LTSS CHOICES

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About this Series

This Spotlight is part of the AARP
Public Policy Institute’s LTSS Choices
initiative. This initiative includes
aseries of reports, blogs, videos,
podcasts, and virtual convenings that
seeks to spark ideas for immediate,
intermediate, and long-term options
for transforming long-term services
and supports (LTSS). We will explore a
growing list of innovative models and
evidence-based solutions—at both the
national and international levels—to
achieve system-wide LTSS reform.

We recognize the importance of
collaborating and partnering with
others across the array of sectors,
disciplines, and diverse populations
to truly transform and modernize

the LTSS system. We invite new ideas
and look forward to opportunities for
collaboration.

For all questions and inquiries,
please contact Susan

at LTSSChoices@aarp.org.

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The COVID-19 pandemic has focused attention on the deficits
of U.S. residential care facilities, which include nursing homes
and assisted living. People in these facilities are more likely

to die or have increased health problems arising from the
COVID-19 pandemic and they are subject to other infectious
diseases, such as influenza. This situation is not unique to the
U.S. Other countries are experiencing the same vulnerabilities.

Nursing homes provide most of the basic requirements

for people who need LTSS, including housing, services,

a workforce to support resident needs, and some level of
community integration (see A Series on Transforming Long-
Term Services and Supports). However, there are driving and
restraining forces that affect how well these basic components
come together to support a high-quality experience for
consumers. Clearly, rapid transmission of a deadly virus is
one of those forces, and a very serious one. Yet deaths of
thousands of nursing home residents are not inevitable. Critical
driving forces for safe care include continual preparation

for pandemics, routine infection control procedures, and
immediate interventions to combat the threats. Lessons from
other countries offer some important ideas for the U.S.

This Spotlight follows on and amplifies the earlier AARP Public
Policy Institute publication, LTSS Choices: COVID-19 and Nursing
Home Residents. In this Spotlight, we next look to the global

 

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LTSS CHOICES: INNOVATIONS TO PROTECT NURSING HOME RESIDENTS FROM INFECTIOUS DISEASES

community to explore how we can help mitigate
the effects of current and future pandemics on
U.S. nursing home and assisted living residents.
For this report, we reviewed the international
community’s experience with the COVID-19
pandemic to learn how other countries have
handled their responses to the pandemic and
what their experts recommend to improve care

Methods Summary

A Google Scholar search identified relevant COVID-19
publications from 2020 and 2021. We then searched
the archives of the International Long-term Care
Policy Network, which is a network of researchers,
policymakers and other stakeholders that promotes
the global exchange of evidence and knowledge on

for residents (see Methods Summary). LTSS policy. The network is based at the London
This Spotlight focuses on two sources for School of Economics and Political Science in the
insights. One is the experience of some United Kingdom. From all these sources, we selected
countries that have had few deaths in their relevant articles from academic authors. The

residential care facilities, how they prepare aie statielha|pvatele xe 2) un vane ddnel “Sees,

for pandemics in general, and how they

responded to the COVID-19 pandemic. The

other is international experts’ agreement

around recommendations to improve how nursing homes and assisted living facilities respond to
infectious disease. Those two areas of focus, in fact, converge, for we found that the relatively successful
countries’ responses to the pandemic align with those recommendations.

After examining the scope of the pandemic problem for residents and workers in other countries, we
focus on how the relatively successful countries have handled the COVID-19 pandemic and any related
special features of their care systems and nursing homes playing a role in that success. We highlight
experts’ recommendations, understanding that the U.S. cannot implement some of them for various
reasons, including differences in government authority across countries. However, sharing ideas offered
by global thought leaders can stimulate new approaches to issues that we must address to help ensure
that we do not repeat the devastating impact of COVID-19 on residents and staff. Note that this Spotlight
does not address all potential workforce innovations. We address additional innovations in a subsequent
Spotlight that focuses on the LTSS workforce across care settings.

Worldwide Impact of COVID-19 on People in Nursing Homes and Assisted Living

Several reports show that residents of nursing homes and assisted living facilities comprise a major
proportion of deaths due to COVID-19, with substantial variation across countries:

@ The July 2020 report from the World Health Organization! shows that in many high-income
countries, about half of all deaths due to the pandemic occurred among people in nursing
homes. At that time, the figure ranged from 24 percent of deaths in Hungary to 82 percent in
Canada.

@ Data from October 2020 show that the situation changed very little through the months of
the pandemic. Based on available data from 21 countries, 46 percent of COVID deaths were
in nursing homes and assisted living for older adults.? The figure was 41 percent in the U.S. at
that time.

1World Health Organization. (July 24, 2020) Preventing and Managing COVID-19 across Long-term Care Services, Policy Brief.

Doty P., Blanco M., Research Brief: Long-term Care and the Impact of COVID-19: a First Look at Comparative Cross-national Statistics,
December 2020. HHS, ASPE, Office of Behavioral Health, Disability, and Aging Policy.

 

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LTSS CHOICES: INNOVATIONS TO PROTECT NURSING HOME RESIDENTS FROM INFECTIOUS DISEASES

@ A third report analyzed deaths in 11 countries with at least 4,000 COVID-19 deaths as of
November 25, 2020 and at least 200 deaths in each of the first two waves of the disease.
Those waves ended on May 15 and September 15, 2020.3 The proportion of deaths due
to nursing home residents fell significantly in most of the countries in the second wave.
However, there was a great deal of variation in risk of nursing homes deaths among the
countries.

Death is only the most extreme of COVID-19 consequences for residents. General health and mental
health have suffered among residents as well. Many residents have existing health conditions, and
those residents have had trouble getting access to the full range of needed health services—prevention,
primary care, rehabilitation, and hospital services.4 At times in some countries, residents’ advance
care directives have been developed without the use of practices to ensure they are making their

own decisions about end-of-life care.5 This, of course, can affect access to care and residents’ health,
function, and independence.

