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Beyond COVID-19: Changes in Long-term Care


By Lori Mars, JD

To date, almost 660,000 nursing home residents in the U.S. have contracted COVID-19[i] and more than 133,000 have died of the virus and/or related complications.[ii] The number of casualties remains unprecedented and astounding. Yet, the full impact of the disease on surviving residents is still unknown. For much of the past year, beyond the bare numbers reported by long-term care facilities to the Centers for Medicare and Medicaid Services (CMS), little was revealed about the lived experiences of facility residents. Contagion containment restrictions imposed by CMS and implemented by facilities prevented most outside visitation and oversight. Even long-term care ombudsmen, who advocate on behalf of residents and ordinarily have unfettered access, were denied entry to limit residents’ exposure to the virus and prevent transmission of the disease within and outside of facilities.

As residents were vaccinated earlier this year, restrictions gradually relaxed, visits provisionally resumed, and the adverse effects of enforced isolation surfaced. Both residents who contracted the virus and those who were collaterally impacted by institutional proscriptions, were significantly affected. Protocols intended to prevent the swell of the disease had the incidental and overwhelming impact of destabilizing residents from the constancy of their known worlds.

Protective recommendations announced by CMS were implemented disparately by facilities, but uniformly felt by residents whose daily routines were upended. Residents who previously roamed facility halls were now confined to their rooms. They were deprived of the companionship and community of their friends at congregate meals and group social activities. When family visits were suspended, many residents became detached from the warmth and security that had sustained them. Residents with neurocognitive deficits became increasingly confused, unable to understand and comply with the restrictions imposed.

By necessity and sometimes without notice, COVID positive residents were removed from their rooms and cohorted in COVID-coded areas. Many were quarantined in isolation units. Some were shuttled between zones depending on the severity of their illness. Overworked caregivers balancing their job duties and their own fears of contracting the virus,[iii] unwittingly added to the situational precarity.[iv] Amid disease, compelled seclusion, and uncertainty, residents often became disoriented and fearful. To make matters worse, the personal effects, photographs, and religious items from which residents had drawn comfort were not permitted in sterile quarters. In many facilities, quarantined residents had no TV, smartphone, or external outlet, exacerbating isolation and loneliness. 

Pervasive systemic deficits which pre-dated the pandemic, including understaffing, high employee turnover, insufficient infection prevention controls, poor quality care, and disparate treatment for Black and Latinx residents further fueled the spread of disease and contributed to resident illness and apprehension. Today, as the pandemic ebbs and wanes, many thousands of facility-bound elders struggle with lingering traumas.

Throughout the past year-and-a-half, even though unable to conduct in-person visits, long-term care ombudsmen worked tirelessly to relieve the suffering and loneness experienced by residents. They mobilized to improve conditions within facilities and increase connectivity to the world outside. For months, ombudsmen surmounted extraordinary obstacles to secure personal protective equipment for residents and staff, coordinate the delivery of food and needed provisions, and facilitate remote interactions between residents and family members. They have risen to the challenge to ease residents’ burdens in manifold ways. But the charge to improve the lives and relieve the traumas of institutionalized elders is not theirs alone.

It is incumbent upon us, individually and as a society, to engage and advocate for reform. Over 30 years ago, the federal government enacted the Nursing Home Reform Act, which included provisions for individualized care and sufficient staff to enable residents to attain the highest possible level of physical and psychosocial wellbeing and function.[v] For far too long, the industry has not met this standard.[vi] Practice deficits are striking. Oversight and enforcement are lacking.[vii] And, with the incursion of coronavirus, facilities have been under-equipped to meet the residents’ heightened needs.

Systems change is long overdue. As advocates, we can urge policymakers to take reformative action: increasing regulatory enforcement, linking Medicaid payments to resident outcomes, mandating minimum care staffing levels to prevent neglect,[viii] requiring facilities to dedicate a portion of their federal funds directly to resident care,[ix] and funding smaller, resident-focused facilities and in-home and community-based services,[x] among other actions. We can also encourage the long-term care industry to foster a culture of healing and recovery to promote resident confidence and wellbeing. Hiring registered nurses with geriatric expertise,[xi] training certified nursing assistants in trauma-informed care delivery, and retaining qualified social workers to provide therapeutic psychosocial supports would be a promising start.[xii] Regulatory reforms and person-centered culture change are needed to assure residents the quality of care and lives they deserve.

The author would like to acknowledge Rachel Tate, MSW, for her expert insights and contributions to this blog. Ms. Tate is the Regional and Special Projects Director for the Long-term Care Ombudsman program at WISE and Health Aging in Los Angeles.


[i] COVID-19 Nursing Home Data. (2021, July 17). Data.CMS.gov. Retrieved from https://data.cms.gov/stories/s/COVID-19-Nursing-Home-Data/bkwz-xpvg/

[ii] Ibid.

[iii] White, E. M., Wetle, T. F., Reddy, A., & Baier, R. R. (2021). Front-line nursing home staff experiences during the COVID-19 pandemic. Journal of the American Medical Directors Association22(1), 199-203.

[iv] Over 588,000 cases of COVID-19 and nearly 2000 deaths have been reported among staff. See COVID-19 Nursing Home Data. (2021, July 17). Data.CMS.gov. Retrieved from https://data.cms.gov/stories/s/COVID-19-Nursing-Home-Data/bkwz-xpvg/

[v] Harrington, C., Chapman, S., Halifax, E., Dellefield, M. E., & Montgomery, A. (2021). Time to Ensure Sufficient Nursing Home Staffing and Eliminate Inequities in Care. J Gerontol Geriatr Med7(099), 2.

[vi] Office of the Inspector General. (2017). Early Alert: The Centers for Medicare and Medicaid Services Has Inadequate Procedures to Ensure That Incidents of Potential Abuse or Neglect at Skilled Nursing Facilities Are Identified and Reported in Accordance with Applicable Requirements. A-01-17-00504 (U.S. Department of Health and Human Services, Aug. 24, 2017).

[vii] Kohn, N. A. (2021). Nursing Homes, COVID-19, and the Consequences of Regulatory Failure. Georgetown Law Journal, 110.

[viii] Ibid.

[ix] Ibid.

[x] Grabowski, D. C. (2020). Strengthening Nursing Home Policy for the Postpandemic World: How Can We Improve Residents’ Health Outcomes and Experiences. New York: Commonwealth Fund.

[xi] Bakerjian, D., Boltz, M., Bowers, B., Gray-Miceli, D., Harrington, C., Kolanowski, A., & Mueller, C. A. (2021). Expert nurse response to workforce recommendations made by the coronavirus commission for safety and quality in nursing homes. Nursing outlook.

[xii] Roberts, A. R., Smith, K., Bern-Klug, M., & Hector, P. (2021). Barriers to Psychosocial Care in Nursing Homes as Reported by Social Services Directors. Journal of Gerontological Social Work, 1-19.

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