AARP Connecticut Urges Lawmakers to Address Deficiencies in Nursing Home & Long-Term Services

The COVID-19 pandemic has been an unprecedented public health crisis, and despite the best efforts of government officials and healthcare workers, nearly 13,000 Connecticut nursing home residents have contracted the virus since March, and more than 3,600 residents have died. These devastating losses have exposed long-standing and serious deficiencies in the systems that we rely on to serve older adults and people with disabilities.

AARP Connecticut is calling on lawmakers to take several actions to address this ongoing crisis and to start building a better future for the older adults and people with disabilities who need long-term services and supports. Below are policy recommendations for nursing homes and long-term services AARP Connecticut submitted to Connecticut’s Nursing Home and Assisted Living Oversight Working Group (NHALOWG) on January 8, 2021.
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AARP Connecticut respectfully submits the following recommendations for the NHALOWG’s consideration. A detailed discussion of each item follows this overview.

Staffing:

• Establish minimum staffing ratios to ensure 4.1 hours of nursing staff care per resident per day at skilled nursing facilities.
• Improve pay for nursing home staff and build a more robust, qualified, and stable long-term care workforce.
  

Social Connection:

• Ensure that resident care plans address isolation, risk for depression, and ability to interact with loved ones.
• Ensure that residents have the right to utilize a variety of communication devices in their rooms to permit residents to remain connected with their loved ones and to permit family caregivers to participate as a member of the resident’s care team.

Infection Control and Emergency Planning:

• Ensure and enforce that all nursing homes maintain an adequate stockpile of PPE.
• Revise the State’s Public Health Emergency Response Plan to include long-term care facilities and home and community-based services.

Accountability:

• Create a direct care payment ratio to ensure that public funding is used for resident care.
• End the civil immunity for nursing homes that was established through Executive Order 7V.
• Provide additional support for home and community-based services and explore other care options for older adults and people with disabilities.

Staffing
Residents, staff, and advocates have addressed the importance of staffing in several NHALOWG and NHALOWG subcommittee meetings. Low staffing levels mean that residents cannot get out of bed, use the bathroom, or eat in a timely manner; staff risk physical injury and cannot give residents the time and attention they deserve; visits with loved ones may be limited or cancelled; and it is more difficult for facilities to contain the spread of COVID-19 and other infectious diseases. In its September 2020 report, A Study of the COVID-19 Outbreak and Response in Connecticut Long-Term Care Facilities, Mathematica determined that “staffing rating [referring to the Centers for Medicare and Medicaid Services 5-star quality rating system] was highly predictive of the ability to limit the spread of COVID-19 in nursing homes.” [i]

Even prior to COVID-19, researchers were exploring the idea that staffing levels and other factors impacting care are interrelated. “For example, low staffing levels are associated with high turnover rates and vice versa. It is likely that adequate staffing levels must be addressed before improvements can be made in other factors such as turnover, management, and competency.” [ii]

Connecticut’s Public Health Code mandates only 1.9 hours of nursing staff care (from nurses and nurse aides) per resident per day, [iii] far below the 4.1 hours of care per resident per day that has been identified by the Centers for Medicare and Medicaid Services (CMS) as the minimum necessary to ensure adequate care. [iv] Legislation to improve staffing levels has been raised on a regular basis in Connecticut going back at least to 2014. [v] Connecticut nursing homes maintain staffing levels that are more or less aligned with national and regional averages, yet at 3.72 hours per resident per day (pre-COVID-19), these average staffing levels still fall below what is recommended. [vi]

The Mathematica report was not alone in finding that “nursing homes with high staffing ratings had significantly fewer cases and deaths per licensed bed.” [vii] A recent article in the Journal of the American Geriatric Society looked at COVID-19 infections in Connecticut nursing homes and found that “every 20 minutes (per resident day) increase in registered nurse staffing was associated with a 22% reduction in confirmed cases.” [viii] Another recent article explored the connection between nursing home staffing levels and COVID-19 outbreak severity and discovered that “implementing efforts to stem transmission, such as regular testing and cohorting of both residents and staff, is difficult without sufficient staffing levels…(and) having enough nurse aides to implement virus containment will be crucial if deaths are to be averted.” [ix]

