Senior Housing During COVID

11 min read

Realities, Challenges and Best Practices  

Three years ago, I published a book that I wrote with Dr. Michael Osterholm, the renowned epidemiologist at the University of Minnesota, entitled, Deadliest Enemy: Our War Against Killer Germs. We called our chapter on coronaviruses, “SARS and MERS: Harbingers of Things to Come.” It wasn’t that we were particularly prescient; we merely looked at the abundant evidence and arrived at a natural conclusion. When it came out, the book was gratifyingly received by the public health community, and practically ignored by the reading public. In April of this year, it became a New York Times bestseller. We’ve joked—and believe me, this is the extent of our joking in these surreal times—that all it took was a worldwide pandemic to make our book a success.

The fact is, whether we like it or not and politics notwithstanding, no one can any longer ignore what is happening in the public health realm, now or going forward, and this is particularly true for those involved with senior housing and assisted living in this time of Covid-19. So, we thought we should offer some realities, perspectives, and best practices to help those involved with that segment of the population and their residents weather this microbial storm.

The Realities
First, let us acknowledge the realities. The Covid-19 pandemic will end in one of only two ways: Either we (and most other countries) reach the level of herd immunity, which means that between 60 and 70 percent of the population has been infected; or an effective vaccine has been developed, tested, certified and manufactured in sufficient millions of doses to inoculate a large part of that population.

Regardless of aspirational pronouncements from political leaders, neither of these events is likely to occur any time within the next several months. As of this writing, with all the societal dislocation, economic losses, physical suffering and hospitalizations, and well over 100,000 American deaths, only between five and 15 percent of the population has been exposed, so we have a long way yet to go with this. As Mike Osterholm has repeated on some of his numerous television appearances, “We are only in the second inning of a nine-inning game.”

Vaccine research, development and early stage clinical trials are going on all over the world and there is great hope that one or more of the candidates and approaches will yield positive results. But vaccine development is an uncertain, trial and error process. Many ideas or concepts that look good in the lab or even in animal models don’t pan out in human trials. Most vaccines take years to develop, and it is sobering to consider that top scientists have been working on an HIV vaccine for 35 years, to the tune of a billion dollars annually, and we still don’t have a vaccine. The influenza vaccine, which has to be reconstituted every year depending on which circulating strains are dominant, is usually only partially effective. Many experts believe, however, that this coronavirus should be susceptible to a preventive vaccine through one modality or another, and if there are no major setbacks, one could emerge by some time in 2021.

If or when that happens, though, there will have to be a massive undertaking to produce enough doses to go around. If a million doses could be produced a day, which seems unlikely, it would still take a year to have enough for everyone in the United States. In the months since this novel coronavirus was first identified in Hubei Province, China at the close of 2019, it is safe to say that what we don’t know is far greater than what we do know.

What we do know is that SARS-CoV-2, the virus that causes Covid-19, runs the gamut in symptoms and effects from virtually none all the way up to death by respiratory distress. And for our purposes here, seniors, especially senior men and especially those with underlying medical conditions, known as comorbidities, are among the most vulnerable cohort.

The Challenges
The most important consideration in dealing with Covid-19 is that it is transmitted by the respiratory route. This essentially means that the microbes come from our lungs, out of our mouths and noses and into the air, anytime we breathe. Sneezing, coughing, talking, singing and even heavy breathing can project those viral particles outward, and they can be anywhere from small droplet size to aerosol. A surgical or nonmedical mask will trap the larger particles and keep them from reaching another person, but the aerosol-sized particles can only be stopped by a well-fitting N-95 mask. As we have all read, they remain in short supply and should be prioritized to medical staff and first responders.

Transmission is far more likely inside, where the air remains relatively still or recirculates throughout the building. Outside, air currents disperse the germs with relative efficiency, so transmission is not quite as great a problem. Still, keeping a distance of six to ten feet is safest. Unlike certain other infectious diseases ranging from influenza to SARS and MERS—the other known coronaviruses—up through Ebola where, by the time an individual is infectious he or she is already feeling the effects, the Covid-19 virus is transmissible before host spreaders have any symptoms. And despite recent proclamations from the World Health Organization (WHO) and some others, the evidence strongly suggests that infected, asymptomatic carriers can transmit.

Now, for what we don’t know. We don’t know how long the pandemic will last, whether it will drop off in the warm weather months and then surge again in the fall as influenza tends to do; whether it will continue as a slow burn without going away but without overtaxing our healthcare facilities; and where it will spike and where it will drop off. We don’t know how many viral particles constitutes an infectious dose. We can’t predict who will be most severely affected by exposure, and the severe reactions of some children and young adults remain a mystery. Also, at this point we don’t know whether immunity, conferred by either exposure or a prospective vaccine, will be permanent or partial, only lasting months or years. We don’t know how effective a vaccine would be for people at greater risk. In general, they tend to respond less effectively to vaccines. We also don’t yet know or understand the full range of residual effects from the disease, which can include both respiratory problems and neurological changes. Given those realities, responsible owners and managers must consider and plan for all eventualities.

