COVID-19 and long-term care: Some light at the end of a long tunnel

Reforms and widely available shots have cut death rate more than 95%, but systemic problems still to be solved
Credit: (AP Photo/John Minchillo, File)
File photo: A senior-care patient is loaded into an ambulance by emergency medical workers.

New COVID-19 cases and related deaths have fallen significantly at long-term care facilities in recent months, both in New Jersey and nationwide, a trend that officials attribute to vaccines, lower community spread and other public health measures.

The good news comes a year after New Jersey reported its first case of the coronavirus. Since then it’s been diagnosed in some 800,000 residents, including nearly 23,500 who have died, and resulted in unprecedented unemployment, economic loss, community pain and personal trauma.

In New Jersey, the pandemic took a particularly heavy toll on the state’s 375 nursing homes and other long-term-care facilities, where a vulnerable mix of frail, elderly residents were especially at risk for infection. Eight out of 10 deaths to date involved people over age 65, according to state data and, as of early May, half of the state’s fatalities involved residents or staff in long-term care. As of now, those deaths account for just over one-third of the COVID-19 fatalities in New Jersey; more than 300 facilities are still reporting active COVID-19 cases, state data shows.

“We got clobbered in long-term care. I think every American state got clobbered, but we really got clobbered,” Gov. Phil Murphy said at a media briefing Wednesday, noting that the state’s proximity to New York, dense population and exposure to international travelers via Newark airport put New Jersey particularly at risk for the pandemic. “God bless every loss of life,” he added.

Highest nursing-home deaths

According to data from the federal Centers for Medicare and Medicaid Services, New Jersey has the highest rate of nursing-home deaths in the nation, with more than 124 fatalities per 1,000 residents. Pennsylvania had the 14th highest rate, with 76 deaths, Delaware was 23rd, at nearly 65, and New York came in 34th, with 55 deaths per 1,000 residents, based on weekly reports from the facilities.

Experts agree New Jersey’s nursing homes were particularly vulnerable to the spread, with some housing three or four residents in a single room, and a history of infection-control problems. Consultants from Manatt Health, hired by the state to review the system, released a 100-page report in early June that called for greater investment in frontline staff, better communication between regulators and operators and stricter state oversight of the industry. Many of the issues identified have long been priorities for elder advocates and labor organizations.

The report offered dozens of short and longer-term recommendations that led to more than a dozen legislative proposals, five of which have been passed and signed into law by Murphy. These include measures to increase wages for bedside workers, boost Medicaid reimbursement rates to facilities, ensure sufficient supplies of protective gear and create a task force to advise the state. Murphy’s administration also invested more than $150 million in infection-control measures and workforce enhancements, some of which he plans to continue in the year to come.

Some have suggested the state could have moved faster to address these issues, especially given the historical nature of many funding and workforce concerns.

Lives lost to earlier inaction

“The pandemic exposed cracks and fault lines in the LTC system that have been known for a long time. Had we addressed them earlier, lives could have been saved,” Evelyn Liebman, advocacy director for AARP New Jersey, said.

While all the reforms in process are important, Liebman said more changes are needed to modernize the facilities, ensure adequate staff and control infection. Others said they would like to see additional investment in workforce development and training.

Liebman also hopes state officials act on the remaining proposals to improve transparency about ownership, operations and licensing, and she urged state officials to restore the civil liability for nursing homes that was suspended at the start of the pandemic. “We can’t have quality nursing homes without quality staffing and accountability,” Liebman said.

Murphy on Wednesday largely defended the state’s track record on long-term care, insisting the administration was “completely at every step of the way transparent,” including in how it hired Manatt to conduct an “unsparing” audit of the response. He also pushed back on those who criticized the state’s decision, based on federal guidance, to require nursing homes to accept COVID-19 patients discharged from hospitals — if they could effectively separate them from others. Within days, hundreds of facilities conceded they couldn’t meet these requirements, officials have said.

“Were there bad actors that didn’t follow (state infection-control guidance)? I fear there were. And they deserve to pay a price for that,” Murphy said Wednesday.

But James McCracken, president and CEO of LeadingAge New Jersey and Delaware, which represents about 50 nonprofit long-term care providers in the Garden State, noted that many facilities — and employees — deserve credit for the strategies they implemented to protect vulnerable residents, even with limited resources. “I know people have died, but we also saved thousands of lives,” he said.

Turn for better in long-term care

It appears that the changes implemented so far in New Jersey — as well as the state’s immunization campaign, which has administered more than 2 million shots since mid-December, 42% to those over age 65 — have clearly had an impact. On Wednesday state health commissioner Judy Persichilli said the numbers of both new cases and deaths among long-term care residents dropped roughly 96% between early January, when the recent surge peaked, and late February. This outpaced the 37% drop in positive diagnoses recorded statewide over that time, she noted.

Persichilli said the drop is likely due to protection offered by the COVID-19 vaccine, which began to be administered in nursing homes in late December and has proved very popular with residents, and other factors. The state Department of Health also announced on Wednesday a new long-term care website — with links to facility inspection reports — designed to help residents, family and staff more easily track the pandemic response and potential reopening at each facility.

“I think we learned a lot about the resiliency, or lack thereof, in the long-term-care industry” through the pandemic, Persichilli told NJ Spotlight News in an interview last week. The new website will help families assist their loved ones and improve transparency and accountability in the system, she said, as recommended by Manett.

The recent trend in New Jersey facilities seems to reflect what is happening nationwide, according to a report from the American Health Care Association and the National Center for Assisted Living, which represent long-term-care providers. Their analysis of federal data showed nursing homes have seen new cases decline 82% since late December, when vaccine programs began in these facilities nationwide. Daily cases among the general population declined 46% in this time, the groups noted.

McCracken, with LeadingAge, said he’s witnessed this positive trend in facilities he represents, where immunizations have been underway for several months. A federal agreement tasked chain drugstores with operating vaccine clinics at long-term care sites and nine out of 10 residents in their facilities opted to get the shots, he said, although participation among staff was somewhat lower.

More work to do

But while the federal program has largely ended, McCracken said the job is not yet done. Additional staff members want to be immunized, he said, and resident populations change. “So now what?” he said, noting the need for a system that allows them to continue immunizations for residents and staff, preferably on-site. “Transporting residents to pharmacies or mega-sites (for shots) is very, very challenging. That’s a barrier we presently have that has to be solved,” he added.

After nearly a year of lockdown, the isolation of elderly residents is also a major concern. McCracken is eager for concrete data that illustrates how vaccines impact the spread of the disease — in addition to protecting against sickness and death — so that facilities can better determine when to reopen their doors to family members.

“Social isolation continues to be a serious problem,” Liebman said. “Policymakers and regulators need to ensure that each nursing home does everything necessary to get their infection rates under control so that in-person, indoor visitation can safely resume for all visitors of a resident’s choosing.”

Liebman and others also encourage policymakers to take a step back and rethink long-term care more broadly, so that people are more able to remain in their own homes, with certain support. Stephen Crystal, a lead researcher at the Rutgers Institute for Health, Health Care Policy and Aging Research, said this would require changes in the way home-based services are funded, steps that have been taken in other states, like New York.

For many people, aging at home is preferable, Crystal notes, and it can certainly be safer than communal living during a pandemic like coronavirus. “Nursing homes are always going to have infectious disease risk,” from COVID-19 or the flu or other viruses, he said. And unless major changes are made, “the next time we have an epidemic, which we will, this will happen all over again,” Crystal said.

We’re in this together
For a better-informed future. Support our nonprofit newsroom.
Donate to NJ Spotlight