Wednesday, May 13, 2020

Could Residents in Nursing Homes, Assisted Living Facilities and Personal Care Homes be "Canaries in the Coal Mines?"

Coronavirus infection rates at nursing homes are hot news, and getting hotter each day.  Some see this as evidence of substandard care.  I had been holding hope, frankly, that when I read another horrific story about a specific nursing home with xxx cases, high death rates, or a staff decimated by infections, the explanation could be as simple as negligent care.  

But, what if that isn't the reason?  What if facilities are employing best available practices, but the "best available practices" just are not good enough in the context of congregate care settings for this complicated disease?  Frankly,  state of the art models for long-term care are ones with strong behavioral programs, where quality of daily life is as important as protection against risks.  Interactions, engagement, exercise, activities are what make those programs "best available."  

A few days ago a friend sent me a news story about an assisted living facility where approximately 50% of the residents have recently been diagnosed with Covid-19 infections -- and where a first Covid-19 related death has occurred.  I was startled, because I recognized the name of the facility.

Less than four weeks ago,  the testing at that facility had shown no patients or staff members to be positive for the coronavirus.  Early in March, the pro-active managers instituted "no visiting" rules for family members and other outsiders, along with other strict precautions.  The facility even made arrangements for nearby housing for staff members -- at no cost to the staff -- to make it easier for them to separate themselves from cross-infections in their own homes during the quarantine.  The staff continued to involve residents in daily activities, recognizing that engagement was a critical part of care, especially without family and friends visiting.

I'd been hoping that the early reports of "no virus" were testament to the fact that best practices can be employed successfully to keep fragile elders or disabled adults safe without locking them in their rooms.  But, that apparently proved not to work out at this very careful facility.  I've heard critics say the solution is for elders to be "at home,"  But "keeping your loved one at home" often won't be a practical solution, especially if the needed care is complicated, often requiring more than "just" family.  

Because this facility was where each of my parents lived during their last weeks, I saw first hand just how diligent and how careful that staff is about infection.

We are all gaining a stronger understanding of how complicated care is even without this particular, terrible new disease.  The disease has also run rampant through many jails, prisons and commercial food plants, all additional examples of congregate settings.  But if dedicated care communities with good ratios of professional staff and very good records on quality of care are struggling to prevent Covid-19 infection, what is the real message the canaries are singing?

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A very thoughtful piece.

In a cascade commencing in January, 2020, I (as oldest child and attorney-in-fact) have experienced the situation where both parents (one having a pre-existing disease and the other’s disease (neither of them Covid)) have been diagnosed with varying degrees of diminished capacity.

Since that time, I have been dealing sequentially – from hospital (Jan) to rehabilitation center (Jan-March) and finally transition - with assisted senior living (to present). The lockdown first took effect the 10th of March and (except for transfer between facilities and “medically necessary” physician’s appointments), this lockdown has been absolute except for essential personnel.

My experiences are akin to those you describe. The staff has been stringent and diligent in preventing Covid finding its way into the facilities (rehabilitation and subsequently assisted living). This is a situation where “every reasonable precaution” may be taken and yet the virus “slips in.” (No positives in their Assisted Living facility as of this date).

However, you might note that confirmed infection rates continue to escalate with the proliferation of testing (presuming a nominal false positive). As one might expect, the more people tested (broader sample) is going to yield greater numbers. Further – having a friend who has been with a national testing laboratory for about 30 years – even with the antibody tests there is little reliable data concerning ongoing immunities; and, if we look at SARS (no vaccine in 20 years) and Ebola (approved a vaccine in 2019 after 19 years in development. Although drug treatments have progressed mightily relating to AIDS, there is no currently licensed vaccine (despite over almost 40 years having lapsed since it received attention). I think anyone relying upon a preventative or therapeutic vaccine in the short-term (1-5 years) with the historic timeline of developments, better get used to achieving “herd immunity.”

To shelter these seniors “at home” is virtually impossible due to the necessity of constant policing of daily medications that the seniors can no long be reliably trusted to administer and oversight of caloric intake.

Posted by: Tom N. | May 13, 2020 12:31:33 PM

Thank you, Tom, for your thoughtful and helpful comments here. It is an unusual time in which older adults are now the focus of much deep thought and medical observation -- and perhaps that means something important for the larger population too. We are, perhaps, getting serious about what it means to have a reliable source of health care, to plan ahead, and to realize the importance not just of the family, but of the larger community in which we live.

Posted by: Katherine C Pearson | May 14, 2020 8:17:44 AM

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