Given the importance of staffing levels, AARP Connecticut strongly recommends that Connecticut adopt policies to:

• Improve nursing home staffing ratios. This could be done by increasing the mandated number of nursing staff care per resident per day outlined in the state’s Public Health Code (Conn. Agency Regs.§19-13-D8t) to the 4.1 hours per resident per day that CMS found to be necessary to ensure adequate care. Connecticut should also ensure an adequate workforce of non-nursing staff, including social workers, therapy, and recreation staff.
  
  Connecticut would not be the only state in our region to take action on staffing ratios. New Jersey’s Governor signed staffing ratio legislation in October of 2020 that requires a minimum of one certified nurse aide to every eight residents for the day shift, one direct care staff member to every 10 residents for the evening shift, and one direct care staff member to every 14 residents for the night shift. [x] In addition, Rhode Island’s Department of Health is currently working on guidelines that would establish a 3.8 hour per person per day requirement. [xi]

• Improve pay for staff and build a more robust long-term care workforce. Adequate pay and benefits are critical to attracting and retaining direct care staff in nursing homes and other long-term care settings. One in three nursing assistants relies on public benefits, and nearly half live in households earning less than 200 percent of the federal poverty level. [xii] As Connecticut’s population continues to age, it is critical for the state to work with long-term care providers to create jobs that pay a living wage, attract and retain quality workers, and offer opportunities for career growth. When possible, workers should also be given the opportunity to work full-time hours; this would lessen the need for nursing home staff to work in multiple facilities in order to make ends meet, and it would give more workers access to benefits.

We understand that these proposed measures come at a cost. We would consider supporting an increase in Medicaid reimbursement rates for facilities that meet augmented staffing levels as long as there were measures in place to ensure that most of this taxpayer funding goes directly to patient care (see our “Accountability” recommendation below regarding direct care payment ratios).

We also believe that serving more people in community settings is cost effective. Connecticut has made progress with its rebalancing efforts in recent years (moving more people out of institutional settings and serving them in home and community-based settings), with slightly more than half of Medicaid LTSS recipients receiving services in the community, [xiii] but there is room for improvement. According to AARP’s Long-Term Services and Supports State Scorecard, 12.3% of Connecticut nursing home residents have low care needs; [xiv] these residents could potentially transition to home- and community-based settings, and the savings from these transitions could be used to support quality of care measures like improved staffing ratios in Connecticut’s long term care facilities.

Social Connection
At some of the NHALOWG’s Socialization, Visitation, and Caregiver Engagement Subcommittee meetings, nursing home staff, residents and their loved ones have shared heartbreaking stories about the impact of visitation bans. At the NHALOWG’s Staffing Level Subcommittee meeting on December 14, 2020, a social worker shared the emotional impact of holding the phone for residents as they remotely said goodbye to family members who couldn’t be with them in their final moments. At other meetings, residents shared stories about not being able to see their friends within the facility, eating meals alone, and seeing a newly born grandchild held up to a window instead of being able to hold her. AARP Connecticut appreciates that resident and staff voices were included in these meetings; their experiences highlight the tension between keeping facilities safe from infection and ensuring that residents, staff, and families do not suffer undue harm from strict visitation bans.

Even before COVID-19, public health professionals warned of the adverse impacts of loneliness and social isolation, which include increased risks for dementia, heart disease and stroke, emergency department visits, and premature death that “may rival those of smoking, obesity, and physical inactivity.” [xv] Connecticut has been proactive in requiring virtual visitation [xvi] and reiterating federal visitation guidance from CMS, but these actions have not been enough to keep residents connected to their loved ones and ensure that their social and emotional needs are met.