A review of the psychological impact of the pandemic on residents shows that loneliness and anxiety
are among its primary consequences, with residents reporting significantly more of these feelings
during the pandemic than they did before it started.* This can result in high blood pressure, depression,
suicidal thoughts, and anxiety for residents. Consequences for residents can also include more
prescriptions for drugs that affect residents’ behavior, mood, thoughts, or perception (e.g., as with
anti-anxiety and anti-psychotic drugs).’ For example, an Ontario study of prescriptions for all nursing
home residents found that practitioners prescribed more of these medications during the pandemic,
and a similar increase occurred in the UK.® The authors speculate that increases in prescribing occurred
because of residents’ isolation due to visitation restrictions.

The pandemic has affected staff too. They witness residents die, and fear getting ill from COVID-19
themselves. Staff also experience uncertainty, hopelessness, work overload, and role conflicts.°

Countries’ Responses to the Pandemic

International and academic authors assert that, with certain exceptions, most countries spent the first
few months of the pandemic ignoring the LTSS sector.'° For example, many countries did not include

3loannidis J., Axfors C., Contopoulos D., (November 2020) Second versus First Wave of COVID-19 Deaths: Shifts in Age Distribution and in Nursing
Home Fatalities. medRxiv

*WHO 2020.
5Ibid.

8Mo, S., & Shi, J. (2020). The Psychological Consequences of the COVID-19 on Residents and Staff in Nursing Homes. Work, Aging and Retirement,
6(4), 254-259.

TAnti-psychotics, anti-depressants, benzodiazepines, and trazodones

8Stall, N.M., Farquharson, C., Fan-Lun, C., Wiesenfeld, L., Loftus, C.A., Kain, D., Johnstone, J., McCreight, L., Goldman, R.D. and Mahtani, R., 2020c.
A hospital partnership with a nursing home experiencing a COVID-19 outbreak: description of a multiphase emergency response in Toronto,
Canada. Journal of the American Geriatrics Society, 68(7), pp.1376-1381.

§Mo & Shi 2020.

Hirdes, J.P., Declercq, A., Finne-Soveri, H., Fries, B.F., Geffen, L., Heckman, G., Lum, T., Meehan, B., Millar, N. and Morris, J.N., 2020. The Long-term
Care Pandemic: International Perspectives on COVID-19 and the Future of Nursing Homes.

 

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LTSS CHOICES: INNOVATIONS TO PROTECT NURSING HOME RESIDENTS FROM INFECTIOUS DISEASES

nursing homes in their initial pandemic planning." In addition, these facilities generally did not get
access to personal protective equipment (PPE), testing, and medical support until after there was
already widespread infection among residents. Attention swung to the LTSS sector only once residents
were dying at disproportionately high rates.’

Governments that minimized the impact of COVID-19 in nursing homes had engaged in pre-planning for
pandemics generally, or had existing LTSS systems that enabled infection control once the pandemic
arrived. We examine both types of governmental approaches next.

Governments that Pre-Planned for Pandemics

Fortunately, a number of countries, or parts of countries, had engaged in pandemic planning

before COVID-19 appeared. Therefore, they had sufficient supplies of PPE and took other steps that
enabled more of their residents to live. The result was that those governments that were prepared

had better outcomes. Researchers report that countries with lower COVID-19 rates in residential

care settings tended to have mandatory prevention measures for nursing homes in place, along with
strong community prevention measures and access to PPE.” Governments with previous pandemic
experiences in Asia were likely to keep nursing home deaths contained. They had plans and sufficient
PPE in place, and their populations followed government regulations. About mid-way through 2020,
Hong Kong and Taiwan reported no COVID-19 deaths in nursing homes and Singapore and South Korea
reported less than 20 each." All four countries had started their infection control measures by February
2020. Below are further details on those countries.

Hong Kong

As reported in a July 2020 study, Hong Kong had no COVID-19 deaths in nursing homes and only one
case in these homes." Researchers said that Hong Kong had learned from its experience with the
SARS* epidemic in 2003. From that epidemic, Hong Kong learned” that older adults were more likely
to become infected and die, facility residents were five times more likely to become infected than

the general population, and older adults acquired most of their infections in hospitals. Also, a high
proportion of older SARS patients required intensive care and ventilators.

UWHO 2020.
2 Hirdes et al. 2020.
Doty & Blanco 2020.

“41 au-Ng R., Caruso L., Perls T., COVID-19 Deaths in Long-term Care Facilities: a Critical Piece of the Pandemic Puzzle. Journal of the American
Geriatrics Society. vol. 68, no.9, pgs. 1895-1898. Tsay, S. F., Kao, C. C., Wang, H. H., & Lin, C. C. (2020). Nursing’s response to COVID-19: Lessons
learned from SARS in Taiwan. International Journal of Nursing Studies, 108, 103587.

wong, K., Lum, T., and Wong, G., (July, 2020) The COVID-19 Long-term Care Situation in Hong Kong: Impact and Measures. International Long Term
Care Policy Network.

16 Severe acute respiratory syndrome coronavirus 2

Lum, T., Shi, C., Wong, G., & Wong, K. (2020). COVID-19 and long-term care policy for older people in Hong Kong. Journal of Aging & Social
Policy, 32(4-5), 373-379.

 

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LTSS CHOICES: INNOVATIONS TO PROTECT NURSING HOME RESIDENTS FROM INFECTIOUS DISEASES

Based on this experience, the government reacted swiftly to the COVID-19 pandemic. Some highlights
include:

@ Early on, the government implemented strict infection control procedures in the community.
— People stayed in the hospital until their COVID-19 infections cleared.

— Officials implemented COVID-19 contact tracing, with those identified as having contact
quarantining for 14 days.

