This article reviews the arc of the first year and a half of the COVID-19 pandemic from the perspective of aging services and describes key lessons learned about vulnerabilities and strengths in the aging services and long-term care system the crisis brought to light. It outlines principles for developing strategies as we frame a vision for the future. It stresses a need to grab this opportunity to remake the structures, services, and financing systems that make up the nation’s aging services system.
long-term care, aging services, LeadingAge, public health emergency, lessons learned
“I am tired. My soul is hurting. I will recover to a place I can live with. But I will never be the same.” So spoke a nursing home leader toward the end of 2020. And here we are, as of this writing, having come so close to being a nation recovering from the pandemic to watching the diagnoses soar again with the Omicron variant and now trend downward.
As an aging services provider community, we will never be the same. Providers, residents, family members, staff members—we are all traumatized and as we recover, we will have to face that trauma squarely. We also will have to incorporate the hard-earned lessons of the pandemic and continue serving a rapidly aging and increasingly diverse U.S. population.
Aging services providers today grapple with crisis-level workforce shortages; continued vaccine and booster hesitancy among staff; severe funding gaps to cover things like personal protective equipment (PPE), agency staff to fill gaps, and increased testing and reporting requirements; and additional new regulatory requirements. Many providers are struggling to stay open.
But even if all these problems were magically solved, the old ways are rapidly fading. A crisis of the magnitude of the COVID-19 pandemic, with its disproportionate impact on older people and people of color, particularly those in congregate settings, is going to usher in big changes. COVID-19 showed the nation that its long-term care (LTC) and aging services are long overdue for a refresh. Our infrastructure is fraying. It was built for a time when expectations about aging and older people were different. Fortunately, many innovative providers of care are already leading the way.
The country has a newfound awareness of aging services, too. Watching hospital ICUs and emergency departments become overwhelmed with COVID-19 cases, the country learned a key lesson: aging services are an essential part of the healthcare infrastructure. In the early months of the pandemic, nursing homes quickly entered the public’s awareness, when many created COVID-19 isolation units to absorb patients leaving hospitals. Recent LeadingAge research has found that long-term care, once perceived by many as the stepchild of the healthcare system, is now something that the majority of Americans want both parties to step up and address with investments and leadership (LeadingAge, 2022).
From Crisis to Change
The pandemic taught us important lessons about what needs to change in the structure, financing, and delivery of aging services. It taught us about what older people want, and what all of us want from an aging services system for the 21st century. We learned lessons about the role of aging services in the economy. And COVID-19 was a master teacher about the people of aging services—older people who use services and their family members, the staff who provide their care and services, leaders of provider organizations, and policymakers.
In this article we review the arc of the first year and a half of the COVID-19 pandemic from the perspective of aging services and describe key lessons learned—about vulnerabilities in the system and strengths we hadn’t seen the true measure of before the emergency hit. We outline principles for developing innovative strategies as we frame a vision for the future. We hope readers will be motivated to begin conversations in their communities about how aging services can “be the change” we all want to see. The public health emergency has been in place for a long time, but the chaos of the pandemic is only temporary. We must collectively grab this opportunity to remake the structures, services, and financing systems that make up the nation’s aging services system.
The Pandemic’s Disproportionate Impact on Older People and Aging Services
It was clear by February 2020 that COVID-19 was going to be a force to contend with, especially for congregate living settings—nursing homes, assisted living, life plan communities, college dormitories, correctional facilities—and places where people work, learn, and play together. As lockdowns were imposed across the states, Americans went home. Schools, from primary grades through university campuses shut down and turned to online learning. Office workers and others who could work from home went virtual. Rush hour traffic disappeared, and vibrant cities went dark. Bars, restaurants, movie theaters, amusement parks, concert venues—all shuttered.
But, nursing homes, assisted living residences, life plan communities, and low-income congregate senior housing—home to millions of older people—did not have the option to close. The people who provided care, services, and supports to older residents could not switch to telework.
‘We must collectively grab this opportunity to remake the structures, services, and financing systems that make up the nation’s aging services system.’
COVID-19 rates of hospitalization and death disproportionately affected older people, particularly those frail enough to use aging services. Although in June 2020, a third of the nation’s COVID-19 deaths were in nursing homes, and by August 2021 that dropped to 20%. The change came about with the advent of effective vaccines and their high uptake by people older than age 65. With lower rates of staff vaccination and even lower rates of booster uptake, increasing rates of COVID-19 among younger unvaccinated people, concerns about influenza on top of COVID-19, and breakthrough infections among those most at risk, it remains to be seen where the trends will end.
