A medic with the Massachusetts National Guard takes a nasal swab that will be used to test for COVID-19 with a resident of the Life Care Center of Nashoba Valley, Littleton, Mass., April 3, 2020. Photo by Staff Sgt. Kenneth Tucceri,
courtesy The National Guard.
When our younger daughter was a teenager, she used to jokingly promise her mother that she would someday put us in “the good nursing home.” That promise was sometimes withdrawn when she found her parents annoying.
She was not joking recently when she amended her youthful pledge. Our daughter instead declared she would never place us in any kind of long-term care facility (a term that covers assisted living facilities as well as genuine nursing homes, although they are often co-located and treated as a unit).
The COVID-19 pandemic has spotlighted an inconvenient truth that the nursing home industry would prefer to keep in the shadows: Institutions catering to frail elderly and disabled populations in close quarters are highly efficient at transmitting deadly infections among their vulnerable residents. This truth does not apply only to a novel coronavirus for which humanity has neither acquired immunity nor developed vaccinations. Nursing homes are a weak link in the health care system during any bad flu season.
The first major outbreak of COVID-19 in this country occurred at a nursing home in the Seattle suburb of Kirkland, Washington. In my own community in Broward County, Florida, some of the first pandemic deaths occurred in a local elder care institution. Last week the Miami Herald reported that a nursing home in the rural north Florida community of Live Oak had at least 51 confirmed cases, including 30 among its staff. The Peconic Landing facility on eastern Long Island – which has been more forthcoming than most – reported at least eight deaths among residents from COVID-19, along with at least 10 more infections among residents and 15 on its staff.
As these stories were emerging, The Wall Street Journal reported last week that the new virus had affected at least 2,100 nursing homes nationally, resulting in more than 2,300 deaths. Yet these figures understate the extent of the problem, probably by a considerable extent. Many states, including Florida, have refused to identify most of the facilities in which COVID-19 has been reported – even when public records laws seem to indicate that they must disclose the information. The usual excuse government leaders give is that this refusal protects the medical privacy of patients and staff. This is a transparent falsehood. Illness and absenteeism among residents and staff are so common at these institutions that identifying a facility by name offers almost no insight into the identity of specific patients.
My take is that the real reason for this reticence is that the nursing home industry is highly dependent on government funding. It draws at least half its income and close to two-thirds of its clientele from the federal-state Medicaid program alone. As a result, this industry has long been politically active, donating and lobbying heavily to protect its reimbursement rates and limit its liabilities.
There is no doubt that the industry will emerge from this pandemic with a reputational black eye. What remains to be seen is whether the damage will be more serious.
Long-term care facilities vary in cost and quality, within communities and from one part of the nation to another. Around 1.5 million people live in them, a population that skews old, white and female. They provide services ranging from low-intensity “assisted living” in private apartments, augmented by group meals and activities, to highly supervised skilled nursing and rehabilitation. Many facilities also offer memory care units for residents suffering from dementia.
Skilled nursing and rehabilitation services usually require institutional settings. But there are alternatives to the other amenities that nursing homes use as selling points. The most fungible is housing: The space provided to residents costs a lot more than housing a senior in a paid-up home or ordinary rented apartment. The challenge is to offer enough support for seniors to live on their own, or with family members who are not in a position to meet an elderly person’s needs unassisted.
Home health aides, visiting nurses and doctors, transportation services and Meals on Wheels programs permit many elderly people to live alone. Community centers can provide social outlets, and some go much further. My mother, at 93, lives alone in a New Jersey community surrounded by younger neighbors who kindly look in on her. Her town provides a senior citizens center that, in normal times, sends a bus every business day to pick her up and bring her home. She can spend the day playing cards or bingo, or socializing with friends. The center’s bus also takes her to the grocery, pharmacy and bank on a regular schedule.
The center shut down last month to protect its patrons from the fast-spreading pandemic. Since then, I have ferried supplies to my mother about once a week, allowing her to remain safely isolated in her apartment. She takes herself out for daily walks in good weather. Her main frustration is the absence of her beloved New York Yankees from the television schedule.
Even during this shutdown, however, the community center has taken the initiative to look after my mother, and other attendees who may have less family support nearby. The center’s director calls from time to time to check on her. The director also arranged for seniors to place orders at a local supermarket, and for the town’s police officers to deliver those orders. I have kept my mother well-stocked, so she has not needed the service. But others no doubt have found it enormously helpful.
We have known for decades that an aging baby boom cohort is going to need support in its later years. This meant the nursing home industry was once poised to be a growth field, but that may not turn out to be the case. A lot of seniors can continue to live comfortably and safely – arguably more safely – at home, if we can provide enough support. Some states are already using Medicaid to provide in-home health aides, who can prepare meals and help with dressing and bathing. These sorts of issues (often called “activates of daily living”) have sent people into nursing homes in the past. We are going to need a bigger supply of low-skilled labor to meet these expanding needs; immigration reform could go a long way toward addressing likely shortfalls.
I have no desire to end up in an old person’s ghetto, whether a traditional nursing home or an “adult community” that shuns young families. I like young people. And it is emotionally healthier and physically safer for senior citizens to live among younger neighbors, as my mother does.
I won’t say “never” to the idea of institutional living, because one never knows what the future will bring. My wife or I could someday develop such a profound need that, even with enough money set aside to sustain ourselves at home, institutional care becomes a necessity. But we have two daughters who are competent to help us when we need it. The likeliest outcome is that we can age comfortably at home, bringing in whatever services we need and avoiding the sort of disease-prone clustering of transient staff and compromised clientele that is endemic to institutional settings. We just need to stay on our daughters’ good side.