COVID and Long Term Care: Proposed legislation would set standards of care for seniors in long-term care facilities

Mike Perry will not engage in the blame game over COVID-19 deaths among residents in America's nursing homes.

Nor will many of his colleagues working in the industry exacerbated by the virus.

"There were a lot of dynamics going on," said Perry, CEO of the WellBridge Group based in Brighton that operates 26 long-term care facilities in Michigan including Rochester Hills, Clarkston and South Lyon.

For one thing nobody had ever experienced anything like it.

"I've been working in the industry for 30 years and have never gone through anything comparable. There were a lot of unknowns and concerns. Everyone was learning and getting guidance along the way," Perry said.

Now more than a year later, with COVID-19 cases in long-term care (LTC) facilities declining and with more studies coming out, the long-term care industry is taking a close look at what happened and making recommendations.

"We've learned a lot as an industry and as a nation and we're taking what we learned to create a better environment for our seniors going forward," Perry said.

"We need to ask ourselves, 'What have we learned today that can help us tomorrow?" said Kevin Evans, who is the executive director of the Martha T. Berry Medical Care Facility, a public skilled-nursing center in Mount Clemens that operates in partnership with the county.

Prioritizing Seniors

Early on in the pandemic, the Center for Disease Control warned that the risk of severe illness from COVID-19 increases with age.

"As soon as we knew that we should have moved to protect our seniors in nursing homes but instead they were the last to get protected," Evans said, recalling his efforts in March to have a resident at the county facility tested for COVID.

The woman was a patient at a hospital in northern Michigan who had been transferred to Martha T. Berry. She said she felt good and she had no symptoms at the time but it was suspected that she had been exposed to COVID-19.

Since the nursing home was unable to get her health records because of the lockdown, Evans sent her to the hospital to be tested. 

"The hospital said, 'We can't approve her for a test because she doesn't fit the criteria,'" Evans said. "I told them, 'If she does have it, God help us all.'"

She had it and, shortly after her arrival at the nursing home, eight other residents had it too.

On March 27, 2020, the nursing home had asked the health department to test all staff and residents, and were told no. "Our medical director called and said he was given the direction to test only those that meet the symptom criteria, again per the CDC guidelines," Evans said, who found out later that the county only had 55 tests.

No one was aware at that time that asymptomatic infections were acting as a 'silent driver' of the pandemic.

On May 15, 2020, Evans was finally able to test staff members, but despite ordering 350 tests so that everyone providing care could be included, only 100 were sent.

He had the same problem with Personal Protection Equipment (PPE).

"We ordered an extra supply of PPE when we heard COVID-19 was coming," Evans said, but their order never came.

"We were told that the Federal Emergency Management Association diverted the shipment away from us," Evans said.

Looking back on what they learned having adequate PPE is what helped the staff in LTC turn the tide.

"When we went to strictly using N95 masks, that's when we started to see some improvement in our numbers," said Perry. "I think moving forward we should have standard PPE that we could procure in case of another outbreak."

Conflicting Directives

During the pandemic and to this day, Evans has kept meticulous records of the directives that he received, from the president of the United States and governor of Michigan to the CDC, Michigan Department of Health and Human Services (MDHHS) and Michigan Department of Licensing and Regulatory Affairs (LARA).

He received 600 such directives and many of them were conflicting.

"If I followed one I would be violating the other," said Evans, who credits these agencies for doing the best they could under the circumstances. But having no single voice for all made it very difficult at times.

At the start of the pandemic for example, he and his staff followed infectious disease protocol and began installing plastic walls to separate portions of the nursing home. They were told by the fire marshal to take them down. The order was changed later but did not have the same impact as it would have had. 

Early on, Evans also had to follow executive orders saying all health care facilities must prohibit visitors even though Centers for Medicare and Medicaid Services (CMS) stated, “it is expected the facilities employ core principles of infection prevention and coordinate visitation whenever possible.”

The Alzheimer's Family Center said the strategy of social isolation used to protect older adults from getting COVID-19 actually had adverse effects on them, especially on those individuals with an Alzheimer's disease or dementia diagnosis.

"Doctors have reported increased falls, pulmonary infections, depression and sudden frailty in patients who had been stable for years," according to a report by the Washington Post, whose analysis of federal data showed that "more than 134,200 people have died from Alzheimer's and other forms of dementia since March. That is 13,200 more U.S. deaths caused by dementia than expected, compared with previous years."

Among the many sons who found themselves shut out of their parent's lives was Ray Jasion of Shelby Township, who later became a voice for families that fought to prevent the state from setting up COVID-19 hubs in nursing homes. Jasion's father was sent to a nursing home for rehabilitation before COVID-19 hit, which became one of regional "hubs" that took in COVID-19 patients.

