Filial Responsibility Rule Means Son, Not Father, Must Pay Legal Bill for Negotiating Medicaid Penalty Reduction

 

A Pennsylvania trial court has ruled that the son of a Medicaid applicant must pay an elder law firm’s requested fee for successfully negotiating a penalty period reduction because the son would otherwise be responsible for paying the nursing home under the state’s filial responsibility doctrine.   Coates, et al., v. Salmon (Pa. C.P., Mont. Cty., No. 2018-16878, June 23, 2021).

William Salmon, Jr., a lawyer, engaged the services of elder law attorney Andrew A. Coates and his law firm to pursue an appeal of an $86,786 Medicaid penalty that the Pennsylvania Department of Human Services’ County Assistance Office had assessed against Mr. Salmon's father when he applied for Medicaid nursing home benefits. During their initial meeting, Mr. Coates explained to Mr. Salmon that if the penalty were upheld, Mr. Salmon could be held personally liable to the nursing home for the shortfall in payment pursuant to Pennsylvania’s legal doctrine of filial responsibility. As his father’s agent under a power of attorney, Mr. Salmon authorized Mr. Coates to proceed.  Mr. Coates failed to provide Mr. Salmon a written statement of the fees he would charge.

Mr. Coates ultimately reached a settlement with the County Assistance Office to reduce the penalty from $86,786 to $18,380, a savings of $68,406.  Mr. Coates sent Mr. Salmon a bill for $6,465.89, reflecting an hourly rate of $325 and applying a 15 percent “professional courtesy” discount.  Mr. Salmon refused to pay and requested “something much more reasonable.”

On January 14, 2021, the Court of Common Pleas of Pennsylvania, Montgomery County, ruled that because there had been no written fee agreement, recovery must be by an action in quantum meruit.  Quantum meruit is a Latin phrase meaning "what one has earned." In the context of contract law, it means  "reasonable value of services performed."  

Mr. Salmon contended that any claim in quantum meruit could be asserted only against his father, and not against Mr. Salmon personally.  Mr. Coates and his firm countered that under Pennsylvania’s doctrine of filial responsibility, Mr. Salmon would have been personally liable for payment of his father's nursing home fees, making Mr. Salmon the beneficiary of Mr. Coates’ legal services and liable for payment. The court ruled in favor of Mr. Coates and his firm for $7,606.64, the amount Mr. Salmon would have owed without the professional courtesy discount. Mr. Salmon has appealed to the Superior Court and in the course of that appeal he filed a Statement of Errors with the Court of Common Pleas. 

The reason this case is interesting because it utilized the law of filial responsibility to reach what was, in the court's determination, an equitable result.  Ostensibly, the father's estate would have been unable to pay the obligation, since the father qualified for Medicaid.  Although the services were performed for the father, contracted for by the father through his agent under a power of attorney, the court used the law of filial responsibility to assign the responsibility for the obligation to the son.  The court even noted that the son understood that he would ultimately be responsible for the father's nursing home bill, and equating that to understanding that he would ultimately be responsible for the attorney's fee. 

The case is also instructive for another reason, and that is that legal contests have costs and sometimes reach unexpected results.  Mr. Salmon probably assumed that the most he could stand to lose was the amount of the bill submitted to him; that assumption would have been incorrect. The Court actually awarded a sum greater than the total bill submitted by the attorney.  Although the attorney extended a courtesy discount on the total sum, the Court, in its judgment, removed the courtesy discount entering judgment for the full fee.  Ouch! 

Pandemic Pets, Pet Companionship, and Estate Planning Considerations

Pet companionship took on new meaning and importance during the pandemic as lock-downs, quarantines, social distancing, and social isolation impacted nearly everyone. For many, life trapped in a home would be unbearable and unthinkable without pet companions.  This blog has previously discussed how important pets are to some, and how important it is to consider pets in estate planning. 

An unanticipated effect of the pandemic has been a surge in interest for fostering and adopting abandoned pets. Although unanticipated, this effect is not surprising given the lack of social human interaction during stay-at-home orders, and subsequent social distancing. Regardless, the renewed focus on pets and pet companionship is welcome and important. 

