COVID & OLDER ADULT POPULATIONS

Since the beginning of 2020, hundreds of thousands of deaths have been attributed to complications from Covid-19, an illness contracted from exposure to the novel Coronavirus. Although symptoms can vary – Covid-19 is commonly diagnosed following complaints of one or a combination of the following: a dry cough, shortness of breath, loss of taste or smell, fatigue, and fever/chills.

Risk Factors

Covid-19 disproportionally affects those with certain chronic conditions and behaviors including those with cancer, COPD, heart disease and those that are obese and/or smoke regularly. Those over the age of 65 are generally at higher risk as it is more common for people in this age group to have chronic conditions. Experts believe that weaker immune systems among the elderly combined with underlying respiratory and cardiovascular conditions make them particularly vulnerable.

With COVID-19, roughly 80 percent of deaths in the United States are in people over age 65, with a dramatic impact on those over age 80 and who have underlying conditions. , Data from Italy suggest that the strongest predictor of mortality and ICU admission is age, with case fatality rates for 70 to 79 year-olds roughly 13 times that for 50-59 year-olds.

Notably, seniors in congregate living arrangements have been particularly vulnerable, especially nursing facilities but also other residential arrangements with shared dining, recreation and sleeping arrangements. Data from early May show that about 28,000 nursing facility residents had died from COVID-19, accounting for just over a third of the country’s deaths. Some states and other countries have seen nursing home patients accounting for about 50 percent of total deaths. The Kaiser Family Foundation estimates that about 40% of Covid-related deaths have been in such facilities.

Covid and its Spread in Residential Care Facilities

Residential care facilities have proved a major hot zone for the spread of COVID-19 for several reasons:

  • Staffing and training issues have challenged the sufficiency of traditional infection control measures. Those issues, combined with a vulnerable resident population in close residential quarters, have increased the likelihood of transmission for both staff and patients.
  • Inadequate supplies of PPE for workers (in part due to supply chain constraints) and the lack of training in the use of PPE have been major problems for care providers.
  • Additionally, industry practices in which staff are employed in more than one facility have enabled transfer of COVID-19 to new vulnerable residents. A fall 2020 study by the National Bureau of Economic Research estimated that about half of these deaths are influenced by the sharing of staff between care facilities.
Lessons Learned from Covid – Residential and Home-Based Care

In the early stages of the pandemic, the practice of hospitals discharging patients to nursing homes without a strategy for isolation likely led to new outbreaks and higher death rates. Information from the Center for Medicare and Medicaid Services (CMS) suggests that about 42 percent of infected nursing home patients died from COVID-19.

Since then, facilities across the country have taken action to isolate and test residents and change policies related to visitors and sharing of staff across facilities. However, the death rates and challenges at nursing home facilities has raised an alarm for many families about their loved ones and has strengthened the desire of many seniors to age in their own homes for as long as possible.

Improved models for care at home are desperately needed. Gaps in care have occurred when discharged hospital patients were prohibited from returning to or entering a nursing facility; turned away patients have had limited options and their families have had to reckon with a home care and hospice sector ill-equipped to deal with a pandemic.

More broadly, seniors at home have been further isolated without appropriate support and unprepared family members have had to step in. The chaos has led to multiple home care workers moving in and out of senior homes, with inadequate protections against disease transmission. Workforce shortages have led to shortages of direct care workers and have exposed a lack of certification or standards and training in infection control or for how to address situations like COVID.

Although transmission risk is lower for those aging in their own homes, it is important that your loved ones understand how the virus is transmitted, what they can do to reduce the risk of transmission and how to manage new limitations on travel and social interaction that may be unwelcome and present hardship.

Lessons Learned from Covid – Residential and Home-Based Care

In the early stages of the pandemic, the practice of hospitals discharging patients to nursing homes without a strategy for isolation likely led to new outbreaks and higher death rates. Information from the Center for Medicare and Medicaid Services (CMS) suggests that about 42 percent of infected nursing home patients died from COVID-19.

Since then, facilities across the country have taken action to isolate and test residents and change policies related to visitors and sharing of staff across facilities. However, the death rates and challenges at nursing home facilities has raised an alarm for many families about their loved ones and has strengthened the desire of many seniors to age in their own homes for as long as possible.

Improved models for care at home are desperately needed. Gaps in care have occurred when discharged hospital patients were prohibited from returning to or entering a nursing facility; turned away patients have had limited options and their families have had to reckon with a home care and hospice sector ill-equipped to deal with a pandemic.

More broadly, seniors at home have been further isolated without appropriate support and unprepared family members have had to step in. The chaos has led to multiple home care workers moving in and out of senior homes, with inadequate protections against disease transmission. Workforce shortages have led to shortages of direct care workers and have exposed a lack of certification or standards and training in infection control or for how to address situations like COVID.

Although transmission risk is lower for those aging in their own homes, it is important that your loved ones understand how the virus is transmitted, what they can do to reduce the risk of transmission and how to manage new limitations on travel and social interaction that may be unwelcome and present hardship.

