En español | Ginny Jeffries laughs when she recounts the craving that her mother-in-law, Jean, developed after recovering from a weeks-long bout with the coronavirus just before her 94th birthday.
"She wanted a Manhattan,” says Jeffries, who, along with her husband, James, was able to bring Jean the cocktail and a cake last month. Jean's Pennsylvania nursing home, closed to visitors for three months as part of the federal ban on such visits during the pandemic, allowed her an outdoor, socially distanced birthday party with a few close family members. “She was so happy seeing us,” Jeffries says. “That was the first time she'd seen anybody since February."
It was nothing like a pre-pandemic visit to the Parkhouse Nursing and Rehabilitation Center, an hour's drive northeast of Philadelphia. And it offers a glimpse into the new normal for nursing homes seeking to reunite residents with loved ones while mitigating the risk of infection.
Jean was placed in a three-sided outdoor plexiglass enclosure while family members, clad in face masks, gathered around. After nearly succumbing to the virus, which landed her in the facility's isolation ward, Jean was “just so happy” to have company again, Jeffries says.
"She wishes we could come up and hug her," Jeffries says, reliving the moment. "We all say that. ‘We wish we could come up and hug you.’ "
Nursing homes and other long-term care facilities that have started offering visits are still the exceptions. More than a month after the federal government began relaxing guidelines that had closed long-term care facilities to most visitors since mid-March, fewer than 20 states have allowed visits, and then mostly outdoors. At the time of Jean's birthday celebration, Pennsylvania had not explicitly signed off on outdoor visits. It wasn't until late June that Gov. Tom Wolf unveiled a multistep, multi-week process paving the way for nursing homes and long-term care facilities to receive visitors.
Even in states where outdoor visits have been approved, implementation varies widely from one facility to the next, depending in part on how much outdoor space is available and on management's risk tolerance. Opening these facilities to visitors, even those who remain outdoors, increases the chances that residents are exposed to the virus.
"The risks of COVID well exceed the risks … of the social isolation. But, having said that, it is certainly a quality-of-life issue,” says David Nace, president of the nonprofit Society for Post-Acute and Long-Term Care Medicine and chief medical officer at the University of Pittsburgh's Senior Communities assisted living and skilled nursing operations.
Nace cautions that these visits are “not ideal” and not quite like “sitting next to somebody, holding their hand.” The federal Centers for Medicare & Medicaid Services is advising that masks be worn at all times during outdoor visits and instructing visitors and residents to stay 6 feet apart. Still, Nace calls outdoor visits “the appropriate thing to do” in communities that have brought the spread of the virus under control.
"Safety is the utmost priority,” says Elaine Ryan, vice president for state advocacy and strategy at AARP, which has pushed for more transparency from nursing homes during the pandemic, along with more personal protective equipment, testing and support for virtual visits. “It is critical all nursing home and assisted living facilities meet CDC guidelines, including no COVID-19 cases for 28 days, adequate staffing, testing of all residents and staff, and adequate personal protective equipment for staff."
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Face masks and socially distanced visitation stations
In the first week of June, Massachusetts became the first state to allow nursing homes to offer regulated outdoor visiting hours. Charlwell House Health and Rehabilitation Center in Norwood was among the first facilities in the state to draw up visitation guidelines.
Administrator Chris Roberts set up outdoor stations 8 feet apart on the building's large front porch. Residents’ loved ones schedule visits in 15-minute blocks, and the facility provides a hydration cart to help everyone stay cool. Visitors must wear masks, with only two visitors per resident at a time.
"If they're letting us do it, why are we not moving mountains to make this happen?” Roberts asks. His 124-bed facility does not have an active outbreak, but 22 people there have died from the coronavirus since the pandemic began, according to state data.
Guidelines requiring masks and restricting visitor numbers have been adopted throughout Massachusetts and the rest of the states that have opened to outdoor visits: Arkansas, Colorado, Connecticut, Illinois, Indiana, Maryland, Minnesota, Missouri, New Jersey, North Dakota, Oklahoma, Tennessee, Vermont, Wisconsin and Wyoming. Some other states, including Ohio and Pennsylvania, have developed plans for outdoor visits but are not yet authorizing them, Ginny Jeffries’ birthday visit at Parkhouse notwithstanding.
"The biggest thing is wearing masks,” says Deb Veit, executive director of the 25-acre Oak Meadows Senior Living community in Oakdale, Minnesota. “There were some families who initially were not too sure why they needed to have a mask on outside. But that's just the way it is.” Health experts say that the virus does not spread as easily outdoors but that masks can still prevent people from infecting others.
Oak Meadows introduced outdoor visits for residents and their loved ones June 18. Veit says demand is high, with 15 calls a day about scheduling one. For residents like 96-year-old Doris Maloney, they've been an improvement over phone calls, videoconferences and window visits.
"I hadn't seen my son for seven weeks,” Maloney says. “He started coming to the window visits, so I would see him then. But it's just been wonderful to be able to sit and talk with him."
Maloney's son, Bob, now stops in twice a week to see her. She also gets visits from friends who live nearby, returning to some sense of normalcy after being cooped up for months. “I just look forward to these visits with people so much. My daughter lives in Florida, and she's coming up July 4,” Maloney says. “Just to see them and know that they're still here."
In states that haven't approved outdoor visitation, some facilities are getting creative in facilitating face-to-face interaction. The St. James Rehabilitation and Healthcare Center on Long Island, New York, borrowed a cherry picker from a tree service and invited visitors to go up in the basket, opening window visits to residents who don't live on the first floor.
A big element of frustration
The new outdoor visits don't always work — they're weather-dependent, and mostly limited to residents able to walk outside or be pushed out in a wheelchair. Nursing home residents who are confined to a bed still rely on phone calls and virtual visits.
And for many, the visits carry an element of frustration, because they're unable to embrace a loved one they haven't seen in months.
"One of us will sit out there during the visit to remind people if they start to take their mask down or try to come around” to hug their loved one, says Justin Teal, nursing home administrator at the North Shore Estates long-term care facility in Duluth, Minnesota. “It's not like they're trying to break the rules. It's just reflex."
The visits can also be challenging for people with medical conditions that limit their ability to talk at a distance. Bill Lundgren, 87, was thrilled to see his wife for the first time since March during a recent outdoor visit at the North Shore Estates.
But Lundgren is hard of hearing. And his wife, Betty, suffers from dementia. “When you put her 6 feet from me, I can't hear hardly anything she says,” he says. “It was pretty much just sitting with each other. There was a little conversation, but there wasn't much."
Lundgren says he plans to visit Betty at least once per week now that the outdoor visits are an option. But he would have liked a more meaningful reunion. “You would've liked to give her a hug or hold her hand or something, which you can't,” he says. “Hopefully sometime in the next couple months, things will change."
Many nursing homes have been cautious in rolling out visitation options, even if their state government has given a green light. And now that coronavirus cases are surging in much of the country, many states and facilities are unlikely to reopen anytime soon.
Veit, the executive director of Oak Meadows in Minnesota, recently got a call from a woman whose mother lives in a different facility, asking how she could convince management to begin offering outdoor visits, like Oak Meadows has. There are no easy answers, she says, describing a balancing act of keeping residents physically and emotionally healthy.
"I get the fears. We're all afraid of getting it. There's no question,” says Veit, whose facility hasn't had a coronavirus case. “But we have to understand it's going to be with us. So how do we live with it but still stay sane? Emotional well-being for these folks is just so critical."