Published on May 14, 2020

  • Tight quarters and staff moving from room-to-room to provide close, personal care fuels the quick spread of the coronavirus through nursing homes.
  • An age-friendly health system focuses on 4 M's: what matters to the person, mobility, mental ability, and medication management.
  • Closing nursing homes to visitors during COVID had a substantial negative emotional impact on residents and their families.
  • Creative virtual visits have helped residents and families stay connected, but aren't always possible due to varying levels of cognitive decline.

Video Transcript

JOHN WHYTE: You're watching "Coronavirus in Context." I'm Dr. John Whyte, chief medical officer at WebMD. Today, we're going to talk about the impact of COVID-19 on nursing homes. And I'm delighted to be joined by two good friends-- Dr. Terry Fulmer, she is the president of the John A. Hartford Foundation, and Dr. David Grabowski. He's Professor of Health Care Policy at Harvard Medical School. Thanks for joining me.


TERRY FULMER: Glad to be here, John. Thank you.

JOHN WHYTE: Dr. Grabowski, let's start with what's the status of COVID in nursing homes? "The New York Times" has reported that nearly a third of all deaths from COVID-19 are occurring in nursing homes. Is that because of the population density of nursing homes? Is it because of comorbidities and age? Why are we seeing such a disproportionate impact on those that are most vulnerable?

DAVID GRABOWSKI: Well, thanks, John. Let's start with the obvious. Older adults live in nursing homes. They do have multiple chronic illnesses. But I think the answer is actually much deeper than that. The reason we're seeing such high death rates in nursing homes also involves just these close, congregate living environments that nursing homes often provide for older adults. We see many nursing homes around the country where residents are sharing rooms, sharing bathrooms, so it's very tight quarters for the residents.

It's also a function of the staff. And the staff are moving from room to room, providing very personal services, like bathing, and dressing, and toileting. And so if one resident on one end of the hall has the virus, it's likely to spread right down the hall, as staff continue to provide services for all of these residents. So it goes beyond just simply old, frail adults living in these homes. It's actually the services that they're receiving as well.

JOHN WHYTE: And then how do we improve the process, Dr. Fulmer? What should we be doing? You've been a big proponent, for years, in terms of age-friendly care. How do we do that in the setting of COVID-19?

TERRY FULMER: Thanks, John. So I think that there's so many variables going on. Certainly, the stealth nature of this virus, not knowing who has it, who doesn't have it-- if you test positive, what does that mean to the rest of the facility? As staff come and leave each day, they are immediately vectors without knowing it. And so there's so many variables.

When we think about age-friendly health systems-- and our organization, the John A. Hartford Foundation is very, very keen on getting to a point where we have an age-friendly health system which starts at your--


--should take you through the emergency room, to the nursing home, to your home, get you right back to your kitchen table. When we think about that, we focus on four Ms. And we talk about what matters to the older person. And so certainly, that's critical to get at. What are their advance directives? What do they think about palliative care? How does their family understand that? What do they feel about getting admitted to a hospital? Has anybody ever talked about a ventilator with them?

So the next thing is mobility. Think about the individuals in nursing homes right now. If you're in a room by yourself, and if there's limited staff, because so many of them are sick as well, is there mobility going on for that older person, to make sure that they stay as fit as they possibly can?

Medications-- are people getting their medications on time, and have their medication needs changed throughout this pandemic? And what's going on with those? And then, thinking about their mentation. So in nursing homes, we know that one of the major reasons to get admitted to a nursing home is cognitive impairment, or dementia, or Alzheimer's disease. All of those words get used by the public.

So if you have dementia, and somebody comes into your room with a mask, it's very frightening. If you ask a person with dementia to don a mask, that's not going to happen. So we're helping people with that. We have a daily nursing home huddle every day, 12 noon to 12:20, to try to solve these problems. Thanks.

