New Programs and Required Reporting for Long Term Care (LTC)

New Programs and Required Reporting for Long Term Care (LTC) New Centers for Medicare and Medicaid Services (CMS) Requirements Slide: D. Burdsall 1

The mission of the U.S. Centers for Medicare & Medicaid Services (CMS) is to ensure effective, up-to-date health care coverage and to promote quality care for beneficiaries. CMS Statement on LTC Situation Healthcare associated infections (HAIs) are largely preventable and occur too often in nursing homes Multiple factors Understaffed facilities Staff without the appropriate training or time to prevent infections early Overtreatment with antibiotics Increasing clinical complexity of the average nursing home resident Frequent transitions between care settings that lead to the transmission of HAIs Lack of a systematic approach to prevent and identify HAIs Source: CMS Survey and Certification Group 2016/2017 Nursing Home Action Plan Personal Cost of HAIs Between 1.6 and 3.8 million HAIs in nursing homes every year Science Photo Infections result in an estimated 150,000 hospitalizations, 388,000 deaths Strausbaugh, L., & Joseph, C. (2000). The Burden of Infection in Long-Term Care. Infection Control & Hospital Epidemiology, 21(10), 674-679. doi:10.1086/501712 Slide: D. Burdsall 2

CMS Infection Prevention and Control Program (IPCP) Reform of Requirements Phase I Phase II November 28, 2016 November 28, 2017 Phase III Basis and Scope Definitions Basic IPCP QAA Committee IPCP linked to Facility Assessment Antibiotic stewardship QAPI plan available for surveyors November 28, 2019 Infection preventionist (IP) IP participation on QAA committee (QAPI) Source: Federal Register Medicare and Medicaid Programs: Reform of Requirements for Long-Term Care Facilities Final Rule: 10/4/16. https://www.federalregister.gov/documents/2016/10/04/2016-23503/medicare-and-medicaid-programs-reform-of-requirements-forlong-term-care-facilities Slide: D Burdsall 7 Illinois SNF Requirements: 2012 Designate Infection Prevention and Control Professional(s) Develop and implement policies governing control of infections and communicable diseases Qualified through education, training, experience or certification (or a combination) Qualifications shall be documented and made available for inspection (Source: P.A. 96-1259, eff. 1-1-11, Section 99. Effective date. January1, 2012. http://www.ilga.gov/legislation/publicacts/fulltext.asp?name=097-0107 ) Phase II Requirements November 28, 2017 Infection Prevention and Control Program linked to the Facility-wide Assessment Antibiotic Stewardship Program Source: Federal Register Medicare and Medicaid Programs: Reform of Requirements for Long-Term Care Facilities Final Rule: 10/4/16. https://www.federalregister.gov/documents/2016/10/04/2016-23503/medicare-and-medicaid-programs-reform-ofrequirements-for-long-term-care-facilities Slide: D Burdsall 9 3

Facility-wide Assessment Determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies The facility must review and update that assessment: As necessary At least annually Whenever there is, or facility plans for, any change that would require a substantial modification to any part of this assessment Source: Federal Register Medicare and Medicaid Programs: Reform of Requirements for Long-Term Care Facilities Final Rule: 10/4/16. https://www.federalregister.gov/documents/2016/10/04/2016-23503/medicare-and-medicaid-programs-reform-of-requirements-for-long-term-care-facilities Image: Pixabay_P. Marco Slide: D Burdsall 10 Must Address: Residents, Patients and Clients The facility s resident population, including, but not limited to: Number of residents Facility s resident capacity The care required by the resident population: Types of diseases, conditions, physical and cognitive disabilities Overall acuity Other pertinent facts that are present within that population Any ethnic, cultural, or religious factors that may potentially affect the care provided: Activities Food Nutrition Pixabay Slide: D Burdsall 11 Must Address: Personnel Necessary staff competencies for level and types of care needed Any ethnic, cultural or religious factors that may potentially affect the care All personnel, including managers, staff (both employees, volunteers, and those who provide services under contract) Slide: D Burdsall 12 4

