A crucial element of controlling the spread of the novel coronavirus in nursing homes is routine testing of the staff who come in and out of the building each day and may have caught the virus without knowing it, experts say.
In North Carolina, nursing home residents make up almost half of all coronavirus deaths in the state, the latest data show. And there have been reported outbreaks at some 40% of the state’s more than 400 nursing homes.
Yet four months into the pandemic, North Carolina still lacks a plan for regular testing in those facilities, where COVID-19 has hit hardest.
State officials now recommend nursing homes test staff every other week, half as often as the U.S. Centers for Disease Control and Prevention and U.S. Centers for Medicare and Medicaid Services advise, though federal guidelines give state and local officials leeway to adjust based on the local prevalence of the virus. At least some states have adopted plans for following the guidelines, but North Carolina has not.
The state and federal recommendations for regular staff testing also come without special funding. Insurance companies have paid for COVID-19 tests when they are “medically necessary,” as required by Congress. But companies generally do not pay for surveillance testing, which is also considered to be mass testing.
Especially now that community spread of the coronavirus is widespread in North Carolina, medical researchers are concerned that staff have a greater chance of bringing COVID-19 into nursing homes, where the state's most vulnerable residents live.
This makes it particularly important that nursing home workers in communities with a rising number of infections are tested repeatedly, experts say, but North Carolina has opted for a focus on infection prevention rather than routine testing.
“(Testing) is not a solution to prevent infection, really, it’s a mechanism to detect infection,” said Dr. Susan Kansagra, the section chief of chronic disease and injury at the state’s Department of Health and Human Services, in an interview Thursday.
Kansagra emphasized that North Carolina has focused on consulting with nursing homes on infection control measures like setting up isolation rooms and better sanitizing the facilities.
Late last month, however, the state announced a plan to test around 70,000 nursing home staff and residents by the end of August. Pharmacy giant CVS will send workers into nursing homes to collect the samples, Kansagra said. Every resident and staff member who consents to a test is supposed to get one, and the state will cover the cost when health insurance will not.
It’s unclear how often nursing home staff in North Carolina have been tested. Few nursing homes responded to a survey by the North Carolina Watchdog Reporting Network and the state Department of Health and Human Services has not been tracking that information to date.
DHHS Secretary Dr. Mandy Cohen said last month, “My understanding right now is if they do not have any cases, they are not doing proactive testing.”
Experts say North Carolina’s turn toward broad-based testing comes too late.
“It should have been done earlier,” said Chris Laxton, executive director of The Society For Post-Acute and Long-Term Care Medicine. “It’s not a useless exercise, it’s a very important one, but it should have been done earlier because we’d know from a baseline perspective where to put resources.”
Charlene Harrington, a professor emerita in the School of Nursing at the University of California, San Francisco, who has been studying long-term care for two decades, called the state’s plan “inadequate.”
“People are going to die that don’t have to die,” said Don Taylor, professor in the Sanford School of Public Policy at Duke University.
West Virginia announced universal testing in nursing homes in mid-April, more than two months before North Carolina.
Testing isn’t cheap
North Carolina has not committed to covering the cost of the repeat staff testing it advises.
“For the follow up testing, we are recommending that facilities use private lab vendors,” Kansagra said Thursday.
The state’s nursing homes have received a temporary bump in Medicaid funding and federal stimulus funds to cover costs associated with the coronavirus, but industry representatives and some experts say that’s not enough.
About 22% of nursing home workers in North Carolina lack health insurance, according to the most recent data from the American Community Survey, and many insurers won’t pay for tests that aren’t prompted by the worker having symptoms of the disease or being notified by a contact tracer to get one.
The tests can cost anywhere from $70 to $250, said Adam Sholer, the executive director North Carolina Health Care Facilities Association, an industry trade group. One nursing home operator told reporters they had been quoted $300 a test.
“It is a huge financial investment to do testing every single week of the staff,” Cohen said in a presentation to legislators in mid-June. “A lot of these staff do not have insurance.”
Cohen said testing staff at facilities would cost “in the multi-millions of dollars every week.” Sholer estimates about $10,000 a week per facility.