A recent study by Harvard Medical School found that larger nursing home facilities located in urban areas with large populations were most likely to have reported cases, particularly if they were in counties with a higher prevalence of COVID-19 cases.

Still, many families feel sending seniors with COVID-19 to nursing homes with patients who were otherwise healthy was among the biggest mistakes made during the pandemic, and have sought legal action against the state because of it.

"It was extremely stressful to watch my dad ask me daily to get him out of this nursing home," said Jasion. "My brother and I finally were able to get him out of the nursing home and into an assisted living facility."

Nursing Home Reform

The coronavirus pandemic has been an unprecedented, once-in-a-century public health crisis.

As of March 2021, more than 29 million Americans have been infected and more than 520,000 have died, although a new study said it could be more like 900,000.

Long term care facilities including nursing homes and other congregate facilities for older adults have been considered the epicenter of the pandemic with more than 1 million cases and 170,000 deaths having been linked to these facilities across the country.

Macomb County had a total of 698 deaths among senior residents in its LTC facilities reporting to the CDC. Twenty-two staff members also died. Oakland County's facilities reported 599 deaths among residents and three staff. Wayne County had 1,063 deaths among residents. They also had 27 staff members die of COVID-19. The state also tracks long-term care facility cases and deaths.

According to the American Health Association and National Center for Assisted Living, the nonprofit that represents the industry, researchers tracking COVID-19 found that while LTC residents made up a small percentage of the total cases in the United States and worldwide, they were a disproportionate share of each country's deaths.

"This research demonstrates the vicious nature of the virus on frail and elderly adults with comorbidities," said the AHCA/NCAL, which represents more than 14,000 facilities across the country.  "Protecting older adults from this virus should have been our nation's top priority. It was not and, tragically, the seniors in our long term care facilities were left behind. It is critical that we figure out what happened, why it happened, and what we can do to keep it from ever happening again. It is time for the country to decide if it will make sacrifices to help those who have sacrificed so much for us. It is time for bold, transformative, and meaningful action."

For its part the AHCA/NCAL has proposed the Care For Our Seniors Act.

The comprehensive reform package, designed to support better pandemic management and strengthen the overall care in the nation's nursing homes has four main reform principles with policy proposals in each of the key areas including:

Clinical: Enhance the quality of care in nursing homes by developing clearer standards for infection preventionists, requiring that each nursing home have a registered nurse on-staff, 24 hours per day, and requiring a minimum 30-day supply of personal protective equipment in all nursing homes.

Oversight: Implement improvements establishing a more resident-driven system by developing an effective oversight system and processes that support better care and protect residents. This would include implementing a process to help turn around or close facilities that are chronic poor performers and adding customer satisfaction to the government's five-star rating system to help monitor the quality of a facility for family members and guide consumer choice.

Structural: Modernize nursing homes by conducting a national study on how to shift to more private rooms, which promote resident privacy, autonomy and dignity, as well as support infection control best practices.

Workforce: Strengthen and support our frontline caregivers by implementing a multi-phase tiered approach to attract, retain and develop more long term care professionals leveraging federal, state and academic institutions.

"This will address the longstanding challenges that have impacted the nursing home industry for years, long before COVID-19 brought them to the forefront," said Melissa Samuel, executive director of the Health Care Association of Michigan.

Help For The Future

Workforce shortages, for example, plagued nursing homes long before COVID-19 hit the U.S., but the pandemic worsened these shortages and left available workers stretched thin.

"We had a situation in the beginning where a nurse just up and quit. She was scared. She didn't know anything about the virus and she was worried about her family," Perry said, all of which was understandable at the time.

But others remained and the unprecedented challenges and traumatic experience of the past year have taken a heavy toll on caregivers, leading to considerable burnout among staff. Industry leaders are concerned that the profession will see a mass exodus of workers.

Outlined in the reform package proposed by the AHCA/NCAL are several solutions that will help to create a strong long-term care workforce for the future such as:

• Providing student loan forgiveness for licensed health care professionals who are new graduates and work in long-term care.

• Develop assistance programs for caregivers like affordable housing, housing down payments and childcare.

• Provide career ladder scholarships that would encourage staff to advance their career by becoming a registered nurse or other positions in aging services.

• Provide funding for universities who have shown graduation rates with direct correlation to long-term care hires.

• Pass common sense immigration reform that increases opportunities for foreign-born individuals to work in the long-term care profession. Expand the ability for international nurses to come to the United States.

"It's difficult work. It's challenging work with long hours. It's definitely a calling to come and do this type of work but it's also rewarding,' Samuel said.

Evans admits it has been a tough year for his staff.

Many of them went beyond the call of duty during the worst days of the pandemic, but they all remain dedicated to the facility and the people they have come to love as family.

“Many of our residents have lost so much, by having to leave a job they loved or a home they owned, and move into one room knowing that it may be their last home,” he said. “It’s an honor to be able to make a life worth living for them.”

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