~— Providers received subsidies for infection control.
@ Hong Kong took several measures in nursing homes.”°

— The government provided a financial supplement to institutional providers for extra
expenses due to the pandemic.

— All nursing homes have trained infection controllers on staff and four times a year conduct
emergency drills simulating outbreak situations such as with the flu or SARS.

— Nursing homes set up temporary isolation wards.

— Other measures included limiting visitors to nursing homes and permitting remote medical
appointments.”

— To address social isolation issues, non-governmental organizations (NGOs) collaborated
with telecommunication companies to facilitate video calls between residents and families
and online activities for older adults.

Singapore

Nursing home residents in Singapore accounted for 11 percent of the country’s 27 deaths due to
COVID-19. Like Hong Kong, Singapore took aggressive action early in the pandemic.”

Some highlights include:

® In January 2020, officials notified practitioners to be vigilant and confirmed the first cases of
COVID-19 late that month.

@ In February, they distributed PPE from a national stockpile, and began screening visitors to
nursing homes.

@ The very first nursing home COVID-19 diagnosis, which occurred on April 1, 2020, marked the
immediate implementation of measures to control spread in these facilities.

— Singapore restricted visits and health workers’ movements between nursing homes.

~ Inter-facility transfers involved strict safety protocols, and nursing homes created
“bubbles” to treat residents with COVID-19 together.

18| au-Ng et al. [n.d_].

Lumet al. 2020.

20Wong et al. 2020 and Lau-N¢g et al. [n.d.].
71Lum et al. 2020.

Graham W., Wong C., Responding to COVID-19 in Residential Care: The Singapore Experience. International Long Term Care Policy Network. July, 2020.

 

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LTSS CHOICES: INNOVATIONS TO PROTECT NURSING HOME RESIDENTS FROM INFECTIOUS DISEASES

— Hospitals were available to support testing residents and staff within 24 hours of exposure
to COVID-19. Those with positive or suspected infections went to hospitals. Hospitals also
helped with medical management of nursing home residents.

— Singapore quarantined nursing home staff exposed to the disease and provided them with
alternative housing.

South Korea

In South Korea, half of fatal cases occurred as a result of infections in hospitals or other institutions.”
By April 2020, South Korea had 247 COVID-19 deaths. Eight percent of those who died were infected in
nursing homes. Nursing homes transferred infected residents to hospitals where they remained until
they recovered or died. South Korea had few nursing-home-related deaths because they implemented
comprehensive infection control procedures, both in the population at large and in facilities.

South Korea initially had the second highest number of COVID cases after China, with a peak of 909
cases in February 2020.” However, South Korea rapidly controlled community transmission of the
disease. Some of South Korea’s success appears to be due to its response to an earlier pandemic—Middle
Eastern Respiratory Syndrome (MERS).”* Given that previous experience, the country was primed to
respond quickly to the COVID-19 pandemic. The country’s strategies included:

™ South Korea’s response started with early recognition of the threat and activation of a
response plan, which involved early and widespread diagnostic capability, contact tracing
and quarantine, and redesign of case management systems.

@ The country also designated triage centers for people with symptoms and allocated non-
hospital beds for people with mild symptoms.

Taiwan

As of March 2020, Taiwan had only 135 COVID-19 cases, despite its close proximity to the People’s
Republic of China.”* Taiwan was successful in preventing a wider spread of the infection because
government, hospitals, and nursing organizations collaborated immediately as a result of their
experience with SARS in 2003. Strategies included:

@ The government set up an internet platform for nurses to report when their hospitals did not
act in compliance with protocols.

@ The country put in place 134 isolation hospitals after the SARS epidemic. In these hospitals,
nurses are experts in infection control.

@ Nurse volunteers run a quarantine call center and the country uses extensive phone tracking
for infection control.

3 Kim, K., (May, 2020). The Impact of COVID-19 on Long-term Care in South Korea and Measures to Address it. International Long Term Care Policy
Network

Oh, J., Lee, J. K., Schwarz, D., Ratcliffe, H.L., Markuns, J. F., & Hirschhorn, L. R. (2020). National response to COVID-19 in the Republic of Korea and
lessons learned for other countries. Health Systems & Reform, 6(1), ¢1753464.

5 Middle East Respiratory Syndrome
6 Tsay et al. 2020.

 

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LTSS CHOICES: INNOVATIONS TO PROTECT NURSING HOME RESIDENTS FROM INFECTIOUS DISEASES

As of May 2020, in its 1,091 nursing homes, Taiwan had no clusters of infections and only one infection
in a staff member.”’ Researchers attribute the low rates to infection control being integral to the culture
of nursing home care and a sufficient supply of PPE. In addition, Taiwan has a Central Epidemic
Command Center that guides local governments, which in turn guide facilities. Care associations

and local networks of institutions coordinate. They banned nonessential visits, while each unit had
designated staff with no crossover to other units.

Hong Kong, Singapore, South Korea, Taiwan: General Takeaways

The Asian countries had previous pandemic experiences that motivated them to have emergency
plans that they used when they were aware of the COVID-19 pandemic. Nursing homes were part

of these plans and had immediate access to PPE. In addition, the countries had aggressive testing,
contact tracing, and quarantining measures that their populations largely followed. Thus, the U.S. can
learn a great deal from their experiences as it considers how to deal more effectively with both future
pandemics and the infectious diseases that more regularly occur in facilities.

LTSS Features Protecting Nursing Home Residents

Generally, countries that experienced high rates of COVID-19 infections did take certain measures,
reducing occupancy in nursing homes and restricting who could visit residents.7® Some countries
restricted workers to one facility, regularly tested staff for the virus, and allowed telehealth services in
facilities.

Other countries were able to minimize COVID-19 deaths in nursing homes likely due to their
infrastructure. We have two examples worthy of further consideration. One actually involves a
comparison of two provinces within one country: British Columbia and Ontario in Canada. Another
example is Denmark.

