Assisted Living After Covid

The images are heartbreaking, the statistics even worse. Though the US leads the world in total deaths from COVID-19, during wave one of the pandemic care homes were, in relative terms, the deadliest place to be in Canada, where they accounted for four in every five deaths. Even allowing for some underreporting, in the USA in only two in five deaths occurred in care homes – a rate also exceeded in FranceScotland, Belgium, Italy and Chile (around half).

That so many seniors perished is not particularly surprising, given that they are physically less able to fight the virus. That more preventative measures were not put in place, especially after the virus took its toll on European elders, is. Roughly 88% of all COVID-related fatalities in Europe by early September were people aged 65 or older

Was that a result of cost-cutting done to boost earnings? In the Canadian province of Ontario, for instance, older COVID casualties were far more often in profit-driven centers than public ones.  Fatalities were also “high in high-income countries where long-term care for older people was underprioritised during the early stages of the pandemic and lacked oversight,” notes Dr Zee-A Han, medical officer at the World Health Organization’s Ageing and Health Unit. People need more “integrated services and quality assurances”.

Indeed, the COVID-19 evidence shows that care home infection control and care gaps varied in two primary ways based on wherever elders were in the world, ranging from fragmented models with complex funding for senior care in wealthier regions, to under-regulated care homes with weak oversight everywhere. To fill these gaps the future global approach appears to be coalescing around home-based care both in high-income countries (with the sickest elderly attached to hospitals and clinics with stricter protocols in the US) while in low-income countries, where care at one’s home is already the prevailing model, far sharper oversight and regulations will likely take root. Amid this budding ‘better off home’ shift, in this notoriously informal, underfunded and unregulated sector, without more centralized models and coordinated measures today, any changes being made are Band-Aids, experts say, warning that there likely will be similarly lethal outcomes from any future pandemic.

Residents of care homes are “the most vulnerable”, laments Finbarr Martin, Professor of Medical Gerontology, at King’s College London.  “You need quality standards of regulation, of medical supervision, of competencies. Of coordination. [Without that] people make ad hoc decisions. Current models are not sustainable and scalable.”

This shift to home-based and rule-bound stems from five dovetailing trends.

First, older healthy adults increasingly want to live outside clinical facilities with friends or families, all the more so after seeing the Covid care home carnage. Secondly, governments increasingly recognise that far more integration between care homes and the mainstream health care system is required. Thirdly regulation is needed to ensure timely preventative care, particularly given the risk of further pandemics. Fourthly, novel financing and business models are emerging as more of us live into our 90s or 100s – with vastly different needs. Finally, new technologies are being developed with the potential to meet these needs, affordably, such as robots able to deliver food, infection free.

How these trends play out is likely to vary in different parts of the world. Asia is perhaps most emblematic of where the global industry is headed, headed by South Korea and Japan. Those countries suffered far fewer COVID-related fatalities in care homes than elsewhere. Many countries had learnt from experience. Earlier MERS and SARS outbreaks helped doctors develop protocols in anticipation of the next big one – protocols adopted too late elsewhere. In South Korea these included rapid testing and rigorous inspections. As a result, by May South Korea (along with Hong Kong) reported no COVID-linked fatalities in care homes. (Australia also fared well due to quick, coordinated plans for surge staffing, rapid reaction healthcare teams and stricter infection control norms in care homes.)

Cultural traditions also mean that many Asian children care for their aging parents at home. “Japan and Korea emphasize community and home-based care. This model will most likely accelerate after the pandemic,” projects the WHO’s Dr Zee-A Han. Especially as “it also brings substantial cost savings.”

Africa in the pandemic’s early days saw far fewer of its people perish, perhaps because like Asia the continent knows all too well how preventative protocols can help fight infectious disease spread. One of several exceptions was South Africa. Roughly 55% of those dying from COVID were over age 60, many in informal and unregulated public care homes (versus private ones, a legacy of apartheid). 

