Kathleen T Unroe, MD, MHA, Indiana University Center for Aging Research
1101 West 10th Street
Indianapolis, IN 46202-3012
This work was supported by the Department of Health and Human Services, Centers for Medicare & Medicaid Services (Funding Opportunity 1E1CMS331488). The opinions expressed in this article are the authors’ own and do not reflect the views of the Department of Health and Human Services, Centers for Medicare & Medicaid Services.
1Marian University School of Medicine, Indianapolis, IN
2Indiana University School of Nursing, Indianapolis, IN
3Regenstrief Institute, Indianapolis, IN
4Indiana University School of Medicine, Indianapolis, IN
Nursing facilities across the United States stopped family in-person visitation in March 2020 in an effort to minimize the spread of coronavirus disease 2019 (COVID-19). Indiana was one of the first states to implement guidance on reopening nursing facilities to visitors, starting with outdoor visitation. A convenience sample of Indiana nursing facility leaders were surveyed regarding both outdoor and anticipated indoor visitation during the pandemic. Questions focused on current outdoor visitation practices and concerns. Responses were compared to current state guidance and summarized. A total of 15 of 39 facility leaders responded to the survey (38% response rate). Policies were similar across facilities and incorporated state guidance. Common concerns regarding visitation included issues with staffing during visitation, scheduling, and visitors not following masking and social distancing guidelines. Additional policies and resources are necessary to facilitate nursing facility visitation during an infectious pandemic. Facility leaders report positive early experiences but raise concerns about operational considerations and potential noncompliance of visitors or residents to policies.
Key words: skilled nursing facilities, COVID-19, social isolation
Of the 1.25 million people residing in US nursing facilities, the majority are older adults, a population disproportionately affected by coronavirus disease 2019 (COVID-19).1-4 As of the week of January 10, 2021, nursing facilities reported a total 549,852 confirmed resident cases of COVID-19 and 107,107 COVID-19 deaths.5 Age aside, nursing home (NH) residents are particularly vulnerable to COVID-19 due to congregate living environments and personal care needs, as well as a high burden of cognitive impairment that can make it difficult to follow risk mitigation strategies such as physical distancing and hand washing.3,6
The high risk of mortality and morbidity among older adults infected with COVID-19 prompted the Centers for Medicare & Medicaid Services (CMS) to instruct nursing facilities to stop all visitation with residents on March 13, 2020.7 Although the goal was to protect residents from exposure, prohibiting in-person visits also meant families and friends were no longer able to provide social support or assist in caregiving. In NHs, family caregivers help maintain continuity of care, keep an eye on residents for changes in health, and contribute to the facility’s community by interacting with others.4,8-10 Without family visits and other outside social contacts, residents can become lonely, despondent, and feel abandoned, which can lead to depression, weight loss, and worsened behavioral symptoms of dementia.11-27
Given the negative impact of social isolation on NH residents and their families, combined with advances in understanding COVID-19 transmission, nursing facilities and health authorities have been working to determine safe approaches to reopen NHs to visitors. The Indiana State Department of Health (ISDH) was one of the first in the country to issue guidance on reopening visitation. Outdoor visitation was permitted starting June 3, 2020, followed by indoor visitation on July 4, 2020.28,29 The guidance included criteria for the facility, resident, and visitor and addressed topics including the use of personal protective equipment (PPE), screening, and testing (Table 1). State guidelines left some operational decisions to facilities, requiring them, for example, to develop procedures for scheduling without providing prescriptive instructions. In this paper, we describe facility-level policies and early experience with resuming visitation at 15 NHs in Indiana. Through this descriptive analysis, we illustrate early approaches and experiences with reopening visitation during an ongoing pandemic.
On July 7, 2020, a survey was emailed to a convenience sample of facility leaders at 39 Indiana nursing facilities participating in a CMS clinical and payment demonstration project.30 The survey addressed the reopening of visitation, issues encountered with outdoor visitation, concerns about visitation, and the implementation of written visitation policies. Concerns about indoor visitation were collected through an open-ended question. Issues encountered with outdoor visitation were addressed via check-the-box options. Facilities were asked to provide their written policies and/or pictures of their visitation spaces.
The survey was created using REDCap software. A reminder was sent out 1 week later, and the survey closed on July 17, 2020. Facility-specific visitation policies were compared with ISDH guidelines to identify similarities and differences.
Overall, 15 of 39 (38%) of facilities responded to the survey. A majority (14/15) reported beginning visitation shortly after ISDH issued guidance permitting it, with start dates ranging from June 3, 2020, through June 26, 2020. A majority (13/15) had developed a written visitation policy. Of these facilities, five provided written policies and resources created and shared with families of residents prior to the visit; four provided photos of their outdoor visitation areas (Figure 1). Two facilities provided information sent to family members to notify them of visitation policies. These resources covered registration, COVID-19 screening, and guidelines for families during outdoor visitation.
