Nursing Homes, the Pandemic, and Caring Enough

As COVID-19 curves plateau and fall, the full extent of the tragedy occurring in our nation’s 15,000 nursing homes is being revealed. In many areas of the country, nursing homes (often referred to as “long-term care facilities”) have struggled against nearly insurmountable odds, with reduced staffing levels due to illness, inadequate testing and personal protective equipment (PPE), and mounting morbidity and mortality.

As of May 28, 2020, among 39 states reporting deaths related to COVID-19 in long-term care facilities, fatalities numbered nearly 40,000, and long-term care facility deaths accounted for 43% of all deaths related to COVID-19.¹ In Massachusetts, a microcosm of the pandemic’s national impact on the nursing home population, the percentage of all deaths occurring in nursing homes, exceeds 60% (Fig. 1). While calls go out for investigations of outbreaks in low-rated nursing homes, many facilities, highly rated for their care, have been similarly affected. As long-term care policy expert David Grabowski has stated, “This is not a ‘bad apples’ problem; this is a systems problem.”

Figure 1

Massachusetts long-term care facilities (LTCFs) with > 1 COVID-19 case and numbers of LTCF deaths versus non-LTCF deaths (April 3–May 31, 2020). Lavender bars represent cumulative number of long-term care facilities affected. Red line represents cumulative number of deaths in long-term care facilities. Blue line represents cumulative number of deaths outside of long-term care facilities. Source: https://www.mass.gov/info-details/covid-19-response-reporting.

Some think of nursing homes simply as just another healthcare setting; however, they are much more than that. Nursing homes are places in which residents live, eat, socialize, and spend their leisure time. In a pandemic, concerns about these settings extend far beyond the advanced age, multimorbidity, and cognitive and functional limitations of residents. Other vulnerabilities include multi-resident rooms and shared bathrooms, close physical proximity, inadequate infection control and prevention capabilities, and less advanced information technology systems than exist in most ambulatory clinics and hospitals.² Limited Medicaid reimbursement, inadequate staffing, high staff turnover, and staff working at multiple facilities further complicate planning for and implementing infection prevention and control practices. This combination of factors, along with the lethality of COVID-19 infection in older adults with multiple chronic conditions, has made the nursing home population uniquely exposed to the pandemic.

There were early warning signs of an impending disaster in nursing homes. A COVID-19 outbreak in a long-term care facility in King County, Washington, first identified on February 28, 2020, highlighted the potential for rapid spread among residents of nursing homes.³ CMS first issued guidance on nursing homes and COVID-19 on March 4, 2020, related to the screening of all visitors and staff.⁴ This was followed on March 13 with a restriction on nonessential medical staff and all visitors, except in compassionate care situations, and suspension of communal dining and all group activities. CMS also recommended that “facilities should identify staff that work at multiple facilities and actively screen and restrict them appropriately to ensure they do not place individuals in the facility at risk…” Further guidance on April 2 encouraged state and local health departments to work with nursing homes in their communities “to determine and help address long-term care facility needs for PPE and/or COVID-19 tests.” The guidance on April 2 also recommended daily symptom screening of every resident and every individual entering, and advised that nursing homes “should ensure all staff are using appropriate PPE when they are interacting with residents, to the extent PPE is available.”

In early April, it became apparent that CMS guidance focusing on symptom-based screening was inadequate, following reports of the very high risk of asymptomatic and presymptomatic spread in nursing homes.⁵ Rapid and widespread transmission of SARS-CoV-2, with substantial morbidity and mortality, had occurred among residents and staff of another nursing home in King County, Washington, despite early implementation of infection control measures. More than half of the residents with positive tests had been asymptomatic at the time of testing.

As more outbreaks in nursing homes began to be publicized, states and communities remained focused on the surge’s impact on hospital resources and capacity. Temporary acute-care hospitals and postacute care COVID-19 sites were created. As the surge hit, hospital systems prioritized their own urgent needs for testing, equipment, and personnel. Local and state health departments, already stretched thin, were overwhelmed with evolving challenges and rapidly shifting priorities (e.g., outbreaks among homeless populations, prison populations, and plant workers), distracting from efforts to address the escalating crisis in nursing homes.

With the situation in hospitals now stabilized in many parts of the country, the circumstances for nursing homes are not. The following recommendations may help address some of the challenges facing nursing homes moving forward:

• 1. There is a need for actionable information on infections among nursing home residents and staff to rapidly allocate resources (e.g., funding, PPE, and staff) to assist nursing homes having outbreaks. In addition, these data may provide important lessons as we prepare for the possibility of a second wave. On April 19, 2020, CMS announced that it would be providing a reporting tool to nursing homes to support Federal efforts to collect nationwide data to assist in COVID-19 surveillance and response.⁵ However, nursing homes are only required to report weekly COVID-19 data no earlier than May 8, limiting the ability to derive lessons from the experience of the first two months of the pandemic.

• 2. Extensive, frequent diagnostic testing of all residents and staff, with rapid turn-around times, is necessary to optimize isolation and cohorting efforts and allow for safe admission of new residents. As the types, availability, and interpretation of diagnostic tests for SARS-CoV-2 infections are rapidly evolving, the approach to the optimal testing strategy will need to be adapted over time.

• 3. PPE must be available, with training in its use, according to the most up-to-date Centers for Disease Control and Prevention infection prevention and control guidelines.

• 4. State survey agencies must further intensify nursing home inspection efforts focusing on infection prevention and control capabilities. Surveyor education must be required, standardized, and continually updated. On April 27, 2020, Massachusetts announced a model COVID-19 inspection program predicated on clinical audits of nursing homes every two weeks. Baseline audit results through May 15 indicated that over a third of the State’s nursing homes were deficient in at least one core competency (e.g., improper use of PPE).⁶ Facilities not in adherence are receiving infection control training prior to being re-audited.

• 5. Finally, there appears to be no end in sight to the social isolation impacting nursing home residents, as restrictions on visitors, communal dining, and social gatherings may need to continue into the foreseeable future. Innovative solutions beyond FaceTiming and window visits with family members are desperately needed.

The US Department of Health and Human Services has announced the distribution of $4.9 billion to nursing homes, along with enhanced enforcement for infection control deficiencies and quality improvement activities. Yet this important first step does not address the long-standing problems in the structure and financing of nursing homes, which short-term funding, more regulation, and penalties for noncompliance are unlikely to fix.⁷ Addressing these underlying issues will require a collective national approach that is centrally supported and administered well beyond the horizon of the pandemic.

The unimaginable fear of a scarcity of medical resources and the potential need to ration became tangible during this pandemic, with troubling implications for our aging population. Our capacity to care enough was never questioned as a resource needing to be rationed. For the sake of residents and staff of our nation’s nursing homes, we hope it never will be.