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Virus puts focus on nursing homes

Senate addresses ways to do more to protect seniors from coronavirus

As the coronavirus pandemic has matured in Pennsylvania and nationally, two opposite but complementary impulses have emerged: to reopen general society, but to tighten the cloistering of older people, especially those in long-term care facilities, where the virus has been most lethal.

On Thursday, a U.S. Senate hearing that included Pennsylvania’s Bob Casey focused on what more can be done, given that people over 65 account for 80% of COVID-19 deaths, while those in nursing and personal care homes account for two-thirds of Pennsylvania’s fatalities.

“We need to put a moat around them,” said Sen. Martha McSally, R-Arizona.

“Seniors are at increased risk, due to the inexorable waning of the immune system” — and chronic conditions that accompany old age, including cancer and heart, lung and kidney diseases, testified Mark Mulligan, director of the Division of Infections Diseases at NYU Langone Health.

It’s not surprising that nursing homes have become havens of infections and death, according to testimony from Tamara Konetzka, a professor in the Departments of Public Health Sciences and Medicine at the University of Chicago.

Large numbers of older people with multiple health issues live there in close quarters, needing hours of hands-on care every day, making social distance impossible, she testified. There are frequently shortages of workers, who thus often need to care for both infected and non-infected residents, she said.

“Given asymptomatic spread and inadequate testing, staff often do not know which residents are infected,” she said.

Moreover, especially early in the pandemic, nursing homes frequently competed with hospitals for personal protective equipment, which was in short supply, and often lost that competition, because officials were more focused on hospitals and the potential for them being overwhelmed, according to Konetzka.

“These circumstances (lent) an aura of inevitability to the spread of COVID-19 in nursing home settings,” she said.

Further exacerbating the problem was the dual role of nursing homes, which provide both post-acute rehabilitation, generously funded by Medicare, and long-term care, frugally funded by Medicaid — which created an incentive for taking residents back who’d been hospitalized for COVID-19 treatment, she said.

“Directly accepting post-acute patients with COVID-19 may help to sustain key relationships with hospitals but may simultaneously endanger vulnerable long-term care residents,” Konetzka testified.

The homes that have fared least well during the pandemic have been those with the lowest percentage of white residents, Konetzka said.

“Because people who need nursing home care usually want to stay close to home, nursing homes are often a reflection of the neighborhoods in which they are located,” she testified. “Consistent with racial and socioeconomic disparities in long-term care historically and in pandemic-related deaths currently, nursing homes with traditionally underserved populations are bearing the worst outcomes.”

Homes with the lowest percentage of non-white residents were twice as likely to have cases or deaths as those with the highest percentage of white residents, she said.

Conversely, “we found no meaningful relationship between nursing home quality and the probability of at least one COVID-19 case or death,” she wrote.

To correct the disparities that led to such outcomes, government needs to begin providing resources directly to facilities, help older people currently funded by Medicaid get care at home and enforce higher data and transparency collection standards for homes, so that experts can figure out a better way to do things, according to Konetzka.

Homes need to be able to provide regular and rapid testing of all residents and staff, whether they have symptoms or not, and to separate the infected from the non-infected, which means they’ll need more staff, so workers don’t need to care for both, Konetzka testified.

It’s challenging, given that most hands-on care in homes is provided by nurses’ aides, who generally earn minimum wage and often have no paid sick leave or health insurance, with oversight and skilled care provided by registered nurses, who “would often rather work in hospitals, which often offer higher wages and better working conditions,” Konetzka said.

In homes that have fared the worst, most such staffers are non-white, low-income and dependent on public transportation, and they live in neighborhoods with other essential workers — all of which makes it difficult to practice social isolation, according to Konetzka.

They are “more likely to be sick, to have caregiving responsibilities for children or other family members, and to be facing financial hardship,” they’re more likely to fear getting sick themselves if they come to work and — paradoxically — more likely not to stay home, even if they are feeling sick, according to Konetzka.

It would help if they would be given “paid sick leave, guaranteed coverage of health care costs, hazard pay” and possibly the use of hotel rooms to prevent infecting family members, she testified.

Homes also need plenty of personal protective equipment and technical assistance and training, given that 40% of nursing homes were cited with inadequate infection control in 2017, according to Konetzka.

“Surge teams” from outside would help, she said.

Home care is growing, with the help of medicaid adjustments, which is good, but the prospect of home care presents families with difficult decisions regarding level of need, effects on employment, stress levels, cost and difficulty of finding the help, according to Konetzka.

There are further complications with home care connected to the pandemic, as people may fear to enter a nursing home, yet also be fearful of caregivers who treat other clients entering their own homes, Konetzka said.

Long-term reform is needed, she said.

“The structure and level of nursing home funding, or long-term care funding more generally, has to change,” she testified. “At least, Medicaid rates need to be substantially higher.”

Better yet, “the fragmented system of state-specific payment rates and cross-subsidization from Medicare (should) be eliminated altogether, consolidating long-term care payment into one consistent program,” she testified.

By the numbers:

New/total COVID-19 county cases: Blair 5/44 (1 death); Bedford 4/36 (2 deaths); Cambria 1/55 (2 deaths); Centre 3/136 (5 deaths); Clearfield 0/33; Huntingdon 6/221 (includes SCI Huntingdon 155 inmates, 2 deaths; 47 employees)

Area new/total cases: 19/525

New/total cases statewide: 980 (up 31 percent)/65,392

New/total deaths statewide: 102/4,869, 7.4 percent of positive cases

New/total negative tests in area counties: 386/8,941

New/total tests in area (new positives plus new negatives): 387/9,466, 1.8 percent of population in Blair; 1.6 percent of population in area

New/total negative tests statewide: 10,270/303,514

New/total tests statewide: 11,250/368,906; 2.8 percent of population

Infection rate (percent of population with confirmed positives) region/state: 0.08 percent/0.51 percent

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