The industry has asked the state to cover the cost of staff testing, Sholer said, and he’s hopeful that part of a $100 million allocation made by the Legislature last month to several COVID-19 relief efforts could help.
However, the state is not paying to test people at other types of residential care homes, including many assisted living facilities. North Carolina licenses 56,000 beds for operation at homes that do not fall into the nursing home category.
Many of the people who live in these facilities are elderly and have chronic health conditions that make COVID-19 particularly dangerous, but so far there have been fewer large outbreaks in these settings than in nursing homes.
Experts say the current arrangement disincentivizes staff testing. On top of the question of who will pay for the test itself is a question of who will pay if a test comes up positive. Many workers in the industry lack paid time off, so it might serve them better not to know their infection status.
Long turnaround times for test results are another obstacle, experts and industry representatives say.
“If you don’t get a result back within 48 hours at the latest it becomes kind of useless,” said Laxton, of the medical society. “You really can’t do good infection control if you have to wait a week, two weeks to get a test result back.”
The results are used to separate infected residents from others who have not contracted the virus.
Kansagra said, ideally, test results would come back within three days, but she did not directly respond to a question about whether CVS would be penalized if it could not deliver timely results and the department has not made the terms of the contract public.
The scale of the cost and the supply-chain problems require federal intervention, with a plan for using the testing program to advance knowledge about the coronavirus and how to contain it, said Taylor, the Duke professor, but he thinks the chances of that happening are slim.
“The cavalry’s not coming,” he said.
Why focus on staff?
A characteristic of the novel coronavirus that has made it particularly hard to control is its long incubation period. Symptoms may not show up for days, and in some people, they never do, but that doesn’t mean the infected person isn’t spreading the virus.
Nursing home staff are the “principal vectors of transmission,” and it’s hard to control what they do when off the clock, said Laxton, the executive director of the medical society.
Routine testing can help identify asymptomatic cases. In April, a Columbus County nursing home reported an outbreak of 40 cases, two of which were staff members who were asymptomatic at the time of their tests.
North Carolina defines an outbreak as two or more cases among residents and staff. All but a handful of the 696 nursing home deaths have been residents.
Both the Centers for Disease Control and Prevention and the state recommend that everyone associated with a nursing home get tested after there’s a single confirmed case. The residents and staff are supposed to be tested every three to seven days until 14 days have passed without the discovery of a new case.
In March, Gov. Roy Cooper signed an executive order that barred most visitors from all long-term care homes. Residents now leave very rarely, only to receive essential medical care that’s not available in the nursing home, such as dialysis.
Though nursing homes are on lockdown, the staff leave, go home, go to the grocery store and mingle in the community, said Lauren Zingraff, executive director of Friends of Residents in Long-Term Care, an advocacy group.
“We continue to have people all over North Carolina who refuse to wear a mask,” Zingraff said. “Wearing a mask is not a political statement. Wearing a mask is a public health need to protect not only yourself but others.”
Zingraff has been pushing for universal nursing home testing for COVID-19 since the pandemic began. Sometimes it is difficult to tell when a resident has symptoms, she said.
“Some people have lost verbal capacity or their ability to write something on a piece of paper,” Zingraff said last month.
“They might not be able to say to anyone ‘I am starting to feel like I have the flu. I might need a COVID-19 test.’ And in a lot of cases, only family members can tell what’s going on.”
But with most visitors barred from all nursing homes, family members can no longer visit in person.
“People are acting like people in long-term care have the capability and ability to freely communicate their health needs,” she said. “That is simply not the case.”
Zingraff said reopening long-term care facilities to visitors is entirely dependent on robust testing for COVID-19.
“We still don’t have a definitive timeline for residents when they can see their loved ones again,” Zingraff said. “Every day we go without (facilities) letting them see their family members is another day from their life.”
This story was updated to correct Lauren Zingraff’s title.
This story was jointly reported and edited by Kate Martin and Frank Taylor, of Carolina Public Press; Carli Brosseau, Lucille Sherman and Jordan Schrader, of The News & Observer; Ames Alexander and Gavin Off, of The Charlotte Observer; Nick Ochsner, of WBTV; Emily Featherston, of WECT; and Tyler Dukes, of WRAL.