British Columbia and Ontario

One of the most interesting set of responses is the contrast between the Canadian provinces of British
Columbia (BC) and Ontario. The former was more prepared than the latter.

As of September 2020, Ontario had 5,965 resident cases and 1,817 deaths in its nursing home
population, whereas BC only had 466 cases and 156 deaths.”° Ontario’s facility resident infection

rate was 7.6 percent, compared to only 1.7 percent in BC. COVID-19 death rates among nursing home
residents were 2.3 percent versus 0.6 percent in the two provinces, respectively. Nursing home
residents in the two provinces had similar age and sex distributions. It is not clear whether there were
differences in residents’ frailty.

The authors of this report comparing BC and Ontario assert that the differences in death rates are due
to BC having*®° responded earlier to the pandemic and having had better pre-existing coordination

77Yang, P., & Huang, L. K. (2020). Successful prevention of COVID-19 outbreak at elderly care institutions in Taiwan. Journal of the Formosan Medical
Association, 119(8), 1249-1250.

8 Comas-Herrera A., Ashcroft E., & Lorenz-Dant K., (May 2020). International Examples of Measures to Prevent and Manage COVID-19 Outbreaks in
Residential Care and Nursing Home Settings. International Long Term Care Policy Network.

Liu, M., Maxwell, C. J., Armstrong, P., Schwandt, M., Moser, A., McGregor, M. J., Bronskil S., Dhalla, |. A. (2020). COVID-19 in long-term care homes in
Ontario and British Columbia. CMAJ, 192(47), E1540-E1546.

%\bid.

 

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LTSS CHOICES: INNOVATIONS TO PROTECT NURSING HOME RESIDENTS FROM INFECTIOUS DISEASES

among the public health, hospital and LTSS sectors. In addition, BC put more resources into its LTSS
system in terms of funding and care hours per resident. BC had 3.25 hours of care per day per resident,
versus 2.71 hours in Ontario. Only 24 percent of rooms in BC are shared versus 63 percent in Ontario.
BC also has more comprehensive facility inspections than Ontario. Finally, BC restricted workers to one
facility starting in March 2020, whereas Ontario waited until April to do so.

Denmark

As of May 2020, Denmark had 563 deaths from COVID-19, with about one-third being nursing home
residents.*! Most other European countries experienced death rates of 40 percent or more.*? Denmark
did better than many other European countries because they had better nursing home environments
and better prepared staff.

Responding to the pandemic, Denmark quickly locked-down facilities. This included restricting
visitors, limiting group activities to two residents, limiting the number of residents that one worker
could serve, and immediately isolating residents with symptoms. Another factor is that in Denmark
municipalities provide integrated health and LTSS, with each nursing home having its own general
practitioner. Interestingly, facility staff have reported that residents are calmer than they were prior to
the implementation of COVID-related practices, perhaps due to smaller group activities.

Two other factors in Denmark include staffing and facilities’ physical environment.*? LTSS workers have
extensive training. Social Care and Health Helpers have a 19-month training program with a five-month
introductory course. Social Care Assistants have an additional 20 months of training and coursework.
Now, during the pandemic, such workers can file a work-related injury claim if they test positive for
COVID-19, enabling them to receive worker compensation payments.

Turning to facilities’ environments, the majority are public, relatively new, and have one resident per
room. In fact, residents typically have small apartments with their own kitchen, bathroom, and two
separate rooms with a doorbell and mailbox. The facilities also have common rooms where residents
socialize. Single occupancy enables easy isolation of residents with COVID-19 symptoms.

International Researchers and Practitioners’ Recommendations for Handling Pandemics

Recommendations to handle the current pandemic and future ones are emerging from a variety of
organizations and professionals who have been analyzing the experiences of nursing home residents
during such situations. These experts have focused on steps to mitigate the problems that have
occurred in many countries across the world. For example, many countries have experienced severe
challenges related to infection control and staffing. So, one of the most frequent recommendations
is the deployment of rapid response teams to help nursing home staff control infections and provide
additional staffing when necessary.

The following recommendations come primarily from the World Health Organization, the American
Geriatric Society, and a number of international researchers. These are important ideas for
discussion, but should not be viewed as AARP recommendations, which are included in the

LTSS Choices: COVID-19 and Nursing Home Residents December 2020 Spotlight. The ideas of the

3! Rostgard, T., (May 2020) The COVID-19 Long-Term Care Situation in Denmark. International Long Term Care Policy Network.
Ioannidis et al. 2020 and Doty & Blanco 2020.
33 Rostgard 2020.

 

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LTSS CHOICES: INNOVATIONS TO PROTECT NURSING HOME RESIDENTS FROM INFECTIOUS DISEASES

experts and researchers converge in several themes, including planning and rapid response measures,
infection control and quality assurance, integration of health and LTSS, resident and worker issues, and
environmental design.

Planning and Rapid Response

Develop a national coordinating system that can be immediately responsive to pandemics.
This system should use relevant data systems to estimate the impact of pandemics and
determine how to improve responses to them.

Ensure that emergency response plans are on hand at care facilities and that facilities update
them and practice their execution. These plans should include nursing homes and assisted
living residences. There should be a designated government or private-sector focal point
(e.g., a response center) to manage the LTSS sector response.

Establish and maintain facility rapid response teams with geriatric expertise to serve
residential settings and reduce avoidable hospital use, and ensure good communication
across the health and LTSS sectors.

Infection Control and Quality Assurance

Ensure adequate pandemic monitoring in nursing homes and assisted living residences and
share results with the health care sector.

Ensure that nursing homes and assisted living residences have a stockpile of PPE. While
multiple sets of recommendations mention this, none seems to define what an adequate
stockpile is. Likely, this occurs because the requirements vary by type of facility and their
resident profiles.

