Special Report, part 1: A storm is brewing for New Hampshire nursing homes

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Publisher’s Note: This is the first in a three-part special report produced by InDepthNH.org.

Part 1- Oct. 19: InDepthNH.org examines what is being done to make sure any COVID-19 second wave is kept away from our state’s most vulnerable nursing home residents. 

Part 2 – Oct. 20: See how your nursing home rates in the quality ranking list published by Medicare.gov, along with the statistics on coronavirus infections in each facility. We also examine recent inspection reports for each nursing home, listing infractions that inspectors found on-site visits. (We list nursing homes via the star system, one star for much below average to five stars for much above average).

Part 3 – Oct. 21: We report The Politics of the Pandemic. And the story of the lone nursing home in New Hampshire that requires special attention from overseers.

Low pay, seriously fatigued and depleted staff, and facilities on the verge of financial collapse: That’s the current scenario for New Hampshire nursing homes.

Several officials warn that fall could be the cruelest season as New Hampshire heads into the colder months and the pandemic continues. Already, daily briefings from the state Department of Health and Human Services and reports in the local media are warning of upticks in the rate of COVID-19 in communities.

A special legislative committee has only weeks to make its recommendations on how the state should handle this brewing crisis in nursing care facilities.

State inspectors have already inspected heating, ventilation and air conditioning systems in several long-term care facilities around the state, coming away without any conclusive evidence that HVAC systems contributed to outbreaks.

The state legislative committee is hearing from experts, including nursing home administrators and others, in an attempt to come up with a list of suggestions that the state might consider.

There have been 36.5 million confirmed cases of COVID-19 in the world, including 1.06 million deaths, reported to the World Health Organization.

In the United States, from January to Oct. 18, there have been 8.02 million confirmed cases of COVID-19 with 218,000 deaths.

And sadly, in the time it takes you to read this story, those figures will be outdated.

In New Hampshire, there have been 9,694 confirmed cases of COVID-19 since the pandemic began in early 2020. Of that total, there have been 467 deaths in the state, and 81.1% of those deaths have been residents of long-term care facilities. (Figures are from Oct. 18)

Borne out by the data is the fact that the virus is most dangerous to the elderly. While 18 of those who died in New Hampshire were under age 59, 448 were 60 and older. And they were more likely statistically to be sicker and more likely to require hospitalization. While 6,787 people infected were under age 59, 238 of those people (4% of the total) required hospitalization. Of the remaining 2,840 confirmed cases, those over age 60, 523 of them were hospitalized, or 19 percent of the cases in that age group. (Data is from Oct. 17)

“One of the things that has been striking about New Hampshire, and I’ve been asked by members of the media and I don’t have an explanation for it. I have theories about it, but I have no real explanation for it: Why such a large proportion of our deaths in the state have occurred in nursing homes,” said Brendan Williams, president and CEO of the NH Health Care Association, before the legislative panel on Sept. 24. “The number of deaths in the general public has been relatively low, making those deaths in nursing homes proportionately very high. I think in part it’s because we have such an elderly nursing home population.”

Nationally, Pro Publica, the large independent newsroom, launched an analysis of nursing home infection deficiency reports and compiled that information on their website. See their report here: https://projects.propublica.org/nursing-homes/

The Kaiser Family Foundation, which follows national health issues, has compiled state reports of long-term care facility cases and deaths related to COVID-19 here: https://www.kff.org/health-costs/issue-brief/state-data-and-policy-actions-to-address-coronavirus/#long-term-care-cases-deaths

While tying the deaths to any particular issue such as infection infractions or HVAC systems is unreasonable, some nursing homes have avoided any confirmed COVID-19 cases while others have been ravaged by it. It does not seem to be the case that the better quality nursing homes are being spared. As evidenced by the star rankings on Medicare.gov, a top-quality ranking doesn’t save a facility from a COVID-19 outbreak, according to InDepthNH.org’s research.

