Long-Term Care Experts Weigh In on How COVID-19 Is Impacting Care

Annals of Long-Term Care asked our readers to comment on the impact of COVID-19 in long-term care. Hear from other experts as they discuss current and future implications of this pandemic. 

This page will be updated regularly. Please feel free to share your comments at the bottom of this page in our feedback section. 

"In Tulsa OK the LTC and SNF took the CDC advisements seriously. All buildings were placed on lockdown starting Monday March 16th.  Lockdown meant all entry to family, friends and non essential vendors was placed on hold until further notice. A log is maintained at the single entry into the building of the persons who entered and their temperature and the visit time. Everyone sanitizes their hands at entry. PPE is not in use yet, but we do have some in storage to be used if necessary. We met as a team and tried to mitigate and streamline some wrinkles in our plan. Our DON has been working tirelessly at keeping uptodate with latest CDC recommendations and operationalizing the recommendations. Staff are following strict hand washing or sanitizing practices. Patients are trying to keep a distance from each other. Our biggest hurdle is the meal time when all our couped up patients want to be out in the dining hall, talk to other folks and mingle.  One building went a further step to hire additional staff to keep the patients needs met. I wonder how other LTC have tackled the mealtimes?!" 

—Chandini Sharma

"As the infection preventionist in my facility, we are on lockdown with no visitors allowed. Because of this we get many calls from family who don't use social media, so at times calls can't come in. We have been asked by the county to halt admissions entirely in order to stop the virus as well as have beds available for hospital overflow. We began fit testing and are listing all PUIs on line listing. We are to reuse our n95s, so staff had to be inserviced on how to effectively reuse the mask without contaminating ones self."

—Anonymous 

"Efforts to reduce mortality from COVID-19—Recommendations from the front line. As we are now experiencing community-based transmission of COVID-19, our state public health and government authorities must shift from a containment-based approach to a triage-based approach.  

Here are some actions that a government rapid response team could take now: 

1. Add a geriatrician to the Governor's high-level advisory team.

a. Geriatricians are some of the only health-care professionals that have worked in all domains of the health-care sector, including care provided in the home, physician offices, assisted-living facilities, nursing homes and hospitals.

b. Geriatricians have specialized knowledge of the frequently atypical early symptoms of disease in older adults, particularly the oldest old (over 85 yrs). 

i. Ex:  There has already been a case of an older adult who presented to the hospital with a fall and confusion and was later diagnosed with COVID-19.

c. A geriatrician should be consulted in the revision of VDH testing guidelines for individuals in residential care communities. 

i. Because of the varied and atypical symptoms early in the disease, rigid testing criteria are unlikely to be useful for the oldest old (the most at-risk population).

d. I would recommend Robert Palmer, MD at EVMS. 

i. https://www.evms.edu/directory/profiles/robert-m-palmer.php

2. Stop testing low-risk individuals.

a. Testing does not impact outcomes for low-risk individuals and therefore is not medically-necessary.

b. The only way to reduce spread in low-risk groups is to impose stricter restrictions on movement outside the home. 

c. Instead of being tested, low-risk individuals with symptoms should call a hotline and be logged as presumed cases.

i. Individuals with symptoms and their close contacts should be instructed to impose strict quarantine measures for 14 days.

d. State and federal authorities should work to develop a blood test that can be drawn after recovery (perhaps in the next 8-12 weeks) to definitively determine which individuals have been exposed and recovered versus those that remain unexposed/non-immune.

i. This would likely reduce fear and anxiety in the low-risk groups.

3. Act to decrease surge in hospitals/ICUs.

a. Prioritize resource allocation to actions that are likely to decrease or slow the spread amongst high-risk individuals.

i. Individuals who are >65yrs and live independently should shelter-in-place.

1. Reach out to these individuals and provide them resources in their homes.

ii. Individuals who live in residential care communities are at the highest risk.

1. These individuals live in congregate settings and depend on a complex network of HCPs and caregivers.

a. Therefore, any strategies to decrease spread to the highest-risk individuals must address the COVID-19 status of HCP and caregivers. 

iii. Actions that can be taken NOW to decrease or slow the spread amongst the highest-risk individuals.