Test everyone entering a facility for COVID-19 or any future virus threat and give them hands-
on training about infection control. All facility staff members serving infected residents
should receive training in infection control and recognition of symptoms. Use experienced
nurses to educate and train staff in infection control.

Limit transfers from hospitals during pandemics.

Integration of Health and LTSS

Ensure that residents continue to receive essential health promotion, prevention, treatment,
rehabilitation, and palliation services. Upgrade clinical services in nursing homes to meet the
more intense health needs of residents.

Ensure that all facilities are supported by a primary care service and that health and LTSS
services are integrated for residents. Illustrating the importance of this recommendation is a
study in France. Researchers compared the experiences of residents in three nursing homes;
two were hospital-based and the third was independent.* They found that at three months,
hospital-based nursing homes had case fatality rates of 6.6 percent versus 25.8 percent for the

*Tartaret, P., Strazzulla, A, Rouyer, M., Gore, C., Bardin, G., Noel, C., Benguerd,i Z., Berthaud, J. Hommel, M., Auflaure, S., Jochmans, S., Diamantis,
S., (2020). Clinical Features and Medical Care Factors Associated with Mortality in French Nursing homes during COVID-19 Outbreak, international
Journal of Infectious Disease.

 

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LTSS CHOICES: INNOVATIONS TO PROTECT NURSING HOME RESIDENTS FROM INFECTIOUS DISEASES

independent facility. Mortality decreased with residents having daily clinical examinations,
three vital-sign measurements per day, and anti-coagulation therapy at the hospital-based
facility. The independent facility had no effective infection control policy.

Develop methods of treating LTSS residents with COVID-19 (or other pandemic virus) in the
primary, secondary, and tertiary care settings, using virtual techniques for consultations
when appropriate.

Scale up initiatives like the Seniors Quality Leap Initiative, which is a private network of
11 US and Canadian organizations serving 11,000 residents in 68 care homes.* This group
collaborates to use evidence-based metrics to establish common improvement initiatives.
The collaborative has improved pain management and reduced inappropriate use of anti-
psychotics. The initiative’s emphasis is on improving performance.

Residents

Involve residents in decisions about whether to have visitors.

Develop interventions during pandemics that can help residents maintain their social
connections with family and friends, and provide opportunities for developing leisure skills.

Use technology during pandemics to facilitate virtual contact between residents and family.
Techniques include video chats, window visits, video calls, phone conversations, and emails.
Facilities should determine what communication methods residents prefer, in the absence of
in-person visits. It turns out that low technology methods may be the ones residents prefer,
but facilities should accommodate resident choice. An online survey of 161 adults in the U.S.
with relatives or friends in nursing homes queried them about nine communication methods
other than physical visits** and how they perceived the resulting emotions of the residents
with whom they had contact. More frequent phone and email communication was associated
with residents having less negative emotion. Video conferencing” had no significant impact
on resident emotions, while letters that are more frequent were associated with residents
having emotions that are more negative. Phone and email were the communication methods
residents appear to prefer.

Ensure that palliative care plans and advanced care directives are person-centered and
current.

Ensure that all parties know resident goals of care, plans for end-of-life, medical needs, and
whether a facility can appropriately serve a resident with COVID-19 or other future virus.
Ensure supplies for symptom management and end-of-life care.

3 Hirdes et al. 2020.

36 Monin, J. K., Ali, T., Syed, S., Piechota, A., Lepore, M., Mourgues, C., ... & David, D. (2020). Family Communication in Long-Term Care During a
Pandemic: Lessons for Enhancing Emotional Experiences. The American Journal of Geriatric Psychiatry, 2812), 1299-1307.

37 Note that video-conferencing does allow families and friends to see and check in on their loved ones,

 

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LTSS CHOICES: INNOVATIONS TO PROTECT NURSING HOME RESIDENTS FROM INFECTIOUS DISEASES

oA MM (e-em elatey|

Many countries locked down their nursing homes once it became clear that residents were dying of COVID-19 at
disproportionate rates. These bans have caused residents high levels of loneliness, depression, and mood and
behavioral problems.*® The literature to date does not provide evidence that visitors introduced COVID-19 infections to
institutions.

There are concerns that the risks of visitor bans outweigh the benefits. Researchers? recommend that residents be
able to designate caregivers who can visit on a limited basis, except during end of life, when they would be able to
visit somewhat more frequently. More generally, visitors need to comply with infection control procedures. Outdoor
visitations are preferable when feasible.

Like other countries, the Netherlands prohibited visitors to nursing homes, and residents were not able to go outside.
Health professionals also had their visits limited. All group activities for residents ceased. Given the risks to residents,
this country developed guidelines for visitors that permitted scheduled visits and required that visitors follow
infection control procedures. Researchers studied the impact of these guidelines on COVID-19 infections for three
weeks after visits were allowed in 26 nursing homes.” They found that 57 percent of residents received visitors, who
mostly followed infection control protocols. Staff workload increased due to managing the visits. Nursing home staff
reported the positive impact that visitors had on residents’ well-being and nursing homes reported no new COVID-19
infections for three weeks after visits were allowed. As a result, the Netherlands lifted its ban on visitors because of the
detrimental impact on residents and residents are involved in decisions about visitation.”

Workers

®@ Secure sufficient staff and resources for facilities, and restrict staff to working in one facility,
if possible, with adequate wages. If not possible to restrict them, provide the incentives they
need to work in only one facility so they do not need to seek employment in two or three
nursing homes. Staff need a salary sufficient to minimize their movement between facilities
and paid sick leave to stay home when they are ill. A literature review showed that increased
facility staffing, particularly registered nurses, was consistently associated with reduced risk
of COVID-19 infections and mortality.*? Another measure that proved effective was voluntary
staff confinement to facilities, with staff sleeping in unused areas of the facility.

