Doctors Without Borders: Nursing Home Reform Should Focus on In-Person Support, Not Just Fines

More closely associated with lifesaving interventions in war zones and developing countries, Doctors Without Borders has made headlines during the COVID-19 crisis with its work on the ground in the United States.

In addition to providing aid to homeless populations in New York City and migrants in Florida, the humanitarian organization — formally known by its French name, Médecins Sans Frontières (MSF) — has provided technical support to American nursing homes, starting in Michigan and then moving to Texas.

One of the top takeaways from MSF’s work, according to medical coordinator Karin Huster, was that the U.S. response to the disaster in long-term care facilities focused too heavily on punitive measures at the expense of on-the-ground support for beleaguered nursing home staff.


While MSF and Huster still emphasize the importance of government regulations, she asserts that developing long-term partnerships between local institutions — such as schools of nursing and public health — and nursing homes is integral to improving elder care, forming a bedrock of in-person expertise that fines and webinars cannot create alone.

“Really, we’re a bit short-sighted, because this is going to be us in a few years. And is this the way we want to be treated? Is this the way we want our places to be, the places that take care of us in 20 years?” Huster said. “We might as well invest in those places the right way — and it’s not even as if these are massive efforts. They’re probably spending way more money sending people to give fines than to work on improving those facilities. It’s just heartbreaking.”

SNN called Huster earlier this month to discuss MSF’s work in American long-term care facilities, and to learn more about the non-governmental organization’s vision for permanently fixing senior care beyond the pandemic


How did the organization end up targeting nursing homes in Michigan?

MSF typically is not working in the United States. We are usually more known to be working in countries that have limited health resources — mostly on the African continent, the Middle East. But again, not so much the United States, nor Europe.

In Europe, we’ve done some things in the past with migrant populations and the homeless. But I believe it was limited to that. And then in this continent, we had been doing some things at the border with Mexico, but we were on the Mexican side of things — work with migrants.

Obviously, when COVID-19 hit, I think it became pretty apparent pretty fast that this was bigger than all of us. But surprisingly — maybe to some it was really surprising — [it was] really overwhelming in this country. We’re not bound by anything in order to respond other than if there is a need for intervention; then we will intervene if it meets our criteria. We don’t look as to whether we would be intervening in a resource-rich country or this or that. It’s according to the needs, and it was pretty clear that the needs were huge and not necessarily addressed.

That’s how we decided to intervene. Just for background as well, we intervened in Italy as well, in France, in Belgium — so it’s not just the United States, but that work started in Europe since Europe was hit first, and Belgium, Italy, France were overwhelmed at one point or another.

The work we did on COVID in Europe, much of it was focused on nursing homes as well. It was a different time of the outbreak; it was really when the curve was going up. A lot of the activities were similar … but we modified them a little bit, because in the United States and in Michigan, we were not on that upward curve. We had already passed the peak, and so we felt we needed to adjust the types of response we wanted to have.

We had a few teams. We started in New York, helping on the homeless response. Then we had a team in Florida that was working with migrants on COVID. And then we had another team in the Navajo Nation, and I believe they were doing [infection prevention and control] in health centers. Then it was decided to focus on nursing homes because we saw that there was a huge need. You know more than me how hard hit the nursing homes have been — what, about 40% to 45% of all the deaths have been in nursing homes? Very disproportionate mortality rates in some sense.

These are places that house vulnerable people, and who often have comorbidities, who are elderly. They were ticking all the boxes for us: This is really an area where we can bring our academic expertise to address the specific needs that those nursing homes might have.

What specifically was different about the experience in Europe versus the United States?

I live in Seattle, so I wasn’t in Europe to do COVID — I was in Hong Kong to do COVID, and we did a little bit of COVID [work] for the elderly, not much at all, because Hong Kong had closed very early on its elderly homes, its nursing homes. In any case, in Hong Kong, the mortality rate in nursing homes is almost zero. I mean, at the end of the outbreak, when I left and even a month and a half afterwards, Hong Kong still only had four deaths. The scope, the scale of the problem in Hong Kong wasn’t at all what we encountered in the United States.

Michigan was chosen more because it’s not easy to come in and plunk yourself in a state, as you can imagine. You need to have a lot of connections, you need for the states to be open to you coming, the department of health.

MSF had some connections with Michigan, some networking connections, so that made it easy. But it was one of the places we were looking at because it was one of the top five or six places that had been the hardest hit at the peak of the outbreak in the March-April-May timeframe. There’s Detroit, and there is a high proportion of disadvantaged folks there, and so again, it ticked the boxes for us.

Here we have a state or an area, the Tri-Cities [Saginaw, Midland, and Bay City, Mich.], that have had a lot of cases, but that also has a population that MSF typically is wanting to focus on. These are vulnerable populations or people who are disadvantaged from the beginning — they have Latinos, they have a high African-American population, and they’ve been disproportionately affected.

