The San Antonio Metropolitan Health District serves the second-largest metropolis in Texas, with 1.96 million people in San Antonio and Bexar County. The population is majority Hispanic (60%) and 7% African-American. In 2017, San Antonio ranked second for poverty among the top 25 largest U.S. metro areas, with significant differences in income by race and ethnicity. The community has 68 nursing homes and 162 licensed assisted living facilities with approximately 8,156 residents and 16,585 staff.

At the end of March 2020, San Antonio experienced its first and most deadly nursing home outbreak to date, with 18 residents and 1 staffer dying of COVID-19. The facility was flagged by Emergency Medical Services (EMS) through the Incident Command System on March 29, after three EMS transports and one death overnight. In response, within two days: 1) a public health nurse conducted a site visit, provided infection control guidance and facilitated PPE transfers from the Strategic National Stockpile (SNS), 2) EMS staff collected COVID tests on all staff and residents, with next-day results from the public health laboratory, and 3) the local health authority closed the facility to admissions, required an outbreak notification to family, residents and staff, prohibited sharing staff with other facilities, and provided daily technical assistance for several weeks.

This model was repeated in more than 250 other long-term care outbreaks (defined as a new COVID infection in any staffer or resident). Over time, facilities became able to test for COVID on their own, and duties of the Congregate Settings COVID-19 Response Team grew to encompass shelters and schools. We now have a 9-person team funded by the CARES Act, consisting of epidemiologists, public health nurses, physicians and an administrative assistant. Each long-term care facility is assigned a nurse and an epidemiologist. Facilities with a positive resident are closed to admission and should test residents and staff every 3-7 days until there are no new positives. Nursing homes are listed on the health department website as either open or closed to admission. The team created checklists for facilities seeking to re-open to admissions and for dialysis centers seeking to prevent transmissions. An email newsletter informs facilities about best practices, guidance updates and COVID vaccine plans. Regular team meetings include state regulators, laboratory staff and an EMS liaison.

The team's goal is to prevent and mitigate COVID transmission and deaths, and initial results demonstrate the public health impact of our approach: Bexar County's nursing home COVID fatality rate of 16% is lower than state’s (21%) and the nation’s (26%) as of November 2020.

In addition, the team decreased health inequities in PPE supply and testing capacity. In April, PPE from the SNS was shared primarily with hospitals, even as some nursing homes had only cloth masks. The team successfully advocated for prioritization of COVID-positive nursing homes. The team also facilitated specimen collection and testing for congregate settings with fewer resources, such as foster care agencies, shelters and residential rehabilitation centers.

Multidisclipinary "strike forces" have been successfully used for public health emergencies such as infectious disease outbreaks and natural disasters [1]. However, the scale and duration of the COVID-19 response has required adaptation of the typical rapid response model to create a sustainable, ongoing public health infrastructure to support nursing homes, their elderly residents and low-wage staff [2,3], who are disproportionately African-American [2,3].

Because long-term care facilities are regulated by the state and not the local health department, our initiative was created from scratch during the pandemic. Even before the Southeast nursing home outbreak, our jurisdiction was on heightened alert because of a well publicized long-term care outbreak in Kirkland, WA. Our local emergency management partner had only a partial list of contacts at long-term care facilities, based on hurricane preparedness exercises. Through collaboration with fire code inspectors who routinely visit nursing homes, the health authority sent information on COVID precautions to every nursing home in the county, hand-delivered by fire department staff, on March 3, 2020, four weeks before the Southeast Nursing outbreak. Over time, our initiative ramped up to include:

• Dedicated epidemiology staff. This group makes daily contact with long-term care facilities during outbreaks, and manages admission closures and re-openings. A checklist for re-opening is used to promote uniform recommendations.
• Academic partners. Teams led by local medical and nursing schools--and consisting of a local public health nurse, state regulators, an academic clinician and an ethicist--visited 55 nursing homes with low star ratings from the Center for Medicaid and Medicare Services (CMS) in April-May 2020. They conducted an environmental scan using a checklist they created. Findings included inadequate personal protective equipment (PPE), with five facilities having only cloth masks; varying degrees of infection prevention; and lack of updated advance directives. This initiative helped build our contact list and focus our guidance and advocacy. 
• Public health nurses and physicians. Three public health nurses conduct site visits and provide technical assistance and specimen collection as needed. Two physicians provide oversight of the response team and additional guidance to facilities as needed, individually and through an email newsletter.
• Public health laboratory. San Antonio's BSL-3 lab provides 24-hour turnaround of COVID tests at no cost to facilities that are unable to quickly test on their own. Over time, more long-term care facilities have contracted with their own laboratories. However many shelters, foster homes and rehabilitation centers remain too underresourced to test on their own, and local public health serves as a safety net.
• Emergency medical services. San Antonio's innovative fire department has an EMS team that provides wellness checks in the community. (Started in 2014, the team delivers mobile health assessments to individuals who are high healthcare utilizers, homeless, in hospice or who recently overdosed on opioids, among others.) This team conducted specimen collection for universal testing at dozens of long-term care facilities early in the pandemic, helping to detect and mitigate infections during our second surge. They remain collaborators for specimen collection at underresourced facilities. They also notify the team if a facility has a large number of EMS transfers, a potential early warning sign.
• Regional hospital coordinating council. As the depot for the Strategic National Stockpile, this council provides PPE to long-term care facilities. Through advocacy by our team, the council elevated nursing homes from Tier 2 to Tier 1 priority for distribution.
• State regulators. State regulators routinely join our team meetings; this ensures consistent state and local guidance. During high-profile outbreaks, state regulators and the Local Health Authority sometimes jointly visit facilities, reflecting a high level of mutual trust and coordination.
• Data and informatics. This part of the team generates a weekly data summary for policymakers, and shares on the health department website whether facilities are open or closed to admissions under Local Health Authority orders.

