Long-term Care Services and COVID-19

The global reach of the coronavirus has been especially damaging to elderly populations. Care facilities for older Iowans have been ravaged by outbreaks, high case counts and deaths. We dive into the issues surrounding the pandemic and the care of older Iowans on this edition of Iowa Press.

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Funding for Iowa Press was provided by Friends, the Iowa PBS Foundation. The Associated General Contractors of Iowa, the public's partner in building Iowa's highway, bridge and municipal utility infrastructure. Iowa PBS is supported in part by Wells Fargo. Fuel Iowa is a voice and a resource for Iowa's fuel industry. Our members offer a diverse range of products including fuel, grocery and convenience items. They help keep Iowans on the move in rural and urban communities. Together we Fuel Iowa. I'm a dad. I am a mom. I'm a kid. I'm a kid at heart. I'm a banker. I'm an Iowa banker. No matter who you are, there is an Iowa banker who is ready to help you get where you want to go. Iowa bankers, allowing you to discover the genuine difference of Iowa banks.

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For decades Iowa Press has brought you politicians and newsmakers from across Iowa and beyond. Celebrating nearly 50 years of broadcast excellence on statewide Iowa PBS, this is the Friday, May 22 edition of Iowa Press. Here is David Yepsen.

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Yepsen: Since COVID-19 led to a widespread shutdown of businesses and schools in March, more than 16,000 Iowans have tested positive for the virus. But the hardest hit segments of our population are older Iowans, some of whom reside in long-term care facilities. Of more than 400 Iowa coronavirus deaths, over half of them have been individuals in long-term care facilities. The state of Iowa still lists dozens of ongoing outbreaks at these facilities as COVID-19 disproportionately impacts individuals over age 65. To discuss Iowa's situation we're joined by Brent Willett, President and CEO of the Iowa Health Care Association, the Iowa Center for Assisted Living and Iowa Home Care. Also joining us is Brad Anderson, State Director for AARP Iowa. Gentlemen, welcome to the show, it's good to have you with us.

Thank you, David. Good to be here.

Good to be here.

Yepsen: Also joining us across the table is Kay Henderson, News Director for Radio Iowa.

Henderson: Mr. Willett, for Iowans who aren't familiar with the organizations you represent, just briefly tell us what they are, what they do.

Willett: Yes, we are a statewide trade association that represents skilled nursing facilities, assisted living facilities and home health care agencies in all 99 counties and about 200 cities and towns.

Henderson: So what is a nursing home? People are more familiar with the term nursing home.

Willett: Sure, a nursing home is a facility where long-term health care is provided to, in our case, Iowans. Typically in two categories, someone who requires long-term care and they are living in the facility, also Iowans that are receiving skilled care in a rehabilitation situation.

Henderson: Mr. Anderson, what is AARP, just briefly?

Anderson: AARP is a national organization, a nationwide organization I should say, and we are dedicated to empowering older folks that are over the age of 50. We do obviously a lot of advocacy, which is what we're doing right now related to what is going on in our nursing homes. And we do a lot of programming here in the state.

Henderson: As David mentioned at the onset of this program more than half, actually 57% of the Iowans who have died are residents of long-term care facilities. Mr. Willett, why?

Willett: The reason that COVID-19 is affecting the population of skilled nursing facilities the way that it is across the country is because of the insidious nature of this virus. The folks who reside in long-term care facilities are typically there because they have very complex, very serious medical conditions. And unfortunately this virus could not be more tailor made to really ravage that population. The ability of the virus to persist in an individual who is not showing symptoms for up to 14 days is a terrible, terrible condition of the virus because it means that folks that work and visit the facility can unknowingly carry the virus and introduce it into a facility.

Henderson: But isn't the Iowa death rate among people who live in, residents of long-term care facilities higher than the national rate?

Willett: It is higher than the national rate. We also would look at the total number of deaths, we grieve every loss of life. The total number of deaths and the total number of outbreaks that we have in our state, which is three cases or more in a nursing facility, we have about 8.6% of our facilities are showing outbreaks as of today. The national average for that is between 15% and 20%. So we need to take a comprehensive look at how we're performing in Iowa because in a lot of cases we are performing remarkably well. Again, any death is unacceptable.

Henderson: Mr. Anderson, there are something in the range of 23,000 Iowans who live in a long-term care facility and about 55,000 Iowans who work there. What is your organization seeking in terms of testing or services for that group?