There are at least seven quantifiable benefits to pet owners, including aging owners and owners with special needs:

1. Reducing Isolation and Loneliness; 
2. Lowering Stress and Anxiety; 
3. Improving Fitness; 
4. Increasing Social Interaction and Connection to the Community;
5. Improving Cardiovascular Health; 
6. Reducing Depression Risk, and;
7. Providing Routine and a Sense of Purpose.

Isolation

Isolation and loneliness are among the considerations for those planning to age in place. Seniors and persons with disabilities may experience feelings of isolation and loneliness if they spend a lot of time at home, sometimes because they lack mobility, security, or just comfort leaving home.  Isolation and loneliness are major risk factors for depression and increase the risk of heart disease, arthritis, diabetes, and dementia. 

Experts at the Centers for Disease Control and Prevention (CDC) agree; pet companionship eases loneliness and isolation. 

Stress and Anxiety

Relieving feelings of loneliness and isolation are not the only emotional and mental health benefits of pet ownership.  Research has shown that simply petting a dog lowers the stress hormone cortisol , while the social interaction between people and their pets actually increases levels of the feel-good hormones oxytocin and serotonin.  Oxytocin is the same hormone that bonds mothers to babies.   A University of Utah study found that even spending time near a pet can reduce stress levels and nervousness. 

The companionship of a pet can be particularly beneficial for reducing anxiety for a persons with disabilities or impairments.  In fact, an astonishing 84 percent of post-traumatic stress disorder patients paired with a service dog reported a significant reduction in symptoms, and 40 percent were able to decrease their medications, according to a recent survey.

Fitness

A pet increases opportunities for exercise. A daily exercise routine and physical activity can improve mobility the ability to perform activities of daily living.  Shelter dogs have been used for animal-assisted therapies to encourage physical activity for residents of nursing homes and assisted living facilities. A study published in Clinical Nursing Research found that people who walked with shelter dogs were more likely to go for a walk than those who walked with a human companion and even walked faster and for longer distances! 

Community

Programs that allow residents of assisted living facilities to spend time with a pet encourage interaction among the residents and give them something to look forward to.  

Pet care offers opportunities for  interaction with others, such as vets, groomers, pet care retail staff, and other pet owners.  Most folks that serve in the pet care industry are, themselves, pet lovers, which creates a community that is naturally sharing, caring, and helpful.  Pet walkers often follow a regime which affords them  insight into the routine of other owners.  A pet owner may notice that another pet owner is suddenly absent, or might observe another owner struggling physically and offer help.  

Pets can help persons with autism improve social skills by facilitating social connections with others, inspiring the person to work harder on communication skills and teaching compassion.

Cardiovascular Health

According to the American Heart Association, pet ownership is associated with lower blood pressure and lower heart rate during mental stress. A University of Utah study found that just the presence of a companion dog is associated with lower cardiovascular responses during stress. The CDC lists decreased blood pressure and reduced cholesterol levels as two benefits of pet ownership. 

Depression

The Research Center for Human/Animal Interaction has found that dog owners are less likely to suffer  depression. Animal-assisted activities and therapy have been used successfully with patients struggling with depression, loneliness, and mental illness and can reduce the symptoms of depression. The effects are particularly apparent with seniors.

Purpose

Pet care invites structure and scheduling, establishing a beneficial routine, and lots of older adults who own a pet say that their pets provide a sense of purpose and help them enjoy life.

For more information how to incorporate pet care into your estate plan, consider the following article:  Ohio Pet Trusts.

Source: Rebecca H. Miller, Pandemic Pets and Pet Companionship: Seven Benefits/Considerations for Care Coordination and Estate Planning, Chambliss Law, May 5, 2021. 

Federal Law Preempts Minn. Law Treating Irrevocable Trusts as Revocable for Medicaid Purposes

Filial responsibility laws make children legally responsible to support and care for indigent parents.  Under these laws, a child's assets are recoverable by the state if a senior receives Medicaid to pay for long-term care, such as a nursing home.  The state is not limited to recovering only inheritance, or return of lifetime gifts, but can recover assets that a child has worked to acquire for his or her family. 