The good news: The majority of New Hampshire nursing homes, or 52 out of 74, are listed as providing average or better than average care to their 5,083 residents (the number of certified beds – Actual patient census figures are down during the pandemic) by the Center for Medicare and Medicaid Services (CMS).

The not-so-good news: Another 2,333 residents, at 21 nursing facilities, are getting services that are rated below average or much below average by the Center for Medicare and Medicaid Services.

In New Hampshire, there are 74 nursing homes ranked by CMS. Twelve are rated 1 star (much below average) on Medicare.gov. One other – Greenbriar in Nashua – is listed as a Special Focus Facility, (meaning it has more problems than others). Nine facilities are rated 2 stars (below average) and 11 others are rated 3 stars (average). Sixteen are rated 4 stars (above average) and 25 are at the top rating of 5 stars (much above average).

Of the 13 poorest-rated nursing homes in New Hampshire, 10 of them are owned by Pennsylvania-based Genesis Healthcare. Genesis owns 22 nursing homes in New Hampshire and operates approximately 500 skilled nursing centers and assisted/senior living residences in 34 states.

The Blame Game

This has been a very difficult time for nursing homes, as staff bristle at the mention of the high death rate and the stigmatizing label of COVID deaths vs. natural deaths.

It’s also been a real morale buster for many.

“You watch the media (back in the early days of the pandemic) and see how the hospital staff were praised and then there would be the story about these bad nursing homes … They had no infection control and on and on, which is a real morale buster for us and our staff,” said Catholic Charities clinical services director Darlene Underhill, RN.

Health and Human Services Commissioner Lori Shibinette is pictured at a recent news conference.

This especially riled Commissioner Lori Shibinette of the state Department of Health and Human Services, who when responding to a New Hampshire Public Radio story in mid-August on the nursing home crisis, used the pulpit of the daily press briefing with Gov. Chris Sununu to issue her scathing rebuke of the coverage.

She said at the time on Aug. 18 that the NHPR coverage sought to place blame on the nursing homes, equating past inspection deficiencies with current outbreaks and brought a “predetermined narrative” to the story. NHPR defended its coverage, stating the story says: “Outside New Hampshire, experts studying the pandemic’s toll on nursing homes across the country have not yet reached a consensus on the connection between a facility’s past track record and its ability to contain COVID-19.”

You may read the NHPR report at this link.

Shibinette spoke before the state legislative panel addressing the issue on Oct. 15. She told them, “Part of what you’re hearing is certain media outlets picking a data point and running with that data point. So yes, 80 percent of our deaths were in long-term care, but when you look at our overall death rate by nursing home licensed beds, it’s far below most of our New England states and many other states across the country.

“If you look at the percentage of nursing home residents that we lost, the number of nursing homes that have had outbreaks, I put that data out at our news conferences on a pretty regular basis because when you have low community-based deaths, which we have in New Hampshire, and you take a percentage of them, it doesn’t mean we have more nursing home deaths than anybody else, it just means that of our total deaths, most of them are nursing home because our community-based deaths are low. The only way to change that percentage is to have more people in the community die, which I don’t think anybody wants.”

In testimony Oct. 1 before the legislative study committee, Craig Labore, administrator of the Grafton County Nursing Home, said, “Nursing homes have certainly been the focus throughout the pandemic, for good reason considering the vulnerability of the residents whom we care for, but I think that there’s been a lot of discussion about quality of nursing homes and the tying of quality versus having COVID-19 in your building, and I think that a nursing home that experiences an outbreak doesn’t mean it’s a bad nursing home because this virus, in my opinion, doesn’t differentiate between a one or a two-star facility versus a five-star facility.”

The state is currently in the midst of four outbreaks at long-term care facilities: Bedford Hills Center, Pine Rock Manor in Warner (assisted living), St. Teresa Rehabilitation and Nursing Center in Manchester, and Warde Rehabilitation and Nursing Center in Windham. They are the latest in a series of 38 outbreaks that began in April at assisted living facilities, nursing homes and long-term care facilities.

It Takes Only One

Community transmission has been one of the more insidious aspects of the coronavirus, especially as the medical community has learned that it can be spread by people showing no symptoms.

