SARS-CoV-2 and Wisconsin Nursing Homes: Temporal Dynamics During the COVID-19 Pandemic

ObjectivesEvidence suggests that quality, location, and staffing levels may be associated with COVID-19 incidence in nursing homes. However, it is unknown if these relationships remain constant over time. We describe incidence rates of COVID-19 across Wisconsin nursing homes while examining factors associated with their trajectory during 5 months of the pandemic.DesignRetrospective cohort study.Setting/ParticipantsWisconsin nursing homes.MethodsPublicly available data from June 1, 2020, to October 31, 2020, were obtained. These included facility size, staffing, 5-star Medicare rating score, and components. Nursing home characteristics were compared using Pearson chi-square and Kruskal-Wallis tests. Multiple linear regressions were used to evaluate the effect of rurality on COVID-19.ResultsThere were a total of 2459 COVID-19 cases across 246 Wisconsin nursing homes. Number of beds (P < .001), average count of residents per day (P < .001), and governmental ownership (P = .014) were associated with a higher number of COVID-19 cases. Temporal analysis showed that the highest incidence rates of COVID-19 were observed in October 2020 (30.33 cases per 10,000 nursing home occupied-bed days, respectively). Urban nursing homes experienced higher incidence rates until September 2020; then incidence rates among rural nursing homes surged. In the first half of the study period, nursing homes with lower-quality scores (1-3 stars) had higher COVID-19 incidence rates. However, since August 2020, incidence was highest among nursing homes with higher-quality scores (4 or 5 stars). Multivariate analysis indicated that over time rural location was associated with increased incidence of COVID-19 (β = 0.05, P = .03).Conclusions and ImplicationsHigher COVID-19 incidence rates were first observed in large, urban nursing homes with low-quality rating. By October 2020, the disease had spread to rural and smaller nursing homes and those with higher-quality ratings, suggesting that community transmission of SARS-CoV-2 may have propelled its spread.     

Dilemmas With Restrictive Visiting Policies in Dutch Nursing Homes During the COVID-19 Pandemic: A Qualitative Analysis of an Open-Ended Questionnaire With Elderly Care Physicians

ObjectivesTo mitigate the spread of COVID-19, a nationwide restriction for all visitors of residents of long-term care facilities including nursing homes (NHs) was established in the Netherlands. The aim of this study was an exploration of dilemmas experienced by elderly care physicians (ECPs) as a result of the COVID-19 driven restrictive visiting policy.Setting and ParticipantsECPs working in Dutch NHs.MethodsA qualitative exploratory study was performed using an open-ended questionnaire. A thematic analysis was applied. Data were collected between April 17 and May 10, 2020.ResultsSeventy-six ECPs answered the questionnaire describing a total of 114 cases in which they experienced a dilemma. Thematic analysis revealed 4 major themes: (1) The need for balancing safety for all through infection prevention measures versus quality of life of the individual residents and their loved ones; (2) The challenge of assessing the dying phase and how the allowed exception to the strict visitor restriction in the dying phase could be implemented; (3) The profound emotional impact on ECPs; (4) Many alternatives for visits highlight the wish to compensate for the absence of face-to-face contact opportunities. Many alternatives for visits highlight the wish to compensate for the absence of face-to-face opportunities but given the diversity of NH residents, alternatives were often only suitable for some of them.Conclusions and ImplicationsECPs reported that the restrictive visitor policy deeply impacts NHs residents, their loved ones, and care professionals. The dilemmas encountered as a result of the policy highlight the wish by ECPs to offer solutions tailored to the individual residents. We identified an overview of aspects to consider when drafting future visiting policies for NHs during the COVID-19 pandemic.     

Factors Associated With the Quality of Life of Nursing Home Residents During the COVID-19 Pandemic: A Cross-Sectional Study

