But the pandemic almost killed her, says Traci Ruiz, an eldercare advocate who has overseen Salinas’ care in recent years.
A childless widow who turns 102 next month, Salinas was a vibrant woman who thrived in the social life at Ingham County Medical Care before the pandemic, Ruiz said. But the pandemic has severely restricted visitors, and residents have been largely confined to their rooms during the past year.
That isolation has been emotionally “devastating” for Salinas, Ruiz said. Over the summer, “she literally mentally broke down. She called me several times a day, screaming and crying,” Ruiz said, and because of the restrictions, Salinas couldn’t see a therapist in person. By fall, Salinas’ physical health deteriorated to the point where her caretakers feared the centenarian might literally die of loneliness.
Ruiz arranged for hospice services, an arrangement that allowed Ruiz to regularly visit Salinas in person. “She immediately blossomed and did a full 360” in terms of health, Ruiz said.
But Salinas still sorely misses the activities and social interactions that occurred in the home before the pandemic, and it’s been a “miserable” year for her, Ruiz said. “This past year has been so emotional, so sad and frustrating.”
Salinas is not alone. Perhaps no group has been hit harder by the pandemic than the elderly. They’ve comprised a lion share of COVID-19 deaths and hospitalizations, and the threat posed by the virus to their physical health has forced many into isolation, taking a tremendous toll on their mental health.
Advocates for the elderly are now hoping the current attention being paid to nursing homes and senior citizen services will galvanize policymakers to adopt long-term reforms.
“I think the pandemic has put broad problems within the system into focus,” said Mark Hornbeck, spokesman for the Michigan AARP. “And we certainly hope that that will have positive, long-term impacts on services and long-term care facilities.”
Among those problems are the way nursing homes are funded and staffed, two issues that are intertwined, said Lisa Sanders, spokeswoman for LeadingAge, a national advocacy agency that represents nonprofits that provide a range of senior services.
“It’s our fervent hope there will be sustained interest and desire now to fix many of the long-standing issues that providers have had,” she said. “The first one is the chronic underfunding of Medicaid,” the primary revenue stream for many long-term care facilities.
That underfunding impacts the quality of care that nursing homes provide, especially in regards to attracting and retaining staff, said Sanders and others.
Even during the best of times, working as a caregiver in a nursing home has meant low wages for demanding work. The pandemic significantly increased the workload and stresses for those workers, even as the situation highlighted the importance of quality caregiving and the chronic issues of staffing turnover and shortages.
Starting last April, Gov. Gretchen Whitmer instituted a $2 an hour pay raise for direct-care workers in long-term care facilities funded by Medicaid, and she has proposed making that permanent. Advocates said the average starting hourly wage for a direct care worker is $11.44.
But pay is just part of the challenge in attracting and retaining staff, said Melissa Samuel, president and CEO of the Health Care Association of Michigan, which represents long-term care providers.
“Regardless of wages, it’s a calling to be in this profession. There’s a certain kind of individual who can work with the geriatric population,” Samuel said. “So it’s about wages, but it’s providing a career path and ladder. That’s critical.”
Samuel’s organization is among those pushing for a certified nurse aides program that would encourage workers to get additional training. The idea is to improve the skill level of aides, which would improve the quality of care, while giving workers a chance to get a salary bump once they earn their certificate.
That training also could be a gateway for aides to become a licensed practical nurse or a registered nurse, Samuel said. “It could be a real nice step in between.”
LeadingAge and the American Health Care Association also are hoping to leverage lessons learned during the pandemic to push a number of other reforms for long-term care facilities.
That includes better infection control strategies; having a registered nurse available around the clock; ensuring a stockpile of personal protective equipment; improving the system to evaluate nursing-home quality, and better strategies to identify low-performing facilities and either closing them or turning them around.
“We know CMS ( Centers for Medicare and Medicaid Services) will be looking at this. We know Congress will be looking at this,” Samuel said. “Our national association has some, what I would consider, pretty bold initiatives, things like having an infection preventionist on staff and looking at chronically poor-performing facilities. These are bold ideas, but given what this sector has gone through, we need to look at and consider them.”
Jaque King, a policy analyst for University of Michigan’s Center for Health and Research Transformation who has looked at nursing homes’ responses to the pandemic, said it’s clear that quality of care within nursing homes is tied to staff.
“There’s really a clear need to care for and support staff,” she said. “During our study, we heard a lot of issues around being undervalued and underpaid, and about the need for training and education going forward.”
The pandemic also underscored some of the culture problems within individual nursing homes, she said, such as taking punitive approach vs. a teaching approach toward staff when problems arose, and the need for clarity as guidelines kept changing during the pandemic and some workers weren’t properly briefed.
Plus, there’s the fact that “staffing levels are really important to keeping nursing home residents safe,” King said. “Those are the kinds of challenges the pandemic really highlighted and brought to light.”
It’s not just the long-term care system that’s under scrutiny. The high coronavirus case and deaths rates in nursing homes, along with the lockdowns and visitation bans within facilities, had some patients and families opting for home care instead, especially for shorter-term rehabilitation stints after a hospital stay.
“Certainly, the pandemic has resulted in more people choosing to be home,” said Barry Cargill, head of the Michigan HomeCare and Hospice Association.
The challenge for his members included trying to handle that increase in patients; dealing with the Medicaid and Medicare funding restrictions, and trying to provide quality care while keeping patients and caregivers safe.
That latter included a big embrace of technology, including telehealth and remote patient monitoring, he said. While those systems existed before the pandemic, they’ve expanded considerably in the past year by necessity.
“There is technology out there that helps accelerate care and how care is delivered, and the home-care arena is going to embrace that,” Cargill said. “It’s fundamental change.”
One barrier that still needs to be address is Medicare currently bans reimbursement of telehealth services by a home health agency, he said. “If agencies wanted to do, they could but they had to do for free — and some did. But that’s not sustainable.”
Like Samuel, Cargill said the pandemic highlights to need to raise wages for direct-care aides as a way to attract and retain quality workers. “We’re in a crisis mode right now,” he said, adding that the $2 an hour wage hike given by the state doesn’t apply to many home care workers..
Robyn Rontal, policy analytics director at U-M’s Center for Health and Research Transformation, said the shift to home care may be one of the lasting legacies of the pandemic.
For years, she said, there’s been a movement “to find ways to shift care to to the home with supportive services,” she said. “There are a lot of good examples innovate programs and polices that are starting to test that approach. But I think the pandemic shone a spotlight on the need for better services in the home.”
These conversations are long overdue, says Ruiz, whose eldercare consulting agency, Traci Ruiz Consulting in Lansing, took on Eva Salinas as a pro bono client.
Ruiz described her frustration when she heard about plan in Ingham County to distribute food to those going hungry during the pandemic, but didn’t take into account housebound seniors.
“They can’t drive, they don’t have family or can’t get to” a mobile food pantry, she said. “This was something that needed to be figured out ASAP. It’s not something where we can just throw up our hands.
“These seniors are people who won’t ask for anything,” she said. “They’re prideful. They’ve very much the generation that asked for the minimal. We’re not going to turn out backs on seniors in the community.”
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