Effects of COVID-19 on Older Adults 2020

Each day more and more cases are being announced and this virus shows no signs of adapting. We are going to take a closer look at COVID-19 in the State of California in the United States. Our focus is on how this virus has effected older people above the age of 60 in Skilled Nursing Facilities or at home, retired/non-retired, and disabled/abled (more commonly know as assisted living or board and care facilities). Older adults are at higher risk of getting severely ill after contracting COVID-19. The reason for this is because at an older age there is a higher chance of having underlying medical conditions that may worsen the virus's effect.

The following factors will be the focus of this Story Map include: Internet Access by age and race, COVID-19 cases in Skilled Nursing Facilities reports and deaths, Elder Abuse Reports, Median Income, and CA Skilled Nursing Facilities with minority count. We will gather and analyze this data and convert it into the form of Maps, making it easier to visualize and understand. The data will be on a State level and County level to look at CA as a whole and then focus in on granulated information for specific areas.

Our work here as SEED Scholar Interns is in partnership with the California Elder Justice Coalition. CEJC strives to seek justice for elders in our community by doing anything in their power to help. Their mission statement is "Protecting the rights, independence, and safety of older people by exploring barriers, sharing information and ideas, and providing a voice from the field to the policy makers."

We are honored to be working with such an amazing non-profit organization that has such good morals and goals to better the lives of older adults in our community in hopes to reach a greater number of people. The main purpose of our analysis throughout the StoryMap is to inform more people of these issues. We want to be able to show the facts with maps and charts so visually it is easy to understand. We also want Policy makers to notice our work for the truths it tells and why it is so important to focus on bettering regulations for older adults in Skilled Nursing Facilities and Residential Care Facilities.

Our community data initiative is to help CEJC gain the statistical information to back up the various issues we want to help solve. If you are interested in CEJC and want to help or learn more visit the link bellow.

 https://www.elderjusticecal.org/ 

Throughout this Story Map, we will be using many terms to properly explain our data and analysis. To help guide you in knowing these terms here is a list of terms and definitions:

*Residential Care Facilities for the Elderly (RCFE): Facilities for older adults that are not required to have medical personnel on their staff. This Facility has many options for the individual's needs from physical health challenges, mental health challenges, and or older age.

*Skilled Nursing Facility (SNF): These facilities are for older adults and adults with disabilities who need around the clock medical attention and assistance with activities of daily living from trained nurses, physical and occupational therapists, speech pathologists, and audiologists.

*Older Adults: People above the age of 65 and people above the age of 35 who have medical conditions that need attention.

If you would like to learn about Elder Justice during COVID-19, or just more information on Older Adults and facilities here are some helpful websites.

 https://www.youtube.com/watch?v=hbqI7mAw0HQ&t=32s 

 https://www.commonwealthclub.org/events/archive/podcast/agenda-elder-justice 

 https://www.medicare.gov/coverage/skilled-nursing-facility-snf-care 

 https://www.seniorguidance.org/senior-living/residential-care-facilities/ 

Skilled Nursing Facilities provide 24-hour skilled nursing care and related rehab services. The residents in the facilities are often chronically ill or rehabilitating from an illness, injury, or surgery. Each resident must have a specialized plan made by their physician for daily care. Generally, Medicare will help cover the Skilled Nursing Facility cost for short stays, but only for certified and licensed facilities by the State. 

Residential care facilities for the elderly (RCFE) provide care for individuals that are 60+ years of age. These facilities provide care, supervision, and assistance with necessary activities like personal hygiene, dressing, eating, and basic activities. RCFEs must meet the care and safety standards set by the State and are licensed and inspected by the Department of Social Services, Community Care Licensing. RCFEs do not require nurses or medical personnel, as such the qualification for the positions is minimal. Residential care facilities are not paid for by Medicare; therefore, RCFEs in more affluent neighborhoods tend to have more amenities for their residents.