Filial responsibility is a general concern for most estate planning clients, but the prospect of a parent becoming a financial burden to children is particularly troubling for those seniors aging in place and/or implementing asset protection from nursing home spend down (Medicaid planning).   

Filial responsibility is one tool that the Centers for Medicare & Medicaid Services (CMS) has long advocated States adopt and enforce in order to financially support Medicaid.  CMS is a federal agency within the U.S. Department of Health and Human Services (HHS) that administers the Medicare program and works in partnership with state governments to administer Medicaid.  

Despite CMS' support, states that have implemented such laws have visited upon their citizens familial discord, hardship, chaos, and inequity.  In addition, these laws even threaten the financial safety net of some seniors by making parents responsible financially for their adult children, ironically making them more likely to need Medicaid!  These problems helps explain why many states have resisted pressure from to fundamentally change their Medicaid resource recovery systems.  

Many states have, nonetheless, employed various alternative methods to fulfill the spirit of the CMS campaign, by, for example, expanding the assets recoverable by Medicaid to "augmented estates," permitting nursing homes to "work around" federal law prohibiting a home from soliciting a guarantee of payment from family members, and restricting legitimate planning options to reduce Medicaid resource recovery or shielding assets from nursing home spend-down.    

One such effort, courtesy of the Minnesota legislature was recently invalidated by a Minnesota appeals court.  The Court ruled that a statute "deeming" irrevocable trusts to be revocable for the purposes of a Medicaid eligibility determination is preempted by federal law governing irrevocable trusts.  See, Geyen v. Commissioner Minnesota Dept. of Human Services (Minn. Ct. App., No. A20-1300, July 12, 2021).

In 2011, Dorothy Geyen created two irrevocable trusts that named her children and grandchildren as beneficiaries. The trust agreements provided that the trustee was specifically precluded from loaning assets or making distributions to Ms. Geyen. In 2019, Ms. Geyen applied for Medicaid benefits. The state denied her application on the basis of her having excess assets; the court determined that under the state law, her irrevocable trusts were revocable when she applied for benefits. Minnesota law provided that when making a determination about eligibility for Medicaid benefits, any irrevocable trust containing the assets that were formerly the applicant's becomes revocable for the purpose of that eligibility determination.  The effect of the law is to invalidate completely transfers to irrevocable trusts specifically permitted by federal law. 

Ms. Geyen appealed the denial, arguing that state law conflicts with federal law. The state affirmed the denial, and Ms. Geyen appealed to court. The district court determined that under federal law, the trusts were not available assets and federal law preempted state law. The state appealed, arguing that the funds in the trust were available to Ms. Geyen under federal law and that the trusts became revocable under state law.

The Minnesota Court of Appeals affirmed, holding that the trusts are not available assets under federal law and that federal law preempted state law. According to the court, “because the trust agreements did not permit the trustees to make payments to or for the benefit of [Ms.] Geyen under any circumstances,” they were not available assets. The court further held that by “deeming irrevocable trusts to be revocable” for the sole purpose of a Medicaid eligibility determination, the state law “conflicts with the federal requirements governing the treatment of irrevocable trusts.”

This holding is a great and welcome result.  Citizens of the State of Minnesota should be outraged at the colossal assault by their legislature on their rights to lawfully plan and orchestrate their affairs, and for the waste of public resources dragging a family through protracted litigation in a craven effort to save pennies rather than supporting a person (and system) in need.  

The only bad news is that as states fail to succeed in efforts to implement alternatives to filial responsibility, filial responsibility becomes more likely.  Good planning is the best and most secure means of avoiding unnecessary and avoidable institutionalization and filial responsibility.   

Staff Shortages Worsen in Long-term Care Industry

Among the many reasons supporting the decision to age in place is a worsening staff shortage in the long-term care industry.  A survey published by the American Health Care Association revealed 94% of long-term care facilities are struggling to hire staff. 

The U.S. faces a certified nurse aide shortage of about 200,000, with the situation made even more dire by a surging number of unvaccinated aides being forced to quarantine as cases of variant COVID-19 cases threaten to surge.  Regional variations make this shortage more or less extreme for the industry and residents.