Anderson: Well, I just want to start by saying it is incredibly sad what is happening in nursing homes today and we have to do better. To me this is like, the virus in nursing homes is like a prairie fire that is just blazing across a dry prairie and we need to do everything we can to stop that fire. So a couple of things that we're looking at, at AARP is number one, testing. We have to do more testing. Testing, testing, testing, across the state of Iowa. It has to be in every single nursing home across the state and it has to be frequent and we have to get those results very quickly. Number two is PPE, personal protective equipment. I had a conversation this morning with Di Findley, the Director of the Iowa Caregivers Association, which represents caregivers and direct care workers on the front lines, they still don't have enough PPE. It is remarkable that we have been doing this since March and we don't have enough PPE. Virtual visitation is another thing that we're looking at, in other words, we want to make sure that residents in nursing homes have access to communicate directly with their loved ones through give them an iPad, give them Skype, there is federal funding right now that is available for that so it should be available in every single nursing home. And finally, increase transparency. And so I will credit the Governor, she was one of the first to shine a bright light on cases on nursing homes with three or more cases. We want to see that one or more. So in other words, if there is one single case in a nursing home we want that public. In addition to that, we want to see it applied to assisted living facilities as well, which are different from nursing homes, we understand that, but we believe that shining a light on what is also happening in assisted living facilities will give people ease in terms of knowing what is going on in the state of Iowa related to people both in nursing homes and those other facilities.

Henderson: Mr. Willett, is that something you would support, having an outbreak defined as one person in a facility and including assisted living facilities, which currently the state is not reporting in terms of outbreaks?

Willett: Well, the definition of an outbreak I think is a different question. Certainly we would support any reporting that is mandated on the sector from the state and federal government. And I think, Brad, that the association is going to get its wish as we have begun to report into the National Health Standards System through the CDC just in the last week which is a new mandate from the Centers for Medicare and Medicare Services. We understand that that data will be publicly available and that should source it down to a single case.

Henderson: In both kinds of facilities?

Willett: The NHSB is not applicable to assisted living because they are not federally regulated.

Yepsen: And what is that acronym for?

Willett: The National Health Standards Board, which is a health care reporting system that has typically been used for hospitals, it has been expanded by order of CMS to now including reporting from all 15,000 nursing homes in the United States.

Yepsen: Mr. Willett, I realize we're in the middle of a storm here. But do you or your members think what should we be doing differently? What should we have done differently? Or what should we be doing differently right now?

Willett: I think that what we are focused on right now is how to play the long game with COVID-19 because we know that as society at large begins to embark on the path towards some semblance of normal, things won't be normal for the health care sector for a long period of time, until we ultimately have a vaccine. And so what we are focused on is what measures we can take not only to further mitigate the introduction of the virus into a nursing home, but what steps can we take to improve the access to loved ones and families for residents of nursing homes?

Yepsen: More specifically, Mr. Willett, do we need more inspections of homes and care facilities?

Willett: We have enhanced inspections underway now. The Department of Inspections and Appeals is conducting an infection control specific survey for every nursing home in the state. Currently we think that that level of enhanced inspection is appropriate and we're not calling for additional inspections, however we would certainly comply with anything that came.

Yepsen: Mr. Anderson, do we need more inspectors in these homes?

Anderson: What I think we need honestly is to double down on our investment in the ombudsman's office because the long-term care ombudsman -- there are two different roles, right, the inspectors that inspect the problems after they happen, but then there's the ombudsman that can catch it on the front end because if you have a complaint you call the long-term care ombudsman and he or she addresses that complaint. In addition to that, the ombudsman educates consumers on their rights. And so right now ombudsmen across the entire nation are under siege because there are a lot of folks out there that have questions. I believe and AARP believes that these are incredibly important offices and right now we've seen their real value, so the time to strengthen, there is no time like the present to strengthen that office and make sure that we're catching these issues on the front end rather than the back end.

Yepsen: Set me some benchmarks. Strengthen, to do more of what and how much more money would it take?

Anderson: I don't know dollars and cents, frankly, but I do know we need more people. We need more people which obviously is going to be an additional investment. So right now it is really up to the legislators to figure out, okay, are we at an adequate position right now with the ombudsman’s office, or do we need more resources? We believe we need more resources there.

Yepsen: Mr. Willett, how do you react to that? Instinctively industries they don't like more regulation, they don't want more inspections. Would these ideas fly with your members?

Willett: We support the work of the long-term care ombudsman office and we would absolutely support their enhanced ability to visit nursing homes. We don't particularly regard them as a regulatory mechanism. We see them as an advocate for the residents and their families and we think they play a very important role.

Yepsen: Do we need to redesign these home and these facilities so the air quality is better and the air movement and the security? Some of these facilities are old. Do we need to redesign these buildings?

