The Covid-19 pandemic has energized calls for a drastic solution: closing nursing facilities altogether. This year, Covid-19 has killed around one in every 35 nursing home residents in the United States—over 50,000 people. More than 1000 nursing facility staff members have also died from the disease. Even in the best of times, the industry struggles with quality care because of short-staffing, poor infection control, and abuse and neglect.

Why do we have these facilities where people are not receiving proper care?” said Susan Dooha, the executive director of the Center for Independence of the Disabled, New York. “Maybe we don’t need them.”

Deinstitutionalization is the effort to expand at-home or in-community care options for disabled people in need of long-term care.  In the US, such ambitions have run up against the for-profit nursing home industry funded by billions of dollars of taxpayer funds through Medicare and Medicaid payouts. That industry is tasked with providing care to vulnerable people in the nation. Institutional care is more expensive, and even though many nursing home facilities suffer from what critics say is a well-documented history of problems.

Advocates say problems have only intensified as large corporations began consolidating nursing home franchises. Around 70% of nursing homes in the US are under for-profit ownership, and, since the 2000s, private equity firms have purchased many facilities, hoping to cut costs and increase profits. One recent analysis, published by the New York University Stern School of Business, found “robust evidence” that private equity buyouts were linked to “declines in patient health and compliance with care standards.”

Nursing homes became commonplace in the 20th century, enabled by twin shifts in American life: government aid for the elderly, and medicine that allowed more people to reach an age where they could actually use it. Such facilities began multiplying shortly after the passage of the Social Security Act in the 1930s, and they expanded with the introduction of federal- and state-run health programs like Medicare and Medicaid in the 1960s. Nursing homes are distinguished by their capacity to provide skilled nursing care and, typically, 24-hour support for residents.

In the early 2000s, policymakers began doing more to prioritize home care for people who might otherwise have ended up in a facility. Emphasis was placed on supporting patients who could receive care in their own homes, either from family members or home health aides. A major 2018 survey from AARP, the aging-advocacy organization, reported that close to four in five Americans aged 50 and above prefer to age at home. “Most older people are anxious about the prospect of moving into a nursing home,” a recent analysis of studies in high-income countries reported, and studies consistently show high rates of depression in facilities.

For years before Covid-19, researchers have warned that norovirus, influenza, and other infections can spread rapidly in nursing facilities. Those risks have increased in recent years, as nursing homes take in more short-term residents who are getting rehabilitation after hospital visits, and who potentially bring infections into the building with them, said Lona Mody, who runs the Infection Prevention in Aging Research Group at the University of Michigan Medical School. In addition, Mody said, “staff members’ compliance to hand hygiene in the past has been not good.”

The scale of suffering during the pandemic has led to calls for change. “We’ve created this system, and now we’re telling all the people who work in it to just make it work. And it doesn’t work,” said Sonya Barsness, a gerontology consultant who works on reforming nursing home culture. “This pandemic,” she added, “has brought light to the reality that the system is not adequate to support the needs of people as they grow older.”

McKnight’s had an interesting article on what can be learned from the nursing home industry’s response to the coronavirus including increasing communication through online webinars where the staff can answer questions. Communicating effectively with staff also has been key.

“From bolstering communications to supporting staff to stepping in to help residents in the absence of visitors, many providers around the country have used the pandemic not to merely maintain operations, but to improve them.”

“It’s really created a comfort to families that they have a live stream with the facility,” he says. “It’s like putting on a familiar TV show … We didn’t expect that. In a general sense, it’s been a chance to express their gratitude and appreciation for the work we are doing under extremely challenging circumstances.”

“From the very beginning of the pandemic, our response efforts included the widespread and consistent use of Zoom meetings for education, communication and leadership support,” says Cheri Kauset, vice president of customer experience and communications for Tampa, FL-based Mission Health. “We even implemented quick and easy ‘Leadership in a Minute or Less’ tutorials at the beginning of our weekly calls to help guide our community leadership through some of the unique challenges they’re facing.”