Must Address: Education SciencePhoto Goal: staff comply with infection control practices Initial and ongoing infection control education Updated education and training when policies and procedures are revised when there is a special circumstance (e.g., outbreak) requires modification or replacement of current practices Slide: D Burdsall 13 Must Address: Training and Competency Task and discipline specific infection control training insertion of urinary catheters suctioning intravenous care Stock Unlimited blood glucose monitoring Follow-up competency evaluations identify staff compliance Slide: D Burdsall 14 M. Makien Antimicrobial Stewardship Require antibiotic stewardship program, antibiotic use protocols, and a system for monitoring antibiotic use The Core Elements of Antibiotic Stewardship for Nursing Homes http://www.cdc.gov/longtermcare/prevention/antibioticstewardship.html Slide: D Burdsall 15 5

Major Changes Photos: SciencePhoto Antimicrobial Stewardship including antibiotic use protocols system to monitor antibiotic use Coordinate and participate in QAPI Slide: D Burdsall 16 Why focus on antimicrobial stewardship in nursing homes? Residents and patients frequently colonized with multi drugresistant organisms (MDRO) 30%-50% of frail, elderly long-term care residents with asymptomatic bacteriuria LTCF reservoir for MDRO Poor communication Pixabay Antibiotic-related complications, (e.g., C. difficile infection), more severe, difficult to treat, lead to more hospitalizations and deaths among people over 65 years Source: CDC: https://www.cdc.gov/getsmart/healthcare/learn-from-others/factsheets/nursing-homes.html#need Slide: D Burdsall 17 Antibiotics are among the most frequently prescribed medications in nursing homes Source: CDC: https://www.cdc.gov/longtermcare/ prevention/antibioticstewardship.html Slide: D Burdsall 18 6

Challenges to Antibiotic Stewardship Approximately 20% of healthcare prescribers account for approximately 80% of prescribed antibiotics 40-75% of antibiotics are inappropriately prescribed Almost 50% of antibiotics are given longer than necessary Source: CDC: Daneman, N et.al. Prolonged Antibiotic Treatment in Long-term Care. JAMA Intern Med. 2013; E1-E https://www.cdc.gov/longtermcare/pdfs/factsheet-core-elements-creating-culture-improve-use.pdf Slide: D Burdsall 19 Source: CDC: Infection Control Assessment Tools: https://www.cdc.gov/hai/prevent/infection-control-assessmenttools.html Slide: D Burdsall 20 CDC Steps to Get Smart about Antibiotic Prescribing Obtain cultures before starting antibiotics when possible Adjust or stop antibiotics when appropriate Use antibiotics to treat bacterial infections only, not viral illnesses Use antibiotics only for as long as needed Antibiotics are generally not indicated to treat colonization Engage residents and their family members to improve antibiotic use Source: CDC: Antibiotic Use in Nursing Homes https://www.cdc.gov/getsmart/healthcare/learn-from-others/factsheets/nursinghomes.html https://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html 21 Slide: D Burdsall 7

Required Reporting in Long Term Care Slide: D. Burdsall Reporting and the Qualified Infection Preventionist (IP) Work with local and state health departments Report and control outbreaks Goal is rapid control of disease Outbreaks have traditionally been under-reported 23 Illinois Department of Public Health (IDPH) The mission of IDPH is to promote health through the prevention and control of disease and injury. IDPH assures the quality of our food, sets standards for hospitals and nursing homes, investigates disease outbreaks, maintains the state s vital records, screens newborns, and many other programs. 8

Illinois Department of Public Health (IDPH) About 1,200 long-term care facilities serving more than 100,000 residents Licensed, regulated and inspected by the Illinois Department of Public Health (IDPH) IDPH assists the U.S. Centers for Medicare and Medicaid Services (CMS) Certifying facilities for participation in federal payment reimbursement programs Reporting outbreaks is an important but frequently overlooked responsibility in LTC Reporting and Precautions in a Social Model Biopsychosocial Model of Care Epidemic or Outbreak Situation Slide: Burdsall, D 9