Testing for the virus has been increasingly important to prevent further spread. Managing for COVID-19 in RCFEs can be difficult for many facilities as they are not required to have medical staff to help guide and implement Covid-19 mitigation plans and outbreak management strategies. The majority of testing occurs at residencies that are private labs and not state department testing. This lack of resources means that facilities with better resources will be able to mandate better social distancing rules and implement new procedures to reduce the spread of the virus throughout their facility.

As of July 2020, Southern California is considered a hot spot of COVID-19 in the State.

From the map bellow we can see Los Angeles County has the most deaths in Skilled Nursing Facilities in the state of California. Los Angeles County also contains the most Skilled Nursing Facilities in the State of California. The heat map displays where the highest amount of deaths in Skilled nursing facilities have occurred. We can see that areas like Downtown Los Angeles, Pasadena, Torrance, and Downey are hot spots for COVID-19 deaths in Skilled Nursing Facilities. An important note is that some Nursing Facilities have patients who cannot social distance or wear masks due to cognitive impairment or serious mental illness.

As of July 12, 2020, Skilled Nursing Facilities in California reported a total of 5803 confirmed COVID-19 cases for their residents. Residents living at the ten facilities above make up 1,078 of the Confirmed cases. Out of the 384 facilities in Los Angeles County, residents living at the ten facilities make up almost 1/5 of all COVID-19 cases in the County.

There are 1438 licensed Residential Care Facilities for the Elderly in Los Angeles County.

According to the California Department of Social Services, there are 5,640 total COVID-19 confirmed laboratory cases and 583 COVID-19 related deaths throughout Residential Care Facilities in the State. The number of cases and deaths include both residents and staff. Residential Care Facilities for the elderly do not require having medical personnel on staff. Looking at the data provided by the California Department of Social Services, their reports on case and death counts are not transparent, since they base counts on <11 or >11. We noted that it is likely due to medical confidentially reasons as some of these facilities are much smaller than others.

In this map, we look at the median income in households across California. The greener the areas are places with people who have higher incomes $70,000+ and the more yellow/red areas are places with people who have lower income $40,000-. It is important to notice we see people making higher income closer to the coastline, therefore if people who do not live near the CA coastline are more likely to be earning a low income.

We will look further into how income affects COVID-19 areas and if there is a direct correlation between the two. During these unpredictable times, income is very important as it can help financially for those who have loved ones in RCFEs and SNF's, as well as demonstrate the community's income, which may reflect staff members' income. Revealing staff members' income may show if they are not being payed enough and the effects of it.

In today's age we gather much of our knowledge of current events and news from the internet. The internet is crucial in helping us stay informed on what is going on in the world and especially what is going on in our communities.

In this Map, we look at the Internet access in households by percentages. The darker blue shades represent a higher percentage of households with no computers in their home, likely meaning, no access to the internet. The lighter yellow and light teal colors represent a lower percentage of households with computers and internet access. It is important to note that the areas with a dark shade that do not have internet access are areas where there is more diversity in race. This goes to say people of color in areas such as Central CA and Northern CA may not have as much access to the internet as most of the other communities such as San Diego County and Inyo County.

Although we do not have much information available to us about internet access inside SNFs and RCFEs it is still an important factor to bring up because older adults deserve to have internet access as they need to be informed on current events through their control. Funding for internet access inside these facilities will benefit the people who live there by giving them control of their news and entertainment, which is very limited when it comes to cable or standard television channels.

Los Angeles County has always been a very diverse county. We understand that areas with more minorities are usually hotspots for the virus in the general population.

The darker blue areas indicate a higher level of diversity in the area, which means a higher chance that two persons, chosen randomly from this area, belong to different races or ethnic groups. COVID-19 hot spot map indicates the following cities as hotspots for the virus:

• East Los Angeles
• Huntington Park
• Bell
• Downey
• Long Beach
• Inglewood
• Compton

The following areas are cold spots in Los Angeles County

• Pacific Palisades
• Beverly Hills
• Westwood
• Santa Monica

This is important to note because these surrounding areas directly impact the lives of the skilled nursing facility patients and the residential care facility residents. these neighborhoods house the families of the residents and the essential workers working within these facilities. Residents have no control over how well their quarantine is enforced. they rely on staff to help them with their daily activities and necessities. Staff living in the COVID-19 hot spot neighborhoods put residents at great risk because they must commute through denser amounts of infected populations.

