Having an infection preventionist on site or as a consultant to lead infection prevention and control training makes a difference. The ability to screen, isolate, or group patients can save lives. Ongoing testing of residents and staff is critical.
When all states fully reopen, long-term care facilities (LTCFs) must balance the needs of residents against the potential for additional deadly COVID-19 outbreaks. COVID-19 uncovered deep flaws in nursing homes that have been worsening for decades. Nursing home is a generic term for a facility for a patient who can no longer remain at home because they require 24-hour nursing care and monitoring, also known as a skilled nursing facility (SNF), long-term care facility (LTCF), or extended care facility (ECF).1 For this article, LTCF will be used to refer to these 3 types of facilities.
Seventy percent of LTCFs are for-profit operations, a factor that’s been linked to the spread of COVID-19.2 Unlike hospitals, most LTCF residents live in these facilities permanently, although some are admitted for shorter periods of rehabilitation after a hospital stay. Although these facilities are designed to be comfortable for long-term emotional, social, and physical well-being, they also are perfect incubators for viruses and bacteria. Their layouts increase person-to-person contact. Most residents share bedrooms, bathrooms, activity rooms, and dining rooms—and staff usually share a break room. Although group spaces encourage socializing and are designed partly to cut costs, they also help spread infectious diseases.3 Residents are generally older, frail, and often have comorbidities that make them more susceptible to severe infections such as COVID-19. Many need help performing basic activities of daily living such as eating, dressing, or bathing, increasing the chances of being infected by the staff who help them or passing the virus along to their caregivers.
When mortality rates at facilities struck by COVID-19 were compared with ones that were spared, the more the virus spread through a facility, the greater the number of deaths recorded for other reasons. In facilities where at least 30% of residents had the virus, the rate of death for reasons besides the virus was double what would be expected without a pandemic. This implies that the care of those who didn’t contract the virus may have been negatively affected as the staff were overwhelmed attending to residents with COVID-19 or were left short-handed as employees became infected.4
Many LTCFs lack the necessary resources to protect seniors from COVID-19. News articles describe LTCF staff as generally underpaid, often living in crowded conditions at home, traveling on public transportation, and working jobs in multiple homes to make ends meet.4,5 Statements from staff and administrators mentioned that staff feared exposure to COVID-19 and other infectious diseases, along with fear of bringing home infections to their family members; some lacked accessible child care; some had competing family obligations. Many staff don’t receive health insurance or paid sick leave, leading some to work even when they are experiencing symptoms. The facilities they work in may have insufficient personal protective equipment (PPE) and training on how to use it. Many facilities lack COVID-19 testing for staff and residents.
The other issues that make LTCFs so vulnerable—chronic underfinancing, inadequate clinical services, and fragile staffing—seem to be endemic to the LTCF industry. Before COVID-19, this sector endured widespread economic and operational problems. Since the initial COVID-19 surge, LTCFs have lost occupancy and utilization, have lower revenues, and face immense staff retention and recruitment obstacles.2
Public opinion on LTCFs has been further eroded by the human toll from the pandemic. According to AARP, “the American nursing home industry exists as it does today because of federal laws and regulations that go back 85 years. The infrastructure these laws created, no matter how well intended, didn’t anticipate the future, nor could it foresee a health storm of this magnitude, speed, and deadliness.”2 (See chart below.)
The Centers for Medicare & Medicaid Services (CMS), an agency within the US Department of Health and Human Services (HHS), is responsible for ensuring the approximately 15,500 LTCFs, with 1.4 million residents nationwide, meet federal quality standards.
LTCFs must meet standards to protect residents. These standards were in place prior to COVID-19 include as follows6:
Under the CMS umbrella, state survey agencies are expected to conduct inspections once a year and can inspect facilities more often if the facility is performing poorly or if there are complaints or facility reported incidents. Inspectors also review the residents’ clinical records and interview residents, family members, caregivers, and administrative staff. The inspection team looks at many aspects of life in the LTCF including as follows:
Infection control inspections are an abbreviated type of inspection that allow the team to focus specifically on LTCF infection control policies and practices. These inspections can identify serious risks to resident health and safety through the spread of communicable disease. They review areas such as:
Not surprisingly, infection prevention and control deficiencies were the most common type of deficiency cited in surveyed facilities, with most facilities having an infection prevention and control deficiency cited in 1 or more years prior to the pandemic. Infection prevention and control deficiencies can include items such as staff not regularly using proper hand hygiene or failure to implement preventive measures during an infectious disease outbreak. Isolating sick residents and using masks and other PPE are critical to preventing the spread of infectious diseases from multidrug-resistant organisms and respiratory viruses.
