Florida’s crash testing program offers snapshot of COVID-19’s deadly toll in long-term care

Testing has provided a window into the extent to which the virus has spread throughout the state’s 3,800 nursing homes, assisted living facilities and rehabilitation centers.
An unidentified Sunstar employee is seen outside an ambulance at St. Mark Village nursing home Monday, April 20, 2020 in Palm Harbor. Several residents were transported from St. Mark Village Monday to local hospitals. It is presumed the residents had tested positive for COVID-19 or coronavirus.
An unidentified Sunstar employee is seen outside an ambulance at St. Mark Village nursing home Monday, April 20, 2020 in Palm Harbor. Several residents were transported from St. Mark Village Monday to local hospitals. It is presumed the residents had tested positive for COVID-19 or coronavirus. [ CHRIS URSO | Times ]
Published June 16, 2020

A crash program to test for COVID-19 at Florida nursing homes and assisted living facilities has given state officials a clearer picture of the devastation wrought by the virus at long-term care facilities — including more than 1,500 deaths and thousands more infections.

In the course of two months, the state went from having tested at just a handful of elder-care homes to 2,215. Another 1,000 homes reported conducting their own tests of staff or residents or both, according to a Times/Herald analysis of records supplied by the state. Advocates applauded the effort.

The rapidly organized program, announced to the industry in a May 21 conference call, set June 12 — last Friday — as a deadline to get the project completed.

Florida didn’t get every home tested. Still, healthcare regulators made major headway toward the goal of comprehensive testing.

The testing has provided a window into the extent to which the virus has spread throughout the state’s 3,800 nursing homes, assisted living facilities and rehabilitation centers.

The Department of Health said 142,000 residents and staff have been tested by either state health department or National Guard testing teams.

Surgeon General Scott Rivkees said last week he is considering requiring follow-up testing every two weeks.

The state has not made cumulative data from the start of the pandemic available but, according to state records updated daily, Florida currently has 1,614 long-term care residents who have tested positive for the virus. Another 2,584 have been transferred out of their facilities because of the virus. A total of 2,448 staffers have tested positive.

A lag in obtaining testing results remains a major obstacle to getting the clearest picture possible. The Centers for Disease Control and Prevention last weekend issued new guidance that said testing practices “should aim for rapid turnaround times (e.g. less than 48 hours) in order to facilitate effective interventions” in long-term care facilities.

Industry officials in Florida report testing delays that often far exceed that standard.

“It depends on the area,’’ said Kristen Knapp, spokeswoman for the Florida Health Care Association, which represents nursing homes and ALFs. “Some report getting results as soon as 48 hours. Others are still waiting for results after over a week.”

The decision to order universal testing appears to be a reversal of a decision by Gov. Ron DeSantis on May 13 to reject a suggestion by the White House Coronavirus Task Force and its coordinator, Dr. Deborah Birx, who recommended to governors that all residents and staff at long-term care facilities be tested immediately.

At the time, DeSantis said that the state didn’t have the resources to conduct the same kind of widespread testing that was occurring in other states. He said he was allowing state officials to distribute tests to homes that wanted to conduct testing on their own and encouraged other facilities to send workers to the state-run drive-through and walk-up testing sites offered in large metropolitan areas.

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A week later, Rivkees advanced the plan requiring that any long-term care facility that had not conducted testing since April 11 have all staff submit to testing supplied and financed by the state. Residents would be subject to voluntary tests.

The idea was to establish a foundation on which to base future tests to monitor and isolate the virus in long-term care homes, which have been responsible for 15% of all positive cases in the state and more than 50% of all deaths.

Advocates and public health experts commended the testing as a good start but said without a testing protocol that includes antibody tests — which show if an individual has had the virus — and rigorous monitoring of both staff and residents for emerging infections the tests serve merely as a snapshot in time.

“AARP Florida is very happy to hear that the state of Florida will test residents and staff of long-term care facilities. That’s a great step, one we’ve been seeking for weeks,’’ said spokesman Dave Bruns. “To be effective, the state should keep that encouraging progress going by continuing to test elder-care facilities’ staff and residents regularly, as well as vendors, contractors and others visiting facilities. Only by regular testing do we have a chance to stop the virus from ravaging the residents.”

Bruns noted that since Friday, Florida has reported 61 deaths from the novel coronavirus, 34 of which (56%) originated as infections in an elder-care facility.