Required Reporting Your local health department TB district Potentially State Health Department Regulatory Health Care Facility Definition Ambulatory surgical treatment centers Home health agencies and hospices Hospitals End-stage renal disease facilities Long-term care facilities Medical assistance facilities Mental health centers Outpatient facilities Public health centers Rehabilitation facilities Residential treatment facilities Adult day care centers Source: Title 77 PART 690 CONTROL OF COMMUNICABLE DISEASES CODE Is there anyone who DOESN T need to report? Physicians, Physician assistants, Nurses, Nursing assistants, Dentists, Health care practitioners, Emergency medical services personnel, Laboratory personnel, Long-term care personnel, Any institution, school, college/university, child care facility or camp personnel Pharmacists, Poison control center personnel, Blood bank and organ transplant personnel, Coroners, funeral directors, morticians and embalmers Medical examiners, Veterinarians, Correctional facility personnel, Food service management personnel Any other person having knowledge of a known or suspected case or carrier of a reportable communicable disease or communicable disease death The master, pilot or any other person in charge of any bus, train, ship or boat, and the commander, pilot or any other person in charge of any aircraft within the jurisdiction of the State Researchers Source: Illinois Title 77 Part 690 Communicable Disease Code 10

Define What to Report Cluster Two or more persons with a similar illness, usually associated by place or time Communicable Disease An illness due to a specific infectious agent or its toxic products that arises through transmission Outbreak The occurrence of illness Epidemiologically associated Rate in excess of normal Number of cases disease specific General Outbreak Definition IDPH Outbreak The occurrence of illness in a person or a group of epidemiologically associated persons, with the rate of frequency clearly in excess of normal expectations. The number of cases indicating presence of an outbreak is disease specific. More Specific Outbreak Reporting Definition IDPH Any pattern of cases, or increased incidence of any illness beyond the expected number of cases in a given period, that may indicate an outbreak, including suspect or confirmed outbreaks of foodborne or waterborne disease, or outbreaks transmitted by laboratory acquisition, animal contact, person-to-person contact, inhalation or other transmission method, shall be reported to the local health authority within 24 hours. This includes, but is not limited to, outbreaks of gastroenteritis and group A streptococcal disease (including invasive infections, necrotizing fasciitis, and toxic shock syndrome). 11

Outbreak Reporting Expectations Two (2) or more cases of a suspected or reportable infectious disease Cooperate with public health authorities Investigate cases, suspect cases, outbreaks and suspect outbreaks Release of food preparation methods and menus Customers, attendees, residents or patients (people) diagnosed Environmental, food, and clinical specimens Long Term Care Regulatory All illnesses required to be reported under the Control of Communicable Diseases Code and Control of Sexually Transmissible Diseases Code (77 Ill. Adm. Code 693) Report immediately to the local health department and to the Department. Facility shall furnish all pertinent information relating to such occurrences In addition, the facility shall inform the Department of all incidents of scabies and other skin infestations. Skilled, Intermediate, Sheltered, Assisted Living and Shared Housing Nursing Facilities Source: Title 77 Subchapter c Long Term Care Facilities Reporting in Illinois Reportable diseases and conditions Extensively drug resistant organisms (XDRO) Active Tuberculosis Disease Outbreaks/clusters Gastroenteritis Influenza and influenza-like illness Scabies and other skin infestations* 12

Who is Included in LTC Reporting? Assisted Living and Shared Housing* Community Living Facilities Illinois Veterans Homes* Intermediate Care Facilities for the Developmentally Disabled* Skilled Nursing and Intermediate Care* Long Term Care for Under Age 22 Shared Housing Sheltered Care Facilities* Skilled Nursing Facilities Supportive Residences* Supportive Residents Specialized Mental Health Rehabilitation * Scabies and other skin infestations reportable http://www.dph.illinois.gov/sites/default/files/publications/publicationsohpstop-and-report-poster.pdf http://www.dph.illinois.gov/sites/default/files/publications/publicationsohpstop-and-report-poster.pdf 13

http://www.dph.illinois.gov/sites/default/files/publications/publicationsohpstop -and-report-poster.pdf "Extensively Drug- Resistant Organisms" or "XDRO" A pathogen that is difficult to treat because it is non-susceptible to all or nearly all antibiotics XDRO Registry Effective November 1, 2013 Report first CRE-positive culture per patient stay The following health care facilities are required to report patient XDRO incident information: Hospitals Long-term acute care hospitals LTACH Hospital-affiliated clinical laboratories Independent or free-standing laboratories Long-term care facilities Source: Added at 37 Ill. Reg. 12063, effective July 15, 2013 14

