May 2020
SPECIAL ISSUE: Celebrating Long-Term Care in the COVID-19 Crisis
Leaders of the Csomay Center for Gerontological Excellence and the Iowa Geriatric Workforce Enhancement Program at the University of Iowa join together to celebrate the remarkable commitment, compassion, and hard work demonstrated by our many long-term care (LTC) partners throughout the COVID-19 crisis. In this special issue, we will discuss both the challenges faced by our LTC partners, and highlight some of our “heroes” who have joined hands to face this pandemic with creativity and resiliency.

We Have Failed Our Nursing Homes

Media attention to COVID-19 case and mortality rates in LTC settings often negatively influences public views. However, our LTC partners and many others have worked against a long list of odds to best assure the safety and wellbeing of older people living in their residences and the staff who provide their care and services.  

Terry Fulmer, President of the John A. Hartford Foundation that is dedicated to improving care of older adults, recently stated “We have failed our nursing homes and all those who live and work there.” In her call for Urgent Action Now 1 she notes
The current situation with COVID-19 is consistent with how America treats nursing homes. [We] put the sickest, frailest, and most vulnerable people in one spot then expect [underpaid and poorly resourced] nursing home staff to care for many individuals who have profound dementia, complex chronic diseases, and decreasing function and ability to eat, bathe or move around on their own. These health care workers perform some of the most difficult and intimate tasks, and we thank them with a long-standing practice of offering incredibly low wages and now, with poor personal protection in the current pandemic. (Fulmer, 2020)
The current situation with COVID-19 is consistent with how America treats nursing homes. [We] put the sickest, frailest, and most vulnerable people in one spot then expect [underpaid and poorly resourced] nursing home staff to care for many individuals who have profound dementia, complex chronic diseases, and decreasing function and ability to eat, bathe or move around on their own. These health care workers perform some of the most difficult and intimate tasks, and we thank them with a long-standing practice of offering incredibly low wages and now, with poor personal protection in the current pandemic. (Fulmer, 2020)
Overcoming the Odds: Contagion Risks
The “odds” stacked against nursing homes include the very characteristics of the population served. By virtue of their advanced age and complex chronic conditions nursing home residents are at higher risk for contracting infections like COVID-19. Their functional dependency demands close physical contact between staff caregivers and residents, and in turn, increases the risk of contagion for both groups given the frequency of asymptomatic COVID-19. The Centers for Disease Control and Prevention (CDC) reported that roughly half of residents that tested positive for COVID-19 were asymptomatic on the day of testing. 2 Morgan Katz, MD, MHS, Infectious Disease researcher at Johns Hopkins, conducted COVID-19 testing with entire resident units with her LTC research partners and reports “Results of doing this universal testing were really stunning.” In units that had one to two positive cases, as many as three quarters (75%) of residents came back positive, and about 60-70% were completely asymptomatic. 3
Confusion of Atypical Presentations

