Op-Ed: Pandemic must drive nursing-home transformation

Fred A. Kobylarz | November 13, 2020 | Coronavirus in NJ, Opinion
COVID-19 presents an opportunity to transform nursing-home care. Residents and staff have been overlooked for too long
Fred A. Kobylarz

When the floodwaters receded after Hurricane Katrina in 2005, they revealed disastrous conditions and losses of life at nursing homes across the Gulf region.

In the aftermath, reports found significant increases in deaths and lingering effects on nursing-home residents, including hospitalizations and functional declines. The disaster exposed a great need to better understand the challenges nursing homes face and to improve emergency planning and response.

The staggering number of COVID-19 cases and deaths in nursing homes across the country has once again highlighted that, although these facilities are home to some of our most vulnerable populations, serious deficiencies remain.

20% death toll

Nursing homes across the country and in New Jersey face many challenges during the coronavirus pandemic. Those hit hardest at the start of the pandemic saw up to 20% of their residents die. Nursing homes should not be blamed. Long-standing issues with understaffing, lack of social interaction and lack of research have contributed.

During our current crisis, changes are needed in advance-care planning, avoiding unnecessary hospitalizations, palliative care, the use of telemedicine and disaster preparedness. These are areas that have often been left out.

Nursing homes are increasingly complex environments. Residents often live in close quarters and require frequent contact and attention from health care providers and staff. Even with bans on outside visitors, the environment does not lend itself to the best practices of social distancing.

Many nursing home residents have chronic diseases and comorbidities that put them at greater risk of complications from COVID-19. Additionally, it may be nearly impossible to impose isolation requirements on those who struggle with cognitive decline and mental health conditions. With already strained staff and resources, nursing homes may be forced to resort to physical or chemical restraint, potentially putting such residents at additional risk.

Spreading the virus

These challenges are only compounded when cases of COVID-19  have been confirmed in nursing homes. The need for staff grows as patients get sicker and the infection spreads, perhaps transmitted by those who are asymptomatic or via common surfaces and spaces. Sometimes health care staff work in multiple facilities and may unknowingly act as vectors of the contagion.

The U.S. Centers for Disease Control and Prevention and the Centers for Medicare and Medicaid Services have issued recommendations for nursing homes in light of the pandemic, and additional federal funding has been earmarked for facilities. A more recent CMS study highlights that our nation’s nursing homes need more.

During Katrina, agencies provided similar guidance on natural disasters and evacuations, but reports found that some nursing homes still struggled with what to do.

Nov. 16 deadline to enroll in COVID-19 safety program

In the midst of this crisis, we must do more to keep nursing home residents and health care staff safe as they shelter in place. Nursing homes are not often first in line for personal protective equipment, and they need clear guidance and support to implement and adhere to standards.

One positive development in providing that guidance has been the AHRQ ECHO National Nursing Home COVID-19 Action Network, a partnership between the Agency for Healthcare Research and Quality (AHRQ), the University of New Mexico’s ECHO Institute and the Institute for Healthcare Improvement (IHI). The network will advance COVID-19 preparedness, safety and infection control, and will work to strengthen nursing home resilience.

In New Jersey, Rutgers Project ECHO will launch the program in partnership with the state Department of Health, New Jersey Health Care Quality Institute, Robert Wood Johnson Medical School, and Trinitas Regional Medical Center — as well as experts from around the state. Rutgers Project Echo will implement the 16-week program of evidence-based best practices and quality improvement. We need every CMS-certified nursing home in New Jersey to participate in the initiative, which will continue to offer a yearlong community of ongoing learning. The deadline for them to enroll is Nov. 16.

This kind of collaborative learning is essential. Our nursing homes need a greater understanding of how to prevent infections in their facilities and how prevention differs in hospitals and at home. We need to use key population health strategies to help nursing homes provide care for residents. We also need to be able to better identify — through widespread testing of residents and staff — who has been infected and prevent the spread among residents, staff and visitors.

In addition, we need more data to address what is happening in nursing homes and to understand what other factors may contribute to deaths attributed to COVID-19. This will assist us in risk-stratifying patients to protect the most susceptible.

The coronavirus pandemic presents an opportunity to transform nursing home care. For too long, these facilities, as well as the residents who live there and staff who provide the care, have been overlooked. We must begin to recognize them among our most valuable populations.

This storm will be upon us for some time, but when the clouds of COVID-19 lift, what will we see?