People may be out on patios, resuming some of their pre-pandemic activities, but in Enrico Lachica’s world, the moment is barely a lull.

“It’s been stable,” he says. “I say that cautiously.”

Lachica is a clinical nurse administrator for the Montgomery County Department of Health, working with the county’s nursing homes and assisted living facilities to support their coronavirus response. At the beginning of the pandemic, Montgomery County’s large number of elder care facilities led the state in a staggering number of cases. Now, after months of weathering significant outbreaks, Lachica faces a new challenge: helping long term care facilities assess their capacity to reopen, even as they continue to deal with testing delays and ever-present worries about staffing, protective gear and costs.

Lachica is weighing those worries with the human toll the pandemic has taken on residents and staff in the facilities, which have been locked down since March.

“You have to put things into context and think that some of these residents, they haven’t seen any family members since this whole thing started,” he says. “So you want to try to find a fine balance between allowing families to see their loved ones in the homes versus trying to protect the residents from the community spread of the virus.”

Keith Hare, who leads the Virginia Health Care Association and Virginia Center for Assisted Living, which represents the majority of nursing homes and assisted living providers in the state, echoes Lachica’s caution. “While the numbers in Virginia as a whole for the population are looking pretty good compared to many other states, the nursing homes are still very much in the middle of the pandemic,” he says.

A reopening roadmap

Nursing homes have accounted for some of the worst outbreaks of the coronavirus in the D.C. region, and industry leaders and public health officials say they’re approaching the idea of reopening warily, particularly as cases in the wider community show signs of trending up.

The picture has improved locally — while some facilities in the region are still dealing with outbreaks, fewer are reporting new cases and deaths compared to two months ago.

Local public health guidance for nursing homes seeking to reopen share some similarities with broader reopening plans. Facilities have to move through a series of phases, each lasting at least 14 days. There are specific requirements to be met along the way, like universal baseline testing for all residents and staff, regular assessments of facilities’ adherence to those requirements and the development of detailed plans for socially distant visits. And local public health authorities are expected to weigh in frequently, providing guidance and support.

Still, even the later stages of reopening don’t necessarily mean that nursing homes will go back to a pre-pandemic normal. That list of restrictions includes aggressive daily screening for residents and all staff and people entering facility doors; universal use of facemasks; successful cohorting of residents with COVID-19 away from the rest of the population; ample protective gear; and extensive and frequent testing.

Maryland, D.C., and Virginia all tie nursing home reopening to the success of reopening in their communities.

If all the puzzle pieces come together, a local facility might be able to begin allow residents to have visitors in outside settings, resume some communal dining, and permit small gatherings of five residents or fewer. In later phases, public health guidance allows for indoor visits, limited access for non-essential contractors, and expanded group activities.

Only some facilities in the region have gotten started on any kind of reopening so far. In Montgomery County, fewer than 10 of the more than 300 nursing homes and assisted living residences have moved into the first phase, according to Lachica.

And as the region as a whole moves into a new phase of the pandemic, Hare, Lachica and others describe a number of major challenges still facing nursing homes.

A testing bottleneck

Like many jurisdictions across the region and nation, long-term care facilities also are experiencing a lag in test results, particularly because they require continuous testing for staff and residents.

Maryland requires all nursing homes to test staff every week — and good testing, according to Lachica, has been key in stemming the spread of the virus. But he says some nursing homes have reported seven to 14-day lag times in getting results back.

Similar lag times are plaguing D.C. facilities, too, according to Ilana Xuman, who leads LeadingAge D.C., which represents nonprofit elder care providers. That’s particularly true when the results are processed by a private lab.

“They’re trying to do the weekly testing for staff,” she says. “So the staff member might get tested in week one. Come week two, they get tested again — but they still don’t have the results from week one, which just makes it not useful at all.”

Maryland and D.C. have been helping nursing homes coordinate ongoing testing, prioritizing processing results in public health labs and picking up the tab for them, too. (Virginia has been conducting one-time, simultaneous testing for all staff and residents in a facility in its nursing homes and assisted living centers, but facilities have to contract with private labs on their own for ongoing testing purposes.)

And in Maryland, that structure is about to change. Starting Aug. 15, the state will stop offering public health lab capacity and funding for testing in nursing homes, meaning that facilities will need to figure out how to keep up their testing regimens on their own.