The nursing home industry are seeing steep drops in occupancy since the start of the pandemic.  Experts do not expect those numbers to rebound any time soon. Weekly occupancy data trends from the federal government’s National Healthcare Safety Network’s database revealed median occupancy rates for skilled nursing providers have fallen as low as 75% in each of the three most recently reported weeks, according to CLA.

“For facilities that lost existing occupancy due to a COVID-19 outbreak, when coupled with a reduced incoming stream of residents, skilled nursing leaders expect it may be 18 months before their occupancy can recover to pre-COVID levels,” Cory Rutledge, managing principal at CliftonLarsonAllen, told McKnight’s Long-Term Care News.

“In addition, some skilled nursing facilities have experienced a significant occupancy decline due to COVID-19 infections in their building, which augments the issue,” he added. The National Investment Center for Senior Housing & Care said the pandemic and falling occupancy numbers have put the industry in a “challenging state,” but added the struggles won’t continue forever and nursing home care will eventually be needed.

Altarum’s Center for Value in Health Care detailed the spending decline in nursing homes this year in a new report. Spending for nursing home care dropped 7.2% from April to May despite other healthcare sectors showing signs of recovery amid the ongoing coronavirus pandemic. Analysts said they expect a gradual decline through at least the end of the year. Overall, nursing home care spending is down 12.7% from February.

The ongoing coronavirus pandemic has the skilled nursing industry in a challenging state right now after new data revealed occupancy at SNFs dropped to 78.9% by the end of April. In March, SNF occupancy had dropped to 83.4%, which were the lowest levels since 2012.

Rhyan also noted that employment in the sector fell 3% and 4% in April and May, respectively, when compared to last year. He added that though the industry is likely seeing increased spending in patients who require care for COVID-19, that’s being offset by a reduction in other types of care. He expects to see a continued decrease in spending as COVID prevalence increases across the country.

“Nursing homes did not have as near of a steep drop that in April, but we are seeing now this persistent decline into May,” senior analyst and report co-author Corwin Rhyan explained that the sector has seen a more “moderate decline” when compared to the other healthcare industries during the pandemic.

The ability for spending in the sector to rebound will depend on the “extent to which nursing homes get the virus under control,” added George Miller, report co-author, fellow and Research Team Leader for Altarum’s Center for Value in Health Care. “That’s a little hard to predict,” Miller said.

The findings also revealed that Medicaid revenue patient per day increased by $10.53, or 4.9%, when compared to April 2019.

The L.A. Times reported that nursing homes continue to violate federal law by “dumping” residents. Los Angeles prosecutors accuse a Lakeview Terrace skilled nursing facility of illegally “dumping” old and disabled residents onto the street and into homes that are not equipped to care for them in order to increase profits amid the coronavirus epidemic.

The “sustained” and “intentional” misconduct by the facility comes as nursing homes have an incentive to dump long-term residents to make room for COVID-19 patients, for whom they are paid much more.

Under Medicare’s new guidelines nursing homes are paid substantially more for new patients, especially in the first few weeks of their stay. So COVID-19 patients can bring in more than $800 per day, according to nursing home administrators and medical directors interviewed by the Times. By contrast, facilities collect as little as $200 per day for long-term patients with dementia, the newspaper said.

“This creates an incentive for nursing homes to seek out residents with higher rates of reimbursement and ‘churn’ residents by any means possible,” prosecutor Feuer wrote.

In one instance an 88-year old man with dementia was transferred from the nursing home and was later found wandering the streets profoundly confused a day later, according to the court filing. Another resident with HIV who was dumped on the street instead of being provided the hospice care he needed wound up cowering in a friend’s backyard, hoping that would keep him safe from the pandemic, the complaint said.

Lakeview Terrace, which has the lowest possible quality rating from Medicare, has a troubled history. Last year the city attorney filed a complaint that accused the facility of patient dumping, failure to provide residents with necessary care, failure to protect their safety and failure to maintain accurate and complete medical records.

The home’s administrators agreed to pay $600,000 as part of that settlement, $150,000 of which would cover the cost of an independent monitor. The home appeared to cooperate at first, Feuer said in an interview with the Times, but after COVID-19 arrived all outside visitors were barred from the building, including the monitor. That’s when the situation deteriorated rapidly, Feuer said.

