The tragic outbreak of COVID-19 in a Washington state nursing home at the onset of the pandemic in the U.S. cast a harsh light on the industry and its unwitting role as a hub of transmissions during the pandemic this year.
The nearly 3 million U.S. nursing home residents will be among the first to receive a vaccine once authorized. But the designation came at a steep cost.
More than 100,000 residents and staff have died from the disease, representing about 40% of all COVID-19 fatalities in the U.S., according to the Kaiser Family Foundation.
Despite the clear needs for resources, and willingness to work with hospitals to keep vulnerable elderly out of the wards, nursing homes faced intense pressure—without enough support, some say.
So when Centers for Medicare and Medicaid Services (CMS) Administrator Seema Verma announced new rules for surveyors in March, and the threat of steep fines were posed to the industry, it created a sense of frustration among health professionals who felt unfairly punished.
Some long term care facilities lacked the space and resources to care for mild to moderate COVID-19 cases, including sometimes not having the space to isolate suspected cases, according to Dr. Ed McManus.
McManus, an infectious disease specialist with long-term care expertise in New Jersey, told Yahoo Finance a confluence of circumstances lead to the nursing homes becoming a hub for transmission.
What has happened
The first issue is the makeup of long-term care residents has changed over time. With the growth of assisted living and independent living facilities, nursing homes have increasingly skewed toward more acute care patients— both in terms of physical as well as mental health, McManus said.
John Whitman, a professor at University of Pennsylvania and executive director of a non-profit focused on elder care, previously explained some of the changes and needs of long-term care, noting that the facilities are also seeing a surge in populations as Baby Boomers age into the homes.
“We still tend to use the word 'senior' but that has become a totally inappropriate description. Seniors span four and five decades now. They come from diverse backgrounds in terms of economic capabilities, family supports and ethnic origins. We have individual nursing homes where as many as five languages are spoken. That increases costs and creates a quality-of-care issue in terms of understanding what a patient needs,” Whitman said in 2017.
Another issue for nursing homes is that they typically are not equipped to care for critical patients, relying on hospitals to do so. This relationship that has taken on greater importance as value-based care models pressured nursing homes to do more to avoid repeat or regular patient admissions to hospitals.
A similar request was made in light of the outbreak.
“Medical directors from hospitals reached out to referring nursing homes to make plans to sit in place and manage,” McManus said.
But that lead to increased deaths in the homes, with little space to accommodate. The news reports which paint a dire picture of nursing home facilities has made the facilities skittish, McManus said.
Conversations about managing loved ones’ end-of-life care are already hard, but the pandemic has made it even more important.
“It’s hard for someone to die in nursing home now. People are afraid,” he said.
Nursing home staffing shortages have also played a role in the spread. A recent study by the Associated Press, based on data reported by nursing homes to the government, found that nearly 1 out of 4 facilities faced a nursing shortage.
Throughout the year, as states and local governments implemented lockdowns and nursing homes restricted visitors, the virus was still able to spread, in part, because of nursing home staff mobility — and the lack of available testing made the situation even harder to control.
Even if patients were discharged from hospitals back to nursing homes, they weren’t tested upon discharge, McManus said.
Poonam Alaigh, former under secretary of health of the Department of Veterans Affairs and a member of the Biden Health Policy Committee, said the hospitals were doing this as a way of preserving tests.
“They just don’t see the value in testing a nursing home patient out the door…when they don’t have enough tests,” Alaigh said.
Some states have addressed the issue, with New York state mandating discharged patients be tested before being released to nursing homes.
But the uneven response nationally to the issues at nursing homes resulted in the tragic environment surrounding these facilities, experts say.
“Nursing homes were devastated by this pandemic,” said former N.J. health commissioner Shereef Elnahal.
Elnahal recently told Yahoo Finance that in addition to residents being the most vulnerable to the virus, “Staff are known to have contracted the disease and actually given it to other facilities and other residents at other facilities.”
“Many of these direct care workers have to have multiple jobs based on their wages,” Elnahal said. And some carpool to different locations which increases the likelihood of spread, he added. On average, nurses at nursing homes earn about $66,000 annually, according to the U.S. Bureau of Labor Statistics.
A ‘dark winter’
Some say the industry has made progress in better protecting patients and staff. CarePort Health, a software solutions company that supports long-term care facilities, has tracked the progress made since the onset of the virus in the U.S.
In a recent survey, the company said more than 93% of the nation’s more than 15,000 facilities are now able to provide timely data of case reporting.
The same survey showed 99% of facilities say they are able to test all staff and residents as of November 1. That has been, in part, achieved through rapid antigen tests, like Abbott’s (ABT) BinaxNow which has been distributed by state governments to some facilities.
The AP study, however, found that for the week ending Oct. 25, about 1 in 6 nursing homes in surge states did not report having tested staff the prior week. The government requires staff be tested at least weekly in areas where the virus is spreading.
As coronavirus cases surge throughout the country, facilities and officials are bracing for what’s been dubbed a “dark winter” ahead.
“We really do need, to prepare for new wave, support. We are going to need support in a streamlined way of PPE (protective gear), surge staffing, testing. Hospitals need to test patients before discharge. It can’t be an afterthought,” Alaigh said.
In addition to the U.S. Centers for Disease Control and Prevention’s (CDC) vaccine advisory committee recommending nursing home residents and staff be among first to receive vaccines, Operation Warp Speed has contracted with large retail pharmacies CVS (CVS) and Walgreens (WBA) to administer the vaccines.
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