In late April, as coronavirus deaths in the state’s nursing homes surpassed 1,200 and the National Guard was called in to inspect the facilities, a local paramedic wrote to state officials urging them to begin testing all residents and staff.
Chris O’Brien had been transporting elderly and disabled residents from nursing homes to hospitals in western Connecticut for weeks and saw firsthand the toll the virus was taking on those vulnerable people.
“The state should reset our testing priorities,” he wrote in an email to Sen. Rob Sampson and Rep. Gale Mastrofrancesco, two Republicans from his hometown of Wolcott. “Begin comprehensively testing nursing home residents and staff. Include inmates and DOC staff. This should be the state’s #1 testing priority.”
Within days, the email made its way to officials at the state Department of Public Health, who thanked him and noted that Connecticut had stepped up its monitoring of infection controls in the nursing homes.
But O’Brien persisted. “Any potential for National Guard to do on-site testing?” he asked. By then, he pointed out, Maryland, South Carolina, Delaware and other states had moved to begin universal testing in nursing facilities.
Nursing home leaders, too, had recognized the need for widespread testing. Genesis Healthcare, which owns 18 homes in Connecticut, began discussions about broad testing in April. The state had not yet made resources available to test all nursing home residents, so Genesis partnered with two out-of-state labs and a local hospital.
By the first week of May, it managed to test all residents at 10 of its 18 facilities.
“We were hoping the tests would be available sooner,” Marnie Talamona, regional vice president of operations for Genesis, said of the state’s effort. “It’s important for cohorting and knowing exactly what residents are asymptomatic and can be carriers.”
Universal testing in nursing homes is considered a crucial strategy in helping curb the spread of COVID-19. Residents and staff can carry the disease but show no symptoms, complicating efforts to separate healthy residents from sick ones, and to prevent infected staff from spreading the virus inside the facilities.
Other states moved in April to begin robust testing in nursing homes. Massachusetts, which initially had tested only symptomatic residents, on April 13 expanded its effort to include non-symptomatic people in those homes. State health officials sent testing kits to the nursing homes and arranged mobile testing at the facilities. Maryland Gov. Larry Hogan on April 29 ordered nursing homes to test all residents and staff, regardless of whether they were showing symptoms.
By the time Connecticut announced it was starting broad testing in its nursing homes – on May 7 – deaths among those residents represented nearly 60% of the state’s COVID-19 fatalities. More than 1,600 nursing home residents diagnosed with coronavirus or presumed to have the disease had died.
State officials pointed to a limited supply of testing materials when asked why the widespread effort wasn’t done sooner.
“We have been constrained since the beginning of this pandemic by test kits and supplies, and more recently, we’ve started to get more supplies and we’ve been able to increase the amount of testing we’ve been doing,” Josh Geballe, Gov. Ned Lamont’s chief operating officer, said on May 7.
It’s long overdue. There’s no doubt about it, the slow rollout of testing has resulted in a lot of deaths that could have otherwise been avoided.”
Deidre Gifford, acting commissioner of the state’s public health department, noted that symptomatic residents in nursing homes were being tested early on. But she conceded the state was hampered by its limited ability to test.
“The constraints on testing supplies have been among the most difficult challenges of managing the pandemic,” Gifford said in an interview with The Mirror. “Had the country had adequate testing capacity, we would have been able to approach this differently.”
But lawmakers, nursing home operators and patient advocates have questioned why the state didn’t direct more of the limited testing supply to nursing homes earlier, given that the overwhelming amount of COVID-19 fatalities have been recorded there.
Studies have shown that comprehensive testing among residents and staff in congregate settings can halt or prevent an outbreak. In Seattle – where nursing homes were among the first and hardest hit in the country – researchers with the University of Washington and the Centers for Disease Control and Prevention studied an assisted living center that did broad testing in March. After two residents became sick, the facility tested everyone and found four asymptomatic carriers. Those residents were isolated.
“A widespread facility outbreak was avoided,” the researchers wrote in a study published in JAMA Internal Medicine.
