En español | With nursing homes in lockdown since mid-March, residents and their loved ones are desperate for in-person visits. The federal government has issued guidelines for reopening nursing homes to visitors, but the process will take some time.
When visits do resume, they will almost certainly be different from those before the pandemic, at least at first. Nursing homes will need to take many steps to minimize the chance of further transmission of COVID-19, which has appeared in about 10,400 long-term care facilities, causing more than 52,000 deaths, according to data from the Kaiser Family Foundation.
Recommendations issued May 18 by the federal Centers for Medicare and Medicaid Services (CMS) lay out benchmarks for state and local officials to use in determining when visitors can return and how to safeguard against fresh outbreaks when they do. The guidelines are broad and nonbinding, and there will be differences, from state to state and nursing home to nursing home, in when visits resume and on what terms.
“Families need to have good communication with the facilities about what’s going on in that facility,” says Lori Smetanka, executive director of the Consumer Voice, a nonprofit that advocates for the public on long-term care issues. “Are they following proper protocols? What are the expectations of the family or the staff? There needs to be really good communication and the setting of expectations so that everyone’s on the same page.”
It will be some time before families, caregivers and nursing homes themselves know what’s on that page, but here are some details about the next steps toward reuniting with loved ones in long-term care.
How long before visits can resume?
Anything resembling traditional visitation remains a long way off. A number of states have authorized nursing homes to allow outdoor visits, under strict rules for distancing, monitoring and hygiene and generally in accordance with the CMS guidelines.
The federal agency is urging nursing homes to continue barring any visitation until they have gone at least 28 days without a new COVID-19 case originating on-site (as opposed to a facility admitting a coronavirus patient from a hospital). There are several other benchmarks to meet, too, including:
- a decline in cases in the surrounding community;
- the ability to provide all residents with a baseline COVID-19 test and all staff with weekly tests;
- adequate supplies of personal protective equipment (PPE) and cleaning and disinfecting products; and
- no staff shortages.
Elaine Ryan, vice president of state advocacy at AARP, expects the wait to be considerable.
“The rising death toll is an indicator that nursing homes and assisted living facilities do not have this virus under control by any means,” she says. “Nursing homes have been in the lowest rung from the outset of the pandemic for any kind of staff support, PPE, infection control, testing, tracing, even reporting of deaths. The prospect of opening doors to visitors in a way that protects the health and safety of everyone seems months away.”
AARP has advocated for increased funding to nursing homes to address staff and PPE shortages and to ramp up testing. Testing all of the nation’s nearly 3 million nursing home residents and staff members just once would cost $440 million, according to the American Health Care Association and National Center for Assisted Living (AHCA/NCAL), an industry group.
“The cost of ongoing COVID testing of nursing home residents and staff is unsustainable without additional funding and support from federal and state governments,” a spokesperson for the organization says.
Since early June, more than a dozen states have authorized outdoor visits as a transitional step. Research has shown that the virus spreads less readily in the open air. Generally, these visits are by appointment, limited to designated outdoor areas, and monitored by staff, with visitors required to wear masks and remain 6 feet from loved ones.
To date, states allowing nursing homes to consider outdoor visits include Arkansas, Colorado, Connecticut, Illinois, Indiana, Maryland, Massachusetts, Minnesota, Missouri, New Jersey, North Dakota, Oklahoma, Tennessee, Vermont, Wisconsin and Wyoming. Check with your state health department about the status of its policy.
What kinds of health checks will nursing homes run on visitors?
The federal guidelines call for everyone entering a facility to undergo “100 percent screening,” including:
- checking visitors’ temperatures,
- questioning them about symptoms and potential exposure, and
- observing them for any symptoms or signs of infection.
The CMS recommendations do not address testing visitors for COVID-19.
“We will need to continue to evaluate ways to make it safe for visitors to enter our buildings without posing a risk to residents,” AHCA/NACL said in a statement to AARP, “whether that is through testing with rapid results, wearing personal protective equipment, limiting who visitors can interact with when they come in or other ways to keep residents safe.”
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Will I have to wear a mask?
If the nursing home is following the federal guidelines, yes. A memorandum to state officials detailing the recommendations says that visitors should be required to “wear a cloth face covering or face mask for the duration of their visit.” Facilities should consider restricting entry for visitors “unable or unwilling to maintain these precautions,” such as young children, according to the CMS.
The guidelines also call on nursing homes to ensure that visitors practice hand hygiene, but they do not address whether facilities should provide masks or sanitizer. LeadingAge, an organization that represents nonprofit providers of elder care, notes that many nursing homes are “desperately in need” of PPE to cover their own needs.
“If it were me, I would assume that I would have to bring a mask or hand sanitizer with me,” Smetanka says. “I think that’s something that facilities are going to want to control themselves, to make sure the masks and the sanitizers are appropriate for use,” she adds, but “people should be prepared to bring their own.”
Will I have to stay 6 feet from my loved one?
The CMS guidelines call on nursing homes that allow visitors to ensure social distancing, but they do not specify what that should entail. States that have authorized outdoor visits are generally mandating that facilities enforce the 6-foot rule.
Nursing homes might opt to limit visitors’ movements to enforce physical distancing. In its own updated COVID-19 guidelines for nursing homes, the federal Centers for Disease Control and Prevention (CDC) lists several “considerations for visitation when restrictions are being relaxed,” including:
- limiting visitors to their loved one’s room or another area designated by the facility,
- requiring visits to be scheduled in advance,
- permitting visits only during select hours, and
- allowing just one or two people at a time to visit a given resident.
A working group at the Florida Health Care Association (FHCA), which represents the state’s long-term care facilities, recommends designating visiting areas as part of a strategy to resume visitation.
“It needs to be facility specific. For example, you may have one facility that has a large communal area where you can have socially distanced visitors,” says Kristen Knapp, the FHCA’s director of communications. “That may determine your ability to determine how many visitors you can have at one time.”
What else can I do to minimize risks to residents?
Don’t go if you feel ill, “even if those symptoms are mild,” or if you’ve had close contact with someone with COVID-19 in the previous two weeks, advises Kara Jacobs Slifka, a medical officer in the CDC’s Division of Healthcare Quality Promotion.
Jennifer Schrack, an associate professor at the Johns Hopkins Bloomberg School of Public Health who specializes in the epidemiology of aging, also emphasizes thinking about possible recent exposure.
“Have you yourself been isolated? Have you minimized your risk? Or are you essential personnel who’s going into the office, who’s going into a grocery store because you work there? Are you going into a hospital every day because you work there?”
Schrack also suggests keeping visits on the short side. “The longer you’re in a small or enclosed space with somebody, the greater the risk of transmission,” she says.
Another option is to make some visits virtual. Videoconferencing and chat platforms like Zoom, Skype and FaceTime have become lifelines for residents and families during the pandemic, and continuing to use them at times even after lockdowns lift can minimize opportunities for illness to spread.
AARP is advocating for a federal requirement that nursing homes support virtual visits between residents and families.
“With families today spread out all over the country, virtual visitation can be an important long-term way for family members to stay in touch with their loved ones,” says Bill Sweeney, AARP’s senior vice president for government affairs. “Everyone should have the ability to do that.”
Editor’s Note: This story has been updated to reflect new information.