The Coronavirus and Long-Term Care

The sick and elderly in long term care facilities are particularly vulnerable to COVID-19. Worse, many aspects of long-term care facilities make them conducive to rapid spread of infectious disease.

We’re talking about a large population. According to the National Center for Health Statistics (NCHS), “about 65,600 paid, regulated, long-term care services providers”—by this, NCHS means facilities, not staff—“in five major sectors served more than 8.3 million people in the United States.” Caring for the elderly is a full-time job for about 1.5 million people.

Of those 8.3 million, about 286,300 adults are in adult daycare centers. The rest are in nursing homes, hospice care, and other types of residential care. Under ordinary conditions, long-term care facilities are vulnerable to outbreaks of respiratory illness. Large groups of patients are cohabiting in a confined setting with communal meals and many group social activities. Many residents are incapable of practicing the levels of personal hygiene required to stop transmission.

But these are not ordinary conditions. A COVID-19 outbreak has already occurred in a nursing home in Kirkland, Washington:

[Kirkland Life Care Center], about 20 minutes north of Seattle, has been battling a coronavirus outbreak for weeks. Since the outbreak started, 26 of the center’s residents have died, 13 of whom were confirmed to have COVID-19, the disease the coronavirus causes. Some others who died have not yet been tested.

We will see more of these stories in the coming days. The elderly and those with compromised health are the groups at the highest risk of dying from COVID-19. Most people in long-term care meet both criteria.

As outbreaks proliferate in long-term facilities, the health-care system will come under serious strain. To begin with, long-term care facilities are neither designed nor equipped to treat patients with serious COVID-19. They have limited abilities to isolate patients, and they do not have ventilators. Staff are not trained to provide this kind of care. They don’t have the personal protective equipment to protect themselves from infection and doing their jobs in protective gear would be difficult.

That’s by design, not negligence. Residential facilities care for elderly patients in a setting that is less expensive than a hospital. Once you start adding acute or intensive care beds to a long-term care facility, you will have just built another hospital (and a poorly functioning one at that). Long-term care facilities are meant to work in parallel with hospitals. When residents become acutely ill, they’re transferred to hospitals that can provide that care.

About one-third of nursing homes house 100 or more patients. If COVID-19 sweeps through a single facility, this surge in case load could overwhelm local hospital capacity. Or the hospital may already have every bed occupied, so that no new patient can be admitted. And if patients cannot be moved to a hospital they will be in peril.

The second challenge is about staffing. The 1.5 million people who work in long-term care facilities will be at high risk when their facilities have COVID-19 outbreaks. Already, scores of employees were infected at Kirkland. When staff get infected, they will be quarantined. Who will take over those shifts? Even before the pandemic, it was hard to recruit qualified long-term care workers.

Absenteeism will be significant. Some staff members will not come to work because they are afraid of getting sick. Others are single parents. With school closures, they may need to stay home to care for their children. Staff who remain will end up working longer shifts. Care will deteriorate as staffing levels fall, raising the risk of COVID-19 outbreaks still further.

Long-term care facilities understand the risks. In response, they’ve begun adopting strict access and visitation restrictions. Indeed, CMS announced yesterday that nursing homes should not allow any visitors unless it is for “an end-of-life situation.”

But locking down long-term care facilities—probably for several months, and perhaps longer—raises its own concerns. Many long-term care residents are elderly and socially isolated; they depend on frequent visits from family and friends to socialize with them. Without these visits, residents may feel increasingly lonely, abandoned, and despondent. That’s a medical problem in its own right, leading to depression, weight loss, and disruptive behavior.

As troubling, family visits are a crucial technique for monitoring quality of care. With visits curtailed and staff absenteeism rising, the quality of care—already low in many facilities—is likely to decline further. And we will have only limited visibility into the full scope of the problem.

In short, we have 8 million sick and elderly patients at high risk from COVID-19. They reside in fragile long-term care facilities, and those facilities have limited backup from the hospitals. Over a million staff members care for them, and they are also at risk. And there may be a tsunami of COVID-19 cases coming.

So, what can we do? First, political leaders need to put this looming crisis front and center. We’ve heard a lot about hospitals becoming overwhelmed. But we have heard little or no discussion of the nursing home population by the President or his team. Long-term care residences should be priority sites for SARS-CoV-2 testing and personal protective equipment.

Second, the staff at long-term care facilities must have paid sick leave. It is a setup for disaster if employees keep working despite being ill themselves. The deal that Congress has apparently cut with the White House will help, but it’s patchy, exempting with more than 500 workers—including most nursing home chains—and allowing firms with fewer than 50 to apply for hardship exemptions.

Third, President Trump’s emergency declaration unlocks CMS’s authority to relax enrollment barriers for Medicaid beneficiaries. The agency should exercise that authority immediately across the country. Many of the staff at long-term facilities are not well-compensated and will qualify for Medicaid, especially if they lose wages as a result of COVID-19. Bureaucratic roadblocks shouldn’t discourage them from enrolling.

Fourth, state officials must redouble inspections at long-term care facilities. They need to make sure that the facilities are adequately staffed, that the residents’ needs are being met, and that infection control procedures are being followed. With family visits banned, we will otherwise have no visibility at all into nursing homes. If we do not watch closely, there is an acute risk that millions of elderly people might be effectively abandoned as the outbreak intensifies.

Fifth, when staff are ill, quarantined, or absent, we need to be ready to hire and quickly train replacements. CMS should consider relaxing certification and licensure requirements for health aides and nursing assistants. State policymakers should give the green light for trainees at nursing schools to start working. Attracting replacements may require raising compensation. So be it: that’s how markets work. An emergency bill to increase the amount that Medicare and Medicaid pay for long-term care could save lives.

For now, however, the most important thing we can do is minimize the transmission of the virus through disciplined hygiene and social distancing. The fewer people who get infected in the general population, the lower the risk of infection for long-term care residents. Likewise, the fewer of us in the general population who get hospitalized, the more hospital capacity will be available for long-term residents.

Bill Gardner, David States, and Nicholas Bagley

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