For anyone living in a nursing home or other long-term or assisted-living facility, these are particularly difficult times. I’ve heard more than one resident complain bitterly about feeling trapped in their rooms, having meals left outside their door (rather than gathering in the dining room with friends), and not being allowed to participate in their routine activities or have visitors. "They’re treating me like a prisoner," said one resident I know. Yes, for many, it’s feeling more like a prison than the place they knew as home before the pandemic.
And yet there are good reasons for all the restrictions. A recent analysis shows that residents of nursing homes and assisted living facilities account for 42% of all COVID-19 deaths in the US. In more than a dozen states, over half of deaths were among nursing home residents. West Virginia (80%), Minnesota (80%), and Rhode Island (73%) had the highest rates.
Unfortunately, nursing homes and other long-term care facilities offer the perfect breeding grounds for viral infections like the novel coronavirus: many people living indoors in close quarters and in close contact — in fact, regularly dining and socializing together.
Other contributors include:
- Advanced age is a risk factor for more severe illness with COVID-19.
- Chronic medical conditions. Hypertension, heart, lung, and kidney disease, and diabetes are common among nursing home residents.
- Inadequate testing and access to personal protective equipment.
- Ability to follow preventive measures. Those with dementia may not remember to wear a mask or maintain a social distance.
- Family adherence to preventive measures. Family members may try to bypass restrictions established by long-term care facilities because they feel the risks of COVID-19 are lower than the risks of keeping their loved one socially distanced, or they may be skeptical about the seriousness of COVID-19.
- Care needs. For people who need help dressing, bathing, and eating, it is impossible for staff to maintain social distance. Staff may lack necessary protective equipment, or find nearly constant mask-wearing and frequent disinfecting and hand sanitizing hard to maintain.
- Shared spaces. In many places, residents share bathrooms, bedrooms, dining rooms, and activity areas. Modifying how and where residents spend their days is challenging, especially for smaller facilities with tight budgets and little flexibility in the physical layout.
- Vulnerable staff. COVID-19 tends to be more severe among people who are poorer and members of minority groups (especially African Americans). Many employees in long-term care facilities are members of these higher-risk groups. Many cannot afford to miss work, and may work at more than one facility. So, if a staff member becomes ill, they may spread infection before they know they have it. Or, they may feel they need to keep working if their symptoms are mild.
- Understaffing, low pay, and high staff turnover are particularly common in this industry, and may also be important contributors.
What happens when a resident develops COVID-19?
Once someone develops COVID-19 in a nursing home, they’re isolated from others and receive necessary medical care. But, then what? If they are recovering but not sick enough to be in a hospital, where can they go? Many long-term care facilities have set aside separate areas (and separate staff) to look after them. But not every place can do this. Even with the best efforts, any infected individual can trigger an outbreak in a facility. And of course, there has to be a plan in place to end the isolation of infected residents — yet it may not be clear when isolation can end without risking spread of the virus.
Keeping residents safe from COVID-19
Some care facilities have been spared an outbreak of the virus so far. Enacting protective measures right away and training staff and residents about how to avoid the virus may have played a role. Some facilities tested staff and residents early in the outbreak and repeatedly, so that anyone infected could be separated from everyone else.
Other factors in their success might include low rates of community spread, a lower number of residents, and halting new admissions (or requiring a two-week quarantine of any new residents). Some credit having staff agree to work in only one facility and providing pay raises to make this possible.
Guidelines from the Centers for Medicare & Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) recommended certain restrictions: limiting visits, no communal dining or group activities, daily screening for symptoms or fever, requiring staff to wear masks. Possibly, facilities that conscientiously followed these guidelines were more successful at avoiding outbreaks. In many states, outdoor visits are recommended because the risk of spreading the virus is lower outside.
Some nursing homes are relaxing visitor restrictions
Recently, CMS released new recommendations about relaxing visitation restrictions that include
- testing all staff every week. Residents should have a baseline test and repeat testing if any other resident or staff member tests positive or has symptoms suggesting COVID-19.
- no new cases for at least a month
- adequate personal protective equipment and cleaning supplies
- adequate staffing
- adequate hospital and ICU beds nearby to take care of residents needing this care.
In many places, these ambitious goals will not be met for weeks or even months from now. Yet it’s clear that nursing homes cannot remain closed to visitors indefinitely. The impact of isolation on residents is just too great. So hopefully, protective measures and community containment of the virus will safely allow visits to resume soon.
The cost of isolation
Even if those living in long-term facilities manage to avoid the virus that causes COVID-19, it’s important to recognize that the mitigation efforts may take a terrible toll. Social interactions matter at every age. Extensive research on older adults links a strong social network to better psychological well-being and physical health.
The impact may be particularly profound on people who are elderly, already have dementia, disability, and psychological problems: these are precisely the people for whom social connectedness, routine, and structure are most important. The pandemic has taken a lot of this away from them.
The way forward
Measures to help residents avoid getting COVID-19 are essential. But so are strategies to help counter isolation, such as:
- re-introducing activities that allow distancing (such as book clubs, art classes, or bingo)
- encouraging outdoor activities, including ones that used to be held indoors (such as art or music classes)
- frequent video or telephone contact with family, which staff may be helpful in setting up. Some nursing homes purchased iPads for residents to allow them to have virtual visits, take virtual walks, or watch a movie with family.
- frequent "window visits" and bringing in favorite meals if allowed
- establishing "bubbles" of residents who have quarantined and can socialize
- sending some people home if there’s adequate support there; this may require major improvements in the availability and capabilities of home care (which will require funding).
While much has been done to contain COVID-19 outbreaks in long-term care facilities, the toll has been substantial, and many residents still feel imprisoned. Balancing the risks of infection with the risks of mitigation efforts will continue to present an enormous challenge to nursing homes and long-term care facilities until the pandemic is under control, or we have effective treatments or a vaccine. Talk to the management of your loved one’s facility to find out what more you can do.
Follow me on Twitter @RobShmerling
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