The Morning Jolt

Politics & Policy

We Need to Take a Hard Look at Nursing-Home Policies

Margaret Hildebrandt, 93, poses for a photo while in self-quarantine due to the coronavirus, Sunderland, Md., March 18, 2020. (Linda So/Reuters)

On the menu today: a deep dive into how different state governments are handling nursing home lockdowns and reopenings, and note about South Korea’s handling of the pandemic.

Stop Yelling at Beachgoers and Start Yelling at Governors over Nursing-Home Policies

When confronted with terrible news, the immediate instinct of far too many Americans is that it must somehow be the fault of the people they already disliked. The Babylon Bee’s satire was painfully accurate once again with their recent headline, “‘Those Dumb Red-Staters Going To The Beach Deserve To Die,’ Man Tweets From New York Subway Train.”

On March 30, the American Health Care Association and National Center for Assisted Living issued updated guidelines, based upon CDC findings, declaring that, “unless a person is tested for COVID-19 and negative before admitting them to your building, you should assume the person has COVID-19 regardless of their having or not having symptoms . . . We strongly urge [long-term-care] facilities to begin now creating separate wings, units or floors by moving current residents to handle admissions from the hospital and keep current resident separate, if possible.” This was typed out in bright red font for emphasis.

On March 20, the Society for Post-Acute and Long-Term Care Medicine issued a statement declaring, “nursing homes should not be forced by local hospitals or officials to accept new admissions who demonstrate clinical evidence or a positive test for active COVID-19, unless they are considered non-infectious based on current CDC guidelines.” The California Association of Long Term Care Medicine issued a similar resolution. Dr. Michael Wasserman, the head of the group, told NPR, “If you push folks out of the hospitals to make space and you push them into nursing homes a couple weeks later, for every one of those you send to the nursing home, you may get 20 back in the hospital.”

All of these health associations and institutions grasped how dangerous it would be to have recovering but still potentially contagious patients in the same buildings as larger groups of elderly people who need care.

As noted late Friday, the state governments of New York and New Jersey enacted regulations that required nursing and assisted living homes to readmit residents who had been treated for coronavirus, whether or not they were fully recovered, in an effort to reduce the use of hospital beds. The New Jersey Department of Health explicitly prohibited the facilities from requiring patients to be tested for the virus before admission or readmission.

Yesterday, New York governor Andrew Cuomo reversed that policy. This policy has been in place since March 25, so for the past six weeks and four days, nursing and long-term care homes in New York state have not been able to say, “we won’t let that patient in, because we fear that patient could expose our other residents to the virus.”

California enacted this policy for ten days, then adjusted it; now the state is promising to pay senior and adult care residential facilities up to $1,000 per day to accept recovering coronavirus patients.

Michigan’s governor Gretchen Whitmer did not enact a policy requiring nursing and long-term care homes to take in recovering coronavirus patients. But the state of Michigan permitted long-term homes to take in these patients, as long as the patients were isolated and the homes determined they had sufficient personal protective equipment. By mid-April Whitmer required nursing homes and other long-term care facilities create “a separate unit” for residents who have tested positive for COVID-19, or send them to a facility in the region that has one. Meanwhile, the state’s lists of nursing homes with coronavirus cases were painfully incomplete.

Not every state did this. Louisiana explicitly banned the transfer of patients from hospitals to nursing homes if the patient has active coronavirus, has a pending test, or has undiagnosed, active respiratory symptoms.

Connecticut set aside four facilities — two of which had been previously vacant, two which set aside separate floors — to house recovering coronavirus patients. Washington opened specialty wings in three assisted-living facilities.

Back on March 29, Massachusetts moved residents out of certain homes to set up ones specifically for recovering coronavirus patients, and when the locals complained, the state’s Department of Public Health explicitly stated that the approach followed by New York, New Jersey, and California would be too risky: “Without designated coronavirus care sites, hospitals would have to discharge COVID-19 patients to any skilled nursing facility with open capacity, which could put the rest of the healthy residents at risk, a DPH spokesperson said.”

But it is worth noting that by April 24, the New York Times reported, “Nursing homes in Massachusetts are also being asked to take coronavirus patients, but only if they verify that they have adequate staff and protective gear and can isolate the infected. In return, those homes will collect 15 percent more in reimbursements for every Medicaid patient.”

Can anyone think of any potential danger from giving a nursing home a greater financial incentive to accept coronavirus patients?

In Pennsylvania, the problem was somewhat different. The Philadelphia Inquirer revealed this morning that by mid-March, the state health department had a “robust and aggressive plan” to respond to coronavirus cases in nursing homes . . . but for some reason state agencies just didn’t do what the plan called upon them to do:

The quick response plan was circulated within the Health Department, with emails showing staff nurses and others were asked to volunteer. In the third week of March, it was shared with providers, said Zachary Shamberg, president and CEO of the Pennsylvania Health Care Association, which represents more than 400 long-term care facilities.

But the plan was never fully implemented, and a similar — though far more limited — effort wasn’t activated until mid-April, long after major outbreaks had already taken hold.

