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COVID is shaping the evolution of nursing homes, experts say

Nursing home residents in Uniondale in August 2011.

Nursing home residents in Uniondale in August 2011. Credit: Newsday/Jessica Rotkiewicz

ALBANY — Nursing homes of the near future may look less like hospital complexes and more like small, cozy homes with eight or 10 residents, which will include sanitized "safe rooms" for family visits and employ robotics and indoor drones to serve residents, according to experts nationwide.

They said the staggering death toll from COVID-19 in nursing homes is forcing a revision of a system that, by its design and traditional practice, is ill-prepared and ill-suited to deal with such threats.

"COVID has amplified what was already a terrible problem and it’s really made it much more obvious," said Howard Gleckman, senior fellow at The Urban Institute in Washington.

"The pandemic’s devastating impact on nursing homes is the result of our nation’s inadequate attention to the needs of residents and staff in long-term care facilities," said Terry Fulmer, president of the John A. Hartford Foundation, which supports research to improve elder care. "As a nation, we have not invested or planned for taking care of people as they live longer." The foundation is supporting a national study on improving nursing homes after the pandemic.

The pandemic, which took more than 100,000 lives nationwide in nursing homes and more than 15,000 in New York State homes, is yielding lessons from the tragedy, experts said.

One revelation was made clear early to Dr. Morgan Katz, an infectious disease expert at Johns Hopkins University: Keep most infected residents in their nursing home.

"My goal was to keep them out of hospitals to prevent a surge in the acute care system back in early March," Katz said. "There was a huge number of [nursing home] residents that were testing positive that didn’t need to be hospitalized and if they were all sent to the hospital, they probably would have overwhelmed the system. Obviously, it’s pretty jarring for these residents to have to go to the hospital, so if it can be treated in-house, we certainly tried to do that."

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In New York State, nursing homes sent infected residents to hospitals for care, and then the residents were returned to nursing homes to recover.

Some relatives of nursing home residents as well as Republican and Democratic legislators have argued that bringing COVID-19 patients back into nursing homes under a March 25 guidance from the Cuomo administration exacerbated the spread of the virus in the homes. Cuomo has said state Health Department records show 98% of homes that accepted COVID-19 patients who had been treated at hospitals already had the virus among its residents.

The issue continued to heat up after a top aide to the governor acknowledged that the administration had delayed in giving the State Legislature data on the deaths of nursing home residents. After that acknowledgment, the U.S. attorney’s office in Brooklyn and the FBI last week opened a criminal investigation into the administration’s handling of the virus in nursing homes, according to sources.

Instead of sending COVID-positive residents to hospitals and back again, Katz said Johns Hopkins and Maryland hospitals created "scrappy teams" of hospital workers who went to nursing homes with which they have been paired to keep one or two cases from becoming a major outbreak.

"If a nursing home resident tested positive, then we would immediately reach out to that nursing home and say, ‘Hey, we’re going to send a team out to test your facility, do you need PPE? What are your needs now?' And we would have constant communication."

Other discoveries included a University of Rochester study that showed that registered nurses were the "linchpin" to respond early to the virus and their presence was a major factor in whether a nursing home had more or fewer COVID-19 infections and deaths. In addition, Minnesota is finding success for patients and in reducing government costs by keeping seniors with low medical needs out of nursing homes and into services provided at senior centers or at home.

There is also growing support for augmenting or replacing nursing home complexes with small homes of eight or 10 residents with common kitchens, some resident staff and some visiting nurses and doctors. This experimental housing in some states have proved better for many patients’ care as well as showing signs of reduced COVID-19 infection, experts said.

"Smaller, more homelike environments are optimal for long-stay nursing home residents, including those with dementia," said Dr. Joseph G. Ouslander, a professor of geriatric medicine at the Florida Atlantic University’s Schmidt College of Medicine.

The goal is a more comforting environment while still providing medical care as needed, said Bei Wu, a New York University professor and director for the Global Heath and Aging Research.

