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By Thomas Goldsmith

Even as more than 1,800 of North Carolina’s nursing home residents have died from COVID since March, thousands more of these most vulnerable have escaped the horrific grip of COVID-related related infection or death during the pandemic.

That positive outcome stems from countless hours of planning and execution by caregivers, facilities, administrators and public health leaders, say business and government officials.

Attention from aging-sensitive quarters in the state has tended to focus on the more than 16,508 cases and 1,906 COVID-related deaths of nursing-home residents. The more encouraging news is that more than 200 skilled facilities in North Carolina have experienced no deaths from COVID.

(The state’s 593 assisted living facilities typically have less critically ill residents; 99 centers have seen cases or deaths and 86 residents have died.)

Bob Willson, 77, a retired engineer, visits the nursing home at Moneta Springs Memory Care in Alamance County every day to see wife Susan, 78, a retired nurse who had a stroke seven years ago. He tends to her daily needs and meets the requirements for such “compassionate care” visits, knowing that the nursing home has tight disease controls. The facility has had five COVID cases and no deaths, according to federal regulators. (Three people have died of COVID-19 at the related Twin Lakes Community senior living locations, not the center where Susan Willson lives, according to CMS.)

“They are very proactive in infection control,” Willson said of Moneta Springs in a phone interview. “So when I go visit my wife, for instance, I obviously wear a mask, I wear a disposable gown, and wear disposable gloves.

“In compassionate care visits, we don’t have to be six feet apart and touching is allowed, but I still wear the mask the whole time. And she does, because I’m helping her eat, but then when we’re done eating, her mask goes back on.”

Like employees in health care settings across North Carolina, Twin Lakes staff check visitors’ temperatures and quiz them on any possible contact with people who are positive for the coronavirus, he said.

‘Our biggest factor’

Two aspects of the coronavirus have caused particular problems, said Adam Sholar, president of the North Carolina Health Care Facilities Association. These are the level of infection in the areas around the nursing home and the virus’s ability to survive in an infected person’s body without transmitting it.

“Our biggest factor in whether a facility has a case of COVID is community transmission in the area,” Sholar said in a phone interview. “The asymptomatic transmission and asymptomatic positives is another huge factor.”

Infection control is a given as a regulatory requirement in long-term care, but the number of cases and deaths makes clear that the wall built against the coronavirus is sometimes too low.

NC Health News has found some themes and techniques among skilled nursing facilities, here and across the country, that have completely or almost entirely kept the disease at bay.

These approaches emerged in interviews with caregivers, administrators, state officials and public health experts. We also looked at recent academic research, which has arrived steadily since the days in which the pandemic gained widespread attention.

What works

Some experts and administrators were reluctant to speak too definitively about solutions that have allowed no cases or deaths or didn’t respond to queries. They also may have been unwilling to sound too proud of their efforts at a time when others in the industry were working hard on infection prevention and control.

Among the mostly COVID-free facilities unwilling or too busy to respond were the western N.C. facilities Smoky Ridge Health & Rehabilitation in Burnsville, and Elderberry Health Care in Marshall, as well as the high-end Forest at Duke in Durham, which has had five cases since the initial reporting of this story..

Many more facilities across the state had had one or fewer COVID cases and no related deaths. Of course, given the continuing level of outbreaks across North Carolina, new cases and deaths could occur in days and months ahead at virtually any nursing home. (This occurred in some of the facilities in which we first found no COVID cases.)

First: Keep virus out

As did Sholar, North Carolina’s public health-care professionals cite the surrounding community’s level of infection prevention and control as a prime factor in keeping long-term care facilities free from COVID-19.

That was the emphasis of Dr. Susan Kansagra, chief of the state Division of Public Health’s Chronic Disease and Injury Section. Like Gov. Roy Cooper and NC public health officials, Kansagra has insistently placed importance on mask-wearing, social distancing, and mask-wearing, known as the three Ws.

“In preventing COVID-19 from entering into a facility in the first place, we see a pretty close tie to community transmission,” Kansagra said in an interview. “The reason for that is that, obviously, staff are also members of the community and they may inadvertently bring it into a facility. So what the transmission rates are in a community and prevention from that standpoint is really important and makes it less likely for an outbreak to happen within a facility.”

A broad range of actions by the state must support a nursing home once COVID-19 has intruded, but it’s perhaps more important to keep it from entering the door, Kansagra said.

“Obviously we don’t want that outbreak to happen in the first place, so we’re really working to strengthen that infection prevention,” she said. “We know, for example, that there continues to be a turnover in facilities. And we really want to make sure all staff are comfortable with all the different infection and prevention control procedures.”

