The first COVID-19 outbreak in the U.S. was at a Seattle-area nursing home, where 37 residents and staff died. It was an almost unthinkable tragedy ― the kind that shakes a nation’s conscience and prompts immediate action, so that it doesn’t happen again.
Instead, the ensuing weeks have produced even more stories and even more horrific death tallies: 47 at a Minneapolis nursing home, 52 at a facility outside Pittsburgh, 70 at a New Jersey home where, notoriously, full body bags were piled in a holding room.
The aggregate numbers are just as arresting. At least 16,000 nursing home residents and workers in the U.S. have died, which works out to about 1 in 4 of all COVID-19 deaths, according to the latest tally by USA Today. The real number may be even higher because of inconsistent testing, autopsy and reporting practices.
The pandemic’s heavy toll on nursing homes is not surprising. Residents are elderly, have significant physical or mental limitations, suffer from serious chronic conditions ― or some combination of the three. That makes them especially susceptible to severe, potentially lethal effects of the novel coronavirus.
Residents also require at least some assistance with daily life functions, including feeding, bathing and toileting, and they are typically in relatively close quarters. Infectious disease spreads easily in those environments.
All of this makes it easy to think nothing could have been done to reduce the level of suffering and that nothing can be done now.
Both of those assumptions are wrong.
The biggest problems at nursing homes include three clearly identifiable deficiencies: not enough testing, not enough protective gear, and not enough workers. Fixing these would not put a stop to nursing home COVID-19 deaths. But it would almost certainly reduce them and, along the way, it would make an increasingly miserable experience for residents and workers a lot more tolerable.
A handful of states are already taking such action. Prominent among them is Maryland, where nursing homes have accounted for roughly half of all state deaths and where the administration of Larry Hogan, the Republican governor, has responded with a series of initiatives to help facilities as soon as possible.
But states can do only so much on their own. What nursing homes really need is more federal intervention along with more federal money. And they need these things right away.
Problem #1: Testing
A shortage of tests has bedeviled the nationwide COVID-19 response from the beginning, and nursing homes were among the places where the shortage had the most detrimental effects.
Forced to ration limited supplies, facilities typically tested and isolated only those patients who were symptomatic ― which was a huge problem, said Morgan Katz, an infectious disease specialist at the Johns Hopkins University School of Medicine, because so many patients were carrying the disease and spreading it even as they showed no symptoms.
Katz has been leading Hopkins’ efforts, in coordination with the state of Maryland, to identify and address outbreaks at long-term care facilities. Early on, she said, she discovered that about half the residents and workers with positive results had no symptoms at the time of testing.
“It was really astounding,” Katz said. “They were shedding virus at that time, and no one had any idea. … We are not capturing this picture by only testing symptomatic residents.”
As testing supplies have finally become more available, several states have moved to test nursing home residents and staff more aggressively.
Maryland, for example, now plans to test all nursing home residents and it won’t be just a one-time thing, Fran Phillips, the deputy secretary of health, told HuffPost. The state is figuring out a schedule for return visits, in order to catch new cases and stop them from turning into outbreaks, and Phillips said she expects that will mean repeat testing every few weeks.
“I can’t give you a frequency now, but we want to stay on top of this,” Phillips said.
One reason Maryland can make the guarantee is that it appears to have test supplies in hand. Officials acquired 500,000 of the kits directly from South Korea, and Hogan has said he has National Guard troops protecting them at a secret location.
But many states don’t have that capacity, which means they cannot make the same promise and likely won’t be able to until the federal government provides more testing supplies.
“Our profession has been sounding the alarm for weeks and weeks,” Mark Parkinson, president of the American Health Care Association, a trade group representing long-term care facilities, said in a prepared statement earlier this week. “If we are not made a top priority, this situation will get worse with the most vulnerable in our society being lost.”
Problem #2: Gear
Personal protective equipment, or PPE, is another, all-too-familiar challenge.
Pearl Gooden, a certified nursing assistant at a Florida nursing home, told HuffPost this week she and her colleagues still get just one mask a day ― a standard surgical mask, not one of the more protective N95 versions ― and just one gown, as well. (HuffPost agreed not to identify the name of the nursing home, because workers speaking out have been subject to employer retribution.)
“You’re going from room to room, with the same stuff on,” she said, with no changes between the start of her shift at 7:00 a.m. and the end, at 3:15 p.m. “A surgical mask was not meant to be worn for an entire day, to be worn in one patient room and then another, over and over again.”
Her story is by no means atypical, David Grabowski, a health policy professor at Harvard, said in an interview. Although facilities may be satisfying official guidelines for adequate protection, Grabowski said, that’s misleading because the federal government relaxed those guidelines to allow for reuse, as new gear was so hard to obtain.
