Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID- 19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active. Pragmatic Innovations in Post-Acute and Long-Term Care Medicine Feasible new, practical products or approaches intended to improve outcomes or processes in post-acute or long-term care How a Barcelona Post-Acute Facility became a Referral Center for Comprehensive Management of Subacute Patients With COVID-19 Marco Inzitari MD, PhD a, b, *, Cristina Udina MD a, b, Oscar Len MD c, Joan Ars PT a, b, Cristina Arnal MD a, b, Hugo Badani MD a, Vanessa Davey RN, PhD a, Ester Risco RN, PhD a, Pere Ayats OT a, Ana M. de Andrés Pharm, PhD a, Cristina Mayordomo MD a, Francisco J. Ros MD d, Alessandro Morandi MD, MPH a, e, Matteo Cesari MD, PhD f a Research Group on Aging, Frailty and Care Transitions in Barcelona, Parc Sanitari Pere Virgili and Vall d’Hebron Research Institute (VHIR), Barcelona, Spain b Universitat Autonoma de Barcelona, Barcelona, Spain c Infectious Diseases Department, Hospital Universitari Vall d’Hebron, Barcelona, Spain d Medical Oncology Department, Vall d’Hebron University Hospital and, Vall d’Hebron Institute of Oncology (VHIO), Barcelona, Spain e Ospedale Le Ancelle, Fondazione Teresa Camplani, Cremona, Italy f Università Statale and Policlinico Maggiore, Milan, Italy a b s t r a c t The COVID-19 pandemic’s greatest impact is among older adults. Management of the situation requires a systemic response, and post-acute care (PAC) can provide an adequate mix of active treatment, management of associated geriatric syndromes and palliative care, both in the acute phase, and in posteCOVID- 19 recovery. In the region of Catalonia, Spain, selected PAC centers have become sites to treat older patients with COVID-19. Referrals come from the emergency department or COVID-19 wards of the acute reference hospitals, nursing homes, or private homes. We critically review the actions taken by Parc Sanitari Pere Virgili, a PAC facility in Barcelona, to manage the pandemic, including its administration, health care, communication, psychological support, and ethical frameworks. We believe that the strategies we used and the lessons we learned can be useful for other sites and countries where similar adaptation of existing facilities may be implemented. Ó 2020 AMDA e The Society for Post-Acute and Long-Term Care Medicine. Keywords: COVID-19, post-acute care, older adults, geriatrics, geriatric syndromes, palliative care Problem/Significance Innovation Older adults are most affected by the COVID-19 pandemic.1e4 The pandemic requires a systemic response. Combined with the Spain, with an exceptionally large aging population, has had one of intensive resources of acute care, and the “gate keeping” role of pri- the worst outbreaks worldwide.5 The management of COVID-19 in mary care, geriatric post-acute care (PAC) can be a key resource. older persons presents specific challenges: 1. PAC offers an alternative to conventional hospitalization,  Its presentation can be atypical,6 and treatment options com- reducing burden on acute care. plex due to multimorbidity, polypharmacy, and drug 2. It can provide active treatment for COVID-19, rehabilitation and interactions.7 palliative care, flexibly prioritizing goals depending on the in-  Delirium and immobility are highly prevalent8,9 and difficult to dividual “situational diagnosis”,14 providing expertise on manage due to patients’ isolation, particularly in people with complex needs and geriatric management. dementia.10,11 3. It may better isolate frail persons.15  Overwhelmed health care systems may reduce priority of older adults based on age alone; conversely, if advanced care plan- The region of Catalonia, Spain, has a widespread network of ning is not available, overtreatment is a risk.12 PAC, including inpatient care, outpatient care, and hospital-at-  Social resources in the community can be limited, and home, providing integrated care for older adults with complex discharge to domestic and nursing homes13 difficult. needs. Inpatient services, mainly managed by specialists in geriat- rics, are similar to high-performing skilled nursing facilities in the United States, with the constant presence of a physician.16 They usually combine care for older adults with acute exacerbations of chronic conditions,17 need for geriatric rehabilitation,18,19 dementia * Address correspondence to Marco Inzitari, MD, PhD, Parc Sanitari Pere Virgili, c and palliative care,20 with goals to avoid admission, if possible, and Eteve Terradas 30, ed Montseny, 08023 Barcelona, Spain. to discharge only once appropriate. E-mail address: minzitari@perevirgili.cat (M. Inzitari). https://doi.org/10.1016/j.jamda.2020.06.015 1525-8610/Ó 2020 AMDA e The Society for Post-Acute and Long-Term Care Medicine. M. Inzitari et al. / JAMDA 21 (2020) 954e957 955 We describe the actions implemented in a large, public, PAC facility day hospital), while hospital-at-home remained active in Barcelona, assigned as a COVID-19 facility for older adults. Our providing care and rehabilitation for patients discharged from experience and challenges may represent a benchmark for other the hospitals and attending patients with COVID-19 in nursing countries. homes; (5) allocated COVID-19epositive wards and noneCOVID-19 wards, each with designated staff and adequate Implementation and Evaluation personal protection equipment (PPE), with restricted access to common spaces and rehabilitation performed in the patient’s Parc Sanitari Pere Virgili (PSPV) is one of the largest PAC facilities in room. Catalonia, with 350 beds plus outpatient resources (rehabilitation day  Staff measures included continuous training on PPE and per- hospital and hospital-at-home teams), dedicated to acute care of sonal protection (patients were required to wear a facial mask decompensated chronic multimorbid patients, geriatric rehabilitation, during staff activities), and “clean zones” for rest periods. Of 50 palliative care, and comprehensive care for dementia. Staffing is physicians providing care during the first month, 9 were multiprofessional, including 24-hour medical care (Table 1). The fa- infected, none from COVID-19 wards (3 reported contact with cility receives approximately 75% of admissions directly from the COVID-19 cases out of the hospital). emergency department (ED) or wards of 2 major acute university  Protocols for treatment, geriatric management, and palliation hospitals (Vall d’Hebron and Clinic hospitals, serving approximately (Figure 1) hinged on initial brief Comprehensive Geriatric 900.000 inhabitants), and 25% from primary care. Assessment22 as a basis to rate the Clinical Frailty Scale,23 a PSPV was adapted to admit acutely ill patients in response to the rapid and visual prognostic tool. This helped to establish pandemic. Medical staffing was expanded by creating mixed teams advanced care planning with reasonable therapeutic effort combining geriatricians from PSPV with other specialists (infectious for each patient.24e26 Acute care treatment of COVID-19 was diseases, oncology) from Vall d’Hebron University Hospital. Nursing balanced with palliative and geriatric care, mainly oriented staff ratios were increased through internal reorganization (Table 1). toward preventing and managing delirium using non- Final capacity for patients with COVID-19 was 167 beds of 350. pharmacological interventions (eg, reorientation, presenta- Referral pathways (Figure 1) included direct admissions from ED or tion of staff names on the PPE, early mobilization) or COVID-19 acute wards, or from private homes or nursing homes. From adapted pharmacological treatment. Physical therapy and March 10 to May 28, 2020, we attended 410 patients with COVID-19 nursing staff instigated early mobilization of clinically stable (mean age ¼ 81.8 years, range 42e99, 48% older than 84 years, 55% patients. women). Referral sources were ED (23.2%, n ¼ 95), acute COVID-19  Psychological care of patients, family, caregivers, and staff antic- wards (32.9%, n ¼ 135), and nursing homes or home (11.7%, n ¼ 48); ipated potential anxiety in patients and families, and supported 32.2% (n ¼ 132) were already inpatients or very recently referred by bereavement. This was especially complex due to visiting re- the acute hospitals for other reasons when they developed symptoms. strictions and deaths within patients’ families. Health care The main actions, progressively implemented from February 27 professionals and other staff were vulnerable to stress from the (first case in Catalonia), are summarized in Table 2, and include the intense workload and personal risks.27 following:  Communication and quarantine-compliant visiting arrange- ments were accomplished