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.
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.
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.
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.
The bonds created during the 75-day lock-in remain strong and motivate compliance with rules. “We built a forever bond,” Williams says. “You cannot hurt someone you care about. You cannot take a shortcut with someone you care about. We are family."
But Moore knows that they must stay vigilant and that their story could have unfolded differently. They planned well, but sheer luck may have helped spare them, too. Also, if not for the ample space and the support of owners who fed everyone and paid overtime and a bonus stipend to workers during the lock-in, they couldn't have pulled this off.
Because Park Springs is a private organization, Moore cannot share financial information, but says: “I can tell you that we were not focused on the cost throughout the lock-in.” When it comes to ordering supplies or equipment to keep everyone safe, “we are going to do the right thing regardless of cost."
Her heart aches for facilities that were hit with COVID-19 outbreaks. “They love their residents, too,” she says. “It's like a wave that knocks you over in the ocean, and you never saw it coming."
Doing everything possible to keep the virus from returning
David Ross sobbed as he drove home from work. It was mid-July, and the 300-bed nursing home that he runs in New Hampshire, the one that once registered 30 new cases of coronavirus per week, had just reached an important milestone: a week of no new positives.
These tears were driven as much from relief and joy as they were from the accumulation of two months of sadness, pain and frustration.
Ross, the administrator of the nursing home, remembers that state representatives wanted to know how a major outbreak could have happened at Hillsborough County Nursing Home, a nonprofit facility in Goffstown. In May, when the first residents came down with symptoms, the staff administered coronavirus tests to all residents in one 50-bed unit and rushed samples to the state lab. About half the residents in the unit were positive, most of the rest soon joined them, and the virus later spread to three more units, infecting 209 people in all, including 57 staff members. Forty-two residents died, but no staff members did.
Employees and residents were being tested each week, although because of an increase in cases in the community, the facility was gearing up for the possibility of twice-weekly tests. When the nursing home is in “outbreak status,” meaning at least one positive case in the building, about 20 members of the National Guard come in weekly to test everyone, Dubois says. She and other nurses scramble to take over the testing of residents who are war veterans, not wanting the military uniforms to trigger PTSD.
Staff also use a rapid-test machine whenever anyone has sniffles, a headache or other minor symptoms. The federal government, through the Centers for Medicare & Medicaid Services (CMS), supplied the machine without cost, but the nursing home still must cover the expense of testing materials. One test runs about $23, Ross says, already costing the nursing home $50,000.
Ross understood why the state officials asked their questions, but the answer was simple: His staff had done what they could with the information and testing protocols available. And while other institutions, like schools and churches, could go virtual, his residents had no place else to go. “It's not like you could shut us down,” he says.
Before COVID-19, signs asking visitors with flu-like symptoms to stay out were about the only restrictions on outsiders, Ross says. That was when 50 visitors a day might stream in, residents gathered in common spaces, and college-student volunteers flitted in and out. Nurses concerned themselves with preventing falls, aspiration control, managing common contagious infections and keeping surgical wounds clean, says Tonya Dubois, the director of nursing. And even before the pandemic, they followed strict protocols for handwashing, sanitizing equipment, and proper disposal of needles and other medical gear.
While all those priorities remain in place today, “the water has been muddied with this pandemic,” Dubois says. “It's taken over a large portion of what we do in our building now and how we do things."
Employees put on surgical masks when they enter the building. Anyone within 6 feet of a resident must add a face shield. Ross says the nursing home has spent close to $300,000 on PPE, contributing to more than $500,000 in unbudgeted expenses since March. All of this has forced a reallocation of funds, a search for coronavirus-relief reimbursement sources and delays in projects, such as a planned renovation of a nursing unit and the expansion of a behavioral health unit.
Test results dictate response, including whether the nursing home is cleared to enter the next stage of reopening. Phase zero was shutdown. Phase 1 — which started after two weeks of no positive cases — allowed the facility to crack the doors open a bit. Residents began seeing family members at a distance outside. Then, once the home kept cases at zero for another two weeks and the county rate of cases dropped to less than 50 per 100,000 people, the doors opened wider — allowing for occasional nonessential appointments inside, like visits from a hairdresser or routine dental or eye exams.
Coordinating 20-minute supervised visits outside took 80 hours of work a week but was a “labor of love,” Ross says. “When you saw families and residents connecting again, it was breathtaking, absolutely the best part of the day."
But that joy was fleeting. Come fall, a resident who had previously been infected tested positive again, forcing the facility to roll back to phase zero. Eleven positive cases were found, Ross says, though public health officials believed they were recurring positives, likely not contagious. Only one person showed short-lived, minor symptoms. Still, Ross worked with the public health officials to add a temporary wall in one unit to create an 18-bed isolation area. Employees working there have gone back to wearing full PPE. “We had to err on the side of caution,” Ross says. The facility remained in phase zero as of mid-December.
Going backward was a blow to residents, who had started to leave their rooms again for socially distant meals in the dining room and spread-out group activities, such as bingo, exercises and crafts. “You just felt like you let air out of a balloon,” Ross says. “Folks were deflated” thinking about the residents’ return to isolation, the need for extra PPE, the potential loss of more lives. Some employees who had stepped away from their jobs at the nursing home when the initial outbreak hit had just come back — only to leave once more, this time questioning if the health care field would ever be right for them.
Dubois cries when she talks about residents separated from their loved ones and says the need to be their support system keeps her and others coming back. “The people that are here really, really, really just care about them,” she says. “Even when you're scared — you don't want to catch COVID and bring it home to your family — you come in because who else is going to help take care of them?"
Long-term care in the time of COVID, Ross says, means never getting too comfortable. Anxiety hovers over the nursing home. Each time he reviews test results, Ross has to stop to remind himself to breathe. “It's kind of like playing with a jack-in-the-box when you're a kid. You know it's going to jump out and scare your pants off,” he says. “That's the feeling when you're looking through those reports. You're waiting for something bad to happen."
Ross clings to the guidance touted by public health professionals to “avoid the three C's,” which he describes as “close contact, closed spaces, crowded places.” But no matter how strictly he and others in the long-term care industry adhere to these rules, he fears outbreaks will continue. All it takes is one asymptomatic employee being COVID-positive — between tests, so not yet aware — to bring it into a building. And as people outside grow tired of taking precautions and start letting their defenses down, community spread will grow, as evidenced by surging numbers this fall, he says. That, in turn, increases the risk for nursing home employees and the residents they want to protect.
"Even the best of facilities are at risk for this because of the nature of what we do and the closeness of people,” Ross says. “We're forever changed. We'll never be the same."
Jessica Ravitz is a former senior writer for CNN Digital whose work has also been published in Smithsonian magazine, The Washington Post and The Atlanta Journal-Constitution.