There are many reasons that contribute to cause these shortages, but among the most surprising is the effect of workplace violence. Violence in all healthcare settings plays a role in the nursing shortage, with the "ever-present threat of emotional or physical abuse adding to an already stressful environment." 

Staff shortages, of course, negatively affect health outcomes. Nursing shortages lead to errors, higher morbidity, and higher mortality rates. 

Lori Porter, founder and CEO of the National Association of Health Care Assistants, is sounding the alarm.  "Bemoaning the twin crises (shortages and vaccinations) won’t resolve them. But neither will throwing just money at potential employees," Porter said, according to McKnights Long-term Care News, adding that "Medicaid pressures continue to make routine higher pay and better benefits elusive for many."

“Pay is one of the scariest things,” she said. “I’ve seen facilities giving up to $20 and hour … I’m not certain how you make that happen in today’s world.”

Porter suggested providers need to look at their individual recruitment efforts to address oversights and messaging, but she also suggested a federal recruitment campaign could be part of the solution.

“People want to be part of a team,” Porter said. “We want to blame the millennials because they don’t want to work. But I would hire millennials all day long because they don’t want to make a job. They want to make a difference.”

Some sociologists and economists have taken to calling the current labor challenge "The Great Resignation." Porter noted that it’s important to consider the cultural shift spurred by COVID-19 and seize on the industry’s intangible benefits to shift momentum.

“Pay and benefits (are) things we’re very weak on as a profession,” she said. “But the second thing we have to sell are emotional benefits, and we’re very high on emotional benefits if care centers and employers will learn how to articulate it in a way that resonates with ‘I want to be part of something that makes a difference.’”

Millennials are, though, among the most unlikely to want a COVID-19 vaccine, another issue that continues to plague providers. Porter told LeadingAge members that vaccine coverage among her membership remains her top concern. She has worked to counter hesitancy with information from AMDA, rather than the Centers for Disease Control and Prevention or the Centers for Medicare & Medicaid Services, and appealing with direct messages about the responsibility to residents.

But Porter said many of the workers her organization represents are still reluctant, at least until the vaccines receive full FDA approval.

“Many of their arguments are becoming weakened. More vaccines have been taken and no one has grown a third arm yet,” said Porter, who noted the rate of unvaccinated people in her area of Missouri recently led two major hospitals there to reopen their COVID units. “Now is the time to push harder than ever.”

Son's Filial Responsibility Nursing Home Debt Dischargeable in Bankruptcy; Not Required to Spend All of Mother’s Assets on Her Care

As previously discussed in this blog, nursing homes have devised various schemes to ensure collection of costs from family members of residents, notwithstanding a federal law making it unlawful to hold families contractually responsible as a condition of admission [the hyperlink will take you to all of the filial responsibility blog articles].  

A recent iteration of this effort includes contesting bankruptcy discharge of the debt.  One effort has, nonetheless, proved futile. A U.S. Bankruptcy Court has ruled that the judgment debt of a resident's son to a nursing home for his mother’s care is dischargeable in bankruptcy.  The Court found that the son’s failure to apply all of his mother’s income and assets towards her care did not constitute an attempt to defraud the facility. Geriatric Facilities of Cape Cod, Inc. v. Georges (Bankr. D. Mass., No. 19-01096-MSH), June 22, 2021).

In April 2010, acting as an agent under a power of attorney, Jonathon D. Georges signed a services agreement with Pleasant Bay, a Massachusetts nursing home to provide care to his mother, C. Doris Georges. The contract identified Mr. Georges as a “responsible party” and obligated him to apply his mother’s funds and assets to pay for the services being rendered to her. 

At the time the contract was signed, the nursing home’s monthly cost typically exceeded $8,000, while Ms. Georges’ monthly income was limited to $2,410.24, consisting of Social Security and payments from an annuity.

In March 2012, Mr. Georges sold his mother’s condominium to pay her obligations to Pleasant Bay, netting $247,395.03.  Mr. Georges paid $104,128.91 to the nursing home to bring his mother’s account current and spent another $63,500 on gifts to various family members, including himself.  By the fall of 2011, with the sale proceeds having been nearly all spent, Mr. Georges applied to Medicaid (MassHealth) for long-term care benefits for his mother.  At the same time, he stopped paying Pleasant Bay with his mother’s income, believing that once Medicaid was approved the balance would be resolved.  

