En español | For America's battered long-term care residents and staff, who account for roughly 40 percent of all U.S. coronavirus deaths — or some 87,000 victims — the upcoming winter could bring with it much more disease and death.
As temperatures drop, “nothing is certain” about what will happen in nursing homes, assisted living and other such facilities, says Justin Lessler, an associate professor of epidemiology at the John Hopkins Bloomberg School of Public Health. “But there's a big chance we will see a resurgence of COVID case numbers.”
It appears to already be happening. As COVID cases in the general U.S. population surged in late September, nursing homes quickly followed suit, reporting a 3 percent uptick in cases, according to a new report by the American Health Care Association and National Center for Assisted Living. The report ties the increase to the broader community spread, concluding that “nursing homes in the U.S. could see a third spike."
But more cases aren't the industry's only worry. There's concern that an expected new surge will be met with continued shortages of personal protective equipment (PPE), testing and staff, which have been lacking in many long-term care facilities. Then there are other winter health hazards, including the annual flu and seasonal affective disorder, which, like COVID, affect long-term care residents at disproportionate rates. The drop in temperatures will also force many facilities to halt outdoor visits, which have been crucial in combating social isolation and loneliness among residents over the summer.
All these factors could create “a disastrous scenario” for residents and staff in long-term care facilities, says Bill Sweeney, AARP's senior vice president of government affairs. “This virus is completely out of control,” he says, noting that the U.S. recently hit its highest daily case count since the pandemic began. “The idea that winter weather, a flu season and continued infection control deficiencies could make what we saw in the spring, in terms of long-term care deaths, just a prologue is an unimaginable nightmare."
Many long-term care facility operators are implementing strategies to help with those challenges, applying lessons of the last seven months, which has seen more than 20,000 long-term care facilities experience COVID cases. Nearly 530,000 residents and staff have been affected nationwide. But Heather Smith, lead psychologist in the long-term care units at the Milwaukee Veterans Affairs Medical Center, says that “everyone's anticipating things to get harder before they get better."
"I feel like we're treading water,” she says.
COVID may thrive in the cold
The main reason COVID cases are predicted to spike in winter is because the cold changes how humans interact. “We know that the weather will force people inside,” says Lessler, “and we know the virus transmits more efficiently when people are in close quarters and the way air moves inside may also contribute to transmission."
As COVID spreads in communities, the virus gets into long-term care facilities, often through staff who work at multiple facilities to make ends meet. And changes in human behavior inside the facilities can increase spread. “Residents won't be able to go into outdoor areas as much, they won't be able to keep the windows open to keep air circulating well,” says Lessler, “and those things could aid transmission when the virus gets in."
While we can anticipate how humans will likely behave come winter, we can't do the same for COVID. “We don't know whether the virus itself will gain any benefit from the colder weather,” says Lessler.
If coronavirus does benefit from winter weather — like the flu, which moves through cold dry air more easily — the threat of transmission intensifies. The way our breathing changes in winter, and how our respiratory tissues respond to the cold, could also aid the virus. Such changes would be keenly felt in long-term care, which generally includes older adults with underlying conditions who are at increased risk of infection and severe illness from COVID-19.
All of which makes infection control measures — washing hands, using PPE properly, screening, testing, social distancing, limiting contact, having a COVID response plan and others — more important as winter approaches. Many facilities are proactively sourcing supplies themselves, rather than relying on government help, which has often been slow to arrive, especially for facilities that are not nursing homes.
In Iowa, Glen Lewis, executive director at Edgewater in West Des Moines, is stockpiling testing kits that can be run through the rapid testing machine his facility got last summer. Only 150 kits accompanied the machine, enough for about two weeks’ worth of staff tests. “So there was a little bit of a hiccup through that process,” he says. “But do I feel that we have the resources now? I do. Absolutely ... It's to our benefit not to be in the middle of winter, when case counts and positivity rates may go up, and you can't get them."
Aegis Living, an assisted living and memory care provider operating 32 facilities in Washington, California and Nevada, has stocked seven months’ worth of PPE, according to founder and CEO Dwayne J. Clark. “We're looking at [the pandemic] as though it's going to run through to next summer,” he says. “That has to be our mentality."
But many other facilities are not as well prepared. An exclusive AARP analysis of government data shows that more than a quarter of nursing homes nationwide recently reported PPE and staff shortages, even though adequate PPE and staffing are core infection prevention and control principles for nursing homes, set out by the Centers for Disease Control and Prevention (CDC).
In New York, while PPE supplies are better than they've been over the course of the pandemic, they're “still pretty unstable,” according to Karen Lipson, executive vice president of innovation strategies for LeadingAge New York, which represents some 400 not-for-profit senior-services providers in the state.
And while its member facilities are not experiencing widespread staffing shortages, Lipson says, shortages do happen, especially when a facility is experiencing a higher COVID positivity rate in the community. “You start to see community exposures, which trigger positive tests among staff and sometimes quarantine requirements, even if the staff tests negative,” she explains. “This can trigger staffing shortages, and we're concerned we'll be seeing broader shortages as a result of higher positivity rates within the community in winter."
Alarmingly, nearly half of nursing homes nationwide are already reporting staff infections, according to AARP's analysis, which used data from late August to late September.
A looming ‘twindemic'
Another threat is the flu, which peaks in winter and, like COVID, disproportionally affects long-term care residents because of their generally weaker immune systems, underlying medical issues and greater exposure risk through living in close quarters with shared caregivers.
Some countries in the Southern Hemisphere, including Australia and New Zealand, reported lower levels of flu activity over their winters this year. But those countries have excelled at social distancing, unlike the U.S.