through telephone/video calls be-  General coordination through a COVID-19 committee composed tween staff and family and by regular videoconferences among of members of the board of directors and clinical leaders, the multidisciplinary team, patients, and their family (aver- meeting daily until June 2020. aging 7 per person, up to May 28, 2020). Waivers for visitors to  COVID-19 transmission control: (1) fast-tracked home discharge end-of-life patients or those with severe hyperactive delirium of existing patients without suspicious symptoms, to increase were established. capacity and protect them from transmission; (2) accelerated  Promotion of post-COVID rehabilitation (Figure 1): physical screening of patients and staff through polymerase chain re- therapists initially worked to reduce immobility and subse- action (PCR) tests (naso-pharyngeal samples), even in cases of quently, provided adapted multicomponent therapeutic exer- atypical symptoms6,21; (3) instituted lockdown to external cise28 or conventional geriatric rehabilitation after COVID-19. visitors; (4) interrupted nonessential services (outpatients and Table 1 Staffing for the 350 Beds of PSPV PAC Facility Before and During the COVID-19 Pandemic Role Usual* COVID-19 Wards Physicians 1 attendee/20 patients 1 attendee and 1 resident/14 patients On-call physicians (4 PMe8 AM) 2 2 attendees and 2 residents Registered nurses 1/18 patients, half at night 1/10 patients, day and night Nursing aides 1/10 patients, half at night 1/10 patients, day and night Physical therapists (PT) and PT aides 2/40 patients Same. Early mobilization after acute symptoms improved and posteCOVID-19 rehabilitation Occupational therapists 1/88 Same. Coordination of videoconferences and posteCOVID-19 rehabilitation Speech therapists 1 Same. PosteCOVID-19 rehabilitation Social workers 1/80 Same. Switch to remote (telephone) Psychologists 3 Same. Switch to emotional support to patients, families, caregivers Clinical pharmacists 2 Same Students All the health care professions Nurse students with only a few months left before completion of their training were hired due to staff shortages Nonehealth care staff (cleaning, housekeeping, Standard Cleaning, surveillance and call center increased surveillance, call center) *The numbers presented are averages (staff/patient ratios are higher in acute care for chronic decompensated diseases and palliative care units than in the geriatric rehabilitation units). 956 M. Inzitari et al. / JAMDA 21 (2020) 954e957 Fig. 1. Overview of the older COVID-19 patient pathway in a post-acute care facility. A downloadable PDF of this form is available at www.sciencedirect.com.  Measures to ensure ethical treatment (access to care or policy for low-threshold (diagnostics were initially delayed because official visits and communication) reflected the statement of the protocols limited PCR testing to people with complete symptom- Bioethics Committee of Catalonia.29 atology or known contacts). With hindsight, we learned a few key lessons: (1) lockdown of Challenging decisions, from an ethical and pragmatic viewpoint, the institution should be immediate (we initially allowed 1 visit included restriction of visits and degree of access to patients’ rooms per day); (2) staff in noneCOVID-19 wards should adopt strict for rehabilitation. Shortage of materials and staff and constant protective measures straightaway; and (3) PCR testing must be changes of directives from the official authorities were additional Table 2 Main Actions to Respond to the COVID-19 Pandemic Within the PAC Facility Area Goal Action General Coordination and roles Constitution of a COVID-19 committee, daily meetings, definition of roles Transmission control Patients’ protection and increase capacity Fast-track discharge of existing patients able to receive care at home Early diagnosis Timely screening of all patients and staff with PCR Minimization of contacts with potential vectors Lockdown to visitors (exceptions for last days of life or severe delirium) Closure of outpatient centers and rehabilitation day hospital Care of patients with COVID-19 Organization of designated COVID-19 wards physically separated Care of patients without COVID-19 Protection of non-COVID wards: rapid PCR, lockdown of common spaces Staff Staff protection PPEs and training modules. Patients with COVID-19 wear masks