Ready to see grandma face-to-face? After three months of lockdowns intended to protect elderly and vulnerable populations from COVID-19, state health officials recently released guidelines for both outdoor and “open window” visits at nursing homes and other long-term care facilities.
It’s a change that some elder care advocates call overdue, and one of several steps that many seniors and their families had asked the Minnesota Department of Health to consider. More are coming.
“Yes, allowing structured visits needs to be done,” said Eilon Caspi, a consultant on dementia behavior and an adjunct faculty member at the University of Minnesota School of Nursing. “It probably should have been done weeks ago. Why not do it outdoors, if we know the outdoors can be safer than indoors, with masks on?”
Caspi added: “I’m not saying we should have family members just walk in. That would be reckless. (But) we have reports of residents dying of social isolation on death certificates, as a secondary cause of death.”
Still, others who speak out for seniors say alongside ramped-up testing, extreme precautions — even bans on family visits — have been warranted given how quickly COVID-19 can rip through a long-term care center. Statewide, 80 percent of known COVID deaths have been in congregate care facilities.
In early June, the state Department of Health identified four facilities that had upward of 100 confirmed cases of the novel coronavirus between residents and staff, including two locations with more than 50 resident deaths apiece.
“(Congregate care) absolutely demands close personal contact from other human beings who are coming in from the outside multiple times a day,” said Dr. James Pacala, a University of Minnesota Medical School professor and past president of the American Geriatrics Society. “There’s no substitute. There’s no video iPad that can help a nursing home resident get out of bed, or toilet properly, or put in their dentures.”
Moving forward, what else should government, industry and families of loved ones be doing differently when it comes to protecting those in long-term care from the virus? Here’s where six elder care advocates stand on that question:
KRISTINE SUNDBERG, ELDER VOICE FAMILY ADVOCATES
Kristine Sundberg is the executive director of Elder Voice Family Advocates, a coalition that came together in 2017 around issues of elder abuse and neglect in congregate care settings.
“I think we need to sit down together — the advocates and the (state) Department of Health — to figure out what makes sense for visitation. There’s going to be risks, no matter what we do. But from the family’s point of view, this is getting dire. People are significantly declining.
"And we know that the isolation is killing some of them. Isolation has been well-established as a critical health and psychological issue, especially for the elderly. Especially now during the summer, there needs to be ways that they can visit outside, or that the facility can help provide a safe area for them to visit.”
MARY JO GEORGE, AARP MN
Mary Jo George is the advocacy director with AARP Minnesota, the nation’s largest association of retired people.
“Given the number of deaths, we are continuing to call on lawmakers to do more. Some of the questions we are raising: Should we be looking to create new sites that just treat COVID? … Should we be eliminating the practice of sending COVID-positive patients from hospitals back to these facilities?
“If you’re in a roommate situation, and one roommate tests positive, we think they should not have to share a room. That is just a death sentence.”
In January, a state statute called the Electronic Monitoring Act took effect that allows families to install their own remote-activated security cameras in a loved one’s congregate care room so they can monitor them from afar.
“(Facilities) do have to allow an Internet provider to come in, if they need to do that,” George said. “I would highly consider folks consider that. We want people to know the law on the books — families can install cameras.”
JULIE ROLES, METROPOLITAN AREA AGENCY ON AGING
Julie Roles is the communications director with the Metropolitan Area Agency on Aging, a regional agency that runs the Senior LinkAge Line and other senior services on behalf of the Minnesota Board on Aging.
“Most Minnesota nursing homes and assisted-living facilities acted quickly to limit visitors and put safety practices in place. They have struggled to attain sufficient cleaning supplies and personal protective equipment, and while there have been improvements, access to supplies must be a priority for state government and for care facilities.
“Lack of adequate staffing and low wages are long-standing problems that must be addressed to help ensure safe environments for residents of nursing homes. Findings from a study released in May found no relationship between the quality of a nursing home (as measured by ‘Nursing Home Compare’ star ratings) and the incidence of infection or death.
“Limiting in-person visits is necessary to protect residents who are especially vulnerable to COVID-19. We do not advocate for broadly loosening those restrictions. We do, however, believe that people with dementia and other serious conditions need family and friend caregivers.
“Care centers should make exceptions for family caregivers who provide essential care. We support Gov. (Tim) Walz’s five-point plan for protecting long-term care residents. … We believe that the state and industry leaders are on the right track, but they must be diligent.
