Keeping COVID-19 from nursing home residents requires money and improved infection control

by Kathryn Hyer, David Dosa and Lindsay J. Peterson, The Conversation

Credit: CC0 Public Domain

At least 11 people have died from COVID-19 in New Orleans nursing homes in the past week, just after the deaths at a Seattle nursing home weeks ago showed the extreme danger of the virus in nursing home settings.

21 Jun 2020--Nursing homes provide care for 1.3 million Americans every day in the U.S. Under normal circumstances, these residents are more vulnerable to illness because they frequently are of advanced age and have multiple chronic conditions, such as diabetes and heart disease. COVID-19 now presents a new and dangerous threat.

Residents of the Life Care Center in Kirkland, Washington, near Seattle, were among the first in the U.S. to die from COVID-19. The frightening speed with which the virus has emerged in other long-term facilities raises urgent questions: How can nursing homes protect their residents? Should they admit patients with the virus? And what should they do if a resident becomes infected? These questions require immediate answers.

As a research team, we study quality of care in long-term care. That includes disaster planning for nursing homes. Based on recent decisions made by our government, we are not certain all is being done to stop the spread of the virus within these facilities.

CDC regulations aren't stringent enough

More than two weeks ago, the Centers for Medicare and Medicaid Services imposed strict limitations on nursing home visits, albeit with some exceptions for end-of-life situations. While these measures are undoubtedly protecting nursing home residents across the country, they have not been universally effective, as we see from the cases now erupting.

Extreme vigilance to these limitations is essential, meaning that families and friends must accept the precautions and find alternatives to communicating with those they care about, not only in nursing homes but assisted living communities and all other senior care homes. Also, every possible step must be taken to ensure that nursing home staff are not carrying the virus.

That said, there are alarming gaps in the government's plan for protecting nursing homes. There are no requirements that nursing homes keep known or suspected COVID-19 residents in isolation rooms. Instead, the Centers for Disease Control and Prevention recommends only that they be placed in private rooms, preferably with their own bathrooms. What's more, facilities are advised they can accept new residents diagnosed with the virus as long as they follow the prescribed CDC precautions.

These guidelines ignore the extreme risk the disease poses to other nursing home residents and staff. They also ignore the lapses, evident in many nursing homes, in adequate infection control.

A 'clear and present danger'

Medical professionals working in long-term care are alarmed, particularly over the prospect that nursing homes will be forced to accept COVID-19 patients. A March 19 resolution from the Society for Post-Acute and Long-Term Care Medicine says the infection poses a "clear and present danger" to nursing home residents. The resolution also highlights a lack of preparedness at nursing homes to handle the "severity and complexity" of managing COVID-19 patients.

The resolution urges local, state and federal governments to establish specialized care sites for COVID-19 patients, away from nursing home residents to whom contact with the virus may well be deadly. Others have made similar recommendations.

Viral outbreaks are not new to nursing homes. Exposure to influenza and gastrointestinal illnesses such as norovirus causes a multitude of infections in these facilities every year. Regulations already require nursing homes to create and maintain their own prevention and control programs for communicable diseases. Despite that, a recent University of South Florida analysis of federal nursing home records found some disturbing statistics: Nearly 60% of nursing homes were cited at least once for inadequate infection control between 2017-19; 15% were cited multiple times. Equally disturbing is that new regulations were to include requirements for a full-time staffer in every facility with specialized training to manage the infection control program. However, this past November the Centers for Medicare and Medicaid Services delayed the regulatory training required to implement the rule.

Enabling nursing homes to operate effectively during a pandemic requires a clear-eyed understanding of their capabilities, and limitations. They are obligated to follow regulatory requirements, yet limited by reimbursement rates. While nursing homes routinely accept previously hospitalized patients for convalescence and rehab as part of their role in the health care system, the novel coronavirus presents an unprecedented challenge: The homes don't have the equipment or staff to care for a COVID-19 level of infection.

To prevent more deaths in nursing homes, the nursing home industry must begin to aggressively advocate for their patients through increased reimbursement and resource allocation. Bottom line: These facilities urgently need more equipment, including effective facial protection and gowns and staff with the necessary infectious disease training. Alternate sites, away from uninfected patients, must be established to care for patients being treated for and recovering from COVID-19. Dedicated staffing should be established for all COVID-19 patients to minimize transmission of the virus within the facility through staff. Additional Medicare reimbursement for nursing home patients with COVID-19 would also help to defray some of the costs borne by nursing home facilities during this outbreak.

In the meantime, all of us need to remember this: Even places with the best infection control program will have difficulty caring for COVID-19 patients. Nursing homes provide skilled care for a specific, highly impaired segment of the population—but they are not hospitals. They are not designed or equipped to provide the hospital level of containment and care that COVID-19 patients require. While the Monday morning quarterbacking that will most certainly occur downstream will be imperative to prepare nursing homes for future outbreaks of COVID-19 or other such pathogens, the findings should not become fodder for punitive action against staff or management who are simply trying to do the best they can under dire circumstances.

