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Keith Loria is a contributing writer to Medical Economics.
Residents and staff have been hit hard by the disease. PPE is in short supply. The deaths are taking an emotional toll on largely unheralded workers.
When COVID-19 started to sweep across this country, much of the attention focused on New York, New Jersey, the city of New Orleans and a fewer other hot spots.
But from the start of the outbreak in this country in February, when residents of the Life Care Center in suburban Seattle started to fall ill and die, it was evident that nursing home residents would be among those most vulnerable to infection by the SARS-CoV-2 virus and serious illness and death from COVID-19. By late April, news organizations had tallied 7,000 COVID-19-related deaths among nursing home residents and people connected to nursing homes. That was about 20% of the total number of COVID-19-related deaths in the country at that time. State and federal government officials have been slow to release nursing home-specific COVID-19 statistics, citing privacy and other concerns. Some critics say that reluctance has obscured the scope of the problem and delayed actions to mitigate it. CMS Administrator Seema Verma changed the reporting procedures in April so nursing home deaths would be reported directly to the CDC rather than local health officials.
The deaths in nursing homes have led to some horrifying situations, such as one in Sussex County, New Jersey, where an overwhelmed nursing home piled 17 bodies in a morgue meant for just a few. The deadliest outbreak was in the Canterbury Rehabilitation & Healthcare Center outside Richmond, Virginia, where 46 deaths had occurred by the end of April. As COVID-19 flared up in nursing home after nursing home, evidence of a history of poor infection control surfaced for some facilities. Especially damning was a report by the Washington Post that found that 40% of the 650 homes with publicly reported COVID-19 cases had been cited more than once for infection control violations.
CMS has responded in several ways. In mid-March, the agency issued a memo restricting all but a few people from visiting nursing homes and ordered the cancellation of group activities and communal dining. About a week later, the agency suspended routine inspections to focus on infection control. The agency also relaxed transfer and other rules so residents with COVID-19 could be grouped together and separated from residents without the disease. And in April, CMS increased the reimbursement rate for testing, partly to accelerate the pace of testing of nursing home patients and staff.
“People will end up blaming nursing homes and talking about how terrible we are, but it is the complete lack of prioritization that has put us in the position we are in,” tweeted Mark Parkinson, former governor of Kansas and now president and CEO of the American Health Care Association and National Center for Assisted Living (AHCA/NCAL), a federation of state groups for nursing homes and assisted living facilities.
Beth Martino, a spokesperson for the organization, says nursing homes are doing everything they can with the resources they have been given to slow the spread of the virus.
“Our providers are struggling due to lack of testing, insufficient personal protective equipment (PPE) and a workforce shortage due to school closures and employee illness,” she says. “We desperately need more PPE in nursing homes, priority testing for our healthcare workers and residents, and the ability to quickly recruit and hire more staff.”
Richard Feifer, M.D., M.P.H., FACP, senior vice president and chief medical officer for Genesis HealthCare in Kennett Square, Pennsylvania, has been working nonstop with the employees across the for-profit company’s network of 381 skilled nursing and assisted living facilities. “This is a deadly, highly contagious virus with a high mortality rate in nursing homes; in fact, up to 20%,” he says. “These are frail … seniors who are the least able to withstand even common infections, let alone a virus like this. The cruel reality is that once COVID-19 enters a nursing home, its spread is incredibly challenging to prevent, no matter how many precautions and controls you have in place - and we have been very rigorous.” Genesis’ stock price at the end of April was half what it was at the beginning of March.
Feifer says the company has had to be resourceful and at times creative in determining ways to protect Genesis’ patients, residents and employees. He says nursing homes need help from federal and state health officials in three areas: prioritizing broader, faster testing; allocating PPE; and charting a sensible, collaborative approach to addressing a shortage of hospital beds without introducing the virus into the nursing homes.
“We need to make sure we are helping our elderly community, as well as the employees who are the true heroes,” says Feifer. “They are putting themselves at risk every shift they work to serve their patients and residents each and every day.”
Eric T. Mizuno, M.D., medical director at The Admiral at the Lake, a continuing care facility in Chicago, says that nursing homes aren’t equipped with the screening necessary to keep the SARS-CoV-2 virus out of their facilities. “Many of these facilities are less sophisticated than hospitals and are not used to dealing with infection control at the same level. If it gets in, it’s like setting the match to gasoline. The staff isn’t trained on how to not spread it, and there are more mortalities.”
