April 21, 2020

Older adults and people with chronic illness are more likely to die from COVID-19 — a disease that can spread quickly in places where people share tight spaces, meals and caregivers. 

In Oregon, more than half of those known to have died of COVID-19 were living in one of 130 state-licensed long-term care facilities when they contracted the virus. Multnomah County is home to 33 of those facilities — and at least 10 have residents or staff — or both — who have tested positive for the virus.

In the latest public briefing on Multnomah County’s response to the COVID-19 pandemic, the Board of Commissioners on Tuesday, April 21, heard from public health and human services leadership about their work to protect residents and staff in long-term care.

“COVID-19 is disproportionately impacting residents of long-term care,” said Lee Girard, director of the County’s Aging, Disability & Veterans Services Division. 

Oversight

Oversight of these facilities is unclear for many of their residents and their loved ones, especially as COVID-19 has highlighted the authority of local public health officials and their recommendations for the community. And so Girard teamed up with Communicable Disease Services to provide a simple guide to those roles and responsibilities:

There are four types of long-term care facilities, Girard explained, and only one type is licensed and regulated by Multnomah County.

The state’s Department of Human Services licenses and regulates nursing homes, assisted living facilities and residential care facilities.  

The County’s Aging, Disability & Veterans Services Division licenses and regulates adult care homes.

Both government agencies, at the facilities they regulate, can use their authority to:

  • Stop new admissions, pending testing, until there are no more positive cases

  • Order compliance with health recommendations, minimum staffing requirements and other measures

  • Assume direct control of a facility

Public health’s authority overlays county and state regulation of normal operations at long-term care homes, but public health does not have the power to assume direct control of a site. Any time a facility faces an outbreak of a reportable disease, local public health steps in and provides  infection control recommendations.

“Typically we try to provide support and education for the facility,” said Communicable Disease Services Manager Lisa Ferguson.

But during COVID-19, her team has needed the support of regulators.

“We have been finding that connecting with licensing boards helps make sure facilities are following through,” Ferguson said. “We can bring concerns and elevate those concerns, but we don’t have regulatory ability to assume control.”

Ferguson laid out how public health is working with facilities and agencies during the COVID-19 pandemic. A care home must report to public health:

  • Whenever it finds multiple residents with respiratory symptoms

  • Any case of severe respiratory illness

  • Any resident or staff who tests positive for COVID-19

Multnomah County’s Communicable Disease Services also receives test results directly from labs and physicians. And once it learns of a case in a care home, it assigns an investigator and reaches out, usually that same day. By phone and through email, the investigator recommends infection controls, discusses staffing and asks about the use of personal protective equipment (PPE).

The investigator and facility management should check in daily with any updates on tests, ill residents, staffing and PPE levels. 

If a facility has more than one resident or staff member with COVID-19, then that’s considered an outbreak. Communicable Disease Services reports that to the Oregon Health Authority and conducts a second assessment of infection control measures. 

If the County investigator is concerned about a facility, they can always consult with a state epidemiologist or ask the Oregon Health Authority to conduct its own infection control assessment.

Before COVID-19, County investigators rarely needed to call on the regulatory power of a licensing agency, like the state Department of Human Services, Ferguson said.

But COVID-19 has changed all that. 

“If we have concerns about the facility, “if we’re not hearing or hearing things that sound concerning,” she said, “we can reach out” to the Department of Human Services.

They will then work together to secure adequate staffing levels, and can meet with facility management to underscore public health’s expectations around detailed, accurate and timely daily updates.

“They have the regulatory ability, if they need to, to make changes regarding compliance,” Ferguson said. “They can take control and provide additional staffing and management.”

Testing

Commissioners Susheela Jayapal and Sharon Meieran asked about current recommendations for testing residents and staff at long-term care homes. 

“What is the testing protocol?” Jayapal asked. “Do we test everyone?”

Public health typically recommends that facilities test anyone with symptoms, but not those who appear well. That’s because testing capacity has been limited, and asymptomatic people could test negative, providing only a snapshot in that moment. 

But there are crucial exceptions, Ferguson explained. When clusters of ill people are identified, public health would recommend broader testing to help isolate COVID-positive residents, even if they have yet to show symptoms. 

Commissioner Meieran urged comprehensive testing of all residents and staff at long-term care homes. That might offer just a point in time, she said, but it’s a start. 

“That would allow us to have a real sense, to have a baseline, of who would be positive, and allow us to do the most effective cohorting possible,” she said. “To really limit the transmission to others in the facility. That seems to be essential and in our capability.”

Communicable Disease Services Director Kim Toevs said testing isn’t yet reliable enough to support a comprehensive approach, with swabs, tubes and necessary chemical reagents periodically in short supply. If the County does increase testing at such facilities, she said, then it should prioritize testing staff, who come and go from the facility, often work shifts and multiple facilities, and have other community contacts.

“We do continue to see testing limitations,” she said. “And we haven’t seen the rapid testing we have wanted to.” 

Public Health is making plans on how to expand that testing, and that will prioritize with facility staff, who are coming and going frequently and often working shifts at multiple facilities.

Meieran pressed her point. 

“You might have the same people taking care of individuals going into other facilities,” she said. “It’s better to have a baseline, a point in time rather than nothing at all. It would be an important focus of resources and an appropriate response.”