How Vermont tackled COVID-19 in nursing homes, avoided massive outbreaks

“As I’m sure you’re all aware, the last 17 days have been nothing that I’ve ever expected in my professional career.”  

These were some of the first words spoken by Dr. Mark Pitcher, medical officer at Burlington Health and Rehabilitation Center, as he briefed lawmakers on the situation the center during a Joint Rules Committee meeting of the Vermont Legislature on April 3.

The long-term care facility was one of the few in Vermont that had witnessed a severe outbreak of COVID-19 cases among its elderly residents and staff members in the early weeks of the pandemic.

One of the first reported COVID19 related death in Vermont, announced on march 19, was a 95-year-old female resident of Burlington Health and Rehab, a nursing facility. This news came just 12 days after Gov. Phil Scott, alongside the state’s Health Commissioner Mark Levine, announced the state’s first presumptive coronavirus case. 

Over the course of the outbreak, Burlington Health and Rehab had 11 COVID-19 related deaths among residents, according to “Long-Term Care Facilities in the Time of COVID-19: Lessons in Crisis Management,” a report released three months after the pandemic started.

The paper included insight from several Vermont health officials involved in the response to outbreaks at Burlington Health and Rehab and Birchwood Terrace, another long-term care facility in Burlington.

“It has been devastating to the staff, it has been devastating to me, and it’s been really devastating to the community,” said Pitcher, who has worked at the center for 25 years.

As of Sept. 15, Vermont had seen a total of 1,702 cases of COVID-19 and 58 deaths.

A June report by USA TODAY found that such facilities across the U.S. accounted for more than 40,000 deaths among residents and staff. A map of the country at the time reflected 30 deaths for Vermont, whereas neighbors Massachusetts and New York had 4,041 and 6,062 deaths, respectively, connected to long-term care facilities. By August, cases in nursing homes have almost tripled for Sunbelt states since June, according to USA TODAY. 

Despite being hit hard at the onset of the pandemic, on May 7, Burlington and Health and Rehab was declared COVID-19-free. 

By mid-July, Vermont hit 30 consecutive days without a COVID-19 death, a milestone Health Commissioner Mark Levine partially credited to strict protocols in long-term care facilities, where 32 residents have died due to the disease.

How did the state succeed in tamping down the coronavirus outbreak in long-term care facilities while so many other states continue to struggle? 

For more: How are nursing facilities protecting their residents from coronavirus?

Outbreaks in Vermont’s long-term care facilities 

Vermont witnessed coronavirus outbreaks at five long-term care facilities, though no new ones have cropped up since April. 

The Vermont Department of Health defines an outbreak in long-term care facilities as a situation in which one resident or staff member tests positive for COVID-19, and at least one additional resident they were in contact with has respiratory illness symptoms.

The state describes long-term care facilities as group living spaces offering care to individuals “who are unable to take care of themselves independently in the community.” These facilities, 201 in Vermont, encompass several types of living accommodations including nursing and residential care homes, as well as assisted living and therapeutic community residences.

The outbreak led Burlington Health and Rehab to begin testing residents for the coronavirus, with some moving temporarily to a DoubleTree hotel a few blocks away in South Burlington under the oversight of clinicians from the University of Vermont Medical Center. 

Burlington Health and Rehab also instituted new protocols in response to the pandemic.

New admissions to the center must test negative for COVID-19 and undergo a 14-day observation period. The new patient is tested four, 12 and 14 days into the observation period as well as symptom screening in eight-hour intervals. Employees can only work if they pass temperature and symptom checks, conducted each shift. 

The center remains COVID free, Dr. Richard Feifer, chief medical officer of Genesis HealthCare, said in a statement to the Free Press. 

Genesis is a national health care provider that owns short- and long-term care facilities across the country, including Burlington Health and Rehab. The Pennsylvania-based company told Vermont in a letter dated Aug. 21 that it would begin selling five facilities in the state, include sites in Bennington, Berlin, Springfield and St. Johnsbury. 

Birchwood Terrace outbreak

Another nursing facility in Burlington, Birchwood Terrace, learned of its first COVID-19 case at the end of March. The location eventually accounted for 20 lab-confirmed deaths among residents related to the disease, according to the long-term care facility report. 

Executive Director Alecia DiMario touched on the work done prior to the outbreak, which included having honest conversations about the disease in order to glean understanding about the kind of care residents of the facility wanted. She said this largely involved those in-house preferring to stay at the facility if possible in the event of any cases. 

