Families applaud, some doctors worry as nursing homes open big doors for visitors

For nearly 20 months, the estimated 1.3 million Americans living in nursing homes and their families have struggled with strict visitation policies which, while designed to protect vulnerable residents from the coronavirus, have caused of distress to separated loved ones and had serious health consequences for many suddenly isolated. seniors.

Initially, visitors were completely prohibited. Later, establishments enforced various rules: some banned visitors from residents’ rooms, allowed visitors only outside and during brief scheduled windows, or allowed only one to stay. that time.

Many of those restrictions were based on rules, called “guidelines,” mandated by the Centers for Medicare and Medicaid Services, the federal agency that closed the facilities to visitors in March 2020. It has issued several revisions since.

Now all that has changed. On November 12, the federal agency removed virtually all such restrictions and advised nursing homes across the country to allow visits “for all residents at any time.” The agency noted that 86% of nursing home residents in the United States and 74% of employees were fully vaccinated and that Covid-19 cases had declined significantly.

Updating means no more limits on frequency, time, duration, location or number of visitors. Access to resident rooms, unless a roommate is not vaccinated or immunocompromised, is permitted and no advance planning is required.

Federal policy still encouraged vaccination and emphasized infection control measures, including masks and distancing policies established by the Centers for Disease Control and Prevention.

“It makes an important statement,” said Lori Smetanka, executive director of the National Consumer Voice for Quality Long-Term Care, an advocacy group that had pushed for such a change. Previously, “the facilities had a lot of discretion,” she said. “While it is quite clear: it puts the rights in the hands of the inhabitants.

While facilities can ask visitors for their immunization status and encourage testing, they cannot require immunizations or entry tests. Even during a Covid outbreak, under the new directive nursing homes must allow visitors inside, albeit with masks. Visitors who refuse to disclose if they are vaccinated must also wear masks.

The rules only cover nursing homes, which are regulated by the federal government, but they can have a ripple effect. “I think many states will apply this to other settings, like assisted living,” Smetanka said. California, for example, has already responded by relaxing some assisted living rules.

In nursing homes, with their frail and disabled residents, “there may be precautions, but cutting residents off from their families was unethical and bad care,” said David Grabowski, researcher in health care at Harvard Medical School. “These are not social visits.”

With nursing homes short of staff long before the pandemic, family visitors frequently helped feed, wash and dress loved ones. They not only reassured and stimulated, but also the ability to monitor the safety and quality of the installation. A study co-authored by Dr Grabowski, for example, showed that nursing home residents with dementia received better end-of-life care if a family member visited them regularly.

When the pandemic interrupted these contacts, for more than a year in many cases, families reported a worrying decline in their health. A study of Connecticut nursing home residents, for example, found substantial increases in depression and unintentional weight loss during lockdown; incontinence increased and cognition decreased.

Trish Huckin spent nearly a year battling administrators at her 96-year-old mother’s nursing home in Pinckney, Michigan, before being allowed in for so-called compassionate visits. Even then, “the restrictions were ridiculous,” she said. The establishment allowed him three one-hour visits per week in a public space, only by appointment. If she couldn’t show up at one of the agreed times, she couldn’t reschedule.

When the facility finally eased restrictions, Ms Huckin – along with his wife, a hospital nurse – was finally able to see her mother, who had dementia, in her room. They found that in addition to losing weight and becoming depressed, her mother developed a pressure sore and early pneumonia.

Claudia Hutchinson also saw her sister, who resides at a facility outside of Philadelphia, become depressed and lose weight and mobility since her visits were limited to an hour or less outdoors. “If we had been allowed in, she wouldn’t have had this downward spiral,” she said. “She would not be in hospice care.”

Some doctors and families now fear that the pendulum has gone too far, that the full reopening will leave an already vulnerable population in the grip of another wave. Covid infections are on the rise in nursing homes; influenza cases are also on the rise nationwide.

On the day the new federal guidelines were announced, a Connecticut nursing home reported the deaths of eight residents with serious underlying health conditions following an outbreak in late September.

“For people to come in and out during an outbreak, we know it’s not a good idea,” said Dr. Karl Steinberg, California geriatrician and president of the Society for Post-Acute and Long-Term Care Medicine, which represents health. long-term care providers.

As a medical director or attending physician in three nursing homes, he saw the pandemic’s early toll: “It was a bloodbath. He would have liked the latest federal guidelines to have left administrators more flexible. Medicare could also have waited after the holidays, he noted, and until the booster shots were more widely distributed.

Despite the removal of federal restrictions, some administrators believe state and local health regulations could replace new federal guidelines, which could lessen their impact.

“The standard rule is that an institution must follow the more restrictive rule,” said Dr. Noah Marco, chief medical officer of the large Jewish home in Los Angeles. He is cautiously optimistic that in a few weeks the state and county will also relax their policies. But for now, the facility continues to require advance planning, limit the length of visits, and allow each resident only one visitor at a time inside.

Since the announcement of the new federal policy, “our staff have been on the phone all the time,” said Dr. Marco. “We’ve had family members who heard about this and say, ‘Yippee!’ We had to say, “We’re so sorry, but not so quickly. “

A representative from the Centers for Medicare and Medicaid Services said state or local health services may need to reinstate restrictions “for serious safety reasons”, but only in “isolated situations.” The representative added that “local governments should generally not seek to add rules and regulations that limit the right of a resident of a nursing home to receive visitors.”

The new federal policy – bolstered by the Biden administration’s mandate that all nursing home staff must be fully immunized by Jan.4 – is likely to relax more extreme local and state policies.

Alison Hirschel, the attorney in charge of the Michigan Elder Justice Initiative, advised a woman whose relative, in her 60s, suffered a brain injury after an accident and entered a nursing home a few months ago.

“She was very distressed,” Ms Hirschel said of the adviser, who lives out of state. “She had to drive seven hours for a visit, and the visit was limited to 15 minutes – and only on weekdays during office hours.”

Then, a day after the liberalized federal policy was announced, Michigan issued new guidelines allowing visits at any time, with no limit on length of visit or number of visitors. “It really is a complete game changer,” Ms. Hirschel said.