Caregiver staffing a key issue in shielding vulnerable in nursing facilities and in their own homes

elderaide-300x200Nursing homes put their residents at heightened health risks by scrimping on personnel costs and failing to deal with significant staffing shortfalls, especially as the coronavirus inflicted some of its highest death and infection tolls on the elderly, sick, and injured in long-term care, media investigations have found.

The profit-focus by health providers is not unique, and it has put huge burdens on poorly paid, lightly trained, and over worked home health aides. They have toiled to keep the vulnerable out of institutional care, even as the agencies that employ them give them little support.

Here is what the Wall Street Journal reported about long-term care facilities, based on its “analysis of payroll-based daily staffing data released … by the Medicare agency …  [for hundreds of] nursing homes that reported to the federal government virus-related deaths in the first half of 2020″:

“The ranks of care givers at dozens of nursing homes plunged to dangerously low levels on some of the deadliest days of the pandemic, undercutting care for vulnerable residents at these facilities … as the novel coronavirus tore through states like New Jersey and New York in April, as many as 127 hard-hit nursing homes on a single day had nurse-staffing levels that fell at least 25% below their levels for the comparable days in 2019, a sign that experts say points to a significant shortage … More than 300 nursing homes with virus outbreaks reported at least one day in the second quarter of 2020 in which their staffing levels fell more than 40% below their levels for the comparable day last year. The Journal’s analysis matched up each day in 2020 to the equivalent weekday in 2019.”

The newspaper also reported this:

“The staffing shortages during the pandemic’s first peak in April were triggered by waves of illness among staff members, quarantine requirements for people potentially exposed to the coronavirus and call-outs sparked by factors including fear of infection and lack of child care. Those factors compounded nursing homes’ struggles to provide care to their residents, experts say. Some family members interviewed by the Journal also believe that the lower levels of staffing hurt their ability to communicate with care givers about their loved ones during a terrifying time.”

Bloomberg news service also tackled the problems posed by staffing shortages at nursing homes, finding this to be a growing concern highlighted by safety advocates, as well as a rising factor in explaining the explosive deaths and infections in long-term care institutions. Respected experts have argued that key factors outside of the control of owners and operators — including community spread of the coronavirus around homes and the size of facilities (bigger proved to be more problematic) — may have played outsized roles in determining how Covid-19 savaged residents in any given institution.

Controlling coronavirus harms

Still, staffing is crucial to controlling the coronavirus’s harms, allowing for greater and important infection-control measures, such as isolating the ill, as well as giving more intensive care for them and those who are not sick. As Bloomberg reported:

“[T]here are strong indications that nursing homes aren’t just blameless victims and that the industry has, by lobbying against stricter federal rules and cutting staff sizes, likely helped accelerate outbreaks. Last year, at the urging of industry groups, the White House proposed easing rules enacted by President Obama that would have required each facility to hire a dedicated infection prevention expert. Trump’s proposal received praise from the American Health Care Association, the main industry trade group that argued for it, and some homes postponed hiring these experts until the rules were finalized. ‘Failure to have this position fully implemented has proven to be a costly mistake,’ says Debra Fey, an infection prevention nurse and consultant for the long-term-care industry.”

The news service also found this, while focusing on how and why the CareRite nursing home chain was so hard hit by Covid-19:

“Four more [scientific] papers have found that certain quality metrics do matter in outbreaks. Yue Li, a professor at the University of Rochester Medical Center, for instance, examined data from nursing home infections in Connecticut through mid-April and compared the homes’ rate of infections to the number of registered nurses they employed. The industry tracks nursing staffing in terms of minutes worked by RNs, per resident per day. Li found that among homes with at least one infection, every 20 minutes of additional RN staffing time was associated with a 22% decrease in Covid cases. Charlene Harrington, of the University of California at San Francisco, found a similar link for homes in California. RNs are ‘the only ones really trained in infection control,’ she says.

“Of course, nurses are expensive, and CareRite, like many other large operators, has financial incentives to employ fewer of them. The company’s four facilities in Tennessee with more than 100 infections apiece averaged only 22 minutes of RN time per resident each day, about half the national average of 41 minutes, according to data compiled by the U.S. government for the fourth quarter of 2019. CareRite’s five other Tennessee facilities fared somewhat better, averaging 38 minutes of RN time, and ranging from 25 to 61 infections each. Meanwhile, nursing aides at CareRite facilities spent 14% fewer hours per resident per day, compared with other facilities in the country. That statistic could also be seen as troubling. A paper published by University of Chicago researchers in August found that higher numbers of hours worked by aides, who are responsible for changing, bathing, and feeding residents, correlated with a lower probability of an outbreak. ‘Having enough nurse aides to implement virus containment will be crucial if deaths are to be averted,’ they wrote.”

Home aides burdened with pandemic extras

As owners and operators have sought to increase their profits by slashing at personnel costs, health workers have struggled — not only with the toil of their jobs but also with balancing their own well-being with the help they give to vulnerable residents, Kaiser Health News Service reported. The independent, nonpartisan KHN focused on health aides:

“During the pandemic, home health aides have buttressed the U.S. health care system by keeping the most vulnerable patients — seniors, the disabled, the infirm — out of hospitals [and nursing homes]. Yet even as they’ve put themselves at risk, this workforce of 2.3 million — of whom 9 in 10 are women, nearly two-thirds are minorities and almost one-third are foreign-born — has largely been overlooked. Home health providers scavenged for their own face masks and other protective equipment, blended disinfectant, and fabricated sanitizing wipes amid widespread shortages. They’ve often done it all on poverty wages, without overtime pay, hazard pay, sick leave and health insurance. And they’ve gotten sick and died — leaving little to their survivors.”

KHN found that health aides haven’t spoken out about their difficulties, fearing retribution from employers. The companies that hire and keep them on the job offer them little support, especially if the aides themselves fall ill while often taking care of multiple elderly, ailing, or injured patients in their homes.

Under daunting circumstances, the aides keep plugging, because they care about their patients and their own situations give them few choices, even when dealing with the fearsome coronavirus, KHN reported:

“[C]are givers like Samira, in Richmond, Virginia, have little choice but to work. Samira — who makes $8.25 an hour with one client and $9.44 an hour with another and owes tens of thousands of dollars in hospital bills from previous work injuries — has no other option but to risk getting sick. ‘I can’t afford not to work. And my clients, they don’t have anybody but me,’ she said. ‘So, I just pray every day I don’t get it.’”

This is not good. In my practice, I see not only the harms that patients suffer while seeking medical services, but also the damage that can be inflicted on them by abuse and neglect in nursing homes and other long-term care facilities. It will be an imperative of the post-pandemic era, which the nation eventually will get to, to investigate and hold accountable politicians, regulators, owners, and operators of long-term care facilities for the suffering and death that has occurred in nursing homes during the pandemic. Some of the harmed — residents and their loved ones — may seek justice in the civil system.

In the meantime, those with loved ones in nursing homes and other long-term care facilities may wish to press owners and operators, as well as politicians and regulators, to step up their work on infection-control and the battle against the coronavirus. This means increasing the support for front-line health workers, including those working at institutions and home aides. We need to ensure that these crucial care givers get the testing, personal protective equipment, and, yes, the pay and training and respect, so they can help the sick, ailing, and injured as they require. This will not be quick or easy to do. We have a long way to not only safeguard the vulnerable in long-term care but also to get this whole sector of health care to a much better place.

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