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COVID-19: Nursing Home Care and Assisted Living

The decision to move a parent or older relative into assisted living or a nursing home has always been a difficult and emotional one. One of the positives has been the comfort of knowing you can visit to maintain a loving social connection and to supplement the care your relative receives.

But with COVID-19, nursing homes and other group housing for older people have been in the news as centers of disease transmission, with tragic reports of high rates of death. And because older people are particularly vulnerable to serious illness and death from COVID-19, many of these facilities have sharply curtailed visits from family members and friends.

If you have a family member in a nursing home or assisted living facility, what can you do to stay connected with them and ensure that they receive the best possible care? How should you decide whether to leave them where they are or move them somewhere else? And if you have an older relative who needs increasing amounts of care, how should you think about nursing homes or assisted living as options?

New Concerns for Older People and Their Families

One of the tragedies of the COVID-19 pandemic has been its toll on the oldest members of our communities. Around the world, the rates of serious illness and death from the virus have proved to be much higher among older than younger people. Of every ten people who have died from COVID-19 in the United States (U.S.), eight have been age 65 or older. And the risk of death is even higher for individuals age 85 and older. People over age 85 are 630 times more likely to die from COVID-19 than people ages 18 to 29 (Centers for Disease Control and Prevention, CDC; Link opens in a new windowhttps://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-age.html). In nursing homes, that trend has been magnified. Residents of nursing homes make up less than one percent of the U.S. population but represent almost half of all deaths from COVID-19 (Foundation for Research on Equal Opportunity; Link opens in a new windowhttps://freopp.org/the-covid-19-nursing-home-crisis-by-the-numbers-3a47433c3f70?gi=b29d4ada87d1). The proportions are higher or lower in different countries (Canadian Institute for Health Information; Link opens in a new windowhttps://www.cihi.ca/sites/default/files/document/covid-19-rapid-response-long-term-care-snapshot-en.pdf) and different states, but the averages are fairly consistent worldwide. Nursing home residents have suffered at devastating levels from this pandemic.

With that increased risk of serious illness and death for residents of nursing homes, family members are understandably worried about their loved ones. But at a moment when they would like to be more involved in their older relatives' care, many find themselves shut out from direct contact through in-person visits. Not only are family members concerned about their older relatives' risk of illness from COVID-19, they worry about the health effects of social isolation for their relatives. Social isolation is associated with higher risks of depression, dementia, stroke, and heart failure (AARP; Link opens in a new windowhttps://www.aarp.org/caregiving/health/info-2020/covid-isolation-killing-nursing-home-residents.html). In normal times, friends and family members play an important role in helping older people in care facilities remain socially engaged and healthy and in meeting needs that staff may not be able to address.

How Nursing Homes and Assisted Living Facilities Are Responding to Keep Residents Safe

The CDC has issued guidance for nursing homes and long-term care facilities to minimize the risk of COVID-19 infection (Link opens in a new windowhttps://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-home-long-term-care.html). These include the following steps:

  • Train staff on infection control.
  • Require staff to wear masks and other personal protective equipment (PPE).
  • Screen residents daily for symptoms of COVID-19.
  • Suspend communal dining and other group activities.
  • Test staff and residents frequently for COVID-19 (subject to availability of tests).
  • Screen anyone entering the facility for COVID-19 symptoms.
  • Suspend or limit family visits (allowing only physically distanced outdoor visits with masks, for example, or compassionate-care visits).
  • Have a plan in place to communicate to staff, residents, families, and the appropriate data-collection authority within 12 hours if a case of COVID-19 is detected in the facility.
  • Have a plan in place to separate residents who are infected with or exposed to COVID-19 from the general community and to provide care to infected residents with dedicated staff.

States have authority to make these recommendations tighter or looser, and to make some or all of them requirements for continued operation. The CDC suggests tighter controls when the incidence of COVID-19 is high or rising in the surrounding community, and to consider cautious easing of some controls when the community incidence of COVID-19 is low.

