Phenelle Segal, RN, CIC, chose to give up a 30-year nursing career in acute care to address a long-ignored need in long-term care: Teaching nursing homes about the prevention and control of healthcare-associated infections (HAIs). When she began working with Philadelphia nursing homes in 2005, very few in the long-term care (LTC) setting realized the impact that infection control might have on their businesses.
In 2007, everything changed: Pennsylvania’s then-Gov. Edward Rendell introduced state legislation for mandatory reporting of HAIs, which included the state’s nursing homes—the nation’s first such requirement. The regulatory impetus started her phone ringing. Segal put her experience to work within the Pennsylvania state health system, training nurses and administrators in the importance of infection control specifically within the LTC environments.
“It was very tough at first,” Segal remembers. “Nursing homes [in Pennsylvania] had to increase their resources, they had to hire people to do the work, and update their software to use the online reporting systems. There was a tremendous outcry at first. But now nursing homes have come back and said, ‘We’re so glad we were forced to do this.’”
She developed programs for LTC and acute care for mandatory reporting of HAIs, and provided education for all 721 nursing homes in the state, including follow-up visits and the development of assessment tools. Her work in Pennsylvania gradually became a hallmark blueprint for LTC facilities in other states. “We used the McGeer’s Criteria and our own, giving us a set of criteria that’s streamlined for nursing homes,” Segal says. “The beautiful part is, it’s all standardized. You can speak to these problems so much better when you have reporting at a consistent, standardized level.”
By 2012, the Centers for Medicare & Medicaid Services (CMS) released a new national action plan to reduce preventable HAIs, which Segal helped to create. Although phase 1 of the plan starts with acute care, long-term care (phase 3) is clearly recognized as a partner in the process. In April 2013, the Medicare Payment Advisory Commission (MedPAC) and CMS recommended that skilled nursing facilities share in the penalties for preventable 30-hospital readmissions, a tide that Segal saw coming. “CMS is now becoming as involved in long-term care as they are in acute care.”
Segal’s ability to see the bigger picture for long-term care—and to speak equally well among LTC administrators, nurses and housekeeping staff—has made her a craved resource for organizations wishing to get ahead of the regulatory curve. “The acuity levels are so much higher in long-term care today than they ever were,” she says. “At the same time, we have this horrendous animal called a ‘multi-drug resistant organism’ that is getting worse by the day. With all those factors in place, infection prevention has become more critical than it ever was. Long-term care is heavily regulated, but despite that, most nursing homes still don’t have enough push to have specific staff dedicated to infection control, like we have in acute care. And I don’t believe that all LTC administrators grasp that yet.”
Antimicrobial stewardship must be a team effort and should be embraced as a business initiative, she adds. “It’s not just the nurses or the DON. It’s about housekeeping and dietary. It’s occupational and physical therapy. You must involve the entire facility, regardless of what they get paid, because that’s what going to get you to compliance.”
Segal says she worries about the number of LTC facilities that are not yet investing in dedicated staff for infection control and prevention. “You can no longer use your DON, who’s also doing the education and the wound care and [managing] the ADONs. You can’t just hand over that infection control multitasking to the nurse managers. That may have worked 10 years ago, but it doesn’t work now. To me, that’s the biggest challenge.”