Dear Neighbor,
More than half the COVID-19 deaths in Massachusetts have been among residents of long-term care facilities, though fewer than 1% of people live there.
This is of course incredibly frightening for residents, their families, and staff, especially since families can't visit unless the resident is near the end of their life.
This 88-year-old man used a bucket truck as the only way to get closer to his wife.
The stories behind the numbers are heart-breaking. The mother with Alzheimer's who tells her daughter, "death is around me, people are sick, people are crying, people are dying." The siblings who take turns talking to their mother, because the staff can only help her make one call a day. The worker who doesn't want to be tested because she can't afford to lose her pay. The nurse who resigns because she's afraid of bringing the virus home to her vulnerable mother. The administrator who has only four CNAs to feed 33 patients who are too weak to feed themselves. The person asking why the state won't release information about the number of deaths in a local nursing home, but only a range of the number of cases, which completely depends on the number of tests. The director frustrated with how hard it is to get personal protective equipment from anywhere, including the state.
Mass Senior Care, which represents the nursing home industry, summarized its concerns and solutions in a Commonwealth magazine article. I concur with them: the administration's actions so far have been inadequate.
The Department of Public Health last Monday started posting daily updates on the spread and location of the disease in long term care facilities, including very limited information on the number of cases in each facility. You can read the report here. The reports are far from adequate: they don't include deaths or the number of people tested, and only have a wide range of the number of cases. For example, the report just lists >30 cases at one nursing home, where there have been 135 cases among 175 residents, with 37 deaths.
I have talked with administrators in nursing homes and assisted living residences in our district, and with family members. Some facilities in our area have few or no cases so far, but a few have many cases and deaths. Along with many others, I have asked that the state take far more aggressive action.
Why are nursing home residents more at risk?
The chance that the virus will enter is high. Many low-paid staff work in more than one job, so may unknowingly carry infections before they're symptomatic.
Once the virus is in, the chance of its spreading is even higher. Most residents share rooms, so isolation is difficult, even though dining room meals and activities have ended. Staff move between rooms and come in close contact with many residents.
And residents are among the groups most likely to be affected: about half of them are over 85 years old, and to be in a nursing facility, residents must be in rehab after hospitalization, or have pre-existing conditions requiring nursing services. The average age of COVID-19 deaths in Massachusetts is 82.
What do nursing homes need right now?
More Staff
Even before this crisis, nursing homes had a staff vacancy rate of 17%. The work is really hard, and the pay is really low. The Committee on Elder Affairs, which I chair, held a February hearing on the senior care workforce. The Globe reported on the overwhelming testimony that recruitment is hard and turnover is very high because the pay is too low to compete with Walmart or McDonald's. (Now it is too low to compete with unemployment for many.). Low pay is largely due to inadequate payment rates by Medicaid, which pays for about 2/3 of the patients. And restrictions on immigration have cut off an important supply of workers.
Now the staff vacancy rate is 40%; nursing homes need over 10,000 direct care workers. Some staff are sick or caring for family members. Others stay home or quit; they're afraid for their own health, especially as testing reveals so many cases in the place they work.
The administration, in response, increased Medicaid rates to nursing homes by 10%, with an added 25% for homes running a dedicated COVID-19 space. They launched a recruitment site, with a $1000 bonus for anyone hired, and 1,970 have signed up. 600 may have been offered jobs. This is a great start, but far from enough.
Yesterday, I'm glad to say, the site started recruiting people with fewer skills and credentials than Certified Nursing Assistants: Resident Care Assistants. A short on-line course will prepare applicants for important nursing home jobs with high demand. But the pay will have to be substantial to compete with the CARES Act's enhanced unemployment benefits, and to attract people to work in a dangerous environment. For qualifications and duties, look here.
The National Guard should be deployed to do tasks like carrying meals to patients, feeding those who can't feed themselves, and helping families have virtual visits. Some of them are nurses or have other important skills. It's probably impossible to find enough people for these jobs, even with fewer requirements and higher pay. It's even more impossible to do it quickly. Even if all of the Guard were deployed to this one need, it wouldn't be enough. But it would make a big difference. California and Wisconsin are among states doing this. (National Guard Photo from Wisconsin)
We need to dramatically increase "hero pay" for direct care workers across the continuum to recruit and retain people to do this work. They were already paid too little; now they risk their lives to care for others. And if we raise it for nursing homes and not for home care, for example, there will be fewer workers to care for people at home. Higher pay needs to continue past the pandemic to respect, recruit, and retain the workers.
We also need to find ways to keep staff working in one site, rather than having to work two or more jobs and possibly carry infection between them. Higher pay is, again, one solution. Dormitories and 2-week-long shifts could help.
More PPE
Like many other programs, nursing homes are having a hard time getting enough personal protective equipment, like masks, gowns, and gloves. They are paying inflated prices, searching the internet. Administrators have found innovative solutions, and the state has created portals for requesting and donating or selling materials. The state has distributed 242,025 N95 and KN95 masks, 51,000 gowns and over 398,000 gloves to long-term care facilities. Some places still have shortages.
More Money
I served on the Nursing Facility Task Force, formed after reports that 20 nursing homes had closed in the past year and half. Our February report and the attached materials are worth reading. We concluded that, among other things that:
due to increased availability and use of home care and assisted living, and changes in Medicare, over 20% of beds are empty in 1/6 of nursing homes, which is inefficient and unsustainable (but a good thing right now, since it allows patients to be separated more easily)
due to low Medicaid rates, and increases in the minimum wage and other costs, most nursing homes are losing money
During the Task Force's meetings, we received a report from the Center for Health Information and Analysis, including an interactive dashboard where you can find information about individual nursing homes': operating margin, positive or negative;
CMS quality rating; occupancy rate, nursing hours/patient/day; and more.
Unfortunately, the information is three years old. Some homes have improved, while others may have gotten worse.
Ratings and quality are no guide to whether a home becomes a center of COVID-19. One with five stars, a great reputation, and a relatively high number of nursing hours per patient has seen 30 COVID-19 deaths at last report. It's often a matter of chance. In one home in our district, the virus was probably brought in by a patient returning from a hospital; in another it probably came with an asymptomatic staff member who also worked at another facility (as so many do because of low pay). Once the virus enters, it spreads fast.
More information
Last week, our Elder Affairs Committee held a virtual hearing, receiving both emailed and Zoom testimony on House Chair Rep. Balser's bill to require daily public reporting of cases and deaths among residents and staff for each nursing home, assisted living facility, and senior public housing. You can watch the hearing here; just click on the arrow under "webcast" or read a report citing the "information gap." We reported the bill out the next day, and it has already passed the House. I am working to ensure the Senate passes it this coming week, or that the administration starts making adequate reports on its own.
More testing
The National Guard has completed 15,595 tests in long term care facilities, and found 9184 cases. 289 facilities report at least one case. 1429 people have died of COVID-19 in those facilities.
The state tried sending 14,000 test kits to nursing homes, but shut down that program after reporting that most kits weren't returned. The Globe editorialized yesterday in favor of more testing and transparency for nursing homes.
Resource for family members
You can call the Nursing Home Family Resource Line at 617-660-5399 from 9 to 5 seven days a week to get answers. Let me know if you find it helpful.