Nursing homes have become the tragic epicenter of the coronavirus pandemic, with more than 45% of the 144,636 deaths nationwide linked to nursing home clusters.
That includes more than 50,000 deaths in the US, including 733 deaths in Arizona. Late last week, the Arizona death toll included 11 in Payson and at least eight in Navajo County.
Moreover, people older than 65 account for 73 percent of all deaths in Arizona. The elderly with additional medical conditions have a death rate from COVID-19 greater than 15 percent.
So nursing homes remain the single most important place to protect from the ravages of the pandemic.
So why don’t nursing homes nationwide have enough tests?
Why must they rely on minimum wage workers – often without health insurance?
Why don’t those workers have enough protective gear?
That’s what family members and the nursing home industry generally are demanding, four months into a pandemic whose impact on the frail elderly has been clear from the beginning.
The consequences of that failure have become increasingly clear in Payson, where Rim Country Health accounts for about two thirds of the deaths recorded so far in Gila county.
The federal Centers for Disease Control maintains an online database showing infection and death rates in US nursing homes (https://data.cms.gov/stories/s/COVID-19-Nursing-Home-Data/bkwz-xpvg/).
The data doesn’t include cases on the Navajo or White Mountain Apache reservations, which have been the epicenter of the outbreak in Apache and Navajo Counties.
The most recent data dates back to July 5 and cases have risen rapidly since then, but the numbers show the devastating impact once the virus gets loose among frail, elderly residents and the staff members caring for them.
For instance, the website showed that Rim Country Health in Payson as of July 5 had 36 confirmed cases and eight suspected cases – reflecting the long wait for test results. At that time, the facility had reported three deaths. Now, the total has risen to 11. Half the residents were infected. Of those infected 8 percent had died as of July 5. The total number of deaths in the facility has increased almost four-fold since then.
The database also documented an outbreak at The Haven in Show Low. As of July 5, the facility had 20 confirmed infections and one suspected infection. Two residents had died. About 67 percent of the residents had been infected and 7 percent had died. Of those infected, 10 percent died.
Elsewhere, the virus has most often entered nursing homes through infected staff members, usually with no symptoms that they’re sick. Studies suggest that perhaps half of people infected with the virus never show clear symptoms, but can nonetheless spread the virus. Even those who do eventually develop symptoms, may spread the virus most readily before those symptoms develop.
To compound matters, many nursing homes rely heavily on part-time, minimum wage workers — many of them without health insurance. As a result, those workers must work in several nursing homes to make ends meet — and can’t afford to stay home when they’re sick. The load on the caretaking staff has only increased as a result of shutdowns that have barred the door to volunteers on which the facilities had previously relied.
“It is spreading via asymptomatic and pre-symptomatic cases, said Harvard researcher David Grabowski.
Brown University Researcher Vincent Mor said “If you’re in an environment where there are a lot of people in the community who have COVID, the patients in the building are more likely to have COVID.” The ability of the virus “to hide in plain sight will continue to crush expectations of halting its spread unless more and quicker testing at nursing homes sweeps the country.”
University of Chicago researcher R. Ramara Konetzka said, “outbreaks in nursing homes are often a signal of the communities into which the virus is spreading. Given asymptomatic spread and inadequate testing, staff often do not know which residents are infected. With policymakers and the public initially focused on the spread of infection within the hospital settings, nursing homes often lost that competition.”
Several national studies have concluded that for-profit nursing homes and nursing homes with a history of citations for quality of care problems were not necessarily more likely to end up with a COVID-19 cluster than nursing homes with high ratings. Most blamed infection levels in the surrounding community and the lack of adequate testing and protective gear.
Arizona’s not among the seven tests states that have required regular testing of nursing home staff and residents. However, even if a nursing home does test everyone weekly, it’s taking a week or two to get test results back. The long lag in getting test results makes it almost impossible to get test results back and take action in time to stop the eruption of a COVID-19 cluster.