“We are not capturing this picture by only testing symptomatic residents.”
“They don’t have the N95 masks ― they have lower-grade masks ― and so it sounds like they have, quote-unquote, adequate PPE, but it’s not up to high quality infection control standards,” Grabowski said.
And although nursing home operators have tried to find gear, it hasn’t been easy, Grabowski said, because hospitals have been grabbing up the limited supply.
“It’s a really desperate situation,” Grabowski said.
Just this past week, the Trump administration announced that it is shipping protective gear to more than 15,400 nursing homes around the country. That will help, but it’s only a week’s supply. And it’s not for other types of facilities, such as assisted living communities, that have reported their own PPE shortages.
“It is now all too clear that states can’t possibly manage a pandemic of this magnitude, if they lack basic supplies to protect residents and staff,” Tricia Neuman, senior vice president at the Henry J. Kaiser Family Foundation, told HuffPost.
Problem #3: Worker Shortages
Even if the testing and supply situations improve substantially, nursing homes are still likely to struggle with insufficient staff.
Researchers have found previously that facilities with fewer workers were more likely to have problems with infections, in part because the best way to prevent the spread of disease is careful, thorough adherence to safety measures ― especially hand-washing ― and staff who are rushing between patients have less time for those practices.
The COVID-19 crisis has only increased the strain on staff. In order to slow the spread of the disease, nursing homes have now reduced or eliminated group activities. Instead of eating together in dining rooms or getting together in communal areas for music and physical activity, residents largely remain in their rooms, where they get everything from meals to physical and verbal therapy.
As a result, workers spend a lot more time going in and out of rooms, if not to deliver food or provide therapy, then just to check in on residents. That’s especially true for the CNAs like Pearl Gooden in Florida, who are the backbone of the nursing home workforce.
“We had a real problem way before COVID struck. These folks have very tough jobs at very low wages.”
At the same time, nursing homes are dealing with unusually large numbers of absences, because workers who get exposed to COVID-19 ― as so many do ― end up self-isolating or, if they get sick, end up in quarantine. There are also some staying home because, given the risks of working without protective gear, they fear they will get sick and bring the virus home to their families.
Making matters even worse, nursing homes can’t rely on visitors to pick up slack ― say, by helping with feeding or simply providing companionship ― because COVID-19 safety protocols require excluding visitors except in extreme circumstances, such as visitors for a resident who is about to die.
“They don’t have any family members to come and talk to them,” Margaret Boyce, a CNA from a New Jersey nursing home, explained. She described one resident in particular who told her he watches the clock every day to wait for her arrival, and how heartbroken she is that she can’t stay long anymore.
“They are just there, and they want to talk to you, they want to tell you, ‘This is what I did when I was young,’ and to give you some nice stories,” Boyce said. “And I love to listen to them, but now you don’t have time to do that because now you have to rush.”
Gooden, who says she prefers the title “caregiver” to CNA because she takes pride in that role, said she doesn’t have as much time to console residents who are “crying or looking like they’re worried.”
“I can’t do any of that,” she said, “because I have to rush in, do what I’ve got to do, and leave them and move on to the next one.”
The underlying problem: money
The surest solution to the staff shortages would be to hire more workers. But nursing homes were having trouble filling spots even before the pandemic, in part because of the pay they were offering.
Median pay for nursing assistants today is $14.25 per hour, according to the U.S. Bureau of Labor Statistics. But that’s for all nursing assistants, and pay in nursing homes tends to be lower, with fewer benefits, experts say.
“We had a real problem way before COVID struck,” Richard Frank, a health economist at Harvard, said in an interview. “These folks have very tough jobs at very low wages.”
Many facilities lean heavily on part-time staff who work at multiple sites in a week or even a day — in part, because part-time workers frequently aren’t eligible for benefits like health insurance or sick leave. Such arrangements are especially problematic in a pandemic because workers are more likely to carry the disease from one nursing home to another.
Labor groups like the Service Employees International Union (to which both Boyce and Gooden belong) have long called for higher pay and better benefits, especially when it comes to paid sick leave. So have national advocacy organizations.
Industry officials say they can’t pay more. Unions and advocates say the industry is plenty profitable, especially for some private equity companies that have run facilities with histories of quality and safety problems.
In the future, many advocates hope, the federal government will require that nursing home operators spend more money on patient care, just as the federal government now requires health insurance companies to do.
But that’s a long-term reform project. It’s not going to bring more workers into the facilities right now. It’s also not clear how much owners can do to raise pay at this particular moment, given the financial pressures they face because of the pandemic.