38 Baumbusch, J., Low, L. F., & Comas-Herrera, A. Rapid review of the evidence on impacts of visiting policies in care homes during the COVID-19
pandemic.

39 Stall, N. M., Johnstone, J., McGeer, A. J., Dhuper, M., Dunning, J., & Sinha, S. K. (2020b). Finding the right balance: An evidence-informed guidance
document to support the re-opening of Canadian nursing homes to family caregivers and visitors during the coronavirus disease 2019 pandemic.
Journal of the American Medical Directors Association, 21(10), 1365-1370.

“Verbeek, H., Gerritsen, D. L., Backhaus, R., de Boer, B. S., Koopmans, R. T., & Hamers, J. P. (2020). Allowing visitors back in the nursing home
during the COVID-19 crisis: A Dutch national study into first experiences and impact on well-being. Journal of the American Medical Directors
Association, 21(7), 900-904.

*' Kruse F., van ToL L., Vrinzen C., vad der Woerd O., Juristen P., (November 2020) The Impact of COVID-19 on Long-term Care in the Netherlands: the
Second Wave. International Long Term Care Policy Network.

#2 National Collaborating Centre for Methods and Tools. (October, 2020). What Risk Factors Are Associated with COVID-19 Outbreaks and Mortality in
Long-term Care Facilities and What Strategies Mitigate Risk?

 

11 | AARP Public Policy Institute © 2021 ALL RIGHTS RESERVED | www.aarp.org/LTSSChoices
~AARP’

LTSS CHOICES: INNOVATIONS TO PROTECT NURSING HOME RESIDENTS FROM INFECTIOUS DISEASES

™ Improve facility jobs by providing a living wage, adequate benefits, and stable employment.
Train workers in gerontology to be part of the clinical team, and mentor them.

@ Ensure the psychosocial well-being of workers by providing assistance, such as a dedicated
helpline and offering flexible scheduling.

@ Educate staff about infection control, and address their concerns about the pandemic and
ethical issues surrounding it.

@ Consider psychological intervention teams for staff, residents, and families during
pandemics.

Environmental Design

@ Redesign nursing homes to make them more homelike. Designs with more private rooms
enable better infection control.

@ New nursing homes should have private rooms, outdoor spaces, non-slip floors, smaller
units, and good sight lines and communication systems.

M@ In-house services, such as providing meals to staff, can help ensure their safety; staff rooms
for breaks and changing out of travel clothes can help reduce virus spread.

@ Nursing homes should have spaces for designated for external community members to
interact with residents.

™ Nursing homes, if feasible, could divide their institutions into one area for people without
symptomis, one for suspected cases, and one for those with the pandemic-related disease.
Consistent staff should work in each area to minimize spread of the disease.

Conclusion

This international review of countries’ experiences with the COVID-19 pandemic reveals that

the countries that were prepared for pandemics and acted on their plans experienced much less
death among nursing home residents. The countries that were prepared tended to have had direct
experiences with previous pandemics and to have learned vital lessons from them. These countries
were primarily from Asia.

A second important observation is that governments such as those in British Columbia and Denmark
had LTSS system features that permit a more effective response to pandemics. Both of these
jurisdictions have primarily private rooms or apartments for nursing home residents, sufficient supplies
of trained staff, and programs that require or encourage staff to serve one facility.

These lessons and others described here offer the United States innovative ideas for handling future
pandemics more effectively than we did COVID-19 in 2020 and 2021.

Advancing the Discourse
We invite comment on these ideas and encourage the submission of new ones. Contact us at

LTSSChoices@aarp.org.

 

12 | AARP Public Policy Institute © 2021 ALL RIGHTS RESERVED | www.aarp.org/LTSSChoices
~AARP’

LTSS CHOICES: INNOVATIONS TO PROTECT NURSING HOME RESIDENTS FROM INFECTIOUS DISEASES

 

Acknowledgements

The authors express their gratitude to the members of the LTSS Choices Team, particularly Carrie

Blakeway Amero. We also appreciate the thoughtful contributions of Rhonda Richards, Dorothy Siemon
and Ben Belton.

https://doi.org/10.26419/ppi.00139.001

 

13 | AARP Public Policy Institute © 2021 ALL RIGHTS RESERVED | www.aarp.org/LTSSChoices
INNOVATIONS TO PROTECT NURSING HOME RESIDENTS FROM INFECTIOUS DISEASES

LTSS CHOICES

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14 | AARP Public Policy Institute © 2021 ALL RIGHTS RESERVED | www.aarp.org/LTSSChoices
INNOVATIONS TO PROTECT NURSING HOME RESIDENTS FROM INFECTIOUS DISEASES

LTSS CHOICES

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15 | AARP Public Policy Institute © 2021 ALL RIGHTS RESERVED | www.aarp.org/LTSSChoices
INNOVATIONS TO PROTECT NURSING HOME RESIDENTS FROM INFECTIOUS DISEASES

LTSS CHOICES

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16 | AARP Public Policy Institute © 2021 ALL RIGHTS RESERVED | www.aarp.org/LTSSChoices
INNOVATIONS TO PROTECT NURSING HOME RESIDENTS FROM INFECTIOUS DISEASES

LTSS CHOICES

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17 | AARP Public Policy Institute © 2021 ALL RIGHTS RESERVED | www.aarp.org/LTSSChoices
INNOVATIONS TO PROTECT NURSING HOME RESIDENTS FROM INFECTIOUS DISEASES

LTSS CHOICES

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18 | AARP Public Policy Institute © 2021 ALL RIGHTS RESERVED | www.aarp.org/LTSSChoices
INNOVATIONS TO PROTECT NURSING HOME RESIDENTS FROM INFECTIOUS DISEASES

