Last week, one of my patients at the nursing home died from a complication of COVID-19. She was given an option to go to the hospital, but she chose to stay at the facility that has been her home the last five years. She understood that she might die, yet she chose to remain among familiar nurses and aides during her final days.
Stories like this are common in adult homes and skilled nursing facilities across New York and the United States, but have not grabbed headlines like other isolated incidents have.
In my experience
I’ve practiced geriatric medicine for 35 years, including the last 20 as medical director of a 250-bed skilled nursing facility in Nassau County. To care for the most vulnerable members of society, we must be vigilant to prevent neglect and demonstrate self-inspection and constant process improvement. Many in the media, government and other organizations have taken a simplistic view about the high mortality that has occurred. While some of this has been fair and fact-based, too much has been sensationalized reports of “stacked bodies,” neglectful caregivers and abandoned families.
This is not what I have witnessed during the past six weeks or over my career. Nursing home and adult care workers are among the most-dedicated caregivers and should be recognized as such. In the United States, there are about 1.5 million people who live in 15,600 skilled nursing facilities. These individuals are mostly elderly, although a significant minority (15 percent) are younger than 65. Over the last several decades, hospitals have been incentivized to discharge patients “sicker and quicker.” The frailest of these patients have been discharged to skilled nursing facilities to recuperate and receive rehabilitative services. Because our patients are so vulnerable is why nursing homes are one of the most regulated and monitored sectors of health care. Staffing ratios are mandated and monitored. Eighteen specific quality measures are required by regulation and posted on the Nursing Home Compare public website. Nursing homes that participate in the Medicare or Medicaid programs (the vast majority of homes nationwide) have an unannounced inspection every year. The Centers of Medicare and Medicaid Services also publishes star ratings based upon these rigorous inspections, staffing ratios and quality measures.
The COVID-19 pandemic has presented an enormous challenge to our health care system. It should come as no surprise that the coronavirus has infiltrated nursing homes where large numbers of chronically ill individuals live in close proximity. Residents almost universally require assistance with dressing, toileting and feeding, and are dependent on staff. Consequently, staff and residents interact closely throughout the day. With a highly contagious virus, the environment and patients’ physical needs make transmission likely even with strict adherence to infection control standards. Add to this the reality that many patients and staff are completely asymptomatic during the virus’ early phases and it is not difficult to understand why nursing homes have become an epicenter of this illness.
We’ve done our part to minimize this risk. Early in the crisis, nursing homes in New York, through guidance by state Department of Health, restricted visitation in an attempt to limit incidence. Staff were mandated to wear masks and everyone entering the building was screened for symptoms. Residents showing symptoms were immediately tested and isolated. Group activities were eliminated and all meals were provided in patient rooms. Infection-control procedures, including correct handwashing and proper use of personal protective equipment, were reviewed with staff and monitored. Despite these actions, COVID-19 still found its way into most facilities, including my own.
Work worthy of praise
Nursing home employees have performed heroically throughout this emergency without much public adulation. They are among the lowest-paid professionals in the health care industry — nurses, aides, therapists, social workers and environmental personnel who have showed up and cared for patients. They demonstrated compassion, dignity and professionalism amid the scariest of work conditions. Many of them contract the illness and they all fear spreading it to their families.
As we plan for future outbreaks, we need to understand and correct the reasons for poor outcomes. Most people are familiar with significant advances that have been made in oncology, cardiology, gastroenterology and medical imaging. In my view, some of the most dramatic and important changes have been in the fields of geriatric medicine and palliative care. In 1981, both of these disciplines were in their infancy and have grown into full-fledged academic programs, providing a better understanding of the aging process and incorporating new information into the care of millions of our most vulnerable citizens. Health care professionals and the public are beginning to understand that managing chronic illness often requires an emphasis of “care over cure” and symptom management over diagnostic investigation. Improving our response to this crisis will require building on these advances, and continuing to focus on safe transitions between hospitals and nursing homes, increased availability of subspecialty care in nursing homes, and ongoing conversations about goals of care for frail patients with advanced illness.
Caring for elderly patients in nursing homes is extremely gratifying work that we are privileged to do. And for many like my patient who knowingly chose comfort over risk, I am forever grateful for the heroism shown by all my colleagues in nursing home and adult care facilities.
Howard Guzik, MD, is medical director of Northwell Health’s Stern Family Center for Rehabilitation. He’s also an associate professor of medicine at the Donald and Barbara Zucker School of Medicine at Hofstra/Northwell.
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