If COVID and flu circulate at high rates in the U.S. at the same time — forming a “twindemic,” as some have dubbed it — it could be disastrous for long-term care residents and staff. Residents who contract the flu may need hospitalization or some other form of contact with the medical system, which could then expose them to the coronavirus. And because the symptoms of the two diseases are similar, and because coronavirus testing isn't perfect, the flu may be mistaken for COVID, which could lead to problems like incorrect cohorting of residents and the misallocation of scarce COVID resources.
It's unclear how the two diseases will interact, but a double infection could be deadly. “There's reason to believe that if you're infected with one, it's likely to increase your frailty and reduce your respiratory competence,” says Lessler, “so if you then get infected with the other one, you'll be more likely to die than you otherwise would be."
Twenty-four states have flu vaccination requirements for long-term care facility health-care workers and 32 states establish requirements for residents, according to the CDC. Yet long-term care health-care personnel reported the lowest flu vaccination rate, at 67 percent, among all health-care personnel in the U.S. during the 2017-2018 flu season.
Over the summer, outdoor visits helped long-term care facilities to reconnect residents with loved ones after months of separation caused by a range of state and federal lockdown mandates. The visits were vital in combating residents’ isolation and loneliness, which can be deadly. But as temperatures plummet, particularly in the northern states, outdoor reunions may become unfeasible, increasing the need for so-called virtual visits via smartphones and tablets.
Even before the pandemic, 43 percent of adults 60-plus in the U.S. reported feeling lonely, with long-term care residents flagged as a potentially higher-risk population, according to a report by the National Academies of Science, Engineering, and Medicine. Experts say the pandemic has likely made these rates much worse.
To address this, the federal government released new visitation guidance for nursing homes in mid-September that still prioritizes outdoor visits but requires the reintroduction of indoor ones if there has been no new onset of COVID-19 cases in the past 14 days, the facility is not conducting outbreak testing and the county positivity level is at or below 10 percent.
At Presbyterian Homes & Services, a faith-based nonprofit senior living provider, bipolar ionization technology, which cleans air with electric charges, is being integrated into the ventilation systems of its 49 communities across Minnesota, Wisconsin and Iowa. But it's not clear how effective the technology is for combating COVID, and facilities are still at the mercy of COVID infection rates in surrounding communities.
"We want to be prepared to return to some version of in-building visits,” says Duane Larson, senior vice president of operations at Presbyterian Homes & Services. But, he says, “we have no illusion that COVID is done with us yet."
At Edgewater in West Des Moines, Lewis is anticipating increased COVID rates and therefore rollbacks on indoor visits, so he's keeping the facility's current “family living rooms” set up. The lobbies of the buildings have been converted into closed-off chat suites that have an exterior entrance for visitors and a separate interior entrance for residents. A clear room divider down the middle of each suite provides a protective barrier, keeping the participants separated.
Current indoor visits don't require such rigorous division. But, if indoor visits get shut down, Lewis's living rooms should be able to keep operating because, technically, visitors don't have contact with the resident or the facility's communal areas.
"What is exceptionally hard on family members is a constant start-stop situation, where you say: ‘Now you can come and see your loved one. Sorry, now you can't,'” he says. “These family visitation spaces are going to help us weather the storm better, rather than being fully open, then fully closed, then fully open, then fully closed."
But many facilities say they do not have the space or resources to achieve this type of setup, despite billions in federal aid for nursing homes amid the pandemic. In Washington, Vicki Elting, assistant long-term care ombudsman of the state, is encouraging family members to use the outdoor visitation option while they still can. “On November 1, it starts raining here,” she says, “and if you don't have an outdoor visit pretty soon, you may not be having one for a while."
Keeping spirits up
Winters bring an increased risk of mental health symptoms for long-term care residents even in regular times. Seasonal affective disorder — a mood disorder characterized by depression that occurs at the same time every year — kicks in, often worsening already high rates of depression. Almost half of nursing home residents have a diagnosis of depression, according to the CDC.
This year, however, mental health declines may be worse. “For residents, the stress is manifesting primarily into increased depression and anxiety, as well as agitated behaviors — so making attempts to leave, suicidal ideation, more verbal aggression toward staff,” says Smith of the Milwaukee Veterans Affairs Medical Center. “We're all on edge.”
Facilities around the country are implementing new strategies to confront the winter blues, focusing on resident engagement — particularly over the holiday season, when annual family gatherings may not be possible.
Smith is implementing a program based on reminiscence therapy called My Life, My Story. Volunteers contact veteran residents and invite them to share their life story, writing it up for residents to share with family and friends. “Finding meaning is a key theme that we want to build upon as much as possible right now,” Smith says.
In New York, LeadingAge members are running activities over in-house broadcast systems, including games, exercise classes, religious services and community news. There's also been a large investment in digital programs that allow for virtual activities and virtual visits with family and friends, plus staff to support the new tech.
Some facility operators are also finding new ways to care for their staff, which are experiencing burnout as well as worker shortages. “They are all very distressed,” says Smith. “They're worried about their residents and they feel responsible, as they always do, about their well-being."
At Edgewater, Lewis is running a meal program where $5 gets a staff member a previously prepared family meal for four from the facility's kitchen, ready to collect at the end of a shift. At Aegis, Clark has set up a staff foundation that team members can turn to during financial difficulties. Around 700,000 certified nursing assistants work in long-term care facilities, with most making less than $15 per hour.
"At the end of the day, it's the care manager going into a resident's room every day that's making the difference,” says Clark. “That's the person that talks to them, bathes them, looks after them, so we have an innate responsibility to keep that person's spirits up, too."