Outdoor Visitation Experience
Participants reported a range of concerns with outdoor visitation. The most frequently reported issues were ensuring adequate staffing during visitation (n=7), scheduling (n=6), and visitors violating the mask requirement and social distancing policies (n=5). Challenges reported less frequently included residents violating the mask requirement and social distancing policies (n=1), the need for staff education on visitation procedures (n=1), visitation site sanitation (n=1), and visitation site set-up (n=1). Another issue raised by a respondent was challenges that masks and outdoor noise presented for residents in hearing conversations. Another respondent noted that visitor screening processes were a challenge, and they were investing in no-touch hardware to help with this process.
Concerns About Indoor Visitation
At the time of the survey, ISDH had released guidance on indoor visitation but it had not yet started in Indiana facilities. Issues anticipated with indoor visitation included: (1) potential for visitors or residents to not follow masking or social distancing policies; (2) decreased ability to social distance in smaller spaces; (3) potential to run out of needed supplies; and (4) need for additional staff, particularly for weekend and evening hours. In addition, concerns were raised about an increased risk of COVID-19 exposure with indoor visitation that could lead to outbreaks in the facility, and that the move to indoor visitation was “happening too quickly.”
Written Visitation Policies
The five written policies provided by respondents aligned with ISDH guidance and shared many similarities (Table 1). Meanwhile, there was variability in areas left to facility discretion.
All policies included 4- to 5-hour blocks of visitation time, with individual visits varying from 15 to 25 minutes. However, two of the five policies requested that visitors stay in their cars while being screened for symptoms and signing in. All facilities required family members to register for a visitation time slot by calling the facility ahead of time; one also provided an online registration option. One facility requested visitors bring their own lawn chairs. Two policies made mention of prioritizing certain residents for visits, specifically those experiencing loneliness or psychosocial distress.
There was heterogeneity in policies related to visitors by minors. One policy allowed children of any age to visit, one allowed children aged 2 years or older to visit, and three allowed only children aged 12 years or older to visit.
Indiana was one of the first states to create policy during the COVID-19 pandemic around reopening nursing facilities to visits from family and friends. Creating safe strategies for resuming visitation is now an urgent priority nationwide.2,18,19,21,31-37
On September 17, 2020, CMS issued federal guidance for reopening nursing facilities to family visitation.38 This review of facility-level policies and early experiences of Indiana NHs in reopening visitation provides insight into operational practices. In addition, we highlight concerns of facility administrative and clinical leaders in implementing these policies.
Facility-specific visitation policies aligned with state-level guidance. In areas where facilities were allowed discretion, there were differences among facilities. This included the age of children allowed to visit, requests that visitors provide their own seating (lawn chairs) for visitation, and screening and scheduling processes. Updated ISDH guidelines, issued after the survey, stated that children of any age can be present for visitation, and those younger than 2 years do not need to wear a mask.35
Facilities offered 4 to 5 hours of visitation a day. Visits lasted 15 to 25 minutes each, with time to clean allotted in between. Scheduling processes were similar among facilities, however, they were not without challenges. Of the provided policies, only one offered online scheduling for visitation. For others, scheduling was on paper or by phone, requiring staff involvement. Increased options for online scheduling as well as online review of instructions may help ease the time commitment for staff.
The most commonly reported issue faced in outdoor visitation was staffing. Staff shortages are a chronic challenge for nursing facilities.5 During the pandemic, this has been exacerbated by staff missing work because of illness or child care issues due to school closures or leaving their job over concerns about adequate PPE and fear of COVID-19 infection.17 Safely facilitating visitation is a new role in nursing facilities. In contrast to prepandemic times, visitation must now be carefully scheduled and monitored. Staff time is needed to: (1) create spaces for visitation; (2) coordinate visits with family members; (3) educate family, residents, and staff on new protocols; (4) clean surfaces between visits; and (5) monitor and provide support during visits.
In colder weather, indoor visitation is necessary to allow in-person contacts between residents and their families and friends. To share creative approaches to visitation, working within federal and state guidance, and best-practice infection control practices, facility clinical and administrative leaders should seek out opportunities to engage with other facilities.39,40
In an attempt to prevent COVID-19 outbreaks in the early months of the pandemic when PPE and testing were in short supply and understanding of the virus was limited, CMS directed nursing facilities nationwide to close off from visitors. Recently issued guidance from CMS now reflects a new urgency: to reopen nursing facilities to reconnect residents with their families and friends in the community.38 This survey is a convenience sample within one state; however, the issues raised likely reflect challenges encountered by facilities across the country as they reopen in-person visitation. The concerns and approaches outlined in this descriptive study may be instructive for the creation of new protocols and staff roles to accommodate safe reopening.
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