Some long-term care facilities are slowly reopening to allow visits from family members, recognizing that residents have been suffering both emotionally and physically after months of isolation. The facilities have been doing so according to guidelines released recently by the state, as well as by federal authorities.
Still, it can be a precarious balancing act: Allowing more people in – especially when adequate testing is lacking – can mean introducing the virus.
“We're always going to be worried about COVID and the spread of COVID and opening to visitors. But there is a balance that needs to be met. The psychosocial well-being of these individuals in nursing homes and their ability to connect with their loved ones is important. And it's just such a huge benefit to them physically and mentally to have those visitors,” Melissa St. Cyr, chief legal officer for NH DHHS said on The Exchange
(For the full conversation, listen here. Excerpts in this story have been edited for clarity.)
Yet some facilities are too worried to relax certain visitation rules, allowing even one family member, considered an “essential support visitor,” indoors, according to Dr. Daniel Stadler, director of geriatrics at Dartmouth-Hitchcock Medical Center and medical director at several skilled nursing facilities in the Upper Valley.
“Many of the facilities that I've been involved with, many of the facilities that I know, have not elected to implement phase two due to the considerable risk." Stadler said.
Stadler says his facilities remain at phase one of reopening, allowing supervised outdoor visits only.
As listener Jamie described in an email, a reunion after a seven-month separation from her sister who lives in a long-term care facility, was short-lived:
“Just this past Sunday, since I am now a ‘designated essential support visitor,’ I was able to visit with her in her room for two hours, only to have that opportunity swept away as a staff member tested positive for the virus. For a few short hours, we felt a bit of normalcy. Now she has to quarantine in her room again for 14 days…This is heart wrenching...
... I can only hope my essential support visitor protocol can resume in two weeks and that she can receive outside medical care that she has decided to put off because of the 14 day quarantine requirement if a residents leaves the facility. We will not be celebrating holidays this year because I cannot bear to do so without my sister. It just would not be right."
A single positive case is all it takes, according to the CDC, to require a drastic reversal, St. Cyr said. One positive case is considered an outbreak. The disease has had catastrophic effects in these settings, as has been the case in New Hampshire for months, accounting for about 80% of COVID-19 related deaths at one time.
“It's catastrophic for everyone involved. And so we need to do everything we can within reason to protect against that,” Stadler said.
Meanwhile, however, Stadler says some of his residents have stopped eating because they miss contact with family, and that, too, can be devastating. He calls it an “unwinnable situation.”
“The psycho-social burden on our residents, and quite honestly on our staff, has been really significant. From the perspective of the residents, it’s the social isolation. It's the lack of physical touch. It's not being able to see a face and read lips if there's a hearing impairment," he said. "And for the staff, I think there's a sort of an existential struggle: In the name of saving lives, am I making people's lives worse? Most, many, many, many of the residents of these facilities I have no doubt, if asked, would say I would choose a shorter life if I could visit with my daughter… We are in a situation where we are trying to choose the lesser of two evils every day.”
How ready are facilities across the state for more visitation? St. Cyr says all have been contemplating the move for some time now, given the impact of isolation.
“I think that they've all put together policies that apply to their facility and how they can accomplish the visitation for their residence. So each of them is really prepared to move forward and implement those policies to ensure safety," she said.
Judith Joy, Statewide coordinator for the Covid Alliance Senior Support Team of New Hampshire, a volunteer group that was formed in April to help support long-term care facilities during the pandemic, says administrators are reporting that direction from government entities can only go so far in helping them to make certain tough decisions.
"It's their experience, their level of staffing , their PPE availabiitly -- all of those things contribute to whether or not they can or should open their facilities or be more restrictive," said Joy, who is also a licensed registered nurse with a doctorate degree in educational leadership.
A big boost to ensuring safety would be more testing, all agreed. “I think the rapid testing would really be the biggest bang for the buck. If we could test and test almost every day with a quick answer, that that would be a huge, huge change," Stadler said.
Meanwhile, the Centers for Medicare and Medicaid Services (CMS), which oversees nursing homes and some assisted living facilities, has updated its guidance for visitation recently. State officials are now reviewing those to make sure their guidelines align with federal policy, St. Cyr said.
Douglas McNutt, associate state director for advocacy with the NH office of the AARP and former director of the NH Bureau of Elderly and Adult Services, says the state ombudsman should also resume on-site oversight.
“Normally, the long term care ombudsman has a federal mandate to be able to have access to facilities and in this case, not just nursing homes, but also assisted living facilities as well. They haven't been able to have that access since the beginning of the outbreak. And we think it's really important that they have the opportunity to have access," he said. "We recognize that there are safety issues and we're not suggesting that the ombudsman go in without PPE, without testing and those sorts of things. But we think that they could play a really important role in helping residents. And from my experience, the long-term care ombudsman is also helpful with facilities. They have the ability to be able to negotiate things, mediate things and to help make things better.”