Protecting the Most Vulnerable Through Partnership: Helping Nursing Homes Respond to the COVID-19 Crisis

The nursing assistant spoke through tears as she shared her experience.  She was unsure which was worse, the isolation and fear she experienced this spring as her facility went into COVID-19 lock-down, or the anxiety she felt this summer when she worried that members of her community held her  responsible for harming the residents for whom she cared.

While all of us have been impacted by COVID-19, the pandemic has been particularly difficult for America’s nursing homes.  Advanced age, underlying frailty, and communal living conditions make nursing home residents especially vulnerable, and their reliance on nursing home staff members put these caregivers at high risk.  COVID-19 has claimed the lives of 125,000 nursing home residents and nearly 1,500 staff.

This past fall, the Department of Health and Human Services (HHS) directed almost $5 billion to support nursing homes to purchase personal protective equipment, increase COVID-19 testing, and compensate essential workers.  Recognizing AHRQ’s leadership in patient safety and infection control, as well as our experience helping delivery systems implement evidence into practice, HHS turned to the Agency to provide nursing homes with additional support to address the pandemic.

Conversations with advocates and experts confirmed that support was needed all across the country, that nursing homes were struggling with potentially too many sources of information during a rapidly evolving crisis, and that facilities had differing levels of skills and experience so that adaptation and customization were needed.

We learned that the people who are caring for our parents, grandparents, aunts, and uncles were feeling alone, unappreciated, and in some instances even demonized by their communities. We heard clearly that staff time was a precious resource and that staff were stressed—but also that there was substantial expertise and innovation to be found in local facilities.

With the knowledge gained from these conversations, AHRQ partnered with the Institute for Healthcare Improvement and the University of New Mexico’s Project ECHO to launch the AHRQ ECHO National Nursing Home COVID-19 Action Network. The Network provides free training and mentorship to help nursing homes increase the implementation of evidence-based infection prevention and safety practices to protect residents and staff.  It was designed to be able to support every nursing home in the country that volunteered to participate. 

In its first four months, the Network has reached more than 8,500 nursing homes and is active in every State, Washington, D.C., and Puerto Rico. It is built around approximately 100 training centers, each working with groups of 20 to 40 nursing homes that meet together weekly. Each week the Network conducts over 250 training sessions that use case-based learning to allow peer-to-peer mentoring along with expert facilitation. 

This model allows AHRQ to work with thousands of facilities and to ensure that the best evidence-based information is shared along with practical guidance on how to implement this knowledge into practice.  Most nursing homes are working with training centers within their State and building trusted relationships with other facilities and referral centers, which will last beyond the pandemic.  We are paying special attention to ensure nursing homes that care for medically underserved communities are engaging with the Network and that that every session includes tools and resources for meeting the needs of diverse populations.  This distributed Network also allows flexibility and customization to reflect local context. 

The Network is achieving its primary goal: helping nursing homes to protect residents and staff.  Last fall in Wagner, South Dakota, the Good Samaritan nursing home confirmed the first positive COVID-19 test among its 40 residents. After learning about the use of monoclonal antibody treatment during a Network session, the staff was well prepared to treat the patient. When more cases were identified, eventually 30 in all, each resident received treatment.  No staff became infected and 28 residents, including two over 100 years old, recovered. 

Staff members at the Teays Valley Center in Hurricane, West Virginia, applied the lessons they learned about how to address vaccine hesitancy among staff.  Nursing and administrative leaders approached staff members individually and listened to their concerns.  By the end of January, the center had already achieved an 82 percent vaccination rate among staff.

The power of the Network to overcome isolation is reflected in the words of Jane Davis, a nursing home administrator in Washington, who said, “After only one or two sessions, I was hooked. I didn’t want to miss a single session because of what I was learning, the support I was receiving, and the relationships I was building. I’ve learned that when we come together to learn with and from each other, we can create something powerful: the knowledge and support to move forward and succeed. We are not alone–and we shouldn’t be.”

These stories are compelling illustrations of how this scalable practice improvement model is working today.  In the future, this initiative can become a model not only for COVID-19, but also for other safety and quality improvement efforts in nursing homes.  

Until the pandemic is over, AHRQ will continue to work with Network partners to support the Nation’s nursing homes as we learn together how to put evidence and experience into practice.  We are humbled by the dedication and perseverance of the tens of thousands of frontline nursing home professionals, and we thank them for their caring.  We are smarter and stronger together.

David Meyers, AHRQ’s Acting Director, and Mamatha Pancholi, AHRQ’s Chief Data Officer, were the architects of the AHRQ Nursing Home COVID-19 Action Network.

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