As an example of how nursing homes are affected, Underhill, of Catholic Charities NH, cited her own example of the outbreak experienced at Mt. Carmel Nursing Home in Manchester this past May.

“When we did the contact tracing, we found it was all related to one staff member who didn’t come forward even though we screen people every day,” Underhill told the legislative study panel on Oct. 8. “He didn’t tell us that he had a sore throat. And we wound up with 37 residents and 18 staff infected. We have two direct COVID deaths and four that were called COVID-related. Those were people who were end-of-life, in the final days of life, but because they also had a COVID diagnosis they were put into that same bucket of COVID deaths so even that data you have to interpret a little bit.”

The Numbers

New Hampshire outbreaks at long-term care facilities have included 20 nursing homes, seven assisted living facilities and several facilities for the developmentally disabled. The state counts 378 deaths among long-term care facilities (as of Oct. 18), which accounts for 81.1 percent of all deaths in the state.

It is this statistic that has brought attention to the state’s long-term care facilities. As Thomas Blonski, CEO of Catholic Charities NH, noted, the other New England states have had death rates in long-term care facilities as follows: Rhode Island at 77 percent, Connecticut at 72 percent and Massachusetts at 64 percent.

Blonski says some of the Granite State’s higher ratio may be attributed to the fact that the average age of a resident in a New Hampshire nursing home is about three years older than the national average (80 in NH vs. 77.4 in the U.S.) They tend to have higher rates of co-morbidity, meaning multiple medical conditions at the same time.

All Aspects

The Committee to Study the Safety of Residents and Employees in Long-Term Care Facilities was created this summer by a bill signed into law on July 24 by Gov. Sununu, HB 578, and is charged with examining cost controls in long-term care,  reimbursement of costs of training nursing assistants, risk of suicide among residents and employees, personal protective equipment, and policies on infection control.

Their final report to the governor is only weeks away, on Nov. 1.

You may find the committee’s draft report at this link

Sununu vetoed another bill, HB 1246, that would have studied what happened at long-term care and nursing home facilities and would have used $35 million in federal CARES Act money, including $10 million for child care scholarships, and created programs for the homeless, a housing subsidy program for renters and homeowners affected by layoffs and job losses due to the pandemic. Sununu called that bill “well intended” but “redundant.”

The members of the study committee meeting remotely include state Sen. Jon Morgan, D-Brentwood; Sen. Ruth Ward, R-Stoddard; state Rep. Jerry Stringham, D-Lincoln, a bill sponsor; Rep. Paul Berch, D-Westmoreland; and Rep. Charles McMahon,  R-Windham.

The committee expects to hold its last hearing on Thursday, Oct.  22, at 9 a.m. Members of the public may attend via Zoom. Morgan has been allowing public comment at the end of their sessions. To find the link, search for the Senate Calendar for this week on the NH.gov website: http://gencourt.state.nh.us/Senate/calendars_journals/default.html

Click on the calendar No. 35 for the week of Oct. 15, 2020, and scroll down to the list of remote meetings for Thursday, Oct. 22, 2020. The committee lists a Zoom link as well as numbers to listen on a telephone.

Committee Work

The committee has met in remote Zoom sessions six times since early September. They have been hearing from experts in the long-term care industry, including Williams of the NH Health Care Association on Sept. 24, who told them the nursing home sector “was already pretty precarious even prior to the effects of the pandemic.”

He told the committee, “In a report issued by the Medicare Payment Advisory Commission to Congress March 12, the average nursing home margin was in the negative for the first time since 2000. Those were the 2018 margins for nursing homes.”

In testimony before the committee Oct. 8, Blonski, of Catholic Charities NH, said, “On average we lose about $45 per Medicaid resident per day and are lucky to achieve a 1 or 2 percent margin in an industry that is already operating in the red and in crisis. For us our Medicaid residents represent anywhere between 60 to 82 percent of our residents depending on our facilities’ locations, either here in Manchester or as far north as Berlin. We continued to serve our frailest elderly for the past 75 years because it harkens back to our mission, and yet mission will only take us so far. Without a margin, we slowly begin to die on the vine. As an industry, this is where we are today.”

