As the coronavirus continues to spread across the U.S., causing dramatic spikes in the number of new cases in states that have reopened, the older population may have to prepare themselves for another round of quarantine.
States such as Arizona, Florida and Texas have been reporting record-breaking spikes in the past weeks as they continue their plans to reopen while ramping up testing. Arizona health officials reported 3,056 new confirmed cases Thursday. Nearly 1,968 people are hospitalized on a seven-day average in the state, which is about a 37% increase compared with a week ago, according to a CNBC analysis of data from Johns Hopkins University.
Arizona was among the first states to reopen, allowing most restaurants and businesses to restart with limited capacity and health measures in early May. It also has one of the largest populations of senior citizens in the country.
"When we first started our lockdown in Arizona, our long-term care facilities were hit the hardest," said Dana Marie Kennedy, Arizona state director at AARP.
"At one point, we had 82% to 84% of deaths coming from long-term care facilities. Today, that number has gone down to 55% of the deaths in a long-term care setting."
In the U.S., people ages 65 and older account for 16% of the population, according to the U.S. Census Bureau. In Arizona, 17.5% of the population are ages 65 and older. The state's department of health services says 75% of deaths from Covid-19 came from that age group.
With more than 140 nursing facilities currently operating in Arizona, the state's most vulnerable population group remains at a high risk of getting infected and potentially starting an outbreak.
"In Arizona we haven't hit our peak, and I don't know when we're going to hit it. It's really concerning, because last week we hadn't even hit the thousands and this week we've been in the thousands every single day and four times we broke records for new cases," Kennedy told CNBC on June 19.
While the elderly and immunocompromised are the most susceptible to dying from the coronavirus, there has been a lack of national data on nursing homes.
To better understand the impact that the epidemic has had on older people, the Centers for Medicare and Medicaid Services, or CMS, started requiring all nursing facilities in the U.S. to report Covid-19 data in May. It published its first set of numbers, including total confirmed cases, deaths and other metrics, on nursing home residents and employees on June 4. The federal agency said it will update its numbers on a weekly basis as more facilities release their data in the coming weeks.
As of June 14, the latest available data, CMS reported that in Arizona nursing homes there have been 792 residents who have tested positive for Covid-19 and at least 215 deaths. Nationally in nursing homes there have been 111,508 confirmed cases of Covid-19 and 30,794 deaths.
Outbreak in nursing homes
The CMS data showed two nursing homes in Arizona that had the biggest coronavirus outbreaks: Sapphire of Tucson Nursing and Rehabilitation and Providence Place at Glencroft Center for Modern Aging in Glendale.
Sapphire reported 107 residents who tested positive for Covid-19 and 30 residents who died from the virus. Among staff workers, there were 38 confirmed cases and zero deaths.
Sapphire did not respond to requests for comment from CNBC.
At Glencroft, 82 residents tested positive for Covid-19 and 20 residents died. There were 81 confirmed cases among staff workers and zero deaths.
"From April 15 to May 25, we had a Covid outbreak, a little bit in our assisted living and a significant outbreak in our skilled nursing center [Providence Place]," said Scott McClintock, chief strategy officer at Glencroft. "At one point, we had about 40 or 50 people who tested Covid positive in our nursing center out of about 150, so about 30% to 40% were Covid positive."
McClintock said Glencroft stopped admitting new residents in March and closed all amenities and communal spaces such as dining halls and activity rooms. It started offering meal delivery services instead and coordinated programs to help residents stay home and quarantine.
Glencroft also screens and takes the temperatures of everyone on its campus every day, McClintock said, and any employee who shows symptoms or has a fever is immediately sent home. McClintock said Glencroft stationed guards around the perimeter to track independent living residents who walk in and out of the campus.
Another nursing home, Solstice Senior Living, said they've also been strictly following the CDC guidelines and testing their employees every day. They also closed down their communal spaces and deliver meals to residents instead.
"We were asking people to not leave the community. It's an independent living [facility], so they could choose to leave, but if they left, they would have to self-quarantine for 14 days," said Cristy Ballard, senior vice president of sales and marketing at Solstice Senior Living.
Testing staff is key
As the number of new coronavirus cases continues to surge in Arizona, nursing homes are emphasizing the need for frequent testing.
