Efforts are underway all across the U.S. to test senior living residents for Covid-19 — but until tests are more widely available and produce results more quickly, providers are hamstrung in their ability to keep residents and staff members safe from infection.
There is a growing pile of evidence showing that the disease is contagious even while those who have it feel little or no symptoms, though researchers are still not definitively sure why. And while there were more than 800,000 confirmed positive Covid-19 cases in the U.S. as of Wednesday, the actual total is certainly higher than that, assuming there are many more people who have the virus and don’t know.
Given the likely wider magnitude of the disease’s spread, the senior living industry will need to test entire communities to truly determine who has Covid-19 and who does not among its resident and staff populations. And only when it does that can it get a handle on mitigating the disease, according to Lynne Katzmann, founder and CEO of Juniper Communities. That is evident in Juniper’s own, comprehensive testing efforts, which found a sizable number of asymptomatic cases in two communities.
“It’s impossible to make a good battle plan without data,” Katzmann told Senior Housing News. “You need to know who you’re fighting, and you need to understand the resources you need to win that war.”
Using community-wide testing, senior living providers can learn who is truly positive for Covid-19 — not just confirm cases among those who are symptomatic — and therefore more effectively manage the disease by separating the sick from the healthy.
“Every one of these facilities is like a tinderbox, and every positive staff member or resident is a lighted match,” National Church Residences Chief Medical Officer Dr. John Weigand told SHN. “To presumptively say the people who have symptoms are positive, and those who don’t have symptoms are negative, is foolhardy.”
Still, there are limitations to widespread testing that include a lack of resources and even the tests themselves. Stakeholders across the senior living industry agree the status quo must change, and industry groups Argentum and the American Seniors Housing Association (ASHA) have been advocating strongly for more testing. There are some signs of progress in the form of increased federal funding for testing, but also an increasing sense of urgency and anger on the part of providers over the lack of necessary resources and support flowing to the sector.
‘If you don’t test, you don’t know’
As the number of Covid-19 cases ramped up in the U.S., so too did the need for test kits needed to detect the disease. The most common variety of Covid-19 test right now is one where a clinician inserts a long wand deep inside a patient’s nasal cavity to swab for evidence of the virus. Once a sample is collected, it’s sent off to a lab for processing, with most results available in a matter of days.
There are also more rapid tests, such as the “ID Now” kit from Abbott Labs, that can yield Covid-19 infection results in as little as five minutes, with some caveats. There are also new, less-invasive tests which need only go as deep as someone’s nostril. Apart from these tests, there are also ways to check for antibodies that indicate exposure to the coronavirus.
The total number of Covid-19 tests performed in the U.S. has climbed to just over 4 million since the pandemic began, according to the Covid Tracking Project. Still, researchers with Harvard University believe that much more testing needs to occur before the country can safely reopen, especially since a widely available vaccine may not arrive until next year at the earliest.
Since the outset of the pandemic, the senior living industry has clamored for more resources to fight Covid-19, including test kits. But some providers have reported difficulty or confusion in obtaining personal protective equipment (PPE) and tests for their residents and staff.
Bloomfield, New Jersey-based Juniper Communities, which was an early proponent of widespread Covid-19 testing in senior living, has been an exception. On April 2, after two days of calling labs across the country, Juniper announced a plan with Magnolia Diagnostics to procure 3,000 Covid-19 test kits for associates and consenting residents across its portfolio of 22 communities. Since then, Juniper has tested more than 1,000 of its residents and associates.
In a typical testing scenario at Juniper, a licensed staff member will don protective equipment and use a long swab to collect a sample from the back of a person’s throat. That sample then goes inside a labeled tube to send off to the lab. Although the lab itself takes about 24 to 48 hours to process a test, shipping delays can extend that period by a matter of days, Katzmann said.
What Juniper found from its testing was a large yet invisible number of asymptomatic Covid-19 cases in two of its buildings. At one Juniper community in Colorado, the company tested every resident and found that 29 out of 50, or 58%, were positive for Covid-19. At another community in New Jersey, Juniper tested 75 residents and found that 47% of them were positive for the disease. There were also positive cases at two other Juniper buildings, but it was a “de minimis” amount, Katzmann said.
“The truth of Covid-19 is that it spreads very, very, very quickly,” Katzmann said. “And that it’s a highly communicable disease that spreads without anyone knowing.”