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Provided by The Conversation

Diagnosis is not enough: Predicting avoidable transfers from nursing homes is complex

Kathleen Unroe, MD, MHA is a geriatrician specializing in long-stay nursing home care. She co-directed Phase I of OPTIMISTIC with Greg Sachs, MD and directs Phase II of the study. OPTIMISTIC is an acronym for Optimizing Patient Transfers, Impacting Medical quality and Improving Symptoms: Transforming Institutional Care. 

Treating acutely ill nursing home residents in place and avoiding hospitalizations when possible is better for their health and for the healthcare system. Common diagnoses, such as heart failure or urinary tract infection, are often used to classify whether a hospitalization of a nursing home resident was "potentially avoidable."

05 mar 2018--But predicting ahead of time which resident transfers will fall into these "potentially avoidable" categories is difficult, according to a new study from the Indiana University Center for Aging Research and the Regenstrief Institute which found that both symptoms and patient risk conditions were only weakly predictive of whether hospitalization would be considered potentially avoidable.
"We need to be asking and answering a lot of questions in order to determine if a nursing home resident should have been transported to the hospital," said Kathleen Unroe, MD, MHA of the IU Center for Aging Research and the Regenstrief Institute, who led the new study. "What was going on with the patient in the hours leading up to possible transfer? What is the association between current symptoms (fever or cough, for example) and the individual's risk conditions (such as Alzheimer's disease)?
"Our findings of the difficulty of predicting the avoidability of hospital transfers with information available at the time of transfer, highlights the challenge of designing targeted strategies to reduce potentially avoidable transfers from the nursing home to the hospital," she said. "Multi-component, comprehensive quality improvement efforts like OPTIMISTIC, which embeds specially trained nurses in the facilities have been successful in reducing these transfers. But continued work is needed to understand and recognize true avoidability of these events."
The care of long-term nursing home residents can be fragmented by hospitalizations and re-hospitalizations which are especially burdensome for frail older adults. There is a significant likelihood of reduced functioning and overall negative impact on their health after discharge from the hospital.
Keeping complex patients in the nursing facility is often the right choice according to Dr. Unroe who notes the nursing facility setting—a familiar place with staff and clinicians who know them—can provide a lot of care and may be the patient's best option in many circumstances.
Dr. Unroe, a geriatrician specializing in long-stay nursing home care, co-directed Phase I of OPTIMISTIC with Greg Sachs, MD and directs Phase II of the study. OPTIMISTIC is an acronym for Optimizing Patient Transfers, Impacting Medical quality and Improving Symptoms: Transforming Institutional Care.
During the four-year initial phase of OPTIMISTIC, IU Center for Aging Research clinician-researchers and partners, including 19 nursing homes, reduced avoidable hospitalizations of long-stay nursing home residents a striking 33 percent, according to an independent evaluation prepared at the request of the Center for Medicare and Medicaid Innovation which funds the OPTIMISTIC study.
The evaluation also found that nearly one in five of all hospitalizations—both avoidable and unavoidable—was eliminated by OPTIMISTIC.
By lowering Medicare expenditures $1589 per nursing home resident per year, OPTIMISITC produced a total Medicare spending reduction of nearly $13.5 million and a net savings of over $3.4 million from 2014 to 2016.


Provided by Regenstrief Institute

Death of spouse ups odds of nursing home care

By Megan Rauscher

31 may 2008--An older person's likelihood of entering a nursing home or other long-term care facility is particularly high immediately after the death of a spouse, new research indicates.
There could be various reasons for this, Elina Nihtila, of the department of sociology at the University of Helsinki, Finland, who led the research, told Reuters Health.
"It may be related to the loss of social and instrumental support, in the form of care and help with daily activities such as help in cooking, cleaning, and shopping formerly shared with the deceased spouse," Nihtila said.
"Second, grief and spousal loss may cause various symptoms, such as depression and anxiety, loss of appetite, sleep disturbances, fatigue and loss of concentration that could increase the need for institutional care." She added. "Furthermore, grief may cause increased susceptibility to physical diseases."
The research team analyzed how the death of a spouse affects the likelihood of entering institutionalized care among nearly 141,000 Finnish adults aged 65 and older. All of them were living with a spouse at the beginning of the study and were followed for five years.
"The data were unique in that they covered a large number of persons bereaved during the follow-up and gave the dates of bereavement and of first admission into institutional care," Nihtila and colleagues explain in the American Journal of Public Health.
Results showed that the risk of entering long-term institutional care was higher among older adults who had lost their spouse than among those living with their spouse. "The excess risk of institutionalization was highest during the first month after the spouse's death -- more than three times higher among both men and women -- and decreased with time from bereavement, stabilizing at approximately 20% to 50% higher over 1 to 5 years," Nihtila noted.
The researcher thinks home help services "should be targeted to the bereaved immediately after a spouse's death to reduce the need for institutional care."
SOURCE: American Journal of Public Health, July 2008 (online May 29, 2008).