 We recommend that the State take action to:

• Ensure that resident care plans address isolation, risk for depression, and ability to interact with loved ones. Care plans should explicitly indicate how residents’ social and emotional needs are being met and include measures to ensure that residents have regular opportunities for virtual and in-person visitation. There should be recourse that families and residents may take when facilities do not abide by visitation guidelines. The state should also, with stakeholder input, establish timelines and milestones to ensure the safe and prompt reinstatement of visitation and monitor the progress of each facility toward that goal. Facilities should be required to report their visitation protocols, visitation policy changes, and other relevant information in a manner that is easily accessible to residents and their family members. Finally, there should be a way for residents and their families to find assistance and hold facilities accountable when they believe they have been inappropriately denied visitation.

• Codify residents’ right to utilize communication devices in their rooms to permit residents to remain connected with their loved ones and to permit family caregivers to participate as a member of the resident’s care team. In addition to giving residents a way to stay connected to their loved ones, cameras and other technologies make it easier for family members to remain involved in their loved one’s care. While virtual visitation has obvious benefits right now while in-person visitation may be restricted and family members are worried about their loved ones’ well-being, it can be of great value even after in-person visitation resumes. Virtual visitation allows family members who are unable to regularly visit their loved ones, whether because of their own physical limitations or because they live far away, to stay connected and involved.
  
  • During the 2020 legislative session, the Long-Term Care Ombudsman proposed Substitute Language for HB 5208 that would have helped to address the use of cameras by nursing home residents. AARP supports this Substitute Language and recommends that it be further amended to include language regarding virtual assistants and other widely available assistive technologies. We believe this proposed language addresses concerns related to privacy and consent.

Infection Control and Emergency Planning
The Mathematica report emphasized the importance of infection control practices and PPE in preventing the spread of COVID-19 and noted that when COVID-19 came to Connecticut, “the state found itself short of staff with infection control expertise and PPE to supplement supplies at facilities.” [xvii] Actions by federal and state government that prioritized critical care hospitals left many long-term care facilities unable to easily access necessary PPE, and early shipments of supplies from the Federal Emergency Management Agency contained faulty gear and did not include the N-95 masks that staff desperately needed to protect themselves and curb COVID-19 spread. [xviii] These early missteps cost lives, particularly in states like Connecticut that were among the first to experience major COVID-19 outbreaks.

While access to PPE has improved since the spring, nursing homes continue to indicate a shortage of PPE, defined as not having a one-week supply of N95 masks, surgical masks, gowns, gloves, and eye protection during the last four weeks. Nationally, about one in five nursing homes (19%) had a PPE shortage during the four weeks ending November 15, a slight improvement from 20% during the previous month and 28-29% throughout the summer. During this timeframe, there was considerable variation in PPE supply among states: the proportion of nursing homes without a one-week supply of PPE ranged from less than to 1 in 20 (4%) to more than half (52%). In Connecticut, 17.1% of nursing homes reported that they did not have a one week supply of PPE during this four week period. [xix]

Given the critical important of PPE and ongoing difficulties with adequate supplies, AARP recommends:

• Nursing homes must be held accountable for maintaining adequate supplies of PPE, and the supply must be accessible to staff when they need it. Connecticut’s Department of Public Health issued an Order on September 24, 2020 [xx] that requires nursing homes to stockpile PPE. While this Order requires facilities to attest to their compliance with this Order, it is not clear that these attestations will be audited or that there will be any kind of intervention if a facility is found to be noncompliant. AARP Connecticut recommends that the state maintain its own stockpile of PPE and make it available to facilities that indicate a shortage of supplies. We also echo Mathematica’s recommendation that if PPE is kept in a locked storage container, facility management should ensure that at least one person on every shift has the ability to access the PPE supply.

No one was prepared for a public health crisis as long-lasting and as widespread as COVID-19, but there were clear gaps in Connecticut’s emergency planning. The Department of Public Health’s Public Health Emergency Response Plan has not been updated since 2011, and it includes no mention of either long-term care facilities or home and community-based services.

