How to Address COVID-19 in Nursing Homes

Controlling coronavirus in nursing homes crucial for national response, says Donald Taylor

Part of the From Health Care to Child Care, the Impact of COVID-19 Series
How to Address COVID-19 in Nursing Homes
Nathan Boucher, Eleanor McConnell and Donald Taylor

Nursing homes will continue to be COVID-19 hotspots until state and federal officials can institute sweeping testing of asymptomatic patients and workers, Duke experts said Wednesday.

The testing is critical to beat back the threat to a most vulnerable elderly population, three Duke scholars noted during a briefing for media that covered this and myriad other topics related to nursing facilities and the coronavirus pandemic.

Audio and vide are available here.

Here are excerpts:

ON WHY NURSING HOMES ARE SUCH VIRUS HOTSPOTS

Donald Taylor, public policy professor

“The best way to think about nursing homes is to think about the people who go there every day. That includes the workers. The workers in nursing homes are at risk of occupational exposure. They’re also at risk of bringing infection into the nursing home from the community, and taking it out.”

“You have patients who are at risk moving in and out. You have long-stay patients who are there, and you have workers moving in and out. Without a broad scale, asymptomatic testing approach, we will not deal with the epidemic in skilled nursing facilities.”

“Given asymptomatic transmission of the disease, we probably will not be able to get control of this in nursing homes without asymptomatic testing. We don’t know what that protocol of testing … will look like, but we desperately need evidence. If we don’t manage to control the epidemic within nursing homes, we’re not going to control it in the United States. Read: "To test our way out of the Covid-19 nightmare, focus on nursing homes"

 

ON WHAT NURSING HOME STAFF CAN DO TO HELP PATIENTS

Eleanor McConnell, nursing professor

“Continue to partner effectively with family members to better understand what matters most to the individuals. These residents are at incredibly high risk for infections and for adverse outcomes. Now more than ever we really need to focus on what matters to these people.”

“They need to make better use of technology. There’s a whole range of ways we can connect family members who can no longer visit with residents in the nursing homes, from simple technology like the telephone, to more advanced technologies like the Zoom platform.”

“Research has shown that people of all different levels of cognitive ability retain the ability to display emotion. Staff need to be particularly attuned to emotional response of the residents living in these communities. Often it’s only through emotional expression -- the ability to express joy or sorrow or fear -- that we’re going to successfully meet both the psychological and social needs as well as the physical needs.”

 

ON WHY IT’S HARD TO COORDINATE AND OVERSEE MASS TESTING

Nathan Boucher, public policy professor

“The big problem here is the disjointedness. We’ve been throwing around the words ‘skilled-nursing facility’ and ‘nursing home’ but there’s all sorts of levels of skilled- nursing facilities and nursing homes and assisted-living facilities, and care homes and residential homes, and the oversight varies.”

“There’s varying degrees in ownership of these organizations’ oversight. That creates a lot of disjointedness in rolling out some of these programs. I do believe there needs to be, because it’s not just statewide … there needs to be more federal input on this.”

 

ON THE CHALLENGES FACING NURSING FACILITIES

McConnell

“If you just get very concrete and think about what does it take to implement basic infection-control procedures, it’s time-consuming to mask, to gown up, to wash your hands. It stands to reason that if you’re starting out with a very thin level of staffing, it’s going to be hard to take those precautions and continue to provide very demanding care.”

 

ON WHY NURSING HOMES ARE HOT SPOTS

Boucher

“These facilities are not closed systems. There’s a constant flow of shift workers in and out of these systems, every hour, every shift. Even if there’s no-visitors policies, there are staff who go out to the community and come back in again. There’s an awful lot that goes out to the wild west of society, depending on where these folks live.”

“Many of these care workers work other jobs, they are caring for their own family members. There’s an awful lot of contact going on before they hit those (nursing home) front doors.”

 

ON CHALLENGES FACING A NURSING HOME RESIDENT WITH DEMENTIA

McConnell

“As a part of the brain disease, there’s often difficulty in communicating, understanding instructions that other people give you, or remembering about things like hand-washing or social distancing.”

“People who have moderate to severe dementia depend upon non-verbal cues to understand someone’s intent. To communicate on a day-to-day basis with all these people with masks on, that to me is a big lift and a huge challenge.”

“There’s this notion in dementia care of emotional contagion. I think if staff are anxious and fraught, there’s likely to be some transmission of that emotion to others. I know from talking to my colleagues in acute care, as they’ve become more comfortable with managing COVID-19 … their anxiety has come down. So there’s part of me that’s hopeful that this can get better.”

 

ONE THING FAMILIES COULD DO NOW TO SUPPORT LOVED ONES

McConnell

“It’s all about relationships. Staying connected with the nursing home staff, be it the administrator or social work staff. Increasingly I’m hearing nursing homes talk about a new class of worker, which is a social connector. Recreation therapists who used to be connecting people in groups are now connecting people on the phone.”

“I would encourage family members to step up and if they don’t already have a relationship (with staff), use this time to forge one.”

Taylor

“It’s important for your loved one to have an advocate. You need to try to stay as engaged as possible. It’s hard.”

 

ON HOW RESIDENTIAL CARE WILL CHANGE IN THE LONG TERM

Boucher

“Just like in regular health care and the rest of society, we’ve done the organic, societal experiment to see if Zoom and other remote connectivity options work. We’ve been forced to use it. I’m hoping that will become a regular thing even if things go back to normal … in these facilities.”

“There will be regular use not just of telehealth for clinicians … but also to mitigate some of that social isolation. That was a problem before COVID-19 and is just worse now. I’m hoping that technology will rise to meet the occasion.”

 

Faculty Participants

Nathan Boucher is an assistant research professor in the Sanford School of Public Policy at Duke. He studies patients’ and caregivers’ experiences and expectations of health care delivery during advanced illness and near the end of life.
nathan.boucher@duke.edu

Eleanor Schildwachter McConnell is an associate professor in the Duke University School of Nursing. She studies factors that influence functional decline in very frail older adults. Her research has been funded by the National Institute of Nursing Research and the Department of Veterans Affairs.
eleanor.mcconnell@duke.edu

Donald Taylor 
Donald Taylor is a professor of public policy who researches aging and comparative health systems, including Medicare, long-term care and health policy. Taylor also directs Duke’s Social Science Research Center.
don.taylor@duke.edu

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Duke experts on a variety of other topics related the coronavirus pandemic can be found here.

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