What’s next: The future of nursing homes

Among the communities hardest hit by the novel coronavirus are nursing home residents. According to federal data, by the beginning of September, over 50,000 Americans living in these facilities had succumbed to COVID-19 – that’s more than a quarter of the nation’s death total.

It’s no different in California, where nursing home residents accounted for 3,855 out of about 14,800 total deaths from the virus, as of mid-September. Nearly 17,000 other nursing home residents in the state had been sickened.

To help avoid the spread of COVID-19 in these facilities, Dr. Susan Huang and her UCI Health colleagues have been funded by the Orange County Health Care Agency and CalOptima to be the Orange County Nursing Home Infection Prevention Team. In this role, they have created a nursing home toolkit dedicated to coronavirus prevention (www.ucihealth.org/stopCOVID) and provide webinars, training and monitoring to keep staff and residents safe from COVID-19.

“Nursing homes are an incredibly vulnerable sector, and there have been many that have seen COVID cases,” Huang told the Los Angeles Times. “The people who are in nursing homes have every risk factor that’s known for poor COVID outcomes. They’re elderly; they have comorbidities, like hypertension and asthma – all the things that make them frail and susceptible and unable to fight a brand-new virus the body has never seen.”

Huang is a professor of medicine in the Division of Infectious Diseases and the medical director of epidemiology and infection prevention for UCI Health. She’s one of the nation’s leading physician-researchers on mitigating MRSA infections in healthcare centers and is on the front lines of the county’s battle against the coronavirus. Here, Huang discusses what it will take to make nursing homes and assisted living facilities safer in a post-COVID-19 world.

What has the novel coronavirus revealed about conditions in nursing homes and assisted living facilities? 

Strategies and practices to reduce the spread of germs in nursing homes have not been robust. In fact, national requirements to have an infection prevention program in nursing homes were only instituted in November 2019, in contrast to long-standing regulations in hospitals. COVID-19 revealed weaknesses in nursing home infection prevention knowledge and practice that will need to be addressed. Continued investment in training programs and public health liaisons will be critical.

How did your partnership with the Orange County Health Care Agency and CalOptima come about? 

For the past 12 years, we have collaborated with OCHCA in studies to prevent the spread of antibiotic-resistant bacteria. Recently, our SHIELD O.C. program demonstrated that antiseptic bathing soap and nasal ointment reduced antibiotic-resistant bacteria across 38 regional healthcare facilities, including 17 nursing homes (https://www.ucihealth.org/shield). CalOptima, which is the county’s Medicaid insurer, looked into its own data and found that nursing homes participating in SHIELD saw a 44 percent reduction in hospitalizations due to infection. Because of that finding, CalOptima has funded antiseptic soap and nasal ointment for O.C. nursing homes that implement the SHIELD program. This experience led CalOptima to reach out to us to provide support in response to COVID-19.

What steps can nursing homes and assisted living facilities take right now to lessen the impact of the novel coronavirus? 

Several steps are important to keep staff and residents safe:

• Universal masking: It takes time to get used to face coverings. Staff should wear them and help residents adjust to wearing them whenever they’re within 6 feet of another person.
• Social distancing: Stay at least 6 feet apart as much as possible.
• Safe eating: Meals for staff and residents are high-risk moments when face coverings come off. Ensure 6 feet of distance between people and good hand hygiene when eating.
• Hand hygiene: Monitoring programs similar to those in hospitals are needed in nursing homes.
• Personal protective equipment: Training for proper use is needed.
• Speaking up and being tested: Speaking up about mild symptoms and following guidelines for routine and symptomatic testing are important.

What are the long-term challenges for nursing homes and assisted living facilities in addressing infectious pathogens like the coronavirus? 

Two major challenges exist. First, the coronavirus is not the only risky pathogen in these settings. Sixty-five percent of nursing home residents harbor an antibiotic-resistant pathogen. In fact, Orange County is currently on alert about the spread of a resistant fungus (Candida auris), in part due to grouping COVID-19 patients without attention to other germs they may carry. Second, new pathogens continue to emerge. We are still overdue for a flu pandemic. These issues mean that constant vigilance and preparedness are essential.

The number of people living in nursing homes and assisted living facilities continues to grow dramatically as the nation ages. What type of commitment needs to be made by health insurers, hospitals and governmental agencies to address what might become even more of a crisis situation? 

Not only are numbers increasing, but complexity of care is increasing as well. Enduring economic and regulatory commitments are needed to a) improve staffing ratios; b) increase highly trained staff, including those with infection prevention expertise; c) decrease administrative turnover; and d) invest in research to identify best practices in this important healthcare setting.

How will the upcoming flu season affect COVID-19 rates? 

The next several months will be critical as COVID-19 collides with cold and flu season. Flu vaccinations should be strongly recommended for all long-term care residents and staff, and preparations for a fall/winter surge should be made: drilling, practicing and providing essential feedback on the level of attention to key infection prevention activities. The goal is to ensure that these practices are second nature before the next wave.