By Barbara Feder Ostrov and Ana B Ibarra, Cal Matters, May 12 2020
Some experts contend the state should prioritize coronavirus testing of vulnerable nursing home residents and staff before mass testing the general public.
As California ramps up coronavirus testing of the general population, the state is still about two weeks away from any mandatory testing of its most vulnerable residents: those in nursing homes.
Testing has been a significant challenge for the state and the country since the beginning of the outbreak, and today, Gov. Gavin Newsom announced that the state had passed a “milestone” of 1 million tests – now averaging about 35,000 a day. It needs almost double that to meet its next goal.
But Newsom and his top health official later acknowledged that the state still needs more time and resources to begin requiring testing in nursing homes for both residents and staff.
“I think we’re a couple of weeks away from having this all ironed out, and it comes down to ensuring that we not only have the supplies but also the people power to get the testing done,” said Dr. Mark Ghaly, head of the California Health and Human Services Agency.
Yet several experts said they believed state health officials should immediately prioritize nursing home residents – and the staff who care for them – before mass testing the general public.
“It’s the wrong population that they’re focusing on,” said Dr. Mehrdad Ayati, a geriatrician who teaches at Stanford University’s School of Medicine and serves as a medical adviser to a number of nursing homes. “When you see the mortality rates around the world, the population that we need to do massive testing in is residents and workers in skilled nursing facilities.”
The statistics tell a grim story of the risks to nursing home residents and workers. In California, the tests that have been done indicate that about 6,250 residents have been infected with the novel coronavirus and 1,058 have died. More than 3,600 workers also have been infected, 23 fatally. About 40 percent of California’s COVID-19 deaths have been of nursing home residents or workers.
Ghaly said the state is working on how to adequately test patients and staff, including how to manage the number of positive tests that would undoubtedly surface. The state takes nursing home testing “very seriously,” he said, noting that there are nearly 120,000 residents living in skilled nursing facilities.
“We’re working to come up with a thoughtful, statewide plan,” he said.
California has largely left decisions on who gets tested in the state’s 1,224 nursing homes to local health departments, even as governors in Maryland, Delaware and Tennessee have promised statewide universal testing for every nursing home resident and worker. Only on Monday did state health officials order every skilled nursing facility to develop a COVID-19 mitigation plan within 21 days that includes plans for regular testing of staff and residents.
California’s state public health agency has offered guidance that residents and workers in skilled nursing facilities should be tested under the following conditions: if they show symptoms; if a new patient transfers into a home or is readmitted after a hospital stay, or if other positive cases have been identified in the facility. So far, there’s been little testing of asymptomatic residents or workers in the absence of an outbreak, said Dr. Noah Marco, chief medical officer for the Los Angeles Jewish Home.
But that has deeply worried public health experts as cases and deaths mount among the state’s frail elderly and disabled people. Two Harvard professors recently argued in a Los Angeles Times editorial that the center of any strategy to contain COVID-19 in the nation’s nursing homes “must be a massive deployment of testing.”
“The secret weapon behind COVID-19 is that it spreads in the absence of any symptoms, even among older nursing home residents. In all likelihood, asymptomatic staff unknowingly brought these cases into the nursing homes,” wrote David Grabowski and Michael Barnett. “This is why, if we don’t immediately begin universal testing of nursing home staff and residents immediately, COVID-19 will soon be in every nursing home in the country.”
“NURSING HOMES – THAT’S WHERE PEOPLE ARE DYING, BOTH RESIDENTS AND THE FRONT LINE STAFF… IF WE WANT TO PROTECT THEM, WE HAVE TO TEST.”Dr. Mike Wasserman, California Association of Long Care Medicine
At the local level, San Francisco health officials are expected this week to order mandatory testing of nursing home residents and workers. In late April, as California’s National Guard members were deployed to help some Los Angeles nursing homes, the city’s mayor, Eric Garcetti, ordered all skilled nursing facilities in the city to test workers and residents monthly. Garcetti said the city’s emergency operations center would help the homes find tests if they couldn’t.
“We have to do testing and we want to do testing, but we don’t have access to testing,” said Jason Belden, director of emergency preparedness for the California Association of Health Facilities, a nursing home industry group.
Belden said skilled nursing facilities are working with county health departments but “they don’t have the manpower” to test everyone. While public health labs can return test results in 48 to 72 hours, the private labs typically used by nursing homes have far longer turnaround times – up to 10 days, and some do not accept Medi-Cal, the payer for many long-term care patients, for coronavirus tests, Belden added.
“We’ll have lost the ability to contain the virus if we have to wait,” Belden said. “Rapid testing is not even remotely close to available.”
Dr. Mike Wasserman, president of the California Association of Long Term Care Medicine, said that while universal testing may be starting in some regions of the state, it’s rolling out slowly.
“We know that here in California that the tests exist, they’re being used, and someone’s got to have the guts to use them in the right places. Nursing homes – that’s where people are dying, both residents and the front line staff,” Wasserman said. “You’ve got vulnerable adults and front line staff who have low socioeconomic status – and those are the people who are dying. If we want to protect them, we have to test.”
While testing overall has lagged in California, it is now picking up pace for the general population. About a month ago, the state was doing some 2,000 tests a day – which Newsom described today as “completely unacceptable” for a state as big as California.
The state is expanding its current testing capacity by establishing 80 new testing sites in underserved and rural communities, of which 76 are now operational, Newsom said. The state is also expanding testing into pharmacies that choose to do so. The state board of pharmacy will allow pharmacists to collect specimens for COVID-19 tests, which will then be processed at public health, university or commercial labs.
In continuing to reopen the economy, Newsom said, the public has a responsibility to protect the state’s seniors.
But one elder care advocate said he worries that “residents of nursing homes are nobody’s political constituency.
“They mostly don’t vote,” said Mike Dark, staff attorney for California Advocates for Nursing Home Reform. “I worry that the state isn’t giving the attention to testing residents that would be merited by the lethality and contagiousness of the virus in these homes.”