JOHN WHYTE: Just like at a normal health system-- that's what they do. I want to get you both in on this question, which folks haven't been--


--I think, in terms of if we're-- let's be honest, we're banning visitors from nursing homes. And there's good reasons to do that in the setting of infectious disease. What impact is that having on the residents' physical health and mental health? Dr. Grabowski, let's start with you. What impact is that having? Is that a good policy? And when will it change? Is it going to exist for two, three years?

DAVID GRABOWSKI: I think it was a good policy at first. We really didn't know what we were facing with the virus. So it was very important that we close the facilities to visitors. This has had a major negative impact on the residents. And it's also impacted the families, by the way, and the staff as well. All three of those groups benefit when families are in close contact with their loved ones.

The residents, and the stories we're hearing out of facilities right now about these residents, it's incredibly sad. They're feeling lonely, isolated, scared. We've heard stories of residents not eating. They're agitated. As Terry just said, there's high levels of cognitive impairment in this population, so they really benefit from a routine and lots of contact.

And they're not-- their way off of their routine right now. And they're not getting that contact.

JOHN WHYTE: So how do you do that safely, Dr. Fulmer? How do you allow visitors in while we recognize the high transmissibility?

TERRY FULMER: We've heard some creative things going on around the country. You can count on families who want to be with their family to get as creative as possible. So certainly, for those who can afford it, they have been having good luck with iPhones and iPads, for those people who have the cognition, who have the mental capacity to use. We've heard about-- in New Hampshire, we heard about a nursing home that had a string quartet come into the courtyard and play. And so the staff could open the windows a little bit and get that to families.

We've heard about even the way in which people are putting materials on the wall-- pictures of families, pictures of yards, things that are familiar. So those are the safest ways, that's when you do it virtually. I think that it'll be a real challenge when we start opening up our nursing homes, to figure out how to do that as safely as possible.

We have seen, in Connecticut, for example, nursing homes that are dedicated COVID nursing homes now. And maybe that's going to be something that creates a safer way to aggregate people with the virus, and keep those with the virus-- who do not have it-- in a different place.

JOHN WHYTE: Dr. Grabowski, how would you create a policy that balances these different interests? And I recognize it could be based on local conditions.

DAVID GRABOWSKI: Absolutely. You most definitely have to take into account the local conditions. But everything Terry said is exactly right. And just to go a little bit further, in terms of our policy going forward, I think the key towards opening up nursing homes and beginning to allow visitors is really testing and personal protective equipment. And those are the two big asks right now for the nursing home sector. We need--

JOHN WHYTE: Are we doing diagnostic? Is it diagnostic testing? Is it antibody testing? Is it-- you know, we've had lots of these discussions. There's this concept of shield immunity, that we would see if front-line workers have antibodies. And those that do would be first. Is it visitors-- and how do we do that, Dr. Grabowski, when we have shortages of supply, shortages of the equipment that's necessary to perform the test.

DAVID GRABOWSKI: So first, on the shortages, we definitely need to ramp up our testing capacity. That a definite. Remember, going back to your earlier question, this is where the fatalities are occurring. This is ground zero for COVID. So if any group warrants increased testing, it's really the staff and residents at nursing homes. So let's direct resources to the problem. And the problem right now is in nursing homes.

In terms of what types of testing-- right now, we need testing for staff. Just, who's got the virus, and who doesn't? Down the road, sure, we'll be doing antibody testing, and further testing. But upfront, most states aren't right now requiring testing. The federal government is not requiring testing. So until we get those in place, it's hard to imagine that we're going to be able to really open up nursing homes to a large extent.

JOHN WHYTE: Do you think that may happen in a few months?

DAVID GRABOWSKI: I'm hopeful that we're going to continue more and more states every week here-- every day, actually, are coming online and announcing that they're going to do universal testing of staff and residents. Let's extend that testing to potential family visitors at some point-- teach family visitors how to don the personal protective equipment correctly, and have them in the facility. I think that would have such a huge benefit to the residents-- once again, the families, and also the staff.

JOHN WHYTE: Dr. Grabowski, you've been studying nursing home policies for quite some time. What keeps you up at night?

