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COVID-19 has made life and business increasingly hard for Maribel Tan, who needs to keep her home safe for both her family and the three elderly clients who live with them as part of Hawaii’s Community Care Foster Family Home program.

She checks the temperature of her kupuna clients three times a day and serves them their meals separately. She disinfects doors, locks, light switches and surfaces. With three generations in her household, keeping the virus out of the house is top of mind.

“We are very, very worried, especially now that there’s a lot more COVID going on,” she said.

The COVID-19 pandemic is putting new stressors on caregivers at community care homes, where thousands of Hawaii kupuna live.

Nursing staff, who before the pandemic typically floated between part-time jobs at multiple care homes, are now harder to hire. Floating is discouraged to prevent disease transmission, and there’s more demand for staff at larger facilities that can offer more competitive salaries.

New expenses like personal protective equipment, disinfectants and extra labor are stacking up, and the is nowhere near enough to cover the costs, she said.

But Tan’s greatest worry, along with the caregivers she represents as the president of the Adult Foster Homecare Association of Hawaii, is what to do if someone in her household catches the virus.

“We’re so frustrated because of all that’s going on and we still don’t have set guidelines,” she said. “Who will take the patient with a positive test? Nobody, if we don’t have a place for them. We don’t want our family members to get affected too.”

State health officials say Hawaii’s elderly care industry has largely avoided the kinds of outbreaks that have happened on the mainland, where COVID-19 cases in elderly care facilities account for

But cases are on the rise again, especially on Oahu, and as more COVID-19 cases emerge in long-term care facilities, caregivers and industry advocates say there are still a lot of questions about how well the state and caregivers are equipped to handle a possible virus outbreak.

Kupuna residents are still at high risk for COVID-19 because those who care for them or visit them do interact outside of the home with the general public, said Keali‘i Lopez, director of Hawaii AARP. ��

“Once these vulnerable residents are exposed and contract COVID, their ability to survive the virus is very limited,” she said.

Few Cases So Far

Twenty-three people associated with at least six different residential elderly care homes have been diagnosed with COVID-19 to date. Four residents have died. Those homes had fewer than 10 patient clients each, according to Dr. Sarah Kemble, the state’s deputy epidemiologist.

As of July 31, 47 other COVID-19 infections have been confirmed among patients and staff of larger nursing facilities. One skilled nursing home resident has died. In sum, of the 70�� cases in long term care settings to date, about half of those infected were patients and the other half were staff.�� Twenty-two elderly patients have been hospitalized to date.

The health department has provided few details about the cases and does not post data about care home related cases online.

In many of the cases, caregivers have unwittingly introduced the virus to households after contracting it in the community, according to Department of Health Director Bruce Anderson.

Some caregivers in affected nursing or community care homes have had jobs in multiple locations — something the state discourages — a spokesman for the DOH said in an email.

Although cases have been low so far compared to the mainland, advocates and caregivers are concerned that Hawaii doesn’t have systems in place to handle an outbreak. Several care home operators say they do not feel equipped to care for patients with COVID-19 because they don’t have proper protective gear and also don’t necessarily have the expertise and training to do so.

“Most, if not all of them, do not have medical staff or protocols that they rely upon,” said Lopez.

They also worry about isolating clients in their homes. Not every patient with COVID-19 will need to be hospitalized, and some may not meet nursing facility entry requirements. Others may not have the health insurance needed to transfer to a nursing home.

Wannette Gaylord, owner of Gaylord’s Adult Residential Care Home and president of the Hawaii Alliance of Residential Care Administrators, says people in her network are worried about space.

“Quite often when you’re in a care home, you are not always able to isolate,” she said. “So then what are you going to do? What alternatives do you have?”

Kemble says what will happen to elderly patients depends on the case, and comes down to details like how many entrances, exits and bathrooms there are in a home.

“We try to understand as quickly as we can how many people are in the house and how feasible it is to create a true isolation barrier in the house,” Kemble said. “It’s very individualized for each setting to see if there’s a way to cohort within the house or if people need to be moved to isolate safely.”

Mixed Guidance

Maria Etrata was a caregiver for 27 years, but now runs a company that provides daycare services for dozens of kupuna and disabled adults. The center has been closed since the pandemic began, but as the president of Primary Care Providers of Hawaii, she speaks with other caregivers regularly. Her colleagues aren’t clear on what to do when someone is sick in the house. And they say they can’t afford supplies anymore.

“They’re saying, ‘We need more PPE, where can we get them? We need direction. Who do we follow, the governor, the mayor, or the lieutenant governor, or what?’” she said.