Why the Continuum Matters in Examining the Impact of COVID-19
Although many home- and community-based and home care providers were deeply affected economically and structurally by the pandemic—and some have closed their doors permanently by this point—in this article we’ll focus on congregate settings where older people live: nursing homes, assisted living, memory care, life plan communities, and low-income senior housing. The best data also are available from nursing homes, because the Centers for Disease Control and Prevention (CDC) has since May 2020 required weekly reporting into the National Healthcare Safety Network by all nursing homes (CDC, 2020).
However, we must first acknowledge that even in this examination of what happened in congregate settings, we are using the lens of the entire aging services continuum—all of these residential settings, as well as adult day centers, PACE programs, home care, and informal care by family and friends. When older people need assistance with daily living, they seek supports in a variety of ways. People commonly weave together combinations of home care, informal support from family and friends, and other paid supports. Even those who ultimately move into residential care may rely upon some home health agency supports, private duty nursing, family care, or adult day services. People move around the continuum of care. As their needs change, their service use may change.
The LTC/Aging Services Continuum and COVID—Disproportionate Impact of Income and Race
Personal and family financial considerations play a major role in the services people use and how they use them. Researchers at the University of Illinois found that a 1% increase in a county’s income inequality was associated with a 2% increase in COVID-19 infections and a 3% rise in deaths. Individuals with low incomes have fewer options when they seek long-term care help. Medicaid programs differ significantly by state in terms of access and benefit levels (Van Beusekom, 2021).
COVID-19 affected Black and Latinx nursing home residents more than non-Latinx Whites. Nursing homes with relatively high shares of Black or Latinx residents were more likely to report at least one COVID-19 death than nursing homes with lower shares of Black and Latinx residents (Chidambaram, Neuman, & Garfield, 2020). Further, though the gaps are closing, Blacks in the United States have a lower rate of vaccination than Whites. There are a number of explanations for this but in a recent presentation, Dr. Rhea Boyd connected reduced access to health insurance to low rates of immunization. She also pointed to economic issues; though people realize the vaccine is free, they need to be able to take time away from work and cover the cost of getting to the vaccination site and, if needed, parking (Friedan, 2021).
Finally, a continuum, or balcony view of COVID’s impact on aging services is essential because frontline staff frequently work for multiple employers and move between settings. The rate of holding second jobs among nursing home aides and LPNs/RNs are 35% and 32%, respectively, higher than those of other workers (Baughman, Stanley, & Smith, 2020). One study estimated that banning shared staff during the first surge of the pandemic could have reduced infections in nursing homes by 44% (Chen, Chevalier, & Long, 2020).
Dr. Paul Offitt talks about COVID-19, particularly the Delta Variant, having many “friends” that promote the spread of the infection (Offitt, 2021). Unfortunately, one of those friends is racial and economic inequity. Approximately 60% of the aging services workforce is made up of people of color (Stone & Bryant, 2020). The pandemic’s disproportionate impact on people of color is directly connected to burgeoning gaps in the aging services workforce. The Bureau of Labor Statistics reports on employment in nursing homes and residential care facilities monthly. The total number varies each month, but overall it dropped from the beginning of the pandemic to the time of this writing.
Lessons from the Pandemic for Aging Services Providers
There is widespread agreement that the COVID-19 pandemic was an unwelcome but master teacher. Recognizing the hard-earned lessons for aging services is the only way to learn from them and move forward into recovery. One of the clearest lessons was that we are a resilient field—it is possible to learn in real time and shift directions and responsibilities quickly. Corollary to identifying the lessons is taking action based on that newfound wisdom. LeadingAge members attribute this skill to their extensive experience providing person-centered care; as situations change, service strategies must change, too.
The pandemic taught everyone how connected we are; we all went through it together. In many ways community, local, state, and federal government officials stepped up to help when they saw what was happening in long-term care. Even the deliberative, slow moving federal government and the Congress can move quickly in an emergency. For example, Congress authorized, and the Department of Health and Human Services (HHS) administered the Provider Relief Fund, HHS distributed free testing instruments to nursing homes when testing resources were scarce, the CDC Pharmacy Partnership for Long-Term Care targeted early scarce doses of vaccines to residents and staff in aging services organizations, HHS put in place a series of waivers to eliminate bureaucratic barriers to emergency care, and FEMA provided nursing home strike teams.
‘The ground fell out from under all of us during the pandemic, but the actual loss and sense of loss in long-term care has been profound.’