Ultimately, the Medicaid application was denied due to the substantial gifts to family members.  Unable to reach an agreement with Pleasant Bay to settle the balance, Mr. Georges used his mother’s income that he had been setting aside to move her to another facility.  In October 2012, Pleasant Bay sued Mr. Georges in state court for the services rendered.  The case settled prior to any hearings when Mr. Georges agreed to a judgment being entered against him in the amount of $128,000, plus interest.  Ms. Georges died in 2013.

In May 2019, Mr. Georges filed a voluntary petition for relief under Chapter 7 of the bankruptcy code and included the judgment debt to Pleasant Bay in the bankruptcy schedule.  Pleasant Bay objected to the discharge of its debt, arguing that the debt was excepted from discharge because Mr. Georges had obtained the debt by false pretenses or false representations when he promised to devote all of his mother’s assets and income to pay for her care when he had no intention of doing so.  Mr. Georges countered that he had not understood or agreed that all of his mother’s income and assets had to be used to pay Pleasant Bay for her care and that he made gifts to himself and family members in accordance with his understanding of her wishes.

The U.S. Bankruptcy Court for the District of Massachusetts found that “no reasonable reading of the services agreement supports Pleasant Bay’s interpretation that Ms. Georges and Mr. Georges were contractually bound to devote every cent of Ms. George’s income and assets to pay Pleasant Bay.”  The court found that “[h]ad Pleasant Bay wanted to bind its residents to devoting the entirety of their income and assets to the payment of nursing home expenses, to the exclusion of everything else, it needed far more detailed and explicit contractual terms.”

Nearly On-Half of Assisted Living Facilities Operating at Loss; Only One-Fourth Confident They Can Last Another Year or More

Assisted living providers continue to face a serious economic crisis in the wake of the pandemic, according to the results of a new survey. A separate survey finds that Americans agree that more needs to be done to support older adults in the United States.

In a National Center for Assisted Living survey of 122 assisted living communities, 49% said they are operating at a loss, and the same percentage said they have made cuts this year due to increased expenses and lost revenue.

Seventy-four percent of assisted living respondents said they are losing revenue due to fewer people seeking long-term care, 44% said they are losing revenue due to move-outs and 37% said they are losing revenue because of fewer admissions from hospitals.

“Even though COVID cases in long-term care are at historic lows, providers are struggling to recover from the economic crisis the pandemic has induced,” Mark Parkinson, president and CEO of NCAL and sister organization the American Health Care Association. “Too many facilities are operating under shoestring budgets simply because policymakers have failed to dedicate the proper resources and this can have devastating consequences.”

Assisted living providers still are incurring COVID-19 costs from higher wages (73%), additional staffing (48%) and personal protective equipment (47%) despite the availability of vaccines, according to respondents. The association previously laid out proposals in its Care for Our Seniors Act to enable providers to address staffing shortages.

Lawmakers and public officials must prioritize residents and caregivers by sending immediate resources through what remains of the federal Provider Relief Fund, Parkinson said. 

AHCA also surveyed 616 nursing homes. Together, only one-fourth of assisted living communities and nursing homes said they are confident they can last a year or more. See more nursing home results on the McKnight’s Long-Term Care News website and more about all survey results in the McKnight’s Business Daily.

Source: K. Bonvissuto, "49 percent of assisted living providers operating at a loss: survey," McKnight's Senior Living (June 30,2021).

Isolation Impact: Death Rate Higher for Institutionalized Residents in Socially Isolated Neighborhoods

Nursing home residents in socially isolated neighborhoods are at an increased risk of mortality according to findings from a new study published in JAMA.

A recent analysis conducted by a Boston-based research team found that long-term care residents in facilities located in areas with high levels of social isolation have higher mortality rates than residents in facilities in places that have more social contact. Findings showed residents entering facilities in neighborhoods with the highest levels of social isolation among older adults had a 17% higher risk of mortality compared with those in neighborhoods with the lowest levels. 

