The Nursing Home Crisis
In this, our third post covering the failures of the U.S. health/healthcare system over the past two years, we consider the case of nursing homes, the best-known and largest category of Long-term Care (LTC) providers. Other congregate living facilities include assisted living, memory care facilities, group homes for the disabled and of course, prisons, which we will consider under the COVID-19 lens in a later post dealing with the justice system.
When queried, around 77% of Americans state that they would prefer to “age in place,” i.e. to remain in their home during their final years. But there are reasons, both economic and health-related, why this is often not possible. Between 1.3 and 1.4 million people are currently nursing homes residents; another 800,000 or so are in assisted living facilities (considered a “step up” from nursing homes in terms of resident independence).
The only significant portion of this sector publicly owned and operated (by the federal government in collaboration with individual states) are Veterans Administration facilities, popularly referred to as “VA Homes.” Of the approximately 15,000 nursing homes in operation today, 70% are for-profit; the other 30% are non-profits or “safety net” homes funded by smaller government units, e.g. states /counties.
While the majority of homes are privately-owned and operated, and the majority of these are for-profit, this is not to say that state and federal governments aren’t directly involved in their funding and oversight: Medicare (overseen by the Department of Health and Human Services, HHS), under which 97% of nursing homes are approved for receipt of federal funding, provides around $25 billion yearly for the rehabilitation/convalescence of patients released from hospital but not yet able to return home, while Medicaid (federal/state) contributes around $50 billion a year, for a total of 60% of nursing home costs.
During the early days of the pandemic (March – July 2020), those paying attention to the statistics became alarmed when data on nursing home mortality rates began to be published, at least by some states and at least in part, although much of the data was hard to interpret since posting practices differed from state to state, making accurate state-to-state comparisons difficult for epidemiologists and other investigators. Overall, however, it would appear that of total deaths in the first wave, about 40% were of those living and working in nursing homes (140,000 total deaths / 5% of total cases). There was considerable variation, however, among states: in New Hampshire, for example, 81% of all reported COVID-19 deaths were of nursing home residents/staff, whereas in Nevada, only 19% of deaths were attributable to nursing home residents and workers. Data from 18 states showed that +50% of all first-wave deaths were of nursing home residents/workers.
It was noted by pundits and news analysts that this was “natural ” and “inevitable,” given that those over 65 residing in nursing homes normally have multiple co-morbidities which made them particularly vulnerable to COVID-19. But, as we saw in our two previous posts (and as we will see repeatedly throughout this series on the revelations of COVID-19), the nursing home / long-term care industry was already operating under its own version of “just-in-time” conditions, something most news reports didn’t make clear.
Some of the challenges homes had long been facing in February 2020:
- Standards for nursing homes / congregate care facilities exist, but enforcement has historically been lax. This was crucially the case with infection control, which led to many homes’ turning into superspreader sites practically from the onset of the pandemic. Inspectors tended to be too few in number to carry out regular, rigorous inspections; nursing home owners often felt that a modest penalty or fine, e.g. for systematic failure to implement infection control mechanisms, was cheaper than addressing protocol breaches.
- Funding conundrums. Medicaid, which foots around 60% of the total budget for nursing home care in the U.S., has no age-at-home option, even when someone could remain at home with minimal-to-modest regular visits/support and community services. If a given state wants to use federal Medicaid money to provide community / in-home care options, it must apply for a waiver through an onerous, time-consuming process.
- Nursing homes are by their nature – as “congregate facilities” – unhealthy environments for the elderly, sick, and frail. Most consist of shared rooms, toilets, and showers; staff often “float” among a large number of residents (even between wings, which led to additional spread before isolation procedures for COVID-19 residents were devised) – and of course, it was staff members who brought COVID into the nursing homes in the first place, given that residents live in a quasi-bubble.
- Nursing homes are systematically understaffed, and staff that carry out nearly all of direct patient care / service – CNAs (certified nurse assistants), food service workers/janitorial/maintenance/laundry staff – are the lowest-paid in the healthcare provision sector. CNAs earned on average $13.00 an hour before the pandemic (with considerable variation between regions/states based on cost of living and local minimum wage laws). In order to survive, many were working at more than one facility, or in another sector altogether (e.g. fast-food service). The more hours they worked outside any given facility, the greater the danger of their contracting COVID through “community spread” and bringing it into one or more of the homes where they worked.