ObjectivesQuality of life (QoL) of nursing home (NH) residents is critical, yet understudied, particularly during the COVID-19 pandemic. Our objective was to examine whether COVID-19 outbreaks, lack of access to geriatric professionals, and care aide burnout were associated with NH residents' QoL.DesignCross-sectional study (July to December 2021).Setting and ParticipantsWe purposefully selected 9 NHs in Alberta, Canada, based on their COVID-19 exposure (no or minor/short outbreaks vs repeated or extensive outbreaks). We included data for 689 residents from 18 care units.MethodsWe used the DEMQOL-CH to assess resident QoL through video-based care aide interviews. Independent variables included a COVID-19 outbreak in the NH in the past 2 weeks (health authority records), care unit-levels of care aide burnout (9-item short-form Maslach Burnout Inventory), and resident access to geriatric professionals (validated facility survey). We ran mixed-effects regression models, adjusted for facility and care unit (validated surveys), and resident covariates (Resident Assessment Instrument–Minimum Data Set 2.0).ResultsRecent COVID-19 outbreaks (β = 0.189; 95% CI: 0.058–0.320), higher proportions of emotionally exhausted care aides on a care unit (β = 0.681; 95% CI: 0.246–1.115), and lack of access to geriatric professionals (β = 0.216; 95% CI: 0.003–0.428) were significantly associated with poorer resident QoL.Conclusions and ImplicationsPolicies aimed at reducing infection outbreaks, better supporting staff, and increasing access to specialist providers may help to mitigate how COVID-19 has negatively affected NH resident QoL.     

Front-line Nursing Home Staff Experiences During the COVID-19 Pandemic

ObjectiveThe Coronavirus disease 2019 (COVID-19) pandemic is an unprecedented challenge for nursing homes, where staff have faced rapidly evolving circumstances to care for a vulnerable resident population. Our objective was to document the experiences of these front-line health care professionals during the pandemic.DesignElectronic survey of long-term care staff. This report summarizes qualitative data from open-ended questions for the subset of respondents working in nursing homes.Setting and ParticipantsA total of 152 nursing home staff from 32 states, including direct-care staff and administrators.MethodsFrom May 11 through June 4, 2020, we used social media and professional networks to disseminate an electronic survey with closed- and open-ended questions to a convenience sample of long-term care staff. Four investigators identified themes from qualitative responses for staff working in nursing homes.ResultsRespondents described ongoing constraints on testing and continued reliance on crisis standards for extended use and reuse of personal protective equipment. Administrators discussed the burden of tracking and implementing sometimes confusing or contradictory guidance from numerous agencies. Direct-care staff expressed fears of infecting themselves and their families, and expressed sincere empathy and concern for their residents. They described experiencing burnout due to increased workloads, staffing shortages, and the emotional burden of caring for residents facing significant isolation, illness, and death. Respondents cited the presence or lack of organizational communication and teamwork as important factors influencing their ability to work under challenging circumstances. They also described the demoralizing impact of negative media coverage of nursing homes, contrasting this with the heroic public recognition given to hospital staff.Conclusions and ImplicationsNursing home staff described working under complex and stressful circumstances during the COVID-19 pandemic. These challenges have added significant burden to an already strained and vulnerable workforce and are likely to contribute to increased burnout, turnover, and staff shortages in the long term.     

Allowing Visitors Back in the Nursing Home During the COVID-19 Crisis: A Dutch National Study Into First Experiences and Impact on Well-Being

ObjectivesTo prevent and control COVID-19 infections, nursing homes across the world have taken very restrictive measures, including a ban for visitors. These restrictive measures have an enormous impact on residents' well-being and pose dilemmas for staff, although primary data are lacking. A Dutch guideline was developed to cautiously open nursing homes for visitors during the COVID-19 pandemic. This study reports the first findings on how the guideline was applied in the local context; the compliance to local protocols; and the impact on well-being of residents, their family caregivers, and staff.DesignA mixed-methods cross-sectional study was conducted.Setting and ParticipantsIn total, 26 nursing homes were permitted to enlarge their possibilities for allowing visitors in their facility. These nursing homes were proportionally representative of the Netherlands as they were selected by their local Area Health Authority for participation. At each nursing home, a contact person was selected for participation in the current study.MethodsA mixed-methods cross-sectional study was conducted, consisting of questionnaire, telephone interviews, analyses of documentation (ie, local visiting protocols), and a WhatsApp group.ResultsVariation in local protocols was observed, for example, related to the use of personal protective equipment, location, and supervision of visits. In general, experiences were very positive. All nursing homes recognized the added value of real and personal contact between residents and their loved ones and indicated a positive impact on well-being. Compliance with local guidelines was sufficient to good. No new COVID-19 infections were reported during this time.Conclusions and ImplicationsThese results indicate the value of family visitation in nursing homes and positive impact of visits. Based on these results, the Dutch government has decided to allow all nursing homes in the Netherlands to cautiously open their homes using the guidelines. More research is needed on impact and long-term compliance.     

