Concerns over the coronavirus are creeping into the nursing home sector, and industry experts are alerting operators and clinicians to take extra care, especially with the steady influx of frailer residents who are most susceptible.
And while it may be too early to determine the eventual clinical and financial effects on the nursing home space, the novel nature of the disease could bring new challenges for skilled nursing operators.
Remaining isolated and not knowing precisely how and when the virus will spread poses a real threat to both nursing residents and staff — who may be unable to differentiate symptoms when dealing with the most complex patients, as nursing homes are now taking in higher acuity residents than in years past.
“I think [the virus] would have a devastating effect on our industry,” Kevin O’Neil, chief medical officer at senior living provider Affinity Living Group, said last week about the senior living and care spectrum as a whole. “And that’s why I think it’s so important that we be really aggressive right now about these infection control measures that we put all the preparations in place to to reduce that risk.”
The Centers for Disease Control & Prevention (CDC) recommends that those who have contracted the virus, also known as COVID-19, should remain “isolated either in the hospital or at home,” and warns that “it’s unclear how easily or sustainably this virus is spreading between people.”
This weekend brought the first reports of the coronavirus in a nursing facility, according to health officials in Washington state, with STAT on Saturday reporting that a resident in her 70s and a staff member in her 40s had tested positive. About 27 of 108 residents of the nursing home in Kirkland, Wash. had “some symptoms,” according to the report, while 25 of 180 staff members had also exhibited signs of the virus.
The New York Times on Sunday night reported that six people at the facility had been diagnosed with the virus, with one dying at a nearby hospital. Three more were in critical condition as of late Sunday, according to the Times.
Life Care Centers of America, which operates the Kirkland building, confirmed the two cases in a statement issued late Saturday. The provider announced that the facility will not accept new admissions, and visits from family members and vendors have also been suspended.
“We take the event very seriously and have members of our corporate clinical team on site to provide extra assistance,” executive director Ellie Basham said in the statement. “We are in contact with the Centers for Disease Control and Prevention as well as the Washington Health Department. We are following their guidance exclusively and will continue to take all precautions necessary for our residents, staff and the community at large.”
Basham also acknowledged that cold and flu symptoms are common this type of year, and added that COVID-19 testing must be done at a hospital, not the facility itself.
While the risk for the general population remains low, a serious spread among vulnerable older populations could create a spike in demand for health care services.
“You’re going to need people who are really clinically astute, because my concern too is that the hospitals get overwhelmed — and the SNFs get overwhelmed. Where are these people going to go?” O’Neil asked rhetorically.
From the hospital to the nursing home
Fear that the virus will turn pandemic, or into a global outbreak, is growing — and should it hit that point, the risk will expand to more nursing homes.
“At that point, it will be in the [nursing home] community, and that’s when we’re more likely to see coronavirus impacting our operations,” Vicky Norby, infection prevention and control coordinator at the Oregon-based skilled nursing operator Marquis Companies, told SNN.
It’s very likely that as the virus spreads, hospitalized residents will need skilled rehab and join the post-acute setting, Norby explained, adding that she believes the virus would have run its course in the hospital before becoming a threat to nursing homes.
But some carriers won’t show symptoms right away or at all.
What’s different about this virus versus usual flu strains is that “people can be without symptoms for up to two weeks but contagious anyway. And now [it is believed] that there are the carriers of the virus who won’t ever show symptoms or come down with any illness, but can still pass it on,” Dee Pekruhn, LeadingAge’s director of life plan communities services & policy, said. “And so that’s part of the crystal ball piece that’s hard for everybody … it’s not going to behave the same way, necessarily, as the flu or norovirus.”
Greater risk for more complex patients
Stakes are higher for those who already have other comorbidities, with these residents at greater risk for serious illness, Pekruhn said.
“Older adults are going to be disproportionately affected by this, and a greater number of people will be going into the hospitals and coming back to nursing homes,” she said, pointing to reports from the CDC and the American Hospital Association.
Those seniors who already have flu symptoms will be in a weakened state and are more at risk for the coronavirus.
“About 2,800 deaths have occurred due to COVID-19 globally, but over 16,000 deaths and 280,000 hospitalizations have occurred due to influenza in the U.S.,” O’Neil said, offering perspective about treating the flu in tandem with the virus scare.
Still, like the flu, the novel coronavirus can be transmitted through sneezing or coughing, traveling through the air, and also spreads through fluids.
“So when people are coughing and sneezing … those droplets can go quite a distance. And so they usually drop at about three to six feet,” Norby explained, emphasizing that residents need to practice proper hygiene, and staff should make sure to appropriately use masks and gowns.
Due to a nationwide shortage of gowns and masks, Marquis’s medical-goods supplier let the company know that it will continue to provide a “normal supply,” but that there’s no way to stock up on extras.
“We reached out to another supplier to have an alternative source and they’re not able to meet their customer needs at this time because we are facing a national shortage,” Norby said.
LeadingAge touted having over 4,000 business partners to help their members prepare, and is currently working to direct the supply chain in a way “to hopefully make sure that our members have access to the supplies and services that they’ll need. It’s not necessarily a guarantee because there are global shortages of masks and gowns,” Pekruhn acknowledged, also noting that hospitals will suffer from similar shortages.
For those reasons, preparation will be key, she said.
“So this is a time to be preparing … and stockpiling and reviewing infection control with your staff, making sure the community is aware and ready and help individuals, including our older adults know how to do some of their own management at home,” she said. “It comes down to the basic same preparedness that we stress with other types of illness outbreaks. We’re just trying to make sure people understand that this will be at a different magnitude.”
No direct market effects so far
So far, the virus has had no direct impact on the nursing home market from a financial standpoint, RBC Capital Markets director Michael Carroll said.
But he sees a potential impact if more seniors housing residents become ill.
“Then they might need to move down or move up into a skilled nursing facility, to a higher acuity-type place, into a nursing home,” Carroll said.
For those in a nursing home for a short rehab stay, which is more of a focus “for higher-quality operators … it’s the more in-shape, elderly population that needs some type of rehab,” Carroll said, but alluded to greater weakness in the long-stay Medicaid population — which could pose more of a problem for operators and caregivers.
The stock market in general has taken a serious beating amid coronavirus fears, plummeting a record 1,192 points in a day on Thursday and finishing last week down a total of 3,500 points.
If masks and gowns run short, alternatives to reducing spread of the virus include residents “coughing into their elbow, doing good hand hygiene, being cognizant to somebody who’s right there in front of them … we kind of do a risk stratification,” Norby said.
Many health care experts suggested continuing to go through flu precautions — including wiping down heavily used surfaces — which are similar to avoiding coronavirus risks.
Acknowledging that most Americans are currently at a low risk, the American Health Care Association urged nursing homes to take immediate action.
“Centers must review their infection prevention and control policies and procedures among residents and staff as this is key to not only prevention of coronavirus but other common viruses from spreading,” the group said in a statement. “We are in close contact with the CDC, and state officials to monitor this virus and communicate any information and materials with our members.”