Man Kissed Wife

The closing of nursing care facilities to all outside visitors and then phased openings of nursing homes has been very hard on the residents, staff and families, according to several nursing home administrators.

Labore, of the Grafton Country Nursing Home, said, “When we first began our visits, we had one family member despite the education that we provided upon seeing his spouse went in and gave her a kiss. He was wearing a mask but he went in and gave her a kiss, and that really upset our staff because of the fact that you just don’t know. There’s still a lot to learn about this virus. … I don’t think there’s really a happy medium if you will.”

Craig Labore, administrator of the Grafton County Nursing Home

Nursing homes have had to be creative in their approaches to social distancing and no-contact visits. This includes numbering the windows on the outside of the building so family can see a loved one, remote visits using everything from Zoom to Skype, and in at least one case, a hugging booth at a nursing home operated by Catholic Charities in Berlin.

Part of the problem has been the lack of activities for the residents. All nonessential personnel have been banned from nursing facilities, including recreation staff, and with a population that in some cases can range as high as 80 percent dementia patients, trying to get people to understand the restrictions is impossible.

Some legislators on the panel asked what can be done to get recreation staff and other nonessential personnel back into the buildings, but they were told by several people that their return is a function of the reopening phases.

Phased Comeback

Under reopening guidance, each facility may reopen in phases, depending partly on the prevalence of COVID-19 in the nearby community.

The factors that determine a specific facility’s ability to reopen in one of three phases is the number of facility cases (no current outbreak), county incidence rates, and facility readiness. A long-term care facility might have to move back and forth in the phases depending on the cases and staffing.

In fact, Shibinette told the legislative panel, “We lifted restrictions on visits probably a month ago. Once you’re in outbreak, visits aren’t allowed. That’s not new to COVID. That’s been around forever. When we have flu outbreaks in facilities, we close down for visits. The difference is flu outbreaks last three to six weeks. It doesn’t last eight months.”

If a nursing home has had no COVID-19 cases in the last two weeks and its county positivity rate is under 10 percent, according to CMS guidance, the facility must have some form of in-person visitation.

  • Phase 0: Facilities with one or more cases should ban all nonessential personnel and conduct no communal dining or group activities.
  • Phase I: Facilities with no cases of COVID-19 in the past 14 days may have limited communal dining with physical distancing, group activities limited to no more than 10 people, and no nonessential personnel.
  • Phase II: Facilities in counties with a prevalence of active COVID-19 cases of 50 cases per 100,000 population or fewer that have been operating successfully in Phase I for at least 14 days may conduct indoor and outdoor visits, limited communal dining with physical distancing, and group activities limited to no more than 10 people. A limited number of non-essential personnel are allowed as determined necessary by the facility.
  • Phase III: Facilities in counties with a prevalence of active COVID-19 cases of 10 cases per 100,000 population or fewer and that have been operating successfully in Phase II for at least 14 days may conduct designated essential support visitation.  Non-essential personnel are allowed with additional precautions as determined necessary by the facility. Communal dining is allowed with physical distancing. Group activities are permitted, including outings, with physical distancing.

“All of the counties were in phase 2 until about two weeks ago,” Shibinette said. Since then, three counties have gone back to phase 1. “But the federal government has been very clear with nursing homes that they are not allowed to restrict visitation for their residents, unless they can show that there is a significant safety or COVID concern.”

Crystal Ball

Where might an outbreak strike?

Are nursing homes that are ranked lower than their peers somehow more susceptible to the virus? Are there any correlations that can be made that show where the next outbreak is likely to occur?

The short answer is no.

InDepthNH.org has examined the public records of nursing home inspections, COVID-19 cases, infection control procedures, ownership, and staffing ratios, and no trends or correlations appear relevant.

