No matter where you live, nursing homes and assisted living facilities are now lethal centres for Covid-19 in the United States.
In fact, nursing home residents and workers now comprise between 30% and 40% of all Covid-19 related deaths in the United States, according to estimates.
The care centres serve as a "well of infection" for the coronavirus that will continue to feed the ongoing epidemic, said Donald Taylor, director of the Duke University Social Science Research Institute in Durham, North Carolina.
"I believe if we don't manage to control the epidemic within nursing homes, we're not going to control it in the United States," Taylor said.
He and other experts are calling for a renewed emphasis on nursing homes as a way of tackling the Covid-19 pandemic, using many of the same infection control tools needed throughout the nation's communities.
These include improved physical distancing, better use of protective equipment, and above all else – regular Covid-19 testing for every patient and worker at a nursing home, regardless of whether they are showing symptoms of infection.
"Without a broad-scale asymptomatic testing approach, we will not deal with the epidemic in skilled nursing facilities," Taylor said. "The reality is one asymptomatic worker or one asymptomatic patient coming in can undo the best infection control, unfortunately."
The most severe Covid-19 cases occur in older and infirm people, as well as people with chronic health problems that leave their immune systems compromised. The typical resident of a nursing home falls into one or more of those categories.
To protect residents, nearly all states ordered that visitors stay away from nursing homes as part of their shelter-in-place or lockdown orders.
Revolving door of patients, staff
But by their very nature, nursing homes have a steady stream of people coming in and out of the facility, said Nathan Boucher, an assistant research professor at Duke University's Sanford School of Public Policy.
"These facilities are not closed systems," Boucher said. "There's a constant flow of shift workers in and out of these systems, and even though there are no visitors, there are staff that go out to the community and come back in again."
These workers, as well as short-term patients, can carry the coronavirus into the nursing home or spread it out into the surrounding community during an outbreak at the facility, Boucher and Taylor said.
Further, the care being offered necessitates close contact between patients and caregivers, said Sheria Robinson-Lane, a gerontologist and assistant professor with the University of Michigan School of Nursing in Ann Arbor.
"If you have someone who needs help getting out of bed and you send two people to the room to assist them, the staff may be almost hugging that person to roll them over," Robinson-Lane said. "A large portion of their body is against that individual, just to provide care."
A bit of an afterthought
Nursing homes also often have at least two people to a room, and in some cases four or five people share a ward, Robinson-Lane added.
"That is one way to create infection, because somebody could have a virus and pass it on unknowingly to their roommate," said Terry Fulmer, president of the John A. Hartford Foundation, a philanthropic institution focused on improving the care of older adults.
Early in the pandemic response effort, nursing homes didn't rate the same amount of attention as hospitals in terms of infection control, she added.
"We were late helping our nursing homes around the country with equipment and supplies," Fulmer said. "They were a little bit of an afterthought, which has been part of the problem as well."
An eye on safety
As a result, nursing homes and assisted care facilities have suffered the lion's share of illness and death during the pandemic, according to a report from the Foundation for Research on Equal Opportunity:
- Four out of every five Covid-19 deaths in Minnesota have been among nursing home employees and residents.
- Nursing homes also account for more than three out of five Covid-19 deaths in Oregon, Washington, Nebraska, West Virginia, Virginia, North Carolina, Pennsylvania, Delaware, and nearly all the New England States.
So what can be done to make nursing homes safer?
Nursing homes already have started physically isolating patients, by moving them to single rooms, Fulmer and Robinson-Lane said.
Facilities also have started dedicating specific floors, wards or buildings to house only people who are Covid-positive, the experts said.
But more federal and state funding is needed to make sure that all nursing facilities have enough protective personal equipment such as gowns, masks and gloves, Fulmer added.
"We started this pandemic with a shortage of it, and that is something that cannot happen again," Fulmer said. "Nursing homes need to be well-stocked with personal protective equipment, and they need to have access to testing."
In fact, experts like Taylor think testing at nursing homes needs to be for everybody, not just people with symptoms, to get ahead of the curve.
"That includes the workers," Taylor said. "Workers in nursing homes are at risk of occupational exposure. They also are a risk of bringing infection into the nursing home from the community and taking it out."
Funding for additional staff at nursing homes also would help bolster infection control, experts said.
It takes a lot of time to put on a mask, gown up and properly wash hands when going from patient to patient, said Eleanor Schildwachter McConnell, an associate professor in the Duke University School of Nursing.
"It stands to reason that if you're starting out with a very thin level of staffing, it's going to be hard to take those precautions and continue to provide very demanding care," McConnell said, noting that more hands on deck will take the pressure off.
Unfortunately, once people start testing positive at a nursing home, staff have tended to start walking off the job, Robinson-Lane said.
"Nursing homes are already challenged with staffing concerns, and we've seen a chance of 15% reduction in staff after Covid patients come in," Robinson-Lane said.
The US Centers for Medicare and Medicaid Services released guidelines earlier this week calling for all of these steps before states relax their restrictions on nursing homes.
Finally, the experts urge that the patients should not be forgotten in all of this.
During lockdown, they no longer have regular visits from loved ones, they no longer can take part in group activities or shared dining, and now even their regular staff come to them decked out in scary-looking protective equipment, Fulmer noted.
"It's a very frightening time in nursing homes right now," Fulmer said.
Some places are experimenting with new activities to help residents get by. For example, one long-term care facility opened up its courtyard window and had a string quartet play outside, Fulmer said.
Facilities can help by making Wi-Fi and technology available to residents, so they can use Skype or FaceTime to connect with family members.
Taylor's mom is in a continuing care retirement community, and he's been impressed with how well technology has helped ease her isolation.
"Now I FaceTime her and she started FaceTiming my children, and actually it's opened a new mode of communication that's been a positive," Taylor said. "It has taken some of the sting out of not being able to visit."
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