Staffing Shortages,Staffing Hours,and Resident Deaths in US Nursing Homes During the COVID-19 Pandemic

ObjectivesStaffing shortages at nursing homes during the COVID-19 pandemic may have impacted care providers' staffing hours and affected residents’ care and outcomes. This study examines the association of staffing shortages with staffing hours and resident deaths in nursing homes during the COVID-19 pandemic.DesignThis study measured staffing hours per resident using payroll data and measured weekly resident deaths and staffing shortages using the Centers for Disease Control and Prevention's National Healthcare Safety Network data. Multivariate linear regressions with facility and county-week fixed effects were used to investigate the association of staffing shortages with staffing hours and resident deaths.Setting and Participants15,212 nursing homes.MeasuresThe primary outcomes included staffing hours per resident of registered nurses (RNs), licensed practical nurses (LPNs), and certified nursing assistants (CNAs) and weekly total deaths per 100 residents.ResultsBetween May 31, 2020, and May 15, 2022, 18.4% to 33.3% of nursing homes reported staffing shortages during any week. Staffing shortages were associated with lower staffing hours per resident with a 0.009 decrease in RN hours per resident (95% CI 0.005-0.014), a 0.014 decrease in LPN hours per resident (95% CI 0.010-0.018), and a 0.050 decrease in CNA hours per resident (95% CI 0.043-0.057). These are equivalent to a 1.8%, 1.7%, and 2.4% decline, respectively. There was a positive association between staffing shortages and resident deaths with 0.068 (95% CI 0.048-0.088) total deaths per 100 residents. This was equivalent to an increase of 10.5%.Conclusion and ImplicationsOur results showed that self-reported staffing shortages were associated with a statistically significant decrease in staffing hours and with a statistically significant increase in resident deaths. These results suggest that addressing staffing shortages in nursing homes can save lives.     

A Proactive Nursing Home Risk Stratification Model for Disaster Response: Lessons Learned from COVID-19 to Optimize Resource Allocation

A coordinated emergency management response to disaster management in nursing homes is desperately needed globally.During the most recent COVID-19 pandemic, aside from a few exemplary countries, most countries have struggled to protect their nursing home populations. Timely and appropriate allocation of resources to nursing homes during disaster response is a challenging yet crucial task to prevent morbidity and mortality of residents.The responsibility for the management of nursing homes during the pandemic was multifaceted, and responsibilities lay at the national, jurisdictional, and regional levels. Success in managing COVID-19 in nursing homes required all these levels to be aligned and supportive, ideally through management by an emergency response leadership team. However, globally there is a paucity of effective management strategies.This article uses the example of the COVID-19 pandemic to propose a risk stratification system to ensure timely and appropriate allocation of resources to nursing homes during disaster preparation and management. Nursing homes should be risk-stratified according to 4 domains: risk of intrusion, capability for outbreak containment, failure in organizational capability, and failure in the availability of community and health care supports. Risk stratification should also consider factors such as current levels of community transmission, if applicable, and geographic location of nursing homes and services.Early identification of nursing homes at risk for infectious disease, or disasters, and targeted allocation of resources might help reduce the number of outbreaks, lower the mortality, and preserve community supports such as acute hospital services. The next step is to debate this concept to validate the selected variables and then develop and pilot test a risk stratification tool for use.     