As of last Wednesday, the death toll in Connecticut’s nursing homes had reached 2,190. Many facilities – about a third of the homes with coronavirus cases – have recorded infection rates of 50% or higher among their residents.
“It’s long overdue,” Sen. Matthew Lesser, a Democrat from Middletown, said of the robust testing. “It’s desperately needed to contain the spread. There’s no doubt about it, the slow rollout of testing has resulted in a lot of deaths that could have otherwise been avoided.”
During a recent visit to a nursing home in his district, Lesser said he was surprised to learn that staff members still had little information about how they could access COVID-19 tests.
“I called ahead and the administrator brought the staff out,” he said of his stop at the Middlesex Health Care Center. “We all met in the parking lot and I asked what they needed. And I was just peppered with questions from the staff saying, ‘How do we get tested? We don’t know how to get tested.’ It was shocking.”
Lisa Freeman, executive director of the Connecticut Center for Patient Safety, said broad testing for people in congregate environments, such as nursing homes and prisons, should have been a priority sooner.
“We didn’t react as fast and as decisively as we should have,” she said. “Perhaps then we could have very quickly separated the population that had COVID-19 versus those who were still healthy.
“The quick testing – that matters,” she said. “You can remove the infection, trace the contact and respond. I think it’s the only way out.”
Leaders at the iCare Health Network, which owns 11 nursing homes in and around Hartford, began a push for broad testing in early May. By May 11, the company had tested all of its 1,200 residents with resources it secured from the state laboratory and from private labs.
David Skoczulek, vice president of development for iCare, said the testing illuminated a silent population – the asymptomatic carriers of COVID-19. Following the tests, nursing home staff were able to move those positive residents away from others who were negative.
“We needed to know where people actually were, not just based on symptoms, but based on their test results,” he said. “Cohorting residents was working. But to bring it to the next level, we needed to know who exactly was in what status, and testing was going to do that.”
While some of the nursing homes were able to begin testing earlier by contracting with private labs, not all of the facilities had the means to do so.
Matthew Barrett, president of the Connecticut Association of Health Care Facilities, said money for robust testing is not included in the Medicaid payments to nursing homes. About 70% of nursing home care here is covered by federal and state Medicaid funding.
“Not all Connecticut nursing facilities are resourced equally,” he said, “and not all are resourced to do the testing.”
In April, Lamont signed an order that may have discouraged some nursing homes from arranging testing on their own. The order shields health care facilities from most lawsuits related to the coronavirus pandemic. That means families who lost a loved one in a nursing home will almost certainly be unable to sue over how the facility responded.
Athena Health Care Systems, which owns 24 nursing homes across Connecticut, began widespread testing in its buildings when the state supplied it with materials this month. But Timothy Brown, a spokesman for the company, said he wishes the state had given the homes testing equipment sooner.
“If it had been done earlier, we would have been able to identify residents and move them into quarantined sections,” he said. “It would have allowed for cohorting in a much more timely manner.”
Connecticut’s push to start broad testing in nursing homes followed a massive commitment of federal funds dedicated to testing. The state’s share of that was $182 million.
I wish we saw the risk sooner in nursing homes. That’s where the tragedy was; testing should have been faster and much sooner.”
But Connecticut has always had more than enough money to cover the cost of widespread testing.
A report by the American Health Care Association and National Center for Assisted Living estimates that testing all nursing home residents and staff in the state would cost about $8.2 million – a small fraction of the money Connecticut has in its rainy day fund.
Lamont acknowledged that the nursing home testing should have been done earlier.
“I wish we saw the risk sooner in nursing homes,” he said during a webinar with Hearst Connecticut Media Thursday. “That’s where the tragedy was; testing should have been faster and much sooner.”
Testing staff remains a challenge
While the state has moved ahead with testing all residents in Connecticut’s 213 nursing homes, testing employees in those facilities remains a challenge.
State officials initially said both would be tested at the same time. But days after the effort began among residents, nursing home operators said they weren’t given enough equipment to test the staff.
“We strongly support the state’s new initiative for testing all nursing home residents and hope that our staff will be included in future mass testing, as they are on the front lines of this pandemic,” Brown said.