during visits Reorientation of roles where usual tasks New tasks (eg, occupational therapists undertook video calls between could not be done patients and family/friends, an important therapeutic role) Patient care Holistic assessment and prognosis Situational diagnosis through short Comprehensive Geriatric Assessment (CGA) and Clinical Frailty Scale as a prognostic tool Avoidance of ageism and overtreatment Advanced care planning based on CGA þ frailty: the desirable intensity of care (scale 1e5) is reflected in the Health Electronic Records Acute care for COVID-19 Provision of reasonable acute treatment options for COVID-19 Right care for older adults Prevention and management of geriatric syndromes (delirium, immobility) Palliative care Implementation of early palliative care PosteCOVID-19 phase Rehabilitation and reablement Mobilization in the room after hyper-acute symptoms (PCRþ patients) Fast-track rehabilitation (7e10 days, resistance þ respiratory training) (PCR) Conventional geriatric rehabilitation if needed (PCR) Discharge Discharge protocols include predischarge contact with primary care Communication Internal-external communication with families Provision of clinical information and shared decision making (phone) Proactive contact between patients and caregivers (phone, video) Ethics Guide decisions Adoption of a reference ethical framework M. Inzitari et al. / JAMDA 21 (2020) 954e957 957 contextual challenges. The pandemic also offered valuable examples 12. Aronson L. Age, complexity, and crisisda prescription for progress in pandemic. N Engl J Med 2020;383:4e6. of collaborative, interdisciplinary, integrated, and creative work, 13. McMichael TM, Currie DW, Clark S, et al. Epidemiology of Covid-19 in a long- which will be pivotal for the posteCOVID-19 system. term care facility in King County, Washington. N Engl J Med 2020;382: 2005e2011. Comment 14. Amblàs-Novellas J, Espaulella J, Rexach L, et al. Frailty, severity, progression and shared decision-making: A pragmatic framework for the challenge of clinical complexity at the end of life. Eur Geriatr Med 2015;6:189e194. PAC may be reoriented to treat older patients with COVID-19 15. Grabowski DC, Joynt Maddox KE. Postacute care preparedness for COVID-19. through a comprehensive approach focusing on all levels, including JAMA 2020 Mar 25 [Epub ahead of print]. 16. Smith T, Smith T, Scott KL, Katz P. Proof of concept: Nursing home specialist in administration, health care, communication, psychological support, action. The impact of full-time physician services in post-acute care. J Am Med and ethical frameworks. Many countries have similar PAC resources Dir Assoc 2019;20:B23. but few have been adequately equipped during the pandemic,30,31 17. Inzitari M, Gual N, Roig T, et al. Geriatric screening tools to select older adults susceptible for direct transfer from the emergency department to thereby compounding the problem rather than becoming part of the subacute intermediate-care hospitalization. J Am Med Dir Assoc 2015;16: solution. Conversely, PAC, if adequately organized32 and supported, as 837e841. described here, is uniquely positioned to provide geriatric manage- 18. Pérez LM, Inzitari M, Quinn TJ, et al. Rehabilitation profiles of older adult stroke survivors admitted to intermediate care units: A multi-centre study. PLoS One ment and rehabilitation in the acute and post-acute stages to improve 2016;11:e0166304. the outcomes of older adults affected by COVID-19 and to ensure 19. Mas MÀ, Inzitari M, Sabaté S, et al. Hospital-at-home integrated care pro- value-based care irrespective of age. gramme for the management of disabling health crises in older patients: Comparison with bed-based intermediate care. Age Ageing 2017;46: 925e931. Acknowledgments 20. Gómez-Batiste X, Blay C, Martínez-Muñoz M, et al. The Catalonia WHO demonstration project of palliative care: Results at 25 years (1990e2015). We acknowledge the staff working at Parc Sanitari Pere Virgili J Pain Symptom Manage 2016;52:92e99. 21. Kimball A, Hatfield KM, Arons M, et al. Asymptomatic and presymptomatic during the COVID-19 pandemic, including health care professionals as SARS-CoV-2 infections in residents of a long-term care Skilled Nursing Facility - well as support staff and central services from this and external in- King County, Washington, March 2020. MMWR Morb Mortal Wkly Rep 2020; stitutions. Their positive and collaborative attitude will be a founda- 69:377e381. 