In mid-March, as San Francisco mayor London Breed issued a citywide stay-at-home order, Peggy Cmiel started getting prepared. Cmiel is the director of clinical operations at the San Francisco Center for Jewish Living, or SFCJL, a 9-acre senior housing complex in the Excelsior neighborhood that includes long-term care facilities, short-term rehab housing, and a memory care wing. The campus houses over 300 elderly residents, members of one of the populations most vulnerable to the deadly and highly infectious coronavirus that has spread across the globe.
Cmiel’s staff stocked up on personal protective equipment and masks for workers and residents; screened everyone who walked in the door for symptoms; hired more staff to clean bathrooms and common areas; and started educating everyone on best practices for containing the virus, like washing hands, avoiding close contact, and keeping an eye out for symptoms like fevers or coughs. And while nursing homes account for nearly half of California’s coronavirus fatalities, at the SFCJL not a single resident has tested positive for the virus. “Getting an early start was really the most helpful thing we did,” says Cmiel. “The doorknobs in this facility have never been more clean before.”
Not every home was so lucky and so well prepared. Nursing homes across the US have been devastated by Covid-19. In many states including Colorado, Massachusetts, and Virginia, nursing home resident deaths account for 50 percent or more of coronavirus deaths. But the success of a handful of homes, like SFCJL, might offer their colleagues some clues about how to keep residents safe as the nation braces for a potential second wave of infections.
Geriatricians and nursing home operators understand why these spaces are so vulnerable. Long-term care facilities are, in many ways, perfect virus incubators. Residents, who are older, frail, and often have comorbidities like heart disease or diabetes, are more susceptible to severe Covid-19 infections. Many need help performing basic tasks like eating, dressing, or bathing—care that can’t be delivered through a video appointment, making it more likely they could get an infection from the aides who help them, or pass the virus along to their caretakers. Those aides may work at several different facilities, and unknowingly carry it from one home to another.
The layout of these facilities also furthers contact in various areas. Most residents share bedrooms, bathrooms, activity rooms, and dining rooms—and staffers share a break room. Those group spaces are designed partly to cut costs, and also to encourage socializing. But shared spaces have also helped spread the virus. Senior facilities do have protocols to handle outbreaks like the flu, but the pandemic arrived so quickly and the SARS-CoV-2 virus is so contagious that many facilities were caught unprepared. “There’s an extent to which this virus just had the upper hand,” says Anna Chodos, a geriatrician at the UCSF. Unlike hospitals, most nursing homes aren't ordinarily well stocked with gear like masks and gowns, which aren’t necessary when containing the flu.
Now, as states slowly start to reopen, senior care facilities are facing a more complicated endeavor: figuring out how to keep residents safe and maintain their quality of life as the Covid-19 pandemic stretches on. Even for facilities like SFCJL, the path forward is far from clear. “How do we safely and slowly introduce visitation and group activities? It’s going to be very careful and very cautious,” says Cmiel. “It will just be very scary to start bringing people back into the community again.”
Unlike hospitals, most nursing home residents live in these facilities permanently, so staff have to create environments that are comfortable for people’s long-term emotional, social, and physical well-being. But the novel coronavirus has put those important psychological services on hold. “The way of life inside nursing homes is so disrupted,” says Kathleen Unroe, an assistant professor of geriatrics at the University of Indiana. “This is where people live. These are social places.”
Or at least they used to be. Many facilities currently are restricting movement as much as possible, keeping people in their rooms and out of shared spaces. Unroe consults for several nursing facilities, and says that at one of them, family members haven’t been allowed to visit for two months. “I have these family members who say to me, ‘I have never been away from my 95-year-old mother for this long in my life,’” she adds. “It’s profound.”
Unroe also points out that at some facilities, even people who have recovered from Covid-19 can’t always go back to their own rooms. If they continue to shed virus and test positive for weeks after their symptoms have resolved, they have to stay in isolation, which can be scary and upsetting. Some don’t understand why they can’t go back to their usual rooms; “others just feel abandoned and are just confused or mad.”
So what helped the SFCJL fare better than many of its counterparts? It’s likely a combination of early action and luck. The facility was one of the first in California to start screening visitors before they entered the premises. They stocked up on protective equipment and were ready to hand out masks to every single resident and staff member. Laguna Honda Hospital and Rehabilitation Center, another long-term care facility in San Francisco that quarantined early, has over 700 beds and has had similar success—reporting only 29 cases among residents and staff. “San Francisco acted really early, so I don’t think it’s by chance,” says Troy Williams, the chief quality officer at Zuckerberg SF General Hospital and Trauma Center, who has been in charge of Laguna Honda's response to the pandemic.
