Those words are burned into my memory. My patient was an elderly man in need of skilled nursing care that his family could not provide. This happened in the 1980s while doing my first social work internship. I witnessed a man, older than my own father, crying and pleading with me not to send him there. “Don’t send me to the poorhouse.”

Poorhouse of the Last Century

My patient knew of ‘poorhouse’ from the Great Depression. The History Channel documentary on the poorhouse era is frightening yet worth watching. Quoting from a 2018 History Channel story by Erin Blakemore quoting Ann Sullivan (Helen Keller’s future teacher):

“Though the poorhouses are no longer, their memory is preserved in testimony by people like Anne Sullivan. “I doubt if life, or eternity for that matter, is long enough to erase the errors and ugly blots scored upon my brain by those dismal years,” she wrote later.”

Will Today’s Nursing Home Leave the Same Negative Legacy?

“Don’t send me to the poorhouse” and the man who said it will live with me forever. I can’t help but think of him today as I read the Coronavirus Commission for Safety and Quality Final Report released this month by MITRE Corporation. This long-detailed report is worth reading for all who care about today’s residential care. In an effort to condense this work, I will list the nine major themes and major findings for your review and action.

Testing and Screening

Nursing homes face four challenges to the successful implementation of testing and screening protocols: (1) testing and screening supplies to a nursing home are not prioritized in Federal response (2) wait times for testing results prevent meaningful infection control (3) funding gaps prevent nursing homes from implementing staff screening and testing per existing CMS and CDC guidance (4) inadequate testing training and insufficient resources and time to conduct screening of visitors and staff per CDC recommendations

Equipment and Personal Protective Equipment (PPE)

(1) Nursing homes do not have consistent access to an adequate quantity and quality of PPE (2)Gaps in understanding of best practices for PPE training, use, and reuse

Cohorting

(1) Cohorting of nursing home residents based on their COVID-19 status negatively affected their social and emotional health contributing to increased anxiety and/or depression among residents. (2) Nursing homes may not be able to implement existing Cohorting guidance because of staffing, equipment, and/or environmental limitations (e.g., cleaning, tight space, lack of physical barriers, inadequate ventilation systems) and/or maybe inappropriately incentivized to isolate residents.

Visitation

(1) Visitation restrictions implemented to prevent COVID-19 transmission have protected the physical health of residents but also resulted in unintended harm. Residents are experiencing loneliness, anxiety, and depression due to prolonged separation from families and loved ones. Such measures also compromised the ability of families and guardians to validate resident wellbeing and safety and caused significant distress for families. (2) Virtual visitation is infrequently and insufficient substitute to address resident needs as limitations related to equipment and internet availability resident, family, and/or staff unfamiliarity with proper equipment use and functionality differing physical abilities may prevent successful implementation. (3) The extent of unintended harm to residents (e.g., loneliness, anxiety, and depression) due to prolonged separation from families and loved ones has not been adequately assessed. (4) Nursing home staff have under-prioritized routine daily activities, exacerbating the unintended harm caused by overly restrictive visitation policies. (5) CMS and its federal partners have issued directives and guidance pertaining to visitation during the COVID-19 pandemic that now exist in multiple documents, making it harder to track federal expectations of nursing homes and any evolving flexibility that has been provided.

Communication

(1) Knowledge about COVID-19 (e.g., incidence, prevalence, virulence, symptoms, prevention, control, and treatment) is rapidly evolving. (2) Keeping nursing home residents and their loved ones informed about the most up-to-date information on COVID-19, related protocols, and policies is a significant challenge.