As Kaiser Health News reports, another set of challenges lies in atypical COVID-19 illness presentations among older adults . 4 Hallmark symptoms of fever, cough, and shortness of breath may be masked by other illnesses, blunted by immune system responses, and altered by earlier issues like stroke that can alter cough reflexes, noted Dr. Joseph Ouslander, professor of geriatric medicine. Instead, unusual or atypical presentations of COVID-19 among older adults, such apathy, confusion, excessive sleeping, dizziness, falls, and not eating, may complicate accurate identification leading to care and treatment . 4
Insufficient PPE, Testing, Family Distress
The other stack of “odds” facing LTC involves shortage of personal protective equipment (PPE) to reduce contagion among residents and staff; the lack of COVID-19 testing kits to accurately diagnose new cases, plus lack of trained nursing staff to do onsite testing; and dealing with initial family and community distress related to lockdowns. The very policies needed to reduce contagion, closing facilities to visitors and suspending all congregate services such as group dining and activities, also generated distress among family and community members. Although initial resistance and disbelief among family members has largely resolved, addressing the downstream effects of residents being alone in their rooms, with no natural socialization with other residents, family or staff, creates another layer of challenge for staff. New plans for independent and one-on-one activities must be devised and implemented – with a masked face that may seem unfamiliar.
Hospital to LTC Transfer
Another set of odds emerged as hospitals seek to discharge individuals treated for COVID-19. Discontinuation of transmission-based precautions for patients with COVID-19 includes fever resolution, respiratory symptom improvement, and two negative tests 24 hours apart. 4 But positive tests persist long after symptoms resolve, demanding alternative approaches to free hospital beds for acutely ill patients. Interim Guidance for LTC facilities in Iowa released in mid-April announced that “test results should not delay timing and completion of an otherwise clinically appropriate discharge” and that “nursing facilities accepting new or returning residents should be capable of designating isolated areas and dedicated staff who are distinct from staff caring for other residents.” As the guidance offers alternatives for facilities that are not able to accept transfers due to lack of isolation precautions, demands shift to those who are willing and able to accept COVID-19 patients and continue their isolation for a minimum of 14 days. Even using the “best practices,” bringing COVID-19 positive patients to an otherwise disease-free campus can be an ethical dilemma.
Join Us as We Celebrate LTC Heroes
In short, we CELEBRATE all the thought, information-sharing, attention to changing demands, capacity to overcome equipment shortages and obstacles to safely isolating and cohorting COVID-19 positive persons, and willingness to accept risks to staff and other residents alike in order to “do the right thing” with transfers.  
LTC Care Heroes at Wilton Retirement Center
Introduction : Administrator Shelley Wicks has been a longstanding research and training partner with M. Smith and the College of Nursing for nearly two decades. She oversees two community-based LTC campuses in small Iowa towns: Wilton, population 2,807 and West Liberty, population 3,794. In spite of using best practices and following both state and federal guidance for COVID-19, the Wilton campus had 3 positive residents in assisted living and 6 in skilled care, and 2 positive staff that were quarantined at home prior to this issue. The story she writes is testimony that even the best are afflicted by COVID-19, AND that community support is essential. 
From Shelley: I did not announce anything to the public about our outbreak, but instead put the following information on the WRC’s Facebook page.
We want our friends and family to know that we have several cases of the positive corona virus among our residents. We are working closely with the Iowa Department of Public Health and Muscatine County Emergency Management in following the CDC guidelines for Covid-19. Early in March, when we first heard about this virus, we started to prepare the campus for the long haul. Our facility has been locked down to all visitors and other non-essential staff. We have educated our employees on the virus, proper hand washing, infection control, proper use of Personal Protective Equipment, social distancing. All of it. We have stopped communal dining, group activities and outings. In spite of all this, it still crept into our building and has afflicted some of our residents. Please know that we continue to work hard to keep it from spreading further within our community. All of our families have been notified that the virus is present in our building. We ask that you send cards and letters to our residents and that you keep us all in your prayers that this will pass soon. We are thankful for the community who has supported our facility through the years. I am grateful for our excellent staff who are working tirelessly because they care for our residents. We will get through this together! -- Shelley Wicks, Administrator
This post had 239 likes, 161 comments, and 316 shares. I am mentioning this because Wilton Retirement Community is such a major player in Wilton and I wanted the public to know. I also did an article with the local paper, the Wilton-Durant Advocate.  We have had no negative comments, no finger pointing, and much community support! and TV stations. Donations from local businesses include face shields, N95 masks, thermometers, gowns, bathing gloves, and goggles. Families and friends have provided pizza for lunch, Subway gift cards, employee gift certificates for 80 employees, and $1,000 for supplies. Each donation helped our residents and staff remain safe and get well. We are so thankful.