Older adults and dependent adults in these lower-income neighborhoods do not have the same resources in their facilities as the more affluent communities. To contextualize this disparity, we have created a heat map that will show where the most nursing home beds are in LA County.

Beds in nursing homes are extremely important for nursing facilities because they help with comfort and proper position for patients' necessities. It is clear that facilities with fewer beds are in areas of low income and higher diversity. Patients in those facilities must endure COVID-19 treatment with less comfort than those living in more expensive facilities. These beds help medical professionals observe, identify, and prevent complications, promote cleanliness, and accommodate the patient's needs. During this pandemic, we know cleanliness and being able to observe a patient is crucial.

Income, race, and internet access definitely contribute to how COVID-19 affects a community. We are able to see where COVID-19 is affecting the most and we can look at different aspects of those communities and make conclusions based on the data. When looking at Skilled nursing facilities in Los Angeles County, COVID-19 has hit every city and there is no data showing that race or income have a direct impact on the number of COVID-19 cases and fatalities. We had no quantifiable COVID-19 data on Residential Care Facilities. We do know that RCFEs in Los Angeles county have less COVID-19 cases and fatalities, but we cannot make any claims pertaining to the factors because we simply do not know the amount of Cases and fatalities for specific Facilities. With that being said, both RCFEs and SNFs rely on their essential workers.

We have concluded that since both RCFEs and SNFs have staff that cares for residents and patients on a personal level, the staff would have the biggest impact on how COVID-19 is dealt with in their respective facilities.

Skilled nursing facilities and residential care facilities for the elderly have different rules for dealing with the virus. Residential care facilities for the elderly are taking the route of trying to prevent the spread. Skilled nursing facilities are also working on preventing the spread. However, it is complicated as many patients cannot wear masks due to medical reasons. Whether COVID-19 is handled properly within all facilities is dependent on their staff and management.

In the chart above, we can see that half of the facilities on the list have higher cases of COVID-19 in their staff than their residents. The table below demonstrates how facilities with low counts of COVID-19 in their staff also low counts of COVID-19 in their residents. This factor is vital because it means the residents are being cared for by staff riddled with COVID-19. We concluded that this can be attributed to nurses working at different facilities. As nurses commute from the facilities to their homes, they encounter many opportunities to contract the virus. The commute from the facilities to their homes must decrease to keep the residents safer and make quarantine more effective. The best solution should be to mandate nurses not to work at multiple facilities and supplement their income, so they do not feel the need to work at various facilities. These are front line workers during the pandemic and deserve a higher salary, considering the importance of their work and the importance of taking precaution from COVID-19 by not exposing themselves in multiple facilities at a time.

The chart above details COVID-19 cases and deaths in residential care facilities for the elderly in the State of California. We can see that it's mostly the same situation as the skilled nursing facilities. We can see that in every significant County, the number of COVID-19 cases in staff shows similar counts in residents. Residential Care Facilities for the elderly have a team that is not qualified to diagnose or treat COVID-19, which means they might have a more difficult time enforcing CDC COVID-19 recommendations because they are not medical facilities. They would not have equipment on par with Skilled Nursing Facilities.

In Nursing Home Staff Networks and COVID-19 written by M. Keith Che, Julie A. Chevalier and Elisa F. long they expanded on researched conducted that shows how a lot of nurses are at multiple facilities during their day. This was the first large-scale analysis of nursing home connections from shared staff using device-level geolocation data from 30 million phones and the research showed 7% of phones appearing in nursing homes also appeared in one or more facilities. Results showed that reducing nurse travel from different locations could reduce COVID-19 infections in nursing homes by 44%.