Moving forward, we recommend:

• As soon as possible, the Department of Public Health should revise its Emergency Response Plan to include all settings in which individuals receive long-term supports and services. These settings include nursing homes, assisted living facilities, and home and community-based settings. Revised plans should consider emergencies that require both evacuations and sheltering in place, and they should address both one-time and long-lasting emergency scenarios.

Accountability
Nursing homes are paid to keep residents safe and to make sure that their needs are met. There are basic standards of care in place to protect residents, and when those standards cannot be met, we need to ask difficult questions and ensure accountability. AARP Connecticut appreciates the extraordinary measures that many nursing home staff have taken during the pandemic to protect residents and meet their needs. Staff have risked their lives, worked extraordinarily long hours, experienced trauma, and done their best to provide social and emotional support while visitation has been restricted. Many of them have gotten sick, and some have died. When we ask for accountability, we are not diminishing the heroic work that we’ve seen from many staff, nor are we pointing fingers at individual facilities or administrators. What we are asking is that the system, as a whole, be held accountable for its ability or inability to serve older individuals and people with disabilities.

Connecticut has spent more than $1.5 billion per year on institutional care, such as nursing homes, in recent years [xxi] ; Medicaid accounts for roughly 70 percent of nursing home spending in the state. [xxii] Taxpayers deserve transparency about how this funding is used, and residents and their loved ones need to know that low-performing facilities will be held accountable for neglect or lapses in care. If facilities are not able to maintain consistent, high-level care at an affordable rate, this funding could be redirected to home and community-based settings. In addition to being the preferred LTSS setting for many individuals, these services are also more cost-effective and better able to minimize the spread of infectious diseases.

AARP Connecticut recommends that Connecticut take the following actions to create more accountability in nursing homes:

• Establish a direct care payment ratio to ensure that public funds are used for resident care. Medicaid is the primary payer of nursing home care, which means that the state has a great deal of control over incentives and payments. Connecticut should hold nursing homes accountable for the use of public funds by ensuring those funds are used to address the health and safety of residents and staff through such measures as testing, PPE, proper staffing, virtual visits, and infection control. Legislation recently passed and signed into law in New Jersey [xxiii] requires that at least 90 percent of a facility’s revenue be spent on direct resident care. This legislation could serve as a model for a direct care payment ratio in Connecticut.

• End civil immunity for nursing homes. While there may be some circumstances beyond facilities’ control for which they should not be held responsible, it is essential that long-term care providers, as well as health care providers more broadly, remain responsible for any negligent actions to ensure long-term care residents have some protection and opportunity for redress. For this reason, we have strongly opposed Executive Order 7V, which grants nursing homes civil immunity for “acts or omissions undertaken in good faith while providing health care services in support of the State’s COVID-19 response.” We are particularly concerned that this immunity extends to “acts or omissions undertaken because of a lack of resources, attributable to the COVID-19 pandemic that renders the health care professional or health care facility unable to provide the level or manner of care that otherwise would have been required.” [xxiv]
  
  Pursuing a nursing home neglect or abuse case in court is not easy to do. No family member who has lost a loved one due to neglect or abuse pursues this course of action lightly. It is always an option of last resort, but it must remain an option. Connecticut should not strip away the rights and protections of residents. Nursing homes should know they will continue to be held responsible for providing the level of quality care that is required of them, and for which they are being compensated, often at increased rates due to COVID-19.

• Provide support for home and community-based services and explore options for other forms of non-institutional care for older adults and people with disabilities. Although nursing home occupancy has been relatively stable in Connecticut in recent years, there has been an estimated 15% decline in occupancy since the beginning of the pandemic. [xxv] More than 8 in 10 adults want to receive care in the community as they age, [xxvi] and although it has always been important to help people receive care in the setting of their choosing, it will be more important than ever to provide robust and quality options for care in the community if low occupancy and changing preferences lead to nursing home closures.

