When Tyson Belanger, the director of Shady Oaks Assisted Living, heard about cases of a mysterious respiratory illness that had entirely shut down Wuhan, China, it reminded him of his days in the US Marine Corps.
“I was deployed five times as a Marine,” says Belanger. “And this felt like a sixth deployment.”
By early March, it was clear that screening visitors wouldn’t be enough to keep the virus out of his facility in Bristol, Connecticut. So Belanger decided he would have to keep everyone at Shady Oaks in.
He offered his employees $15,000 to $20,000 to live at work until transmission rates went down—triple what his employees normally made. “I wasn’t sure people would say yes,” said Belanger.
But some did, agreeing to work 12- and 13-hour shifts to cover the whole schedule. For the next two months, 17 nurses, care assistants, and Belanger himself lived in a tiny geographic bubble along with Shady Oaks’ 36 residents. Belanger slept in his office so his home next door was available for nine people to occupy. The remainder slept in trailers in the parking lot.
Belanger’s decision and his staff’s work made Shady Oaks an exception among group elderly homes in the United States, which account for about 40% of the country’s deaths. Shady Oaks has not recorded a single case of Covid-19, even though 69% of Covid-19 cases in Connecticut come from nursing homes.
There are exceptions around the globe, too. Up to 80% of the world’s coronavirus deaths were attributed to similar facilities in May, according to researchers at the Canadian Institute for Health Information. But facilities in Singapore and France have staved off infections by keeping staff close by, and those in Hong Kong implemented strict visitation and protective-equipment policies to keep the virus out of nursing homes.
Shady Oaks and its global peers are success stories amid the devastation of the Covid-19 pandemic. But their extreme measures come at a price. Long-term surveillance can be unsustainable for financially taxed businesses, overworked employees, and isolated residents.
The financial and emotional constraints may ultimately be too much for the elder care industry, and families, to bear as the pandemic rages on.
Unsustainable efforts lead to an uncertain future
In other countries, individual homes employed the same bubbling strategy, including three facilities in the states of Connecticut, Ohio, Georgia in the US, and one in France.
And then there’s Singapore, whose response falls in a class of its own.
Starting in early May, the tiny island-nation had nearly 20,000 active Covid-19 cases, due to large outbreaks among its large migrant-worker population. So Singapore’s ministry of health began working with its 80 long-term care facilities to find ways to temporarily house staff in hotels close to the facilities they worked in.
Singapore was the only country to uniformly “bubble” its private and public long-term care facilities. It was uniquely positioned to do so, says Rahul Malhotra, a public health expert at the Duke-NUS Medical School Singapore. In Singapore, there are only 16,000 nursing home beds, compared to the 1.7 million beds in the US.
Singapore’s nursing homes also rely heavily on migrant workers—60% or more of employees may be living in the country on work visas or other semi-permanent passes that mean that they were already separated from their families, Malhotra says. Asking them to uproot their lives may not require asking them to leave their families more than they already have been, which could make the choice easier for them. And while migrant dorms have been hotspots of Covid-19 cases, those working in nursing homes may have been protected from these outbreaks.
By June, employees were allowed back to their homes in Singapore again, says Malhotra. Visitation is largely restricted, residents can have up to two people who are cleared to see them for up to 30 minutes a day. The strategy helped protect the 16,000 residents in long-term care facilities; in July, the Singapore government reported roughly 350 new cases of Covid-19, mostly attributed to migrant worker dormitories, presumably for workers outside of nursing homes.
Singapore’s economic realities made this strategy more practical to implement. But the financial foundation of most global elder care makes it less likely to succeed in other countries.
Take Shady Oaks, again. When Belanger tripled 17 employees’ salaries, the decision cost him over $300,000 out of his own savings, even with help from the US federal government’s Paycheck Protection Program and public donations. Although he was able to pay everyone’s paychecks—and present plaques for the staff who lived with the residents—Belanger ended up short some $250,000.
The costs of such extreme measures are not simply monetary. Extreme quarantining takes a mental and physical toll on residents and workers. Loneliness can increase the risk of stroke, Alzheimer’s disease, and other forms of dementia.
Keeping staff within a bubble could benefit some residents, who tend to have better experiences when they work consistently with the same nurses and certified nursing assistants, says Barbara Bowers, a sociologist who studies the quality of care in nursing homes and other long-term care facilities at the University of Wisconsin-Madison.
But “it’s totally impractical,” she says. Eventually, staff members will burn out and new workers will have to rotate in. Emotional health and financial health become one and the same.
It’s all in the details
Social bubbles are the most extreme, disruptive, and costly intervention nursing homes can adopt in the face of Covid-19. Ideally, they could be better-prepared to prevent infection from the outset.
That’s the strategy that seems to have worked in Hong Kong, where the threat of a respiratory pandemic was all too familiar. Less than 20 years ago, over 600 of the 813 deaths related to SARS took place in either Hong Kong or mainland China. Nursing home residents were roughly five times more likely to become infected with the respiratory illness.
So when Covid-19 hit Hong Kong in late January, the city was ready. Because nursing homes and acute care are largely paid for by the government (pdf, p.39), they must adhere to a uniform set of standards, like a 2004 mandate that all facilities have some staff trained as infectious control officers. It was relatively easy to add coronavirus-specific rules to the list.
The region knew from SARS that older adults living in long-term care facilities were most vulnerable, and that hospitals were hotspots for transmission. So pandemic policies started with the use of face masks and temperature checks upon entry for employees, explains Terry Lum, director of the Sau Po Centre on Aging at the University of Hong Kong (HKU).
Shortly after, the facilities shut down visitations from family members. They also created more distance between residents, who ate meals alone in their rooms, while group activities were put on hold. When residents did have to go to the hospital, which was their only permitted outing, they were given extra personal protective gear.
There wasn’t any transmission in nursing homes at first. According to Lum, a nurse working in two nursing homes tested positive for Covid-19 in mid-March, but her protective gear prevented her from infecting any residents.
But even facilities with fresh memories of SARS couldn’t hold off its new cousin forever. In May, around Mother’s Day, nursing homes relaxed their rules, allowing residents to see their family members and participate in small group activities, Lum says. The moment of relaxed vigilance was fleeting: The first week of July brought with it the first case of Covid-19 within one of Hong Kong’s nursing homes. Within three days, there were 28 cases among its residents and four among staff, some of whom worked in other nursing homes. Last week, there were 40. One resident died.
The local government has issued guidelines suggesting that nursing home residents should not be permitted to leave and that staff should not make house calls unless absolutely necessary. These guidelines have been voluntary, although care homes in Hong Kong need to licensed by the government, and could theoretically have those licenses revoked. These measures did work at first—but now, Hong Kong’s nursing homes are seeing the effects of loosening their vigilance too soon. Now, the government is stepping in once again to help tighten safety practices, including extra testing for staff and residents.
“I think the practice [of maintaining strict hygienic and visitation limits] will likely become the new normal,” said HKU’s Lum, or at least until there’s a vaccine. Any relaxation can quickly result in a surge of cases.
It’s that strategy that Shady Oaks Assisted Living returned to, after its initial 70-day bubble was popped. Today, the facility is open for visits again; the staff can go home at the end of the day, and they take frequent tests to keep Covid-19 out. The Centers for Medicare and Medicaid Services in the US has required stricter infection control measures in long-term care facilities.
Meanwhile, transmission in Connecticut has lowered overall, so there’s less risk to the residents of Shady Oaks. But it will take constant vigilance—and investment—to keep it that way.