LTSS CHOICES

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19 | AARP Public Policy Institute © 2021 ALL RIGHTS RESERVED | www.aarp.org/LTSSChoices
INNOVATIONS TO PROTECT NURSING HOME RESIDENTS FROM INFECTIOUS DISEASES

LTSS CHOICES

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20 | AARP Public Policy Institute © 2021 ALL RIGHTS RESERVED | www.aarp.org/LTSSChoices
INNOVATIONS TO PROTECT NURSING HOME RESIDENTS FROM INFECTIOUS DISEASES

LTSS CHOICES

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21 | AARP Public Policy Institute © 2021 ALL RIGHTS RESERVED | www.aarp.org/LTSSChoices
INNOVATIONS TO PROTECT NURSING HOME RESIDENTS FROM INFECTIOUS DISEASES

LTSS CHOICES

ESD ee tN

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22 | AARP Public Policy Institute © 2021 ALL RIGHTS RESERVED | www.aarp.org/LTSSChoices
INNOVATIONS TO PROTECT NURSING HOME RESIDENTS FROM INFECTIOUS DISEASES

LTSS CHOICES

ESD ee tN

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23 | AARP Public Policy Institute © 2021 ALL RIGHTS RESERVED | www.aarp.org/LTSSChoices
INNOVATIONS TO PROTECT NURSING HOME RESIDENTS FROM INFECTIOUS DISEASES

LTSS CHOICES

ESD ee tN

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24 | AARP Public Policy Institute © 2021 ALL RIGHTS RESERVED | www.aarp.org/LTSSChoices
INNOVATIONS TO PROTECT NURSING HOME RESIDENTS FROM INFECTIOUS DISEASES

LTSS CHOICES

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25 | AARP Public Policy Institute © 2021 ALL RIGHTS RESERVED | www.aarp.org/LTSSChoices
INNOVATIONS TO PROTECT NURSING HOME RESIDENTS FROM INFECTIOUS DISEASES

LTSS CHOICES

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26 | AARP Public Policy Institute © 2021 ALL RIGHTS RESERVED | www.aarp.org/LTSSChoices
INNOVATIONS TO PROTECT NURSING HOME RESIDENTS FROM INFECTIOUS DISEASES

LTSS CHOICES

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27 | AARP Public Policy Institute © 2021 ALL RIGHTS RESERVED | www.aarp.org/LTSSChoices
INNOVATIONS TO PROTECT NURSING HOME RESIDENTS FROM INFECTIOUS DISEASES

LTSS CHOICES

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28 | AARP Public Policy Institute © 2021 ALL RIGHTS RESERVED | www.aarp.org/LTSSChoices
INNOVATIONS TO PROTECT NURSING HOME RESIDENTS FROM INFECTIOUS DISEASES

LTSS CHOICES

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29 | AARP Public Policy Institute © 2021 ALL RIGHTS RESERVED | www.aarp.org/LTSSChoices
 

 

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31 | AARP Public Policy Institute © 2021 ALL RIGHTS RESERVED | www.aarp.org/LTSSChoices
INNOVATIONS TO PROTECT NURSING HOME RESIDENTS FROM INFECTIOUS DISEASES

LTSS CHOICES

ESD ey IN

BUTI ESTO ToS TAGE

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32 | AARP Public Policy Institute © 2021 ALL RIGHTS RESERVED | www.aarp.org/LTSSChoices
INNOVATIONS TO PROTECT NURSING HOME RESIDENTS FROM INFECTIOUS DISEASES

LTSS CHOICES

ESD ey IN

BUTI ESTO ToS TAGE

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33 | AARP Public Policy Institute © 2021 ALL RIGHTS RESERVED | www.aarp.org/LTSSChoices
INNOVATIONS TO PROTECT NURSING HOME RESIDENTS FROM INFECTIOUS DISEASES

LTSS CHOICES

ESD ey IN

BUTI ESTO ToS TAGE

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spunoy Aay| “Juapuadapul sem plyy
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au} pasedwioo sioyyne ay

 

POTUE yo be Wei ele Bel WLS
pue Sulsinn uo s}edu] 6T-GIAOD

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6ulsanu jo jousnof
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‘yea1q3NO 6T-GIAOD
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youasy ul Ap eOW

YzIM pazelossy

$10}3e4 a1eD ]e21PaNW
pue sainjeay jeriun>
*(0Z0Z) ‘s ‘sueweig

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“fp ‘pneyyeg

6-9-7 ‘paansuag “> ‘aon
fn ‘ulpaeg co ‘105

Sw “aAknoy ‘y ‘e]]nzze1S

“d ‘ouepeL

 

 

34 | AARP Public Policy Institute © 2021 ALL RIGHTS RESERVED | www.aarp.org/LTSSChoices
INNOVATIONS TO PROTECT NURSING HOME RESIDENTS FROM INFECTIOUS DISEASES

LTSS CHOICES

ESD ey IN

BUTI ESTO ToS TAGE

*pamoyje

3JAM SUSIA Jaye SY9OM 9214
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pouad Apnjs ay} 3uling
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0} ]Ud191JjNS Sem ]O90} 01d
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,S]UAPISAJ UO PeY SIOJSIA
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ANP Paseasdu! PeO}YIOM 4421S

 

.