The requirements don't cover steps to prevent social isolation among residents, which is also a significant public health risk. Facilities are coming up with their own measures to address this. These include

  • Making it easier for families and residents to communicate by video chat
  • Enabling safe visits from family members, usually outdoors, masked and physically distanced, but with carefully controlled exceptions for some residents
  • Finding social activities within the facility that can be conducted with minimal risk (physically distanced bingo games and church services, for example)
  • Allowing limited in-person visits among residents who have not had contact with outside visitors

This careful balance between infection-control measures and the need to address the social needs of residents is among the biggest challenges faced by administrators of nursing homes and assisted living facilities. There is no "right" answer to striking that balance. The need for social connection will be greater for some residents than others, and the risk of COVID-19 transmission will rise and fall with the incidence of the disease in the surrounding community.

What to Look for and Questions to Ask When Evaluating a Facility

In choosing a nursing home or assisted living facility it has always been important to research the quality of different options. The Medicare website offers a Nursing Home Compare tool (Link opens in a new windowhttps://www.medicare.gov/nursinghomecompare/search.html) that allows you to locate and compare evaluation ratings for nursing homes anywhere in the U.S. The Centers for Medicare & Medicaid Services (CMS) offers a guide to choosing a nursing home, with a detailed checklist of questions to ask and things to look for (Link opens in a new windowhttps://www.medicare.gov/Pubs/pdf/02174-Nursing-Home-Other-Long-Term-Services.pdf).

Standard guidance has been to visit different housing options to get a sense of the life there, the community of residents, the comfort and cleanliness of the physical space, and the quality of the staff. All of this is still important—the facility's philosophy of care, the number and type of staff, meals, activities, special services, as well as how staff members interact with residents and whether residents are treated with respect. But it may no longer be possible to directly observe these factors when outside visitors are not allowed. And some new considerations have become critically important.

With the heightened risk of serious illness and death from COVID-19 in group care settings, some families are also exploring options for moving an older relative who is currently in a nursing home—either to bring them home or transfer them to another facility.

Here are some questions to ask in evaluating care facilities in a COVID-19 world.

Infection Control

  • Has the facility been cited in the past for deficiencies in infection prevention and control? According to a May 2020 report from the U.S. Government Accountability Office, eight in ten nursing homes were cited for these types of deficiencies between 2013 and 2017, half of them more than once (Link opens in a new windowhttps://www.gao.gov/products/GAO-20-576R). The great majority of the citations were from minor lapses, like staff failing to wash their hands regularly. But even a minor lapse in observing safe infection-control measures could have devastating consequences during the COVID-19 pandemic.
  • What specific measures is the facility taking to minimize the risk of COVID-19 entering the facility and spreading once it is present? Compare those measures to the guidance from the CDC (Link opens in a new windowhttps://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-home-long-term-care.html, highlights of which are listed above).
  • Do staff have an adequate supply of masks and other PPE? With nationwide shortages of these critical supplies, many facilities have struggled to provide their staff with the protection needed to keep themselves and residents safe from infection.
  • What are the facility's testing practices? How often are staff and residents tested for COVID-19? Are tests administered to people with and without symptoms?
  • Are new residents tested for COVID-19 or quarantined on arrival?
  • Has the facility had cases of COVID-19 among residents and staff? Have there been deaths? The CMS shares data on the COVID-19 cases and deaths for nursing homes in the U.S. (Link opens in a new windowhttps://data.cms.gov/stories/s/COVID-19-Nursing-Home-Data/bkwz-xpvg).
  • How are residents who have COVID-19 separated from residents who have not been exposed? How are staff who serve infected residents kept separate from other staff and residents?

Communication

  • How is the facility sharing information with residents and families about protocols and changes at the facility during the pandemic?
  • Does the facility have emergency contact information for each resident? If your relative is a resident, make sure the facility has your contact information.
  • How does the facility share information about residents' options for social activities and changes to those options?
  • How will the facility share information if a staff member, resident, or visitor is found to have COVID-19?

Social Connection

  • What is the facility doing to help residents stay connected with their families or loved ones while visits are restricted? Do the staff help residents communicate with loved ones by phone or video chat? Are devices or tablets provided to residents who do not have the equipment for video communication?
  • What are staff members doing to meet the need for social connection and engagement among residents when outside visitors are no longer allowed?

