Knowledge Is Power as Nursing Homes Combat COVID-19
There’s a lot we don’t know about the pandemics’s toll in care centers, but what we do know is bad
By Margaret Nicklas, Fri., May 22, 2020
The COVID-19 pandemic in the U.S. dawned with the tragic story of Life Care Center, a nursing home outside Seattle where dozens of residents succumbed to the novel coronavirus earlier this year. Though the disease has spread far and wide since then, with havoc and suffering in its wake, nursing homes remain the site of COVID-19's harshest punishments, as it has proved especially deadly to those over age 65 and those with underlying health conditions who need high levels of care.
There's a lot we still don't know about COVID-19's toll in nursing homes and other care centers, but what we do know is bad. Not all states report relevant data, and federal reporting has until recently not been required. But where information is available, nursing homes and other long-term care facilities are estimated to account for up to 80% of the COVID-19 deaths in some states and for tens of thousands of fatalities nationwide. In Texas, 614 deaths due to COVID-19 of nursing home and assisted living residents were reported as of May 18 by the Texas Department of State Health Services – 46% of the total statewide death toll as of that date.
The federal Center for Medicare and Medicaid Services (CMS) now requires nursing homes to report weekly on COVID-19 cases and fatalities at their facilities, with that information to be publicly available perhaps as soon as next week. This should provide some greater transparency in Texas, where local officials cite state law prohibitions on disclosing information about cases or deaths by facility. Meanwhile, data from assisted living centers, which are not regulated by CMS, may remain spotty. Those residents generally need less medical care and assistance than those in nursing homes, although they still remain highly vulnerable to COVID-19.
CMS has also mandated that nursing homes inform residents, and their families and representatives, of any confirmed or suspected COVID-19 cases among residents and staff within one day. (This rule covers both any infections confirmed by testing and any respiratory symptoms occurring within 72 hours among three or more people). The federal rule comes amidst complaints in Texas and elsewhere that family members have not been informed about their loved ones' risk of exposure as the pandemic has unfolded.
Safety Costs Money
The lack of COVID-19 testing across the state and nation has hindered our ability to understand the scope of the pandemic in nursing homes and similar settings, even after cases were confirmed among their residents. Following recent federal recommendations, Gov. Greg Abbott on May 11 called for all nursing home staff and residents statewide to be tested, though it was not immediately clear how and when this would happen. The company that operates Focused Care at Stonebriar in Austin (and 30 other facilities across the state) said it is "awaiting guidance from the state" on who will conduct the testing, how often it will be done, and who will be responsible for payment, among other questions.
The industry's trade and lobbying group, the Texas Health Care Association, welcomed Abbott's announcement but highlighted existing concerns about shortages of staffing and personal protective equipment (PPE) and increased costs associated with the pandemic response. "The cost of ensuring the availability of PPE, the staffing, and all the other resources – it's very expensive," THCA president and CEO Kevin Warren told the Chronicle, adding that more testing would likely identify more workers needing to be quarantined.
For the two-thirds of all Texas nursing home residents whose long-term care is covered by Medicaid, current reimbursement levels to those facilities already fail to cover the cost of their care, Warren claimed. In a press release issued May 12, he reiterated these concerns, urging the Legislative Budget Board to approve a request for relief funding previously made by the Texas Health and Human Services Commission. Warren warned that without the financial assistance, "We will not be prepared for what comes next."
Patty Ducayet is the State Long-Term Care Ombudsman, a program housed within but independent of HHSC that advocates for residents of these facilities. In an interview with the Chronicle, Ducayet described a system that has responded well in some ways to the COVID-19 crisis, but which relies heavily on individual facilities with varying cultures, skills, and resources to protect residents adequately and communicate with their families effectively.
Regulatory agencies and individual facilities have taken steps to curb COVID-19 transmission, Ducayet said, such as restricting visitors and stepping up efforts at infection control. But some facilities took the crisis more seriously than others early on, or may have been better positioned to respond. "It's kind of bad luck if you get one or two COVID-19 cases in your facility – probably something well beyond a facility's control," Ducayet told the Chronicle. "It's the spread afterward, or the spread when first detected if it's everywhere, that exposes real failures in an infection control program."
Such failures have occurred at all levels, Ducayet said, and may have been exacerbated by preexisting weaknesses. "We, as a state, weren't prepared for a pandemic, and neither were we as a nation. So there are absolute failures, some at the micro level of a facility and some all the way up the chain. Things like PPE shortages and the total overreliance of staffing – with the same staff in multiple facilities – that's been going on for decades," she said.
Ducayet is particularly alarmed by shortages of direct-care certified nursing assistants, or CNAs, who help residents with bathing, dressing, eating, and other activities that require close contact. "They are not valued, they're not paid enough, they often don't get sick leave, they often don't get health benefits in general," she told the Chronicle, adding that CNAs often work part time at multiple facilities to make ends meet – something experts say increases the risk of transmission.
Ducayet's office has received complaints about facilities with confirmed COVID-19 cases regarding communication and information-sharing with families, she told us, as well as about visiting restrictions and testing. "Being a good nursing facility administrator doesn't always make you a good communicator or a good crisis manager," Ducayet said. Administrators dealing with outbreaks may be more focused on tangible crisis responses – like making sure they have enough staff coming in every day – than on the needs of family members, who may have little choice but to rely on whatever information they can get. Removing a loved one from a nursing home is often not feasible, given the level of constant medical care and assistance they need, Ducayet said.