A US Government Accountability Office report found that from 2013 through 2017, 82% of all surveyed LTCFs were cited. In each individual year, approximately 40% of surveyed LTCFs had infection prevention and control deficiencies, which continued in 2018 and 2019. Approximately half (48%) of LTCFs with an infection prevention and control deficiency had this same deficiency cited in multiple consecutive years from 2013 through 2017.7 This indicates persistent problems that existed long before the onset of the pandemic. The safety of the residents, who often are in frail health and live in close proximity to one another, was brought to the attention of the world during the COVID-19 pandemic.
Most critics of the LTCF industry agree that it was dealt a nearly impossible hand during the pandemic, left to take the brunt of public anger over the large number of deaths at LTCF facilities. The American Health Care Association, a not-for-profit federation of affiliated state health organizations that represents more than 14,000 not-for-profit and for-profit LTCFs, states that “the failure of public health services at all levels to prioritize [long-term care facilities] for both testing and personal protective equipment left the industry unequipped to stop the spread of the virus.”
But there are some data that show a link between LTCF quality and COVID-19 cases. Investigators found that facilities that had lower quality ratings from regulators before the pandemic were more likely to have outbreaks.2 And the New York Times found that residents in top-rated facilities were as likely to die from COVID-19 as those in facilities ranked near the bottom.8
LTCFs do have protocols to handle outbreaks such as influenza, but the COVID-19 pandemic arrived so quickly and the SARS-CoV-2 virus was so contagious that many facilities were caught unprepared. The reasons vary from state to state and facility to facility. In general, when SARS-CoV-2 reared its head, many LTCFs did not have enough PPE on hand or adequate staff trained to use it to sustain the volume of patients with COVID-19.
They couldn’t institute mandatory use of PPE for staff in order to protect them or offer PPE to visitors. They couldn’t provide testing for staff and residents to help them and their families make good decisions regarding working ill and visitation. Instead, hospitals were prioritized over LTCFs in terms of emergency assistance, even though elderly adults and individuals with disabilities, who make up the vast majority of LTCF residents, are at highest risk for serious illness and death from COVID-19.
An article by the John A. Hartford Foundation sums up how some view LTCFs: “Unfortunately, the situation in LTC [long-term care] with COVID-19 is consistent with how America treats LTC. We prefer these essential facilities and their residents and staff to be out of sight and out of mind. We place the sickest, frailest, and most vulnerable people in 1 spot and then pay less than minimum wage to those who will be caring for them, despite the difficult nature of their jobs. LTCF staff provide care for many individuals who have profound dementia, complex chronic diseases, and decreasing function and ability to eat, bathe, or move around on their own.”9
What We Learned
The COVID-19 pandemic emphasized LTCF patient and staff safety and infection control practices as critical public health issues. The impact of the pandemic on residents and staff in LTCFs called for reexamining the relationship between the physical environment and the factors of infection control, quality of life, and overall resident and staff safety.9 Yet even now these facilities continue to be a major source of US COVID-19 cases.
Investigators at UCLA and Yale University found that LTCF aides who worked in multiple facilities in order to make more money contributed to the spread of COVID-19. They found restricting workers to a single facility had the potential to reduce COVID-19 infections by 44%.10
An LTCF aide can be responsible for more than 20 residents on a shift. The job is physically and emotionally demanding, and the average wage is approximately $13 an hour. Requirements for the job vary by state. In most states, workers complete a hands-on training course and a certified nursing assistant (CNA) program, which is approximately 75 hours of training over 3 months. Surprisingly, state requirements to gain a hairstylist license are more demanding than those for a CNA, says Lori Porter, cofounder and CEO of the National Association of Health Care Assistants.8 Now that COVID-19 restrictions have limited CNAs to working at just 1 facility, many are now unable to afford basic living expenses. Without increased pay and benefits, coupled with the mandated vaccine, LTCFs will remain short-staffed.