Kristen Knapp, director of communications for the Florida Health Care Association, which represents approximately 560 nursing homes throughout Florida, says the organization has been pushing out regular updates to its facilities and providing guidance from the local, state and federal levels. “Right now, everyone working in a nursing home and long-term care facility is required to wear a mask and gloves, and we did that even before it became a mandate by the federal government,” she says. Nursing homes have also set up areas in their facilities to isolate any residents with COVID-19, she adds. In addition, the association has an infection prevention specialist on staff who has been training nursing home workers, providing guidance on everything from cleaning solutions to the best way to do laundry to proper PPE use. “The problem,” says Knapp, “is that we are at crisis-level supply shortages, and many facilities are utilizing hand-sewn masks from the community or wearing bandannas. There is just not enough supply, and it’s getting concerning.”
Controlling the spread
Before COVID-19, nursing homes held group social activities to engage residents and provide some social and intellectual stimulation. Families were encouraged to visit as often as possible. All of that has stopped because of COVID-19.
The AHCA/NCAL has suggested that nursing homes “cohort” residents who are positive for or suspected of having COVID-19 by setting aside separate wings, units or floors for them. “Governors and public health officials should be directing nursing homes to create segregated units, in areas where it makes sense, right now,” says Martino, the organization’s spokesperson. “They should also explore creating dedicated COVID-19 facilities that can accept hospital discharges. As a profession, we have made these recommendations, but we need state officials to waive regulations that limit our actions. We also need to find ways to work with state public health agencies to get the necessary support to nursing homes so they can accept positive patients.” At the end of March, CMS waived discharge rules to allow facilities to isolate COVID-19 patients.
Feifer says it’s better to overreact than underreact to COVID-19. “We have been extremely stringent on visitation restrictions, use of personal protective equipment and many other precautions across all our centers from early on,” he says. “We’ve followed guidelines and protocols set by CDC and CMS, in some cases getting out in front of them.” First and foremost, says Feifer, Genesis has required all staff to wear PPE in patient areas.
“We are also vigilantly screening residents for symptoms, first daily, then twice daily and, since March 26, three times daily,” Feifer says. “We are also actively screening and taking temperatures of all staff upon building entry, and we have canceled all outside medical appointments, except for lifesaving treatments, like dialysis and chemotherapy.”
Tracy Humble, RN, vice president of clinical services for The Compliance Store in Montgomery, Alabama, a company that advises nursing homes on regulatory and other issues, says suspending visits has been the hardest adjustment for residents and staff. Facilities have been getting creative and using technology like video chat to maintain connections between residents and their loved ones.
“Implementation of the suggestions made by CMS and the CDC are paramount in protecting residents,” says Humble. “As new information is released, facilities have to learn more and adapt as indicated.”
CMS Administrator Seema Verma has appeared at several of the daily White House coronavirus briefings, and her agency has issued a barrage of guidances and regulatory waivers designed to help nursing homes respond to COVID-19.
“It’s clear that CMS shares our goal of containing the virus and limiting the spread as much as possible,” says AHCA/NCAL’s Martino. “We appreciate CMS targeting surveys and inspections to only critical issues, which will greatly help our staff focus on resident care and fighting this virus.”
The emotional toll
Doctors and nurses have been celebrated as the heroes of the COVID-19 outbreak. But the people working in nursing homes, many of whom are in low-paying jobs and traveling long distances to get to work, have also been heroic. “We have seen the incredible dedication our staff has had during this pandemic, many coming to work even when COVID-19 is in the building and masks and other supplies are low or unavailable,” Martino says. “It’s important to keep in mind that like all other healthcare facilities, nursing homes have to delicately balance ensuring that there are enough caregivers to properly aid residents and patients, while also making sure sick employees do not create unnecessary, additional risks to residents.”
The pandemic has created other challenges for staff, according to Martino. Many have had to scramble to find child care because schools are closed. The deaths in the facilities take an emotional toll. The most helpful thing any advocacy group or media outlet can do right now is encourage people not to visit long-term care facilities, she says - and to stay home to reduce transmission.
Feifer, speaking in early April, said testing of nursing home residents and employees should be priority. “Where we have had access to test kits and swabs, results have been taking too long, usually three to nine days or more,” Feifer said. “We know it can be done faster because we’ve had residents transferred to the hospital and seen results come back in a few hours.”
Maryland, Massachusetts and Rhode Island have accelerated testing in nursing homes. A CDC guidance on April 15 mentioned that nursing home residents with COVID-19 may not have typical symptoms like fever or a cough. The guidelines for reopening businesses and other parts of the economy issued by the White House say that nursing homes should continue to prohibit visitors during the first two of the three phases outlined in the document. Feifer emphasized the need for testing: “In the absence of the ability to test everyone, and potentially more than once, nursing homes are sure to see
Mizuno, of The Admiral at the Lake, says until a screening test for COVID-19 is available, keeping the coronavirus out of nursing homes will be impossible. “That does not preclude you from morally or legally making every effort you can to keep this thing from coming in, but you will not be successful,” he says. “You are trying to fight a war with rubber bands and rocks, and that’s not how you fight a war in the 21st century.”
Keith Loria is a freelance writer in northern Virginia.