Written by Brieanne Lyda-McDonald

As North Carolina continues a phased reopening from a quarantine designed to stem spread of COVID-19, many businesses have been permitted to reopen. Yet, services for older adults, one of the populations most vulnerable to poor health outcomes from the virus, are nowhere near opening for normal business. Long-term care facilities, which primarily serve older adults, have cut visitation* to protect their residents, senior nutrition programs are operating in very different ways, and senior centers have their doors closed for in-person activities. While these efforts have been important to reduce the spread of the virus to older adults, the resulting isolation experienced by this population is a significant concern for health and well-being. The Centers for Disease Control identifies social isolation as a risk factor for dementia, heart disease, stroke, premature death of all causes, and mental health issues like depression, anxiety, and suicide. Isolation resulting from COVID-19 quarantine measures may leave older adults wondering when daily activities will return to normal. Federal, state, and local guidance on reopening services for older adults is sparse and public messaging often suggests that at-risk populations will be safer staying at home for an undefined amount of time. Here we discuss available guidelines and planning for reopening services for older adults.

Long-Term Care Facilities

Individuals living in long-term care facilities are one of the most vulnerable populations to the health consequences of COVID-19, with outbreaks in these facilities across the state leading to more than 5,000 cases and 719 resident and staff deaths as of June 18. This accounts for a staggering 60% of COVID-related deaths in North Carolina.

In an effort to reduce the risk to those living in long-term care facilities, Governor Cooper’s Executive Order No. 120, signed March 23, restricted visitation by all visitors and non-essential personnel in long-term care facilities, including skilled nursing facilities (SNFs), adult and family care homes, mental health group homes, and intermediate care facilities for individuals with intellectual disabilities. Executive Order No. 131, signed April 9, added further restrictions on internal operations of SNFs, ending communal dining and all group activities, among other protective measures. While mandatory for SNFs, these restrictions are strongly encouraged for other long-term care settings. The order states that these measures should remain in effect until another order rescinds them or the Declaration of the State of Emergency for the state is rescinded.

The Centers for Medicare & Medicaid Services (CMS) provided guidance in May to state and local officials about considerations for reopening long-term care facilities to visitors. Guidelines for facilities are to wait until Phase Three [1] of reopening, test all staff once a week, test all residents once and test again if a resident or staff member tests positive, and also meet the following criteria:

• “there have been no new, nursing home onset COVID-19 cases in the nursing home for 28 days (through phases one and two),
• the nursing home is not experiencing staff shortages,
• the nursing home has adequate supplies of personal protective equipment and essential cleaning and disinfection supplies to care for residents,
• the nursing home has adequate access to testing for COVID-19,
• referral hospital(s) have bed capacity on wards and intensive care units.”

AARP estimates that it will most likely be months until visitors are able to safely re-enter long-term care facilities. Some states, such as Massachusetts, have started to permit outdoor visitations as studies indicate that virus spread is less likely outside. Many facilities have implemented virtual visits for resident family and friends and AARP is advocating for a federal requirement that facilities support these visits.

Senior Nutrition Programs

Around 2% of North Carolina’s senior population receives meals through congregate nutrition meal programs offered in senior centers and churches or through home-delivered meals, such as Meals on Wheels. Demand for these services has greatly increased since the start of quarantine measures in March, with a Meals on Meals America survey finding that 89% of programs nationally had an increase in meal requests, and of those, 79% reported that requests had doubled. Along with needed nutrition, these programs offer seniors the opportunity for socialization with multiple people at congregate sites or with delivery volunteers.

To protect the high-risk populations who participate in these programs, congregate meal sites have turned to grab-and-go options and Meals on Wheels has transitioned many programs to weekly deliveries of multiple meals, rather than daily deliveries. The national Administration for Community Living (ACL), which helps support many of these programs through grant funding, has issued guidelines for operating programs through the phases of reopening. North Carolina is currently in Phase Two of reopening and ACL guidelines state that home-delivered meal services could resume daily or weekly meal delivery with appropriate social distancing, and congregate sites could consider:

• offering a “lunch buddy” program to allow two diners to interact in person, with appropriate social distancing, or virtually;
• implementing a reservation system to reduce the number of people congregating at any time; and
• limiting congregate sites to less than 50 people at a time, with social distancing [2].

Even as the state enters Phase Three in the future, congregate sites will need to carefully implement social distancing and consider that many participants may have concerns about safety. ACL also recommends that as congregate meal sites reopen, they screen participants who had temporarily transitioned to home-delivered meals and may have lost some functional abilities.

Senior Centers

As popular social gathering places, senior centers have had to transition primarily to online programming to avoid gatherings and protect client health. However, a National Council on Aging (NCOA) survey of senior centers estimated that only 46% of clients have broadband internet, 39% are comfortable using the internet, and 38% have a tablet or computer. This leaves many seniors who typically engage in social activity outside their homes facing isolation through months of quarantine.

Senior centers also often offer important services and the NCOA survey found that a limited number of centers planned to offer those virtually or over the phone, including: benefits counseling (25% of respondents), caregiver support (24%), chronic disease self-education (11%), fall prevention education (10%), elder rights (95), and legal services (8%). Ten percent of respondents were not planning to offer any services virtually.

NCOA offered recommendations for senior centers as they consider reopening plans. They recommend the following activities during Phase Two before any on-site programming begins:

• tracking of a sanitizing schedule,
• reviewing how groups will be managed (seating to maintain physical distance for groups under 10, tracking of participants for purposes of contact tracing if an individual tests positive for COVID-19 in the future),
• establishing participant policies (stay home when sick, stay six feet apart, wear a face mask, wash hands on arrival and departure, wellness screening for entry, training on safe public restroom use),
• developing signage to convey policies to participants,
• ensuring ventilation systems are working properly and increase outdoor air circulation as much as possible, and
• planning for necessary closures (staff and participant education).

Once these policies are in place, NCOA suggests that centers can consider opening first for one-on-one appointments for services and small group programs under 10 people for two to three days per week. Early programming should include lower-risk activities that do not involve aerobic activity or singing. During Phase Three, centers can consider expanding programing, such as fitness classes, presentations, art classes, and hobby groups meeting in large open areas. However, even during Phase 3, senior centers should still forego large group events, day trips, singing groups, and card groups. Items that are shared should be quarantined for three days, similar to procedures some libraries are following.

As state and local infection rates continue to fluctuate, progress through the phases of reopening may change. It will be important to consider the health and social needs of older adults during this time and develop and communicate inclusive guidelines that address these needs.

*Note: The North Carolina Department of Health and Human Services issued guidance on June 26, 2020 allowing outside visitation at adult care homes, behavioral health/IDD, intermediate care facilities, and psychiatric residential treatment facilities. There are many requirements for facilities, residents, and visitors to abide by. Skilled nursing facilities and combination skilled nursing/adult care assisted living facilities are excluded from this guidance.

[1] North Carolina has a three-phase plan for reopening businesses based on gating criteria released by the White House related to COVID-19 case counts, testing, and available health services. https://files.nc.gov/governor/documents/files/NC-3-PHASE-PLAN.pdf

[2] North Carolina’s Phase Two guidelines limit indoor gatherings to 10 people and outdoor gatherings to 25 people. https://www.nc.gov/covid-19/staying-ahead-curve/phase-2-faqs#what-is-the-new-mass-gathering-limit