The Adverse Effects of the COVID-19 Pandemic on Nursing Home Resident Well-Being

ObjectiveQuantify the effects of the COVID-19 pandemic on nursing home resident well-being.DesignQuantitative analysis of resident-level assessment data.Setting and participantsLong-stay residents living in Connecticut nursing homes.MethodsWe used Minimum Data Set assessments to measure nursing home resident outcomes observed in each week between March and July 2020 for long-stay residents (eg, those in the nursing home for at least 100 days) who lived in a nursing home at the beginning of the pandemic. We compared outcomes to those observed at the beginning of the pandemic, controlling for both resident characteristics and patterns for outcomes observed in 2017-2019.ResultsWe found that nursing home resident outcomes worsened on a broad array of measures. The prevalence of depressive symptoms increased by 6 percentage points relative to before the pandemic in the beginning of March—representing a 15% increase. The share of residents with unplanned substantial weight loss also increased by 6 percentage points relative to the beginning of March—representing a 150% increase. We also found significant increases in episodes of incontinence (4 percentage points) and significant reductions in cognitive functioning. Our findings suggest that loneliness and isolation play an important role. Though unplanned substantial weight loss was greatest for those who contracted COVID-19 (about 10% of residents observed in each week), residents who did not contract COVID-19 also physically deteriorated (about 7.5% of residents in each week).Conclusions and ImplicationsThese analyses show that the pandemic had substantial impacts on nursing home residents beyond what can be quantified by cases and deaths, adversely affecting the physical and emotional well-being of residents. Future policy changes to limit the spread of COVID-19 or other infectious disease outbreaks should consider any additional costs beyond the direct effects of morbidity and mortality due to COVID-19.     

A Robotic Device to Enhance Nursing Home Provider Telepresence During and After the COVID-19 Pandemic

The COVID-19 pandemic presented significant challenges to face-to-face communication with people residing in post-acute and long-term care (PALTC) settings. Telemedicine is an alternative, but facility staff may be overburdened with the management of the equipment. Here we introduce the use of a mobile HIPPA-compliant telepresence robot (MTR) to bridge this barrier, which may be beneficial to reimagine options for PALTC in the future.     

Assessing Social Functioning During COVID-19 and Beyond: Tools and Considerations for Nursing Home Staff

Social functioning is defined as how a person operates in their unique social environment (ie, engagement in activities, connectedness with others, and contributions to social roles). Healthy social functioning is important for nursing home residents as they are at increased risk for loneliness and isolation. Social functioning has long been an underacknowledged aspect of nursing home residents’ health, but now, with the COVID-19 pandemic, residents’ risk for decreased social functioning is increased. Several reliable and well-validated tools are available to supplement routine care planning and delivery and track and improve changes in social functioning over time. The overarching aim of this article is to provide resources and recommendations for interdisciplinary team assessment related to social functioning for nursing home residents. We describe 2 domains of social functioning measures, care-planning measures and outcome measures, and provide recommendations for how to integrate said measures into practice. Healthy social functioning is needed to maintain nursing home residents’ well-being and quality of life. Measures and recommendations outlined in this article can be used by nursing home staff to understand residents’ social preferences and address social functioning during COVID-19 and beyond.     

Evidence on the Effects of the Federal COVID-19 Vaccine Mandate on Nursing Home Staffing Levels

ObjectiveTo assess the federal COVID-19 vaccine mandate's effects on nursing homes' nurse aide and licensed nurse staffing levels in states both with and without state-level vaccine mandates.DesignCross-sectional study using data from Centers for Medicare and Medicaid Services, Centers for Disease Control and Prevention, and Economic Innovation Group. Including nursing home facility fixed effects provides evidence on the intertemporal effects of the federal vaccine mandate within nursing homes.Setting and ParticipantsThe sample contains 15,031 nursing homes, representing all US nursing homes with available data.MethodsOn January 13, 2022, the US Supreme Court upheld the federal COVID-19 vaccine mandate for health care workers in Medicare- and Medicaid-eligible facilities, with workers generally required to be vaccinated by March 20, 2022 (ie, the compliance date). We examined actual nursing home staffing levels in 3 time periods: (1) pre-Court decision; (2) precompliance date; and (3) postcompliance date. We separately examined staffing levels for nurse aides and licensed nursing staff. Because 28% of nursing homes were in states with state-imposed vaccine mandates that predated the Supreme Court's ruling, we divided the sample into 2 groups (nursing homes in mandate states vs nonmandate states) and performed all analyses separately.ResultsStaff vaccination rates and staffing levels were higher in mandate states than nonmandate states in all 3 time periods. After the Court's decision, staff vaccination rates increased 5% in nonmandate states and 1% in mandate states (on average). We find little evidence that the Court's vaccine mandate ruling materially affected nurse aide and licensed nurse staffing levels, or that nursing homes in mandate states and nonmandate states were differentially affected by the Court's ruling. Staffing levels over time were generally flat, with some evidence of a modestly greater increase for nurse aide staffing in mandate states than nonmandate states, and a modestly smaller decrease for licensed nurse staffing in mandate states than nonmandate states. Finally, regression results suggest that for both nurse aides and licensed nurses, staffing levels were lower in rural and for-profit nursing homes, and higher in Medicare-only, higher quality, and hospital-based nursing homes.Conclusions and ImplicationsResults suggest the federal COVID-19 vaccine mandate has not caused clinically material changes in nursing home's nurse aide and licensed nurse staffing levels, which continue to be primarily associated with factors that are well-known to researchers and practitioners.     