We are working daily with the Iowa Department of Public Health, the Muscatine County Department of Public Health and the Muscatine County Emergency Management. They have helped us get the PPE that we need plus the test kits we needed for both staff and residents.
Our staff are so dedicated. They come to work because they care about these residents. They come to support each other. They come because they know that they are making a difference in someone’s life. 16 employees were sent home ill and were tested. All of them were negative and are back to work. I have always told my employees that working in long term care is a calling. It is not just a job with a pay check. During this pandemic, it is evident that these employees want to be here. They come knowing that they could be exposed and/or catch the virus. They come even though they have to quarantine from their kids. They come because they want to. They can’t help it; it is in their soul.
These are the long term care heroes here at Wilton Retirement Community. Not just the CNAs and the nurses. It is the activity staff, dietary staff, housekeepers and laundry people, the assisted living workers and the maintenance staff.  All of them are our heroes!
On the LTC Front Lines in Johnson County
Introduction: Kim Bergen-Jackson is the Administrator of Oaknoll Retirement Community in Iowa City which is located in Johnson County, the home of the University of Iowa. Kim also serves as Co-Chair of the Johnson County Long-Term Care Quality Committee that has met monthly for many years. In response to the request for a story about LTC in the COVID-19 pandemic, Kim offered the following story.
From Kim: Older adults living in senior living communities, their families and the staff across the country have experienced many changes since the pandemic started. Some of those changes have caused isolation due to restricted visitation, loneliness, grief, and helplessness. The virus seems to be targeting older adults with underlying medical conditions who live with other older adults. The very definition of our population.
The virus is scary. It's scary for residents/tenants; it's scary for families; and it's scary for the staff who work in senior living. There is an overwhelming fear of what could happen if the virus enters your building and then the terrible reality as we see the communities around us experience terrible sickness and the death of residents and some staff.
As time goes on, we realize we are not helpless to the virus and senior living communities in Iowa have implemented a number of interventions to try and keep the virus out. These interventions include social distancing, no group activities, no communal dining; staff in masks and face shields; no family, volunteers, students or vendors; and health monitoring for staff and residents alike. All in hopes of beating the peak and surviving the wave.
So, when do we get to the good story? Valid question.
For the past 8 weeks, representatives from Johnson County (JC) Public Health, JC Emergency Management, JC Board of Supervisors, our Regional Medical Classification Center, Iowa National Guard and all JC senior care providers – independent living, assisted living, nursing homes, and our lifespan community -- have participated in a daily call, every day 7 days/week. Five local and state-based organization and 12 LTC representative discuss the status of our residents and staff, pending Covid tests and protocols, and assess PPE needs. All privacy laws are honored and no identifying information is used, but the conversations are rich with ideas and information.

