Episode 172

Delphi Panel of Long-Term Care Clinicians

 

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Delphi Panel of Long-Term Care Clinicians

The Delphi Panel of Long-Term Care Clinicians is a group of experts who are specialized in their field of geriatric care. Based on their expertise in , a consensus is formed and recommendations provided to those who care for the elderly. In this episode, we welcome Dr. Michael Wasserman to talk about how this panel is contributing to the care given in nursing homes during the Coronavirus pandemic.  

Schenk: Hey out there. Welcome back to the podcast. My name is Rob. I am going to be your host for this episode. We have a very, very interesting episode today. We are having Dr. Michael Wasserman of the Delphi Panel of Long-Term Care Clinicians on the show to talk about the Delphi Panel, what their findings are, what their methodologies were and what their recommendations are for nursing home care in the age of COVID, that is to say how does PPE, the availability of PPE affect infection rates in nursing homes? What are some recommendations for nursing home facilities moving forward with regard to everything from testing, how often testing should be done, who should be tested to visitation? So a lot of great talk from Dr. Wasserman today.

Just in case you don’t know, Dr. Wasserman is a geriatrician who has devoted his career to serving the needs of older adults. He previously served as chief executive officer for the Rockport Healthcare Services overseeing the largest nursing home chain in California. Prior to that, he was the executive director care continuum for Health Services Advisory Group, the quality improvement organization for California. In 2001, he cofounded Senior Care of Colorado, which became the largest privately-owned primary care geriatrics practice in the country before selling it in 2010. Dr. Wasserman published his book, “The Business of Geriatrics,” in 2016, which details how to succeed in geriatrics in today’s healthcare marketplace. He was also the lead delegate from the state of Colorado to the 2005 White House Conference on Aging. His bio goes on and on. This guy is highly educated and highly motivated on the care of our nursing home population, and we are so happy to have him on the show. Dr. Wasserman, welcome to the show.

Wasserman: Nice to meet you.

Schenk: Okay, fantastic. So I guess, it makes sense from an introductory question would be what exactly is the Delphi Panel of Long-Term Care Clinicians, and how did you become a part of that organization?

What is the Delphi Panel of Long-Term Care Clinicians?

Wasserman: So the Delphi process is a process that’s been around for quite a while. It’s a process that allows experts to share their opinions, their recommendations in a way that allows us to make recommendations when there’s not a lot of other information available. So in my field of geriatrics, there are not a lot of studies done on older adults. There’s certainly almost no studies done on nursing home residents. So when a doctor prescribes a medication for a nursing home resident, they’re not doing it based on the fact that someone has done some clinical trial or study that chose the value of benefit of that medication. They’re actually doing it based on studies that have been done in younger people, which is why oftentimes older people get medications and they don’t react well to them. 

How did the Delphi Panel conduct its survey of nursing homes? 

So the Delphi process brings together experts who have many of them years of experience, and when COVID hit, it became obvious to me that this was a virus that we had never seen before. We weren’t going to have studies being done in real time. We wouldn’t have that sort of information available to guide us. And so what we started doing at the California Association of Long-Term Care Medicine back in April when actually what led us to really get running on this was a lot of my colleagues knew that we needed to start testing the front-line staff and the residents. And no one was really listening to that. No one was paying attention. 

So what we did was we realized, “Let’s use the Delphi process,” and the Delphi process included them gathering experts from around the country, so experts in geriatrics, experts in infectious disease, experts in nursing home care, and pulling them into a group, starting to ask questions, looking at whatever research or literature was available, but then posing questions as a group and then seeing if the group of experts could come to consensus. And that’s the key to an effective Delphi process where you pick ultimately recommendations and you go around and you survey the group and you say, “We agree with these recommendations.”

Schenk: That’s so interesting. So how did you pick the group? How did the group form, you know what I mean? There’s millions of people out there. How did Dr. Wasserman know which infectious disease doctor or which maybe administrator, whatever the case may be?

Wasserman: So if there’s a critique one can make of any Delphi process is it’s how you chose the people who are a part of the group. Now I’m a geriatrician. I did my fellowship in geriatrics back in the 1980s. I’m actually the editor of chief in an upcoming revision of a major geriatrics textbook. I’ve been very active in my discipline for many years and I know a lot of people. So one of the things I did was reach out to a number of my own mentors, and keep in mind, I’ve been around for a while, but I have mentors who literally are a who’s who of geriatric medicine. 

And so your audience won’t know the names of these folks, but Joseph Auslander, who is like the grandfather of nursing home medicine, John Morley, who taught me so much over the years and is very well known, Thomas Yoshikawa, who is a former dean of Drew Medical School, who is probably the father of geriatric infectious diseases and is at the VA Hospital in Los Angeles. And then I had a number of folks who I knew just from my own circle, especially because of COVID, I had been interacting with some infectious disease specialists and others. I met some new folks through Twitter. Twitter’s been a pretty good way of meeting people. 

