Report from the U.S.: the COVID-19 epidemic’s arrival reveals safety net gaps and deficiencies that will harm long-term care workers, carers, and their care recipients

By Courtney H. Van Houtven and Nathan Boucher

As COVID-19spreads in the U.S., the long-term services and supports (LTSS or LTC) system is grappling with how to protect workers and meet growing demand for care among vulnerable adults currently receiving care from informal or formal carers in their homes, in assisted living facilities, in post-acute care facilities, and in long-term nursing homes. Transmission concerns between workers and residents, care recipients and home health aides, and between family carers and care recipients abound.  Restrictions on visitors to LTC facilities, and physical distancing and home quarantine practices are important but insufficient steps to reduce risks.


Unlike all industrialized countries, there is a lack of paid sick leave for workers in the LTC sector in the United States and for  workers in many other settings as well.  This means that many workers providing informal care to family members and friends lack sick leave.  Lack of paid sick leave depends on one’s profession and is especially pronounced in gig economy and low-wage jobs.  Paid leave to care for sick family members is even rarer.  Specifically, “according to the Bureau of Labor Statistics National Compensation Survey, just 13% of private industry workers had access to paid family leave in 2017, with the lowest?wage earners being four times less likely than the highest quartile wage earners to have access to paid leave (6% vs 24%, respectively). Thus, both unpaid and paid leave remains elusive for low?wage working Americans.” (Source: United States Bureau of Labor Statistics (BLS). National Compensation Survey. In: Labor USDo, ed. Washington, DC: US Bureau of Labor Statistics; 2017:Table 32.  Quotation comes from Wolff, Drabo and Van Houtven, Annals of Internal Medicine, 2019)

In light of these challenges, multiple policy proposals and legislation arose over the last two weeks that we want to highlight. 

The first proposal we highlight discusses guidelines for minimizing spread in institutional long-term care settings, and highlights the tension faced by the lack of sick leave and the fact that workers are living paycheck to paycheck.

Long-Term Care Facilities and the Coronavirus Epidemic: Practical Guidelines for a Population at Highest Risk

This thought-provoking editorial echo’s CDC guidelines and urges us to consider the 5 domains that indicate preparedness in long-term care facilities:

1) reduce morbidity and mortality among those infected;

2) minimize transmission;

3) ensure protection of health care workers;

4) maintain health care system functioning; and

5) maintain communication with worried residents and family members

Importantly, this editorial reflects the glaring lack of basic benefits for workers (e.g. no paid sick leave and inability to afford staying home because of lost income from staying home).  The writers state:  “It is noteworthy that many long-term care workers live paycheck to paycheck in an environment without reserve staffing; they therefore may be conditioned to report even when sick. Providing a work environment that allows healthcare workers to call out without repercussion will be critically important. Within the facility, protecting workers involves maintaining an adequate supply of gowns, gloves, and face masks. This involves both keeping track and awareness of inventory and negotiating with suppliers and public health officials who might seek to redirect limited resources to other healthcare environments.”

For the full Editorial please see:

And for the Society of Post-Acute Care and Long-term Care Medicine (AMDA) Guidelines please see:


There is some notable progress in this area to address these risks with the passage of a second proposal,  Family’s First Coronavirus Response Act, which was passed into US law on March 18.  This law extends paid sick leave to many Americans (although not those with >=500 employees) and yet, it is important to note that many LTC workers cannot meet living expenses with a benefit that provides at minimum 2/3 of their usual income.  Industry-nitiated worker protections could supplement these early legislative moves.  Additionally, the sub-population of American Veterans receiving care in LTC facilities – and the staff caring for them — also stand to benefit from this Act’s passing since it will provide $60 million in funds for VA patients and healthcare workers. Additionally, costs of care for individuals who are not insured by a federal plan or group plan (this includes many LTC workers) will be reimbursed to their providers if the care is related to the Coronavirus.

For a summary see

A third strategy being posed to ameliorate concerns of worker-to-resident or resident-to-worker transmission is to approve telehealth visits for providers (e.g. physician assistants, nurse practitioners, and physicians who do not need direct patient contact).  These concerns are not limited to nursing home settings, of course, and telehealth could play a very large role in hospice or home health care settings.  To date, whereas Centers for Medicare and Medicaid Services (CMS) have massively expanded telehealth for most outpatient services due to COVID-19 and allows tele-delivery of care across state lines, this expansion excludes so far home health and hospice care delivery. CMS administers Medicare, the public insurance program for older Americans.

However, as Peter Jamison of the Washington Post points out, this is an urgent issue to address because paid LTC workers in the homes of older and/or disabled adults risk spreading COVID-19 due to lack of support.  See link below.  “Unprotected and unprepared: Home health aides who care for sick, elderly brace for COVID-19 Millions of poorly paid workers are being given little support and risk spreading the coronavirus, warn those in the health-care industry.”

As such, late last week, Sens. Klobuchar and Bod Casey introduced a fourth strategy – their bill – Advancing Connectivity during the Coronavirus to Ensure Support for Seniors Act (ACCESS) – would provide $50 million to Health and Human Services (HHS) to expand Telehealth platforms for “senior living centers.” 

This proposed bill responds to long-term care patient’s need for ongoing health care expertise during the pandemic, provided at a distance via tele-health, and supports on-site clinical staff via the same. Additionally, it reduces the number of clinicians entering the facility bolstering social distancing.  It still does not address tele-home health needs or tele-hospice needs.

In all, telehealth expansion will not protect other service lines in nursing homes, e.g. food service and environmental sciences teams, and thus stronger worker benefits and protections across service lines will be critically important to help minimize COVID19 spread.  Examples of these already implemented are residents eating in their rooms to minimize spread to each other and the food service staffs.

In our next post we will examine how the as of yet unsigned economic stimulus bill may affect LTC industry, LTC workers, and family carers; we will also provide an update on the Klobuchar/Casey ACCESS legislation.

Courtney Harold Van Houtven, PhD, MSc. is a Research Scientist, Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System and professor, Department of Population Health Sciences and Duke-Margolis Center for Health Policy, Duke or

-Nathan Boucher, DrPH, MPA, MS, is an assistant research professor at the Duke University Sanford School of Public Policy and the Duke School of Medicine as well as a Research Health Scientist at Durham VA Health System’s Center of Innovation to Accelerate Discovery and Practice Transformation. or

Suggested citation:

Van Houtven C. H. and Boucher N (2020) Report from the U.S.: the COVID-19 epidemic’s arrival reveals safety net gaps and deficiencies that will harm long-term care workers, carers, and their care recipients. Article in, International Long-Term Care Policy Network, CPEC-LSE. Available at

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