By Kali S. Thomas, Paula Carder, and David C. Grabowski STAT News March 25, 2020
With the national spotlight turned on nursing homes following the Covid-19 outbreak at the Life Care Center in Kirkland, Wash., that led to the deaths of 35 residents, the nearly 1 million residents of assisted living communities are getting lost in the shadows. They need the same kind of attention as nursing home residents.
The Centers for Medicare and Medicaid Services and the Centers for Disease Control and Prevention aim to beef up infection prevention and control in nursing homes. Unless similar efforts are made in assisted living communities, we will almost certainly see Kirkland-type outbreaks in them.
Assisted living, also referred to as residential care, is part of a continuum of long-term care services. Assisted living communities provide a combination of housing, personal care services, and health care designed for individuals who need assistance with normal daily activities but who want to be as independent as possible. There are nearly 29,000 assisted living communities across the U.S. caring for more than 800,000 residents. Most residents are age 85 or older, and many have one or more chronic illnesses — the very people who are at high risk for developing serious complications of Covid-19.
Why Covid-19 is a unique problem for assisted living communities
Like nursing homes, assisted living communities have many older adults living in close proximity. Staff members typically move from resident to resident to provide assistance. The majority of residents experience physical or cognitive impairment, which can make it challenging for them to follow infection control measures such as hand-washing and social distancing. Clinical staff, including licensed nurses and physicians, have limited presences in assisted living communities.
Unlike nursing homes, care in assisted living communities is largely paid out of pocket. Although states regulate these residential centers, the degree of regulatory stringency and requirements around staffing and infection control vary from state to state. Because they are not responsible for medical care, assisted living communities might not be equipped with medical or protective equipment like face masks, hoods, and full body suits.
Perhaps one of the greatest challenges in responding to Covid-19 in assisted living communities stems from their founding on a social model of care. It rejected the medical practices associated with nursing homes and emphasized core values such as resident choice, independence, and privacy. Balancing this model with medical needs during the pandemic will no doubt be challenging.
In Oregon, the director of the agency that licenses assisted living communities explained a policy to limit visitors this way: “We’re balancing social wellness with need to prevent a pandemic.” An owner/operator of an assisted living community said, “While we don’t want to underreact, we also don’t want to overreact such that communities begin to look like hospitals.”
Because this social model emphasizes choice and independence, residents and their families typically schedule and access medical care on their own and might be expected to purchase their own medical and personal care supplies. Although likely a rare case, a resident of an assisted living community in Massachusetts who was concerned about her health drove herself to a local emergency department and was diagnosed with Covid-19.
Preventing Covid-19 outbreaks in assisted living
To reduce the potential widespread and devastating impact of Covid-19, assisted living providers and policymakers should take several steps.
Providers should update — or in many cases develop — an emergency operations plan specific to dealing with a pandemic. Although almost all states require assisted living communities to have emergency/disaster preparedness plans in place, most of the plans only address fire safety. Short-term mitigation activities would include implementing no-visitor policies except for private duty/personal care aides, limiting communal dining and recreational activities, encouraging or requiring residents to practice social isolation, limiting residents’ non-essential trips outside of the community, and requiring residents returning to the community after a hospitalization, time with their family, and the like to have a negative test or be subject to a 14-day quarantine.
In terms of preparedness, infection control must be ramped up immediately in assisted living communities. They should be adequately stocked with necessary supplies such as masks, gowns, and respirators to keep residents and staff safe. In addition, staff members must be supported with additional training and paid sick leave, particularly since most staff members in assisted living facilities are caregivers without advanced medical training and are paid minimum wages.
Given the limited presence of skilled nurses and clinicians in assisted living facilities relative to nursing homes, medical personnel need to support assisted living facilities in response to Covid-19. For example, Florida’s Agency for Health Care Administration is sending in a “strike team” consisting of a nurse, epidemiologist, infection control specialist, and a representative from the agency to help assisted living providers when a resident tests positive for Covid-19.
State and federal responses might include translating CDC, CMS, and states’ recommendations and guidance for nursing homes into practice in assisted living facilities given the different model and skill level of assisted living staff members; allowing temporary, emergency funding for assisted living communities to both keep residents and staff safe and to prevent massive hospitalizations and associated health care expenditures; and ramping up testing for assisted living residents and staff.
Although some states and individual assisted living communities have made strides to improve infection prevention and control, without a national effort supported by federal and state initiatives we risk serious outbreaks for vulnerable older adults.
Kali S. Thomas, Ph.D., is an associate professor of health services, policy and practice at the Brown University School of Public Health in Providence, R.I., and an investigator in the Center of Innovation in Long-term Services and Supports at the Providence VA Medical Center. Paula Carder, Ph.D., is the director of the Institute on Aging and professor of community health and health promotion at the OHSU-PSU School of Public Health in Portland, Ore. David C. Grabowski, Ph.D., is professor of health care policy at Harvard Medical School in Boston.
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