- Systematic understaffing soon reached crisis levels in many homes as staff began to fall ill or quit in fear. This led, inevitably, to some homes’ shutting down entire wings, thus reducing the number of beds available to patients ready for release from hospitals into convalescent care. And this had a backward-ripple effect on hospitals themselves, which were forced to keep patients who, although ready for discharge, had nowhere to go, in turn forcing the hospitals to turn away patients who urgently required hospitalization.
- The long-term care sector provides few decent – and no public, universally-available – options for insurance. Medicaid pays $6,180 per month ($74,160 a year) per resident, but this is not enough to provide sufficient staffing/services even in non-pandemic times. The sector, which is now enormous, is thus both a victim of underfunding as well as an inevitable predatory one, given that the majority of homes are run for profit.
- The profit motive means that many homes do not provide the bare minimum of professional oversight of facilities, e.g. by having an RN present 24 hours a day, or by employing an infectious disease specialist to monitor for infection control. Homes which do have an RN present experience both lower morbidity/mortality rates as well as an overall better level of care. Given that a federal agency, HHS, has the right to set standards for staffing of nursing homes, it would be possible to establish minimum staffing ratios across the board / across the country (as we saw that California did in 2004 for hospital ratios, and as Illinois and Pennsylvania are proposing). But this would require around 150,000 care-workers be added to nursing home staffs.
- This leads us to staff shortages, which have now (2022) expanded from primary care providers like CNAs to nursing home directors (liability concerns?), RNs (as part of the overall shortage / fear of liability?), and even dining staff. Today, 54.5% of all nursing homes are experiencing staffing shortages; since February 2020 (i.e. the past 2 years), 420,000 nursing home staff have left the field entirely – partly out of fear of contracting COVID, certainly, but also partly because more attractive / less health-threatening jobs opened up during the 2021 recovery. In some states, the National Guard has been called up to assist with keeping homes open, but overall, 58% of the country’s 15,000-odd homes are now limiting admissions, either because they have closed beds or due to inadequate (even by minimum standards) staffing, or both.
As if the above weren’t enough, a significant percentage of elder-care workers remained unvaccinated months after vaccines became available to them. In July 2020 (7 months after vaccines became available), 40% of CNAs remained unvaccinated; as of September, it was 30%. Some states (a total of 15 as of Feb. 1, 2022) have mandated that healthcare workers be vaccinated, but in states where mandates do not exist (e.g. Ohio), the rate of unvaccinated workers remains stubbornly stuck at around 40%. The highly-transmissible omicron variant has led to high rates of infection among these workers, and consequently to even more serious staff shortages.
At first glance, this reluctance – refusal appears hard to comprehend or countenance, given the population with which LTC workers interact.
Let’s turn the mike over to the workers themselves, whose initial concerns mimic those of millions of others (some of whom hold PhDs) who refuse to get vaccinated. But nursing home workers have additional concerns rarely aired in mainstream media.
We begin from the well-known standard objection, which may be summarized as “I’m not against vaccines, but it all happened too quickly”:
First up: Kia Cooper, Philadelphia, who has worked as a CNA for nearly 2 decades: “I’m not totally against it. But it was so rushed. I want to wait and see how others do.”
However, Kia has additional concerns:
“Her experience with a health-care industry that seems to put profits over the interests of patients and staff—that denies hazard pay, that fails to provide adequate protective equipment—also contributes to her hesitancy. ‘I do wonder if it’s a money thing. These are big companies trying to force these products on everyone. You have to wonder, Are they doing it for us or are they just trying to make money?’” (emphasis added)
Second up: Destiny Hankins, an LPN from Tennessee currently working in Ohio (no vaccine mandate):
“Sometimes, it feels like no one cares about us. I’ve worked in places where pretty much the whole staff walked out because the facility lied to us. They said there was no COVID when there was. They didn’t give us P.P.E. They didn’t have the decency to be straight with us.” (emphasis added)
Ms. Hankins has, after reading / reflection, decided she does want to receive the vaccine. “But because she works part time at several facilities, and full time at none, she hasn’t been able to get one.”
And then there’s lack of trust, which must be considered in light of a distrust of the medical establishment among POC/ marginalized communities whose members form the backbone of CNAs:
David Grabowski, a professor of health-care policy at Harvard:
“In many cases, vaccine hesitancy is not a lack-of-information problem. It’s a lack-of-trust problem. Staff doesn’t trust leadership. They have a real skepticism of government. They haven’t gotten hazard pay. They haven’t gotten P.P.E. They haven’t gotten respect. Should we be surprised that they’re skeptical of something that feels like it’s being forced on them?”