1. Provide resources to rapidly test any symptomatic older adult or HCP.

a. Test early and test often. 

i. This is the approach we take with influenza and it is known to be effective. 

b. When the COVID-19 status of a HCP is known, then a convalescent HCP can return to work and care for residents that are ill with COVID-19. 

i. This measure is critical to break the chain of transmission in residential care settings. 

ii. This measure is especially important when PPE supplies are low.

2. Prioritize PPE, especially face masks, to residential care communities so that they can implement mandatory masking for HCP.

a. Even with robust face mask re-use protocols, residential care communities will not have enough face masks. 

4. Seek out recommendations and advice from clinicians and authorities in Washington state. 

The actions outlined above are simple and immediately actionable 

— Mary E. Simmers, MD,  Medical Director, The Virginia Home, Richmond, VA

"Our issues come with the lack of PPE and the non-specific symptoms. Patients are not easily isolated and wandering is a common issue both into rooms infected with COVID and out."

—Anonymous 

"I work with a team of one other doctor and foreign practitioners, and we see patients in postacute and long-term care at 11 nursing facilities. All facilities are currently on lockdown. We have a growing concern that as we travel from facility to facility we could inadvertently start spreading the virus from one facility to another. We are currently looking into telemedicine to see our patients until this crisis is over."

—Anonymous 

"I am in rural NC. Positive cases are in all surrounding counties. We do employee screenings with temp and o2 sat in addition to questions about symptoms, have increased frequency of resident vital signs monitoring, are not taking admissions, and no visitors. We have also cut out any non- medically essential consultants from coming in the building (podiatry for example). We have screened our agency and in house staff to determine if they go to other facilities. No group activities, we use Skype, phone calls, and walkies with visits to glass corridors. Thus far we have only tested one employee—results pending. No residents have shown signs/symptoms."

—Shelby Randolph, DPT

"The hallways are quiet. It feels like the calm before the storm. Our in-house pharmacy of 5 pharmacists have 3 quarantined."

—Anonymous 

"I am a geriatrician and work full time in a long-term care facility. Our facility closed last week to all visitation to mitigate COVID-19. We are screening staff as they enter the building however I don't believe most temps that are taken are accurate (temporal thermometer use on staff entering the building from outdoors in the northeast US where temps are commonly around 40 degrees F).  I feel like it is only a matter of time until we are affected."

—Anonymous 

"I am a psychiatrist and have a mental health team with a psychologist and 3 CRNPs all with psychiatry training yet some facilities will not allow us to see patients due to fear of infection, we take all the usual general precautions, I am  the only one who sees patients in the hospital to protect my staff and other patients. I don't go to the nursing homes and my staff don't come to the hospital or my office. We have patients who are more distressed due to no visitors, room restrictions, etc and we can still evaluate better in person than by phone."

—Charles T Nevels MD

"Staffing shortages become critical if several members of the staff become infected with COVID-19.  Residents are so lonely.  Falls increase.  Behaviors worsen.  The supplies that are in short supply become less available."

—Anonymous 

"Limited PPE means difficult decisions on when to use, no visitors means less joy for residents, social distancing, and isolation hard to provide care to multiple people who enjoy activities together."

—Anonymous 

"So many places are or soon will be out of PPE, that is the biggest concern I have by far."

—Anonymous

"We are doing regular visit at this time but may stop in the future. Plan to observe a 6 ft distance so no exam and no family visits."

—Anonymous 

"The major issue even prior to COVID-19 is that in the majority of situations you have newly skilled nurses on our front lines without oversight or mentorship. It is even worse now with the quarantines in effect. I can't imagine what is happening without the watchful eyes of providers and family members. I guarantee people will die due to lack of knowledge, skills, and assessments. I believe the virus will be passed through facilities due to lack of knowledge and equipment. LTC is heading down a raging river without a guide. Leadership and mentorship is gravely needed at this juncture."

—Anonymous