Staffing

Is the facility fully staffed? If the facility is understaffed, how are the critical needs of residents being met—for meals, bathing, medication management, and social engagement?

How to Stay Connected with Your Loved One

Three key measures are recommended by public health experts to reduce the spread of COVID-19: physical distancing, wearing masks, and avoiding prolonged sharing of indoor spaces with people other than the members of your immediate household. To protect older people, those measures should be followed scrupulously. That is why most nursing homes and assisted living facilities have blocked family members from in-person indoor visits with residents.

So how can you stay connected with an older relative who is in a nursing home or assisted living facility?

  • Call often. Make up for the in-person visits you're missing with frequent phone calls to check in and talk. Make a point of not rushing these calls. Ask questions to find out how your relative is doing and listen carefully to what they tell you.
  • Connect by video chat. Supplement your phone calls with video chats so you can see your relative and they can see you. Video chats are also a great way to bring in younger family members—for example, to show your relative how a grandchild is growing. If your relative needs help setting up or participating in a video chat, ask if a staff member can help at a scheduled time.
  • Visit. If in-person visits are allowed, follow the facility's rules faithfully to keep your relative and other residents safe. For example, some facilities allow time-limited outdoor visits with physical distancing restrictions and masks. It may not be the same as an indoor visit with a hug, but it's a way to connect that your relative may value greatly. Never visit, even outdoors, if you have symptoms of COVID-19, such as fever, cough, or difficulty breathing, or if you have been in contact with anyone with such symptoms. Inform staff immediately if, after your visit, you develop symptoms.
  • Send letters, homemade gifts, or favorite food. Check with the facility on its policies for accepting home-cooked food for residents. If this is allowed, you might drop off or mail a home-cooked treat, such as cookies or another of your relative's favorites. Sanitize the outside of all containers. If it's allowed, you might arrange for a meal to be delivered from a favorite restaurant.

The AARP has posted a state-by-state guide to nursing home visitation rules across the U.S. (Link opens in a new windowhttps://www.aarp.org/caregiving/health/info-2020/nursing-home-visits-by-state.html). This won't tell you what the rules are for a particular nursing home, which may be stricter than what is allowed in the state, but it will give you a sense of where visiting rules are loosening or tightening.

Considering Alternatives

With a new set of pros and cons tipping the scale on nursing home decisions, many families are considering alternatives. These include

  • Providing additional support to an older person who lives in their own home
  • Having an aging parent or older relative move in with you
  • Moving an older relative from one nursing home or assisted living facility to a different one

If you're concerned about the safety and wellbeing of a loved one in a nursing home or assisted living facility, talk with the administrators of the facility to see if they can address your concerns. If you're not satisfied with their responses, contact your state's Long-Term Care Ombudsman (look these up here: Link opens in a new windowhttps://www.aarp.org/caregiving/health/info-2020/long-term-care-ombudsman.html), who may be able to intervene on your behalf. If you're still concerned, despite your best efforts to advocate for your relative, you might consider a move.

Whether you're weighing a move into or out of a care facility, the right decision for your older relative, your family, and you will depend on some key factors:

  • How serious do you consider the risks to be in your older relative's current situation? How significantly would those risks be reduced with a move?
  • What services does your older relative need? Could you provide those services or arrange to have them provided in your home or your relative's home? Find out whether the services your relative needs are available during the pandemic. Your local Area Agency on Aging (AAA) can help you find out about services in your community (Link opens in a new windowhttps://eldercare.acl.gov/Public/About/Aging_Network/AAA.aspx).
  • Does your home or your relative's home need to be modified for safety and accessibility?
  • What are the costs of the services your relative needs and any required home modifications?
  • If you plan to provide care in your home, what is your backup plan if you become ill or are otherwise unable to provide needed care?

Keep in mind that if you move your older relative out of a nursing home, they may not be guaranteed a place should they later choose to return. There may also be costs to moving out of an assisted living residence, either for terminating the lease or rental if the move is permanent or for continuing the rent if the move is temporary.

Additional Resources

Morgan, H. (2020, September). COVID-19: Nursing home care and assisted living (C. Gregg-Meeker, Ed.). Raleigh, NC: Workplace Options.

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