Listening to the experts, the nursing home death rate in New Hampshire can be seen as a failure of what we didn’t know about the virus and the lack of testing early on in the pandemic. Community transmission seemed to have been a large determinant of where the virus would strike with the most lethality. It was in most cases staff who were bringing the virus into the facility.

About the only sure statement that can be made about long-term care facility outbreaks in New Hampshire is that they tend to be centralized around population centers where larger community transmitted disease outbreaks have occurred. Plotting the outbreaks on a map of New Hampshire reveals a cluster of outbreaks at assisted living and long-term care facilities in the Manchester and Bedford areas, with a scatter of cases around the state, from the Seacoast to the Salem and Nashua areas. About the only statement that can be made is that no outbreaks occurred beyond Greenfield in the Monadnock region, none in the Upper Valley and anywhere in the North Country from Campton on up.

In testimony before the long-term care study committee, Catholic Charities clinical services director Underhill told them, “The majority of the deaths and the majority of the deaths in nursing homes happened in the early days – March and April – when the Northeast was really in crisis. It was out of control in Massachusetts, Connecticut, and, of course, southern New Hampshire are bedroom communities to Massachusetts. And that’s where the nursing home outbreaks, almost all the outbreaks were there. We had our own outbreak in April, early May at Mt. Carmel (in Manchester), one of our facilities. Also at the same time two major hospitals in Manchester experienced COVID outbreaks. Those were a huge problem in the community … The staffs live in the community, they have family in the community. There’s no way to prevent it.”

The Fix

How do we treat the problem?

As money has trickled down from the federal $2.2 trillion CARES Act emergency relief funds signed into law by President Donald Trump March 27, $1.25 billion made its way to New Hampshire. The Governor’s Office for Emergency Relief and Recovery (GOFERR) has been distributing that money in phases.

Some of it has gone to nursing homes in the form of Emergency Healthcare System Relief Funds, in some cases more than a half-million dollars per facility.

Some of it has gone directly into the wallets of direct-care workers through the state’s Long-Term Care Stabilization Fund, which added an extra $300 stipend to full-time workers’ paychecks and up to $150 for part-time workers. That program ended July 31, however. Several of the administrators testifying before the legislative panel asked that this program be reinstated.

Blonski’s organization, Catholic Charities NH, received an $881,200 Long-Term Care Allocation in August.

“Without the CARES Acts funds, our initial projected loss for this year was in excess of $5 million,” Blonski told the panel. “Going back to my initial argument, if we want long-term care reform, it’s going to be expensive and require more money. Physical plants are old. They need to be updated or torn down, rebuilt and rethought.”

Williams, from the NH Health Care Association, testified on Sept. 24: “4.2 percent of  the $175 billion set aside by Congress for health-care provider relief has gone to nursing homes, even though the percentage of COVID deaths in the country at long-term care facilities has been 40 percent.”

At the end of August, another $11.4 million in CARES Act funds were made available, but Williams said his member nursing facilities have had difficulties trying to get second-round grants, and he used the word “hoarding” to describe the state’s actions regarding CARES Act funds.

Workers Needed

Rockingham County Commissioner Tom Tombarello from Sandown, told the legislative panel, that at his facility, the Rockingham County Nursing Home in Brentwood, “We’re about 80 nurses short. I think if you go to the nursing homes across the 10 counties, you’ll find the same thing. The nursing shortage. We’re trying everything. Way, way back we tried so many incentives to get these people in here.”

The same is true everywhere in the state.

Labore, in Grafton County, noted, “We’re currently down 14 LNAs (full-time employees), and that’s dominantly on our evening and night shift. We’re currently down 12 nursing full-time employees, adding in both RNs and LPNs, so comparatively speaking, I’d say we’re better off than other nursing home providers that I’ve spoken to, but our overtime costs and contract nursing costs continue to rise. The worry about staff burnout, trying to cover the holes that we have in our schedule, is there, and then focusing on the stress that we’re living under daily, that staff burnout is a real concern for us.”

