The coronavirus disease (COVID-19) pandemic has been particularly challenging for nursing home staff and residents. Centers for Medicare & Medicaid Services regulation waivers are burdening staff and affecting how care is delivered. Residents are experiencing social isolation, which can result in physical and behavioral health issues, particularly for persons with dementia. These challenges can be addressed in part through technology adaptations. Full integration of electronic health record systems can improve workflow and care quality. Telehealth can improve access to outside providers, provide remote monitoring, and improve social connectedness. Electronic and audiovisual programs can be used for end-of-life planning and information sharing between nursing home staff and families. Online learning systems and other online resources provide flexible options for staff education and training. Investing in and adapting technology can help mitigate workforce stress and improve the quality of nursing home care during and after the COVID-19 crisis.
The coronavirus disease (COVID-19) pandemic has placed unprecedented strain on the US health care system, and the possibility that it could become endemic—meaning it will be a common dweller that regularly infects humans—suggests that this strain will persist for some time. As COVID-19 cases accelerate, health care workers are becoming more vital than ever, and they are rightly being hailed as heroes for their generous, brave dedication to caring for patients at the risk of their own health. Providing these heroes with resources to safely deliver high-quality care to their patients and themselves is imperative not only in acute care settings such as emergency rooms and intensive care units (ICUs), but also in nursing homes, where staff provide care for vulnerable older adults in settings that are at risk for infectious disease outbreaks. Nursing home staff face unique challenges during the COVID-19 pandemic because they care for older adults with a high level of vulnerability to COVID-19 and experience constraints that far exceed those imposed in acute care settings. Telehealth strategies, automatic clinical decision-making reports, and other uses of technology commonly found in other care settings hold great promise to improve nursing home care and outcomes.
By 2030, almost 1 in 5 Americans will be 65 years or older [
Because of these vulnerabilities, nursing homes were early reporters of positive COVID-19 cases. The first reported COVID-19 death in the United States was a nursing home resident in Kirkland, Washington, reported on February 28, 2020. Nursing homes across the country and the Centers for Medicare and Medicaid Services (CMS) acted quickly; by March 13, 2020, they enacted guidelines to protect nursing home residents, including barring visitors and adding infection control measures that restrict communal activities, essentially isolating residents in their rooms. Despite these measures, COVID-19 infections spread quickly between nursing home residents and staff. As of April 29, 2020, more than 2700 Medicare-certified nursing homes across the country (1 in 6 facilities) acknowledged infections in residents or staff, and in some states, a majority of nursing homes have reported COVID-19 cases [
Currently, nursing homes continue to battle COVID-19 infections among residents and staff, which is challenging how nursing homes provide care to our most vulnerable older adults. In addition to preventing the spread of COVID-19 within nursing homes, it is now necessary to plan for the admission of patients who were hospitalized with COVID-19 and are too debilitated to return to their homes. The recovery trajectories and continued health care needs of these patients are uncharted; however, increasing evidence points to long-term post–COVID-19 complications that may increase the complexity and length of rehabilitation [
During the COVID-19 pandemic, there has been much focus on personal protective equipment (PPE), the lack of testing and supplies, and the need for infection control training; however, this pandemic has also highlighted problems that nursing homes were already facing, such as frequent staff shortages and high turnover. It is important to take this opportunity to increase awareness of other aspects of care delivery within nursing homes that have been affected by the pandemic. These aspects of care delivery can be enhanced by leveraging strategies such as technology used in other areas of the healthcare system to improve nursing home care both now and in the future.
COVID-19 has presented unique challenges and highlighted ongoing issues faced by nursing homes in providing effective, compassionate, and safe care for vulnerable older adults in an institutional home setting. While the strict regulatory controls currently in place for nursing homes have likely prevented further spread of COVID-19 and subsequent deaths, nursing home staff are being challenged with new work patterns, longer hours, and the need to find new ways to communicate with families. These measures pose additional risks for nursing home residents, such as isolation, which limits their mobility and social interactions. Furthermore, family members are not able to visit their loved ones, which can be particularly devastating when residents have dementia or are at end-of-life. Together, residents, families, and nursing home staff are facing unprecedented stress as they navigate these challenges and their own fears about the virus.
Prior to COVID-19, the nursing home industry was highly regulated by CMS, which partners with state survey agencies to monitor every Medicare-certified and Medicaid-certified nursing home for safety and quality. Many of these challenges are related to CMS regulations on how nursing home care is delivered.
During the COVID-19 pandemic, CMS has provided nursing homes with flexibility to decrease COVID-19 infection risk, emphasizing resident care over paperwork [
Nursing home staff, including nurses, physical and occupational therapists, social workers, and direct care workers, often work at several different facilities; this increases the risk of acquiring and spreading COVID-19 between facilities, especially since many people who are positive for COVID-19 do not show outward symptoms. As the virus spreads among staff and residents, large numbers of nursing home personnel are remaining at home, contributing further to often pre-existing staff shortages. Some nursing homes must rely on agency staff at the risk of inconsistent care delivery and documentation. The relaxed CMS regulations support the hiring of new CNAs to fill vacancies; however, due to the lack of training requirements, more staff are unprepared to work with nursing home residents during the pandemic. Further, staff must adjust to workflow changes resulting from residents being confined to their rooms and the added time required for implementing infection control practices. The negative impact of social isolation on the physical and mental health of residents further contributes to staff stress, particularly in the face of the probable endemic nature of COVID-19.
