What have we learned from the 50,000+ covid-19 deaths of residents and staff in long-term care facilities? As the pandemic spreads aggressively in states such as California, Texas, Arizona, and Florida, we are about to find out.
Multiple studies found that facility-based covid-19 cases and deaths from March-May closely tracked the experience in surrounding communities: If a facility was located in an area with a lot of covid-19, it likely would have an outbreak.
In those early cases, we saw facilities struggle with shortages of personal protective equipment (PPE) such as masks, gowns, and gloves. We saw severe staff shortages. Aides and nurses got sick, were afraid to come to work, or needed to care for their children.
Staff who did work commonly took moonlighting jobs in a second facility or in people’s homes. That likely increased the chances that they’d pick up the coronavirus. And because testing was limited and slow, aides—often asymptomatic– would bring the virus into facilities where it killed residents.
We also learned about the risks of combining in the same facility residents without covid-19 and those who test positive for the disease.
Will Florida learn from New York?
Will it be better this time? Or are we about to make the same mistakes in July as we made in April?
Take Florida. This week, the state averaged more than 9,000 new covid-19 cases a day. Its case rate of 45 per 100,000 is triple the national average. Overall, it has had 232,000 cases and nearly 3,900 deaths.
More than half–nearly 2,000–were residents and staff of the state’s long-term care facilities.
On July 10, the state’s nursing homes and assisted living facilities reported 2,817 active COVID-19 cases among residents and a stunning 4,922 cases among staff. Both are almost double what they were on June 25, and have increased almost daily for the past two weeks. One facility reported 103 active cases among its residents.
More than 142,000 Florida residents live in nursing homes and assisted living facilities. If the state’s nursing home death rate approaches, say, New Jersey’s at its worst, it could be looking at more than 15,000 covid-19 deaths.
What is Florida doing now?
Like many states, Florida bumped up its Medicaid payments to nursing homes—the extra $74 million was the first increase in more than a decade. But Florida’s tax base has been badly hurt by the covid-19 economic slump. Sales tax revenues in May were one-third lower than the year before. Thus, the state is now beginning a debate over deep budget cuts. Medicaid likely will be a target.
In an effort to relieve pressure on rapidly overburdened hospitals and protect current nursing home residents, DeSantis created a dozen covid-19-only nursing homes. That is a better choice than allowing covid-positive patients to move into facilities where those without the disease live. But continued slow testing makes it hard to know who has the virus and who does not.
Adding to the risk, the state also has many facilities with double, and even quad rooms—an extremely dangerous arrangement in a pandemic.
What could facilities do to slow the spread of covid-19? Long-term care facilities could learn from past experience and pay aides more. There is some evidence that facilities can slow outbreaks by giving staff raises in exchange for an agreement to work only one job.
They also could redesign care to limit the number of staff who have contact with each resident. One internal industry analysis found that pre-covid, as many as 20 nursing home staffers could interact with residents. Hard to imagine, but there are aides, housekeeping staff, food servers, social workers, physical therapists, nurses, managers, maintenance workers, cooks, and the like. In a hotspot such as Florida, each now carries a risk of spreading the virus.
Shamefully, the US still does not have an effective system for procuring and distributing masks and other PPE. Despite repeated White House promises, long-term care facilities continue to struggle getting this necessary equipment.
PPE and testing, again
In Florida, the state requires testing of nursing home and assisted living staff once every two weeks. That isn’t nearly enough.
Yet, facilities there say they continue to face shortages of test kits and, just as bad, delays in results. That mirrors what appears to be yet another national shortage. We’ve all seen the television images of miles-long lines for testing. Thus, even where testing is readily available, bottlenecks are growing in labs. And without rapid results, aides and residents remain at high risk.
As the Sunbelt pandemic explodes, most of the attention has been on young people hanging out, maskless, in beaches and bars. But if we have not learned the lessons from states like New York, the real victims, once again, will be frail older adults.