COVID-19 and the Future of Long-Term Care

Daughter Carmen Gray and grandson Tyler Schrock visit with Susan Hailey on Mother’s Day at the Life Care Center of Kirkland, a long-term care facility linked to several coronavirus deaths in Kirkland, Wash., May 10, 2020. (Lindsey Wasson/Reuters)
The coronavirus pandemic has created an impetus for change in the way we administer congregate care to those who need it.

NRPLUS MEMBER ARTICLE U niversity of California, Berkeley urban-policy professor Carol Galante, writing in the New York Times last week, argued that “now is the time” for cities “to embrace density.” She worried that NIMBY types might be emboldened by a coronavirus that preys on the closely congregated, and insisted that society has “an obligation to ignore the short-term reactionary impulse to blame density for the spread of the coronavirus and instead use this opportunity to rethink the policies that impede the construction of new housing, at more price levels, in the places where housing is most needed.”

Galante’s opponents — you will not be surprised to learn — have long “cloaked” their opposition to further development with feigned outrage over things like “neighborhood character and traffic impacts,” meant to conceal their ostensibly unsavory motives. COVID-19, she worries, will provide them with another “rallying cry to maintain [their] sprawling fortress neighborhoods designed to foster exclusion.”

While Galante’s piece reads like a flailing attempt to salvage her imperiled commitment to “density,” she is right that the coronavirus pandemic will eventually pass, and that our debates over things such as urban policy will retain much of their pre-pandemic character when it does. Population density won’t disappear any time soon, and much less of our urban policy and related debates will change than those now wishfully touting a “new normal” would have us believe.

One source of population density has, understandably, received a lot of coverage of late: nursing homes. The buzzword that has defined the American long-term care debate for the past 40 years is the word “community” — read through any policy brief on “long-term supports and services” (LTSS) and you’ll find it saturated with euphemisms like “community-based care.” The underlying ideological assumption is that it is almost always better for someone who needs long-term care to be serviced “in their community” — with an at-home attendant, in a small group-home setting, or in an outpatient arrangement — than in a congregated setting like a nursing home.

To be sure, most people would agree that it is preferable for an elderly person to be cared for by their family, whenever possible, and that “putting grandma away” is not a preferable alternative to caring for her at home. But there are nevertheless many forms of “long-term care,” many different types of “long-term-care facilities,” and still more reasons why a person might require LTSS in the first place.

Just as population density has proven to be a handicap in fighting the coronavirus in cities and other urban centers, long-term-care facilities for the elderly and infirm have been especially vulnerable to the spread of the virus. The Washington Post reports that more than one-third of national COVID-19 deaths have occurred in “nursing homes and other long-term care facilities.”

It is worth noting that the phrase “long-term-care facility” is often used as a synecdoche for “nursing home,” which itself covers everything from skilled nursing facilities (SNFs) to assisted-living facilities to memory-care homes. In more normal times, each type of facility has a unique role in the provision of long-term care. But in the fight against COVID-19, they all face similar challenges, because they house elderly people — an already vulnerable population made more vulnerable by the virus — in relatively close proximity to one another, making viral outbreaks within their walls more likely.

Other forms of long-term care present different challenges. Many group homes for persons with intellectual or developmental disabilities have struggled to contain COVID-19 outbreaks: Some in the IDD population struggle to understand and thus adhere to social-distancing guidelines, or have underlying health comorbidities that make them especially vulnerable to the virus. Psychiatric hospitals and intermediate-care facilities for the developmentally disabled have struggled in different, but still profound, ways.

All of which raises the question: What should change in congregate-care settings when the pandemic ends? There will certainly be calls to abolish them outright in favor of a universal, “community-for-all” regime, but — to borrow from Galante — we should avoid that “reactionary impulse.” It is not always possible to offer effective “community-based” long-term care to the many different populations that need it; severely demented adults, for instance, are often a danger to themselves or others, and require the more structured environment of a state hospital or memory-care facility.

One plausible long-term change might be prompted by current CDC coronavirus guidelines. The CDC is telling nursing homes to use internal “COVID-19 care units” for affected patients, isolating them from other residents. This, if taken to its logical conclusion, might inspire a return to the spacious facilities pioneered by the more rural “cottage-plan” model of congregate care that flourished in the early 20th century. The cottage plan is a campus-style arrangement in which residents reside in separate buildings on a large plot of land, rather than being consolidated into a drab and clinical central facility. A return to something like it would ward off future outbreaks by making it easier to isolate affected residents, while also helping to make long-term institutional care more humane and home-like for those who require it.

Crucially, the fact that COVID-19 is spreading more aggressively in poorly ventilated buildings might inspire a renewed focus on architecture, reviving a more beautiful and intentional approach to facility design. The beauty of the spaces we inhabit matters, and it matters all the more to people in long-term care who spend a great deal of time indoors, on facility grounds.

Congregate care will remain with us when the coronavirus pandemic ends. We ought to learn what lessons we can from our present crisis to better structure and administer such care in the future.

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