Evaluating Perspectives of Relatives of Nursing Home Residents on the Nursing Home Visiting Restrictions During the COVID-19 Crisis: A Dutch Cross-Sectional Survey Study

ObjectivesCoronavirus disease 2019 (COVID-19) has caused many nursing homes to prohibit resident visits to prevent viral spread. Although visiting restrictions are instituted to prolong the life of nursing home residents, they may detrimentally affect their quality of life. The aim of this study was to capture perspectives from the relatives of nursing home residents on nursing home visiting restrictions.DesignA cross-sectional online survey was conducted.Setting and ParticipantsA convenience sample of Dutch relatives of nursing home residents (n = 1997) completed an online survey on their perspectives regarding nursing home visiting restrictions.MethodsThe survey included Likert-item, multiselect, and open-answer questions targeting 4 key areas: (1) communication access to residents, (2) adverse effects of visiting restrictions on residents and relatives, (3) potential protective effect of visiting restrictions, (4) important aspects for relatives during and after visiting restrictions.ResultsSatisfaction of communication access to nursing home residents was highest when respondents had the possibility to communicate with nursing home residents by nurses informing them via telephone, contact behind glass, and contact outside maintaining physical distance. Satisfaction rates increased when respondents had multiple opportunities to stay in contact with residents. Respondents were concerned that residents had increased loneliness (76%), sadness (66%), and decreased quality of life (62%), whereas study respondents reported personal sadness (73%) and fear (26%). There was no consensus among respondents if adverse effects of the visiting restrictions outweighed the protective effect for nursing home residents. Respondents expressed the need for increased information, communication options, and better safety protocols.Conclusion and ImplicationsProviding multiple opportunities to stay in touch with nursing home residents can increase satisfaction of communication between residents and relatives. Increased context-specific information, communication options, and safety protocols should be addressed in national health policy.     

Greater Opioid Use Among Nursing Home Residents in Ontario,Canada During the First 2 Waves of the COVID-19 Pandemic

ObjectivesTo examine the association between the COVID-19 pandemic and opioid use among nursing home residents followed up to March 2021, and possible variation by dementia and frailty status.DesignPopulation-based cohort study with an interrupted time series analysis.Setting and ParticipantsLinked health administrative databases for residents of all nursing homes (n = 630) in Ontario, Canada were examined. Residents were divided into consecutive weekly cohorts (first observation week was March 5 to 11, 2017 and last was March 21 to March 27, 2021).MethodsThe weekly proportion of residents dispensed an opioid was examined overall and by strata defined by the presence of dementia and frailty. Autoregressive Integrated Moving Average models with step and ramp intervention functions tested for immediate level and slope changes in weekly opioid use after the onset of the pandemic (March 1, 2020) and were fit on prepandemic data for projected trends.ResultsThe average weekly cohort ranged from 76,834 residents (prepandemic) to 69,359 (pandemic period), with a consistent distribution by sex (69% female) and age (54% age 85 + years). There was a statistically significant increased slope change in the weekly proportion of residents dispensed opioids (parameter estimate (β) = 0.035; standard error (SE) = 0.005, P < .001). Although significant for all 4 strata, the increased slope change was more pronounced among nonfrail residents (β = 0.038; SE = 0.008, P < .001) and those without dementia (β = 0.044; SE = 0.008, P < .001). The absolute difference in observed vs predicted opioid use in the last week of the pandemic period ranged from 1.25% (frail residents) to 2.28% (residents without dementia).Conclusions and ImplicationsAmong Ontario nursing home residents, there was a statistically significant increase in opioid dispensations following the onset of the pandemic that persisted up to 1 year later. Investigations of the reasons for increased use, potential for long-term use and associated health consequences for residents are warranted.     

