COVID 'Ground Zero': How Can We Reduce Nursing Home Deaths?

John Whyte, MD, MPH; David C. Grabowski, PhD; Terry Fulmer, PhD, RN


May 20, 2020

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  • The high rate of nursing home deaths from COVID-19 is caused not only by the age and medical condition of the residents but also by the close living quarters and the very personal services provided by staff.

  • Initially, it was important to close nursing homes, but doing so has caused residents to feel isolated and lonely, with some residents refusing to eat.

  • Because nursing homes are "ground zero" for COVID-19 deaths, government officials need to make it a priority to test not only residents and staff but also family visitors.

  • Nursing homes in Europe are experiencing similar COVID-19 death rates. Half of COVID-related deaths in Europe are in nursing homes.

This transcript has been edited for clarity.

John Whyte, MD, MPH: You're watching Coronavirus in Context. I'm Dr John Whyte, chief medical officer at WebMD. Today we're going to talk about the impact of COVID-19 on nursing homes. I'm delighted to be joined by two good friends: Dr Terry Fulmer, president of the John A. Hartford Foundation, and Dr David Grabowski, professor of healthcare policy at Harvard Medical School. Thanks for joining me.

David C. Grabowski, PhD: Thanks.

Terry Fulmer, PhD, RN: Glad to be here, John. Thank you.

Whyte: Dr Grabowski, let's start with the status of COVID in nursing homes. The New York Times has reported that nearly a third of all deaths from COVID-19 are occurring in nursing homes. Is that because of the population density of nursing homes? Is it because of comorbidities and age? Why are we seeing such a disproportionate impact on those that are most vulnerable?

Grabowski: Let's start with the obvious. Older adults live in nursing homes. They do have multiple chronic illnesses. But I think the answer is actually much deeper than that. The reason we're seeing such high death rates in nursing homes also involves the close, congregate living environments that nursing homes often provide for older adults. We see many nursing homes around the country where residents are sharing rooms and bathrooms. It's very tight quarters for the residents.

It's also a function of the staff. The staff are moving from room to room, providing very personal services like bathing, dressing, and toileting. If one resident on one end of the hall has the virus, it's likely to spread right down the hall, as staff continue to provide services for all of these residents. It goes beyond just simply old, frail adults living in these homes. It's actually the services that they're receiving as well.

Whyte: How do we improve the process? What should we be doing? You've been a big proponent, for years, of age-friendly care. How do we do that in the setting of COVID-19?

Fulmer: There have been so many variables going on, certainly the stealth nature of this virus—not knowing who has it and who doesn't have it. If you test positive, what does that mean to the rest of the facility? As staff come and leave each day, they are immediately vectors without knowing it. There are so many variables.

Our organization, the John A. Hartford Foundation, is very keen on getting to a point where we have an age-friendly health system which should take you through the emergency room to the nursing home to your home and get you right back to your kitchen table.

We focus on four M's. We talk about what matters to the older person. That's critical to get at. What are their advance directives? What do they think about palliative care? How does their family understand that? How do they feel about getting admitted to a hospital? Has anybody ever talked about a ventilator with them?

The next thing is mobility. Think about the individuals in nursing homes right now: If you're in a room by yourself, and if there's limited staff because so many of them are sick, is there mobility going on for that older person to make sure that they stay as fit as they possibly can?

Medications—are people getting their medications on time, and have their medication needs changed throughout this pandemic?

And then there's their mentation. In nursing homes, we know that one of the major reasons to get admitted to a nursing home is cognitive impairment, or dementia or Alzheimer's disease; all of those words get used by the public.

If you have dementia and somebody comes into your room with a mask, it's very frightening. If you ask a person with dementia to don a mask, that's not going to happen. We're helping people with that. We have a daily nursing home huddle every day, 12 noon to 12:20, to try to solve these problems.

Whyte: I want to get you both in on this question. Let's be honest: We're banning visitors from nursing homes. And there are good reasons to do that in the setting of infectious disease.

What impact is that having on the residents' physical health and mental health? Dr Grabowski, let's start with you. Is that a good policy? And when will it change? Is it going to exist for 2, 3 years?

Grabowski: I think it was a good policy at first. We really didn't know what we were facing with the virus, so it was very important that we close the facilities to visitors. This has had a major negative impact on the residents. And it's also impacted the families, by the way, and the staff as well. All three of those groups benefit when families are in close contact with their loved ones.

The stories we're hearing out of facilities right now about these residents are incredibly sad. They're feeling lonely, isolated, scared. We've heard stories of residents not eating. They're agitated. There are high levels of cognitive impairment in this population, so they really benefit from a routine and lots of contact. They are way off of their routine right now, and they're not getting that contact.

Whyte: So how do you do that safely, Dr Fulmer? How do you allow visitors in while we recognize the high transmissibility?

Fulmer: We've heard some creative things going on around the country. You can count on families who want to be with their family to get as creative as possible. For those who can afford it, they have been having good luck with iPhones and iPads. We've heard about a nursing home in New Hampshire that had a string quartet come to the courtyard and play. The staff could open the windows a little bit and get that to families.

We've heard about people who are putting materials on the wall: pictures of families, pictures of yards, and things that are familiar. Those are the safest ways when you do it virtually. I think that it'll be a real challenge, when we start opening up our nursing homes, to figure out how to do that as safely as possible.