Willett: Ideally absolutely yes. We have facilities that, to your point, that range in age across the state. And with adequate resources the investment in capital, physical plant improvements would be a top priority and continues to be a top priority for facilities. What we've seen is in light of, in response to COVID-19 is a real reshuffling of physical plant space in most nursing facilities, as most nursing facilities have established COVID-19 isolation capabilities to prepare for the eventuality of a case.

Henderson: What about designating a whole facility as COVID-19 capable and segregating completely in a separate facility?

Willett: You're talking about like a COVID-19 specific facility? We'd support it. We've looked at those models, there are a handful of states, Massachusetts is a state, for example, that has done that and have looked at some models. We would support it. I think what most policy makers that look at this would need to look at is where is the demand on the hospital system? In our case in Iowa fortunately thus far we haven't seen that really strong surge scenario that we were concerned about. As we tick closer to that I think that it's very appropriate to plan for those kinds of eventualities and we would absolutely be supportive and work to establish one of those facilities.

Henderson: Mr. Anderson mentioned a lack of PPE. Do nursing homes need more PPE? And how are you getting it?

Willett: Nursing homes need more PPE. Nursing homes need more PPE because we know that we are in this for the long haul and that we need to be inventorying PPE, the entire health care system needs to inventory more PPE than it ever has before. I think that we have seen thus far that we have not faced a PPE shortage crisis in a nursing home where we ran out of PPE. When we have needed to access emergency supply of PPE the state has responded and so we have had some access to that.

Yepsen: The state of Iowa and county governments spend an awful lot of time and money building up piles of rock salt. Why do they do that? Because we have blizzards and we need these stockpiles. Is it time for us as a state, and I'll start this with you, Mr. Anderson, for Iowa to be stockpiling more PPE, ventilators? This COVID is going to be around for a while and if not this, what's next? Do we need more of a strategic stockpile of these things?

Anderson: We do and we've had these conversations with every member of the delegation here in Iowa and we've made that clear that the time has come to make that investment. But, David, I want to go back to your question about the nursing home care industry and the model. I think the time has come, the fact that we're having this show right now is great, right, the fact that we're talking about long-term care is great news. I think the time has come to revisit the entire model of long-term care in the state of Iowa. What is our long-term care plan is a great question to start asking people. Secondly, we at AARP have been doing surveys now for over 25 years on what consumers want in terms of long-term care. Do you know what the answer is? It boils down to three words, stay at home. They want to stay at home. And so we still have this outside emphasis in Iowa on nursing homes. But why are we not paying closer attention to what consumers want and thinking of a model that allows them to stay at home? In Iowa, another data point is we have among the highest rate of people with low care needs in nursing homes. That may sound like an obscure data point. It's a really profound data point actually because what that means is there are a lot of people in nursing homes right now that could get that care or better at home which is where they want to be. This whole model that we have needs to be revisited. COVID-19 is a wake-up call to this industry and the time has come to start having those conversations at the federal and at the state level.

Willett: I'm not familiar with that particular data point. But I do know that the desig -- in order to receive care in a nursing facility you have to meet something called nursing facility level of care, that is a state and federal regulation. That is something that is routinely reviewed and we adhere to. We represent home care agencies as well at our association and so we absolutely support Iowans receiving care in their home if they can do so safely. What we also know is that as Iowans grow older they develop more and more complex comorbidities which makes it more and more difficult to care for those individuals at home. We have 36,000 Iowans receiving care in nursing facilities in Iowa, we have 20,000 living in assisted living programs and another 20,000 to 25,000 in home care. So we need to recognize that we have a robust home care system, we want people to receive that care when they can, but we also need to recognize that there is a very important role for long-term care facilities to provide that kind of care.

Yepsen: We've got way too many questions and not enough time. Kay?

Henderson: A lot of people have been talking about the heroes of the pandemic, truck drivers, grocery store clerks and people who work at nursing homes. What will be the discussion in the middle of the pandemic and after about raising their salaries?

Willett: I think that long-term care health care providers have shown their medal in a way, they have shown valor in a way that we haven't seen in peacetime in probably two generations. And what we're seeing is their investments paying off in controlling this pandemic. And so they absolutely need to be fairly compensated. And what is important about our sector, just like the rest of the health care sector, is that we participate in market wages, for our long-term care facilities represent about 80% of the cost. And so we're acutely aware in the necessity to be competitive for wage levels. Quite frankly the job got harder and it's probably more permanently difficult because of COVID-19.

Yepsen: So you think the marketplace is going to take care of this problem of low paid --

Willett: I do.

Yepsen: Mr. Anderson, what do you say?