“sJUapIsad YIM

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aaey Sai}}ioej 3ey} SuLNsuy
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JeaM 0} SJOUSIA SuLINbay
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pue JOUSIA UgaMmjaq
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JOPSIA QUO A]UO BuUNyWad
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ay] ‘2IWapued au} 8ulNp
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dno }]y ‘peywi) S}sIA

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aoueinssy Ayend>

YET eee Re BESS

ICO RU) USS

POTUE yo be Wei ele Bel WLS
pue Sulsinn uo s}2edu] 6T-dIAOD

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SuolDIDOSSY $10}2a4IG
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12M Uo }DedUI pue

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*(070Z) ‘d ‘f ‘suawieH
791 ‘y Ssuewdooy

&S ‘a ‘a0q ap fou
‘sneyyoeg “1°
Suas}ay “H ‘yaaqian

 

 

35 | AARP Public Policy Institute © 2021 ALL RIGHTS RESERVED | www.aarp.org/LTSSChoices
INNOVATIONS TO PROTECT NURSING HOME RESIDENTS FROM INFECTIOUS DISEASES

LTSS CHOICES

ESD ey IN

BUTI ESTO ToS TAGE

aoueinssy Ayend>

YET Lee Re Boe

PUSS) Uys

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pue jelD0s apiAoid 0} suaquiaw
ye2 AjsejnBa yng ‘paso}d sia}uad
Jojuas pue sjual]> Jo Jaquinu

ay} paonpai siaquad aed Aeq
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YUM pasauyed aveyu SOON

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UI SaANSeal SUIMO}]O} 84} YOO} 3uoy
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ul DIWapida syys ay} WJ) pausea)
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yo ased Ajuo sj pey AujuNOD ay}
“ozoz Ajne ul ‘pue saiiioey Suisunu ul
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Eye y Weil ele BoE BCE
pue Sulsinn uo s}edu] 6T-GIAOD

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4eD Wa}-3u07]
6T-GIAOD PUL (0707
‘Aynp) “5 ‘Zuo pue

cy ‘wnt “y ‘Suom

 

 

36 | AARP Public Policy Institute © 2021 ALL RIGHTS RESERVED | www.aarp.org/LTSSChoices
INNOVATIONS TO PROTECT NURSING HOME RESIDENTS FROM INFECTIOUS DISEASES

LTSS CHOICES

ESD ey IN

BUTI ESTO ToS TAGE

aoueinssy Ayend>

YET eee Re BESS

ICO RU) USS

‘aseasip ay} WO}

AjaNOI9J 0} UO!PSUEI} YJOOWS aiNsUy
*sdayJOM djay 0} Ayjiqixayy Suljnpayos
asn pue auljdjay payesipap e

se sounseaw Yons Yysnosyy SS17
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*SUOI}E9|UNWWILUOD poos ainsua

pue suojjezijeydsoy yuanaid djay

De} JOJ aSIWadxe DYeNad
UUM sea} asUOdsal pided ysi}qeysy
*S]USPIS9J JO} 31C9 0} BIIAJS

ase Ayewilid e yzmM diysuoiejas

& BAY O} PIau SA!}]I92} |]V

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aye yyeay ay} YUM Ajaanoaya
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dy} Ul SuO}UOW ayenbape ainsug
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JO JUaWASeUCLW JO} JUIOd ]ed0} e YUM
suluuejd jo saseyd je ul SS] apnjouy

 

solWapued ay} 0}

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padojanap ‘uonenzs jeuonewajul
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sem asayy Jaye }!yuN Yoddns jes!paw
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awodaq pey jeu} Saiz}I9e4 Yoddns 0}
pey jauuosiad asuodsai Anuasiawa
4Jayjo pue Awe ay} salsjun09

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SWODU! YUBIY BWOS UI Og se YsiY se
sadejuaciad YUM ‘saiq}I9e} SS17 0}
pou!) Useq aAeYy SUieEP GT-GIAOD

JO JUadJad Oy SalyyUNOD AUew U]

POTUE yo be Wei ele Bel WLS
pue Sulsinn uo s}2edu] 6T-dIAOD

*yoiig Adi)0d ‘sa21A1as
d12D W1a}-3U07 ssoi3de
6T-GIAOD Suiseuew
pue Suluanaid (0707
‘yz Ayn) ‘uoneziuesio
4yneeH POM

 

 

37 | AARP Public Policy Institute © 2021 ALL RIGHTS RESERVED | www.aarp.org/LTSSChoices
INNOVATIONS TO PROTECT NURSING HOME RESIDENTS FROM INFECTIOUS DISEASES

LTSS CHOICES

ESD ey IN

BUTI ESTO ToS TAGE

“S}IUN J9Y}O 0} JAAOSSO1D
jnoyym jeys payeusisap pey
sun pue ‘SuISIA jelUassauUOU
pauueg Aau| “ayeulpso002
SUOI!}N}ISU! JO SyYJOMIOU
]e90] pue suoljeldosse aied
*salqioey apins win} ul Aayz
pue s}UaWUJaA08 e290}
sapin3 sajuaD puewWoD

DIWapidg jesjUaD ayy °
“Add 40 Ajddns
qualoyyns e si se ‘ased AoE}
SUISINU JO B41N}ND dU} 0}

Je48a}U! S$! }01]U09 UOIDaJU] «

10}. Jey} ajnquye

ssJoyyne sy] Uequsew jyeys e

UI SEM Jeu} Pue UO!}DajUI BU
Ajuo pue saiz}ioe} Bulsinu TEOT
JI9Y Ul SUOIDAJU! JO Sua}SN]d
ou pey uemiel ‘0z0z Aew jo sy

aoueinssy Ayend>

YET Lee Re Boe

ICO RU) USS

sjuapisay Aq)1IDe4 SUIAI] paysissy
pue Sulsinn uo s}2edu] 6T-dIAOD

*OSZT-6rZT ‘(8)6TT
‘uonpiz0ssy )DIIPaW
UDSOULIO ay} Jo JOUINOT
*UeMIE] Ul SUOI}N}}SU!
ase> Aylap)a ye yeaiq}no
6T-GIAOD JO uoUanaid
Inyssa2ong *(070Z)

*y °7 SSuennp 79 “‘q ‘Sue,

 

 

38 | AARP Public Policy Institute © 2021 ALL RIGHTS RESERVED | www.aarp.org/LTSSChoices