If we don’t immediately begin universal testing of nursing home staff and residents immediately, COVID will eventually be in nearly every nursing home in the country where COVID is present in the surrounding community,” warned Harvard Health Policy Professor David Grabowski in testimony to Congress. It is too late by the time any staff member or resident develops symptoms. The Harvard researcher cautioned without universal testing nursing home workers have no idea what they are facing when they come to work each day. One of the barriers to universal nursing home testing, Grabowski said, is federal agencies are giving conflicting advice:

“The Centers for Medicare & Medicaid Services, the oversight agency, wants nursing homes to test workers weekly, but has not made it a requirement. The Centers for Disease Control and Prevention, however, has said that facilities can adjust how often they test workers based on the local prevalence of coronavirus.”

Nursing home staffers need personal protective equipment (PPE) like gowns, gloves, and masks. However, many nursing homes are reusing supplies while some do not have access to the strongly protective N95 masks and have to rely on lower-grade alternatives.

Grabowski said because of the lack of PPE and testing, most nursing homes have been closed to family members since March even though there is no reason that family cannot be tested and trained in the protective devices the same way that as staffers are.

“Nursing homes function better when family are involved in the care of their loved ones. Our research has supported the idea that care improves when a family member visits,” he noted.

In addition to universal testing and universal availability of high-quality PPE, nursing home care could be improved by a robust strategy to attack the critical shortage of workers at the facilities by quickly matching  unemployed workers to the job openings and to continue to develop a pipeline of trained staffers said Grabowski.

Gayla McDaniel was concerned when she got a call last week from the SavaSeniorCare nursing home where her uncle is recovering from a stroke.  The call from the caregivers at the SavaSeniorCare facility -Brian Center in Gastonia -was to let her know that her uncle was exposed by a staff member who tested positive for COVID-19. The next day, he was tested for the virus with a positive result.

Records released by the Gaston County Health Department show Cartner is one of at least 15 residents that have tested positive for the virus, along with two staff members. The paperwork shows the nursing home first reported a case on July 3 and the latest onset of symptoms was on July 7.

However the Brian Center in Gastonia is NOT included in the list of nursing home with outbreaks released by the N.C. Department of Health and Human Services. DHHS agreed to start publishing a list of outbreaks in April, after being threatened with a lawsuit to get access to the data. The agency publishes an “updated” list of facilities with outbreaks every Tuesday and Friday at 4:00 p.m. It has never been accurate or complete.

Gayla McDaniel, whose uncle is battling COVID-19 at a nursing home, said she wishes more would be done to alert the public.

“I think, when you’re exposed, family members should know immediately,” she said of nursing home residents exposed to COVID-19. “You know, the community should know. Everybody should know that there was an exposure.”

The COVID-19 pandemic has caused tens of thousands of deaths and more than three million infections, with predictions of many more to come. Nursing home residents have been among the most affected by the pandemic. In some states, half or more of all COVID deaths have occurred among nursing home residents. The situation is compounded by short-staffing; a lack of preparation, including insufficient personal protective equipment (PPE) for caregivers and testing to identify those infected in a timely fashion; and inadequate infection control procedures like hand-washing and cleaning.

COVID-19 cases are spreading rapidly throughout Texas nursing homes, recent state figures show. Overall, more than 1,500 residents have died from coronavirus in the state, while more than 11,100 cases have been reported.  The number of nursing home residents in the state who have tested positive for the coronavirus has increased by more than 60% in the last month.

“We had an opportunity to avoid what we’re experiencing right now,” Patty Ducayet, Texas’ long-term care ombudsman, told NBC News.

“We got this chance to see what other states did, what awful things they were experiencing, so we might be ahead of the crisis. Now I’m bracing for more deaths to come and more cases,” she added.

Last week, Texas Gov. Greg Abbott (R) confirmed that the state would not be easing restrictions on non-essential visitors at long-term care facilities. A spokesperson added that the decision was the “most prudent” for the safety of residents.