Portrait of relaxed mature woman taking a Self-swabbing home tests for COVID-19 at home.
(Credit: stefaname / Getty Images)

“It is essential that the assisted living COVID-19 experience be understood to prepare for future emergencies,” researchers from the Center for Excellence in Assisted Living write in a  special article published Dec. 30 in JAMDA — The Journal of Post-Acute and Long-Term Care Medicine.

Calling assisted living a “vital part of long-term care,” the researchers made several recommendations after examining COVID-19’s effect on the sector, reviewing what is known about COVID-19 cases and deaths, infection control and the pandemic’s effects on residents and staff members. Further research is needed to document the importance of the sector, the authors said.

The researchers referred to CEAL’s 15-year Assisted Living Workgroup Report to highlight how gaps — and successes — in adopting previous recommendations may have affected assisted living’s pandemic preparedness.

Lindsay Schwartz, PhD, founder of Workforce & Quality Innovations and CEAL board chair, said that moving forward, the hope is that all key stakeholders — residents, families, staff members, providers and policymakers — have a seat at the table not only for future research but also for policy formulation and best practice implementation.

“Good policy is based on research and evidence-based practice,” she said, adding that the CEAL board intends to disseminate its findings to policymakers and other stakeholders, as well as offer their expertise on implementing the report’s recommendations.

Data collection important

Estimates place the number of COVID-19-related resident deaths in assisted living at almost 30,000 between January 2020 and March 2021, according to the paper. 

The exact number of COVID-19 cases and deaths within assisted living likely will never be known, the authors noted, because only 39 states were publicly reporting limited data for the setting as of October 2020. 

Schwartz said that the importance of data collection — which was included in the first Assisted Living Workgroup Report in 2003 — remains. Measuring resident outcomes, the authors stated, is important to understanding cases, deaths, hospitalizations and other resident outcomes during a pandemic.

“Through the pandemic, it became obvious that assisted living does need to collect data, and states need to work on that so they understand the quality issue and where they can help,” she said. “It’s more about improving quality and ensuring residents have good quality of care and quality of life rather than something that is punitive.” 

The report recommends that states apply existing data-tracking measures to assisted living. The authors also suggest that states provide financial assistance to relieve the data collection and reporting burden for providers. 

Infection control, preparedness key

Infection control and preparedness, the authors wrote, was hampered by inadequate state and federal support, low staffing levels and limited clinical expertise and medical oversight of staff members. Ongoing challenges, they said, included obtaining sufficient personal protective equipment and testing supplies while trying to implement conflicting regulations and guidance for federal, state and local health agencies. 

“Without additional resources and supports, many ALs did not have the staff or resources to respond to the practically overnight need to maintain and monitor PPE supply and use, identify cases through regular testing, make up for staff absences because of quarantine, illness and child care or family obligations, assisted with telehealth appointments or virtual family and friend visits, and complete tasks usually done by family and friends who were no longer permitted to visit,” the authors wrote.

Revised emergency preparedness plans, they said, should include infection control practice information, personal protective equipment use training for all staff, access to supplies, dealing with staffing shortages, stronger partnerships with local health departments, temporary relaxation of administrative requirements, surveillance, and even staff transportation and temporary adjacent housing.

Educating policymakers about sector’s role remains important

They also suggested educating state, local and federal organizations overseeing emergency preparedness about the types of residents served by the sector and how best to communicate with assisted living communities during crises.

“We heard a lot about how groups didn’t realize the need for assisted living to be included in all of these plans,” Schwartz said. “It’s really important for providers, if they are not already, to start making those connections with local health departments, hospitals and other long-term care providers so they understand who they care for and formulate a plan around emergencies — and probably the next pandemic.”

Staffing remains top issue for senior living

Staffing was the biggest issue and continues to be a crisis, Schwartz said. The report authors emphasized that states should provide guidance and that providers should see improved staff recruiting and retention with a respectful organizational culture, improved human resource policies and adequate staffing ratios.

Although most states require some form of entry-level certified nursing assistant training, the authors noted that only 17 states and Washington, DC, require minimum training hours. Only 38 states require continuing education. 

“Flexibility around training regulations may be needed in emergent and pandemic situations, allowing shortened duration and/or delaying state testing,” the authors wrote. “It is long past time for direct care workforce jobs to be seen as desirable.”

The report also addressed establishing essential caregiver programs in every state, adding a clinical or medical director — even on a part-time basis — to every assisted living community to provide clinical oversight, and requiring communicable disease testing and vaccination of all staff members and volunteers.

Preserving assisted living as a model of care

Future research should examine staff clinical training, the infrastructure needed to handle a pandemic, and infection control protocols, the researchers recommended. 

“The pandemic has shown that AL is a vital part of long-term care and the entire healthcare continuum,” they concluded. “Research is needed to document the importance of this model of care, including the preservation of resident and staff well-being in the face of a deadly disease that targeted this demographic.”