The Post-Acute and Long-Term Care Crisis in the Aftermath of COVID-19: A Dutch Perspective

To the Editor:

We read with great interest the article by Laxton et al about solving the COVID-19 crisis in post-acute and long-term care.¹

In the Netherlands, the peak of the first wave of the pandemic seems to be behind us, and it is now becoming apparent how hard the nursing home population has been hit and how disruptive the pandemic is for Dutch nursing homes as well. Morbidity and mortality in nursing homes that suffered outbreaks of COVID-19 have been high despite the fact that Dutch nursing home care benefits from well-developed care infrastructure that is fully integrated in the national health sector.² Despite this, the nursing home sector was overshadowed by the huge national attention for COVID-19 in acute hospital care, resulting in evident shortages of personal protective equipment (PPE) and the inability to develop an adequate testing policy because of a too low national test capacity as well. As such, the nursing homes were, through no fault of their own, prone to become a prey of the virus. Furthermore, the influx of new nursing home residents has been severely reduced.³ Negative expressions in the media, the fear of contracting SARS-CoV-2 if admitted, and isolation from loved ones because of profound restrictions on family visits to curtail outbreaks have led to a situation in which many potential new residents prefer to stay at home despite their actual need for nursing home care. These developments are alarming on several levels, conceivably leading to an increased risk of adverse outcomes in very frail old patients who currently receive suboptimal care at home. We foresee that the virtual standstill nursing home care has reached will cause a subsequent wave of increased older adult abuse, falls, and increased morbidity and mortality in frail old community-dwelling people. There are also important financial implications. Most notably, in US nursing homes with more patients financed by Medicaid, COVID-19–related mortality was higher, likely because of fewer resources compared with other facilities.^{4 , 5} As such, new value-based financing models may help to ensure appropriate and affordable post-acute and long-term care in the long run. Nevertheless, in the Netherlands, having a robust public insurance system aimed at ensuring health equity from birth till long-term (nursing home) care, we are currently still on the brink of a new era in which ethical debates regarding the organization and financing of long-term care are necessary to guarante sustainable nursing home care in the future.

We are now at serious risk of permanently disrupting our nursing home care. In the Netherlands, this development has occurred despite a prior embrace of value-based health care practices.⁶ We therefore wholeheartedly agree with Laxton et al that although still in grip of this terrible crisis and anxious for a second wave, the time for change is now. Urgent policy is needed to curtail the extent of the nursing home crisis. Successful recovery will depend not only on whether nursing home care is delivered through a value-based approach, but also on effective precautions that prevent nursing home outbreaks. It is therefore reassuring that the first experiences allowing visitors back in the nursing homes have had a positive impact on well-being and have not led to new COVID-19 cases,⁷ but it remains to be seen how this situation evolves if a second wave were to occur.

Another important aspect that deserves reconsideration is the (architectural) design of the nursing home facilities. It is self-evident that private rooms, and thus the ability to isolate suspected patients, will help in limiting virus transmission. Moreover, by clustering smaller numbers of residents in living and/or dining rooms, or even in small-scale freestanding living facilities (such as the Green House Model or Green Care Farms), a possible outbreak may be contained more easily.^{8 , 9} A convenient by-product is that more individualized and intimate care can be delivered. Furthermore, interventions within existing infrastructures such as optimization of factors such as adequate ventilation, regulation of temperature, more space per resident, and separate office spaces have been long known to contribute to infection control and may be interventions that are easier to achieve short-term.¹⁰ However, because it is very unlikely that all nursing homes will be renovated or rebuilt in the near future, we also suggest that stronger structural attention be paid to the controlled implementation of good hygiene and infection protocols, with special attention to basic hand hygiene (washing), providing and using PPE, timely recognition of symptoms, and testing. The effectiveness of such interventions should be investigated in clinical studies to achieve evidence-based policies.

US nursing homes may benefit from informed policy decisions by careful comparisons between the United States and countries such as the Netherlands that are now in the recovery phase after the initial peak.