Nursing homes must ensure that they are adhering to infection control guidelines issued by a number of CDC, CMS, state, and local regulatory bodies [
Under COVID-19 restrictions, nursing homes are closed to everyone but essential health care providers and staff. Congregant activities, including meals, are not allowed, and residents are mainly confined to their rooms. The consequences of isolation on the physical and mental health of nursing home residents will not be known for some time. However, anecdotal reports from staff and families suggest that residents’ health is declining rapidly as a result of COVID-19 isolation. Below, we discuss several areas of particular concern.
Because COVID-19 regulations prevent outside visitors and congregating of nursing home residents, the residents are socially isolated from each other and from family and friends. Social isolation itself is associated with increased loneliness, which has been associated with a plethora of behavioral and physical health issues, including increased depression and anxiety, increased risk of falls and hospitalization, and even death [
Nursing home residents are at increased risk for pressure injuries because they already have limited mobility and are now being confined to their rooms. Residents will spend more time sitting or lying down; this increases the intensity and duration of pressure exposure, which are two factors that lead to pressure injury development [
As residents spend more time in their rooms, they are at risk for physical deconditioning, malnutrition (due to a lack of shared meals or assistance with eating), and depressive symptoms, all of which increase risk of hospitalization [
Electronic health record systems have been used in other health care settings to improve workflow and quality of care; however, full integration has been slower in nursing home settings. Enabling all nursing home staff to access and document records electronically provides an opportunity for real-time communication between staff members. However, many nursing homes only have computers at central nursing stations that are distant from resident rooms. For electronic charting to be efficient, adaptation of mobile charting platforms is needed, such as the use of tablets or point-of-care mobile workstations. The pandemic has also greatly stimulated the need to increase use of electronic medical record systems to collect data and use them for clinical decision-making in nursing homes. Several potential technology solutions are proposed below.
One example of successful implementation of health information technology is the On-Time Quality Improvement for Long Term Care (On-Time) program to decrease high pressure ulcer incidence rates in nursing homes [
Development and testing were followed by incorporation of the On-Time tools into more than 10 different long-term care electronic medical record systems. Using electronic medical records to implement On-Time standardized documentation and clinical decision-making reports in nursing homes resulted in enhanced quality improvement (QI) efforts; focusing staff on high-risk residents, improving team communication, and prompting timely interventions; providing a clear and practical process to maximize the role and contribution of CNAs in pressure ulcer prevention; and increasing CNA engagement with QI by showing them how their documentation, summarized in clinical reports, is used as a basis for proactive clinical decision-making. An evaluation of the On-Time Pressure Ulcer Prevention Program in 12 New York State nursing homes (3463 residents) found a large and statistically significant reduction in pressure ulcer incidence associated with the joint implementation of the four core On-Time reports [
Telehealth encompasses a broad range of electronic information and telecommunication technologies to support long-distance clinical health care and related activities through videoconferencing, internet-based applications, store-and-forward imaging, streaming media, and telephone-based services [
Nursing homes should consider adopting telehealth approaches that have been successfully used in other health care settings to help keep nursing home residents safe and facilitate social connection while observing physical distancing. The Electronic Intensive Care Unit (eICU) uses two-way cameras and video monitors connected to a central hub for remote monitoring and care delivery [
Several barriers to expanded use of telehealth in nursing homes merit attention. First, older adults may be less familiar with tablets or mobile phones and may require initial face-to-face orientation to a new platform [
Now more than ever, information sharing between nursing home providers and staff, residents, and family members is particularly important at end-of-life to ensure resident preferences are respected. Since 2016, Medicare has reimbursed providers for formalized advance care planning discussions that can be conducted by telehealth visits [
In addition to telehealth technologies, videoconferencing and tablet-based applications have been used to enhance social interaction among nursing home residents and family [
Relaxed guidelines for CNA training, the need to train new or agency staff quickly, and the increased workloads faced by nursing home staff increase the need for staff education and training. Technology can be leveraged to address these challenges and to avoid bringing staff together for training. Some nursing homes are already using learning management systems for staff training. Other online educational modules and training videos from reputable sources such as the CDC, health systems, and professional organizations can also be used. For example, training on donning and doffing PPE is needed, and demonstration videos that provide this training are available from a number of sources. The CDC recommends that nursing homes have a staff member available for every shift to monitor PPE use; this staff member could assess and approve staff members’ PPE use. Almost all of these online training programs can be accessed on a smartphone or tablet, which can help staff complete required training.
The unprecedented challenges of the COVID-19 pandemic place particularly great burdens on nursing home staff who are unfairly stigmatized and had the fewest resources in prepandemic times. At the same time, the dedication and sacrifice of the majority of nursing home staff go unnoticed. Today, more than ever, it is important that we support nursing home staff, particularly those providing direct care such as nursing, dietary, social, therapy, pharmacy, and custodial services, to our most vulnerable older adults in their time of greatest need. Technology presents opportunities to address the challenges these staff members are currently facing. We owe increased support to vulnerable older people and those who care for them, and we call for an investment in technology and other resources to support older people and their caregivers during the pandemic.
Conflicts of Interest: None declared.
Centers for Disease Control and Prevention
Centers for Medicare & Medicaid Services
certified nursing assistant
coronavirus disease
electronic intensive care unit
intensive care unit
Physician Orders for Life-Sustaining Treatment
personal protective equipment
quality assurance and performance improvement
quality improvement