Staff members at the Canterbury Rehabilitation and Healthcare Center
in Richmond, Virginia, did everything they could to prevent the spread
of COVID-19. Even before the first case arrived at Canterbury — a
190-bed facility that includes units for long-term care, memory care,
and rehabilitation — visitors were banned and group dining was shut
down.
After the first case of COVID-19 was identified on March 13,
Canterbury’s owner, Marquis Health Services, “brought in a lot of
resources and spent a lot of money,” said Jim Wright, MD, the facility’s
medical director, in a phone interview. Because the company owned
several long-term care facilities, Marquis “also had the advantage of
having PPE [personal protective equipment] at multiple facilities, and
they were able to divert PPE to us.” Marquis also paid staff members at
double the usual rate to boost retention.
As more COVID-19 cases appeared, “we immediately set up part of our
nursing home just for people with COVID-19,” he continued. “We moved
them into isolation rooms and followed CDC guidelines; we closed the
door and had an isolation cart outside that everyone used to change into
gowns and gloves” when they went into a COVID patient’s room. Moving
patients to the ward was difficult because “we had to take residents and
their belongings out of rooms they had lived in for years and move them
down the hallway to a different unit, which was most strenuous in
people power and time.”
In addition, Canterbury assigned specific nurses to work only on the
COVID ward “so they wouldn’t be going from a COVID ward to a COVID-free
ward,” Wright said. “We developed ingress and egress from those wards so
they wouldn’t be in another part of the facility any time during the
day.” The nurses even parked in a separate parking lot, and had separate
showers they could use before they went home. The facility also tried
to test patients and workers, but it had limited access to testing, and
the tests that were available took 11 days to be returned, he said.
Cases, Deaths Still Rampant
Even with all of that, with a census of 165 residents, Canterbury had
130 infections and 49 deaths, said Wright. “When we were finally able
to test our entire population, we found that almost half of those tested
were asymptomatic carriers. So we had residents with no symptoms still
shedding the virus, transmitting it, and infecting others.”
COVID-19 has been especially devastating for the dementia patients,
he added, “especially if they’re isolated in their room and they used to
have a common area to visit and see family members. When they can do
that, they’re reminded what time of day it is, and if they see someone
next to them eating, they’re going to eat, so we’ve had quite a bit of
trouble in those people living with dementia” and the facility is
working hard to reestablish eating and hydration patterns. As a result,
reintroducing group dining to dementia patients “is a number one
priority right now,” he said.
Unfortunately, Canterbury’s story has become all too common, said
David Grabowski, PhD, professor of healthcare policy at Harvard Medical
School in Boston. “It’s a similar story in Massachusetts,” he said in a
phone interview, noting that at one nursing home there, “they closed the
facility to visitors, they had no communal dining, they were taking the
temperature of the staff as they came into the building, and yet it
still spread.”
These facilities account for a disproportionate number of COVID-19
deaths, Grabowski noted. “Nursing homes account for about 0.5% of
individuals nationwide … and yet the flawed data we have is that 25% of
the deaths are in nursing homes,” he said. Data from
The New York Times support
that conclusion, with the paper reporting that “more than 63,000
residents and staff members at those facilities have contracted the
virus, and more than 10,500 have died. That means that nearly a quarter
of the deaths in the pandemic have been linked to long-term care
facilities.”
Grabowski said that percentage is probably an undercount: “I think the true number is closer to 50%,” he noted.
Ready-Made Vectors
Nursing homes are ready-made vectors for coronavirus, Wright
explained. “Nursing homes, especially state-supported nursing homes, are
the home for people who generally have had little access to healthcare
because of poverty through their entire lives, and they have reached the
point where they can no longer live in the community because of illness
and disability,” he said.
“So it’s the home for the most frail, the most ill, the most
impoverished members of the community. Add to that the shared quarters
that most publicly funded nursing homes have, and you have the perfect
storm for infectious disease to spread from one person to the next.”
