Theresa Schmidt

As I made my own plans during the past two holiday seasons, I often reflected on how especially difficult it must be for residents living in long-term care communities and their families to celebrate separately or come together safely. Navigating pandemic restrictions to allow people to spend meaningful time with their loved ones has also been a challenge for long-term care leaders and staff. 

Overcoming this challenge is necessary, however, to ensure person-centered care during the holidays and throughout the year – even in the face of a global pandemic. In the second installment of the Advancing Excellence in Long-Term Care Collaborative Policy Series, Victoria Walker and Tonya Roberts discuss recommendations for policymakers related to visitation guidance. We welcome you to use this content and reference the first article in this series and our complete set of recommendations to help promote change in long-term care.

Theresa Schmidt, for Advancing Excellence

Person-centered care values have been endorsed by policymakers, providers and consumers of long-term care, yet current regulations and policies provide conflicting guidance about how to prioritize or achieve it. The pandemic brought into sharp focus the conflict between paternalistic protective measures and person-centered care, highlighting the tension between safety and autonomy or meaningful living for nursing home residents. 

Severe restrictions imposed by federal and state governments on visits from loved ones and social interactions with other residents and staff members were intended to keep residents safe but had a devastatingly negative impact on resident wellbeing and non-COVID mortality.

The Advancing Excellence in Long-Term Care Collaborative addressed this in an open letter to the Biden Administration in September 2021 (Figure 1). Recent visitation guidance from the Centers for Medicare & Medicaid Services on Nov. 12, 2021 (QSO-20-39-NH) makes strides towards prioritizing person-centered care by allowing widespread, open visitation, but provides conflicting guidance that lacks flexibility and is confusing for residents, leaders, employees, surveyors, and visitors.

Figure 1.

Current guidance does not help providers achieve multiple goals that are often directly competing. On one hand, the guidance states that visitation cannot be restricted in any way. On the other hand, the guidance states that facilities are responsible for enforcing the core principles of COVID-19 infection prevention

Victoria Walker, MD, CMD

These core principles are in many ways inconsistent with socialization patterns that are foundational to relationships, making it difficult for people to adhere to them. Most people who live independently have a social circle “in their bubble” with whom they do not follow these core principles.

People who live in nursing homes understandably would like the same. Regulations that have unintended consequences of reinforcing the traditional medical model to the detriment of resident rights and person-centered care should be modified.

Despite a sincere commitment to resident safety, facilities cannot carry responsibility for enforcing core infection prevention principles if they are inconsistent with resident wishes or person-centered care.

Current guidelines state visitors who are unable to adhere to the core principles of COVID-19 infection prevention should not be permitted to visit or should be asked to leave, while simultaneously stating that there can be unlimited visitors to an unlimited number of residents regardless of facility capacity to safely monitor and enforce safe principles of infection prevention during visits. 

Facilities need flexibility to tailor their approaches to balance multiple competing factors in ways that maximize person-centered care while maintaining safety. Clear guidance to surveyors is needed to ensure that good-faith efforts to allow appropriate visits in a safe manner do not result in citations or civil monetary penalties. Surveyors should also be required to follow the same guidelines as employees in long-term care for testing and/or vaccination. 

Tonya Roberts, PhD, RN

To help update this guidance, one strategy is to convene a multi-stakeholder panel that includes infection prevention professionals, person-centered care advocates, residents, family members and PALTC professionals to review and refine this guidance to safely normalize visitation and intra-nursing home socialization.

Updated guidance should 1) resolve conflicting statements; 2) address circumstances under which it is acceptable to discontinue mask-wearing for residents and staff regardless of vaccination status; and 3) resume non-distanced and unmasked group activities. This panel should inform future efforts to prioritize person-centered care priorities.

While COVID-19 has created an urgent need to convene stakeholders that can help reconcile these problematic person-centered care policies, such a panel could also set the tone for continued efforts to review and reconcile conflicting or inconsistent guidance around person-centered care and help eliminate situations that leave providers unable to make decisions that can meet directly competing goals for care. This panel could also engage in longer-range efforts to inform the development of other mechanisms to make person-centered care priorities visible such as through the development of person-centered care quality measures. 

Until valid measurement exists of self-determination, privacy and meaningful activities, it will be impossible to understand the impact of issues like COVID-19, other policies, or funding models on person-centered care and the well-being of residents who live in nursing homes. 

Victoria Walker, MD, CMD, is a board member of the Advancing Excellence in Long-Term Care Collaborative. She is also a board member of AMDA-The Society for Post-Acute and Long-Term Care Medicine and 2013-14 Health and Aging Policy Fellow. She is the Medical and Clinical Officer for Avel eCare Senior Care and Corporate Medical Director for Avera Health Long-Term Care.

Tonya Roberts, PhD, RN, is a member of the Advancing Excellence in Long-Term Care Collaborative. She is an Affiliate of the Center for Aging Research and Education and an Associate Professor at the School of Nursing at the University of Wisconsin – Madison. 

Theresa Schmidt, MA, was the 2021 Secretary of Advancing Excellence and has served on the board since 2014. In this role, she led the development of the open letter to the Biden Administration. She is a Vice President at Discern Health, part of Real Chemistry. 

The Advancing Excellence in Long-Term Care Collaborative is a not-for-profit entity that creates a forum for organizations and individuals committed to the needs of long-term care residents and staff to discuss policies that affect these vulnerable populations.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.