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As COVID-19 Cases Fall, Nursing Homes Feel Out New Normal

Visits and activities are resuming in facilities, but long-term problems persist

spinner image A female nursing home resident swinging a stick at a virus bug shaped piñata
Staff and residents of the Jewish Home Family in New Jersey take aim at the coroñata, a piñata shaped as a coronavirus.
Courtesy Jewish Home Family

The residents and staff of the Jewish Home Family, a group that includes a nursing home and long-term care facility in New Jersey, have been partying. The recent arrival of CVS nurses carrying batches of newly authorized COVID-19 vaccines was cause for celebration.

"We made it very festive,” says Carol Silver Elliott, president and CEO of the facility. “We gave everybody who got their second dose a T-shirt, we had stickers, we had balloons.... We even had piñatas in the shape of the coronavirus; we hung them up on the nursing units and residents and staff took long poles and smashed them, and candy rained all over us.”

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After a devastating year of loss and suffering — almost 180,000 residents and workers in long-term care have died from COVID-19 in the U.S., and more than 1.4 million have been infected — many facilities finally have reason to exhale. The federal program tasked with administering vaccines to almost all long-term care communities is expected to wrap up in a few weeks. COVID-19 infections and deaths in nursing homes have declined significantly since the beginning of the year. And new federal guidance is making it easier for residents to interact with visitors.

"We all feel relieved,” says Silver Elliott, who is also the chair of the board for LeadingAge, a national association representing 5,000 nonprofit aging services providers. “People are walking around saying, ‘I have my COVID superpowers now’ and ‘OK, I'm not as afraid’ … It's starting to feel like life is coming back.”

But while most long-term care residents are now fully vaccinated, most other Americans are not, meaning there are still plenty of opportunities for the virus to reenter facilities. The threat is compounded by vaccine hesitancy among many long-term care workers. And there are unknowns about just how effective the vaccines are in protecting long-term care residents as a specific group.

spinner image nursing home staff lined up for their covid 19 vaccination
Staff at the Jewish Home Family line up for their COVID-19 vaccinations.
Courtesy Jewish Home Family

"It's OK to be optimistic,” says Jennifer Schrack, an associate professor in the epidemiology of aging at the Johns Hopkins Bloomberg School of Public Health. “But we still have to be diligent. This is a new disease. We don't know how it's going to behave. We don't know how the variants are going to behave.… Just because you're vaccinated doesn't mean you can't get it.”

That puts the country's long-term care facilities in an awkward in-between phase. Getting back to a semblance of normal is now possible, but not without continued safety measures. Just how cautious facilities must be is “the million-dollar question,” says Schrack, who predicts that confusion and stumbles are inevitable.

Beach balls in the garden

The Jewish Home Family includes a nursing home and assisted living, where communal activities that were either heavily restricted or completely canceled during the pandemic are starting back up again. Nearly every resident except hospice patients, and around 75 percent of staff are fully vaccinated against COVID-19.

Residents can now eat with each other in the dining rooms, take exercise classes in the boxing gymnasium or rehearse for the upcoming annual musical, The Lion King, which had to be postponed last year.

Infection-control protocols still hold, including wearing masks, social distancing where possible and capping the number of people participating in each activity, in accordance with federal guidelines. But these activities represent some of the first opportunities for socialization that residents have had in months.

"In a lot of ways, we're coming back to ourselves,” says Silver Elliott, who is calling the next few months of programming at the Jewish Home Family “Project Welcome Home.”

The toll of the past year on residents is clear, she says: “The cognitive decline is significant, and it breaks my heart.” Her facility's activities are focused on ending isolation and revising restrictive environments as quickly as possible, while still being careful.

The Holly Heights Nursing Center in Denver is taking a similar approach. Now that the majority of the facility's residents and staff are fully vaccinated, bingo and exercise classes are back on the agenda, as are some group meals. But precautions, such as masks and social distancing, continue.

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And whenever possible, the center continues to follow federal recommendations for hosting activities outside, where the coronavirus is far less likely to spread. On a particularly warm day in early March, executive director Janet Snipes jumped at the chance to blow up beach balls and invite residents to pass them around in the garden, enjoying the sunshine.

"It was a lot of fun,” Snipes says. “After such a devastating year, you could see that spirits were starting to improve.”