I think that the needs are so massive in this place that I think it was a good idea to pilot what we wanted to do in a place that had cases, and in a place where we had connections on the ground so that we could not waste a lot of time figuring out all those relationships so that we could get going. You can’t get inside nursing homes just like that, right? I mean, rightfully so. It takes a lot of working and networking and phone calls.

Now we are in Texas, which from an [epidemiological] standpoint, it’s a much more timely intervention in that things are on the upswing there. We can have a really good opportunity to limit the spread of the outbreak in the nursing homes if we find it.

What were some of the biggest lessons from the work in Michigan?

My take was that this country is massive, the needs are massive. We have a ton of nursing homes — [the answer is] not MSF, we’re going to be coming in and saving the world. We need to figure out a way to make whatever is working more sustainable, and sustainable for the long-term. And how that translates completely on the ground, for us, was to do collaboratives with schools of nursing and schools of public health.

They’re typically in the community. They are vested in those communities, and they are there for the long-term, right? The school is not going to close in a year, and so all that HR, those students — those masters students, those nurse-practitioner students, those social work students — they’re all there and we can leverage them to offer the support that the nursing homes so desperately need sometimes. As we were thinking of our exit strategy, we realized this is really the right answer, because we don’t, if you look at QIOs [Quality Improvement Organizations], they are stretched super thin over the entire United States.

They don’t have the time and the HR that are needed to provide all the support that those facilities need, and the support that those facilities need is mainly mentoring, coaching, capacity building — not over the internet, not in the form of webinars, none of that.

They really want to have your infection control preventionists, your experts in isolation and cohorting, there next to you, training you — coming several times a week for half a day, for an extended period of time, to really build that capacity that isn’t there because the resources and the funding and all these things have been lacking for so many years.

We were able to do this with our small team. The embedding activity that we did was mainly with 34 facilities. But that’s not even [enough] time that I really wanted them to dedicate. These facilities need support for weeks on end — maybe it’s a three-month commitment several times a week, half a day, that you work with the housekeepers or that you work with the nurses doing this.

MSF can’t provide this — no NGO can — but the schools of nursing, the schools of public health, the social workers, they can do that, and they are part of the community. What better way than to have this public health response?

It really felt to us that this wasn’t existing, but it was enabling — really easily — to build capacities that nursing homes need so much. That’s what we put in place when we exited. So the collaborative is with schools of nursing, and schools of social work, but as well with the Detroit public health department, because they provide the epi data, so [they] can provide the direction and the up-to-date priorities that you’d want the team to focus on.

Now that we’re in Texas, we’re doing this right away. We’re engaging right away with the schools of nursing and with a school of public health, because we know that this is your fundamentals.

For me, the biggest takeaway besides this was the importance of having people on the ground. They have a ton of guidelines, of guidance. The nursing homes — they have a ton of webinars. They’re drowning in webinars and guidelines, and they have no help to implement, to operationalize those guidelines completely. And if they can’t do it per the specs, per the protocols, they don’t have anybody to turn to to say: “Well, okay, you don’t have this, but we can do it like that.”

And that means people on the ground. You don’t do this over the phone. You don’t understand, you don’t see the reality. You don’t. And so it was flooring to me to see that this is the United States, and everybody is doing this COVID response remotely except for the doctors and the nurses in the hospitals.

I’ve had a bird’s-eye view on this throughout the pandemic: The federal and state governments have been issuing all these edicts around the use of PPE, the frequency of testing, and other infection-control issues under threat of fines and penalties, but so many folks have said they just didn’t have the access to the resources they needed in the moment.

The punitive approach never works, right? We know this with our kids, right? You don’t slap your kids; it doesn’t make a difference. It just does not work. So to slap those facilities with fines just because “oh, you’re not doing this, you’re not doing that,” and expecting them to do things that they all well know are impossible, it’s just not going to solve the problem.

I had one person tell us during an assessment that we did, she said: “I have 53 pages of citations and no help.” When you listen to this, you’re like: “Okay, well, now we understand why things are not working so well.”

It’s because a punitive approach is just not the end-all, be-all. Of course, you need to have some form of regulation. It’s important. It plays an important role. But it can’t be the primary tactic to effect true behavior change and improve health outcomes for the residents.

I’ve said it over and over, but my main concern is that we’re not thinking about nursing home reform broadly enough — the most we can muster outrage about publicly is lawsuits and fines. To be clear, they have a place in achieving justice and fairness, but we’re not going to fix long-term care with those levers alone.

I was talking to somebody else, and talking about this elderly population. You and I are going to be one of them — tomorrow, one day. What does it say about us, how we treat our elderly? Really, we’re a bit short-sighted, because this is going to be us in a few years. And is this the way we want to be treated? Is this the way we want our places to be, the places that take care of us in 20 years?

We might as well invest in those places the right way — and it’s not even as if these are massive efforts. They’re probably spending way more money sending people to give fines than to work on improving those facilities. It’s just heartbreaking.

This interview has been condensed and edited for clarity.

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