key: cord-0779448-9qqfegbw
authors: Gurwitz, Jerry H.; Bonner, Alice
title: Nursing Homes, the Pandemic, and Caring Enough
date: 2020-07-14
journal: J Gen Intern Med
DOI: 10.1007/s11606-020-06022-7
sha: e49346b7243a9e2480a96942e050c7f5b05e5a99
doc_id: 779448
cord_uid: 9qqfegbw

nan

older adults with multiple chronic conditions, has made the nursing home population uniquely exposed to the pandemic.

There were early warning signs of an impending disaster in nursing homes. A COVID-19 outbreak in a long-term care facility in King County, Washington, first identified on February 28, 2020, highlighted the potential for rapid spread among residents of nursing homes. 3 CMS first issued guidance on nursing homes and COVID-19 on March 4, 2020, related to the screening of all visitors and staff. 4 This was followed on March 13 with a restriction on nonessential medical staff and all visitors, except in compassionate care situations, and suspension of communal dining and all group activities. CMS also recommended that "facilities should identify staff that work at multiple facilities and actively screen and restrict them appropriately to ensure they do not place individuals in the facility at risk…" Further guidance on April 2 encouraged state and local health departments to work with nursing homes in their communities "to determine and help address long-term care facility needs for PPE and/or COVID-19 tests." The guidance on April 2 also recommended daily symptom screening of every resident and every individual entering, and advised that nursing homes "should ensure all staff are using appropriate PPE when they are interacting with residents, to the extent PPE is available."

In early April, it became apparent that CMS guidance focusing on symptom-based screening was inadequate, following reports of the very high risk of asymptomatic and presymptomatic spread in nursing homes. 5 Rapid and widespread transmission of SARS-CoV-2, with substantial morbidity and mortality, had occurred among residents and staff of another nursing home in King County, Washington, despite early implementation of infection control measures. More than half of the residents with positive tests had been asymptomatic at the time of testing.

As more outbreaks in nursing homes began to be publicized, states and communities remained focused on the surge's impact on hospital resources and capacity. Temporary acutecare hospitals and postacute care COVID-19 sites were created. As the surge hit, hospital systems prioritized their own urgent needs for testing, equipment, and personnel. Local and state health departments, already stretched thin, were overwhelmed with evolving challenges and rapidly shifting priorities (e.g., outbreaks among homeless populations, prison populations, and plant workers), distracting from efforts to address the escalating crisis in nursing homes.

With the situation in hospitals now stabilized in many parts of the country, the circumstances for nursing homes are not. The following recommendations may help address some of the challenges facing nursing homes moving forward:

1. There is a need for actionable information on infections among nursing home residents and staff to rapidly allocate resources (e.g., funding, PPE, and staff) to assist nursing homes having outbreaks. In addition, these data may provide important lessons as we prepare for the possibility of a second wave. On April 19, 2020, CMS announced that it would be providing a reporting tool to nursing homes to support Federal efforts to collect nationwide data to assist in COVID-19 surveillance and response. 5 However, nursing homes are only required to report weekly COVID-19 data no earlier than May 8, limiting the ability to derive lessons from the experience of the first two months of the pandemic. 2. Extensive, frequent diagnostic testing of all residents and staff, with rapid turn-around times, is necessary to optimize isolation and cohorting efforts and allow for safe admission of new residents. As the types, availability, and interpretation of diagnostic tests for SARS-CoV-2 infections are rapidly evolving, the approach to the optimal testing strategy will need to be adapted over time. 3. PPE must be available, with training in its use, according to the most up-to-date Centers for Disease Control and Prevention infection prevention and control guidelines.

4. State survey agencies must further intensify nursing home inspection efforts focusing on infection prevention and control capabilities. Surveyor education must be required, standardized, and continually updated. On April 27, 2020, Massachusetts announced a model COVID-19 inspection program predicated on clinical audits of nursing homes every two weeks. Baseline audit results through May 15 indicated that over a third of the State's nursing homes were deficient in at least one core competency (e.g., improper use of PPE). 6 Facilities not in adherence are receiving infection control training prior to being re-audited. 5. Finally, there appears to be no end in sight to the social isolation impacting nursing home residents, as restrictions on visitors, communal dining, and social gatherings may need to continue into the foreseeable future. Innovative solutions beyond FaceTiming and window visits with family members are desperately needed.

The US Department of Health and Human Services has announced the distribution of $4.9 billion to nursing homes, along with enhanced enforcement for infection control deficiencies and quality improvement activities. Yet this important first step does not address the longstanding problems in the structure and financing of nursing homes, which short-term funding, more regulation, and penalties for noncompliance are unlikely to fix. 7 Addressing these underlying issues will require a collective national approach that is centrally supported and administered well beyond the horizon of the pandemic. The unimaginable fear of a scarcity of medical resources and the potential need to ration became tangible during this pandemic, with troubling implications for our aging population. Our capacity to care enough was never questioned as a resource needing to be rationed. For the sake of residents and staff of our nation's nursing homes, we hope it never will be.

State Reports of Long-Term Care Facility Cases and Deaths Related to COVID-19 (as of

COVID-19) and safety of older adults

COVID-19 in a long-term care facility-King County

Trump Administration Announces New Nursing Homes COVID-19 Transparency Effort

Presymptomatic SARS-CoV-2 infections and transmission in a skilled nursing facility

Weekly COVID-19 Public Health Report

Long-term care policy after Covid-19 -solving the nursing home crisis