In a joint letter to Governor Larry Hogan (R) reviewed by DCist/WAMU, the state’s long-term care facilities expressed concerns about the move.

“Maryland continues to experience surges of cases in some communities, and as such, outbreaks in skilled nursing and rehabilitation centers are subject to rise again after several weeks of declining cases,” the letter reads. “Now is not the time for the State to stop coordinating and underwriting testing in centers.”

Allison Ciborowski, who leads LeadingAge Maryland, one of the organizations behind the letter, says she was pleased that the state agreed to extend its sponsorship of nursing home testing until the 15th, but noted that there are more challenges ahead.

“Continued testing is in the best interest of public health in Maryland, especially as we are seeing cases on the rise again,” she told WAMU/DCist.

Mounting costs 

Though health officials acknowledge that increased testing is vital in containing the virus, the costs associated with that level of testing is another barrier for long-term care facilities as they look toward reopening.

LeadingAge Maryland and other industry groups estimate that universal testing in nursing homes could cost between $15,000 and $75,000 per week, depending on the size of the facility.

In Montgomery County, Lachica says public health officials have been working to secure a deal with a testing company in Rockville that will process results for local nursing homes. The county will pay for that testing.

“We know that the costs associated with this weekly testing is pretty significant and not all facilities could afford to do this on an ongoing basis,” he explains.

It’s a service the county has already offered to hundreds of assisted living providers that didn’t qualify for state testing help in the first place. According to Lachica, only assisted living facilities with more than 50 residents could access the state aid — which meant only about 8% of the county’s facilities made the cut.

In addition to testing, personal protective equipment is expensive and it can still be a logistical challenge to procure enough stock, according to Hare, of the Virginia Health Care Association. “We’re going to nontraditional suppliers,” he says. “In some cases nursing homes are dealing with 10 to 15 different vendors. And they traditionally would only have to deal with one.”

Progress toward more reliable PPE availability feels tenuous, according to Lachica. “We’re kind of holding our breath because with a potential second wave, that can all change very quickly,” he says.

There are a host of other costs to consider too, says Xuman.

“In addition, costs to reopen services to the community may prove prohibitive for some of our members to fully reopen safely,” she wrote in a letter Wednesday to Wayne Turnage, D.C.’s Deputy Mayor for Health and Human Services.

Operating expenses for her member facilities are close to 15%, and include the cost of waste disposal, better internet connections for virtual visits with family members, hazard pay for staff, licensing fees for HIPAA-compliant Zoom calls, and the installation of glass barriers to promote social distancing.

“All of that is cost that was not anticipated when people created their budgets,” she says.

Nursing homes are also seeing lower numbers of residents in facilities, and they’re having to shift residents who are still there to private instead of shared rooms — which means less pay. Hare says the average nursing center in Virginia operates on about a 1% budget margin, and notes that he’s seen the census in some facilities drop as much as half. To him, that means increased costs and lost revenue will be a long-term challenge that could take years for the industry to overcome.

LeadingAge Maryland’s Ciborowski worries that some facilities — especially assisted living facilities, which usually do not receive insurance money from Medicaid and Medicare — simply won’t survive the onslaught of costs.

“I wouldn’t be surprised to see some of those businesses cease to operate just because financially it’s not feasible to keep going,” she says.

Community outbreaks 

Reopening for nursing homes is also uncertain as local communities begin to see another rise in cases. Hare says the industry in Virginia is bracing for more potential outbreaks, especially in the Hampton Roads area, where cases are spiking again.

“There tends to be about a one to two-week lag [between] when you see spike in cases and then it ultimately making its way into the nursing centers,” Hare says.

One of the strongest indicators of whether a nursing home will experience a COVID-19 outbreak is the incidence of the virus in its surrounding community — not its quality rating or infection control track record. Independent researchers at the University of Chicago, Brown University, and Harvard University have all reached similar conclusions. And in testimony in May before the U.S. Senate, Tamara Konetzka, a University of Chicago researcher echoed that research. “While some nursing homes undoubtedly had better infection control practices than others, the enormity of this pandemic, coupled with the inherent vulnerability of the nursing home setting, left even the highest-quality nursing homes largely unprepared,” Konetzka said.

For Hare, that research underscores what he says is a vital community imperative.

“Our plea…is please social distance, please wear your mask again,” Hare says. “It can definitely prevent someone else from getting sick, and that could ultimately be an elderly person that’s in a nursing home or an assisted living provider.”