By Ingrid Ulrey, Policy Director, PHSKC

Residents of nursing homes, assisted living facilities and adult family homes are at high risk for serious illness and death from Covid-19, as we outlined in a recent blog. Washington State Department of Health Director John Wiesman issue an order requiring COVID-19 testing for all nursing home residents and staff by June 12th and in all assisted living facility memory care units by June 26th.  A second order is expected soon, requiring testing in all types of long-term care (LTC) facilities, including adult family homes.

To get perspective on the new testing requirement, I checked in with Patricia Hunter, the State LTC Ombuds, who oversees the Washington State LTC Ombudsman Program.   In Washington, approximately 300  LTC Ombuds—most of them volunteers—advocate for the safety, health, welfare, and rights of residents in LTC facilities. 

What is your perspective on the order for testing in all nursing homes and memory care units?

It is very much welcomed by the LTC Ombudsman Program.  Still, it must go a step further to cover all LTC facilities such as adult family homes. The order should also cover all testing costs, such as training, personnel and personal protective equipment (PPE) for staff.

Long term care facilities were hit hard early on in the COVID 19 outbreak.  In my view, they need to be the top priority in stopping it and preventing a second wave.  This is a moral, human rights issue.  As we re-open our society and economy, it’s critical to make our most vulnerable populations — our elders, the very sick, the disabled, and the low-wage, hard-working people who care for them — a top priority. 

Can you provide an example of how testing is making a difference in LTC facilities?

Yes!  Recent testing in one adult family home revealed that all residents and staff were negative – with one exception.  One asymptomatic staff member tested positive.  Without testing in this facility, this person would have continued going to work each day, while unwittingly spreading the virus to dozens of individuals.  Thankfully, the test enabled the facility to pull the staff member from caring for residents so she could quarantined in her home until she could safely return to work.  The knowledge of her COVID-19 status made a life-and-death difference in this facility.

What role does testing play in restoring the right of residents to receive visitors?

Testing in LTC facilities is critical to addressing the emotional and physical stress that LTC residents have been enduring.  The first limitations on the right to visitors came on March 10 and was quickly followed by a total ban on all visitors, with very limited exceptions.   It was heartbreaking to accept this unprecedented suspension of rights, even though we understood the need for it.  But the prolonged nature of this crisis has presented enormous challenges for residents and their families. 

Testing, tracing, PPE use, and social distancing are the key metrics for restoring many rights of LTC residents, including the right to have visitors.  Given that PPE is not widely or readily available and that social distancing is not always feasible in congregate settings, the role of testing is simply paramount.

COVID outbreaks across the nation have been higher in facilities with a high percentage of residents who are people of color. How has this played out in Washington as we test LTC residents?

We know that institutionalized racism exists, along with implicit bias by some healthcare professionals.  These and other factors have led to worse health outcomes in communities of color. Some people of color are understandably mistrusting of the health care establishment in this country. When implementing a testing program for LTC facilities, we need to expressly confront the racial, ethnic, and cultural barriers that exist, and mitigate any negative perceptions of mandated testing upon these groups.

For example, many adult family homes primarily serve immigrant residents and are also owned and staffed by immigrants. Both staff and residents may have a mistrust of government and concerns about public charge impacting their immigration status. In South King County, for example, we have been working with public health to build trust with these individuals as testing is rolled out.  

Racism is a big challenge overall for the LTC workforce. Across all facility types, many of the workers are middle-aged women of color.  When these workers test positive, they face the loss of a paycheck due to the lack of sick leave that is common in this sector. In addition, many are uninsured or underinsured and fearful of the medical costs. We cannot ignore the plight of LTC workers, while claiming to emphasize the health of residents.  Maintaining continuity of staffing is vital to the health and safety of LTC residents.

What are the barriers to testing King County’s adult family homes and assisted living facilities?

First, King County has over 1,000 adult family homes.  Second, testing in adult family homes presents unique challenges, due to the small size of these settings and the lack of medical directors. Yet residents in adult family homes have medical and functional needs just as complex as those of nursing home residents. Assisted living facilities have very diverse populations that are more “independent,” and they also lack the role of medical director that exists in nursing facilities. This means no one is automatically on site to order tests, collect specimens, and report results. It will take partnership to get this done.

Once tests are conducted, we must have a detailed plan for potential staff shortages due to positive test results. A number of adult family homes have had so many residents and staff test positive that the homes could no longer operate. Residents were transferred to nursing homes or hospitals. While these residents had to move to stay safe, it was traumatizing to lose their homes and be forced into institutional settings.

Any final thoughts for our readers?

Although LTC residents live in regulated settings, they retain their rights as U.S. citizens and Washington residents.  As our state re-opens, we must focus not only on reducing risks to LTC residents, but also on implementing measures to ease their stress.  LTC residents have weathered an inordinate burden of death, illness, and isolation due to this virus.  If we prioritize LTC facilities for testing, tracing, and PPE, we can lift this burden, make great strides to contain the virus, and get our economy and society back on track.