Nursing homes’ high COVID-19 prevalence and mortality rates have
gained the attention of the Trump administration. On March 23, following
a COVID-19 outbreak at a nursing home in Seattle, the Centers for
Medicare & Medicaid Services (CMS) announced it would be
having more targeted infection-control inspections of nursing homes.
CMS also took other steps related to nursing homes, including
announcing forthcoming transparency rules requiring homes to report COVID-19 cases to patients, families, and the CDC, and
doubling Medicare payments for certain COVID-19 tests run on high-throughput equipment.
But CMS’s efforts can only go so far, said Christopher Laxton,
executive director of AMDA, the trade group for nursing home medical
directors. “CMS, I think, has really tried to be helpful by waiving
certain restrictions and allowing telemedicine to come in with greater
frequency and intensity,” Laxton said in a phone interview. However,
“CMS is a regulator and what regulators do is punish entities when
conditions aren’t met.”
Tricia Neuman, executive director of the Program on Medicare Policy
at the Kaiser Family Foundation (KFF), noted that she spoke with one
nursing home medical director “who had been in touch with other nursing
homes who were concerned about coming forward with the problems they’re
facing because they’re worried about being slapped with fines. In the
midst of this crisis, when they’re needing urgent help, they’re
reluctant to put their cards on the table,” she said.
Keeping adequate staffing is a particularly difficult problem for nursing homes, experts said.
According to KFF,
38% of workers in long-term care facilities are age 50 or older, and
58% make $30,000 or less annually. “We’re talking about a workforce that
is 80% female, low-income, and disproportionately African American —
people who are working in long-term care facilities under an enormous
amount of stress,” said Neuman. “It’s not easy work, yet we as a nation
rely on these workers to care for our parents and grandparents, and now
in the COVID crisis, under the most strenuous circumstances.”
Treating these workers poorly seems to be part of the culture, said
Canterbury’s Wright. “If you had a living wage paid to staff so that
staffing levels would always be where we want them to be, then it would
have made a difference, but we would have had to have nursing homes in a
country that values elders more and contributes more resources to elder
care,” he said. “We are not in that country; we’re in a country that
devotes about a third of the average resources to its elders compared to
what other developed countries devote.”
Reimbursement Issues
The reimbursement system for nursing homes also is a big issue. “The
larger picture is that we’ve always had under-investment in nursing
homes,” said Grabowski, who is a member of the Medicare Payment Advisory
Commission, but who emphasized he was speaking only for himself. “We
have a strange system where we overpay on the Medicare side of nursing
homes — for short-stay, post-hospital patients.”
“On the other side are long-stay residents who are going to be there
for the remainder of their life; their care is paid for by Medicaid,
which typically pays below cost,” he continued. Therefore, the whole
structure is built on “bringing in enough short-stay Medicare patients
to subsidize long-stay Medicaid residents.”
The COVID crisis “shows that that model is broken,” he said. “Right
now, elective surgeries have stopped, and the COVID patients — many
nursing homes are not able to admit them, or they shouldn’t. Put that
together with the idea that the cost structure has gone way up with
infection control and staffing issues, and it’s a really challenging
time. It has shown how fractured this financing model is … It begs
rethinking of how we pay for nursing homes in the U.S. We are so reliant
on Medicaid, and we’re going to need to rethink that going forward.”
In the meantime, what can nursing homes do to stop the spread of
COVID-19? “In the end, it’s shoe-leather epidemiology, with contact
tracing, isolation, and quarantine,” along with more testing, said
Laxton.
He also urged more cooperation between hospitals, nursing homes, and
state and local health officials. “We have seen orders coming from state
governments that say nursing homes have to take hospital discharges,
whether we’re able to care for them or not,” including in some cases
fines for nursing homes that refuse to do so, he said. “That
demonstrates the degree to which people don’t understand nursing homes …
We have to fight these battles on a daily basis.”
https://www.medpagetoday.com/infectiousdisease/covid19/86157