There were facilities which succeeded in protecting residents and staff during the initial wave of the virus, but this required a genuine sense of community, shared commitment and sacrifice which had been created over time.
Kimberly Delbo, the director of nursing services and innovation at an assisted-living facility in central Pennsylvania:
“‘We’re a small, tight-knit family. The most important thing we can do as an organization is make sure people know that we truly care about them.’ In an industry where a fifty-per-cent annual staff-turnover rate is not uncommon, Delbo’s facility did not lose a single employee in 2019; last year, it had a ninety-per-cent retention rate.” (emphasis added)
Delbo herself engaged in active campaigning for the vaccine:
“We’ve been very proactive about building confidence in it, about getting them the facts, about debunking conspiracy theories and social-media myths. We can engage in this dialogue because they trust us. I think what’s important for people to understand is that you don’t build trust in a day and you don’t build it for a specific purpose. We’ve been investing in trust for years. We were doing this before the pandemic, and we’ll do it after.” (emphasis added)
In sum, the major problems identified in the nursing home sector pre-pandemic – all of which were exacerbated by the pandemic itself – included: systematic underfunding and understaffing; unsanitary living conditions (shared rooms/toilets/showers/staff), inadequate senior (RN) supervision and infection control protocols; absence of a stockpile of PPE (masks, goggles/shields, gowns, gloves, sanitizer), whether that stockpile was at federal, state, or local level, and an absence of testing / tracing capabilities.
When the pandemic struck, it was inevitable that COVID-19 would wreak havoc among nursing home residents and staff. On average, the mortality rate in nursing homes among (residents + staff) during the early months of the pandemic was more than five times that among the general population (16% vs. 3%).
As regards PPE, nursing homes were/are not prioritized, and many had but a week’s supply of equipment laid by. This led to competition between homes – hospitals, and homes – homes (similar to that witnessed between states for ventilators), with larger chains winning out, and smaller ones (including safety-net homes) left behind, along with their residents and staff. Price-gouging was common. And during the first months, there was a “nearly complete absence of national efforts to improve the availability of testing and PPE.”
The nursing home crisis must therefore be interpreted within a “wider context of historical disinvestment and chronic underfunding,” rather than as a one-off, unavoidable disaster.
Addendum: The Biden Administration’s “Build Back Better” Act of 2021 foresaw a substantial and unprecedented investment ($150 billion, i.e. twice the amount spent yearly by Medicare and Medicaid for nursing homes) in Home and Community Based Services (HCBS) programs.
It appears that Senator Joe Manchin (WVa) has succeeded in killing the bill’s chance of passage, certainly in its original form and perhaps even in some stripped-down future iteration. (“Pressed by CNN on whether he has had talks on the proposal, Manchin said, ‘No, no, no, it’s dead.’”)
Interestingly, Manchin’s family once built a “safety net” nursing home, the John Manchin Sr. Health Care Center (founded 1899 for disabled miners) in Marion County, West Virginia (near the Pennsylvania border). Until he was questioned about his involvement with the home, Manchin was listed as a corporate officer of the home, which is registered as an LLC (two days after questioning, his name had been removed from the corporate officers). There is currently a concerted effort underway to close the Manchin Center (which provides vital care and health – as well as food-provision – services to Marion County) because it is inefficient – it has around 30 residents requiring a high level of care who would probably not find places in another facility. The ongoing struggle to save the Center – there are only 150 state-run nursing homes left in the U.S. (1%) – would have been aided by the passage of the BBB Act.
The pandemic has revealed that while the U.S. pays lip service to caring for its most vulnerable population, in fact the oldest and frailest among us have been neglected for decades due to increasing privatization and the profit-driven operations of congregate care.
We will see later in this series when considering COVID’s revelations about pre-K thru 12 education that the youngest among us – infants and toddlers – have been similarly neglected. They too would have benefited greatly from the passage of the Build Back Better Act.
Readings
“Nursing home staff shortages are worsening problems at overwhelmed hospitals”
“Nursing home health care shortages, a ‘crisis’”
“State Policy Responses to COVID-19 in Nursing Homes”
“Nursing Homes Can’t Find Enough Workers: How That Affects Care”
“Rising from the COVID 19 crisis: Policy responses in the long-term care sector”
“Don’t You Work with Old People?”: Many Elder-Care Workers Still Refuse to Get COVID-19 Vaccine”
Reimagining the Nursing Home Industry after the Coronavirus
“Why Are So Many Health-Care Workers Resisting the COVID Vaccine?”
“Senate Build Back Better Act Draft Language Maintains Historic $150 Billion Investment in HCBS”