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The COVID-19 Nursing Home Crisis: What Went Wrong and What Can Be Done?

By Saif Elayan Published 14.04.2021

While people all over the world were preparing to celebrate the beginning of a new year on December 31, 2019, the World Health Organisation (WHO) was being informed of an outbreak of a lung infection of unknown cause in Wuhan City, China. At that time, nobody, not even the most pessimistic among us, could have imagined that the then-unexplained pneumonia-like illness (later called COVID-19) would evolve into a global health crisis and upend life as we knew it.

In a matter of weeks, any semblance of normal life disappeared. Unprecedented lockdowns and curfews have left streets and public spaces deserted. Many people lost their jobs, and those who still had one were requested to work from home. Hospitals ran out of beds and personal protective equipment (PPE). Countries fought for face masks and respirators, and people went on panic-buying sprees. Amidst all that, a tragedy, a heartbreaking one, was taking place in nursing homes, where residents and staff, the most vulnerable of us, were left alone to bear the worst of the pandemic.

Although health policy responses to the pandemic varied considerably across the world, one thing is consistent: governments, including those in the rich world, have failed to protect nursing home residents and staff. According to the International Long Term Care Policy Network report, 41 per cent of all COVID-19 deaths in the 22 countries covered in the report have occurred in nursing homes even though less than 1 per cent of people live in them. The report also estimates that one in 20 nursing home residents have died due to COVID-19 in countries, such as Belgium, France, the Netherlands, Spain, Sweden, the UK and the US. As horrific as this death toll is, it is not the complete picture as nursing home deaths were underreported, especially during the first wave of the pandemic. And as telling as these figures are, they cannot tell us how lonely and isolated nursing home residents felt when they were left alone on their deathbeds and prevented from saying goodbye to their loved ones.

What went wrong?

The high death toll at nursing homes during the pandemic can be partly attributed to the failed early responses due to gaps in scientific knowledge, the high rate of compromising health conditions among residents, and the late or insufficient access to personal protective equipment (PPE) and healthcare. However, beneath those causes, there are deeper and long-standing structural problems that, without evil intent, had built up over decades, and then very quickly, have been exposed and amplified by the pandemic. While the list can go on, some of these problems are fragmented long-term care systems with responsibilities scattered across different departments; insufficient coordination between health and care services; lax standards of care at nursing homes in many countries; chronic understaffing, undertraining, and poor working conditions at nursing homes; and under-recognition of informal caregivers.

What should be done?

In the wake of the crisis that “robbed us of a generation of wisdom”, the WHO called for a ‘rethink’ of long-term care for older people. If, as a Chinese proverb says, “a crisis is an opportunity riding a dangerous wind,” then perhaps this crisis, as horrific as it is, is the opportunity for all countries to “rethink” long-term care for older people.

The COVID-19 nursing home crisis has triggered two opposing viewpoints for rectification: one arguing for abolishing nursing homes and investing in home care, and the other wanting to reimagine and reinvent these facilities. But, in my opinion, finding a middle ground between the two viewpoints would be the key.

Rethinking nursing homes:

Ironically, all it takes to rethink nursing homes is delivering what the term “nursing homes” promises, providing nursing care and a homelike atmosphere. The term is currently often a euphemism rather than an accurate description of what the vast majority of nursing homes actually are. Indeed, the nursing home of the future should create a “home” in, and put “nursing” back into these facilities. Of course, there will be challenges ahead, the first of which is certainly the longstanding shortage of registered nurses and care workers in nursing homes. In the UK, it is projected that two million additional care workers will be required by 2033. While this is partly due to the ageing of the population, it is also a fact that people are turning their backs on caring jobs. For instance, in Germany, a third of care workers quit their jobs after only one year. It is a trend that is not surprising given the limited training, low pay, poor working conditions, and demanding nature of the caregiving profession. Addressing these unfair working conditions and retention issues must be a top policy priority, and without that, it is impossible to solve the challenges of long-term care for older people.