But again, the majority of these folks are all well-trained, have been published, and we pulled the group together. Anyone who looks at the group we put together, who knows anything about the field of geriatric care medicine. I’m very comfortable that they would say, “Yeah, this is an august group.”

Schenk: That’s right. It’s like the Justice League, like you’ve got your Superman, you’ve got your Wonder Woman, you’ve got your Batman. You’re taken care of. So you’ve got your team, you’re at the Hall of Justice, what were the methods? Can you walk me through the methodology and kind of your approach to the study itself?

Wasserman: So we had a couple of meetings to just talk first, and that gave me as sort of the leader of the group a good feel of where everyone was, what issues might be problematic, which issues might be pretty much close to 100 percent consensus. And I then set up a framework around which we could have these discussions, and it became obvious. At the time, there were a lot of folks that were very confused about what nursing homes could and should do as it related to testing for COVID. 

And so what we did is we set up several scenarios, because it became clear that people were like, “If this, then we can’t test,” or “If that, we can’t test.” And so I realized very early on that we needed all the scenarios covered. So we had scenarios all the way from you’re a nursing home that just can’t get personal protective equipment and you can’t find the test kits, what do you do? All the way to you’re a nursing home that has all the supplies you need, everything’s available, what do you do? And then we set up some specific questions around do you test, how important is it to test. We went from strongly agree to strongly disagree. And we actually then just did a survey of all the members of the group.

One thing I do love about science is numbers don’t lie. And you set up a survey and everyone takes it. You then put the numbers together and you see that there are certain questions where you have either 100 or 95 percent agreement. And then you have some where there’s 50 percent. And now you know. And one of the beauties of research and data is when the numbers tell the truth. And it became very clear very quickly that we had consensus on some very specific areas. And then we had another set of meetings to discuss those findings. 

And then I think the most interesting part of this was a number of us then wrote a paper to send it to a peer review journal. And I think that was really the cornerstone of what the Delphi process led us to because once you have the paper written and you have your introduction and you have your methods and you have your recommendations and results and what you’re going to say you believe. Now you can go back to the whole group again and say, “Are you okay with this paper?” And when everyone who has been part of the group says, “Yes, we are fine with the paper as it’s written,” you sort of have the ultimate in your Delphi process. We weeded out where we didn’t agree. They weren’t there in the paper.

What conclusions were reached by the Delphi Panel?

At the time we finished rewriting the paper, we really had honed in on our core messages, and in this case regarding testing. And the group came to this conclusion in paper form by early May was we needed to be testing every staff member of every nursing home in the country. And it was because we knew from the data, from the CDC itself back in March that asymptomatic staff could and were bringing the virus into the nursing homes. And we’re seeing that. What’s really frustrating to me is here we are in October and we’re seeing it again, and it’s like haven’t we learned from this? 

But one of the things we had also been frustrated with prior to May, the direction from the CDC, from the Centers for Medicare here in California, the California Department of Public Health regarding testing were fairly vague and actually focused more on testing people with symptoms. And we were saying, “No, you want to test everybody.” And so this is actually the first time I think I’ve shared this with the media or at least speaking live or with someone is before our paper was published – it was published on May 31st – a couple weeks before it was published, I shared an embargoed copy with folks from Centers for Medicare and Medicaid, with someone from the CDC, with someone from the California Department of Public Health. And lo and behold, by the time our paper was published on May 31st online, some of the guidance that we had recommended had started to be included in the federal and state guidance. I’m very, very proud of that.

Schenk: Yeah, I was going to say, that’s got to feel super good that you possibly had a hand in that. That’s amazing. Okay, so let me try to understand this. So you went through the process. You talked about the methodology and you talked a little bit about one of the areas in which you reached consensus and you have recommendations which ultimately were adopted. But what were some other areas your panel found consensus on and that you also had recommendations for? There are other areas as well?

What are some current recommendations for nursing homes regarding Covid-19 prevention and treatment?

Wasserman: Yeah, I mean at the end of the day, California Association of Long-Term Care Medicine back in April put out what we call our “Long-Term Care Quadruple Aim for COVID-19 Response.” And the Delphi Group essentially validated what a core group of us published online, on our website, back in April, which were four elements. 

The first element is abundant personal protective equipment. If a nursing home does not have masks and gloves and personal protective equipment, it will lose to this virus. And I think part of that point was you can do all the testing in the world. If you find out folks have it, you’re going to have to send everyone home because you don’t have any way of protecting anyone. But it needed to be stated, and I think we were able to at least validate and reiterate what I think now looks obvious. Then, it was obvious to the infectious disease doctors and the geriatricians, but that was really important.