At the same time, aging services organizations were far from alone in needing help during the crisis. Nursing home, assisted living, housing and other aging services leaders found they were on their own to solve emerging problems.
“I saw what happened and my staff saw what happened and we aren’t going there again,” said a LeadingAge provider member whose community lost many residents and staff to COVID-19, describing why he mandated that his staff be vaccinated long before the federal government made that decision for all nursing home providers. Others who had the ability to do so described building up their own stock of PPE and testing supplies to be sure they could protect staff and residents in the case of another surge.
From Learning to Action
Aging services providers have made some changes and continue to pursue others based upon concrete and actionable realizations. Here are five sets of activities that we should keep pursuing. None are easy to achieve, but all are within reach.
First, leadership matters. Active, respectful listening and transparent communication with all staff, residents, and family members promotes trust and loyalty and produces the best results. In more than 400 update calls with our members, we heard this from nearly every LeadingAge member with whom we spoke. Telling the unvarnished truth, acknowledging fears, and listening to peoples’ concerns were among the hallmarks of providers who successfully navigated the pandemic. (Though communication and trust weren’t the only factors.) These actions became important after the advent of COVID-19 vaccines, when high levels of trust, respect, and open communication led to higher levels of vaccine acceptance. It took more than the miracle of vaccines alone.
Second, nursing homes and other organizations that house and serve older people in congregate settings are typically held to high standards of emergency preparedness by federal and/or state regulators. COVID-19 reinforced the need to continue to take preparedness seriously and to be expansive in preparing for not only the unexpected but the unimaginable. Providers who conducted extensive tabletop exercises (practice training for emergencies), beyond the minimum required, reported being ready to jump into action when the pandemic hit.
Third, like emergency preparedness, infection control has always been a key concern in long-term care. The testing and quarantining protocols required to defend against COVID-19 took fighting infection to a new level. Two key lessons here. One, provider organizations, especially nursing homes, are staffed by professional healthcare workers who maintain high infection control standards. Second, federal nursing home requirements for infection preventionists may not be the only, or even the best, path to continuous improvement and the constant changes in preventing and controlling the spread of infection.
Fourth, we have learned how important data, reported in real time, are for fighting a constantly changing adversary like COVID-19. While mandatory reporting can be burdensome for an already stretched staff, regular information on cases, hospitalizations, deaths, PPE, staffing and other aspects of care makes it possible for Congress, government, and the research community to identify issues and provide solutions. Extending federal data collection requirements to other healthcare settings would minimize the inconsistent nature of the available information and enable policy makers to consistently target resources to where they are most needed.
Fifth, pandemic lessons, and, we hope, strategies and solutions related to coping and mental health in aging services settings will fill volumes for years to come. The ground fell out from under all of us during the pandemic, but the actual loss and sense of loss in long-term care has been profound. This was especially apparent for people with dementia who had a higher risk of contracting COVID-19 and are more likely to experience severe outcomes when they are infected. (Numbers & Brodaty, 2021). Providers have learned a lot about coping with grief—for the 135,000 resident and 2,000 staff lives lost in nursing homes and assisted living settings and dealing with a range of other losses.
‘Without a consistent public resource stream, our physical infrastructure for long-term care is increasingly unsynchronized with the needs of an aging population.’
Anecdotally, and documented by a growing body of research, the isolation imposed on all congregate settings for the first six months of the pandemic (and continuing anytime there is an outbreak) caused its own set of losses. And staff trauma and exhaustion round out the mental health impacts of COVID-19.
Social connection programs, trauma-informed care, and staff engagement had all previously been a focus for human and technological problem solvers. But today, government and philanthropic interest in finding and promoting the use of solutions to loneliness and social isolation is at an all-time high. Experts recognize that planning for resident connection is an integral part of emergency preparedness. This is no longer a fringe issue. Similarly, staff mental health support programs and engagement technologies abound.
Moving the Immovable Because There Is No Other Option
Other lessons from the pandemic are even harder to activate but recognition is growing that we must takes steps to make change. As the U.S. Armed Forces slogan says, “the difficult we do immediately, the impossible takes a little longer.” Two “impossible”—and frequently connected—lessons for aging services providers relate to workforce and racial disparities.
As the pandemic rages on, the aging services system is being stretched, in some cases beyond its ability to serve people in need of care. Increasingly, providers report they cannot accept new residents and clients because they do not have the staff to serve them. In the words of one relatively small rural provider in September 2021, “I am losing two social workers, three registered nurses, and five to ten certified nurse aides. It is not good. we are currently planning to close our skilled unit to consolidate staff and residents. It feels like we are falling apart.” This provider has a license to serve 75 people but can only serve 45 because of staffing shortages.
