April 09, 2020
As Covid-19 sweeps through the U.S., the challenges of caring for frail and disabled older adults is growing exponentially. Nursing homes and other residential long-term care settings are on high alert trying to prevent and control the spread of a highly contagious virus. While hospitals are experiencing a severe lack of personal protective equipment (PPE) and ventilators, nursing homes tend to be even less well supplied. Despite these deficits, regulators are rightly focused on infection control in nursing homes. But infection control is not all we can do.
Advance Care Planning
Since all nursing home residents are at substantial risk, we should know what they would want to happen if they become very ill. Covid-19 infection gets worse quite rapidly in older adults – in as little as a few hours. Nursing homes should encourage advance planning conversations and documenting residents’ wishes. Knowing in advance which residents do and do not want to transfer to the hospital and likely ventilator care will enable health care providers to make decisions honoring those wishes and avoid using scarce medical resources on people who don’t want the intervention. There are some good suggestions on how to phrase an advance care planning conversation at VitalTalk.org, the ConversationProject.org, and the Social Work Hospice and Palliative Care Network.
If residents develop respiratory failure, they will need oxygen, and each nursing home should try to prepare for this. Homes may need to stock up on oxygen concentrators, tanks, tubing, and masks. In addition, nursing homes should communicate with attending physicians to anticipate the need for opioid drugs to relieve “air hunger” often experienced by Covid-19 patients. For most people, opioid treatment allows a person to relax and have enough oxygen to survive, and hopefully to recover. Other residents will not recover and will need sedation and comfort measures through palliative or Hospice care at the end of their life.
Within a few weeks, tests for immunity to Covid-19 virus may become available. Serological tests use blood serum, the liquid part of blood, excluding cells and clotting proteins and has already been used overseas in contact tracing efforts. This is important, because if a person is immune and no longer infectious as documented by a diagnostic test, that person is probably no longer a target of the virus nor a person who can spread the disease, assuming ordinary good hygiene. Knowing which staff are immune will ease some of the strain of scheduling adequate staff to care for residents.
Going forward, the much stricter focus on infection control in nursing homes has the potential to improve matters. But it also has the potential to isolate and close off nursing homes from the wider community. Preventing this isolation is a priority, and nursing homes can see how they are performing through formal assessments and seeking out recommendations on ways to improve protocols or procedures that ensure residents are comfortable.
Nursing home residents, their families, and staff will all be highly stressed as they cope with this virus. Both clinical challenges and social and emotional stresses from isolation will make providing nursing home care more difficult than ever. Short-term solutions, like isolation, will require conscious effort to undo or ease after the worst of the pandemic is over. Providing quality of care and life needs to be the paramount goal – and nursing homes will need added support to do it. Knowing resident wishes and following them, supporting staff with training and PPE, and generous doses of compassion are all essential.
The best we can hope for is lasting improvement to nursing home practices that keep residents safer, but also in touch with their loved ones and outside community. That balance is always the nursing homes’ job: It is now more crucial than ever before.
Director, Eldercare ImprovementAreas of Expertise
Anne Montgomery develops policy and research initiatives that improve long-term services and supports and medical care for older adults receiving services from Medicare, Medicaid, the Older Americans Act, and other programs. She is leading efforts to implement and evaluate comprehensive culture change in nursing homes, and is working with colleagues to develop a new volunteer-based Community Care Corps program at the national level.
Deputy Director, Eldercare ImprovementAreas of Expertise
As deputy director of Altarum's Center for Eldercare Improvement, Sarah Slocum strives to create innovations and system changes that will make care for frail elders and people with disabilities available, accessible, and high quality in the setting of their choice. Through PACE expansion, benefit flexibility, and culture change efforts, she aims to change care delivery to a person-centered model.