This is the fourth story in a series by 番茄社区 examining the impact of COVID-19 on vulnerable populations. Past stories reported on the homeless, immigrants in detention, and the undocumented.
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 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 of nursing homes.
CMS also took other steps related to nursing homes, including requiring homes to report COVID-19 cases to patients, families, and the CDC, and 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. , 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."