How to Talk with Your Loved Ones About Covid-19

  1. Ask Questions:
    Ask what they have heard about Covid-19, what they have been doing to be safe during this time, how it makes them feel and what they wish they were able to do.  This can give you a basis for their understanding of the Covid risks and things you can do to help them with wants and needs.
  2. Take Stock of Their Safety:
    Ask your loved ones if they are able to get the things they need – essentials like food and personal care supplies. This should include protective masks, soaps and sanitizers. Also ask about any challenges with day-to-day tasks they need help with.
  3. Assess Their Knowledge:
    Does your loved one know about the value of wearing masks, keeping social distance and regularly washing hands with soap and water? Are they aware of the level of Coronavirus infections in their community and whether the rate is going up or down? What about where to go in their area for a Coronavirus test?
    Expert resources like the Centers for Disease Control and Prevention have made efforts to post the most up-to-date information on the outbreak and how best to respond to it. Visit www.cdc.gov for more information.
  4. Pay attention to other medical needs:
    Your loved one has likely delayed seeing their physician for regular exams, treatment of chronic conditions, or preventive health visits due to Coronavirus restrictions. Getting them back on track with those appointments and helping them with a plan to see their doctor if needed will be important but challenging. That includes making sure they are up to date with their prescriptions and immunizations, like the flu shot.
    Since the onset of the pandemic, many doctors are seeing patients remotely using telemedicine visits, including over the phone (audio). You can recommend they call their doctors to see if this is possible and help them get the technology they need to facilitate those virtual visits and get comfortable with the model. Many seniors have been surprised at how convenient telemedicine has made their care experience!
  5. Add Structure to Communications and Innovate:
    Set up regular times during the week, or a set day and time, for a check in call. Use the opportunity to ask about their mood, sleep, changes in physical condition and any wants and needs.
    If you are using technology and/or social media to communicate, ask if your loved one is comfortable using it. You may also want to do a ‘walk through’ by phone on the setup and use of technology if possible.
    For family events that normally occur in person, but are recommended to be done at a distance due to state or local guidelines, consider getting a free or paid video meeting service like Zoom, Google Meet or Skype.
  6. Make Connections with Community Resources if Needed:
    If your loved one needs help with day-to-day needs, resources may exist in their community to help. One good resource for this is your local Area Agency on Aging – a national network of non-profit or state-run offices that helps the elderly and disabled remain in their own homes and communities for as long as possible. Visit https://www.n4a.org/ to learn more.

Working with Paid Caregivers in the Era of Covid

If You Are Seeking In-Home Help:
  1. Seek help from reputable, licensed and well-reviewed care providers.
    Such providers must follow state-based guidelines and requirements for home care. If your state has no such requirements, providers should be tied to a reputable brand.

    Providers who operate multiple facilities, or operate under a national franchised brand, are more likely to have established protocols, and procured necessary protective equipment, to deliver Covid sensitive care.

    If you are considering hiring an independently-employed care provider know you are the employer of record in this situation and you are the one who must establish and monitor protocols intended to minimize the risk of Covid infection.
  2. Inquire and confirm the steps the provider is taking to follow Covid-19 protocols
    • Do they test staff for Coronavirus infection? If so, what is the frequency of staff testing and turnaround time for results.
    • Do they provide personal protective equipment (PPE) or does the caregiver have to purchase? Quality operators will purchase PPE for their staff. Ask what is provided and how often it is refreshed.
    • Ask them for their process for starting the shift and ending the shift in-home. Staff should wash hands at start of shift, wear masks at all times and sanitize their supplies.
    • Accountability – ask how these processes are checked for consistency and how the provider handles client/family concerns when caregivers arrive at the home.
  3. Ask about who they hire and how they manage their staff
    Is staff 100% dedicated to that agency’s clients? Or do they work part-time and work in residential care facilities or with other home care providers? Does the provider know where that staff member also works, if that provider or facility has seen outbreaks and what steps are being taken to contain any spread of the disease, or how the provider is compensating for any shortfalls in those steps.
  4. Ask Who Manages Staff When They Are On The Job?
    Is it a professional care manager like a licensed social worker? Are nurses involved? Does the caregiver use technology to report when they arrive, leave and if any concerns come up during their shift? If concerns do come up how are they escalated back to you?

    A quality home care operator will have trained their staff to look out for changes in condition which may indicate a concern, escalate this to their case management team and – after their own analysis – informing you of the issue and what can be done to address it.

Tips for Managing In-Home Care Providers in the Era of Covid

  1. Establish a routine that is sensitive to the presence and potential spread of the disease. This includes:
    1. a. A trusted ‘ringing protocol’ to announce to your loved one that the provider is there.
    2. b. Immediate hand washing for at least 20 seconds using soap and water at start of shift.
    3. c. Wearing of N95 rated masks indoors at all times.
    4. d. Sanitization of any equipment or supplies brought into the home before use including surfaces where such pre-sanitized equipment is placed for cleaning.
    5. e. Empowerment of the caregiver to recognize and report any changes in condition or other issues that are of concern.
  2. Empower caregivers to raise any concerns they notice with their case manager and/or with you.

    Such concerns could be an observed change in mood or wellness with your loved one, disruptions in sleep patterns, new skin condition issues, fatigue, shortness of breath, coughing and ‘just not seeming right’.
  3. If you live far away from your loved one

    Work with your home care provider to identify your loved one’s primary care doctor and others involved in his or her care and get permission to contact on loved one’s behalf if there are any issues. Make sure the provider has good contact information for you including your preferred method of contact in an emergency.
  4. If there is a need for a primary care visit:

    See if an in-home visit is possible or if a telemedicine visit can happen. Caregivers can be used to help facilitate such visits. Make sure any provider coming into the home follows protocols consistent with item 1 above.
  5. Consider technology:

    Remote monitoring solutions offer a way to check in with your loved ones in a way which is secure and private. Such solutions also offer an avenue to call for help if there is a fall, safety or general concerns. See our “Introducing Technology” resource area for more information.