DAVID GRABOWSKI: This is a under-resourced industry to begin with. Medicaid is the dominant payer of nursing home services in this country. So I think there's often an image of this well-resourced, sort of very experienced staff. And that's not nursing homes. We have very dedicated staff in nursing homes. They're heroes, with everything they're doing. But we need more individuals working in these buildings. We need more resources.

And so that's what keeps me up at night, John. It's this idea that as workers get sick, as workers aren't able to come in every day, are we going to have new individuals that are able to work in these buildings and really give that high quality care to older adults? We need to put resources into our direct caregivers.

And then at a broader, kind of industry level, we need to make certain that nursing homes have the resources to provide good quality care, because historically we've underfunded this sector. And we've really depended on a direct caregiving workforce that makes close to minimum wage. And I just don't think that's going to be acceptable going forward.

JOHN WHYTE: So Dr. Fulmer, what advice do we give to caregivers, to family members when they're, you know, reasonably concerned based on what they're hearing on television and on the news about a loved one that might be in a nursing home? They're thinking about putting a loved one in a nursing home-- how do they make those decisions? And what resources can they look to?

TERRY FULMER: It's heartbreaking, John. And I think that you point out that people who have money will be able to sort this out better than those people who do not. And we need to be clear about that-- that if you are a person on Medicaid, in a nursing home, without supports around you, it's going to be a different scenario than if you're in a place where you have resources, so I think that's really important.

The other thing I would say is that this crisis has been horrifying, and there will be another one. So whether it's Katrina, whether it's Sandy, whether it's a power outage, what we need to do is get ahead of this. And so the important thing, from our perspective, is working with the National Academies of Medicine so that we-- our foundation has agreed to fund a study related to quality and safety ahead of the next crisis. We need data. It's been 30 years since we've done this with great systematic approaches. It's time. It's over time.

DAVID GRABOWSKI: I think the key factors on whether to pull a family member out of a nursing home-- I think you have to remember why they were in that nursing home to begin with. It's because they needed a lot of service. And are you going to be able to provide those services for your family member at home? Are you going to be able to give them good infection control?

And then finally, this-- you know, we know the numbers right now in nursing homes. Over a third of the nursing homes in the US have reported cases. You're going to pull a family member out, you better be sure that they're COVID free. And so that comes back to the point around testing. And so it's really important issues to weigh there as to whether to bring them home or not.

My sense is that, in the majority of instances, it's going to be very challenging for family members to take an individual out of a nursing home. We've certainly heard of cases where that's working well, but in the majority of instances, I think this is going to be about partnering with the nursing home, and really working with them to make certain that your loved one is actually safe in that nursing home.

JOHN WHYTE: One quick follow up on that. You mentioned about-- the third of deaths are in nursing homes. Is that unique to the United States? Are we seeing that in other countries? Is the nursing home industry different in other countries? It doesn't seem like we've been hearing that in other countries.

DAVID GRABOWSKI: It's actually interesting, John. The US, as I said earlier, spends a lot less than other countries, especially northern European countries, on long term care. And yet, if you look at the numbers in those countries-- the Netherlands, Sweden, all over Europe, France, Belgium, they're seeing death rates in nursing homes very similar to what we're seeing, even more so. So they're seeing rates around-- half of all COVID deaths in Europe seem to be in nursing homes.

So I think when it's all said and done here in the US, our rates are actually to be very similar to those in Europe. I think the reason, John, you're quoting a figure of one third-- it's actually under-reporting. The true numbers is probably closer to 50%. And once we have the data in place, that's what we're going to see. So this isn't really about what we invested up front. I think it's about the lack of testing-- how we couldn't contain this in the community. Now that it's in nursing homes, they need lots of resources, obviously, to prevent further outbreaks. But this is a system wide problem. It's a problem in Europe, and it's a problem here.

JOHN WHYTE: I want to thank you both for joining me.

TERRY FULMER: Thank you, John.


JOHN WHYTE: And thank you for watching "Coronavirus in Context."