key: cord-0889921-ny4cumot
authors: Wilkins, James M.; Nowak, Lisa M.; Forester, Brent P.
title: Disparities in the Luxury of Distance for COVID-19 Care
date: 2020-05-04
journal: Am J Geriatr Psychiatry
DOI: 10.1016/j.jagp.2020.04.028
sha: 7d877e58dd90ffe47a8a2c6c09ff2af56c0ce189
doc_id: 889921
cord_uid: ny4cumot

nan

Long-term care skilled nursing facilities seem to be exquisitely vulnerable to coronavirus disease 2019 (COVID-19) not only due to the older, frailer populations but also logistical challenges such as inadequate supply of personal protective equipment (PPE) and access to COVID-19 tests (1) . Healthcare facilities have implemented proactive steps to reduce COVID-19 transmission such as visitor restrictions, eliminating group activities and communal dining, and PPE use for staff (1, 2) . Due to the apparent idiosyncrasies of COVID-19 (e.g., high contagiousness in asymptomatic people, atypical presentations in some older adults, high falsenegative testing rate) front-end preventative measures may be insufficient in curtailing spread of the virus (1). Beyond intra-facility spread, there is concern for inter-facility spread with some staff working at multiple care facilities (3).

Frontline staff in long-term care facilities such as certified nursing assistants often are underpaid, given fewer work-related benefits, exposed to high levels of occupational injury/illness, work long/irregular hours, and have low job security with short-term and part-time contracts (4). These occupational strains not only lead to poor retention, high turnover, and increased work-related stress but also pressure to work multiple jobs to make ends meet, particularly in larger urban centers with higher costs of living (4) . As the majority of the longterm care workforce in the United States comes from minority racial/ethnic backgrounds, the disproportionate impact of COVID-19 in Latino and African-American communities is particularly alarming (4, 5) .

Telemedicine options may be available for physicians to provide care in multiple settings while minimizing in-person contact; frontline staff, however, do not have this luxury of distance (2) . Without commensurate efforts to support frontline staff, any expansion of front-end resources will simply add water to a leaky bucket that cannot hold. This is not to diminish efforts to expand and sustain the larger workforce but to highlight an essential link on which the vulnerable older adult population desperately relies and that may be insufficiently addressed in current policy discussions. Recommendations have been made for increasing the supply of PPE and testing materials in the long-term care nursing environment, increasing the preparedness of post-acute care settings, and providing paid sick leave for all staff (1, 2) . Beyond short-term benefit support, however, a comprehensive approach is needed to provide stability for frontline staff.

To target inter-facility spread, frontline staff should be paid at least the national average wage and provided full work-related benefits; by providing sufficient support to earn a living through a single institution, there is less incentive to work at multiple care facilities and to work if unwell given enhanced benefit support. To bolster frontline personnel and maintain adequate staffing ratios, there need to be avenues to bring new people into the workforce and train them quickly and effectively. Options include reassigning workers within an institution whose jobs have been affected by COVID-19, bringing in people from industries that have suffered higher numbers of layoffs (2) , and expediting international recruitment and the process of obtaining work permits and visas (4) . To sustainably protect the health of older adult populations, a multipronged approach is needed that provides opportunities to implement best practices and also security and support for all members of the workforce, particularly the most vulnerable members of the frontline staff.

AGS) Policy Brief: COVID-19 and Nursing Homes

Postacute Care Preparedness for COVID-19: Thinking Ahead

COVID-19 in a Long-Term Care Facility

The Long-Term Care Workforce: Overview and Strategies to Adapt Supply to a Growing Demand

Social Distancing Is a Privilege