Champing at the bit for visitors

At many facilities, visits are also resuming. New recommendations this month from the federal Centers for Medicare & Medicaid Services (CMS), which regulates America's 15,000-plus nursing homes, represent the most dramatic steps toward reuniting residents with loved ones since nursing homes were first shuttered to guests in March 2020.

Citing widespread vaccinations and drops in COVID-19 infections, CMS said “facilities should allow indoor visitation at all times and for all residents [regardless of vaccination status].” There are exceptions, including for residents who have COVID-19 or who are unvaccinated and in high-risk environments.

Fully vaccinated residents can choose to have close contact with visitors, the recommendations say, including touching and hugging while wearing a face mask and washing hands before and after. The CMS acknowledged “the toll that separation and isolation has taken” on residents and said “there is no substitute for physical contact.”

After completing its vaccination clinics in late February, the Edgewater senior living community in West Des Moines, Iowa, “were champing at the bit for the guidance to change,” says executive director Glen Lewis. With 98 percent of residents and 75 percent of staff vaccinated, “we were just sitting there, waiting … ready to go,” he says.

AARP had called on CMS to review visitation guidance, noting it had heard from thousands of families who “urgently want to visit their loved ones who desperately need their care and support.”

Lewis opened Edgewater's doors the day after the CMS's new guidelines came out and watched as residents embraced loved ones for the first time in over a year. “There's nothing like that sense of community and communication and companionship that comes from their own families,” he says. “It feels like a new day.”

Edgewater also hosted a facility-wide dinner to reunite residents from different sections of the facility. The event brought together two lifelong friends, one from the skilled nursing area and the other in assisted living, who hadn't seen each other in a year. “These two ladies were literally holding each other's hands and just saying, ‘It's so good to see you, it's so good to see you',” says Lewis. “They just kept holding each other.”

A different future

Yet a complete return to pre-pandemic ways of life in long-term care is probably not an option. Infection control deficiencies in nursing homes were "widespread” and “persistent" even before the COVID crisis. The U.S. Government Accountability Office found that 82 percent of homes surveyed between 2013 and 2017 were cited at least once for infection-control lapses, such as improper hand hygiene among staff or a nurse coming to work with a cough and fever.

Such violations, previously classified as “not severe” by nursing home surveyors, turned deadly in the pandemic, forcing many facilities to step up their infection control protocols. Those measures will remain after the pandemic, says Silver Elliott of the Jewish Home Family.

"I think masking is going to be with us for a long time,” she says, especially during flu season. “I think my hands being raw from washing them 1,050 times a day is probably here to stay, too.”

Greater access to tele-visits, via video conference platforms, may also remain, “particularly for those families who live far away from their loved ones,” says Lori Smetanka, executive director of the National Consumer Voice for Quality Long-Term Care, a nonprofit that advocates for the public on long-term care issues.

And experts and advocates are pushing for bigger reforms that could help prevent a repeat of the COVID-19 disaster. One key area: staffing. Certified nursing assistants (CNAs) are “the backbone — the absolute total foundation” of the long-term care industry, says Silver Elliot, but there are few incentives to become a CNA.

Most make less than $15 an hour and many don't receive sick leave or benefits, which has aided high rates of vaccine hesitancy. Plus, nursing home workers had one of the deadliest jobs of 2020. For the majority of the pandemic, more than a quarter of U.S. nursing homes have reported a shortage of direct care staff, according to an AARP analysis of CMS data.

"We have to find ways to make [long-term care] careers meaningful for people,” says Silver Elliott, including more pathways for career advancement, from a CNA to a nurse practitioner, for example. “But I think it also requires some support on a regulatory basis,” she adds.

Rhonda Richards, AARP's senior legislative representative in government affairs, says it's time to reimagine the whole long-term care model, which in the U.S. is made up mainly of large “big box” facilities with hundreds of beds. “It's important to encourage small-house nursing home models, like Green Houses, with private rooms,” she says. “Also, giving people more options to live in their homes and communities, where they want to be.”

Why COVID-19 Killed So Many in Nursing Homes

Emily Paulin is a contributing writer who covers nursing homes, health care, and federal and state policy. Her work has also appeared in Broadsheet, an Australian lifestyle publication.

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