Juniper is not alone in its findings. Other senior housing and care providers are also discovering high rates of asymptomatic cases in their communities, according to Mark Parkinson, president and CEO of long-term care industry association The American Health Care Association and National Center for Assisted Living (AHCA/NCAL).
“We’re hearing from our nursing homes and assisted living communities that have undertaken expanded testing that they are finding a high number of residents and staff who are positive, but without symptoms,” Parkinson wrote in a press release Wednesday. “Without access to more testing, long-term care providers are at a severe disadvantage in identifying more of these asymptomatic residents and staff.”
At both of Juniper’s affected communities in Colorado and New Jersey, the majority of residents who tested positive for Covid-19 did not show symptoms when the tests were administered. For Katzmann, this is a major sign that testing only symptomatic residents is not enough to get a full snapshot of who can potentially spread the disease.
“Screening at the door, while necessary, is not sufficient,” Katzmann said. “That only keeps out those who are symptomatic. It doesn’t keep out the asymptomatic transmitters.”
It’s also a sign that, with proper identification and quick mitigation, the spread and impact of the disease can be limited. Using data on who had Covid-19, the provider was quickly able to establish a protective “bubble” around five of its at-risk communities, Katzmann said.
Today, both buildings in Colorado and New Jersey are free of active Covid-19 cases, Katzmann said. In Colorado, 16% of the residents who tested positive eventually died of the disease. And in New Jersey, that number was 11%.
The high percentage of Covid-positive residents that Juniper discovered in some communities, and the fact that some residents died, is not the sort of information that any senior living provider is happy to learn. And, being transparent with these sorts of numbers opens up providers to media reports that focus on high infection rates rather than the work that goes into obtaining testing to gain this vital information. However, it was knowing exactly who had the disease that helped Juniper effectively handle the outbreaks in the end — and it’s a lesson other providers and even some in the media should pay attention to.
“We can keep our buildings safe. We can keep our staff safe. We can keep the greatest and silent generations intact. We can honor elders, rather than dispose of elders,” Katzmann said. “And we must do it.”
The state of testing elsewhere
Juniper is not alone in its quest to test residents for Covid-19, though many other senior living providers have not tested for Covid-19 nearly to the extent which Juniper has.
One other sizable senior housing provider looking to test its residents for the disease is National Church Residences, a Columbus, Ohio-based nonprofit with 340 communities in 25 states and Puerto Rico. The communities span the continuum from affordable senior housing to traditional senior living and long-term care.
Last week, the organization announced it had joined forces on a unified testing effort with another Buckeye State provider, Ohio Living; and with LeadingAge Ohio and Central Ohio Geriatrics. The initiative, dubbed the Post-Acute Regional Rapid Testing (PARRT), aims to test older adults living in long-term care for Covid-19. While the initiative doesn’t include all of the older adults in the entire state of Ohio, its current footprint includes people who live at more than 1,500 senior housing communities across the continuum of care.
Under PARRT, older adults or their caregivers can call a hotline and request a visit from a “swab team” trained by Ohio State University. The swab team can visit a resident in their home or care setting, administer the test, pack it in an ice chest and deliver it to an Ohio Department of Health lab that can turn around results within a day.
The provider only began testing through PARRT on Easter Sunday, and has completed an average of about 20 to 25 swabs per day since then, according to CMO Dr. John Weigand. Like Katzmann, Weigand believes the only way to truly mitigate the effects of the disease is to get a real sense of who has it and who doesn’t. And that means eventually testing everyone living and working in senior housing for Covid-19.
“The only way you’re going to flatten the curve of senior housing facilities is to identify who’s at risk of [transmitting Covid-19] and separate them from the people who haven’t gotten it,” Weigand said.
Other senior living providers have begun testing residents and staff on a much smaller scale. These providers include Bloom Senior Living, a Birmingham, Michigan-based company with nine communities in Ohio, Indiana, Louisiana, Florida, and South Carolina; and Assured Assisted Living, a company headquartered in Castle Rock, Colorado, with 10 small-home communities in the Centennial State.
In both cases, the companies linked up with lab providers who are supplying and processing test kits as needed. Neither company currently plans to test all of their employees or residents, as both feel that their current infection control protocols are adequate to screen for and prevent new Covid-19 outbreaks. But the providers are open to the idea of widespread community testing, should the availability and ease of Covid-19 testing improve.
