Practice Title: Congregate Settings COVID Response Team, San Antonio, TX

Department: San Antonio Metropolitan Health District
Size: Large (Population of 500,000+ people)
State: Texas

Summary of Practice: 

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.