Here, Florida is indeed quite vulnerable. The state has roughly 350,000 residents and staff at more than 4,000 long-term-care facilities.
The state took precautions with its seniors generally. “We advised, before there was even mitigation,” DeSantis points out, “if you’re 65 and older, stay home as much as possible and avoid crowds. And that was just something that made sense.” The state talked to senior communities like The Villages about what they were doing to mitigate risk, and they took common-sense measures, such as stopping big indoor gatherings.
But the nursing homes represented a different level of risk. “It was clear to me,” says Mary Mayhew, “that there were much higher standards related to infection control being outlined by the federal CDC that well exceeded what our nursing homes traditionally have been expected to adhere to. So we never had false expectations.”
Inspectors and assessment teams visited nursing homes. The state homed in on facilities where, Mayhew says, “we had historically cited around infection control. We used that to prioritize our visits to those facilities, understanding that the guidance from CDC was changing frequently. So our initial focus was to be an effective resource education to provide guidance to these facilities to make sure they understood how to request personal protective equipment from the state.”
Florida, DeSantis notes, “required all staff and any worker that entered to be screened for COVID illness, temperature checks. Anybody that’s symptomatic would just simply not be allowed to go in.” And it required staff to wear PPE. “We put our money where our mouth is,” he continues. “We recognized that a lot of these facilities were just not prepared to deal with something like this. So we ended up sending a total of 10 million masks just to our long-term-care facilities, a million gloves, half a million face shields.”
Florida fortified the hospitals with PPE, too, but DeSantis realized that it wouldn’t do the hospitals any good if infection in the nursing homes ran out of control : “If I can send PPE to the nursing homes, and they can prevent an outbreak there, that’s going to do more to lower the burden on hospitals than me just sending them another 500,000 N95 masks.”
It’s impossible to overstate the importance of this insight, and how much it drove Florida’s approach, counter to the policies of New York and other states. (“I don’t want to cast aspersions on others, but it is incredible to me, it’s shocking,” says the Florida health official, “that Governor Cuomo [and others] are able to kind of just avoid real questions about their policies early on to actually send individuals into the nursing home, which is completely counter to the real data.”)
Mary Mayhew had daily calls with the hospitals, with people involved in discharge planning on the line. “Every day on these calls,” she says, “I would hear the same comments and questions around, we need to get these individuals returned back to the nursing home. We drew a hard line early on. I said repeatedly to the hospital, to the CEOs, to the discharge planners, to the chief medical officers, ‘I understand that for 20 years it’s been ingrained, especially through Medicare reimbursement policy, to get individuals in and out. That is not our focus today. I’m not going to send anyone back to a nursing home who has the slightest risk of being positive.’”
“What we said constantly is let’s not have two cases become 20 or five become 50,” she continues. “If you don’t manage this individual as you return them back, you will have far more being transferred back to the hospital.” Early on, when tests had a slow turnaround, there was a lot of pressure to give way, but Mayhew was unmovable on the question.
At the other end of the equation at the nursing homes, the state made it clear, according to Mayhew, “if you are unable to adhere to these infection-control standards, if you are unable to safely isolate and dedicate staff to an isolation wing or unit, you need to transfer that individual to a hospital.”
As the health officials put it, succinctly, “We wanted people out, not in.”
When the state was seeing infections at nursing homes presumably caused by staff, DeSantis deployed what he calls “an expeditionary testing force,” 50 National Guard teams of four guardsmen together with Department of Health personnel that tested staff and residents.
Most facilities haven’t had confirmed cases. “But the ones that have,” he says, “the majority of them have had between one and five infections. So the infections are identified, but then, you’re isolating either the individual or the small cluster before you have an outbreak.”
The state has just deployed a mobile testing lab in an RV that has a rapid test with results in an hour or two. It goes to a community and the staff goes to different long-term-care facilities. “If you’re talking about an asymptomatic carrier, if you can identify that person instead of waiting 48 hours for lab results to come back, I mean, that could be the difference between saving a lot of infections,” according to DeSantis.
The state has also started a sentinel surveillance program for long-term-care facilities, routinely taking representative samples to monitor for flare-ups.
Finally, it has established several COVID-19-only nursing homes, with a couple more in the pipeline. The idea, again, is to get COVID-19-positive residents out of the regular nursing homes to the maximum extent possible.
