Turning a complete “lock-in” into a more sustainable community
On June 13, a team of 33 aides, administrators and other employees at the Pebblebrook long-term care facility emerged through a zippered plastic barrier to music and cheers. It marked the return to their own lives after 11 weeks of sacrifice. In the early days of the COVID-19 pandemic, these staffers agreed to move into the care center within the sprawling Park Springs Life Plan Community in Stone Mountain, Georgia, near Atlanta.
Donna Moore, chief operating officer of Isakson Living, the company that owns Park Springs, was among those who chose to lock in. She pitched a tent in the community hall; others claimed beds in empty rooms and slept on air mattresses and in sleeping bags in offices or common areas. Nadia Williams, the health center administrator, promised one resident that she would always say good night to him. When he felt anxious, she stayed up late with him and watched a movie, tiptoeing from his room once he fell asleep.
Employees deepened relationships with residents — over meals, courtyard conversations, games. Marcia Davis, a certified nursing assistant at Pebblebrook, shared tastes of Jamaica, like ackee and saltfish, boiled bananas and oxtail. O'Neil Marriott, a maintenance technician at Pebblebrook, became known for his fried dumplings.
With no physical visits allowed inside the building, residents were limited in interactions with their families. So staff rolled around a large TV connected to a computer for virtual visits. Residents (or “members” in Pebblebrook vernacular) could also visit with loved ones through room windows.
The bold decision to go to a total lock-in kept the coronavirus at bay, and it bought time for leadership to develop a phase 2 of its virus response that wouldn't require staff members to shelter in place.
Of course, a price was paid. Months of lock-in uprooted the staffers’ lives. The health administrator missed being at her sister's wedding, instead serving as maid of honor via a video call. The maintenance technician had to skip a family fishing trip, planned as a last outing before his father would retire to Jamaica. Yet they felt mixed emotions when they left. “It was bittersweet because we had just been through something together that people on the outside don't understand,” Moore says.
Beginning in mid-June, Pebblebrook's managers implemented phase 2, allowing employees to come and go while increasing testing and screening, social distancing and mask wearing, and other infection-control protocols — such as the daily use of a cleaning system that uses a mist to sterilize surfaces.
Pebblebrook, which has 60 beds, has largely remained free of COVID-19, with one resident and three staff members testing positive since the lock-in ended. Employees and vendors are screened before entry. They are given a health questionnaire and temperature check. They must wash their hands and wear a medical-grade face mask and face shield provided by the facility.
Pebblebrook staff members are tested regularly, and all residents were tested once after the facility entered phase 2. Since then, residents are tested only when there is a positive case among staff. Any resident who has a temperature is isolated, even if the infection is known not to be the coronavirus. If there's any question about the cause and a COVID-19 rapid test or lab test were to come back positive, that resident would be moved immediately to an isolation area, Williams says.
Staff members wear masks throughout their shifts and full personal protective equipment (PPE) — shields, gowns and gloves — when necessary, such as if they're working with newly admitted short-term rehab residents who are awaiting COVID-19 test results. All those steps have addressed the crucial measures needed to battle the coronavirus and, for that matter, future viruses.
Ending racial disparities in long-term care
Maricruz Rivera-Hernandez, assistant professor of health services, policy and practice at Brown University, and Tetyana Shippee, associate professor in the division of health policy and management in the University of Minnesota School of Public Health, discuss the biases people of color face in nursing homes and why diversifying staff is so important.
What's the scope of the problem?
Maricruz Rivera-Hernandez (MRH): COVID-19 has shown us that differences in quality of care are striking, with far higher infection and mortality rates in nursing homes with a higher concentration of African American residents. One example is that after a hospital stay, residents of these nursing homes tend to return to the hospital more often.
Tetyana Shippee (TS): Black nursing home residents are also more likely to be physically restrained, compared with white residents. They also have inappropriate use of feeding tubes considerably higher than white residents, and are less likely to be vaccinated for preventable illnesses like the flu and pneumonia. There are some similar disparities for Latinx and Indigenous residents. If you're restrained and can't get up and move around, you lose mobility and muscle mass. That can affect your independence in the long term and worsen chronic conditions. When it comes to quality of life, if the food and activities don't reflect your culture and if you're not treated with respect, daily life isn't very satisfying.
Are there any immediate fixes?
TS: More BIPOC [Black, Indigenous and people of color] administrators, directors of nursing, heads of social work and activity directors. I've been in majority Black and Latinx nursing homes where the administrators on the first floor are all white and the aides upstairs are of color. But I've also been in some urban nursing homes with tight budgets, where a Black director of nursing makes a real difference. It's one way to break through systemic racism.
MRH: I'd like to see more minority administrators as well as more minority doctors, nurses and other health care practitioners working in these nursing homes. But there's a shortage. You have to attract more young minority students into health care and provide scholarships.
What's surprised you about the issue?
TS: How much BIPOC families are interested in getting home health care for their loved ones so they don't need a nursing home in the first place. There's funding through Medicaid if you qualify, but also waiting lists and lots of steps involved. We held a community meeting about this recently, expecting 20 people to show up. More than 100 came.
Visits from family members in the building remain off-limits in phase 2, so the staff erected a square tent with three clear plastic walls next to the building's entrance. A resident can sit in a comfortable chair inside the tent while family members gather on the other side of the plastic. Microphones and speakers on each side of the tent help facilitate conversations for those who are hard of hearing or soft-spoken. The residents “are overjoyed,” Williams says. “It just fills my heart because they are able to still connect with their families in the height of the pandemic."
Within the walls of Pebblebrook, as has always been the case, residents are divided into “households” of 18 people. These smaller contained communities, by design, bolster relationships and control the spread of infection, Moore says. While residents don't have to wear masks, they are kept at a safe social distance, sitting at least 6 feet apart during activities like arts and crafts. And for the resident who wants to see a friend who lives in a different household, meals shared from opposite sides of a long table are arranged.