Social isolation among seniors has been an ongoing topic among the long-term care industry due to the COVID-19 pandemic and it’s connection with depression, anxiety and cognitive decline among nursing home residents.  Isolation impact is not well known or studied, though it is addressed elsewhere in this blog (here and here, the latter being a collection of articles tagged with the topic "isolation" meaning that the subject was mentioned).   

Researchers said the findings suggest the need for operators to place special attention and strategies to keep long-term care residents connected to their friends and family for optimal health: 

“Such measures could eventually contribute to improved health trajectories in the US population that is increasingly aging and at growing risk of entering LTC facilities.”

For those interested and/or committed to aging in place, the findings provide additional justification for avoiding institutionalization, to be sure sure, but they also underscore the importance of planning and implementing a rigorous social plan, including and incorporating family, friends, and fraternal organizations and associations.  For secular and non-secular organizations serving the needs of seniors, the findings of the study underscore the importance of outreach and involvement, for example, by ensuring transportation for seniors otherwise unable to travel. 

COVID-19 Still Killing 800 a Month in Nursing Homes

Nursing home deaths from COVID-19 remain sharply down from their winter peaks, but the declines have now plateaued and more than 800 residents and staff members each month continue to die from the virus, according to an exclusive new analysis of federal data by AARP.  The analysis did not comment upon and likely did not factor recent data suggesting that seniors in nursing homes may have lower immune response from the vaccines. 

There was little change in the national rates of COVID-19 infections and deaths in nursing homes from mid-March to mid-May, the analysis shows, even as rates in the wider community continued dropping. More than 10,000 residents and staff members are becoming newly infected each month.

Experts say that limited vaccine uptake among long-term care workers, worker shortages and the recent relaxation of nursing home restrictions might be causing the plateau, although more data and analysis are required.

Since the pandemic hit, COVID-19 has killed more than 184,000 residents and staff of long-term care, which includes nursing homes, assisted living facilities and other residential settings. Those deaths constitute almost a third of America's entire COVID-19 death toll, according to the Kaiser Family Foundation.

In nursing homes, the infection and death rates peaked last winter, when close to 20,000 residents and staff were reported dead from COVID-19 in just four weeks from mid-December to mid-January; 1 in every 51 residents died from the virus.

Then, cases and deaths started to plummet, dropping more than 90 percent by mid-March, with the arrival of vaccines, tougher restrictions from governments, and high levels of natural immunity from months of high infection rates. Though the situation has improved, nursing home advocates say current COVID-19 rates in nursing homes shouldn't be accepted as the new normal.

The federal government asked the country's 15,000-plus nursing homes to loosen visitation restrictions in March. Citing widespread vaccinations of residents, drops in COVID-19 infections among residents and staff, and the tolls of separation and isolation on residents and their families, the federal Centers for Medicare & Medicaid Services (CMS) said facilities should allow indoor visits “regardless of vaccination status of the resident or the visitor."

The resulting uptick in visitors could, in part, be contributing to the halt in COVID-19 declines, according to Jennifer Schrack, an associate professor in the epidemiology of aging at the Johns Hopkins Bloomberg School of Public Health in Baltimore.

"Every visitor is another potential exposure, particularly those who are not vaccinated,” she says. “They have to really consider carefully if they're going to visit their loved one, and if they do, they should wear [personal protective equipment] and be very cautious, even if their loved one is vaccinated. … Low risk doesn't mean no risk.”

Unvaccinated staff, which could represent nearly half of the nursing home and assisting living workforce, may be an even bigger factor.

Source: Emily Paulin, AARP, June 10, 2021 COVID-19 Still Killing 800 a Month in Nursing Homes, AARP Analysis Shows, 

Nursing Home Mortality Rate Soared 32 Percent in 2020

The coronavirus pandemic’s “devastating impact” on nursing homes led to a 32% spike in overall mortality rate among Medicare residents during 2020, according to a new report by the Office of Inspector General. The spike means there were 169,291 more deaths in 2020 than would be expected if the mortality rate had remained the same as in 2019. There were 3.1 million Medicare beneficiaries who resided in nursing homes in 2020. 

