand washing.

And as time goes on, some of them feel better returning to their homes with others that may not have tested positive. They can't stay in the hospital, which is their choice. So we just work with them to make them feel as comfortable as possible. And again, it's more education and more phone calls, working with families and patients. Which is labor intensive for all of the health care providers, but necessary.

DIANE KITTLE: So Patti-Jo and Sarah, what does case management and social work need to do to accept the new normal when assisting with the discharge needs of these patients?

PATTI-JO DIXON: Well, a flexible and can-do attitude is right up there. And then to know that nothing remains the same. Restrictions put in place by post-acute providers changes often. Stacey mentioned this-- it's minute by minute day by day.

You think you have something figured out, you're ready to go, and something changes. It could be the patient's medical status, or it could change the criteria set forth by some of the post-acute care providers. The new guidelines and processes that come to us on a daily basis from these post-acute care providers makes discharge planning labor intensive and challenging.

Patient may be doing well one day, and then the next day the patient may transfer to our progressive care unit or intensive care unit for higher level of care. Case managers can be told one day that the patient will go home the next day with oxygen, only to find out that all the effort you put into getting the oxygen and now they are no longer going to be discharged.

So the entire health care team is on a learning curve on how to tackle discharge planning due to the constant changes in inpatient status and available resources. Med/surg care managers, social workers are monitoring statuses daily because of the acute changes that can happen. And again, the communication with health care team and family is necessary for timely discharge planning. Lots of communication, lots of pacing the case. Sarah?

SARAH BLAKEMORE: So to add on to what Patti-Jo had shared, our roles within care management have always involved being creative and solving problems with no prescriptive solution. In the setting of COVID, the patterns and formulas that we've used in the past have been disrupted. The equation is different but our techniques remain valid.

Techniques involving communication, persistence, open-mindedness, and enthusiasm to achieve success and provide excellence in patient care remains the same.

DIANE KITTLE: So Patti-Jo and Sarah and Stacy, do you have any final thoughts for those listening today?

PATTI-JO DIXON: Well, we all can agree that caring for COVID patients is challenging. For the med/surg floor, start early in the hospitalization for a safe discharge plan, identifying the resources that will be needed based upon the unique situation of every patient that we are working with. But for me, I found that to recognize that regardless of individual roles of health care team, needs of patients have become more challenging. And what was once our stable routines and established previously have changed abruptly.

Supporting each other, our families is very important. But supporting all of the health care workers that we work with on a daily basis that are all feeling the stress of working with the population, whether it's emotional or just coming up with a safe discharge plan. So we all know it's labor intensive, regardless of which floor you're working on.

And the emotional toll that it's taken on those of us who work daily with this population is something that we're thankful that is recognized by leadership. And having that supportive leadership is extremely important in order to keep coming back, day after day, and doing what we do best, which is good patient care.

SARAH BLAKEMORE: Yes, adding on to what Patti-Jo just said, being supportive of each other and other members of the health care team is especially important right now. On the critical care unit we are in the process of developing programs to help patients, families, and staff, such as a virtual support group where families can engage in open processing with each other.

In addition, I have partnered with the unit chaplain to create a tea time for staff to promote interunit socialization and a safe space to process. Last week we had our first moment of silence during morning huddle to honor the lives lost and acknowledge our unity and strength as a team to move forward through whatever the next week will bring.

This will be an ongoing weekly event. And in the setting of COVID we are all at a heightened risk of burnout. It's important to communicate with each other, reach out to your leadership if you or a co-worker are struggling, explore employee assistance programs that's available within your organization, and recognize the importance of self-care. We are all in this together.

STACEY HUNTER: So I would just say really knowing your resources, be willing to get creative and negotiate, and remember that you're dealing with humans on the other end. So post-acute providers-- there's fear in the community. There's lack of education here and there. So be willing to communicate a little more to provide education and just to be creative.

Things are not going to work as well as they used to in areas where they were. And that's just the way that it is. So really just continuing to be kind, that goes a long way. And always have a backup plan.

MODERATOR: So I'd like to say thank you to our panelists today. Also thank you to those who are listening today.