When the first case hit, the facility revisited those goals of care and largely found that most of the respondents wanted to remain at the location. 

“So that is really what precipitated us trying to maintain and contain the illness in-house,” DiMario said. “That was really the crux of all of our decisions, was trying to honor patients’ wishes throughout this outbreak. And it started with establishing goals of care.”

Birchwood initially tried to establish an isolated COVID section in the facility, which later proved difficult when it came to patients who resided in the certified dementia unit. 

“To bring memory-care patients off a secured unit onto a different unit with unfamiliar caregivers and an unfamiliar surrounding in the middle of a pandemic obviously wasn’t ideal,” DiMario said. “But in our attempts to contain, at that point, that was the decision that we made.” 

Individuals were isolated, but a second round of mass testing revealed that the virus made its way onto each unit, DiMario said. Constant relocation felt impractical and unsafe. When it came to the certified dementia unit, memory-care patients could pose wander risks or may be unable to grasp specific concepts like isolation, face masks and hand hygiene. 

The facility also had to manage its response to the outbreak in the wake of more than 20 staff members testing positive in early April. 

UVMMC and Birchwood collaborate during COVID-19 outbreak

The University of Vermont Medical Center temporarily offered staffing assistance to Birchwood Terrace during the outbreak. 

“When the staffing assistance ended, they really also stepped up from a medical provider standpoint,” DiMario said of UVMMC, including a team of rotating physicians to provide additional support, as well as a palliative care team. 

Long-term care facilities operate with their own care models and work flows, and that differed from what UVMMC medical providers were use to, said Daniel Hudson, a nursing director at UVM Medical Center who was part of a team tasked with supporting Birchwood’s response to COVID-19 cases.

“Everybody was navigating something that they haven’t navigated before,” Hudson said.

Additionally, the inclusion of staff and contract nurses required the response team to come up with temporary ways to address infection control to avoid a surge of COVID-19 cases among staffers.

One solution was to develop a makeshift hygiene station outside the care facilities. The “clean and dirty room” ensured that staff could safely dispose or replace personal protective equipment before and after treating residents with COVID-19. 

“It became a little bit more than supporting them from a staffing standpoint,” Hudson said.

Birchwood was declared COVID-19-free on May 28. 

Look back: Coronavirus cases reported at 8 Vermont senior facilities including 7 at Burlington site

McClure Miller Respite House

Amid the initial outbreak in Chittenden County, McClure Miller Respite House in Colchester saw no cases of the coronavirus. 

As the pandemic was unfolding in Vermont, the respite house began preparing, according to Gretchen Bates, vice president of clinical operations for the UVM Health Network’s Home Health and Hospice, which oversees the hospice center.

McClure Miller staff worked with their partners and leaders at the UVM hospital, who were sharing information weekly and assisting them in watching trends and anticipating surges.

The respite house put in protocols to help staff members and clients feel safer during the pandemic, including limiting visitors, daily temperature checks and designated changing rooms for staff who may interact with those with COVID-19.

Some people receiving hospice care could have symptoms that mimic COVID-19, such as coughing and respiratory issues. In those cases, if doctors were particularly concerned that an individual was symptomatic, they would isolate that client from others while they finished conducting tests.

“I think really that collaboration is key,” Bates said. “We had an opportunity as a network to be able to understand perhaps what one institution was doing even if it wasn’t a respite house.”

Woodridge Rehabilitation and Nursing

Woodridge Rehabilitation and Nursing, affiliated with the Central Vermont Medical Center, took notice when COVID concerns ramped up around the country. The facility in Berlin started screening temperatures, providing scrubs for staff and emphasizing hand hygiene.

“Thankfully we didn’t have any positives,” said Allen Yearick, administrator and vice president of aging services. “But we were ready.” 

Examples of measures taken at the facility included training on how to properly don protective gear, shutting off access to the dining room and encouraging activities that could be done individually or in limited group sizes. 

Residents’ family members showed “perseverance and understanding” with the facility’s efforts and Woodridge started visits outdoors a few months into the pandemic.

“So at least the family members can see their loved ones,” Yearick said. 

Part of Woodridge’s success also came down to employees who took  precautions outside of work and were encouraged to communicate if they felt under the weather.

What Vermont learned

The response at the site of Burlington Health and Rehab and Birchwood Terrace was delayed due to confusion over who was responsible for overseeing the crises and providing necessary resources, according to the long-term care facility report. 

This report was written to highlight the experience of those responding to COVID-19 and to assist as an educational tool for long-term care facilities moving forward. 