The overall challenge, then, for those responsible for senior housing and assisted living in the time of Covid-19 is: How to keep residents physically and emotionally well and still afford them the semblance of a normal life.

Best Practices
First and foremost among best practices is infection control. There are two levels. One is to wipe down and disinfect all frequently touched surfaces, such as door handles and push plates, bathroom fixtures and food trays. Though the air is a far more dangerous medium for transmission than surfaces, it is known that the virus can live on surfaces for at least several hours, which is a problem if that surface is touched and then that same hand touches anywhere near the nose or mouth.

The second level of infection control is personal. Though anything short of an N-95 mask is only partially effective and there is no convincing data on how effective other kinds of face protection are, staff members should wear masks covering the nose and mouth, as well as gloves. Remember, the facemask is not primarily for the protection of the wearer; it is to protect everyone else from the wearer, so it is also a sign of professional responsibility. Any employees who have a fever, feel as if they have COVID-like symptoms or test positive should stay away from work for two weeks after symptoms abate. The best way to insure compliance is if they can still receive pay during this period.

As mentioned, personal protection also means maintaining a separation of at least six feet; ten feet is even safer. Admittedly, it is tough to keep families visiting older relatives or friends to maintain those distances, but unless they are absolutely certain they have not been exposed or are already immune, it is very important to stress. Too many outbreaks in assisted living facilities have started with family visits, and no one wants to be known as the one who brought Covid-19 into a senior community. Visitor policies should be informed by local public health authorities.

The overall concept here is that the chain of safety is never stronger than its weakest link.

What this means is that each building or complex should engage in a community-wide discussion about how the community can best be protected, given its individual circumstances.

Now, if the community can stay completely closed to the outside and staff health and contact is closely monitored, members can socialize with each other all they wish. But that kind of shelter-in-place agreement is difficult to maintain, particularly if some residents have aides who come in every day from the outside.

Office visits should be tightly limited and as much as possible should be done digitally.

All nonessential and nonemergency maintenance projects should be postponed and as few outside contractors and visitors as possible should be brought in. Package deliveries are not a major source of transmission; it’s the people who carry them that could be, so boxes and packages should be dropped off in a designated spot and then picked up and distributed after the carrier leaves.

Food is not a source of infection and food packaging, likewise, has not been found to be a problem. As long as those deliveries are left in a neutral space and then picked up by residents or left at their front doors, this should not be a major area of concern.

Any resident who returns from a hospital or treatment facility should isolate for 14 days.

Testing, either the molecular tests that determine if you have Covid-19, or the serology tests that determine if you’ve had it and now have developed antibodies, is among the most complex and misunderstood aspects of the entire crisis. Many pages could be written on the subject. The best advice is to coordinate with the local health department for the recommendations in a given area, which will depend on the current prevalence in the community. Public health officials might want to conduct testing to “bubble” the community. We do not advocate routine testing of asymptomatic individuals, either residents or staff. In low-prevalence communities, false positives are just as likely as true positives.

If a staff member or resident does become sick, testing is indicated and in any community with a high density of senior residents, the local health authority should be informed immediately so it can conduct contact tracing and protect the facility and surrounding area.

What Managers Can Do

After keeping residents and staff physically safe, the most important function of the individual in charge of the building or complex is information – keeping her or himself up-to-date and conveying that information to residents. CIDRAP, the Center for Infectious Disease Research and Policy, which Mike founded and heads at the University of Minnesota, is an excellent and reliable resource that is updated daily. ( So is the Centers for Disease Control and Prevention (

The pandemic intensity is going to vary greatly by region as time goes on and managers should keep close track of conditions in their local areas to understand the relative threat. A flexible attitude is key. They should try to enable technology, such as Zoom, FaceTime and Skype for all capable residents so they can communicate with family and friends, as well as staff. It is critical to try to discern what individual residents need during the crisis. Many may need financial advice or help with food or medicine, and whenever possible, management should have access to local social work services for aid it cannot provide itself.

Managers should encourage phone trees through which residents can keep virtual watch over each other and communicate new information quickly and conduct regular checkups on residents’ physical and mental wellbeing. Overall, managers should encourage the sense that everyone has a stake in protecting everyone else.

We have to accept the fact, as Mike puts it, that we’re not leading the tiger, were riding it, and the new normal may last for quite a while with unpredictable disease spikes and lulls. We may hope that it tapers off, that a vaccine is quickly successful, and that in the meantime, new treatments can blunt the effects on the severely affected. But again, as Mike says, hope is not a strategy, so we must respond accordingly.