Workforce Ecosystem

(1) Nursing home workforce ecosystem (education, recruitment, training, and retention) challenges are some of the key systemic failures in this nursing home crisis. Specifically, low wages, high resident-to-staff ratios, the pressure to deliver care for residents with complex needs under difficult conditions, and a dearth of systemic support significantly contribute to gaps in care for nursing home residents during the COVID-19 pandemic. (2) Certified Nursing Assistants (CNAs) spend more time with nursing home residents—including residents with additional COVID-19 care needs—as compared to other members of the nursing home workforce. CNAs earn the lowest wages among direct care providers and receive few to any benefits. The pandemic has disrupted CNA training critical for reinforcing the nursing home workforce, leading to serious CNA workforce deficits. (3) Emerging evidence indicates an increased risk of infection of direct care providers who work across multiple nursing homes. A preliminary analysis from the CDC concluded that direct care providers working across multiple nursing homes — along with direct care providers continuing to work while sick — helped to hasten the spread of COVID-19. Systemic workforce ecosystem problems prevent the wholesale prohibition of multi-facility employment. (4) SARS-CoV-2 manifests itself in sudden clinical changes that require astute triage, assessment, intervention, and stabilization and/or transfer of the resident to a higher level of care. These capabilities fall within the scope of practice of a registered nurse (RN). RNs are insufficiently present in nursing homes, especially during overnight hours, leaving LPNs and CNAs to complete tasks that may fall beyond their scope of practice. (5) Nursing facilities must designate a minimally qualified infection preventionist, the requirement is insufficient to meet the infection control and prevention demands. There are few recommendations included in training and licensure requirements. This position is not financially supplemented, so the position is traditionally assigned to a supervisor, nursing manager, or provider as an added rather than a core responsibility. (6) Workforce members with expertise in infection prevention and control competency development are not sufficiently utilized in nursing homes. Nursing homes often use external vendors/ staffing agencies with fewer insights into local nursing homes. Underutilization and insufficient integration have yielded knowledge and skills deficits among the workforce for infection mitigation. Maintaining updated standards of care requires dedicated, onsite education and infection prevention professionals. This is a critical workforce problem that has caused serious infection prevention and control challenges throughout the pandemic. (7) Workforce ecosystem (education, recruitment, training, retention) challenges are notably longstanding. Efforts to address workforce ecosystem challenges have been delayed, further jeopardizing an already fragile nursing home system. Low pay and limited benefits, lack of educational support (e.g., limited assistance in progressing into LPN/RN training), insufficient competency standards, low-to-no exposure to geriatrics informal education programs, and limited opportunities for professional advancement (e.g., no clinical ladder or lattice) limit the potential of the emerging workforce required to stabilize the nursing home system.

Technical Assistance and Quality Improvement

Technical assistance and quality improvement support have not been sufficiently available to nursing homes during the pandemic. While Quality Improvement Organizations (QIOs) provide asynchronous toolkits, information guides, and online learning options, nursing homes need proactive, tailored, timely, on-the-ground support in emergency management, infection prevention, and control, and workforce capability development.

Facilities

The physical environment in many nursing homes is not optimally designed to limit the spread of transmissible diseases. Fundamental design changes are costly and may take longer to implement but may be necessary due to the prolonged risks to residents from COVID and to position facilities to manage future epidemics.

Nursing Home Data

(1) Nursing homes’ burden to report COVID-19 data to the federal government is not being sufficiently offset by the resulting benefit provided to nursing home residents, families, staff, and other stakeholders. (2) Information about the pandemic that is relevant to nursing homes has been inconsistent and scattered across multiple locations, making it difficult to find relevant, trustworthy, up-to-date data and guidance. Although the situation is rapidly evolving and some initial efforts have been made to consolidate information, a more cohesive approach to data collection and information dissemination is needed. (3) The lack of consistent nursing home data communication standards has hindered data management and data sharing between providers and payers delayed effective care delivery and resulted in poor data integration across care settings.

Problems and Opportunities are Tremendous

MITRE Corporation’s 181-page report tells a story of failure. We have failed in regulations, oversight, consumer protection, funding, and competence. The pandemic infection and death rate at nursing facilities are testimony to our failures.

Now is the moment for action.

1. Add your story to the conversation.

2. Contact your State and Federal officials and demand CARES Act funding

3. Become a certified Ombudsman

4. Post your outrage on social media and tag government officials

5. Demand in-person visits with loved ones at nursing homes

6. VOTE