Bloom Senior Living, through a partnership with Assurance Scientific Laboratories, has so far tested 17 residents and staff for Covid-19, according to Bradley Dubin, a principal of Kandu Capital, the family operated investment company affiliated with Bloom. The provider uses the ubiquitous nasal swab test and its wellness directors administer the test on residents in their own apartments. Obtaining the 17 tests was not difficult, and most were paid for through residents’ insurance plans.
Although the company has not yet seen a positive case among any of its residents, one of its workers tested positive for the disease on April 3. But that worker had not been in any of Bloom’s communities since March 30.
The provider is currently testing all of its newly admitted residents for Covid-19, and plans to test anyone who develops symptoms of the disease. The company has enacted infection control measures that include taking temperatures of residents and staff every day, barring most visitors to the community, encouraging mask-wearing among associates and moving away from communal meals.
“We’ve been super proactive and aggressive from the beginning,” Dubin told SHN.
Like Bloom, Assured Assisted Living has tested a little less than a dozen residents and staff, and has not yet seen a positive case among its residents. Currently, the provider is testing all incoming residents and those who develop symptoms for Covid-19 through a partnership with Centennial State Lab.
Other precautions include barring non-essential visitors, making telehealth visits when possible, monitoring staff and residents for symptoms, taking daily temperatures and providing paid sick leave for staff members with potential Covid-19 exposure. And most of the provider’s workers live in the communities in which they work, meaning there’s less exposure to possible disease vectors in the outside world, according to Allyson Whitehead, who works as a nurse administrator for the provider.
“With us having a smaller population, we know our residents so well, and we can really tell if anything changes from their baseline,” Whitehead told SHN.
‘Working in the dark’
Even if every stakeholder in the senior living industry suddenly came to the consensus that all residents and staff must be tested for Covid-19, there are significant barriers to doing so today. Those barriers include the physical invasiveness of the common nasal swab test, the slow speed of results for some tests, a general lack of the supplies used in the testing process and a lack of resources to enact widespread testing.
And, lacking state or federal help, many providers have had to seek out business relationships with private laboratories just to procure tests for their residents and staff.
Assured has not made strides to test all of its residents and employees for Covid-19, but would consider testing more people if there was a less painful way to do so, and with quicker results. Unclear guidance from federal and state authorities also muddies the waters, according to Brian Turner, co-owner of Assured Assisted Living.
“It’s not very clear on whether [we should] test everybody or not … even if they are asymptomatic,” Turner told SHN. “So, we’re working with guidance, we’re working with what the state rules are, and we’re also working with our knowledge and what we believe is the best care for our residents.”
For Katzmann, it’s clear that widespread access to a more rapid Covid-19 test is required in order to move to the next phase of testing for Covid-19 in senior living. And senior living providers must be able to test quickly and widely to enact airtight isolation and contact tracing procedures.
Katzmann is not alone on this front. Rapid testing for large numbers of employees and residents is a necessity for dealing with Covid-19, according to Sean Kelly, President and CEO of Kennett Square, Pennsylvania-based The Kendal Corporation.
“It is ever more apparent that this sector is in particular need of high-quality, widely available and reliable testing,” Kelly wrote in an opinion piece emailed to SHN. “Reliable mass testing will provide those served by aging services providers, as well as the heroes who provide that care, with the greatest assurance that they are being cared for in a safe environment, without exacerbating the risk of inadvertent spread among highly vulnerable older adults.”
For Herbert Heflich, CEO of Fanwood, New Jersey-based Chelsea Senior Living, a more rapid test could be a “game changer” in the fight against Covid-19. Like others in the industry, Chelsea is only testing symptomatic residents at the moment, but sees a rapid test as a crucial component to ramping up those efforts.
“The lack of testing is a serious problem,” Heflich said. “We are working in the dark.”
Help may be on the way. A new coronavirus relief package approved by the Senate Tuesday would set aside $25 billion for Covid-19 testing. But if signed into law, when that money might arrive and how much assistance senior housing and care providers might receive for testing is unclear.
“Do I think there will be additional resources? I think there has to be,” Katzmann said. “Because the only way to really open up the economy is to have consistent testing to make sure that the disease doesn’t continue to spread. And the testing has to be rapid, otherwise it can’t effectively stop the disease.”
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