We echo Mathematica’s assertion that it is increasingly important for the state to “maintain and potentially strengthen Connecticut’s Rebalancing Plan strategies, including increasing transitions of institutional residents to community settings through the Money Follows the Person program, Medicaid waiver programs, workforce development, connecting people to information about care options through MyPlaceCT.org, improving housing and transportation supports, and assisting the nursing home industry with aligning its business model with rebalancing trends while delicensing excess skilled nursing beds.” The state’s 2021 budget must maintain or increase support for the Connecticut Home Care Program for Elders, Community First Choice, the Alzheimer’s Respite Program, and other programs that keep people in their homes and communities. As previously mentioned, 12.3% of Connecticut nursing home residents have low care needs; [xxvii] with access to the right supports and services, it is likely that many of these individuals could thrive in community settings.

Connecticut could also learn from care models that have performed well during the pandemic. The Green House Project, a network of nonprofit homes that feature between 10 and 12 single-bed rooms per home, appear to have performed well during the pandemic. Although they only have publicly available data through July of 2020, during the first six months of the year, Green House Project homes had 32.5 confirmed COVID-19 cases per thousand residents compared to 126 cases per thousand in all certified nursing homes. During this same time period, 95 percent of Green House homes remained COVID-free. [xxviii]

None of this is to say that nursing homes do not have a valuable place in the future of our state’s LTSS system or that they are not an appropriate setting for some individuals. Many facilities throughout Connecticut provide excellent care, and thousands of Connecticut residents would likely select a nursing home as their preferred care setting. We do, however, have an opportunity to both improve the quality of nursing homes and create better and more innovative options for serving people in home, small group, and community settings. This presents an opportunity to engage older residents, people with disabilities, and their families who are currently receiving care as well as individuals who may need care in the future. What do current residents need? What do their families need? What is important to them? How do they want to live their lives?