"We can think of building small neighborhood nursing homes, that are situated in communities that residents are familiar with," Wu said.

Within nursing homes, change is already underway.

"We have learned to be flexible, to adapt to change, which is daily," said Stuart Almer, chief executive of the Gurwin Healthcare System on Long Island. "The future of nursing homes will be different."

Academics said that change should begin with higher compensation for direct care workers. Nursing homes faced low staffing levels before the pandemic hit nearly a year ago and lost more during the crisis to illness, death and other jobs that paid more. Low pay also often forced workers to take shifts at more than one nursing home, potentially spreading the virus, or to go to work when they were sick instead of staying home because they couldn’t lose wages.

But staff compensation is among many of the proposed changes that require greater funding.

Stephen Hanse of the New York State Health Facilities Association said nursing homes receive about $8.79 per hour in government funding per resident, less than "most folks pay their babysitter."

Most countries fund elder care through a tax for all citizens. But the United States chose to rely on private insurance for middle class and wealthier Americans, while poorer people could depend on nursing home care paid through Medicaid and Medicare. But with the cost of a nursing home typically at $10,000 a month. experts say, few Americans can afford the private insurance. The result is that most Americans, including those in the middle class and wealthier, rely on government programs that were intended for the poor.

"That’s become a public policy failure," said Gleckman of the Urban Institute.

The Urban Institute has a proposal to create a payroll tax to be used for that worker’s long-term care, similar to the benefit from paying the Social Security payroll tax, rather than requiring a prospective resident to turn over all his or her assets.

But it’s a hard sell for politicians who would have to sponsor the tax and for workers who would have to pay it.

"Everybody is in denial," Gleckman said.

The burgeoning need is also becoming unaffordable for governments, including New York where Medicaid funding to nursing homes has been trimmed three times in the last two years alone.

On Friday, Gov. Andrew M. Cuomo called for reform of nursing homes. He said the homes must stockpile protective gear, more aggressively test staff and residents during the pandemic, and establish salary caps for administrators and profit caps for for-profit nursing homes so that care isn’t sacrificed for profit.

"I will not sign the budget without this nursing home reform, period," Cuomo said.

Experts agreed the pandemic has created a turning point, and, "If we don’t step back and see the problems of the past, we are doomed to repeat this," said Michael Balboni, executive director of Greater New York Health Care Facilities Association.

"Our aging services infrastructure is headed toward collapse," said Katie Smith Sloan, chief executive of LeadingAge, a nonprofit think tank based in Washington that researches and advocates for aging Americans. "We can’t just put a Band-Aid on the systemic problems that the pandemic has made worse."

Proposals for improving nursing homes

Many ideas are being explored to make nursing homes safer for residents and staff in the next pandemic, while seizing the moment to improve elder care. Among them:

  • “Socialization bots” in the form of a playful seal or other animal that checks in on residents, passes along calls from relatives, and tries to brighten their day.
  • Indoor drones that can spot spills, such as urine, and quickly call for clean up, perhaps by a robotic, electrostatic device.
  • Self-driving wheelchairs that take patients to physical therapy or the cafeteria, all the while chatting away about the news or agenda of the day.
  • Gov. Andrew M. Cuomo plans to look at capping the profit that can be earned at for-profit nursing homes that are about 70% of the industry nationwide: “If you’re trying to make profit, it’s too easy to sacrifice patient care,” he said last week.
  • Alter enforcement of the many health regulations at nursing homes from a punitive system to one that seeks to find and share best practices.
  • Heftier fines, so a nursing home can’t accept the penalties as simply the cost of doing business.
  • Apps to constantly monitor a resident’s vital signs.
  • “Health passports” that show the test results and infection status of visitors, vendors and staff before entering a home.
  • Reduce isolation of residents to curb dementia, heart disease and strokes: “Social isolation has been a mental and physical health problem in nursing homes long before COVID-19,” said Bei Wu, director for research at the Hartford Institute for Geriatric Nursing at New York University.

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