“Residents and staff of these facilities make up less than 2 percent of the state’s population,’’ Bruns said. “When 2 percent of the population is suffering 56% of the deaths, our leaders have all the information they need to create a sense of urgency. “

Dr. Michael Mina, assistant professor of epidemiology at Harvard T.H. Chan School of Public Health, said the approaches states take to testing in long-term care facilities should be dynamic, and responsive to the level of infection in each community.

“If you’re in a nursing home in some part of the United States, and that community has not seen a single case of the virus, do you have to be testing everyone every single day, for example? Probably not,’’ he said. “But if you’re in a region where work cases out in the community are abundant, then you probably need to have more frequent testing.”

On April 8, the first day for which the Herald has data, nearly 3,000 long-term care facilities didn’t report any testing data to the state and only about 6% of the state’s long-term care facilities had been tested between April 11 and May 11. By May 18, when Florida began to reopen, more than 1,300 long-term care facilities still hadn’t reported any testing. By June 1, that number had shrunk to fewer than 550 facilities.

To increase testing, the Florida Department of Health began shipping COVID-19 testing kits to elder-care homes that responded to a state survey that they had the capability to conduct tests on their own. For those that couldn’t do the testing, DOH coordinated with local health departments and the National Guard to administer tests, as well as sending its mobile testing lab.

“In the past few weeks they really ramped up the effort to do the testing,’’ said Nick Van Der Linden, a spokesman for LeadingAge Florida, an association representing about 250 mostly nonprofit long-term care facilities. “For the most part I’m not aware of any member that hasn’t either been testing either by receiving a testing kit or through DOH, or the American Health Associates, a new lab they have partnered with.”

The initial launch of the program was rocky. Because testing labs could accommodate no more than 10,000 tests a day, facilities were asked to administer the tests within three days. Tests arrived with little warning and few directions, leading several facilities to miss the shipping deadline. Others conducted tests and then waited more than a week to get results.

“One of our members got a call on Saturday that they were going to show up at noon and start testing,’’ said Veronica Catoe, chief executive officer for the Florida Assisted Living Association. “That’s short notice for a community this size which needed to communicate to all residents and all staff. Staff had to come back in or they have to go to the local health department to be tested before they return to work.”

The Windsor Court and St. Mary’s Assisted Living Facility, both in Palm Beach, said they got tested at the end of May.

“We got the phone call today stating that we were all negative,” said Lisa Rojche, a medical technician at St. Mary’s.

While some facilities sought testing only after the state mandated it, others reported having trouble securing testing earlier.

Mila Goldin, the administrator of the Hollywood Beach Retirement Home in Hollywood, said she had been trying to get testing from the Broward County Department of Health since mid-April before giving up hope and bringing in her own nurse to conduct testing on May 29.

“We asked them in April, and after that we would ask every day,” Goldin said. “They said they would come in, but they never did.”

Goldin said that she ultimately tested only her staff, as was required by the state.

Catoe of the Florida Assisted LIving Association cautioned, however, that drawing conclusions from baseline tests is not helpful unless there are regular follow-up testings, rapid results, and constant monitoring.

“It doesn’t tell you anything more than it did the day that person was tested,’’ she said. “Some of these tests are taking seven days to get back to the facilities. You can have a test on Monday and that doesn’t mean you didn’t have someone infiltrate your home on Tuesday, Wednesday or Thursday.”

Knapp said the increase in testing has revealed a slight increase in the number of employees who are testing positive and “the number of residents [with COVID-19] didn’t seem to have gone up significantly.”

Once all facilities have been tested, the department will continue to test at the facilities with active outbreaks but who pays for that remains a question, Knapp said.

“We have to figure out where would these tests come from and who would pay for these tests,’’ said Van Der Linden of LeadingAge Florida. “DOH wants to move to a model of self sustainability where facilities have the capability to conduct testing on their own. That could imply some of the cost will be put on the provider but that’s not a sustainable model.”

Mina, of the Harvard Chan School of Public Health, said that many facilities should do continued monitoring for cases and impose “very low bars to ask a staff member to not come into work, if they’re feeling any sense of illness — and to go get tested instead.”

He added that delays in obtaining results that exceed one or two days can offset the value of the test.

“The leadership within these nursing homes has to feel empowered to be able to do the testing when they need to, in a way that can really term results quickly, in a way that can allow them to continue functioning,’’ he said. “Whether that means that they’re doing testing of everyone or subsample of everyone, three days or every week or for two weeks or or not at all, and waiting till there’s some reason to test. I think that there’s a role for any of those different options.”

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