"Outbreaks in U.S. nursing homes have persisted despite nationwide visitor restrictions beginning in mid-March. An early report issued by the Centers for Disease Control and Prevention identified staff members working in multiple nursing homes as a likely source of spread from the Life Care Center in Kirkland, Washington to other skilled nursing facilities." Chen, Chevalier, and Long

In the article COVID-19 Risk Factors vary for nursing home Staff, Residents by Mary Van Beusekom, we noticed a similar pattern when it came to data reported from staff members working often in multiple facilities at a time. They conducted a research reporting on staff members testing positive for covid-19 and these numbers do not come as a shock to us.

"The researchers found that 14 of 27 (52%) of staff working at different facilities were infected, versus only 37 of 223 (17%) working in a single home." Beusekom

"Seven of 15 workers (47%) who reported regular contact with residents and sometimes worked at different care homes tested positive for COVID-19, versus 7 of 12 (58%) of staff with regular resident contact who often worked at different sites." Beusekom

We cannot ignore the fact that staff members who work at multiple facilities are more likely to test positive and spread the disease further. Instead of blaming staff members on working at multiple locations at once we first must see the reasons why.

• Forbes wrote an article What Some Nursing Homes do to Retain Quality Staff discussing the important and kind work staff members do, although their contribution is great it does not reflect such great compensation. Some of the reasons why staff members leave their jobs and some factors included;
• Working for a for-profit organization
• Low pay and high workload
• Inability to deliver high-quality service due to workplace/system issues
• Feeling undervalued by society and the workplace

In a similar article Underpaid Nursing Home Workers Caring For Most Vulnerable Patients=Dangerous by Jonathan Rosenfeld we noted crucial information on the truth of underpaid staff members.

"Approximately 50% of all nursing assistants in the United States live well below the federal poverty level. Low pay often results in the need to work longer hours, which could cause fatigue and place the resident’s health in danger." Rosenfeld

Staff members work in multiple facilities in order to make ends meet, and with the heavy hours, low wages, and poor benefits all this stress added onto their body/health makes them much more vulnerable to get infected. It is time we start paying our staff members the well deserved salaries they need. Links to the articles are listed bellow.

 https://www.cidrap.umn.edu/news-perspective/2020/07/covid-19-risk-factors-vary-nursing-home-staff-residents 

 https://www.anderson.ucla.edu/faculty_pages/keith.chen/papers/WP_Nursing_Home_Networks_and_COVID19.pdf 

 https://www.forbes.com/sites/nextavenue/2019/06/11/what-some-nursing-homes-do-to-retain-quality-staff/#3844e16c589b 

 https://www.rosenfeldinjurylawyers.com/news/underpaid-nursing-home-workers/ 

With help from Molly Davies and Wise and Healthy aging, we were able to obtain Ombudsman complaint data from 431 facilities. This data is very important for us as it is not available to the public. Wise and healthy aging's Long-Term Care Ombudsman Program investigates and attempts to resolve complaints made by or on behalf of residents in long-term care facilities. These facilities include skilled nursing facilities and residential care facilities for the elderly.

Looking through the data set, we saw similar cities were hot spots for complaints as they were for COVID-19. The Data is split in 4 Quarters from July 2019- May 2020. We wanted to see where the most complaints were coming from and if they correlated with any of the COVID-19 data. The data was split in 4 quarters.

• Quarter 1 is July, August, and September 2019
• Quarter 2 is October, November, and December 2019
• Quarter 3 is January, February, and March 2020
• Quarter 4 is missing June, but spans from April-may 2020

We saw that in the first Quarter there were a total of 1289 Complaints that include: Physical, sexual, verbal, financial, gross neglect, inter-facility transfer, and bed hold/eviction. The second Quarter followed with a total of 725 complaints. The thirds Quarter contained 565 Complaints, and the last Quarter had 349 complaints. The last quarter is missing one month but we can still see the downward trend from the other quarters. We see that every month that follows there are dramatically less complaints than the previous month.

