Nursing Homes, the Pandemic, and Caring Enough
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Meyers Primary Care Institute, a joint endeavor of University of Massachusetts Medical School, Fallon Community Health Plan, and Reliant Medical Group, Worcester, MA, USA; 2Division of Geriatric Medicine, University of Massachusetts Medical School, Worcester, MA, USA; 3Johns Hopkins University School of Nursing, Baltimore, MD, USA; 4Institute for Healthcare Improvement, Boston, MA, USA.
J Gen Intern Med DOI: 10.1007/s11606-020-06022-7 © Society of General Internal Medicine 2020
COVID-19 curves plateau and fall, the full extent of the A stragedy occurring in our nation’s 15,000 nursing homes is being revealed. In many areas of the country, nursing homes (often referred to as “long-term care facilities”) have struggled against nearly insurmountable odds, with reduced staffing levels due to illness, inadequate testing and personal protective equipment (PPE), and mounting morbidity and mortality. As of May 28, 2020, among 39 states reporting deaths related to COVID-19 in long-term care facilities, fatalities numbered nearly 40,000, and long-term care facility deaths accounted for 43% of all deaths related to COVID-19.1 In Massachusetts, a microcosm of the pandemic’s national impact on the nursing home population, the percentage of all deaths occurring in nursing homes, exceeds 60% (Fig. 1). While calls go out for investigations of outbreaks in lowrated nursing homes, many facilities, highly rated for their care, have been similarly affected. As long-term care policy expert David Grabowski has stated, “This is not a ‘bad apples’ problem; this is a systems problem.” Some think of nursing homes simply as just another healthcare setting; however, they are much more than that. Nursing homes are places in which residents live, eat, socialize, and spend their leisure time. In a pandemic, concerns about these settings extend far beyond the advanced age, multimorbidity, and cognitive and functional limitations of residents. Other vulnerabilities include multi-resident rooms and shared bathrooms, close physical proximity, inadequate infection control and prevention capabilities, and less advanced information technology systems than exist in most ambulatory clinics and hospitals.2 Limited Medicaid reimbursement, inadequate staffing, high staff turnover, and staff working at multiple facilities further complicate planning for and implementing infection prevention and control practices. This combination of factors, along with the lethality of COVID-19 infection in
Received June 3, 2020 Accepted June 30, 2020
older adults with multiple chronic conditions, has made the nursing home population uniquely exposed to the pandemic. There were early warning signs of an impending disaster in nursing homes. A COVID-19 outbreak in a long-term care facility in King County, Washington, first identified on February 28, 2020, highlighted the potential for rapid spread among residents of nursing homes.3 CMS first issued guidance on nursing homes and COVID-19 on March 4, 2020, related to the screening of all visitors and staff.4 This was followe
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