Each month of 2020 had a higher mortality rate than the corresponding month a year earlier. In April 2020 alone, a total of 81,484 Medicare beneficiaries in nursing homes died — more than twice the number in April 2019.

Federal investigators added that the data shows the pandemic had “far-reaching implications for all nursing home beneficiaries, beyond those who had or likely had COVID-19.” This blog has previously addressed the higher rate of medical mistakes and errors and neglect that occurred amidst the pandemic as well as the horrific impacts from isolation, loneliness, and lack of psychological care and treatment.

The findings also revealed that more than forty percent of Medicare beneficiaries (1.3 million beneficiaries), in nursing homes had or likely had COVID-19 in 2020. The number of infected beneficiaries swelled dramatically during the spring of 2020, with just over 21,000 diagnosed as having or likely having the disease between January and March. By the end of June, the number was close to 419,000. 

Federal researchers also found about half of Black, Hispanic and Asian beneficiaries in nursing homes had or likely had COVID-19 in 2020. Each group was more likely than their white counterparts to contract the disease. 

Harvard health policy expert David Grabowski, Ph.D., said those who work in the field “knew this was going to be bad” but didn’t think “it was going to be this bad.” “This was not individuals who were going to die anyway,” Grabowski told the Associated Press. “We are talking about a really big number of excess deaths.”

“The COVID-19 pandemic has been devastating for Medicare beneficiaries in nursing homes,” the government watchdog agency wrote. “The toll that the COVID pandemic has taken on Medicare beneficiaries in nursing homes demonstrates the need for increased action to mitigate the effects of the ongoing pandemic and to avert such tragedies from occurring in the future.”  

The report is the first in a three-part series focusing on the impact of COVID-19 in nursing homes. Upcoming analyses are expected to focus on strategies nursing homes have used to combat the pandemic. 

Source: D. Brown, "Nursing home death rate soared 32 percent in 2020," McKnight's Longterm Care News (June 23, 2021).

Nursing Home Residents May Have Lower Vaccine Immune Response

A COVID-19 vaccine administered to nursing home residents in northeast Ohio was less effective in creating an antibody response in them than in a control group of health care workers, according to a Case Western Reserve-led study.

Some residents responded "reasonably well," but a portion responded "poorly to very poorly," concluded university researchers. What's not yet clear is why, or what the threshold for protection is when measured in terms of antibodies.

"We urgently need better longitudinal evidence on vaccine effectiveness" to inform best practices for nursing home infection control measures, outbreak prevention and potential indication for a vaccine boost, stated the study. Its co-principal investigators include David Canaday, MD, a professor in the School of Medicine’s Division of Infectious Disease, and Mark Cameron, PhD, an associate professor in the school’s Department of Population and Quantitative Health Sciences.

Once COVID-19 reached the United States, nursing homes became hotspots, with a rapid rise of infections and deaths; when vaccines became available, nursing home residents were among the first to receive them.  The study focused on the antibody immune response in residents by comparing a blood sample taken before the first vaccination, with another taken about two weeks after the second one.  It included 149 residents and a younger control group of 110 health care workers. All participants received the Pfizer vaccine.

Researchers examined three measures of antibodies; in all cases, residents had lower levels. For example, residents had a quarter of the anti-virus antibodies as the control group.

Canaday said the study's results can’t be compared to Pfizer’s vaccine efficacy rate of 95% because the Pfizer clinical trial focused on the number of adults of any age who got COVID-19, not the quantity of antibodies in the blood.

"The vaccine does make an immune response in almost every nursing home resident, although the magnitude is lower than in the younger age," Canaday said.

The study was the first outcome from a $2.3 million National Institutes of Health grant focused on COVID-19's spread in nursing homes awarded to Canaday, Cameron and fellow co-principal investigator Stefan Gravenstein, MD, a geriatrician and professor at Brown University.

They are now exploring varying responses to COVID-19 in nursing home residents and what level of antibodies is protective.

"There are so many questions to be answered surrounding the role of one's immune system in determining whether an infected individual has a mild, moderate or very severe form of COVID-19," Cameron said, "especially in people who are older or have underlying health issues that put them more at risk for poor outcomes."