Diana Cervantes is an infection control expert and assistant professor of epidemiology at the University of North Texas Health Science Center in Ft. Worth and chairs the Tarrant County Infection Prevention Council, which supports that county's nursing homes. She told the Chronicle she thinks current stepped-up efforts will help curb new transmissions in nursing homes, as long as they are maintained. "It has to be an ongoing, sustainable push for nursing home safety and to give nursing homes, the administrators, the staff, and the residents the right resources to be able to contribute to that sustainment."
A strong foundation in infection control may be even more crucial as nursing homes reopen to families and visitors, something Cervantes said is key to the well-being of residents. "You can't just shut off nursing homes from the rest of the world," she said, which means family members and visitors will also need ongoing education on how to keep residents safe.
Doing More in Austin
In Austin, a resolution adopted by City Council on May 7 directs significant new resources toward the problems that local nursing homes, assisted living centers, and long-term care facilities face as a result of COVID-19. The resolution calls for testing all staff and residents, with priority given to facilities with identified infection clusters; for supplemental staffing and PPE to be made available quickly to all facilities that need it; and for a funding mechanism to provide financial incentives to certain workers to help with recruitment and retention.
Council Member Ann Kitchen told the Chronicle that assistance to nursing homes has sometimes lagged as resources were being identified. "One reason we stepped in with the resolution is ... that we needed a very clear statement that the city would commit the funds," she said. Council is set to receive an update today, May 21, including requests for budget amendments if needed.
Jessica Lemann of the AARP spoke in support of the resolution at Council; she later told the Chronicle the measure was important so that city staff had clear direction to use whatever resources are necessary to ensure access to PPE. Previously, "not all of them have had that, nor have the facilities been requiring their staff use them," she said. Lemann also praised the city's emphasis on staff and residents of assisted living facilities – as well as nursing homes (covered by the governor's order) – being tested and retested as needed. Since people without symptoms can spread COVID-19, rigorous use of PPE and regular testing of both staff and residents are essential to preventing infection.
Kitchen's resolution calls for the city to collaborate with the UT Dell Medical School's Design Institute for Health to identify system improvements that will further protect nursing homes, assisted living centers, and long-term care facilities. Stacey Chang, who leads the Institute, told us that the project will use a multidisciplinary approach to find and solve underlying problems that contribute to the disease's spread in certain settings, beginning with nursing homes. Chang hopes to deliver initial results in a month or so.
"I'm certain that in that first round of observation, we will discover things that have somewhat immediate, somewhat obvious solutions, and we shouldn't wait to deploy a response to those," Chang said. The team will later provide additional results and expand its study to include other congregate settings, he said, noting that while the threat of COVID-19 for the general population may diminish over time, it is going to be "an enduring risk for a long time" for vulnerable populations.
Still Much More to Know
Prior to the Council resolution, Austin Interim Health Authority Dr. Mark Escott – the city and county's top public health official – and others took action to protect those vulnerable residents. In March, within days of the local disaster declaration, Escott issued control orders that, among other things, required temperature checks of employees, visitors, or volunteers entering facilities. In April, Escott required nursing homes to notify residents, staff, and next of kin of positive cases at facilities. Austin Public Health has also stewarded staffing and technical resources toward infected facilities through its Nursing Home Task Force, in collaboration with the state's "Nursing Home Strike Teams." An APH spokesperson said that strike teams had been deployed to eight Travis County facilities as of May 15.
While that local support may be strong and swift, reporting on the scope of the pandemic among care facilities remains frustratingly opaque. On April 28, Escott told Council of 13 COVID-19 clusters, with a total of 280 positive cases among residents and staff. These facilities were identified as "nursing home, long-term care, and institutional," with an assigned letter rather than a name. At that point, 26 residents and one staff person had died.
Subsequent updates have shown there are now at least 17 such clusters, some shockingly large. As of May 19, 319 residents and 154 staff had been infected and 47 persons had died. In what appears to be the worst outbreak in Austin to date, at "Facility L," 19 residents and one staffer have died; 11 residents have died at "Facility M" and eight at "Facility G." A spokesperson for Austin Public Health told the Chronicle on May 15 that no information could be shared regarding which letters are nursing homes, long-term care centers, or other types of institutions, or even how many of each type are on the list.
Transparency among the facilities themselves hasn't been much better. The Chronicle reviewed what many larger nursing homes in Austin (with 120 beds or more) share about COVID-19 online and followed up with several to learn more. We found only one company, Caraday, that publicly shares information about COVID-19 cases at its facilities. It operates Stonebridge Health Rehab in Austin, where it had identified 24 residents and 11 team members who have tested positive as of May 12. A company representative told the Chronicle in a statement, "Transparency is a cornerstone of our organizational culture." Regency Integrated Health Services, which operates seven nursing homes in Austin, posts information about COVID-19 but not about its cases. Regency's Brooke Ladner told the Chronicle in a statement that the company has consistently followed federal and state guidance for reporting of COVID-19 to family members and to the public.
Kitchen would like to see more detail being reported about nursing home outbreaks to indicate whether they have the PPE, the staffing, and the access to testing they need. "When you talk about it globally – yes, there's a lot of progress being made," she said. "But without a more specific level of detail, we really don't know what is happening at every one."
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