Cell phones, tablets, and other videoconferencing devices have been invaluable in helping reduce isolation and loneliness in LTCFs. Virtual visits were linked to a 50% lower risk of depression compared with emails, social media, or instant messaging.
“Social isolation was a mental and physical health problem in nursing homes long before COVID-19,” says Bei Wu, PhD, director for research at the Hartford Institute for Geriatric Nursing at New York University. Lack of connection is associated with a 50% higher risk of dementia, 29% higher risk of coronary heart disease events, and a 32% higher risk of stroke.11
Physical contact is also important. The creation of spaces where LTCF residents and family members could meet and hug demonstrated the importance of incorporating safe areas for in-person visits. These are spaces made out of plastic sheeting with holes cut into it to allow protected physical contact. Moving forward, there could be plexiglass walls, a sound system, antimicrobial surfaces, and perhaps a “hug wall” made of flexible material for germ-free embraces.8
Telehealth increases patient engagement, reduces costs, and saves time. Telehealth enables patients to be more engaged in their own health and well-being. During the pandemic, Medicare authorized payment for telehealth services to residents in any health care facility and in their home.12 Clinicians who were able to virtually assess LTCF residents via video monitoring were more likely to catch health issues sooner and then treat patients where they were, rather than having to admit or readmit them to a hospital. Avoiding unnecessary trips to the hospital can promote better health outcomes for patients and benefit LTCFs by reducing lost revenue when a patient is in the hospital. Clinicians were better able to assess and provide care while avoiding risk of exposure to SARs-CoV-2.
LTCFs that had the resources and staffing to anticipate and prepare for the pandemic fared much better than those that didn’t. These facilities shared what they learned: Stock up on cleaners, disinfectants, and PPE and masks for workers and residents; screen everyone who walks in the door for symptoms; hire more staff to clean bathrooms and common areas; educate everyone on best practices for containing the virus—wash hands, avoid close contact, keep an eye out for fever or cough; lock down the facility and isolate infected residents.
Having an infection preventionist on site or as a consultant to lead infection prevention and control training makes a difference. The ability to screen, isolate, or group patients can save lives. Ongoing testing of residents and staff is critical, as is vaccination of residents and staff to keep the virus under control.
LTCFs should stockpile PPE, not just for COVID-19 but also for other contagious events. Even more safety improvements and changes may be necessary. Not just because another pandemic may be around the corner, but because the aging US population demands them to stay independent and safe. By 2030, every baby boomer will be at least 65 years old, with Generation X and the millennials aging right behind them.8
PROVIDE MORE AT-HOME CARE
Although infection prevention is a critical component for patient and staff safety, critics think the LTCF system needs attention beyond what infection prevention practices can provide. It may be time to rethink what LTCFs should look like based on what was learned from the pandemic. Too often, LTCFs look, feel, and function like hospitals. Besides looking at creating smaller LTCFs, familylike household facilities may be a better option.
“Making nursing homes the de facto choice for older Americans in need of care set the stage for the ravages of the pandemic,” says Patricia McGinnis, JD, executive director of California Advocates for Nursing Home Reform. “LTCFs are not good places for anyone except for short-term rehab. I would hope this is a wake-up call that the system isn’t working.”2
Advocates for alternatives to LTCFs include AARP and the Green House Project. AARP, a nonprofit, nonpartisan organization dedicated to helping older Americans achieve lives of independence, dignity, and purpose, has more than 33 million members.12 They have been outspoken on behalf of their members, urging LTCF reform.
The Green House Project is an innovative, nationally recognized model in LTCFs that creates small homes that recognize the individuality of residents and respect their autonomy, choice, privacy, and dignity, yet are also affordable. Founded in 2003, the Greenhouse model has key features that provide infection mitigation, including private rooms, more access to outdoor spaces, open floor plans that allow for social distancing, and a staffing model that limits the number of people with whom each resident interacts.13 There are approximately 300 Green Houses in 32 states. These homes house only 10 to 12 residents that live in a housing center and share an open kitchen, dining room, and living room. Specially trained CNAs work exclusively in 1 house—making meals, doing laundry, socializing, helping residents pursue their interests, and looking for early signs of health issues.