Purpose of the XDRO registry Improve CRE surveillance First CRE-positive culture per patient stay must be reported to the XDRO registry Improve inter-facility communication Healthcare facilities can query the XDRO registry to see whether a patient has been previously reported as CRE-positive January 2017, IDPH entering Candida auris cases into the XDRO registry. April 2017, IDPH entering carbapenemase-producing Pseudomonas aeruginosa cases into the XDRO registry. Source: https://www.xdro.org/index.html XDRO registry overview Participants: All Illinois acute care and long-term acute care hospitals (~200), skilled nursing facilities (~800), laboratories Slide: IDPH and the CDC Chicago Prevention and Intervention Epicenter Created August 2016 15

How to obtain XDRO registry access Apply for access at: http://portalhome.dph.illinois.gov/ Slide: IDPH and the CDC Chicago Prevention and Intervention Epicenter Created August 2016 Illinois National Electronic Disease Surveillance System (I-NEDSS) A secure, web-based application available to health care providers and other reporters Input demographic, medical and exposure information on patients diagnosed with reportable conditions Once a report is entered, it is immediately routed to the appropriate local health department for additional follow-up No Access to I-NEDSS? Report by mail, telephone or fax to the local health department No local health department? Report to the Illinois Department of Public Health Division of Infectious Diseases at 217-785- 7165 TTY (hearing impaired use only) 800-547- 0466. 16

Sample Single Shot Case Studies 10 FOR COMPARISON 2011- No Bundle Norovirus Confirmed Gastrointestinal Outbreak 101 Cases Residents and Staff Attack Rate= 29% 34 days duration 9 8 7 6 5 4 3 2 1 0 12/4/11 12/11/11 12/18/11 12/25/11 1/1/12 1/8/12 1/15/12 1/22/12 1/29/12 D. Burdsall 50 Outbreak Control with Bundle and Health Department Guidance 17

Acute Gastroenteritis on a Dementia Unit January 2013 9 Cases: 3 Confirmed Norovirus Attack Rate: Residents and Staff 6.6% 8 days duration 10 9 8 7 6 5 4 3 2 1 0 Reported, Lab Sample Sent, and Bundle Started Confirmed Norovirus Lab Result Received AFTER Outbreak Controlled SX Case Def D. Burdsall 52 Contact/Droplet Precautions Source: E. Nelson, Lutheran Life Communities D. Burdsall 53 IDPH Confirmed Influenza Outbreak LTC Influenza like illness (ILI): Fever (a temperature of 100⁰ F [37.8⁰ C] or higher orally) AND new onset cough or sore throat Two or more cases of ILI occurring within 72 hours among residents in a unit of the facility with at least one of the ill residents having laboratory-confirmed influenza 18

Influenza B and RSV Mixed Respiratory Illness March 2013 7 Influenza B, 1 RSV, and 12 unknown 20 cases Attack Rate 10% Duration 9 days Started Bundled Approach Influenza B Pos RSV Other Reported 5 2 0 1 1 3 1 0 0 0 1 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 D. Burdsall 55 How Many Cases of Influenza do You Need to Consider it an Outbreak? Scenario: Two residents on one unit are complaining of chills, aching, fever, coughing and congestion. One resident states she wants dinner in her room because she is coming down with a cold One resident swabs positive for influenza Is this an outbreak? If the facility is not doing active surveillance, how would you know? 19

Infection Prevention and Control is a Human issue, and needs to be dealt with within a biopsychosocial and spiritual framework Spiritual Social HUMAN Psychological Biological Slide: D Burdsall 20