“We also hope that it will highlight the importance of collaboration, as outbreaks at one facility impact people and organizations far beyond the facility’s walls,” the report stated.

While the UVM Medical Center’s Incident Command eventually oversaw crisis management at both facilities, many caregivers said that an ability to more quickly designate authority as well as an understanding of how nursing facilities operate could have improved the state’s response.

“In general, I feel most individuals have little understanding of the amount of work that occurs in a [skilled nursing facility] at any level,” stated a facility leader quoted in the report. “It is not glorious or sexy to say you work in a nursing home… There were several instances in which the facility staff were made to feel less valued/valuable than UVMMC staff, which I am certain was not the intention.”

Such findings pushed the report to recommend future collaborators remain “aware of these sensitivities” to ensure better crisis management.

The report outlined four takeaways:

  • Prepare as if you will face an outbreak.
  • Designate an individual to lead the response.
  • Advanced care planning with residents steers the entire ship.
  • Decide what you can and can’t do to honor your residents’ wishes and act accordingly.

“I think we can all appreciate that the position we were in in March and April, while we were dealing with two large, nursing home-based outbreaks, is different than the position that we’re in now,” said William Fritch, a nurse programming coordinator in the state’s Health Department. 

Fritch gave a nod to steps taken by the state early in the pandemic, like halting visitations to long-term care facilities and having public health nurses follow up with facilities to proactively run through infection control assessments. The state provided webinars for staff in long-term care facilities. At the individual level, the state checked in on the specific needs of facilities, from staffing to personal protective equipment. 

“There has been a tremendous partnership across state government in this response,” said Monica Hutt, commissioner of the Department of Disabilities, Aging and Independent Living, which oversees the long-term care facilities. 

Levine, Vermont’s health commissioner, reiterated points made by Fritch and Hutt, emphasizing Vermont’s innovation in its response to COVID-19 and the significance of collaboration. 

“In the beginning of a pandemic, you have a bit of a playbook,” Levine said. “But you don’t have, by any means, a complete playbook.” 

Personal pandemic: Short stories of Vermonters facing life in the coronavirus era

Timeline: Coronavirus in Vermont 

March 7: First reported case of COVID-19 occurred in Vermont.

March 19: First reported deaths of COVID-19 announced by Gov. Phil Scott in a press conference. One of the two reported deaths was a 95-year-old female resident of the Burlington Health and Rehab long-term care facility.

March 21: Vermont Health Department reports seven cases at Burlington Health and Rehab. Residents and staff at facility given priority testing, daily temperature checks.

March 23: Health Commissioner Mark Levine reports three additional deaths at Burlington Health and Rehab, bringing the total fatalities at the facility to four. At the time, 14 residents and one staff member tested positive for COVID-19.

April 3: Nursing facility Birchwood Terrace Rehab and Healthcare announces staff-and resident-wide testing for COVID-19. At the time, 12 residents of the 144-bed facility and one staff member have tested positive for the virus.

Dr. Mark Pitcher, medical director of Burlington Health and Rehab, speaks at a Joint Committee on Rules meeting, discussing what happened at the facility.

April 6: Birchwood Terrace reports 22 staff members tested positive for COVID-19.  UVMMC sends additional staff support while the Health Department is arranges more tests.

April 8: Birchwood Terrace reports eight more residents tested positive for COVID-19. That is in addition to the 29 residents and 22 staff members (of 130) who had already tested positive.

April 20: Birchwood Terrace reports that many of its residents who contracted COVID-19 are showing hopeful progress. At the same time, the residents who died made up nine of the 38 COVID-19-related deaths that occurred statewide. 49 residents tested positive for COVID-19, at the time, with 23 of those residents “graduated” off transmission-based precautions, seven discharged to the hospital and 10 residents continue to receive care under transmission-based precautions (4 planned to “graduate” this week). 26 staff tested positive for COVID-19.

April 28: Birchwood Terrace updated numbers for cases and deaths related to COVID-19. At the time, the facility cared for 32 residents who have tested positive and monitored 18 residents. 57 residents tested positive for COVID-19, while 16 residents have died.

June 19: Vermont reopens long-term care facilities, with limited visitation, to the public. These facilities can allow two guests per resident per day, so long as those visits occur outside and follow social distancing protocols. 

Contact Maleeha Syed at [email protected] or 802-495-6595. Follow her on Twitter @MaleehaSyed89. 

Contact Ethan Bakuli at (802) 556-1804 or [email protected] Follow him on Twitter @BakuliEthan.

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