Friday, April 17, 2020

Covid-19 Deaths in Nursing Homes: Why It Is Important to Consider Causes and Solutions

Sunset over Lake Vattern in Sweden

This headline in yesterday’s Washington Post caught our eyes: “Covid-19 is ravaging nursing homes.  We’re getting what we paid for” (see link below).  There’s no question that clusters of infections and deaths have been common in nursing homes across the country, as well as other countries such as the UK where statistics on prevalence of Covid-19 has been reported.  Half of the deaths in Pennsylvania have been among nursing home residents and staff.

We should not be surprised.  Nursing home residents constitute the most vulnerable group in society.  But it’s not just that residents are old and frail.  Rather, the articles we have seen report that the nursing homes and assisted living facilities that had clusters of cases did not take the steps needed to protect residents and staff.  We want to be clear that there are excellent, well-run residential facilities for older people that have done a good job of protecting residents and staff.  The point raised in the Post article is that inadequate funding for nursing homes is a long-standing issue and so it should not be surprising that there are deficiencies in responding to a crisis like Covid-19. 

Nursing homes are not the only problem area.  The Covid-19 crisis has revealed many weaknesses in our health and public health infrastructure.  Federal and state governments have spent the last few decades cutting back public services and investments in health, education and most everything else.  With all the people who still have no health insurance or lost their insurance when they lost their jobs, it’s clear that we need universal health care.  We also need the state and federal government to have the infrastructure to respond in a crisis, for example, with more efficient ways of delivering unemployment benefits.  And then there is testing and tracking of the virus.

But once the crisis is past and there are discussion about building our infrastructure, let’s not forget long term care. The US alone among economically-advanced countries has no program of universal long term care.  Instead, we have a rickety system of funding.  People who can pay privately for care can often, but not always, receive good care.  But the typical nursing home that depends primarily on Medicaid will, despite good intentions, struggle to provide a high quality program.  

Here is a modest list of what we need, or at least where to start.

1.     Along with discussions of universal health care, we need to advocate for a national program of long term care insurance that will assure that people get good quality care when they need it.  We could follow the model instituted in Japan and South Korea, where the tax funding long term insurance goes into effect when people turn 40.  That way, the tax burden does not fall on young workers, who tend to have lower earnings.  And by 40, most of us have realized we may need to help aging parents, and indeed, that we may need help for ourselves.

2.     Long term care programs, and indeed, all of health care, should be run either by government or by non-profit organizations.  Simply put, when there is a choice between paying for improved care or maximizing profits, it is too easy for administrators and owners to cut corners that improve their bottom line.  We have seen that happen over and over.  Some of the worst clusters of Covid-19 have been in for-profit nursing homes.  They didn’t pay for adequate staffing or for taking the steps to protect residents and staff.  When owners of these programs have been identified by the press, they often hide or refuse to comment.  

The perversions caused by using a business model that prioritizes profits over care affects all of health care.  With nursing homes, however, the effects are particularly pernicious because residents are the least able to advocate for themselves and because we have such low expectations for quality of care.

3.     We need stronger programs for helping older people remain at home.  Almost no one wants to end their life in a nursing home.  But while we have given lip service to supporting people to remain at home, the system of community services remains fragmented and inefficient, and workers are typically poorly paid and trained.  All-too-often, community service agencies make excuses instead of delivering the type of help that people need that will keep a frail person at home.     

4.     The people who work in aging services need better training.  We have each been in this field for over 40 years, and it is frustrating to say that we have not made much progress in training the front-line people better.  Everyone from administrators to nurses to the aides that deliver the care needs specific training in aging and long-term care.  All too often, the training people receive involves how to meet various state and federal requirements and not how to provide optimal care.

In the US, a certified nursing assistant receives 75 hours of training.  By contrast, in Sweden where nursing home care as well as community services are generally quite good, care assistants (vardbiträde) receive one year of training, and nursing assistants (undersköterska) complete three years training.  Pay is not great, but it is relatively better than in the US, and everyone—employees and their families—are covered by the Swedish national health care.  As a result, they can live on their salary.  Workers can also gain the training needed to move up, from care assistant to nursing assistant to nurse.  Tuition is free. We saw one recent article that proposed extending the GI bill education benefits to health care providers working with Covid-19 patients. That would be quite a nice step forward.

5.     The best facilities we have visited over the years in the US has someone in charge, either the administrator or director of nurses, or both, who has a vision of what good care means.  They pay attention to the details of everyday care, and make sure that all staff share the same values around good care.  We need to find more people like that, reward them, and make sure their voices are heard. 

There are likely to be shakeups in how we do things in this country, once the immediate crisis diminishes.  We need to make sure that long term care gets included in the discussion.  

Reference:  

1 comment:

  1. Hi Mr. Steven Zarit, I am a researcher student and I work with eight classmates from the Nursing program at Universidad de Valparaíso in San Felipe, Chile. I am writing to you to let you know that we are in the process of developing a research project to obtain a degree in nursing which deals with the overload of the main caregiver of the demobilized older adults and its correlation with the social support they receive in San Felipe, Valparaíso Region, Chile.
    I write this cooment in order to request authorization to use your assessment instrument "zarit scale for assessing caregiver burden" in our thesis project, or to request your email for a more formal solicitation.
    I would like to thank you in advance for considering my request.
    Should you have any questions, please let me know in my email javier.rivera@alumnos.uv.cl.

    Javier Ignacio Rivera Silva
    IV Year Nursing Student
    Universidad de Valparaíso

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