“What we’ve done in testing in nursing homes and assisted living is a total disaster. No one is getting it right. Not one. Not a single state. Our nation gets a failing grade in testing in nursing homes,” concluded Brian Lee, director of Families for Better Care as quoted in a report on nursing home infections issued recently by the PEW Foundation.
In New York, Gov. Andrew Cuomo has generally gotten high marks for dealing with the nation’s worst outbreak, but has also come in for intense criticism for an order that required nursing homes to accept COVID-19 patients discharged from hospitals. Critics say the transfer of 4,500 patients helped accelerate the disastrous spread of the virus in the nursing homes – which had far fewer resourced to deal with the outbreak than hospitals.
The backlog in getting testing results has risen since the PEW report was issued, as cases have spiked nationwide. The plan to reopen schools in Arizona and elsewhere will likely dramatically increase the test shortages.
David Voepel, director of the Arizona Health Care Association, commented “We don’t have the ability” to do weekly testing. “A lot of facilities don’t have that ability because that’s a lot of money going out.”
The initial COVID-19 test cost $150 per person, a budget-busting item if done for residents and staff on a weekly basis, as Medicare has recommended. Studies suggest nursing homes generally operate on a profit margin of 3 or 4 percent, facing low rates from Medicare and Medicaid programs like the Arizona Health Care Cost Containment System (AHCCCS), which pay most of the nursing home bills.
The federal Food and Drug administration has approved 173 COVID-19 tests, including six tests that can produce results in about an hour. The rapid tests aren’t as accurate, but can operate as a screening test. Unfortunately, the rapid tests are even harder to get than the conventional tests.
The American Health Care Association and the National Center for Assisted Living last week issued an urgent plea for Congress and state governors to provide money for universal, testing and screening in the nation’s nursing homes to avert an even bigger disaster. The list of changes included:
• Onsite testing and results. About 90 percent of nursing homes say it takes at least two days – and often five – to get test results.
• Sufficient protective gear – especially surgical masks – for staff and residents. Currently 20 percent of nursing homes report they have less than a one-week supply of gear and half have less than a two-week supply.
• Allow family visits: Most states like Arizona simply banned family visits, resulting in sometimes serious mental and emotional consequences for residents. The industry group appealed for help in allowing family visits – including video conferencing. This requires sufficient staffing and protective gear to make such visits safe.
“We know our collective priority is the well-being of our long-term care residents and caregivers and by working together we can protect them through this pandemic,” said Mark Parkinson, president of the industry lobbying group.
Some federal lawmakers have weighed in, urging new measures to limit the lethal spread of the virus through nursing homes and other long-term care facilities.
Arizona Sen. Kyrsten Sinema wrote a letter to Medicare administrators, urging new initiatives to ensure nursing homes track the spread of the virus, do adequate testing and receive enough protective gear.
“Every day my office hears from Arizona families, health care workers and seniors worried about the spread of coronavirus. The federal government must take action now to stop the spread of the virus in senior living facilities,” wrote Sinema.
However, months into the pandemic the fresh surge in cases in states like Arizona has overwhelmed the testing system. Arizona has been especially hard it, with among the fastest rising case loads and the lowest testing rates.
The state’s hospitals and Intensive Care Units are now about 90 percent full. Some 3,500 COVID-19 patients are hospitalized. Each COVID-19 patient requires medical staff to use a lot of masks, gloves, gowns and other protective gear during the sometimes prolonged hospital stay. Nursing homes have a hard time competing for gear, given the low profit margins and lack of added federal support that has been directed towards hospitals.
“COVID-19 is the greatest public health challenge since the Spanish flu pandemic of 1918,” Arizona Democrat Krysten Sinema and Maine Republican Susan Collins wrote in a letter to the Centers for Medicare and Medicaid Services. “It has strained our health systems, placed a heavy burden on front-line workers and has brought tremendous tragedy. Up to 8 in 10 deaths caused by the new coronavirus involved adults ages 65 and older, and older adults in nursing homes and group care settings are disproportionately at risk.”