And to punctuate what the nursing home administrators reported, Cathy Gray,  president, CEO and administrator of Cedarcrest Center for Children with Disabilities in Keene and a member of the Monadnock Region Health Care Group, said last week, “Statewide, just in the long-term care area, there are 564 LNA or MNA openings. That is a lot of caregivers. It represents just under 23 percent of the LNAs that these employers have on staff. Similarly the numbers of vacant positions, the percent of vacant positions, for LPNs and RNs was similar. The numbers of positions are fewer. For LPNs, it’s 130 open positions, which represents 22.68 percent. For RNs, it’s 137 open positions representing just about 24.5 percent.”

Factor in traveling staff – people who come from another state to fill hard-to-fill positions such as overnight staff at a premium wage – without them “these numbers would be much worse.”

Competing for PPE

Last spring, in the earliest days of the pandemic, New Hampshire nursing homes found themselves in the odd position of having to compete against each other and larger health-care entities such as hospitals, as well as the federal government in the hunt for personal protective equipment (PPE) including disposable gowns, gloves, face masks and face shields.

Shibinette said this part of the crisis has lightened up somewhat. “We’re better positioned than what we were in the spring. We have plenty of PPE. There is no nursing home that should be reporting that they are short of anything. We had a period of time in the last couple of weeks where we had a shortage of large size gloves. Outside of that, we have plenty of masks, N95s, gowns, gloves, anything that they need. Anybody who has put orders in has had them filled, so there should be no shortage of PPE at all. We’re better positioned for PPE. We’re better positioned for testing. I think we’re in a better place to handle it.”

Williams’ organization, the NH Health Care Association, early on alerted the media to the federal government’s shortcomings in the provision of PPE in New Hampshire. Williams himself posed in a gown without armholes to demonstrate the poor quality of the supplies being provided.

Brendan Williams, president and CEO of New Hampshire Health Care Association, is pictured wearing defective personal protective equipment from FEMA.

The PPE supplies dried up very quickly at the beginning of the pandemic, according to Labore in Grafton County. “We’ve had to in certain instances go out to the secondary market to purchase personal protective equipment and those prices on the secondary market are substantially higher than what we would pay through our vendors. The quantity comes in a smaller case size. One prime example of this is surgical masks. Pre-COVID we were paying roughly 8 cents per mask and now we’ve seen prices as high as a $1.10 per mask so it’s added a considerable amount of expense for us.”

The emergency was abated somewhat with the assistance of entrepreneur Dean Kamen, who was able to use his contacts to have PPE supplies flown to Manchester.

So what does the future hold?

“I think any challenges in regards to PPE that we are seeing now or are going to continue to see are really going to be out of the control of the state … because I feel very confident in saying that if it was within their control to be able to secure items such as medical gloves or just disinfectant wipes, which is another thing that we’re starting to see shortages on, if they were able to secure those, they would certainly be doing it and allowing the nursing homes in the state to be able to access them,” Labore said.

However, New Hampshire finds itself competing against other, larger states trying to obtain the supplies necessary to keep staff and patients safe.

Margaret D. “Peggy” LaBrecque, commandant of the NH Veterans Home in Tilton, said right now, the home has an adequate supply of PPE, but “all bets are off if we get COVID-19 in house, and we have been fortunate not to have any residents with COVID-19 from March to now. We do have our own vendor sources that we use if we run into a back order issue with a statewide vendor. We have also access to the federal supply schedule because we are a veterans’ home and so with the VA in Manchester, they have reached out to us as well as said is there anything we can help you procure, so we know we can use them as well.”

Other organizations, such as Catholic Charities NH, actually found itself in the position of having to compete against the federal government, according to Alain Bernard, assistant vice president for health care services. “Back in March and April, FEMA was confiscating PPE for a national stockpile, and our facilities were left to fend for themselves.

“We had to compete with state and national corporations to find PPE unless at that time you were willing to buy large quantities and pay inflated prices. Our facilities were fortunately able to pool our resources, buy in bulk and buy at a higher price than we normally would have,” he said.

