Protecting residents in long-term care facilities – progress and challenges

By Ingrid Ulrey, Policy Director and Chief, Long-term care facility response, Public Health – Seattle & King County

A looming heartbreak in the coronavirus pandemic is the impact of the virus on people living in long-term care facilities such as skilled nursing homes, assisted living facilities and adult family homes. Locally and nationally, the biggest outbreaks have been in these facilities, which house and care for more than 12,000 people in King County.

Impact to date

More than 300 people living in these facilities have died, a toll that represents more than 60 percent of all COVID-19 related deaths in King County thus far.  Advanced age, underlying health conditions and living conditions with close constant between residents and staff combine to put this population at very high risk.

Early in the outbreak locally, there were a high number of cases associated with long-term care facilities: In the month of March, there were 748 positive cases of COVID-19. That number has since dropped to 72 cases thus far in May. This downward trend suggests that a public health response in partnership with long term care facilities can have a large impact in reducing the spread of illness.

Major efforts to reduce transmission have been focused first and foremost in King County’s 52 nursing homes, the majority of which are now affected with at least one COVID case. Once infected, the individuals living in these facilities, many in the 80s and 90s with multiple chronic health conditions, are at far higher risk of severe illness and death than younger people living in the community who test positive.  Tragically, more than 17 nursing homes in our county have lost five or more residents to this disease, and six have seen mass casualties of 15 residents or more over a short time frame.

Ana Elekes  &  Mihail Elekes  -  Adult Family Home residents
Ana Elekes & Mihail Elekes - Adult Family Home residents

Our County’s 148 assisted living facilities have also been deeply impacted, and those with memory care units face additional challenges in encouraging residents with cognitive decline to understand and adhere to social distancing protocols.

At the same time, numerous smaller outbreaks in adult family homes, which are neighborhood homes licensed to care for up to six residents, silently take their toll.

Elisabeta Elekes, operator of Tiburon Estates Adult Family Home in Sammamish, says she feels like she has been through a war.  Since mid-March, two of her five residents died from COVID-like illness, including her own father.  As she and her two sisters struggled to care for the remaining residents, they too fell ill. When her crisis hit, Elisabeta called out for help for to the Adult Family Home Association and to Public Health. “I changed everything I was doing. I put people in different rooms, I used PPE, people kept calling me.  That helped a lot, I didn’t crash mentally, talking to them let me know I was not alone.”

Impact on staff

Of all of the COVID positive cases associated with these facilities, nearly 30 percent of them are among staff. These staff are dedicated to the care of residents in a particularly vulnerable time.  Our data show that staff are overwhelmingly middle-age women, a high percentage of whom are women of color. These include relatively low-paid Certified Nurse Aides and others who often work 2-3 jobs to make ends meet, a practice that some employers have curtailed due to the risk it carries for the residents.  As more staff have become ill or simply afraid to go to work, short staffing – already a challenge in this sector, has worsened.

Public Health’s Role

With Life Care of Kirkland as the alarm bell in late February, Public Health immediately launched an aggressive response to beat back the rapid spread virus in long term care facilities.  This strategy includes aggressive infection control, testing and coaching providers on separating the sick from the well. 

Public Health is coordinating with state agencies – including the State Department of Social and Health Services who license these facilities and the State Department of Health. Multiple health system partners including UW Medicine, CHI Franciscan, MultiCare, EvergreenHealth, Kaiser Permanente and the Seattle Fire Department are working together to get this work done.

Here are some details on what this entails:

Infection prevention and control – Public Health supports facilities to increase and strictly adhere to infection control practices. This is the best defense for keeping the virus from getting into a facility and stopping the spread among residents when it does. 

Infection control specialists provide guidance on everything from appropriate and correct use of personal protective equipment (PPE) such as masks, gowns and gloves; placement of hand washing stations, and best practices for screening of healthcare workers for illness.

Seattle Fire Department preparing to test at Hearthstone at Greenlake.

Testing Understanding who is COVID positive is critical to inform action to decrease spread of the virus. With the help of partners, testing of all staff and residents has now been completed in the majority of skilled nursing homes in King County and pilots are underway with adult family homes and assisted living, starting with assisted living with memory care units. 

People with COVID may not always have symptoms. When feasible, regularly testing of all residents and all staff, not only those who are exhibiting symptoms, is the best approach — and a monumental task in the face of critical shortages of test kits and PPE.

Separating the sick from the well – A key strategy is cohorting, which means moving residents within a facility so that positive residents are in a separate room or wing and are cared for by different staff than negative residents.  

Keeping people separate so that they can safely isolate is not always feasible, especially in small adult family homes. To address this, Public Health refers people to nursing homes to admit COVID-positive residents.

These interventions are critically important to reduce the spread of the virus.  They also create hardships for the workers and residents of these facilities, as well as their family members who are now restricted from visiting their loved ones except in the case of end-of-life situations.

As one family member of a long-term care facility resident shared, “The circumstances of the past two month have taken their toll on my mom and she is deteriorating mentally and physically with each day. Without my daily interaction she is feeling abandoned and doesn’t always understand why she is left alone.”

Flattening the curve for our most vulnerable

Public Health provides data in a dashboard that illustrates the extent of COVID-19 cases and deaths in long term care facilities across King County and details the key characteristics of people who live and work in these high-risk settings. While the data are daunting, there are also signs of hope.  Since the beginning of the outbreak, the number of confirmed cases reported in a single day peaked on March 28, 2020 and the number of deaths reported among people associated with long-term care facilities peaked (11 reported deaths) on April 5, 2020.  Since that time, cases and deaths have varied day to day but declined overall.

To reduce the risk of what could potentially be an even more deadly second wave in these facilities, everyone in our community – inside and outside of these facilities – will need to continue to make short term sacrifices for longer term gain.    Families will need to continue to support their loved ones in facilities without being able to see them in person, and all of us out in the community will continue to do our part by staying home as much as possible.

As Washington begins a phased approach to recovery  and we begin to  increase our activities in the community, the risk for COVID-19 transmission will increase.  During this time, we must keep a vigilant watch on the health of long-term care facilities. Containing the virus for the entire community and all generations will not be possible if the fires in these facilities keep burning.

For up to date information on Long Term Care Facility related cases and deaths click here to view Public Health’s LTCF data dashboard.

Originally posted May 13, 2020.