The push to resume in-person nursing home visits after a four-month absence is colliding with a national resurgence of Covid-19 cases that has, once again, put facility residents at greater risk of infection.
A growing number of industry experts and patient advocates say a Trump administration directive banning non-essential nursing home visits has become too hard on residents and should be re-evaluated and relaxed. They want the Centers for Medicare & Medicaid Services to allow “essential care partners,” like close family members and friends, to visit residents under strict safety protocols.
But the appeals come as 46 states and the District of Columbia report increases in new Covid-19 cases over the past two weeks. The virus surge is also causing infections to increase at nursing homes, where Covid-19 kills 20% of infected residents, said Mark Parkinson, president and CEO of the American Health Care Association, the industry’s leading trade group.
“So as difficult as it is to not have visitors, this is a matter of life and death,” Parkinson said. “And as sympathetic as we are to the family members and the residents, everybody’s just got to keep the perspective that if we don’t keep Covid out of these buildings, older people are going to die.”
The nation’s 15,000-plus nursing homes have been on virtual lockdown since March 13, when the pandemic forced the CMS to halt most visits, except in “compassionate care” situations like end-of-life episodes.
The policy made sense as nursing home employees infected residents, causing thousands of facility deaths nationwide. But facility residents are now deteriorating physically, while others battle depression and struggle with feelings of loneliness, isolation, and abandonment from the lack of human interaction, said Robyn Grant, director of public policy and advocacy at the National Consumer Voice for Quality Long-Term Care.
“There are now a number of residents that, one could say, are as much at risk from the impact of not having access to their families as they are to the virus,” Grant said.
Advocates and frustrated family members will be closely watching how states and facilities balance the risk and rewards of increasing visitations.
A Rise in Cases
Even Parkinson acknowledged the policy is taking a severe toll on residents.
He said the industry appeared to be turning a corner recently when new nursing home infections fell from 10,000 a week at the start of June to 5,000 per week by month’s end.
But in “Texas, Florida, Georgia, Arizona—and all of the states where you see an increase in Covid—it’s now, unfortunately, starting to increase in the nursing homes,” Parkinson said. California is the only state with an increasing infection rate that hasn’t seen a corresponding increase in nursing home infections, he said.
As of July 13, nursing homes and other long-term care facilities in 42 states reported 56,143 Covid-19 deaths, according to the Kaiser Family Foundation. That’s 44% of all Covid-19 deaths in those states.
On May 18, the CMS recommended that nursing homes only resume in-person visits if the larger community is in phase 3 of the federal reopening plan. That calls for no new facility-based infections for four straight weeks, adequate levels of staffing and protective gear, baseline Covid tests for patients, and weekly tests for staff.
Parkinson said a “very low percentage” of the nation’s 15,400 nursing homes could meet that criteria.
No-Contact, Outdoor Visits
But at least 31 states have issued guidance to allow no-contact, outdoor visits at nursing homes, including Colorado, Connecticut, Illinois ,Indiana, Minnesota and New Jersey, according to LeadingAge, the trade group for nonprofit nursing homes and assisted living facilities. Pennsylvania’s guidance calls for prioritizing the visits for residents with symptoms of cognitive impairment, loneliness, or depression.
Each state has different guidelines, but they generally require that the visits are scheduled in advance and monitored by staff. Guests must be screened for symptoms, and both participants must wear masks and remain at least six feet apart.
David Grabowski, a Harvard Medical School professor, said by email that the limited-access visits were only a short-term, seasonal solution because fragile residents can’t endure uncomfortable summer and winter weather. In a separate message, Allison K. Hoffman, a professor and health law expert at the University of Pennsylvania law school, called the visits a good “first step.”
In a recent opinion piece, Grabowski; Hoffman; and Jason Karlawish, a professor of medicine at the University of Pennsylvania, urged the CMS to allow nursing homes to designate an essential care partner who could visit with their loved one and help with their care. The CMS didn’t respond to a request for comment about the proposal.
“Family members are part of the care team,” Grabowski said. “These visits would have huge benefits for the residents, many of whom haven’t seen family since March.”
A Husband’s Fears
It was March 12 when Warren Mass of Cleburne, Texas, made his last daily visit to see his wife, Martha, an 84-year-old nursing home resident who suffers from dementia. Even before the Covid-19 pandemic hit, Mass said the facility was often short staffed, requiring him to help clean, feed, and change his wife’s soiled clothes.
In the four months since his last visit, Mass has noticed his wife doesn’t carry phone conversations as long as she used to. He worries she may not be eating properly. And her frequently changing regimen of six psychotropic medications also concerns him.
“I want to have a good, hard conversation with somebody” at the nursing home, Mass said. “But I haven’t been able to arrange that yet. Naturally, not being able to visit in person makes it more difficult.”
Without friends and family like Mass providing hands-on assistance—and an extra set of eyes to spot potential problems—nursing home residents aren’t as safe, said Michael Dark, staff attorney with California Advocates for Nursing Home Reform.
He said facility conditions “spiraled into despair” after the visitation ban was imposed.
“People were being left in unchanged bed linens, they weren’t drinking, they weren’t getting enough to eat. And that is still the case right now, partly as a result of these restrictions,” Dark said.
Keeping Patients, Staff Safe
Parkinson disputed Dark’s claim and said nursing homes were much safer now than they were early in the pandemic.
While he agreed the visitation ban has taken a toll on some residents, he said the policy was and is necessary to keep patients and staff safe.
There’s a “very low percentage of nursing homes right now where it is safe for families to visit. And so it would be a mistake for families to push this and get us back to the kinds of numbers that we were seeing in March and April,” Parkinson said.
The AHCA and the National Center for Assisted Living recently asked the National Governors Association to speed up state lab processing times for Covid-19 tests, provide more personal protective equipment, and direct state public health agencies to work closely with facilities on workable plans to resume visitation.
A Trump administration plan to send new rapid test kits to 2,000 nursing homes in high-infection areas is a good step toward resuming visits, Parkinson said. The technology allows facilities to test staff, residents, and even visitors for Covid-19 and get results within minutes. The administration has indicated an interest in providing the kits to all nursing homes, Parkinson said.
The tests will start shipping next week. The manufacturers have committed to setting up a “concierge” service for nursing homes to acquire additional testing supplies after they exhaust the initial month’s supply of roughly 400 tests.