Villa Crest, a long-term care facility on Hanover Street in Manchester, is pictured with National Guard members setting up testing May 20, 2020. Photo/Jeffrey Hastings

The Right Testing

Homes perform what is called sentinel surveillance testing, a process by which all staff are tested one week a month and then 10 percent of the staff the other weeks of the month.

New Hampshire is shifting its testing program to a system in which the nursing homes will be reimbursed up to $100 by DHHS for each COVID-19 test. It will be up to the individual nursing homes to contract with a lab, and therein lies the problem for some facilities.

“I know that I’ve heard ranges of $100 upwards to $150, I believe, on what a lab would be charging to process a COVID-19 test,” Labore said. “I’ve also heard instances on the flip side of that, that some labs are only charging between $75 and $85 or $90. There’s variation there and if the nursing homes … go out and look for what we know of the service availability of our areas and see what we can do to find the best deal and limit the potential of cost-shifting.”

Williams said “some providers are going to be in a little more difficult situation.”

Shibinette’s response to that: “Moving to self-directed testing gives the facility the flexibility to test whenever they want.” She said each facility can test staff throughout the week rather than try to get everyone together on a date which the state has scheduled. She also has had her staff check around for lab fees, and the going rate has been right around $100 per test.

The federal government has sent each facility an antigen testing machine, and they can use that in addition to the contracted testing, Shibinette said.

As to testing equipment, several types are on the market. They are grouped as molecular tests, antigen tests, and antibody tests.

The gold standard is the molecular tests, which companies have developed to diagnose COVID-19 based on detecting the virus’s genetic material collected on a swab from the nose or throat. Typically highly accurate, this test usually does not need to be repeated.

An example of this type of test is an RT-PCR test, or polymerise chain reaction test. These tests, however, are not foolproof. False negatives can occur up to 30 percent of the time, according to one report. They have been described as being more useful for confirming the presence of an infection than giving a patient the all-clear.

An antigen test detects the presence of a specific protein associated with the virus, rather than the virus’ RNA, or genetic material. Positive results are usually highly accurate with antigen tests, but negative results may need to be confirmed with a molecular test.

Antibody tests are more of a “historical” test, meaning they are more useful in telling who has been infected because they detect the presence of antibodies developed to fight the virus. Antibodies may develop several days to weeks after infection and thus these tests can’t accurately diagnose an active infection.

According to Williams, the federal government has supplied antigen testing machines to nursing homes, but some are better than others. One machine, he said “generates a false negative rate of 16 percent, which is so high that if you were to test someone and if they test negative for the virus, you actually have to validate the result with a PCR test which sort of begs the question of what the value is of the … machine if it’s a rapid result test that requires validation through a test that takes days to get returns on.”

New tests and devices are coming on to the market, and one Williams said that shows promise is one that uses cards with a very high sensitivity rate as well as a cost of $5 each. “Between that and some other developments like the Yale saliva tests, we’re hoping that we can be armored with a lot of different testing mechanisms including the state-required PCR testing that will hopefully do a better job of keeping our facilities free from the virus.”

Labore, in Grafton County, noted, “From the testing standpoint, I think New Hampshire has been at the forefront with the implementation of the sentinel surveillance testing program. It’s helped nursing homes identify asymptomatic transmission of the virus and potentially get ahead of outbreaks.”

But Labore also echoed concerns that some antigen testing equipment from the federal government has a very low accuracy rate. With one test, a negative result “requires that be followed up with a traditional nasal swab to confirm that it is actually negative. To my knowledge, many of the nursing homes in the state of New Hampshire received this, if you will, lesser antigen testing unit so that adds a little bit of comfort in that you’re 84 percent sure that a resident doesn’t have COVID-19, or a staff member doesn’t have COVID-19, but still knowing that, you have to follow it up with a traditional nasal swab.”

Human Toll

The administrators shared tales of people burning out on the job and resigning, others quitting because they don’t want to catch the virus, and others who are ostracized within the community.