UCSF’s Chodos agrees that Laguna Honda’s early moves to lock down the facility and isolate infected residents were integral in abating the outbreak. “They crushed it like a bug,” she says. But she says facilities in San Francisco also got lucky: “Got lucky in that we had great leadership. Got lucky in that we had less virus.” San Francisco issued stay-at-home orders early compared with the rest of the nation, and has seen relatively low infection rates. With less viral spread in the community, it’s less likely that staff would accidentally introduce it into the facility.
Another factor is likely that both Laguna Honda and SFCJL participated in San Francisco’s universal testing program, mandated by the mayor and spearheaded by the city’s Department of Public Health. Both facilities will continue to test all staff and residents every few weeks, testing more often if they start to see more positive results. (Staff go home every night, and each day teams of physical and respiratory therapists, aides, nurses, and other staff reenter these complexes, potentially bringing new infections with them.) “We have to keep our pedal to the metal,” Williams says, “because it could change.”
They are also working on other strategies to reduce risk. For example, SFCJL has opened a new wing that accepts patients from local hospitals who are recovering from Covid-19, and who need short-term rehab care before they can go home again. That unit has an entirely separate medical, nursing, and cleaning staff. Patients use a different entrance, and staffers clean the elevator immediately after they are taken to their rooms.
For all seniors in nursing homes, whether or not there is a viral outbreak, staying in bed without any physical contact with loved ones is bad for mental and physical health. Normally, facilities have lots of activities and visitors; volunteers play music, bring therapy dogs, or play card games with residents. To adapt during the pandemic, both Laguna Honda and SFCJL staff bought iPads so residents can video call their families. Laguna Honda is now starting to run a few socially distanced activities like bingo games and art classes where participants can be six feet apart and wear masks.
Chodos says these measures can help stem the spread of the virus from asymptomatic carriers. With a virus this infectious, she adds, “no precaution is superfluous in any circumstance.”
But those precautions are only helpful to a point, according to Unroe. “These outbreaks are continuing and they’re going to continue in nursing homes,” she says. There are still a lot of unanswered questions about how and why the virus has spread so quickly in some homes, but not in others. Based on early data, she says: “It’s about the size of the facility and the amount of spread in your community.”
Nevertheless, Unroe warns that while researchers are working furiously to figure out solutions, they still don’t have all the answers: “It's a turbulent time and we're trying to make clinical and operational decisions with incomplete information.”
As San Francisco starts to reopen, SFCJL’s Cmiel is nervous. “This scares me to death,” she says. “I actually think we need to tighten up now that the city is reopening.” If community transmission of the virus starts to increase in the city, nursing home residents will be at an even greater risk. But how long can people go without seeing their loved ones, or getting exercise or intellectual stimulation? “It’s this constant balance,” adds Cmiel, “between the safety and health of our residents and the needs of the families.”
A much more far-reaching approach to keep older people safe from Covid-19 would be to care for them in their homes, keeping them out of long-term residential settings. Two initiatives in California, Community-Based Adult Services and Multipurpose Senior Services Program (CBAS and MSSP, respectively), serve thousands of low-income seniors—the majority of whom are people of color. The programs provide essential services like at-home nursing care, physical and emotional therapy, meals, and transportation that are on-par with the support received by residents in senior homes.
Out of the nearly 10,000 seniors served by MSSP, only three have died of Covid-19 so far, says Claire Ramsey, a senior staff attorney at Justice in Aging, a nonprofit that advocates for low-income seniors. “This is a way safer way to provide care,” she comments. Chodos notes that seniors who receive care in their homes also have lower rates of depression, and experience slower cognitive and physical decline. And home care is also usually what seniors would prefer, says Unroe: “People should be cared for where they want to be cared for. Almost anyone would say that is in their homes.”
Advocates say that nursing homes are necessary, but they shouldn’t be the default care solution for seniors who need some assistance. “There should be a continuum of care, and institutional care should really be reserved for people who need it, who can’t be successful and safe in their own homes,” says Ramsey.
But the economic effects of Covid-19 are forcing states to cut budgets; both California and New York have proposed cuts to programs that provide low-income seniors with at-home help that keeps them out of institutions. In the Golden State, Governor Gavin Newsom’s revised budget will eliminate both CBAS and MSSP and reduce the hours of in-home care MediCal funds by 7 percent. New York state already has decided to limit eligibility to the Consumer Directed Personal Assistance Program, which pays for home nursing aides for disabled or chronically ill New Yorkers. Ramsey says that without these programs, many seniors will have no choice but to move into long-term care facilities. “You are literally going to have more people die if you do this,” she adds.
Another worry is that even if seniors aren’t forced into high-risk living situations, other cuts could jeopardize their overall health. California’s proposed budget would also cut eligibility for MediCal and eliminate optional MediCal benefits like podiatry, physical therapy, and diabetes prevention programs. Those benefits are important for keeping people healthy and alive, regardless of the threat from the novel coronavirus. “One of the things we’re very worried about is how bad these are cumulatively for people,” says Ramsey. “It’s really death by 1,000 cuts.”
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