The second challenge is the current institutional nature and structure of nursing homes. For sure, the traditional large-scale nursing home care model had been failing for years. In terms of infection control, herding vulnerable older people into large-scale nursing homes where they live in close proximity to each other and share common areas was a disaster waiting to happen. These overcrowded living conditions have also been associated with poor quality of life and clinical outcomes.

Describing the future of nursing homes, David Grabowski, a professor of health care policy at Harvard Medical School envisions “smaller, home-like settings that are more resident-centred”, where the residents can live as if at home and develop closer friendships with each other and staff. Luckily, nursing homes similar to the one Grabowski envisions already exist in some countries and have demonstrated their effectiveness. For instance, small-scale nursing homes have thrived in the Netherlands and showed promising effects in improving both the quality of life and functional status of residents. One particularly inspiring example is the Hogeweyk Dementia Village. The village comprises 27 houses, each with 6-7 housemates, as well as shops that span from a grocery store to a hair salon, which the residents are free to roam around. Another promising example is the Green House model in the US. In this model, small houses are home to 10–12 residents in which resident-centred care is provided, and much like being at home, residents, when able, determine all aspects of their daily schedule and activities. In addition to having better outcomes, Green House residents were found to be 5 times less likely to contract COVID-19 and 20 times less likely to die from it, compared to residents of traditional nursing homes. These successful examples show that the problem is not a lack of ideas or possible superior alternatives, but often a lack of will to adopt and execute them.

Rethinking home care:

While, for many health- and social-related reasons, there will always be individuals who want or need nursing home services, research has shown that many nursing home residents can receive the care they need at home. For instance, it is estimated that 25-60 per cent and 40 per cent of the care provided at nursing homes, in the Netherlands and Canada, respectively, may be provided at home. Also, even before the pandemic, most people preferred to age and be cared for at home. For example, the Better At Home report found that 97 per cent of Britons prefer being cared for at home, rather than moving into a nursing home. A similar preference was also found among US adults. It should come as no surprise if this preference for home care continues to grow after the trust in nursing homes was undermined by the recent crisis. The benefits of home care do not stop here. There is also evidence suggesting that home care can, in some cases, be more cost-effective than nursing home care and associated with better health outcomes.

So all sounds good then? Unfortunately not. Despite its benefits, home care can sometimes be challenging. At higher levels of disability and cognitive impairment, home care may not be a viable option. Home care also requires greater participation from informal caregivers (typically close relatives and friends) that is not always available. Another major challenge is the growing shortage of home care workers due to unattractive pay and working conditions. This shortage led to increasing the costs of home care and the reliance on migrant care workers, which in turn, bring other challenges. The industry is also often undeclared and underregulated with no clearly defined quality standards. The pandemic made the situation even worse, with the lack of personal protective equipment (PPE) and testing, and the increased chance of infection for care workers.

Despite these challenges, many opportunities are presented for implementation to enhance home care. The first is addressing the workforce problem by regulating the industry, defining quality standards, improving working conditions, and offer training opportunities. Second, reviewing the overall government spending on long-term care, and move more resources into home care. Third, devising national strategies to identify and support informal caregivers, and acknowledge their right to receive ample financial support and access to support services to enable them to stay in employment and maintain their quality of life. Fourth, embracing the technological advances in telecare to improve care outcomes and integrate home care with other services for older people.

Finally, we all know that we cannot bring back those who have died in nursing homes during the pandemic, but what we can certainly do is honour them by implementing whatever it takes to help our loved ones age with dignity and to prevent such a disaster from happening again.

About the author
I’m Saif Elayan, a pharmacist and health economist with interests in the economics of elder and end-of-life care. I’m currently a PhD Candidate at the University of Groningen in the Netherlands studying the economic value of informal care, and the future demand and supply thereof in Europe.
Want to connect? Find me on Twitter (@SaifElayan) or send me an email at s.y.i.elayan@rug.nl