“In April, we had a positive staff member and subsequently a positive resident and immediately when that happened our nursing home was immediately branded with a scarlet letter, if you will,” said Labore. “Our staff who work here, in the community they were kind of treated a little differently in a way. ‘You work at Grafton County Nursing Home, now you have COVID.’ And it resulted in our staff in some instances losing child care because of that, and I’ve heard stories from other nursing homes of staff who have lost apartments and housing because of that, working in a facility that has a positive case in it. I think fear certainly played a role there and fear for our staff that led to medical leaves being asked for immediately as well as in our case, two resignations.”

One of the areas the legislative panel is looking into is working with community colleges and private contractors to offer more caregiver training, especially licensed nursing assistants, but even that will not be an easy fix.

As Underhill pointed out, “We can’t get people to do it. I’ve been looking at ads this week. When you have ads where you can go into retail and make $16 or $17 an hour, and we’re offering $12 or $12.50, there’s no comparison. LNAs are now classified as the most dangerous job in America. You can imagine how attractive that career path is right now for the wages we can pay.”

The Future

At the state level, a group called the NH Alliance for Healthy Aging sponsored a workshop in mid-July, “Call to Care,” examining the pending crisis in the health-care workforce. The group cited figures that show the state will need 4,000 more direct care workers in the total health-care workforce (from hospitals to nursing homes) by 2026.

Amy Moore of Ascentria Care Alliance, based in Concord, said nationally 86 percent of direct care workers are women, their median age is 41, and 59 percent are people of color. The sobering statistic cited is that two in five require some form of public assistance.

Nancy Rollins, chief operating officer of EasterSeals NH, VT, ME and Farnum, said people in health-care direct-care positions need higher pay, more incentives, better benefits, access to housing, public transportation, tuition reimbursement and school loan forgiveness.

Margaret D. “Peggy” LaBrecque, commandant of the NH Veterans Home in Tilton, pointed out to the legislative study committee Oct. 8, “We are passively stealing all the hires from local homes and they’re passively stealing from us because we just don’t have enough bodies out there that are licensed LNAs, registered nurses or nurse practitioners.”

Money Is Key

Shibinette in her remarks to the legislative study committee summed up her thoughts on where the solution lies:

“Reimbursement rates in long-term care have been a struggle for at least the 20 years that I have been in nursing homes and this was before counties had the non-federal share and after counties had the non-federal share. Reimbursement rates in nursing homes are simply a budget issue, and I know it’s not simple because it’s not just the state budget, it’s also county budgets. If there is a bump in rates, there has to be a bump in the cap and that is going to hit the county taxpayer dollar.”

Later, she told them, “What you do have control over is the budget process and the county budget process. Those two components. It’s not just state budget. It’s county budgets. That’s probably where you have the most area of control, over things like reimbursement rates, stipends, enhancements, anything that’s monetary that comes from state and county is probably where you can have real impact.”

Last Word

There’s a famous quote from Mahatma Gandhi: “The true measure of any society can be found in how it treats its most vulnerable members.”

Tom Blonski, the CEO of Catholic Charities, told the state legislative committee looking at long-term care that ageism (defined as prejudice or discrimination on the grounds of a person’s age) has its consequences.  “We don’t value our seniors like we value our youth or really even job titles perhaps.  It’s as if they have an unwritten ‘expire-by’ date on their foreheads with which they get cast aside and rendered useless. The way we value our frailest seniors has also affected the amount of funding we set aside for their care to adequately meet their needs. New Hampshire for example is at the bottom of the heap for nursing home funding for Medicaid residents. I think right now we’re No. 47 out of 50 states and we’ve stagnated there for years.”

Coming Tomorrow – Part 2: See how your nursing home rates in the quality ranking list published by Medicare.gov, along with the statistics on coronavirus infections in each facility. We also examine recent inspection reports for each nursing home, listing infractions that inspectors found on-site visits. (We list nursing homes via the star system, one star for much below average to five stars for much above average).

Longtime reporter Bob Charest reports and writes a column “Why You Should Care New Hampshire” for InDepthNH.org. He also serves as board secretary for the New Hampshire Center for Public Interest Journalism, the parent organization of InDepthNH.org.