We have seen in Connecticut, for example, nursing homes that are dedicated COVID nursing homes now. And maybe that's going to be something that creates a safer way to aggregate people with the virus and keep those who do not have the virus in a different place.

Whyte: Dr Grabowski, how would you create a policy that balances these different interests? I recognize that it could be based on local conditions.

Grabowski: Absolutely. You most definitely have to take into account the local conditions. But everything Terry said is exactly right. I think the keys to opening up nursing homes and beginning to allow visitors are really testing and personal protective equipment. Those are the two big asks right now for the nursing home sector.

Whyte: Is it diagnostic testing? Is it antibody testing? We've had lots of these discussions. There's this concept of shield immunity, that we would see if frontline workers have antibodies. And those that do would be first. Is it visitors? How do we do that when we have shortages of supply and shortages of the equipment that's necessary to perform the test?

Grabowski: First, on the shortages, we definitely need to ramp up our testing capacity. That's a definite. This is where the fatalities are occurring. This is ground zero for COVID. If any group warrants increased testing, it's really the staff and residents at nursing homes. Let's direct resources to the problem, and the problem right now is in nursing homes.

In terms of what types of testing, right now we need testing for staff. Who's got the virus and who doesn't? Down the road we'll be doing antibody testing and further testing. But upfront, most states aren't right now requiring testing. The federal government is not requiring testing. So until we get those in place, it's hard to imagine that we're going to be able to really open up nursing homes to a large extent.

Whyte: Do you think that may happen in a few months?

Grabowski: I'm hopeful that we're going to continue. More and more states every week, every day, are coming online and announcing that they're going to do universal testing of staff and residents. Let's extend that testing to potential family visitors at some point. Teach family visitors how to don the personal protective equipment correctly and have them in the facility. I think that would have such a huge benefit to the residents, the families, and also the staff.

Whyte: Dr Grabowski, you've been studying nursing home policies for quite some time. What keeps you up at night?

Grabowski: This is an underresourced industry to begin with. Medicaid is the dominant payer of nursing home services in this country. I think there's often an image of this well-resourced, very experienced staff. And that's not nursing homes. We have very dedicated staff in nursing homes. They're heroes, with everything that they're doing. But we need more individuals working in these buildings. We need more resources.

So, that's what keeps me up at night. It's this idea that as workers get sick, as workers aren't able to come in every day, are we going to have new individuals who are able to work in these buildings and really give that high-quality care to older adults? We need to put resources into our direct caregivers.

At a broader level, we need to make certain that nursing homes have the resources to provide good-quality care, because historically we've underfunded this sector. We've really depended on a direct caregiving workforce that makes close to minimum wage. I just don't think that's going to be acceptable going forward.

Whyte: What advice do we give to caregivers and family members when they're reasonably concerned, based on what they're hearing on the news, about a loved one who might be [going to] a nursing home? They're thinking about putting a loved one in a nursing home; how do they make those decisions, and what resources can they look to?

Fulmer: It's heartbreaking. I think that you point out that people who have money will be able to sort this out better than people who do not. And we need to be clear about that. If you are a person on Medicaid, in a nursing home, without supports around you, it's going to be a different scenario than if you're in a place where you have resources, so I think that's really important.

The other thing I would say is that this crisis has been horrifying, and there will be another one. So whether it's Katrina, whether it's Sandy, whether it's a power outage, what we need to do is get ahead of this. Working with the National Academy of Medicine, our foundation has agreed to fund a study related to quality and safety ahead of the next crisis. We need data. It's been 30 years since we've done this with great systematic approaches. It's time. It's over time.

Grabowski: I think the key factor on whether to pull a family member out of a nursing home is remembering why they were in that nursing home to begin with. It's because they needed a lot of service. Are you going to be able to provide those services for your family member at home? Are you going to be able to give them good infection control?

Over a third of the nursing homes in the US have reported cases. If you're going to pull a family member out, you better be sure that they're COVID free. And so that comes back to the point around testing. It's really important to weigh whether to bring them home or not.

My sense is that, in the majority of instances, it's going to be very challenging for family members to take an individual out of a nursing home. We've certainly heard of cases where that's working well. But in the majority of instances, I think this is going to be about partnering with the nursing home—really working with them to make certain that your loved one is actually safe in that nursing home.

Whyte: You mentioned that about a third of deaths are in nursing homes. Is that unique to the United States? Are we seeing that in other countries? Is the nursing home industry different in other countries?

Grabowski: The US spends a lot less than other countries, especially northern European countries, on long-term care. And yet, if you look at the numbers in those countries—the Netherlands, Sweden, France, Belgium—they're seeing death rates in nursing homes very similar to what we're seeing, even more so. Half of all COVID deaths in Europe seem to be in nursing homes.

I think when it's all said and done here in the US, our rates are actually very similar to those in Europe. You're quoting a figure of one third; it's actually underreporting. The true number is probably closer to 50%. And once we have the data in place, that's what we're going to see. This isn't really about what we invested up front. I think it's about the lack of testing, how we couldn't contain this in the community. Now that it's in nursing homes, they need lots of resources, obviously, to prevent further outbreaks. But this is a systemwide problem. It's a problem in Europe and it's a problem here.

Whyte: I want to thank you both for joining me.

Fulmer: Thank you, John.

Grabowski: Thanks, John.

Whyte: And thank you for watching Coronavirus in Context.

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