And the second was what we were talking about mostly, which was the testing, that back in March and April, there was resistance to testing. Some of that resistance came from the nursing home industry. There were facilities that were worried, if we test and we find the virus, we’re going to get bad media reports or we’re going to have to send staff home and we won’t be able to have enough staff. Now my response and actually as further background, an email had kind of led to the founding of this Delphi Group, was I posed a sort of ethical question to about 50 other people, and I said, “If we know that one of our staff had the virus and we let them come to work and they infect residents and those residents died, how is that different from not testing? What’s the ethical difference of testing, knowing someone’s got it and not sending them home from not testing and saying, ‘Out of sight, out of mind, we don’t know so it’s plausible deniability?’” 

And so it was really important because, again, there was even resistance to testing from some state and local government and healthcare entities, because again, everyone was like, “What do we do with this information?” As a clinician, I was like, “Just because we don’t know what we’ll do, just because we may not have enough PPE, just because we may not have enough resources doesn’t mean that we shouldn’t find out that we’ve got people who can give a virus to nursing home residents who will die.”

And so the group wholeheartedly concurred with that. And it’s interesting because one of the members of our group, Dr. Yoshikawa, who’s at the West Los Angeles VA Hospital, they were testing right and left their staff back in April. Myself, by late March, early April, we were doing whatever we could to get ahold of tests to test our nursing home staff and residents. So we were practicing what we were preaching at the same time.

Schenk: Right.

Wasserman: So I think our group validated all of that, which was very important. I’m someone who, even though I can be pretty strong-willed in my beliefs, I’m always willing to listen to other experts, and that’s what I love about the Delphi process is when you get a group of experts, we’re not always going to agree on things. We’ll have disagreements, but we’ll hash it out. And when you can find a group that can agree on something, then you know you’re pretty good at that. And areas where we had some disagreements related more to what happens if you don’t have the PPE, if you don’t have the testing, what do you do? And those were very problematic, and we didn’t make recommendations around that. 

We also at that point in time didn’t really know everything we know now in terms of how frequently. We said in our recommendations that you should test every week or two depending on community prevalence. And I have to say, that has actually been pretty prescient in the sense of there are communities around the country that still don’t have COVID or have very little COVID. The nursing homes in those communities are pretty safe. But we’ve also seen in those very communities that were okay in May, June, July, when COVID hit that community – there was an article yesterday, COVID hit a community in Wisconsin that had a college. The college kids are partying, they’re getting COVID, it’s now in the nursing home and nursing home residents are dying.

Schenk: Right.

Wasserman: There was the wedding in Maine where they had a wedding and people took the virus from that wedding and seeded nursing homes 50, 100 miles away and people died.

Schenk: Right.

Wasserman: And so again, there’s still a lot to learn and actually the most recent Delphi, we’ve done a second one that has to do with how and when to let visitors into nursing homes. And we actually just published a paper on that with recommendations.

Schenk: What were the recommendations on that?

Wasserman: You know, the key recommendations we’re making is we can’t take the easy way out. I think it’s been really easy for government folks, healthcare folks to say, “Let’s just lock down nursing home residents.” Look, I was saying back in April, put a moat around the nursing home. But what I wasn’t saying was socially isolate frail, vulnerable older adults who we know from existing literature, if you have social isolation, you will have increased deaths. You will have increased morbidity. So what we’re saying is use the science we have, figure out how to allow socialization using personal protective equipment, using testing, using outdoor visitation, using whatever means. It may not be easy, but let’s devote time and energy and resources to figuring out how to make it happen. And clearly we do know a lot. We know that if everyone wears a mask and distances themselves and is outside, you’re going to be pretty safe.

Schenk: Right.

Wasserman: And I think there clearly is a strong movement right now towards outdoor visitation for nursing homes. Clearly during the winter, that may be more difficult, but could you set up something right out the door with heaters? At the same time, if the family is trained properly and they’re wearing a mask, the gowns, the gloves, then there’s risk-reward questions that we have to come to grips with because none of us should be making unilateral decisions for older adults living in nursing homes just because we can.

Schenk: Right.

Wasserman: Respect their rights and their dignity.

Schenk: Yeah, as you mentioned, it’s kind of like a balancing test. You have your literal wellbeing in terms of your psychosocial, your dignity and your mental and personal wellbeing in relations with your family versus your literal health in preventing infectious disease from killing you. You’ve got to weigh those, because as you mentioned, it seems at least when you lock down a nursing home, these negative outcomes from a social standpoint happen.