Online, the state offers some general guidance and links to the national website for the Centers for Disease Control and Prevention. But the CDC rules are aimed at larger nursing facilities, advocates say.

“The guidelines that they sent were guidelines for nursing homes, which is so different from us,” Tan said.

Larger nursing facilities are subject to federal oversight by the Centers for Medicaid and Medicare Services.

The federal government requires those facilities to report suspected and confirmed cases on a weekly basis, but CMS does not provide regulations for smaller operations like Tan’s, according to John McDermott, the state Executive Office on Aging’s long-term care ombudsman.

“We don’t know what DOH requires of those homes,” he said.

The guidelines that have been distributed are “hit or miss,” Gaylord said, noting that most of the language is pulled directly from the U.S. CDC. Some of the guidance is longer than 50 pages and difficult for many to understand, especially those who speak English as a second language.

The case management agency that oversees foster care homes for the elderly recently put out a call for volunteers who’d be willing to help out in other care homes affected by COVID-19. The caregivers would be paid, trained, and given personal protective equipment from the DOH, according to an email from the agency, Community Ties of America.

“If you are not willing to care for clients in another person’s home but ARE willing to take care of clients in your own CCFFH that have been potentially exposed (which doesn’t mean they were — it only means there is a probability they were), tested negative for COVID-19 or even tested positive for COVID-19, then let us know that too,” wrote Angel England, CTA Operations Manager.

Tan doesn’t think many people will volunteer.

“Nobody would want to do that,” Tan said. “They’d want to take care of their clients first before volunteering with someone else’s patient.”

Nowhere To Go

Department of Health officials say they have some quarantine spaces under contract, but no dedicated space for care home residents.

At a recent legislative briefing, DOH Office of Health Care Assurance Chief Keith Ridley said transfers are made on a case-by-case basis. Caregivers may be asked to keep and care for a COVID-19 positive patient, rather than discharge them.

“In some cases it may be better for the (COVID-19) positive person to stay where they’re at, and to take the negative one — the person who is not infected — and move them temporarily,” he said at the July 9 hearing. “We work very closely with the care homes in these situations.”

Gaylord said she was “floored” when she heard that, as it would put family members in the household at risk for the infection, and caregivers don’t feel equipped with the expertise or protective gear to handle caring for a COVID-19 patient.

“I almost had a heart attack when he said ‘discharge the healthy ones and keep the assumed COVID-19 positive one,’” she said.����

Dr. Curtis Toma, the medical director for Hawaii’s Med-QUEST Division, which oversees government-subsidized health insurance and long-term care for low-income adults and families, said small care homes want hospitals or the state to take care of people with COVID-19, but the state and hospitals want people who aren’t in need of urgent care to stay where they are.

“From a nursing facility and hospital setting, their preference would be to keep them in the community and provide more support there,” Toma said.

Some patients from smaller care homes have been transferred to Hale Nani Rehabilitation and Nursing Center and housed in specialized isolation quarters the facility created while dealing with COVID-19 on campus. That doesn’t necessarily mean Hale Nani will take more patients, Toma said.

The experience so far has been a “steep learning curve,” he said. Some homes may have a COVID-19 positive caregiver but negative patient, or vice versa. Then there are other patients who may have been exposed.

Another issue was many homes didn’t have enough protective gear, but the department has been distributing more in recent weeks.

“As the COVID-19 crisis grows and we have more cases, it’s going to be harder to place these patients,” he said.

The state has contracts for 171 beds at hotels as a quarantine option for people who have nowhere to isolate on their own, according to DOH Director Anderson. He said about 20 to 30 beds are reserved for that situation on Oahu.

Toma says it would be useful for the state if there was a dedicated COVID-19 nursing facility “set up and ready” for elderly patients.

Kemble recognized that a facility would be useful in certain scenarios.

“Many of these patients are accustomed to living in their homes, so sometimes it’s not the best decision,” she said, but “it’s not optimal for them to go to an emergency department just to find a placement. Those are the situations where it would be helpful.”

Lopez says Hawaii has a quarantine facility for the state’s homeless population. She’d like to see something similar for kupuna, as well as a rapid response team ready to deploy to help caregivers and patients in outbreak scenarios. In other states, doctors, nonprofits and National Guard members have “banded together” .

The teams also visit elderly care facilities before outbreaks arise, she said.

“They don’t have to reinvent the wheel,” Lopez said. “Other states are going through this and have devised strategies to reduce outbreaks, hospitalizations, and deaths. We are in a position to prevent deaths if we can act.”