“All the features that make them a great place to live also make infection prevention and control easier,” according to Susan Ryan, senior director of the Green House Project. Both of these organizations believe few individuals would choose to live in LTCFs if there were more viable options to allow them to stay at home. Under Medicaid law, states are required to pay for nursing home care for anyone who qualifies. States are not required to pay for the home- and community-based services that would help seniors stay in their homes. This is why LTCFs have become the default for many.
What Else Needs to Change
AARP representatives met with more than 36 experts.11 Here are some additional suggestions for change that came out of the meeting:
MORE REGISTERED NURSES
LTCFs with higher staffing levels of registered nurses (RNs) did better at controlling SARs-CoV-2 and reducing death, according to results from a study at the University of Rochester Medical Center. Facilities with at least 1 positive COVID-19 case had a 22% decline in cases for every additional 20 minutes of nursing coverage, the results showed. But federal laws and regulations only require LTCFs to employ an RN for 8 consecutive hours a day, leaving 16 hours with no RN coverage. Federal law also allows states to grant waivers to LTCFs that can’t meet the regulations even though regulations for RN staffing were put in place as part of the Nursing Home Reform Act of 1987. The legislation was in response to a congressional study that found that many Americans were receiving poor medical attention in LTCFs and that some experienced neglect and abuse. More than 30 years later, this is still an issue.
PARTNER WITH HOSPITALS
During the pandemic, some hospitals began working with LTCFs to provide testing and expertise on infection control and use of PPE. This type of partnership helped prevent major outbreaks in LTCFs that would have overwhelmed emergency departments.
Unless funding for home- and community-based services is substantially and steadily increased over the next several years, the failures of the current LTCF system will worsen. The US spends less of its GDP (1%) on LTCFs than virtually every other wealthy country. Moving to a higher level of GDP spending on LTCF services would enable expansion and improve access to community-based programs and make it possible to pay care workers a livable wage, health care benefits, and sick leave. There would be funds for transitioning from the traditional nursing home of 100 beds or more to a smaller, homelike, individualized care facility.
IMPROVE OVERSIGHT, REPORTING
On paper, the rules and regulations for operating safe LTCFs are detailed and strict. However, advocates for LTCF residents say that they are not strictly enforced. Sen. Bob Casey (D, Pennsylvania), who is chairman of the Special Committee on Aging, says that COVID-19 has “supercharged” the need to root out nursing homes that are failing residents. Casey and Sen. Pat Toomey (R, Pennsylvania) introduced legislation, also supported by AARP, that aims to hold nursing homes more accountable.
Approximately 70% of nursing homes are for-profit entities, and many are part of large, complex, and often opaque organizations. Ending the for-profit ownership model that dominates the industry—especially the private-equity investment model of flipping properties for big, fast returns—could possibly help.
So what’s changed since COVID-19 arrived and took the lives of more than 186,000 residents and staff at LTCFs as of December 2021? The pandemic emphasized the need to better prepare LTCFs for future outbreaks, especially in facilities that are home to an older, more frail population. The federal government has taken some actions. It is requiring LTCFs to self-report COVID-19 cases and deaths at the federal level, order testing, provide limited PPE and other resources to LTCFs, establish requirements for education on vaccines, offer COVID-19 vaccines to residents and staff, report LTCF resident and staff vaccination status, and require LTCF staff vaccinations.14
Renewed awareness has brought more government and regulatory oversight. Better wages, working conditions, and benefits for LTCF staff are being discussed. More innovative thinking, such as virtual family visits, “hug” rooms, facility design, and telehealth/telemedicine, is in the works. The staff and leaders of LTCFs, and the 1.5 million people they care for, deserve Americans’ attention and action to make it through this evolving crisis and look to a future where this loss of life will never happen again.
SHARON WARD-FORE, MS, MT(ASCP), CIC, is an infection prevention consultant located in Chicago, Illinois. She is also a member of the Infection Control Today® Editorial Advisory Board.
AARP is one of the organizations monitoring how long-term care facilities (LTCFs) weather the COVID-19 pandemic. LTCFs have been particularly hard hit by SARS-CoV-2. Of the approximately 780,000 individuals in the United States who died from COVID-19 as of early December 2021, approximately 186,000 (nearly 24%) were residents and staff at LTCFs. Deaths at LTCFs were declining as of December 2021. Unfortunately for the already understaffed LTCFs, staffing shortages were on the rise.