Let me ask you this and I don’t know, this might not be something you guys talked about, but was there any data, was there any correlation between negative outcomes with COVID and whether or not a facility had embraced already the federal regulations regarding having an infectious disease preventionist or having a policy or procedure in place regarding infectious diseases?

Should nursing homes have full-time infectious disease doctors on staff?

Wasserman: So I will tell you on March 5th, we, California Association of Long-Term Care Medicine, made a recommendation to the California Department of Public Health. We actually offered to do education and training to nursing homes around infection prevention and infection preventionists. On March 9th, we did our first webinar where we recommended that every nursing home in the state or in the country make their infection preventionist full-time.

I’m going to tell you, this wasn’t Delphi. This was me – I will actually own this – calling my expert infection preventionist colleagues and friends and then putting my CEO hat on because I actually ran the largest nursing home chain in California a couple years ago, and I asked myself if I were still in that position, what would I do? And one thing came to my mind, and that was every nursing home had to have their infection preventionist full-time, solely focused on infection prevention. And my organization, our board passed a resolution on March 20th. We actually asked that the governor of California mandate every nursing home to have a full-time infection preventionist.

Here’s the positive result of that. By the end of June, the state of California’s Department of Health had included full-time infection prevention in their mitigation plan for every nursing home. On September 29th, Assemblyman Woods’ bill AB 26-44 was passed and signed by Governor Newsom requiring every nursing home in California to have a full-time equivalent of an infection preventionist.

And here’s the bottom line. That’s not the only thing we need to do, but when we’re dealing with a pandemic or we’re dealing with infectious diseases in nursing homes, you can’t do this part way. You can’t have the person in your facility who’s responsible for making sure that you’re doing all the right things around infection control and prevention, you can’t have them pulled in multiple directions. You can’t have them distracted. They need to be doing their full-time job focused on making sure that everyone’s wearing their PPE properly, everyone’s washing their hands. And also they need to be deputizing staff on every shift and every ward to be their eyes and ears when they’re not there. 

And we actually got I think the association that represents infection preventionists to pass a similar resolution, but I’m proud of the fact that my organization was front and center on that topic and I think there’s a message that nursing homes have to dedicate clinical focus if they’re going to impact clinical care. 

And so when we’re talking infection, we’re talking infection preventionist. As a next step, there are two other things we’re actually advocating things for right now and there are other things we could advocate for, but one is every nursing home should have an RN in their facility 24/7, because if something goes wrong, if a resident’s not feeling well, you need a licensed clinician to look at them. The other thing is while every nursing home has a medical director. Very few nursing homes have medical directors who have competencies in geriatrics and long-term care medicine, who understand the regulatory environment. 

There’s actually a certification by the American Board of Post-Acute and Long-Term Care Medicine for medical directors to be certified to be more effective, to be more effective clinical leaders. And we are making a big push, and for your audience, they should be asking, “Who’s the medical director of my facility, of my loved one’s facility? Are they certified? And if not, why not?” because I believe that every nursing home in the country should have a certified medical director.

I have faith in physicians in general. There’s always exceptions to every rule. But we all took an oath, it’s called the Hippocratic Oath, and I believe if you have a medical director who has the tools and the expertise, they will then follow their oath as professionals and they will get engaged in their facility. On the other hand, when you have a medical director who’s not certified, who’s not trained, who’s not prepared, all they’re being asked of from their facility is to sign forms once a month, that’s what they’re going to do. But give them the certification and then let them own their oath, and I think we can bring nursing homes into the 21st century in terms of quality and clinical care, because nursing homes are basically mini hospitals these days, and what hospital would you go to that doesn’t have an engaged physician as a leader? And yet nursing homes almost generally don’t, and that needs to change.

Schenk: That’s extremely very well said, Dr. Wasserman. Thank you so much for sharing your knowledge, letting us know your group’s recommendations and educating our audience on these things. It’s really important and I have all your information in our show notes, so if anybody listening or watching is interested in learning more about Dr. Wasserman and the Delphi Panel, then it’ll be in those notes or I guess in the video description. So again, Dr, Wasserman, thank you so much.

Wasserman: Thank you very much. Really enjoyed this.

Schenk: What an interesting conversation with Dr. Wasserman. Had such a great time with him. If you are only listening to this, you are missing out that he has a really cool fedora on. So check that out. If you didn’t know this podcast was also a video podcast, now you know. Check us out on YouTube at Nursing Home Abuse Podcast on YouTube. You can go to the website, NursingHomeAbusePodcast.com. Every other week on Monday is a new episode. That is twice a month. Check us out. We are getting close to almost the 200 mark of episodes, so there are hours of hours, some would say hundreds of hours of content for you to learn more about the nursing home industry and keeping our loved ones there safe. And with that, folks, we’ll see you next time.


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