Anderson: Do you know what the pay is? The median wage for a direct care worker right now is $13.80 an hour, David. I know you're a dollars and cents guy so you understand this. $13.80 an hour is not enough money for the type of work that these folks are doing and right now is a great example of that because right now they are working through the night, they're working multiple shifts and they are literally risking their lives. It just makes me emotional to think that these people are on the front lines, they are heroes, like Kay said, I agree with that 100%. And they are making $13.80 an hour. We need to commit ourselves to raising that wage at a minimum and then of course providing them the PPE they need to be safe.

Yepsen: Okay, but the marketplace is not raising that $13. Maybe that will happen as people see the risks. I can see a situation where you'd have a hard time attracting people to work in this industry, not just because the pay is low, but because it's a hazard. So, Mr. Anderson, won't this require some sort of government regulation and standards of what the salary levels ought to be?

Anderson: I think it will require some government intervention. I also think it requires a spotlight. Again, we are having this show, which is great, we have been putting out studies for 25 years on long-term care consumers and frankly it has not received the type of coverage that we think that it should receive in terms of from political folks, from the media, from all the partners. And so I think the fact that we are now paying attention to these direct care workers, people need to know what they're getting paid. The median wage, again, $13.80 an hour is simply not enough.

Henderson: Mr. Willett, what percentage of folks who are living in an Iowa nursing home today are on Medicaid?

Willett: 52%.

Henderson: So how much of the price or operating funds of a facility are controlled by rates that are set by the government?

Willett: Effectively 52%. The revenue entering a facility is derived almost exclusively by Medicaid and private pay rates.

Henderson: So what is the industry position? Are you lobbying for X amount? I know there are some discussions at the federal level about providing hazard pay. What is your industry lobbying for at the state and federal level?

Willett: At the state level we are lobbying to close the gap, the Medicaid shortfall. The Medicaid system was designed never for facilities to make a dollar on Medicaid, it was designed to cover the cost of an Iowan receiving care so that facility can do that. Currently our state share shortfall of Medicaid is about $32 million. We took an important step last session by helping to close that gap with an appropriation of about $24 million. We need to take another bite out of the apple. At the federal level, our national association continues to lobby Congress for additional dollars into the system and we have had a series of infusions of stimulus dollars into the sector from the federal government, most recently from the CARES Act.

Yepsen: Mr. Anderson, what do you want the legislature to do in the next session? They're still coming back for a session so they could --

Anderson: Well, I want them to pay attention to a couple of things, the ombudsman's office, I want them to talk about that and have a conversation about that, number one. Number two is elder abuse. So this is something that has bipartisan support, that is going on, financial exploitation and we're seeing it certainly with the stimulus dollars that are going with seniors. We need to curb elder abuse. Believe it or not, I believe your organization supports that as well, that today it is not a crime, elder abuse is currently not in the statutes as a crime. And so we're working with the Attorney General's Office and republicans and democrats to get that done and I'm confident that we will get that done this legislative session.

Yepsen: We've only got a minute left. Real quickly, a lot of us confront the issue of having to put a loved one in a home. What should a consumer look for in a care facility? What are some of the things, quickly, that you think people ought to look for as they shop around for a home?

Willett: Due diligence is incredibly important. They should check Nursing Home Compare which is a federal website which provides survey history for that facility. They should talk to staff members. They should ask the staff for contact information for families that have volunteered to be available to discuss their experience in the facility. And they should be talking with the facility about their response to COVID-19.

Anderson: Be persistent. So if you have a question about your loved one, call the home. If you still have questions and you’re not getting answers, call the ombudsman. If you're still not getting answers, call the media.

Yepsen: I've got to interrupt. We're out of time. Thank you both for being here and thank you for the work that your members are doing.

Thank you.

Thank you, David.

Yepsen: And we'll be back next week for another edition of Iowa Press at our regular times, Friday night at 7:30 and again at Noon on Sunday. For all of us here at Iowa PBS, I'm David Yepsen. Thanks for joining us today.

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Funding for Iowa Press was provided by Friends, the Iowa PBS Foundation. The Associated General Contractors of Iowa, the public's partner in building Iowa's highway, bridge and municipal utility infrastructure. Iowa PBS is supported in part by Wells Fargo. Fuel Iowa is a voice and a resource for Iowa's fuel industry. Our members offer a diverse range of products including fuel, grocery and convenience items. They help keep Iowans on the move in rural and urban communities. Together we Fuel Iowa. I'm a dad. I am a mom. I'm a kid. I'm a kid at heart. I'm a banker. I'm an Iowa banker. No matter who you are, there is an Iowa banker who is ready to help you get where you want to go. Iowa bankers, allowing you to discover the genuine difference of Iowa banks.