“Public sentiment also has a role, and we fear the public is dismissing the severity of COVID-19 — seeing it as a problem for old people rather than a collective problem. Leaders must ask themselves if the decisions they make about the economy are at the expense of the lives and well-being of older adults.”
EILON CASPI, GERONTOLOGIST
Eilon Caspi is the founder of Dementia Behavior Consulting and an adjunct faculty member at the University of Minnesota’s School of Nursing. He is a founding member of the Elder Voice Family Advocates coalition.
Caspi said family members visiting care facilities are often the first to pick up on bruises, skipped medications, bed sores and other evidence of potentially life-threatening abuse or neglect. Without structured visits, that level of protection has been missing until now.
“We’re missing the family advocates, because they can’t visit,” he said. “We’re missing 95 percent of investigations that would have been conducted prior to COVID-19.
“There’s a lot of neglect taking place. Because of worsening staffing conditions, they’re not getting the care they received prior to the pandemic, but on the death certificate, it won’t say ‘COVID’ (because they’re not infected).
“Staffing was a major issue before COVID-19. … The crisis was here well before the mega-crisis was here.”
Caspi supports outdoor visitations. However, he said the state needs to release more detailed guidelines on structuring visits for dementia patients, who may be confused about why they cannot hug their loved one, or who may attempt to remove their mask.
With regard to fatalities, “over the past several weeks, I’ve asked the Minnesota Department of Health to consider providing a breakdown of the number of COVID-19 deaths with a distinction between nursing homes versus assisted-living residences, versus other long-term care settings in their daily situation update reports,” Caspi said.
“Such basic reporting will allow us to track and examine important trends unique to each type of long-term care setting over time. My hope is that they will start using this important surveillance measure, which is already implemented in some of the most populous states in the country.”
CHRIS ORESTIS, AUTHOR
Chris Orestis, a former Capitol Hill lobbyist for the insurance and long-term care industries, is the author of “A Survival Guide to Aging.” He is based in Maine.
“Nursing homes, assisted-living facilities are the safest, most dangerous places a senior can be. By that I mean they are in an isolated environment. You have trained professionals who can provide care. They are very familiar with (how to contain) influenza, pneumonia and other conditions that can start to spread.
“But COVID is particularly insidious and effective in its spread. I’ve talked to many facilities around the country where they’ve caught one or two infections, and maybe one or two staff members, and they’ve been able to isolate it before it spreads like wildfire. But the potential for a wildfire spread is there.
“If you can, stay in contact with your loved one via phone, via internet. Know what’s going on in the facility. And if there are confirmed cases, don’t overreact.
“If you’re planning on taking a loved one out of a facility, you need to be sure you’re not taking them out of the frying pan and into the fire. If you do pull them out, you have to become a 24-7 care provider. Is your home set up? Do you have the right kind of bed, bath or shower? You may be putting them in a household environment where you don’t have control over possible spread, or you may be exposing yourself to what they’re carrying.
“But if there is a wildfire outbreak (at your loved one’s care facility), you may need to intervene, regardless of those concerns.”
DR. JAMES PACALA, U MEDICAL SCHOOL
Dr. James Pacala, a past president of the American Geriatrics Society, teaches family medicine at the University of Minnesota Medical School.
Pacala isn’t the first expert to wonder aloud whether some elderly patients haven’t asked to be allowed to die in peace.
“In Minnesota … we’ve got a higher percentage than most other places of elderly to total deaths. That may in fact be a good thing.
“You’re talking to a geriatrician. It’s not that I devalue older people’s lives. The older adults who are being admitted to the hospital, who are being given very aggressive care, may be the ones who would most appropriately respond to that care and who want that care. What we’re seeing may be a better approach to palliative care than what we see in other states, to see that patients’ wishes are being respected.
“I don’t think anybody’s studied that yet. It could be. Part of it could be how it’s being counted, but there could be other differences. I just don’t think we know.
“Should different steps be taken than what’s being taken now? Ramping up widespread testing, understanding who is infected, who is not, I think that’s the right direction. … That’s the direction I see things going. It’s agonizing because it seems so slow, but it’s actually moving quickly.
“Are facilities going overboard (with precautions)? I’d give you a qualified no. Given the double-whammy that they’re in — forced congregate living and a vulnerable and ill population — you have to take some extreme measures.
“The question is how much more introduction of risk do you tolerate, with visits from family and friends? Everyone is struggling with that. Overall, I don’t think they’re going overboard. I’m sure there’s examples (to the contrary).”
June 21, 2020 at 5:33 a.m.