(I am reminded of the city of New Orleans having a lot of plans for hurricane response and evacuation before Hurricane Katrina, and then not enacting them when it counted.)

Pennsylvania’s state government is also unwilling to say which long-term care facilities have coronavirus cases and deaths:

The Pennsylvania Department of Health has repeatedly refused to release data showing coronavirus deaths at specific long-term care facilities across the commonwealth.

Efforts by The Caucus, a publication of LNP Media Group, to obtain the names of affected long-term care institutions with coronavirus cases and resulting deaths have been rejected by the agency, which regulates, inspects and licenses the facilities.

Florida’s health department tried to work out agreements between hospitals and nursing homes; some nursing homes in the state have isolated patients returning from a hospital for 14 days, whether or not they’ve tested positive for the coronavirus. But the state is still dealing with a rising number of cases and deaths in these homes, in part because of insufficient testing of the staff working there:

There is little mystery behind what is considered the main culprit in this grim statistic: asymptomatic carriers — many of them long-term care staff members, who are getting tested infrequently or too late. But despite state efforts to ramp up testing, administrators at nursing homes and assisted-living facilities told the Miami Herald and Tampa Bay Times it is a piecemeal program that is failing to identify risk and completely contain the virus among the state’s most vulnerable.

All of these states barred visitors to nursing homes, cutting off the elderly from their children and grandchildren. And then some states brought in coronavirus patients, and then I guess they just hoped that the ventilation systems wouldn’t spread the virus too much.

These decisions are so spectacularly wrongheaded, so epically foolish, that those responsible deserve to be remembered forever. Think about how much ink has been spilled, telling us what a great job is being done by Cuomo, Whitmer, New Jersey governor Phil Murphy, California governor Gavin Newsom, and Pennsylvania governor Tom Wolf, and how lucky those states’ residents are to have such visionary and indefatigable leaders.

You will probably see someone citing these numbers and declaring that the death toll from this pandemic is the result of a handful of blue state governors. That is not quite accurate.

Even if a state enacted a strict policy like Louisiana, it cannot guarantee that the coronavirus will not end up in a nursing home or long-term care facility. According to the New York Times, Louisiana ranks 10th in the country in the number of deaths in long-term care facilities with 784 — 35 percent of the deaths in the state. Because coronavirus patients can be asymptomatic, staff may be unknowingly spreading it around — or anyone who enters the facility, like deliverymen or paramedics. New York tops the list with 5,380 deaths in nursing and long-term care homes, but that sum is only 20 percent of the state’s total. New Jersey has 4,825 deaths in nursing and long-term care homes, 52 percent of that state’s total. Massachusetts ranks third in the country with 2,837 deaths, and 59 percent of that state’s total. Pennsylvania ranks fourth, with 2,518 deaths, making up two-thirds of all deaths in the state.

Even good policies can be enacted too late. Connecticut ranks fifth, with 1,627 deaths, 55 percent of that state’s total.

ABC News this morning: “The deadliest place for COVID-19 transmission remains in nursing homes, which now account for more than 26,000 deaths in the U.S., according to public figures released by 35 states and Washington, D.C. That means that of the data available, nursing homes account for one-third of the nation’s fatalities from the ongoing viral outbreak, a new ABC News analysis shows.”

For most of America, today begins week nine of quarantine, lockdown, social-distancing, and other measures. Across much of the country, the rules are getting loosened a bit, and communities are taking the first tentative steps to reopening. The chances are good that you’ve found the past eight weeks, at minimum, deeply frustrating, and perhaps even agonizing. Businesses closed, jobs lost, kids at home from school, everyone isolated, keeping six feet apart, wondering how much longer they can keep living their lives with just neighborhood walks and take-out and delivery and Netflix and every darn commercial beginning, “in these uncertain times . . .”

And all this while — with everyone in America sacrificed in the name of keeping the most vulnerable safe — state administrators deliberately placed those who were still contagious with the virus under the same roof as large groups of elderly Americans and just hoped it would work out okay.

ADDENDUM: Over the weekend, Michael Kim laid out a detailed firsthand description of South Korea’s far-reaching measures to handle the potential spread of the coronavirus — a level of invasive monitoring and mandatory quarantines that many Americans would find unacceptable. “If you’ve been to a place where someone who has coronavirus has also visited, someone will contact you to get tested and undergo self-isolation for another 14-day period . . . There’s absolutely no protests or demonstrations about the anti-freedom measures or invasion of privacy. I’m not an expert in Korean politics but it seems like everyone accepts these measures as required to address this pandemic.”

Kim’s description is useful to keep in mind every time you encounter a “why can’t the United States respond as well as South Korea has?” complaint. South Korea has a different culture, different expectations for balancing individual liberty and responsibility to others, a different level of trust in their government, and a smaller, more densely populated population. (Maybe if you’ve spent almost 70 years living with the threat of a sudden bloody invasion by your neighbors to the north, you listen to government warnings more and you don’t blow off talk of a deadly threat as hype.)

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