As the COVID-19 pandemic unfolds in the United States, nursing homes are increasingly in the spotlight. About 20% of the COVID-related deaths across the nation occurred in nursing homes, and here in Philadelphia, that percentage exceeds 50%. Sadly, this is a tragedy that surprises no one familiar with nursing-home care.
Several factors contribute to nursing homes’ place at the center of this health-care crisis. More than half of nursing-home residents are 85 years or older, and most have multiple health issues. Physical space is shared, thereby hindering appropriate social distancing. We can’t alter these risk factors; we can only confine residents to their rooms and limit their contact with others. These practices, however, increase resident isolation and are difficult to implement. Try explaining to a man with advanced dementia why he can’t leave his room to pace the hallways. Try bathing a 98-year old woman with severe arthritis while maintaining minimal contact between her and the nursing assistant.
Residents are also at risk for COVID because the importance of the care provided in nursing homes is often overlooked. Rather than offering aggressive therapies that save lives, care comprises many, small actions like feeding residents spoonful by spoonful or helping them brush their teeth or get dressed. Most people receiving care in this setting are old and/or disabled, two groups that are marginalized in our youth-loving, achievement-oriented culture. Reimbursement for nursing homes is also low compared with hospitals, which often translates into poor staffing ratios and low wages for frontline workers.
The nursing-home industry additionally bears a heavy burden of regulation. While many state and federal regulations are necessary and improve care, they can also create impediments that distract staff from the real job of providing compassionate, individualized care. For example, timely, comprehensive documentation of care is important, but unnecessarily demanding requirements take staff away from interacting and caring for residents.
In times of uncertainty and fear, people seek to assign blame. Such is the case in this pandemic, and many people are quick to conclude that the high rates of infection and mortality among nursing-home residents reflect poor care and negligence. But as of April 28, almost one-quarter of Pennsylvania long-term care facilities, which include personal care and nursing homes, have at least one resident with COVID-19, Although neither the state nor federal governments report data on individual facilities, the affected nursing homes include those that are highly rated according to Nursing Home Compare, a website maintained by the Centers for Medicare and Medicaid Services (CMS). We owe it to older adults, their families, and to nursing-home staff to examine the myriad causes of the problem and move beyond the usual responses — levying stiff fines and publicly shaming nursing homes in the media — to take positive, coordinated action against the COVID-19 pandemic in nursing homes.
We need to take immediate action to counteract the outsized toll of this current crisis in nursing homes. As a result of insufficient monitoring, testing, and reporting around the country, we have missed many opportunities to minimize the spread of COVID-19.
However, it’s not too late to limit additional losses. For example, Ireland’s prime minister, Leo Varadkar, recently committed to providing nursing homes in his country with additional funds and staff, priority testing, and more infectious-disease experts to ensure implementation of adequate infection-control efforts. Closer to home, Maryland is deploying “strike teams” to the state’s hard-hit long-term care facilities. These teams are composed of infection-control experts, National Guard personnel, and additional clinical staff. They provide several services, including supervising testing and helping facilities to separate COVID-19-positive residents from those without the disease. The teams also deliver medical supplies and staff to manage residents with COVID-19 at the facility, thereby avoiding hospitalizations. Although the National Guard has been called in to help nursing homes in Pennsylvania and New Jersey, Ireland and Maryland offer models of coordinated strategies that can and should be applied across the United States.
In addition to these immediate steps, there is a moral imperative to identify strategies to strengthen the existing long-term care infrastructure to avert future disasters. We need to address the larger, chronic problems of long-term care in this country. Yes, it is important to continue to identify facilities that consistently provide substandard care and take aggressive steps to protect residents, which may involve revoking the licenses of chronically poor-performing nursing homes.
We cannot, however, stop there. Instead, we should also adopt payment models that promote high-quality, person-centered care for nursing-home residents, and conduct research to find models of care that lead to the best outcomes. Incentive payments could be tied to demonstrating investment in the workforce (for example, increasing wages and benefits) and other changes to improve care rather than rewarding investors.
We also must ensure that admission to a nursing home includes a comprehensive discussion and documentation of the resident’s values, goals, and preferences for life-sustaining treatment. Many nursing-home residents want to avoid hospitalization and choose comfort-focused care over aggressive life- prolonging therapies. If these preferences are not discussed and documented, the default is to hospitalize and expose residents to non-beneficial, burdensome treatments. Together, all these approaches will make nursing homes better prepared to deal with the next pandemic by improving care overall.
What’s happening in our nation’s long-term care facilities is a national tragedy. At the same time, we must resist simple answers and easy blame. This is our chance to move toward real improvement in a health-care sector that is poised to grow exponentially as our population ages. In the face of this pandemic, let’s commit to improving care for our most vulnerable and oldest citizens. It is a powerful way to honor those who have died from COVID-19 and improve the health and well-being of all citizens.
Mary Ersek is a professor at the University of Pennsylvania School of Nursing and the university’s Perelman School of Medicine.