The Washington Post had a fantastic article from Steven Lee Berk, dean of the School of Medicine and executive vice president of the Texas Tech University Health Sciences Center ,and Abraham Verghese, vice chair of the Department of Medicine at the Stanford School of Medicine. They are co-authors of the seminal book “Infections in Nursing Homes and Long-Term Care Facilities.”
It is tragic but not surprising that nursing homes should suffer such heavy losses from covid-19. When it comes to a contagious pathogen, nursing homes are like cruise ships, with large numbers of people confined to finite spaces and sharing common dining and recreation areas. Except nursing homes come with a smaller crew that has repeated, hands-on contact with an aging and often sickly population that requires assistance with intimate daily tasks.
Historically, nursing homes in the United States evolved to sit somewhere between almshouse and hospital. The modern nursing home has a superficial and deceptive resemblance to a medical environment, with aides in uniform, hospital beds, bedside tables and a few nurses. But they lack the resources and personnel to allow them to live up to that appearance. The backbone of the institution is the poorly paid nursing assistant. Infection control and good sanitary conditions are championed but often difficult to execute. One of us (Abraham) worked in a nursing home as an aide as his first job in this country, before becoming a doctor. Although astonishing changes have taken place in hospital care, the nursing home remains frozen in time.
Nursing homes that have not yet seen patients with covid-19 are fortunate. We have perhaps a small window of time to keep the infection from exploding in these settings. To that end, the Centers for Disease Control and Prevention recently published “Coronavirus Disease 2019 (COVID-19) Preparedness Checklist for Nursing Homes and other Long-Term Care Settings.” This eight-page document has boxes to check off and blank spaces for filling in the names of the people responsible for the numbered items. The effort is laudable, but we would argue that it is unrealistic to expect nursing homes that are chronically underfunded by Medicare and Medicaid to develop “a system to monitor for, and internally review, development of COVID-19 among residents and healthcare personnel,” or to establish “criteria and a protocol for initiating active surveillance” or “criteria and a process for cohorting residents with symptoms of respiratory infection.”
What is needed urgently in this pandemic is a crisis task force and czar to take on nursing homes. Just as hospital ships were dispatched to covid-19 hot spots, state and federal governments need to send meaningful assistance in the form of medical reserve personnel and equipment to every nursing home to help them prepare and prevent as best they can. An effort evolving along these lines in Massachusetts might be a model for other states. Rapid on-site virus testing, monitoring and screening of patients and personnel, already so hard to do in the best settings, is unlikely to happen in nursing homes without such direct intervention.
Critically, there is a pressing need for on-site, responsive and rapid physician assessment of sick patients. Medicaid and Medicare only require a nominal monthly visit by the doctor of record; they get what they pay for. When a nursing home resident takes ill, it is almost the rule that the physician when called (or whoever is taking calls for them) will direct the patient to an emergency room. In short, the ambulance crew, the ER physician and the ER personnel of a nearby hospital serve as a very expensive and inefficient way to make up for the lack of on-site physician assessment. Even most cruise ships have a doctor; a nursing home deserves rapidly responsive, on-site clinical assessment, never more so than in the current pandemic.
To be clear, we can think of many situations where it is important to move the patient to a hospital, to relieve suffering, to assess a fall or to treat a reversible condition. But the use of emergency rooms as surrogates for primary care for nursing home patients wastes billions every year. In the current pandemic, as we saw early in Washington state, this practice efficiently spread infection into the community.
In the aftermath of this pandemic, let’s give nursing homes the attention that is their due. Let’s ensure they are safe places for our loved ones and have the tools to be as medically sophisticated as they look. Let’s support and reward the heroic personnel who labor in such settings, caring for our loved ones; they don’t get the pay or recognition they deserve. The best measure of a society is how well it cares for its elderly and keeps them safe. By that measure, we fail in our nursing homes. We are now paying the price.