Recommend readings
[1]. Allison, T. A., Oh, A., & Harrison, K. L. (2020). Extreme Vulnerability of Home Care Workers During the COVID-19 Pandemic—A Call to Action. JAMA Internal Medicine, 180(11), 1459–1460. https://doi.org/10.1001/jamainternmed.2020.3937
[2]. Bilodeau, S. (2020, July 7). Nursing Homes in COVID-19 time: Why so many examples of failure to care and protect? Medium. https://towardsdatascience.com/nursing-homes-in-covid-19-time-why-so-many-examples-of-failure-to-care-and-protect-e0ea38f6fd2c
[3]. Camosy, C. C. (2020, May 17). Opinion | What’s Behind the Nursing Home Horror. The New York Times. https://www.nytimes.com/2020/05/17/opinion/nursing-home-coronavirus.html
[4]. Chan, E. Y. Y., Gobat, N., Kim, J. H., Newnham, E. A., Huang, Z., Hung, H., Dubois, C., Hung, K. K. C., Wong, E. L. Y., & Wong, S. Y. S. (2020). Informal home care providers: the forgotten health-care workers during the COVID-19 pandemic. The Lancet, 395(10242), 1957–1959.https://doi.org/10.1016/S0140-6736(20)31254-X
[5]. Eveleth, R. (2020). It’s Time for an End-of-Life Discussion About Nursing Homes. Wired. https://www.wired.com/story/its-time-for-an-end-of-life-discussion-about-nursing-homes/
[6]. Grabowski, D. C. (2021). The future of long-term care requires investment in both facility- and home-based services. Nature Aging, 1(1), 10–11. https://doi.org/10.1038/s43587-020-00018-y
[7]. Stevis-Gridneff, M., Apuzzo, M., Pronczuk, M., & Lima, M. (2020, August 8). When Covid-19 Hit, Many Elderly Were Left to Die. The New York Times. https://www.nytimes.com/2020/08/08/world/europe/coronavirus-nursing-homes-elderly.html
[8]. Szczerbińska, K. (2020). Could we have done better with COVID-19 in nursing homes? European Geriatric Medicine, 11(4), 639–643. https://doi.org/10.1007/s41999-020-00362-7
[9]. Sze-Yunn, P. (2020, October 13). Why it’s time to look again at home care for older people. World Economic Forum. https://www.weforum.org/agenda/2020/10/why-home-could-be-the-safest-place-for-seniors-during-the-pandemic/
[10]. The pandemic shows the urgency of reforming care for the elderly. (2020, July 25). The Economist. https://www.economist.com/international/2020/07/25/the-pandemic-shows-the-urgency-of-reforming-care-for-the-elderly
[11]. Thompson, D.-C., Barbu, M.-G., Beiu, C., Popa, L. G., Mihai, M. M., Berteanu, M., & Popescu, M. N. (2020). The Impact of COVID-19 Pandemic on Long-Term Care Facilities Worldwide: An Overview on International Issues. BioMed Research International, 2020, e8870249. https://doi.org/10.1155/2020/8870249
[12]. Usher, K., Hickman, L. D., & Jackson, D. (2020). Put “nursing” back into aged care: Nursing care is essential to aged care homes beyond the COVID-19 pandemic. Contemporary Nurse, 0(ja), 1–5. https://doi.org/10.1080/10376178.2020.1843511
[13]. Werner, R. M., Hoffman, A. K., & Coe, N. B. (2020). Long-Term Care Policy after Covid-19 — Solving the Nursing Home Crisis. New England Journal of Medicine, 383(10), 903–905. https://doi.org/10.1056/NEJMp2014811
[14]. Williamson, L. (2020, March 31). Coronavirus: The grim crisis in Europe’s care homes. BBC News. https://www.bbc.com/news/world-europe-52094491

Recommend videos
[1]. TED (Director). (2019, April 8). The “dementia village” that’s redefining elder care | Yvonne van Amerongen. https://www.youtube.com/watch?v=YSZhrxOkBZI
[2]. TEDx Talks (Director). (2016, November 22). 3 huge problems with care homes, 1 small solution. | Debbie Harris | TEDxRoyalTunbridgeWellsWomen. https://www.youtube.com/watch?v=bd5yM5VgAMQ&t=181s
[3]. The Economist (Director). (2020, November 27). Care after covid: the future of elderly health-care | The Economist. https://www.youtube.com/watch?v=60AjDw492RU&t=1s