22. Ellis G, Gardner M, Tsiachristas A, et al. Comprehensive geriatric assessment for tional basis for the posteCOVID-19 normality. older adults admitted to hospital. Cochrane Database Syst Rev; 2017:CD006211. References 23. Rockwood K, Song X, MacKnight C, et al. A global clinical measure of fitness and frailty in elderly people. CMAJ 2005;173:489e495. 24. Colprim D, Casco M, Malumbres J, et al. Management of avoidable acute 1. Bialek S, Boundy E, Bowen V, et al. Severe outcomes among patients with transfers from an intermediate care geriatric facility to acute hospitals: Coronavirus Disease 2019 (COVID-19) d United States, February 12eMarch 16, Critical aspects of an intervention protocol. Rev Esp Geriatr Gerontol 2017; 2020. MMWR Morb Mortal Wkly Rep 2020;69:343e346. 52:75e79. 2. Verity R, Okell LC, Dorigatti I, et al. Articles estimates of the severity of coro- 25. Sachs GA, Ahronheim JC, Rhymes JA, et al. Good care of dying patients: The navirus disease 2019: A model-based analysis. Lancet Infect Dis 2020;20: alternative to physician-assisted suicide and euthanasia. J Am Geriatr Soc 1995; 669e677. 43:553e562. 3. Shahid Z, Kalayanamitra R, McClafferty B, et al. COVID-19 and older adults: 26. Cesari M, Proietti M. COVID-19 in Italy: Ageism and decision making in a What we know. J Am Geriatr Soc 2020;68:926e929. pandemic. J Am Med Dir Assoc 2020;21:576e577. 4. Landi F, Barillaro C, Bellieni A, et al. The geriatrician: The frontline specialist in 27. Lima CKT, de Medeiros Carvalho PM, de Araújo Araruna Silva Lima I, et al. The the treatment of COVID-19 patients. J Am Med Dir Assoc; 2020. emotional impact of Coronavirus 2019-nCoV (new Coronavirus disease). Psy- 5. Khafaie MA, Rahim F. Cross-country comparison of case fatality rates of COVID- chiatry Res 2020;287:112915. 19/SARS-COV-2. Osong Public Heal Res Perspect 2020;11:74e80. 28. Izquierdo M, Martínez-Velilla N, Casas-Herrero A, et al. Effect of exercise 6. D’Adamo H, Yoshikawa T, Ouslander JG. Coronavirus Disease 2019 in geriatrics intervention on functional decline in very elderly patients during acute and long-term care: The ABCDs of COVID-19. J Am Geriatr Soc 2020;68:912e917. hospitalization: A randomized clinical trial. JAMA Intern Med 2019;179: 7. Morley JE, Vellas B. Editorial: COVID-19 and older adults. J Nutr Health Aging 28e36. 2020;24:364e365. 29. Consideracions Sobre La Limitació de Recursos i Decisions Clíniques En La 8. J. Holroyd-Leduc, D. Gandell, A. Miller and D. Petrov. COVID-19 in older adults Pandèmia COVID19. Available at: https://www.iborjabioetica.url.edu/sites/ atypical COVID 19 presentations in frail older adults. Available at: https://www. default/files/inline-files/Consideracions del CBC davant la Pandemia pel rgptoronto.ca/wp-content/uploads/2020/04/COVID-19-Presentations-in-Frail- COVID19- %281%29.pdf. Accessed April 9, 2020. Older-Adults-U-of-C-and-U-fo-T.pdf. Accessed June 2, 2020. 30. Scott A, Pu CT, Thompson RW, et al. Asymptomatic spread of COVID-19 in 97 9. van Seben R, Reichardt LA, Aarden JJ, et al. The course of geriatric syndromes in patients at a Skilled Nursing Facility. J Am Med Dir Assoc; 2020. acutely hospitalized older adults: The Hospital-ADL Study. J Am Med Dir Assoc 31. Arons MM, Hatfield SC, Reddy A, et al. Presymptomatic SARS-CoV-2 infections 2019;20:152e158.e2. and transmission in a Skilled Nursing Facility. N Engl J Med 2020;382: 10. Wang H, Li T, Barbarino P, et al. Dementia care during COVID-19. Lancet 2020; 2081e2090. 6736:19e20. 32. Lester PE, Holahan T, Sisking D, Healy E. Policy recommendations regarding 11. Gual N, Morandi A, Pérez LM, et al. Risk factors and outcomes of delirium in skilled nursing facility management of Coronavirus 19 (COVID-19): lessons older patients admitted to postacute care with and without dementia. Dement from New York State. J Am Med Dir Assoc 2020;21:888e892. Geriatr Cogn Disord 2018;45:121e129. The pragmatic innovation described in this article may need to be modified for use by others; in addition, strong evidence does not yet exist regarding efficacy or effectiveness. Therefore, successful implementation and outcomes cannot be assured. When necessary, administrative and legal review conducted with due diligence may be appropriate before implementing a pragmatic innovation.