The chart above quantifies and categorizes Abuses complaints. In every quarter we see Physical abuse being the highest. Inter facility transfer is important to look at because during a pandemic moving patients and elderly is not advised as quarantine regulation are in place. Starting in march the governor advised Angelinos to Stay at home and avoid contact with others. Qtr 3 includes the month of march and shows only 10 complaints of inter facility transfers. In contrast to quarter 4 which is only 2 months (April and May) there are 48 complaints. April and May reported very high COVID-19 cases and deaths in California. There was almost 5 times as many complaints from the 2 months in Qtr 3 than the 2 months in Qtr 4. On a lighter note, April and May had the least complaints pertaining to bed holds/evictions.

COVID-19 is affecting Residential Care facilities and Skilled Nursing facilities throughout all of California and precisely as we looked into Los Angeles. Los Angeles holds a large group of minorities and low-income communities, which are being affected at higher rates than higher-income cities with less diversity. Internet access is crucial to this data as we see neighborhoods with more diversity and less income are less likely to have internet access. Low income and low percentages of Internet access are factors relevant to acknowledging where communities are getting hit worse with COVID-19 because many gain important news and information from there. The RCFEs and SNFs in these areas are at high risk because of these factors. Just because there is internet in the community's households does not mean the same for the RCFE's and SNFs which is something that needs to be prioritized in the future, the internet and news should not derive fear for the residents but instead provide crucial information for them.

Although skilled nursing facilities have higher fatality counts than residential care facilities, residents in both are still at high risk because of the communities around them suffering from the factors that amplify the spread of the virus. It is also essential to understand that residents in skilled nursing facilities are either very ill or rehabilitating, signifying they already have preexisting conditions, which makes them more risk of getting sick severely with COVID-19 and even resulting in death. The California department of public health provided the data we used to determine residential care facility fatalities and mostly included numerical values of <11 or >11. Some facilities had exact values, but since the precise counts for all facilities were unknown, we took their fatality count for the whole State and compared it to the Skilled nursing facility count, which did have exact values for their facilities. Upon analyzing the maps, we understand that all skilled nursing facilities and residential care facilities are negatively affected by the virus. In these facilities, there are no indicators that show whether or not race or income is a determining factor on whether or not COVID cases or deaths will be higher. We know that the neighborhoods surrounding these facilities tend to have higher COVID-19 cases and deaths in populations with more minorities and lower household income.

 It is essential to look at this data of COVID-19 that affects older adults and to present solutions to the issues. Since we know that staff with high counts of COVID-19 will likely lead to the residents having high counts of COVID-19, regulations must be put into place so that nurses cannot work in multiple facilities. To ensure staff only work in a single facility, they need to get a higher salary as the main reason they work in various facilities is to make ends meet. These people are front line workers right now during a global pandemic, and their work should financially reflect that as well. It is also vital they have the right resources to properly work in the safest way possible. Increased funding for their supplies will also be a significant factor in implementing more comprehensive health and safety regulations.

• Strict regulations for Staff members working at SNF's and RCFE's such as prohibiting them from working at multiple locations at the same time
• Increase salary for Staff as they are front line workers doing very important work during the pandemic
• Enforce more regulations inside these facilities to ensure proper cleaning, sanitization, and careful work with the residents
• Increase funding for SNFs and RCFEs in order to provide more resources
• Raise awareness for these issues to get policymakers to notice and make a change

This pandemic has already affected millions of people around the world. It may seem overwhelming during these uncertain times, however, it is crucial to stay up to date with what is going on in your neighborhood and community. Follow the CDC guidelines every day as these steps can save your life or someone else's life. As older adults and people with underlying medical conditions are at higher risk is it important for them or people who live with them to ensure they are being safe as well. Please share the information you've learned to raise awareness and get more people's attention.

We also created a Dashboard as a short version of this StoryMap, which you can find using this link below. This dashboard includes maps and charts demonstrating some of the information we used in this StoryMap.

Here are some recourses to help you gain more knowledge of Covid-19 and information on how to take of your self as well as others.

 https://health.usnews.com/conditions/articles/how-coronavirus-affects-older-adults 

 https://www.medicalnewstoday.com/articles/the-impact-of-the-covid-19-pandemic-on-older-adults#COVID-19-deaths-in-care-homes 

 https://www.cdc.gov/coronavirus/2019-ncov/index.html