Inside the Pandemic's Most Deadly Targets: Nursing Homes
As nursing homes across the country continue to emerge as the most deadly hotspots of coronavirus infections, the University of Pennsylvania's Leonard Davis Institute of Health Economics (LDI) convened a virtual seminar of top experts to discuss why this is happening and what can be done to prevent it in future epidemics.
Titled Caring for Patients After Hospital Discharge During a Pandemic, the session was the fourth in an ongoing series of LDI "Experts at Home" seminars bringing together scientific authorities to discuss various aspects of the current COVID-19 crisis.
This infection has been like no other infection we've ever managed in a nursing home setting. It's key feature is asymptomatic spread — the infection is really contagious in both staff and patients who have no symptoms.
"When we decided to host this event," said seminar moderator and LDI Policy Director David Grande, MD, MPA, "we were a bit hesitant to use the word crisis but I do think that is where we are today. The World Health Organization has announced that up to half of those who have died from COVID-19 in Europe were residents in long-term care facilities. We've heard similar numbers, even from one of our nearby counties here in the Philadelphia region."
High fatality rate
Currently, coronavirus deaths among residents of nursing homes are reported to constitute about half of Pennsylvania's known fatalities from the disease. In New Jersey, more than 95% of long-term care facilities report positive cases. Nationally, a New York Times analysis calculates that 10,500 nursing and long-term care facility patients have died of the virus so far.
"This infection," said panelist, geriatrician and Medical Director of a local skilled nursing facility (SNF), Joshua Uy, MD, "has been like no other infection we've ever managed in a nursing home setting. Its key feature is asymptomatic spread — the infection is really contagious in both staff and patients who have no symptoms. Here's how it works in most of the nursing homes I know about: once they identify their first case and then swab the rest of the facility or wing, they go from one case to ten or twenty in about a week, because the infection was already quite present."
"Social distancing isn't possible in nursing homes," explained Uy, who is also an Associate Professor of Clinical Medicine at Penn's Perelman School of Medicine. "The patients require hours of daily care in very close quarters, and no nursing home has enough testing, personal protective equipment (PPE), or staffing to deal with this infection that actually takes out a lot of the staff just as the facility is trying to increase its capabilities."
It's just so horrible that as we have increasing care needs in this pandemic, our workforce is actually shrinking."
Moderator Grande noted, "There's been a huge amount of attention to how we think about protecting the workforce and patients in hospitalized settings but it's not clear that there's been as much attention focused on how to think about these issues and properly resource skilled nursing facilities in the same way."
Panelist, Postdoctoral Fellow at Penn's School of Nursing and LDI Associate Fellow Ashley Ritter, PhD, CRNP, concurred. "There's no backup care team for nursing homes right now," she said. "There's no substitute for the direct care workforce and we really need to protect them and plan to scale them moving forward. It's just so horrible that as we have increasing care needs in this pandemic our workforce is actually shrinking."
"These facilities' nursing workforce is predominantly female," said Ritter. "They often identify as a racial or ethnic minority and they're paid minimum wage or at least less than their hospital counterparts to take care of individuals in nursing homes. And they've been treated as an expendable resource in many places with extremely high rates of turnover and burnout. The common practice of using staging agencies to fill the gaps in your workforce falls short in very significant ways when you're facing a pandemic."
"Without adequate personal safety equipment in these facilities, we're going to continue to lose lives," Ritter continued. "We need to create systems that can distribute personal protective equipment in an equitable fashion, and much of that needs to be done at the state and local department of health level."
Ritter is also frustrated by the press coverage of virus-ridden long-term care facilities. "I think one of the biggest things we could do is stop calling nursing homes 'death pits'," she said. "Behind every sobering story are five other stories of frontline workers facing considerable personal risk as they treat very vulnerable individuals with dignity and skill. We must tell these stories."
In many ways, the Coronavirus pandemic is revealing the strengths and importance of home care.
Another major theme of the seminar was the widening trend of sending post-acute care patients home rather than to a skilled nursing facility after they've been discharged from a hospital. This "home care" movement has been growing in recent years as various kinds of communications technologies have made it possible for clinicians to effectively treat many kind of patients remotely. The pandemic has greatly increased the movement in a way likely to influence this area of health care delivery far beyond the current crisis.
"In many ways," said panelist and Chief Medical Officer of Penn Medicine at Home Nina O'Connor, MD, "the Coronavirus pandemic is revealing the strengths and importance of home care because we now have a situation in which, for many public health reasons, figuring out ways to care for sick patients at home is actually better than sending patients to facilities."
Home care tech
O'Connor explained that the kinds of technological support continue to grow as they are customized to specific patient needs. She noted one benefit of the technologies was how enabled a home health care agency to check in more often with more people than home visits would. Some home health agencies are providing technologically challenged patients with very simple pulse oximeters and thermometers, then calling those patients on the phone to collect the data. "PulseOx" meters are small, noninvasive devices that clamp onto a patient's fingertip and provide liquid crystal display readouts of oxygen saturation and pulse rate.
"We also work with a group using tablets delivered to their home and that allows us to call them on the tablet twice a day, do a video visit, check their vital signs. It's almost like hospital-level monitoring and has worked well, even for older patients. At the high end, we do have a group of patients who are very technologically savvy and we can instruct them to download an app to their own device and use other types of machines we mail out to them."
Given the challenges that skilled nursing facilities are facing right now, if it was me or my family member, I would strongly encourage them to go home.
The decision of whether to have a family member being discharged from the hospital sent to a nursing facility or home care is one now facing many families. Panelist and leading national research expert on post-acute care systems, Rachel Werner, MD, PhD, discussed the tradeoffs between the two. Her research in the pre-COVID era looked at discharged patients "in the middle" who could have gone to either a skilled nursing facility or into home care.
"What we found then, not surprisingly, was that patients who go home with home health are more likely to be readmitted to the hospital within 30 days of discharge," said Werner. "There appears to be a tradeoff in terms of outcomes as well as a tradeoff in terms of costs. Patients who go home are much less expensive to the insurer than patients who go to a skilled nursing facility. As a result there has been a big push to get people home instead of into skilled nursing facilities."
SNF vs. home care decisions
Werner, who is also an economist, practicing physician and Executive Director of LDI, was asked what advice she'd give a family facing this decision about a loved one's post-acute care in this time of pandemic.
"It's a hard question," Werner answered. "But given the challenges that skilled nursing facilities are facing right now, if it was me or my family member, I would strongly encourage them to go home."
She noted one issue not getting a lot of attention is the health affect of socially isolating often frail, elderly patients in nursing facilities that now prohibit visitors as an infection control measure. "I think that is really hard, and that a combination of not being socially isolated and the potential to get a similar level of care at home swings the pendulum for me to suggest that people go home," Werner said.
Fixing the cracks in long-term care
Closing out the seminar with a longer view of issue, Werner said "I think if we want to save lives, we need to do widespread testing and contact tracing for people in nursing homes, the workforce and for the community at large. A year from now we're going to look back and say 'I'm really glad we did that' because that is going to save lives."
"If we've learned one thing as we've moved forward through this pandemic, it should be that the long-term care system in this country is fundamentally broken and that we have undervalued it and underpaid for it for decades. It's become very apparent through the COVID pandemic that this is true because of all the struggles people have described in this seminar today in the delivery of care to sick patients and the keeping of infection under control in these facilities. But it's not just the pandemic that is causing these problems. We need to think about how we're going to ultimately fix the system by having a universal way to pay for long-term care for everybody in this country in a way that fully compensates the people who are providing it."