‘The clamp came down’

Keeping infection out of nursing homes quickly led to North Carolina’s decision in March to bar all visitors. That applied to spouses even when they were essential caregivers, a move opposed by Willson and others across North Carolina.

“When the clampdown came, they clamped down hard,” Willson said. “Right there in the middle of March, I’d taken her out for one doctor’s appointment.

“And when we got back, they said, ‘Okay. This is it. She’s in here now and you can’t come back.’”

Under pressure from politicians, advocates and residents’ relatives, the state Department of Health and Human Services and the federal Centers for Medicare and Medicaid Services have revised policies to allow compassionate caregivers to visit once a day.

The drive to keep infection out and to control it if it enters a nursing home got reinforcement in June from the early release of a COVID-themed edition of the Journal of the American Medical Directors Association, or JAMDA. Triangle long-term care experts Dr. Philip Sloane and Sheryl Zimmerman planned and edited the JAMDA articles, which urged facilities to use specific means to keep everyone on the same page while fighting infection:

Tips for facilities

  • Devise easy-to-read ID cards so that residents can match staff members with their names and titles, even when they are wearing masks and other protective equipment.
  • Use video devices or windows to let residents meet with families without risk of contamination.
  • Use posters with clear directions to remind residents and others of necessary infection-control measures.
  • Mark doors with different colors that show staff which PPE should be worn within.
  • Understand that a higher rate of impaired hearing comes along with old age. That means many will have trouble understanding or lip-reading from medical staff or others who are trying to speak through a mask.
  • Supply writable communications boards in residents’ rooms to allow for questions in writing.

What’s the big picture?

Another thought-provoking article in the same Triangle-led issue of JAMDA suggested solutions from the 30,000-foot level, including some pointed ideas for national policymakers.

The paper notes that many nursing homes were designed years ago, when residents were on the whole younger and not as sick as they are today.

“Staffing levels have stayed fixed, while residents’ needs and medical complexity have increased well beyond this minimal capacity,” the authors write. “Buildings themselves are older, with smaller rooms, often 2 to 4 individuals to a room, narrow hallways, and old heating, ventilation, and air conditioning systems.”

First, the paper recommends that policymakers draw on people with expertise in post-acute and long-term care — clinical specialists, health care operators, and families affected by the disease.

“We are discussing state-level policy here because another thing we have learned is that, in the absence of clear leadership at the Federal level, states, counties, and localities have stepped into the vacuum,” the authors write.

In North Carolina, for example, state DHHS planners used a panoply of sources in devising a telehealth strategy announced July 28. Keeping in mind the need for distance communications with long-term care residents, the plan included partners such as NC Medicaid, the state’s Area Health Education Centers and Community Care of North Carolina, as well as consumers, patients and academic papers on telehealth’s merit.

In light of exigencies

“The new NC DHHS telehealth section gives technical assistance, education and resources to providers to help them implement and expand telehealth,” said Dr. Shannon Dowler, DHHS’s chief medical officer for NC Medicaid. “It also allows consumers and patients to find resources that answer their questions, making telehealth easy to use.”

The paper further recommended that health care providers continue to work closely across lines that might divide clinicians, public health and emergency management agencies, operators of long-term care centers and chains, long-term care residents, hospitals, and researchers.

Perhaps more controversially, authors Christopher E. Laxton, David A. Nace and Arif Nazir recommend that regulators adopt a framework that recognizes ongoing changes in long-term care — low staffing and flagging physician reimbursement. Dealing successfully with the pandemic and other pressure points means that long-term care policies built by legislators, government leaders and private administrations must offer support as well as potentially devastating penalties from federal regulators.

“In light of the extraordinary exigencies nursing homes have faced in this public health emergency, it is difficult to justify measures that are tantamount to setting our homes up to fail and which implicitly suggest that they themselves may be the cause of COVID-19 in the home,” the authors say.

But they don’t leave it there, advancing the idea that the harrowing pressures of the pandemic should lead in time to overall improvement of the continuum of services for older citizens not only in North Carolina but across the country. The authors give a summation with an inspirational tone:

“It is now up to us to turn this deadly crisis into something that makes these deaths, this misery, and this heroism contribute to a greater value beyond the immediate: namely, the reinvention of how we provide care and support to our parents and grandparents; how we honor their sacred needs and wishes; how we celebrate and lift up those who have chosen the aging professions as a career; and how we build a just culture of true accountability.”

Coming next: Testing, staffing, maintaining supplies of personal protective equipment — all must play a role when a nursing home’s goal is to exclude COVID-19 entirely.

Thomas Goldsmith

Thomas Goldsmith worked in daily newspapers for 33 years before joining North Carolina Health News. Goldsmith is a native Tar Heel who attended the UNC-Chapel Hill, and worked at newspapers in Tennessee...