McClintock told CNBC that Glencroft had no access to coronavirus testing until the facility identified and reported an outbreak to the county in April.
"If we're going to battle this again in the future, we have to have the capabilities to do testing with quick turnaround results, because we need to be able to separate the people that are positive right away," he said. "And we need PPE," or personal protective equipment.
"If we had test results quickly we probably could have stopped half of the infections," he said.
The CMS is now mandating weekly coronavirus testing for all skilled nursing centers, according to McClintock.
Kennedy agrees that testing on a regular basis is essential to minimizing infection and curbing the spread of the virus.
"If you don't continue to test, then the virus can get in. So, knowing that it's so contagious in these facilities, you want to make sure that you test frequently, and you also want to make sure that they have adequate PPE," she said.
"We've only tested skilled nursing facilities, and in Arizona, that's 147. Our assisted living facilities is over 2,000, and they have not been tested. So there's no baseline test for assisted living facilities," she added.
Kennedy emphasized the importance of testing staff workers at nursing homes and providing them with sufficient PPE as they work closely with residents in skilled nursing and assisted living facilities.
"In the beginning, the only way Covid got in a facility was from somebody working at the facility," she said.
"At skilled nursing facilities, these are people who need the most help in terms of basic daily activities such as getting to the restroom and bathing, so there's a lot of personal contact with residents."
Much of the workforce at nursing homes work more than one job at multiple facilities, according to Kennedy. This could pose a serious risk to other staff workers and residents who come in close contact with them.
"You're dealing with staff that usually makes minimum wage, very little PPE training and sometimes English may not be their first language. All of a sudden you have this pandemic, and they may be asymptomatic," she said.
Glencroft also suspects that its outbreak could potentially trace back to an employee at skilled nursing, because the facilities have been locked down since March.
"This is probably true in elderly communities anywhere in the country but it's the staff that usually infects the residents. This is not a new thing when you have to provide such personal, direct care. Our staff go home every night to their family, and they have contact with other people," McClintock said.
No return to quarantine
Long-term care facilities can include three types of communities: independent living apartments, assisted living facilities and skilled nursing facilities.
Independent living is a housing arrangement for retired residents who can live independently without daily medical assistance but want access to personal care services, amenities and security. Assisted living facilities are licensed providers that offer housing, personal care services and clinical care on a daily basis. Skilled nursing facilities are based on a 24/7 medical model that provides care for residents who have a higher level of clinical need.
When the coronavirus epidemic hit the U.S., skilled nursing facilities had to follow strict guidelines set by the Centers for Disease Control and Prevention, or CDC, because the federal government oversees them. The CDC recommended that other types of long-term senior homes follow the guidelines as best they can.
"Assisted living and skilled nursing are licensed areas, so we control access to it," McClintock said. "We, very quickly in March, closed them down. No visitors were allowed, not even family unless we had a patient who was actually dying."
McClintock said Glencroft could not force residents at independent living apartments to stay home or wear masks.
"When they rent our place, it's essentially their home from a legal perspective and we can't force them to do anything and we don't provide them their care," he said.
While most residents were compliant with the community's health measures in the past months, McClintock said, he thinks they won't accept a return to quarantine.
"They were bored out of their minds. They were terrified. They were really wanting news, and they really wanted to get out," he said.
Slow reopening
Despite recent spikes in new Covid-19 cases in Arizona, many senior living homes in the state are following through with their reopening plans. They have more PPE and testing readily available now compared with the beginning of the epidemic, allowing them to feel more prepared for a future outbreak.
After having experienced an outbreak, McClintock said he is confident that Glencroft's skilled nursing and assisted living areas are controlled and safe from Covid-19.
"In our nursing center, it appears that we have effectively achieved herd immunity. Enough people have had it and now have antibodies. I don't think we'll have another outbreak in the nursing center," he said.
Many nursing homes have already reopened their communal areas and started holding group activities with a limited number of participants and social distancing. While visitors are still not allowed in these nursing homes, they're continuing to relax some restrictions.
"You have to go in phases," said Ballard, of Solstice Senior Living. "It's a transition. It's not like you can flip it on like a light switch. You have to transition slowly."