Instead of focusing on the things the virus has taken from us, we are choosing to focus on what the virus has given us. For instance, improved communication, virtual meetings, a spirit of us vs. the virus, an appreciation for the resiliency of our residents/tenants, the support of our incredible families, harp music in the courtyard, baby bunny visits, banners, walls of thank-you cards, new skills in Zooming, FaceTiming, Microsoft Teaming and other apps that bring people together, and building amazing community relationships. We have purchased hundreds of face shields together (which were donated by IC FabLab), collected and distributed hundreds of cloth masks (which were donated by the Old Capital Quilter's Guild), purchased gallons of hand sanitizer (made by Cedar Ridge Distillery), given each other leads on other PPE and received many donations from JC Emergency Management.
The daily call brings us together as providers to care for all our residents/tenants in Johnson County. The open dialogue of the meeting has allowed us to remain consistent in the county and follow the recommendations put forth by Iowa Department of Public Health. There is a sense of calm and reassurance when the call leader asks each community to report on how they are doing, and laughter when one of us forgets to mute the microphone. It's very reassuring to have our former administrator, now Board of Supervisor member, on the call supporting everyone and support and assistance from our JC Public Health representative is invaluable.
I see this collective as an exemplar of leadership for senior living, emergency management, and public health to reduce vulnerability in the older adults of Johnson County. It also serves as a touchpoint for my day, a moment of clarity and a chance to feel that I am not alone in the fight to keep the virus out, but in fact, we are all in this together. I find myself looking forward to the call each day.
Quad Cities Senior Care Coalition Rapid Redirection
Introduction : Member of the Coalition are located in the geographic region known as Quad Cities – four cities in Iowa and Illinois that border the Mississippi River. Two large health systems, Genesis Health in Iowa and UnityPoint–Trinity in Illinois, partner with more than 25 skilled nursing facility leaders in both states. The Iowa GWEP has collaborated with the Coalition for several years and since 2020 has provided data support related to unplanned transfers. The Coalition goals -- to improve care transitions by sharing resources and data, implement best practices and person-centered interventions, and utilize quality improvement process tools -- provided a sound foundation on which to address the many demands of COVID-19 contagion.
From Usual Business to the COVID-19 Crisis:  The monthly Coalition meeting held March 4th spent considerable time discussing COVID-19 to promote awareness among members. Testing criteria, public health department notification policies, PPE supply chain issues, policies for potentially sick staff or children at home, and the impact of travel restrictions were all reviewed. By March 12th the Coalition leadership call made an abrupt turn from usual quality improvement planning to address emerging demands of the COVID-19 pandemic. Monthly in-person member meetings were redirected to twice monthly conference calls to address shared COVID-19 issues: shortages of PPE, staff training to advance safety, accessing tests, safe resident transfer, and reassuring families and community members that all steps were being taken to follow state and national guidance for safety. The group’s longstanding history of working collaboratively to improve the care and safety of older adults in LTC settings has served them well. Years together have promoted a culture of being community-minded, willingness to share best practices with “competitors”, and capacity to work together for the good of the community – all critically important for addressing the pandemic.
A LTC Provider’s View
Introduction: N. Jane Stickney, DNP, RN, provides care and treatment to residents living in nursing facilities in the small rural community of Fairfield, Iowa (population 9,447). She provides a view of the rapid adoption of telehealth by her LTC partners to assure residents care and treatment continues in spite of COVID-19 restrictions.
From Jane: The rapid establishment of telehealth systems to maintain contact with my patients was met with enthusiasm, and most importantly, willingness on the part of LTC staff to do whatever was necessary to ensure high quality care. New computers with video capability were purchased. Directors of nursing freed up their time for several hours every week to act as my eyes and ears. Staff pop in and out of the video conference to say hello as nurses virtually “round” with me on the unit.
We talk often of their efforts to obtain sufficient PPE – and they have done a remarkable job. They share stories about time spent on the phone, reassuring residents’ families and friends who call frequently because visiting is limited. We exchange all the up-to-date information about this pandemic. Through this, we are forging stronger interprofessional bonds as we explore and use telehealth to deliver healthcare.
My partners are taking new residents, but this requires a special “Covid Unit” with dedicated staff, placing additional burden on a workforce that is already stretched thin. The staff is largely composed of parents of school-age children – and their concerns of becoming potential vectors are well-founded. But they are committed to their work; they have not abandoned their residents and have honored the Florence Nightingale pledge – “with loyalty will I . . . devote myself to the welfare of those committed to my care.”
National Support for LTC
Both the issues faced by LTC, and resources to support the important work by ALL staff, are increasingly coming into focus. We offer the following resources as exemplars and hope more support for LTC, and also more positive attention to the work undertaken by our partners, will be highlighted soon!!
Supporting Nursing Homes in the COVID-19 Crisis: A Rapid Response Network & National Nursing Home Huddles (May 1, 2020 Webinar) reviewed a four-step solution to support best and better practices to address for clinical and operational issues, including (a) National nursing home huddles held daily; ( b ) Work groups to rapidly build practical solutions; (c) Media kits to help nursing homes change the story in their local communities; and (d) Collective Voice and Advocacy to advance support for nursing homes. Co-sponsored by the Institute for Healthcare Improvement (IHI) , with support from The John A. Hartford Foundation the COVID-19 Rapid Response Network for Nursing Homes is designed to support nursing home leadership, staff, residents and families impacted by the COVID-19 pandemic. Daily 20-minute Huddles provide real-time, pragmatic solutions that can be implemented in nursing homes “today” to solve many of the key problems brought about or exacerbated by COVID-19. Learn about the Huddles and Sign up here .
Civil Money Penalty (CMP) Reinvestment for COVID-19 Communication Technology offers nursing homes an opportunity to request CMP to provide residents with adaptive communication technologies such as iPads, Amazon Echo Show, Kindle Fire, Microsoft Surface and Samsung Galaxy tablets. The application template is found here and frequently asked questions about the application are found here .
Supporting Family Caregivers of Older Adults Through Times of Stress and Isolation ( April 30, 2020 webinar ) is available to view; slides and Resource Guide are available here .
FACE COVID - How to Respond Effectively to the Corona Crisis , a short YouTube developed by R. Harris (2020), provides advice about managing Covid-related stress.
COVID-19 and Living with Dementia: Maintaining Well-Being and Purpose , a webcast cosponsored by the Minnesota Gerontological Society, Minnesota Northstar Geriatrics Workforce Enhancement Program, and Minnesota School of Public Health, reviews virus related risks among those living with dementia and strategies to enhance family care. The recording and slides are archived here .
Meals Together is an online “matching” service that adds flavor to social distancing by creating companionship through intergenerational dinner parties over video calls. To do this, the program pairs users with a FoodFriend from a different generation to share meals and stories. For information about the program and how to enroll here .
Share Your Lessons for Living Through a Crisis invites older adults to share their advice and lessons learned about living through a crisis – like the Great Depression, World War II or the Jim Crow era. The Legacy Project invites older people to share advice on how to cope with our current crisis based on past experiences. To participate, visit here .
The Conversation Project is dedicated to helping people talk about their wishes for end-of-life care. Their main website provides free Conversation Starter kits. They also offer a 2-page handout, “ Being Prepared in the Time of COVID-19: Three Things You Can Do Now ,” that offers guidance on how to best prepare for serious illness.
COVID-19: Lost on the Front Lines is a project from the Guardian and Kaiser Health News that aims to document the life of every health care worker in America who does from COVID-19 during the pandemic. This remarkable testimony underscores the risks taken by ALL providers.
1. Fulmer, T. (April 20, 2020). Nursing Homes in the Time of COVID-19: We Need Urgent Action Now and a Long-Term Care Strategy. Blog published by The John A. Hartford Foundation. Retrieved from

