Nursing homes have been Petri dishes for COVID-19. Across the country, 133,351 cases and 37,213 deaths from the virus happened in nursing homes, among both staff and residents. In Massachusetts, there have been 23,760 probable or confirmed cases in long-term care facilities, with 5,312 deaths as of July 16. There was at least one case of COVID-19 reported in 386 of the state's 413 nursing homes, according to the state department of public health.
There has been a wide disparity in the concentration of cases, however. Nursing homes located just miles apart can have widely different COVID-19 numbers. Two local nursing homes show this sometimes stark contrast. At Wingate at Harwich, 71 residents and staff tested positive for the virus, and there were 21 deaths at the facility, according to DPH data. At Liberty Commons Rehabilitation and Skilled Care Center in Chatham, two residents tested positive and no staff infections have been reported.
There's no consensus on what accounts for these differences. Nursing home quality, as measured by the Medicaid Nursing Home Compare system, doesn't appear to be a factor. A recent study concluded that standard quality measures do not distinguish which nursing homes had positive virus cases or deaths associated with COVID-19.
“While some nursing homes undoubtedly had better infection control practices than others, the enormity of this pandemic, coupled with the inherent vulnerability of the nursing home setting, left even the highest-quality nursing homes largely unprepared,” Dr. R. Tamara Konetzka, a professor of public health science and medicine at the University of Chicago and an author of the study, said during testimony before the U.S. Senate Special Committee on Aging in May.
Konetzka added that patterns of infection and death are not random, however; nursing homes with traditionally underserved populations have the worst outcomes, consistent with historical disparities in long-term care.
Quality, as measured by the Medicaid Nursing Home Compare system, wasn't a good indicator of which local nursing facilities had outbreaks. Wingate has an overall rating of one out of five stars, while both Liberty Commons and the Pleasant Bay of Brewster Nursing and Rehabilitation Center — where there were 90 cases and 19 deaths — has a five-star rating. In April the state issued a 28-point nursing home facility infection control competency checklist. Wingate was found to be in adherence with core competencies in two of three audits, while Liberty Commons and Pleasant Bay were in compliance in all audits.
Liberty Commons, which has 132 beds, has been highlighted by the Centers for Disease Control for its successful infection control response to COVID-19. One of the first steps, said President and CEO Bill Bogdanovich, was to limit access to the Orleans Road building. There was initial concern about infringing on residents' rights to have visitors, but once Gov. Charlie Baker declared a state of emergency on March 10 and Department of Public Health Commissioner Monica Bharel ordered visitation restrictions, “we were on it immediately,” he said.
While shutting down the facility to outside visitors was relatively simple, ensuring staff didn't bring the virus inside was more complicated. Bogdanovich met with staff who had second jobs. “Sometimes people had to choose whether they wanted a second job,” he said. Likewise, visits from outside service providers were limited and those who could worked remotely.
“We exponentially reduced exposure just by cutting that traffic out,” he said. Staff movement in the building was also limited, and the initial high bar for getting a COVID-19 test was overcome by having the facility's practitioners help get appointments. But just testing everyone in the facility at once, he said, would just be one snapshot in time, so groups were tested together over a period of weeks. A second round of testing of the facility's 300-plus staff is now underway.
The nursing home staff collected samples from residents, which helped make the process less intimidating, he added.
Communication was also a key component to addressing the fears and concerns of both residents and families, said Bogdanovich. Automated voice messages were sent out and posted on the facility's website daily, showing not only COVID-19 test results for residents and staff, but also information about personal protective equipment procurement and updates on visitor restrictions and isolation precautions. The information was also printed out for residents each day.
“That was incredibly valuable,” Bogdanovich said.
The two residents who tested positive recovered quickly and were never seriously ill, he said. No residents or staff at the company's assisted living facility across the street, The Victorian, tested positive.
The biggest problem the facility encountered was in securing PPE, Bogdanovich said. At the beginning of the pandemic, staff scoured hardware stores throughout the region for eye protection. He tracked every shipment of masks and other equipment “like a kid watching Santa's sleigh at Christmas.”
“We still have an order of disposable gowns that was supposed to be here in late May that's just coming in now,” he said.
Bogdanovich met regularly with the state nursing home trade association, the Massachusetts Senior Care Association, to discuss strategies, and the state gave the group a seat at the table in determining nursing home policies, along with experts from MIT.
Liberty Commons is beginning to allow visitors, but only by appointment and if they are asymptomatic. “We have two full-time staff members who facilitate that now,” Bogdanovich said. “That kind of carefulness is important.”
He credits well-executed decisions made early in the process with keeping the number of cases at the facility low.
Michele Clark, administrator of the 135-bed Wingate at Harwich, one of eight Wingate-owned nursing homes in the state, declined to comment for this story. Wingate's corporate headquarters and its public relations firm did not respond to requests for comment by deadline.
In May, after an outbreak was reported at Wingate, Clark said that the facility “aggressively implemented containment strategies, including widespread testing, isolation of infected residents, securing all building entrances, restricting visitors, constant resident wellness checks, staff temperature checks, and disinfecting and cleaning programs, including the introduction of UV-C sterilization equipment.” Training for staff, particularly in infection prevention and control, and the procuring the right equipment, particularly PPE to protect both residents and staff from cross-contamination, was a top priority, Clark said.
A DPH epidemiologist worked directly with Wingate on COVID-19 cases and protocols, according to Harwich Health Agent Meggan Eldredge. The VNA also did contact tracing, and the National Guard came in to assist with staffing.
Konetzka, in her Senate testimony, said regulation and oversight of nursing homes is important, but have done little to improve poorly-performing facilities in the past. A likely outcome is more emphasis on infection control, but, she notes, before the pandemic, deficiencies in infection control were found at 40 percent of nursing homes and enforcement did little to prepare for the crisis. “New regulations to increase focus on infection control are clearly warranted,” she said, “but in resource-constrained nursing homes, it may be a zero-sum game; better infection control may come at the cost of focus on other critical aspects of care.”