From Outdoor Visits to Designated Family Caregivers, Nursing Homes Cautiously Reopen Doors

When it became apparent that COVID-19 was sweeping the country, one of the earliest major preventative steps was a move by the federal government to instate a near-total lockdown on any unnecessary visits.

The Centers for Medicare & Medicaid Services (CMS) announced the sweeping ban on March 13, which did include an exception for end-of-life visitations. Health care workers, such as third-party practitioners like hospice staff and dialysis technicians, were exempt as long as they met the Center for Disease Control and Prevention (CDC) guidance at the time.

The ban also included a complete suspension of group activities in nursing homes.

The result was to effectively keep residents confined to their rooms. It was a move that made sense at least at first; there were many unknowns about how COVID-19 spread, and one of the few known facts about the illness was its heightened lethality for older people and those with underlying chronic health conditions.

“The first real epicenter for COVID in the U.S. was in a nursing home, you know, in Kirkland,” Tony Chicotel, a staff attorney for the advocacy organization California Advocates for Nursing Home Reform (CANHR), told Skilled Nursing News on July 15. “That, I think, just drove up the panic level by a multiple of two or three, so that it was just: Okay, shut it down, build a moat. Don’t let anybody into these places other than the staff.”

But as COVID-19 continues to ripple across the country, “building a moat” is becoming less and less feasible, especially as the possibility of resuming visits as they were pre-COVID seems to be years away, he said.

That was why CANHR began to revisit the efficacy of this visitation restriction towards the end of April and beginning of May. The effects on residents over time, both in terms of neglect and in terms of the damage from isolation, could end up coming to outweigh the damage from the coronavirus, Chicotel said.

With COVID-19 likely to remain the top challenge for nursing homes for a significant amount of time, this means SNFs have to start taking stock of how they can bring their residents more interaction with families than just a video or phone call when a facility is COVID-19-free. If there are new cases, they have to find creative ways to foster interaction, while making sure electronic communication is as easy as possible.

And depending on the circumstances, they may want to consider how they can make residents’ loved ones a regular presence in a way that acknowledges their role as caregivers — and essential support for both the residents and the staff at a nursing home.

For Chicotel, there’s a great deal at stake.

“This is the right to free association, as a First Amendment constitutional rights, the right to see people of your choosing,” he said. “It is such an intimate, sacred right that we have, but it’s been mostly denied for this million-plus population … it required emergency declarations from the federal and state government to get here, but it shouldn’t be lost at all that this is a huge civil rights problem as well as a health problem.”

Hire for tech support – and strengthen mental health

Melody Taylor Stark from Monrovia, Calif., whose husband has lived in a SNF for almost five years, has seen the effects of that isolation firsthand. Her husband was admitted to Huntington Drive Health and Rehabilitation, a 99-bed nursing home in Arcadia, Calif., after his mobility declined from post-polio syndrome.

Before the lockdown took effect in March, she would visit him him each day, bringing newspapers to read the horoscopes in the morning — just as they would before his moving to the SNF — and stopping by after work in the evenings. Fridays included ordering out from a restaurant for a date night.

These visits included catching up with the staff and other residents who became her friends, and Stark also would help with activities, through such errands as picking up supplies from the Dollar Store; effectively, she became part of the community.

“On March 13, all of that stopped short,” she told SNN. “I got the message that Friday afternoon, so it was also calling the restaurant that I preordered dinner from to say, ‘I’m sorry, but I’ve got to cancel.’ Then everything changed.”

At the time her husband’s room was near enough to a window to make it easy to bring a folding chair and speak on the phone while seeing him, but because of the facility’s size and layout, his room was also better suited to be an isolation unit, which led to him being moved. That meant electronic communication such as text and FaceTime became the primary way to stay in touch.

But as any regular user of technology knows, devices are liable to going haywire, usually at the most inopportune moments. Stark was able to help one of her friends at the SNF connect to family through Facebook, using an old tablet from a staff member.

But when the tablet began to give Stark’s friend trouble, there was no one there to help fix the problem. Stark also ran into problems with communication with her husband when something went wrong with his cell phone. Because she was essentially the tech support, she and her husband had been communicating by a poorer-quality landline for the two weeks prior to her speaking with SNN on July 15.

Many states have begun to implement at least some form of socially distanced visitation for their residents, as Kaiser Health News recently reported. But since many states also require a visitation suspension if residents or staff at a facility develop new COVID-19 cases, virtual visits through video chats and phone calls will likely be key part of visitation for quite some time.

Given how important technology is — and will continue to be as the U.S. battles new outbreaks — Stark had a recommendation for SNFs.

“There should be tech people, tech assistance on staff,” she argued.

This is true not only for the sake of residents, but also staff short on time; Stark is well aware of the staffing challenges faced by SNFs across the country, as well as the challenges inherent in trying to keep COVID-19 out of the building. But she has seen the effect of isolation on her husband.

“It’s just been such a marked decline,” Stark told SNN. “I think we were doing okay up until maybe mid-May, and even at that, I was noticing the disconnect, the disinterest. For example, when we video chat at night, we’d oftentimes be watching the same television program together in two different cities on our phones. And over time, it was just …. something like: ‘I haven’t really felt like watching that lately.'”

Even before COVID-19, the primary mental health field at the SNF was psychiatric, essentially assessing whether medication was needed. And while Stark emphasized that she is not opposed to medication, she stressed this would need to go hand-in-hand with counseling, and this, she said, “is absolutely a foreign concept.”

