Opinion by Jason Karlawish, David C. Grabowski and Allison K. Hoffman, The Washington Post, July 13 2020
Jason Karlawish is a professor of medicine at the Perelman School of Medicine and co-director of the Penn Memory Center at the University of Pennsylvania. David C. Grabowski is a professor of health-care policy at Harvard Medical School. Allison K. Hoffman is a professor at the University of Pennsylvania Carey Law School.
In March, after an outbreak of covid-19 in a Seattle nursing home launched the pandemic in the United States, long-term care facilities generally shut their doors to visiting family and friends. This ban followed guidance from the Centers for Medicare and Medicaid Services (CMS), which regulates most nursing homes: Facilities were ordered to restrict visitors except for “compassionate care” for a resident who was dying.
As an early containment strategy, it made sense. At that time, there was great uncertainty on the disease’s transmission, but we have made progress in that area. Although the pandemic continues, and resurges in some areas, long-term-care facilities should reconsider their rules — especially in areas where cases are steady or decreasing. Keeping the doors shut is harmful to the health of residents. Good policy demands more nuanced thinking about how some visitors contribute to their safety.
The fact is that for many nursing home residents, a visit is not simply a social call. Many family members are not company as much as essential caregivers and care monitors. Their involvement is vital, especially at facilities with shortages in staffing. Caring visitors make sure that their loved ones eat, can communicate with the staff, and receive daily hygiene and dignified engagement. Family members are often the first to see changes in a resident’s condition or other issues. Unsurprisingly, quality of care has been found to be poor for residents without regular visitors.
The sudden disruption in residents’ contact with loved ones has caused notable declines in residents’ cognition and function, depression, as well as anguish for family members.
During normal times, CMS regulations recognize a right to visitors as necessary to promote and facilitate residents’ self-determination. Even in these extraordinary times, facilities should balance the loss of self-determination and other medical harms against the risk of transmission of covid-19.
Under CMS’s May 18 guidance on reopening, many nursing homes are far from meeting standards for resuming normal visitation. To do so, a facility must have at least 28 days of no new covid-19 cases, as well as adequate staff, protective gear and covid-19 testing. Until then, visitors should be allowed only in an “end-of-life situation.”
The caution is understandable, but we think the recommendation draws too stark a line. CMS’s guidance should take into account visitors who are “essential care partners” and give nursing home leadership more leeway to allow these visitors reentry — under careful procedures, of course.
We do not minimize the threat covid-19 poses to nursing homes. Even with strong precautions in place, residents and workers at long-term care facilities account thus far for 42 percent of U.S. covid-19 deaths and 10 percent of cases. But we are seeing huge variation across areas of the country in active cases, and local conditions should inform decisions on allowing nursing home visitors.
Nursing homes in areas where covid-19 cases are slowing or declining are strong candidates for reopening. The harm of keeping essential care partners out can itself be a great threat to well-being, as many families have learned. The risks of visits can be minimized in these controlled situations, as we know more now about the spread of covid-19. And family and friends will likely be the most vigilant of anyone in protecting their loved ones from exposure.
Nursing homes already have procedures to make sure that workers do not bring covid-19 into facilities; they can do the same with visits from essential care partners. A facility might stagger visitors, limit where they can be and require covid-19 testing, temperature checks and masks. Some nursing homes are already allowing limited and distanced outdoor visits.
All this will demand staff time, but it will also save staff time. Visits will reduce worried family members’ phone calls and add more hands to help with basic care.
A 26-facility study in the Netherlands offers encouragement for allowing visitors to long-term care facilities, even those with active cases of covid-19 infection. Criteria included spacing visits to a facility through the day and week, allowing one visitor per resident, and requiring distancing or personal protective equipment. No resurgence of covid infections ensued, and the Dutch government reopened nursing homes to visitors using these guidelines.
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At the very least, essential care partners should not be more restricted than nonessential health-care workers, whom CMS guidance allows into nursing homes that have recorded no new infections for 14 days. We are certain that some visitors are at least as important as these nonessential personnel to residents’ well-being.
It is understandable that regulators and nursing home operators want to do everything possible to keep covid-19 out. But blanket visitation bans fail to capture how some friends and family are critical to good care. These benefits are worth the low risk posed by well-monitored visits.
In the long run, keeping these essential care partners out will lead to more harm than good.