A large home care provider has turned away 86% of new clients since the beginning of the year due to lack of staff to provide care. Such descriptions of the workforce crisis in aging services fill volumes. Solutions are harder to come by. Most observers agree that hiring and retaining enough committed qualified staff to meet the needs of an aging population will take “a hundred different solutions.”
LeadingAge and others leading the way on workforce solutions promote a framework of expanding the caregiver pipeline, strengthening education and training, facilitating career advancement, increasing compensation, preparing universal workers and reforming financing for long-term care. An ambitious path forward, but we have no alternative. Recognizing that aging services workers have been at the front lines of the pandemic and celebrating them as heroes is a start, but solutions must go far beyond clichés and one time recognition.
As our culture writ large grapples more aggressively with racial and economic disparities, so, too, must aging services providers. “The COVID-19 pandemic has brought social and racial injustice and inequity to the forefront of public health and highlighted that health equity is still not a reality,” according to the CDC website. This applies across the board in aging services, for care users and care providers.
Everyone—policy makers who play a key role in supporting aging services, providers, consumers, family members—must frame solutions through the lens of equity.
There is a path forward on these seemingly intractable challenges; but we cannot make progress as a field, a leading economy, or a society without progress on equity and workforce.
Time for a Bold Vision—An Aging Services System for the 21st Century
With so many eyes focused on nursing homes and assisted living residences, many people realized for the first time something that anyone who has sought long-term care for themselves or a loved one knows—that aging services in the United States are not especially well organized because there is no entitlement to long-term care. Without a consistent public resource stream, our physical infrastructure for long-term care is increasingly unsynchronized with the needs of an aging population.
While no one would have asked for a pandemic health emergency, it may be that only a crisis of this size would bring policy makers to a willingness to face the reality that by 2030, 20% of the people in the United States will be older than age 65, compared to 15% today. At age 65, an individual has a 50% chance of needing paid long-term care services some time before they die.
We are, in fact, late to arrive at the table given the country’s rapidly aging population, though history supports the idea that big change comes in response to a big crisis. A post–COVID-19 roadmap to an aging services system for the 21st century should be designed in a way that recognizes the hard-earned lessons of the pandemic. Every facet of the system should be shaped with racial and economic equity considerations in mind. Such a system should recognize the increasing number of people living with dementia. Reform guideposts should include:
- A financing system that recognizes the need for new public spending. We have underinvested in aging services. The new system should involve everyone paying their fair share and promote personal choice and equity for everyone who needs and qualifies for supports.
- A community services infrastructure that provides frail older adults and their families a one-stop shop to determine eligibility, assess needs, and offer service coordination.
- Home- and community-based models of care that are available to all who choose them and are able to continually evolve as consumer needs change.
- Additional housing units for low-income individuals who qualify, so no low-income older individual experiences homelessness or has their options limited because they do not have a community residence in which to receive home care.
- Residential models of care that meet the needs of people who require 24/7 care, and are modern, homelike settings where people want to live and work.
- A special focus on the professionals who provide care and services, ensuring they are trained, qualified, and compensated fairly.
- A focus on diversity, equity, and inclusion in both staffing and the population served.
Increasingly, there is consensus that the country is more likely to have to learn to live with COVID-19 and similar infections than we are to beat them. The long-term care and aging services field will need to evolve and continue to innovate as the population of the United States continues to age. Understanding the lessons of the pandemic is an essential part of this evolution.
Ruth Katz is senior vice president of Public Policy/Advocacy at LeadingAge. Katie Smith Sloan is president and CEO of LeadingAge and executive director of the Global Ageing Network, both in Washington, DC.
Baughman, R. A., Stanley, B., & Smith, K. E. (2020). Second Job Holding Among Direct Care Workers and Nurses: Implications for COVID-19 Transmission in Long-Term Care. Medical Care Research and Review, November 19. Retrieved March 5, 2022, from https://journals.sagepub.com/doi/abs/10.1177/1077558720974129.
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Van Beusekom, M. (2021). Race, income inequality fuel COVID disparities in US counties. University of Minnesota Center for Infectious Disease Risk and Policy. Retrieved March 5, 2022, from www.cidrap.umn.edu/news-perspective/2021/01/race-income-inequality-fuel-covid-disparities-us-counties.