For nearly 20 months, the approximately 1.3 million Americans living in nursing homes and their families struggled with strict visiting policies that, while designed to protect vulnerable residents from the coronavirus, caused distress to separated loved ones and seriously impacted the health of many. who suddenly became isolated seniors.
Initially, visitors were completely barred. Later, the facilities enforced a number of rules: some banned visitors from residents’ rooms, allowed visitors only outside and during short scheduled windows, or allowed only one at a time.
Many of these restrictions were based on rules, known as “guidance,” imposed by the Centers for Medicare and Medicaid Services, the federal agency that closed facilities to visitors in March 2020. It has since issued several revisions.
Now that has all changed. On November 12, the federal agency virtually all such restrictions removed and advised the country’s nursing homes to allow visits “at all times to all residents.” The agency noted that 86 percent of US nursing home residents and 74 percent of workers were fully vaccinated, and the number of Covid-19 cases had fallen dramatically.
The update means no more limits on frequency, time, duration, location or number of visitors. Access to residents’ rooms is permitted unless a roommate is unvaccinated or immunocompromised, 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, the executive director of the National Consumer Voice for Quality Long-Term Care, an advocacy group that had pushed for such a change. Previously, “facilities were given a lot of discretion,” she said. “While this is pretty clear: it reflects the rights in the hands of the residents.”
While facilities can ask visitors about their vaccination status and encourage testing, they cannot require vaccination or testing for entry. Also during a Covid outbreak, nursing homes under the new guidance must let visitors in, albeit with mouth caps. Visitors who refuse to reveal whether they have been vaccinated must also wear masks.
The rules only apply to nursing homes, which are federally regulated, but they can have an spillover effect. “I think many states will apply this to other institutions, such as assisted living,” said Ms Smetanka. For example, California has already responded by relaxing some rules for assisted living.
In nursing homes, with their frail and disabled residents, “there may be precautions, but it was unethical and poor care to separate residents from their families,” said David Grabowski, a health researcher at Harvard Medical School. “These are not social visits.”
Because nursing homes were short of staff well before the pandemic, family visitors often helped feed, wash and dress their loved ones. They not only provided reassurance and encouragement, but also the opportunity to monitor the safety and quality of the facility. A study of which Dr. Grabowski co-authored showed, for example, that nursing home residents with dementia developed better end-of-life care when a relative comes to visit regularly.
When the pandemic cut off this contact, in many cases for more than a year, families reported troubling declines in health. For example, a study of nursing home residents in Connecticut found: significant increase in depression and unintended weight loss during the closure; incontinence increased and cognition decreased.
Trish Huckin battled administrators at her 96-year-old mother’s nursing home in Pinckney, Michigan, for nearly a year before being allowed in to make so-called compassionate care visits. Even then, “the restrictions were ridiculous,” she said. The facility allowed her three one-hour visits per week in a public area, by appointment only. If she couldn’t meet one of the agreed times, she couldn’t make another appointment.
When the facility finally eased restrictions, Ms. Huckin — with her wife, a hospital nurse — was finally able to see her mother, who has dementia, in her room. They found that her mother had not only lost weight and become depressed, but had also developed bedsores and early pneumonia.
Claudia Hutchinson has also seen her sister, who lives in an institution outside of Philadelphia, become depressed and lose weight and become less mobile since her visits were limited to an hour or less outdoors. “Had we been let in, she wouldn’t have had this downward spiral,” she said. “She wouldn’t be in hospice.”
Some doctors and families are now concerned that the pendulum has swung too far, that a full reopening will make an already vulnerable population prey to another wave. Covid infections on the rise in nursing homes; flu cases are up also nationally.
The day the new federal guidelines were announced, a Connecticut nursing home reported the deaths of eight residents with serious underlying health conditions as a result of an outbreak in late September.
“Having people walking in and out during an outbreak, we know that’s not a good idea,” says Dr. Karl Steinberg, a California geriatrician and the president of the Society for Post-Acute and Long-Term Care Medicine, which represents health. health care providers in long-term care.
As a medical director or attending physician at three nursing homes, he saw the early toll of the pandemic: “It was a bloodbath.” He wished the latest federal guidelines had left administrators more flexible. Medicare might also have waited until after the holidays, he noted, and until booster shots were more widely distributed.
Despite the lifting of federal restrictions, some administrators believe state and local health regulations could replace the new federal guidelines, potentially mitigating their impact.
“The standard rule is that an institution should follow the most restrictive rule,” says Dr. Noah Marco, the chief physician of the Great Jewish Home in Los Angeles. He is cautiously optimistic that within a few weeks the state and province will also relax their policies. But for now, the facility continues to require advance planning, limit visit times, and allow each resident only one visitor indoors at a time.
Since the new federal policy was announced, “our staff has been on the phone constantly,” said Dr. Mark. “We’ve had relatives who have heard of this and say, ‘Yippee!’ We had to say, ‘We’re so sorry, but not so soon.’”
A representative from the Centers for Medicare and Medicaid Services said state or local health departments may need to reinstate restrictions “for serious safety reasons,” but only in “isolated situations.” The representative added: “In general, local governments should not try to add rules and regulations that limit the right of nursing home residents to receive visits.”
The New Federal Policy – Supported by the Biden Administration requires all nursing home staff to be fully vaccinated by January 4 – is likely to ease more extreme local and state policies.
Alison Hirschel, the chief attorney for the Michigan Elder Justice Initiative, has advised a woman whose relative, in his 70s, suffered a brain injury after an accident and entered a nursing home a few months ago.
“She was very upset,” 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 liberalized federal policies were announced, Michigan has issued new guidelines that made visits possible at all times, without restrictions on the length of the visit or the number of visitors. “This is really a complete game changer,” said Ms. Hirschel.