“I had a conference call with the admin and the two nursing supervisors, and the activities coordinator who’s a social worker and also their social work director,” she said. “I had mentioned to them, ‘I’m seeing a lot of depression with him. He really needs some support in that area.’ And the response was, and this came from a social worker: We asked him if he was depressed, and he said: No.”

Her husband was able to get some support through his palliative care team, which he was assigned to due to a lung cancer diagnosis, and that team has been a help to Stark as well in terms of case management. She said this has led to some improvement for her husband, but she knows he is not the only person at the SNF dealing with this problem from isolation.

That makes it all the more important for SNFs to make mental health a priority, which could be a challenge given that many facilities struggled to identify depression even before the pandemic. But as COVID-19 cases continue to surge across the country — and SNFs have to lock down accordingly — mental health support for residents must become integrated into the care provided.

Plan ahead for reopening

No one is advocating that nursing homes need to return to the way visitation worked prior to COVID-19, Chicotel said, but the role of visitors in resident well-being is becoming increasingly clear — and it’s something that SNFs need to find ways to accommodate while maintaining social distance.

CMS in May issued guidance on how SNFs could reopen in phases, but Chicotel argued that the government should mandate access to outdoor visits, with social distancing and masks, for facilities that are free from COVID-19.

“I think facilities have been understandably very concerned about any visitation and minimizing exposure for the residents; minimizing exposure to liability I’m sure is a concern,” he said. “I think it is going to take state and federal mandates to get outdoor visits established, and I just don’t see from a public health perspective or even from a nursing home protection perspective why we can’t mandate outdoor visits for residents who want them.”

But in the meantime, that CMS guidance is what remains on the books federally, though different states have taken their own approaches.

The state of Connecticut did not move into the first phase of that reopening guidance until June 20, Angela Perry, the administrator at the SNF Vernon Manor in Vernon, Conn., told SNN on July 16.

The SNF has been allowing outdoor visitations, socially distanced at 10 feet, under certain conditions for visitors: the visits are supervised, with two family members at a time. Visitors have to complete a questionnaire and temperature checks; food and drink is not permitted because that would involve removing masks.

As of July 16, the SNF had been doing outdoor visits for about two weeks, slightly delayed from the June 20 clearance as Vernon Manor conducted the point prevalence testing for residents and employees. Per an executive order from Connecticut Gov. Ned Lamont, the first potential date for visitors inside a SNF — the third phase of reopening — is September 9, but Perry emphasized that this is fluid depending on circumstances, especially given how cautious the state is being.

Still, Connecticut is doing relatively well, with an overall positivity rate of 0.59% as of Monday.

“If we continue the trend in this positive light, we do want to be prepared,” Perry said. “We have identified indoor visitation protocols — of course as the Department of Public Health gives us additional guidance, other recommendations, we will have to follow what those recommendations are.”

Vernon Manor’s protocols include surveillance at the entrance through Swiped-on, a contact-free sign-in technology; leaders are also looking at infrared thermometers, and a wall-mounted device that would automatically send an alarm for any abnormal temperature, Perry said in a follow-up email to SNN July 16.

Indoor visits would include social distancing with floor markings, designated areas, supervision, scheduling through a calendar, and disinfecting between visits — and of course, masks required for all.

This is some ways away, but in the meantime, communal dining and activities can resume if employees and residents test negative for COVID-19 for 14 days.

“We received guidance from our local health department actually this week and we will be able to transition into communal activities next week,” she said on July 16. “Communal dining — we’re still waiting for further clarification so we can implement those protocols here. The biggest concern is, again, with food and having to remove your mask, and even though you’re still social-distanced, what that exposure could be.”

Consider the caregiver

Even with visitation in person allowed in many places, one of the painful parts of the lockdown was the fact that it cut off many residents from family members whose visits served a caregiving role.

As a result, the state of Minnesota on July 10 released guidance for long-term care facilities on designating an essential caregiver for residents.

“We determined that it made a lot of sense to not open the doors completely for long-term care because of everything that’s happening with COVID … but how do we balance that wellbeing of the residents with that safety?” Lindsey Krueger, health facilities section chief at the Minnesota Department of Health told Skilled Nursing News.

The guidance acknowledges the role essential caregivers play in observing and advocating for residents, alleviating caregiving tasks for staff, and the promotion of quality of life and autonomy for residents.

Facilities have to take scheduling into account to keep track of the number of essential caregivers in a building at a given time, and the caregivers have to wear all necessary personal protective equipment (PPE). That means facilities have to make sure to educate caregivers on proper donning and doffing techniques.

Long-term care facilities in Minnesota that choose to set up an essential caregiver program have until July 25 to draft policies and prepare for program implementation, though they do not need to wait until that date to start the program if the necessary policies and arrangements are in place. That said, facilities can implement after July 25 if they aren’t ready by that date, Krueger told SNN.

But even beyond essential caregiving tasks, the role of visitors in resident wellbeing is critical. Perry pointed to an example she had seen, where a resident’s grandson had twins, who were finally able to visit.

“Of course, they’ve been able to share pictures via the phone and FaceTime, but it’s still not the same until you can see them in person,” she said. “And it was a surprise — the resident had no idea that the grandson was bringing the twins to the facility today. So she was overwhelmed with joy. It’s a great feeling to see the light shine within the resident, when they reconnect with their families.”

For Stark, that connection endures, and it’s why she made – and continues to make – the effort to give her her husband some semblance of normality.

“For me, my philosophy is home is with my husband and the house is where I sleep and shower and have coffee before I go to work in the morning,” she told SNN.