2. Kimball, A., Harfield, K. Arons, M. et al. (April 3, 2020). Asymptomatic and Presymtomatic SARS-CoV-2 Infections in Residents of a Long-Term Care Skilled Nursing Facility – King County, Washington, March 2020. Centers for Disease Control and Prevention, Morbidity and Mortality Weekly Report , 69(13): 377-379. Retrieved from

3. Keeping Nursing Home Residents and Staff Safe in the Era of COVID-19. (Webinar, April 22, 2020). Sponsored by the National Academies of Sciences, Engineering, and Medicine (NASEM). Terry Fulmer, President of The John A. Hartford Foundation, Moderator. A video of the webinar and webinar's PowerPoint slides are archived at:

4. Graham, J. (April 23, 2020). Seniors with Covid-19 Show Unusual Signs, Doctors Say. Kaiser Health News . Retrieved from

5. Iowa Department of Public Health. (April 13, 2020). Interim Guidance for New Admissions or Return of Residents to Long-term Care Facilities. Retrieved from
Csomay Leadership for Gerontological Excellence and Iowa GWEP Leaders
Marianne Smith, Csomay Center Director and Iowa GWEP Project Director

Linda Seydel, Csomay Center Leadership Team and Iowa GWEP Program Director

Ryan Carnahan, Csomay Center Leadership Team and Iowa GWEP Data Director

Mercedes Bern-Klug, Csomay Center Leadership Team and Iowa GWEP Leader

N. Jane Stickney, Csomay Center Leadership Team and Iowa GWEP Leader

Keela Herr, Csomay Center Co-Director

Larry Newman, Csomay Center Leadership Team

Ryleigh Maas, Csomay Center Administrator
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