Recommendations include integrating LTC centers into a national pandemic plan, coordinated guidance and monitoring, trained staff rosters, and earmarking isolation spaces. Professor Peter Lloyd-Sherlock at the School of International Development at the University of East Anglia is working with South Africa’s government on emergency guidance for facilities with scarce resources; long-term he hopes to identify and help bring informal care homes under the formal umbrella to agree on accountability, standards and protocols.

In Israel, known for its prompt and focused response teams, officials set up a command center and assigned individuals within ministries to improve its response to outbreaks of infection in care homes.  

In France, “cool rooms” and processes created for checking in on elders undoubtedly helped reduce the death toll. These efforts grew from major care home reforms in France following a 2003 heat wave in which more than 15,000 mostly elderly perished.  

Across Europe, the home-based reference point is Denmark’s “aging in place” model (i.e.. at home rather than in a home) for more personalized and affordable care – reducing costs by 12% while improving the quality of care and satisfaction levels. Again, this reduced reliance on care homes paid off during the pandemic, along with requiring well-trained staff and private rooms in care homes and national indicators for care home quality. As of early August, just one-third of Denmark’s COVID-19 deaths occurred in care homes, versus more laissez faire Sweden’s nearly half. 

That many care home deaths were surely preventable has triggered much soul searching.  We need “a protective ring around care homes [to] respond in a coordinated way,” says Finbarr Martin. He recommends standardized assessments and connecting one medical director to each care home. “There is no substitute for locally based networks of collaboration and health expertise,” he insists. ”You can’t do that in a profit-oriented sector.”

Like Asia, Latin America’s familial culture has kept its care home industry quite small. Even in wealthy families, older adults tend to live with their children, often aided by lower cost specialized labor. As a result the pattern of its COVID-19 casualties among the elderly is murky. Many who lost their lives to COVID most likely did so at home in a pandemic that endures. However a handful of high-end facilities are scattered across Latin America’s biggest cities, with high quality regulated care that is costly. But informal centers are all over the map. That’s why in Argentina, Lloyd-Sherlock worked with La Plata’s government on a Trip Advisor-type app rating the quality of care in LTC facilities. For the home-bound during the pandemic, Buenos Aires also set up a 38,000-strong volunteer service to check in by phone on and run errands for the elderly.

New York State’s early stumbles in its handling of the virus in nursing homes and growing  casualties among the elderly elsewhere will prompt care reforms in a complex industry largely driven by core financing from publicly funded programs Medicare (free healthcare for those over 65) and Medicaid (free healthcare below an income threshold). This structure sets up perverse incentives that increase inefficiencies and fatalities in an already highly fragmented system, with people of color disproportionately dying. “It’s important to note the role of financing in our industry,” notes Christopher Koller, president of the Milbank Memorial Fund. “We are discharging the sicker quicker.”

Long-term, experts see the U.S. sector bifurcating. For the healthier elderly, Terry Fulmer, president of the John A. Hartford Foundation says that all models are on the table, including villages and Green Houses, and novel ideas like using hospital extended care wings for short-stay rehabilitation patients. But these will need to be watched for quality and safety, she stresses.   “We need to rethink how we provide care, more age-friendly care that follows older adults and keeps them at home whenever possible,” she says. “We can watch experiments with home-based models and learn.”

Meanwhile, Jack Rowe, professor at Columbia University’s Mailman School of Public Health, a former AETNA CEO, and founder of Harvard Medical School’s Division on Aging expects a streaming of the most chronically ill patients into different kinds of facilities near or within hospitals, all with dedicated disease control staff. He laments the ill-equipped and underfinanced nature of the US care industry at the pandemic’s outbreak, and foresees the slow erosion of private facilities. ““I like the idea of “ hubs” which concentrate infected patients in facilities, thus avoiding admitting infected patients to facilities without infection,” he says. 

As the world races towards a vaccine, the care industry is limping along.  Colliding forces will push it to speed up as older adults continue to embrace a ‘not the years in your life, the life in your years’ ethos: a life in which families or communities work harder to safeguard their health, and to ensure they are well cared for in their final days—increasingly at home.  “We should use the COVID-19 crisis to ask questions about quality and equity in nursing homes, about how we care for our elderly,” notes Koller, before asking a stark question: “Will there be enough victims to change political sentiment?”

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