Geballe, the chief operating officer, said at a recent press event that “union-related issues” had stalled testing among staff members. Where employees would be tested and whether they would be compensated for that time were among the issues Geballe recounted.
“We are a little frustrated by how long it’s taking to get the staff testing ramped up,” he said. “We’re doing everything we can to try to support that and push that along.”
The state is also working to ensure privacy rules are followed when employees’ test results are processed and returned.
Jesse Martin, a vice president of SEIU 1199 New England, Connecticut’s largest health care employee union, said the group has submitted recommendations to help speed up the process of testing workers. They include reimbursing staff for travel to testing sites – which for some can be far away – by paying them the equivalent of one hour’s work, and arranging for employees to be tested on their days off.
“We support testing en masse for both nursing home residents and staff,” he said. “That’s the only reasonable way for the state to start to understand the spread of the virus in long-term care facilities.”
In a memo to nursing home leaders on May 11, state health officials said worker testing should be considered, but that residents were the first priority.
“Cohorting residents is the priority for this … as they are a high-risk population residing in a congregate living setting,” they wrote. “As testing resources allow, staff testing should be considered. A resident [test] should not be delayed while planning for staff testing.”
The officials warned nursing home operators to have a plan in place for staffing should many workers test positive for COVID-19. Industry leaders said they are awaiting state guidance on that issue, given that some facilities were short on workers even before the pandemic began.
Dr. George A. Kuchel, director of UConn Health’s Center on Aging and chief of geriatric medicine, cautioned against waiting too long to test the staff.
Every single legislator in Connecticut has gotten at least one phone call from a panicked constituent who was worried about mom or grandma or grandpa in a nursing home.”
“In nursing homes, if you have limited testing capacity, who would you test first? The answer is … staff, because it’s become increasingly clear that that’s the common mode of transmission,” he said. “Many staff work in more than one facility.”
Despite warning signs from nursing homes elsewhere in the country and overseas, the state’s early, limited supply of testing materials was mostly directed toward hospitals and other urgent care centers, Kuchel said. Testing for non-symptomatic nursing home residents and staff should have been a priority.
“A lot of resources are put into the hospitals because … when it comes to infections and pandemics, we view hospitals as the main battlefield,” he said. “We listened more carefully to what was happening in other countries that were involved in this earlier. There were lessons – state leaders did not expect [nursing homes] to be the major battlefield.”
Additional scrutiny
With the prospect of another wave of COVID-19 cases this fall, some lawmakers want to take a closer look at how the spread of the virus was handled in nursing homes.
Rep. Sean Scanlon, a Guilford Democrat, has suggested putting together a task force to study the response from the state and nursing home leaders.
The group would include legislators, health experts, nursing home industry officials, union leaders and workers from the facilities. Members would review policies on the use of personal protective gear, the availability of protective equipment, infection control strategies and cohorting practices, among other issues.
In a study of nursing homes in 12 states – shared recently with the U.S. Senate’s Special Committee on Aging – University of Chicago researchers found that Connecticut had one of the highest percentages of facilities with coronavirus cases.
Of the 38 states that have reported nursing home and assisted living facility data, Connecticut ranked fourth highest in long-term care center deaths as a share of overall COVID-19 deaths, behind Minnesota, Rhode Island and New Hampshire, according to an analysis by the Kaiser Family Foundation.
The state ranks fifth in the total number of deaths in long-term care facilities.
“Every single legislator in Connecticut has gotten at least one phone call from a panicked constituent who was worried about mom or grandma or grandpa in a nursing home,” Scanlon said. “This is one of the issues I think has resonated with people more than any other and it’s something we should be looking at.”
A key area of focus would be testing in nursing homes – “Did it happen quickly enough, and if not, why?” he said. Scanlon is still gauging his colleagues’ interest in forming the task force.
“Legislators have a responsibility to serve as an oversight of other branches of government. I think we need to look at this with independent eyes,” he said. “We can learn from the mistakes and have a plan to address them in the event of a second wave.”