The Trump administration has called nursing homes “ground zero for Covid-19,” and the analogy is apt—one New York City facility has seen 98 residents die from the disease, while more than two-thirds of Massachusetts nursing homes have reported infections. Though the link to long-term care facilities from deaths after hospitalization is not always recorded, 19 percent of those dying from the virus in Hungary, 51 percent in France, and 62 percent of those in Canada were identified as nursing-home residents.
The population in nursing facilities is vulnerable, and the disease is easily transmitted through extensive personal care in crowded quarters from staff who travel back and forth from the wider community. Several innovative senior homes have secured their facilities by paying bonuses to staff to stay on-site during the most hazardous phase of the crisis. Many lives could be saved if Congress were to support expanding these efforts. Indeed, preventing nursing homes from acting as super-spreaders might help broader communities more swiftly return to normal, too.
In 2016, nursing homes housed 1.3 million Americans, 39 percent aged 85 or over; 800,000 more lived in assisted-living facilities. Nursing-home residents are extremely vulnerable to the coronavirus due to multiple comorbidities: 72 percent have hypertension, 38 percent heart disease, and 32 percent diabetes. Even under normal circumstances, this population faces disproportionately high mortality risks: in 2016, while nursing-home residents made up just 0.4 percent of the U.S. population, they accounted for 19 percent of deaths.
But the vulnerability of nursing-home residents to the coronavirus is not simply due to the demographics of age and illness. Nursing homes have long been particularly susceptible to infectious diseases, as residents spend most of their days in close contact with others—stuck indoors, eating meals together, sharing rooms, and needing extensive high-touch care from caregivers who move from room to room. In 2016, 45 percent of nursing homes had infection-control deficiencies; as many as 380,000 people die every year of infections in long-term care facilities.
The current crisis deepens these challenges. Social distancing is hard to practice for residents who need an average of four hours of personal care per day: 45 percent of residents have dementia diagnoses, 63 percent have bladder incontinence, 32 percent require rehabilitation, 65 percent are chair-bound, and 15 percent need respiratory treatment. And long-term care facilities have found themselves short of masks, gloves, and gowns, as protective equipment has been stockpiled for hospitals.
Unavoidably, nursing homes must interact on a regular basis with hospitals and other external medical providers. Reductions in routine visits from physicians may increase residents’ underlying medical risks. Facilities must isolate and manage patients with Covid-19 who aren’t hospitalized, as well as those who return and may still be infectious. New York has refused to allow overstrained nursing homes to send patients elsewhere; the state requires facilities to readmit medically stable infected patients, where doing so is deemed safe. Nationwide, only 10 percent of nursing homes say that they are willing and equipped to accept Covid-19 patients returning from hospitals.
The Centers for Disease Control has instructed nursing homes to restrict visitors, screen staff on entry, disinfect surfaces, wash hands, limit communal meals, and quarantine infected residents. But these measures have proved inadequate to protect facilities from the disease, in part because of the delayed onset of symptoms and the difficulty in identifying cases. Indeed, one study of nursing-home residents found 57 percent of those testing positive to be asymptomatic.
Nursing-home staff can easily become vectors for Covid-19 infection. They often work in multiple facilities, share housing with those who work at other care homes, and rely on public transportation. In 2018, 4.5 million Americans worked in long-term care settings. About half of these workers are aides and personal-care workers, who earn an average of $12.71 per hour, or $26,440 a year.
With schools closed, many long-term-care workers have children to look after and would earn more under the CARES Act by staying home than by going to work, where they may risk getting infected and infecting family members. As a result, many nursing homes are currently staffed at less than 50 percent—putting further strain on those workers who remain and causing safety standards to slip even further.
Nursing-home finances are often precarious, with average profit margins ranging from 0.6 percent to 3.8 percent between 2001 to 2017. The Covid-19 crisis has caused occupancy rates to slump and costs associated with infection control to spike. Nursing facilities have called for a $10 billion funding boost from the CARES Act, but assisted-living centers have generally been ineligible for payment boosts associated with Medicare or Medicaid patients.
A more hopeful model can be found in the Shady Oaks assisted-living facility in Bristol, Connecticut. The facility is taking an innovative approach, paying bonuses to 18 staff members to live on-site, full-time, while the disease rolls through the area. The idea is to isolate the senior home from physical interaction with the outside world. So far, the approach has worked: while two-thirds of long-term-care facilities in Connecticut have suffered Covid-19 outbreaks, Shady Oaks has seen no cases among staff or residents.
According to its owner, Tyson Belanger, the key is to pay enough to motivate staff to work overtime (a 60- to 80-hour work week) and justify leaving their families for an extended period. In practice, this has required roughly tripling staff salary for a few months. Staff are housed in campers parked on-site, and unoccupied rooms, nearby rental houses, or hotel rooms might also be put to use. Management has taken precautions to segment the facility, so that if someone does get infected, transmission can be limited. Some staff and rooms are set aside for quarantining residents who will inevitably break the bubble to go to the hospital for unrelated issues. Similar approaches have been tried with success in Georgia, Ohio, and Southern France.
Belanger has mostly financed the Shady Oaks approach with his personal savings, with assistance from a Payroll Protection Program loan. But these measures are unlikely to be sustainable or widely scalable without more help. A Marine veteran and political scientist with a graduate degree who took over the family business, Belanger suggests that Congress could provide targeted assistance by expanding the PPP program to support payroll increases for organizations classified as health-care providers under Workers’ Compensation. He estimates that it might cost taxpayers $55 million to expand such an arrangement to all nursing homes and assisted-living facilities in Connecticut. Scaled up nationwide, this would add up to $5 billion, which would amount to only 0.3 percent of the cost of the CARES Act.
Growing public pressure to resume ordinary life and restart the economy has contributed to the neglect of senior homes, whose residents are not in the labor force. But unsecured nursing homes easily become institutionalized super-spreaders, causing infections to multiply and spread back into the wider community. Fewer than 1 percent of New York residents live in senior homes, but residents of such homes account for 22 percent of Covid-19 hospitalizations—the curve that most needs flattening.
Long-term-care facilities may be held liable for negligence if an outbreak occurs; they will incur enormous expenses in the attempt to deal with the fallout; and they may need to provide hazard pay to maintain their staffing. Most lack the funds to cover such needs. Washington should step in to help facilities pay these costs, so that thousands more of the nation’s seniors don’t fall prey to the virus.