Like hospitals, which have lost revenue because of a sharp decline in moneymaking elective procedures, nursing homes have lost out on a big source of income: patients who will stay for only a short time while they recover from procedures or treatment. Payment for those patients comes from Medicare, which pays more than Medicaid, the primary financier of long-term care.
With those Medicare dollars in decline, Grabowski says, smaller, independently operated nursing homes in particular may have a harder time finding the extra money it would take to attract staff.
An idea for state action: ‘bridge teams’
State governments are starting to act on their own. Several are already using “strike teams” they dispatch to nursing homes where outbreaks have started in order to help test more residents, assess equipment needs, and make whatever arrangements are necessary (like moving residents to different parts of facilities) to isolate the sick.
Typically these strike teams include some combination of infectious disease specialists, nurses and National Guard troops.
But Maryland, which has had these strike teams operating since early April, announced this week that it has also started deploying “bridge teams” that can provide supplemental, temporary staff for nursing homes that don’t have enough workers.
“Seniors think we have just decided their lives are not worth saving ― that is not and cannot ever be true.”
Each of Maryland’s new bridge teams will include at least one registered nurse plus between five and seven CNAs, according to Phillips, the deputy health secretary, with a goal of providing care for up to 100 residents at a time. One reason for the teams, she said, was a recognition that more testing would likely yield more positives among existing staff, creating even more absences.
“We did not want the last resort, which would be for the nursing home to have to transfer these patients to a hospital simply because they didn’t have adequate nursing home care,” Phillips explained. “The patients themselves are stable … they don’t need to be hospitalized. And these are folks that don’t travel very well ― it’s very disruptive to put them in an ambulance.”
Even Maryland’s initiative has its limits. As of now, bridge teams will be available only for four days at a time, because, as the name implies, they are supposed to be an interim solution while nursing homes hire more workers on their own.
That can’t happen without offering workers a lot more money, which many nursing homes simply don’t have right now and the states, constrained by balanced budget agreements, cannot provide on their own.
Ideas for federal action: hazard pay and a ‘care corps’
The federal government, on the other hand, can borrow at will. And there’s already a proposal under discussion that could help nursing homes immediately. That proposal is for hazard pay.
Under the “Heroes Fund” initiative that Senate Democrats put forward a few weeks ago, wages for nursing home workers could nearly double and the newly hired could get bonuses of up to $15,000. Sen. Mitt Romney (R-Utah) this week introduced a similar, if less generous, proposal.
Money alone might not be enough to lure workers, simply because nursing home work is so difficult and hazardous in the current environment. Experienced health care workers on furlough or getting laid off, as so many have been in the past few weeks, may feel they are better off staying on unemployment, at least for the time being.
But it might be possible to target an additional labor pool: students and new graduates of colleges and health care training programs. Under a proposal now being developed by a pair of economists, Harvard’s Frank and the Massachusetts Institute of Technology’s Jonathan Gruber, the federal government would offer free training for caregiving jobs and then match those who complete the training with openings. They’re tentatively calling it a “care corps.”
The training wouldn’t take long. Even CNAs normally need only 75 hours of instruction, and federal regulators, in response to the crisis, are allowing nursing homes to hire temporary workers who complete shorter online courses. For many graduating students, the chance to get some early-career experience, along with hazard pay, could be appealing.
“Students make particular sense because right now, unlike other workers, students aren’t getting unemployment insurance,” Gruber said. “They are graduating with no prospect of a job, but no government support either. … And so it’s a good group to target, particularly students who were trained in the caring professions.”
The proposal is very much in its embryonic stages and could, for example, include an offer of debt forgiveness for students and new graduates carrying large tuition loans. Under the proposal, the program would also be open to the more than 7,000 Peace Corps workers that the government brought home and fired last month.
It’s a question of political will
Any serious initiative to bolster nursing home staff is going to require a lot of new government spending.
Democrats never put a price tag on the Heroes Fund, but it would likely run into the tens of billions of dollars, and already Republican leaders in Congress like Mitch McConnell, the Senate majority leader from Kentucky, are saying the government is taking on too much debt.
But even tens of billions of dollars is not a lot of money in the context of a relief spending effort that is now, cumulatively, well into the trillions ― especially when a lot of that spending has gone to large corporations. Besides, any new spending on nursing homes is arguably money that should have been spent already, if residents of nursing homes and other long-term care facilities were getting the care they needed all along.
“Seniors think we have just decided their lives are not worth saving ― that is not and cannot ever be true,” Rep. Debbie Dingell (D-Mich.), who introduced legislation to help nursing homes back in March, told HuffPost on Saturday. “We need to ensure that every person in a nursing home knows their life matters, we care and there is a reason to live.”
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