Works Cited

• [i] Rowan et al. A Study of the COVID-19 Outbreak and Response in Connecticut Long-Term Care Facilities: Final Report. Princeton, NJ: Mathematica; September 30, 2020. p 20
• [ii] Harrington et al. The Need for Higher Minimum Staffing Standards in U.S. Nursing Homes. Health Services Insights 2016:9 13-19 doi:10.4137/HIS.S38994.
• [iii] Conn. Agency Regs.§19-13-D8t
• [iv] Centers for Medicare & Medicaid Services (CMS). Report to Congress: Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes Phase II Final Report. Baltimore, MD: CMS; 2001.
• [v] For example, Connecticut General Assembly House Bill 5322 from 2014. https://cga.ct.gov/asp/cgabillstatus/cgabillstatus.asp?selBillType=Bill&which_year=2014&bill_num=5322
• [vi] Rowan et al. A Study of the COVID-19 Outbreak and Response in Connecticut Long-Term Care Facilities: Final Report. Princeton, NJ: Mathematica; September 30, 2020. p 63
• [vi] Ibid p 19
• [viii] Li, Yue et al. COVID-19 Infections and Deaths among Connecticut Nursing Home Residents: Facility Correlates. Journal of the American Geriatrics Society 2020: 68 1899-1906 doi:10.1111/jgs.16689
• [ix] Gorges, Rebecca J. and R. Tamara Konetzka. Staffing Levels and COVID-19 Cases and Outbreaks in U.S. Nursing Homes. Journal of the American Geriatrics Society 2020:68 2462-2466 doi:10.1111/jgs.16787
• [x] New Jersey State Legislature, Senate Bill 2712, 2020. https://legiscan.com/NJ/bill/S2712/2020
• [xi] Gregg, Katherine and Patrick Anderson. “Raimondo discusses taxes, nursing homes, legalizing pot and more.” The Providence Journal, 15 December 2020, available at: https://www.providencejournal.com/story/news/politics/2020/12/15/where-raimondo-stands-taxes-nursing-home-staffing-marijuana/6549015002/ 
• [xii] PHI Staff. Raise the Floor: Quality Nursing Home Care Depends on Quality Jobs. Bronx, NY: PHI; April 2016. p 3
• [xiii] AARP, The Commonwealth Fund, and the SCAN Foundation. “Long-Term Services and Supports State Scorecard: Connecticut.” 2020. Available at: https://www.longtermscorecard.org/databystate/state?state=CT
• [xiv] ibid
• [xv] National Academies of Sciences, Engineering, and Medicine. 2020. Social Isolation and Loneliness in Older Adults: Opportunities for the Health Care System. Washington, DC: The National Academies Press. https://doi.org/10.17226/25663external icon
• [xvi] Connecticut DPH. “Order.” Hartford, CT: Connecticut Department of Public Health, May 9, 2020. Available at: https://portal.ct.gov/-/media/Coronavirus/20200509-DPH-Order-modifying-therequirements-regarding-visitor-restrictions-at-nursing-homes-reside.pdf?la=en.
• [xvii] Rowan et al. A Study of the COVID-19 Outbreak and Response in Connecticut Long-Term Care Facilities: Final Report. Princeton, NJ: Mathematica; September 30, 2020. p 39
• [xviii] Eaton, Joe. “Who’s to Blame for the 100,000 COVID Dead in Long-Term Care?” AARP. December 3, 2020, https://www.aarp.org/caregiving/health/info-2020/covid-19-nursing-homes-who-is-to-blame.html?intcmp=AE-HP-BB-LL2
• [xix] AARP Public Policy Institute. “AARP Nursing Home COVID-19 Dashboard.” AARP. December 10, 2020, https://www.aarp.org/ppi/issues/caregiving/info-2020/nursing-home-covid-dashboard.html
• [xx] Connecticut DPH. “Order.” Hartford, CT: Connecticut Department of Public Health, September 24, 2020. Available at: https://portal.ct.gov/-/media/Coronavirus/20200928-DPH-Order-on-PPE-in-nursing-homes-and-rest-homes.pdf
• [xxi] State of Connecticut Long-Term Care Planning Committee. “CT Rebalancing: Medicaid Long-Term Care Clients and Expenditures SFY 2020.” January 1, 2020.
• [xxii] Phaneuf, Keith. “Nursing homes want more emergency beds, state funding, to continue battling COVID-19.” CT Mirror, 17 July 2020, available at https://ctmirror.org/2020/07/17/ct-nursing-homes-want-more-emergency-beds-state-funding-for-covid/
• [xxiii] New Jersey State Legislature, Assembly Bill 4482, 2020. https://legiscan.com/NJ/text/A4482/2020
• [xxiv] Lamont, Ned. “Executive Order No. 7V: Protection of Public Health and Safety During COVID-10 Pandemic and Response – Safe Workplaces, Emergency Expansion of the Healthcare Workforce.” Hartford, CT: Office of the Governor of Connecticut, April 7, 2020. Available at https://portal.ct.gov/-/media/Office-of-the-Governor/Executive-Orders/Lamont-Executive-Orders/Executive-Order-No-7V.pdf
• [xxv] Jaffe, Susan. “Pandemic deals another blow to nursing homes: plummeting occupancy.” CT Mirror, 20 September 2020, available at https://ctmirror.org/2020/09/20/pandemic-deals-another-blow-to-nursing-homes-plummeting-occupancy/
• [xxvi] AARP Research. “Attitudes Toward Long-Term Care Amid COVID-19.” AARP. November 2020, https://www.aarp.org/content/dam/aarp/research/surveys_statistics/ltc/2020/nursing-home-long-term-care-attitudes-report.doi.10.26419-2Fres.00421.001.pdf
• [xxvii] AARP, The Commonwealth Fund, and the SCAN Foundation. “Long-Term Services and Supports State Scorecard: Connecticut.” 2020. Available at: https://www.longtermscorecard.org/databystate/state?state=CT
• [xxviii] The Green House Project. “The Green House Project COVID Study Report.” June 2020. Available at https://www.thegreenhouseproject.org/application/files/2415/9526/8890/GHP_COVID-19_Study_Report_Two_Pager_Jul_1.pdf