While an evidence base is still scarce for nursing home response teams, other jurisdictions also have adopted this model, including multiple states ("A Novel Way to Combat Covid-19 in Nursing Homes: Strike Teams," The New York Times, Aug 18, 2020) and Harris County (Houston, TX). San Antonio's initiative stands out for its robustness, and for being in the vanguard of what would later become state or national policies. Examples include:

• Two weeks before Texas announced universal testing of nursing homes in May 2020, San Antonio was facilitating universal testing at facilities. 
• In early April 2020, San Antonio required nursing homes to routinely notify all staff and family members about outbreaks. In May 2020, CMS made the practice mandatory nationwide.
• Two months before the state of Texas started posting names of nursing homes with outbreaks (July 2020), San Antonio's health department already did so on its own website.

Two key infection mitigation practices that are stricter in San Antonio than at state and national levels are: 1) Prohibiting shared staff among long-term care or dialysis facilities, through a Mayor's order, and 2) Closure to new admissions of facilities with a positive resident, until at least 14 days and two sets of negative universal tests of residents and staff. (Readmissions may be taken so long as they can be quarantined for 14 days with dedicated staff in full PPE).

The team's goal is to prevent and mitigate COVID transmission and deaths, and initial results demonstrate the public health impact of our approach: Bexar County's nursing home COVID fatality rate of 16% is lower than state’s (21%) and the nation’s (at least 26%) as of November 2020.

[1]  Greiner AL, Stehling-Ariza T, Bugli D et al. (2020.) Challenges in Public Health Rapid Response Team Management. Health Security 18 (S1): S8-S13.

[2] True S, Cubanski J, Garfield R et al. (2020.) COVID-19 and Workers at Risk: Examining the Long-Term Care Workforce. Kaiser Family Foundation. Accessed Dec. 5, 2020. https://www.kff.org/coronavirus-covid-19/issue-brief/covid-19-and-workers-at-risk-examining-the-long-term-care-workforce/.

[3]  PHI National. (2019.) U.S. Nursing Assistants Employed in Nursing Homes: Key Facts. Accessed Dec. 5, 2020. https://phinational.org/wp-content/uploads/2019/08/US-Nursing-Assistants-2019-PHI.pdf.

Our goal is to minimize illness and death from COVID at nursing homes, and key steps are:

Assigning a public health nurse to each facility, who visits it pro-actively and during outbreaks, using a standardized checklist

Assigning an epidemiologist to each facility

Providing detailed recommendations, including through a standard Local Health Authority letter, to every facility with an outbreak

Assisting facilities with testing during outbreaks as needed, and requiring two sets of negative universal tests before a facility with a positive resident can re-open to admissions

Facilities provide input on planning and implementation during their frequent conversations with us—if we propose an idea that is not practical, they will let us know. Input from other partners is sought at large team meetings three times a week. These team meetings are attended by a state regulatory liaison, EMS liaison, laboratory staff, epidemiologists, nurses, physicians and administrative staff. As needed, a regional hospital advisory council liaison attends. As new national or state guidance comes out, or infection rates rise or fall, changes in planning and implementation are discussed among the whole group.

An email update helps foster collaboration with facilities. Whenever a public health nurse visits a facility, she checks to make sure the facility contact is receiving the newsletter.

An unexpected benefit of the pandemic has been the new partnerships with facility administrators and directors of nursing. Long-term facilities represent a large sector of the healthcare industry that we did not reach before. We were able to leverage our existing relationship with the regional hospital advisory council to address disparities in PPE access, and use our own laboratory to address disparities in access to testing.

In addition, we now have stronger connections with emergency medical services and the state health department, allowing a synergistic and unified response to our community's nursing home outbreaks.

Our initiative evolved along with the pandemic. During the first surge in April, the team had three core members, and our response was more reactive than proactive. More than 77 facilities with outbreaks were advised through frequent calls, a public health nurse visit and a standardized Health Authority letter. A large part of the workload involved facilitating access to universal testing, tracking down test results and providing results to facilities, along with the basic work of completing surveillance reports.

Starting with the second surge in July, staffing increased to 9 through CARES Act funding. Checklists and facility assignments were implemented, and a standard operating procedure was written. Checklists now exist for public health nurses, with items to address during a site visit; for facilities, with initial steps to take during an outbreak; and for epidemiologists, for approving a facility to re-open to admissions after an outbreak. In addition to a general guidance letter provided to all facilities with an outbreak (which is updated about once a month with new resources), guidance is available on the health department website for dialysis facilities specifically, and for clinicians providing in-person care. With a streamlined workload, public health nurses are able to make proactive visits to their assigned facilities regularly, regardless of whether an outbreak exists. The group can provide assistance to a wider variety of congregate settings. To date, the team has advised all 68 nursing homes at least once, and provided technical assistance more than 4,680 times to nursing homes, assisted living facilities, schools, shelters and group homes.

By facilitating COVID testing and reducing cases in long-term care facilities, which are staffed with low-paid workers from marginalized communities--and which contain the population most likely to die from COVID if infected--this team's work reduces inequitable health outcomes. Additionally, the team's insights provide the basis for advocacy efforts by local health department leaders: for paid sick leave (currently an unenforceable ordinance in San Antonio due to ongoing litigation), for prioritizing vaccine administration in long-term care facilities, and for PPE distribution to long-term care facilities. 

An interim After Action Report is in process for the congregate settings team's work. Lessons learned include the value of communication among team members, such as with team huddles three times a week, and the benefits of assigned facilities, checklists and standardized procedures. These lessons are likely to be sustained and incorporated into future Epidemiology Program practices post-pandemic, as are partnerships with external partners such as emergency medical services and the state health department.