Proceedings from an International Virtual Townhall: Reflecting on the COVID-19 Pandemic: Themes from Long-Term Care

Residents of long-term care (LTC) homes have suffered disproportionately during the COVID-19 pandemic, from the virus itself and often from the imposition of lockdown measures. Provincial Geriatrics Leadership Ontario, in collaboration with interRAI and the International Federation on Aging, hosted a virtual Town Hall on September 25, 2020. The purpose of this event was to bring together international perspectives from researchers, clinicians, and policy experts to address important themes potentially amenable to timely policy interventions. This article summarizes these themes and the ensuing discussions among 130 attendees from 5 continents. The disproportionate impact of the COVID-19 pandemic on frail residents of LTC homes reflects a systematic lack of equitable prioritization by health system decision makers around the world. The primary risk factors for an outbreak in an LTC home were outbreaks in the surrounding community, high staff and visitor traffic in large facilities, and crowding of residents in ageing buildings. Infection control measures must be prioritized in LTC homes, though care must be taken to protect frail and vulnerable residents from their overly blunt application that deprives residents from appropriate physical and psychosocial support. Staffing, in terms of overall numbers, training, and leadership skills, was inadequate. The built environment of LTC homes can be configured for both optimal resident well-being and infection control. Infection control and resident wellness need not be mutually exclusive. Improving outcomes for LTC residents requires more staffing with proper training and interprofessional leadership. All these initiatives must be underpinned by an effective quality assurance system based on standardized, comprehensive, accessible, and clinically relevant data, and which can support broad communities of practice capable of effecting real and meaningful change for frail older persons, wherever they chose to reside.     

Policy Recommendations Regarding Skilled Nursing Facility Management of Coronavirus 19 (COVID-19): Lessons from New York State

To provide policy recommendations for managing Coronavirus 19 (COVID-19) in skilled nursing facilities, a group of certified medical directors from several facilities in New York state with experience managing the disease used e-mail, phone, and video conferencing to develop consensus recommendations. The resulting document provides recommendations on screening, protection of staff, screening of residents, management of Coronavirus 19 positive and presumed positive cases, communication during an outbreak, management of admissions and readmissions, and providing emotional support for staff. These consensus guidelines have been endorsed by the Executive Board of the New York Medical Directors Association and the Board of the Metropolitan Area Geriatrics Society.     

Stronger Impact of COVID-19 in Nursing Homes of a French Region During the Second Pandemic Wave

ObjectivesQuantify the effects of characteristics of nursing homes and their surroundings on the spread of COVID-19 outbreaks and assess the changes in resident protection between the first 2 waves (March 1 to July 31 and August 1 to December 31, 2020).DesignAn observational study was carried out on data on COVID-19 outbreaks extracted from a database that monitored the spread of the virus in nursing homes.Setting and ParticipantsThe study concerned all 937 nursing homes with >10 beds in Auvergne-Rhône-Alpes region, France.MethodsThe rate of nursing homes with at least 1 outbreak and the cumulative number of deaths were modeled for each wave.ResultsDuring the second (vs the first wave), the proportion of nursing homes that reported at least 1 outbreak was higher (70% vs 56%) and the cumulative number of deaths more than twofold (3348 vs 1590). The outbreak rate was significantly lower in public hospital–associated nursing homes than in private for-profit ones. During the second wave, it was lower in public and private not-for-profit nursing homes than in private for-profit ones. During the first wave, the probability of outbreak and the mean number of deaths increased with the number of beds (P < .001). During the second wave, the probability of outbreak remained stable in >80-bed institutions and, under proportionality assumption, the mean number of deaths was less than expected in >100-bed institutions. The outbreak rate and the cumulative number of deaths increased significantly with the increase in the incidence of hospitalization for COVID-19 in the surrounding populations.Conclusions and ImplicationsThe outbreak in the nursing homes was stronger during the second than the first wave despite better preparedness and higher availabilities of tests and protective equipment. Solutions for insufficient staffing, inadequate rooming, and suboptimal functioning should be found before future epidemics.     

Solving the COVID-19 Crisis in Post-Acute and Long-Term Care

Our nation's nursing home industry has been in need of overhaul for decades—a situation made all the more evident by COVID-19. AMDA–The Society for Post-Acute and Long-Term Care Medicine is dedicated to quality in post-acute and long-term care process and outcomes. This special article presents 5 keys to solving the COVID-19 crisis in post-acute and long-term care, related to policy, collaboration, individualization, leadership, and reorganization. Taking action during this crisis may prevent sinking back into the complacency and habits of our pre-COVID-19 lives.