Chodos says these measures can help stem the spread of the virus from asymptomatic carriers. With a virus this infectious, she adds, “no precaution is superfluous in any circumstance.”

But those precautions are only helpful to a point, according to Unroe. “These outbreaks are continuing and they’re going to continue in nursing homes,” she says. There are still a lot of unanswered questions about how and why the virus has spread so quickly in some homes, but not in others. Based on early data, she says: “It’s about the size of the facility and the amount of spread in your community.”

Nevertheless, Unroe warns that while researchers are working furiously to figure out solutions, they still don’t have all the answers: “It’s a turbulent time and we’re trying to make clinical and operational decisions with incomplete information.”

As San Francisco starts to reopen, SFCJL’s Cmiel is nervous. “This scares me to death,” she says. “I actually think we need to tighten up now that the city is reopening.” If community transmission of the virus starts to increase in the city, nursing home residents will be at an even greater risk. But how long can people go without seeing their loved ones, or getting exercise or intellectual stimulation? “It’s this constant balance,” adds Cmiel, “between the safety and health of our residents and the needs of the families.”

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A much more far-reaching approach to keep older people safe from Covid-19 would be to care for them in their homes, keeping them out of long-term residential settings. Two initiatives in California, Community-Based Adult Services and Multipurpose Senior Services Program (CBAS and MSSP, respectively), serve thousands of low-income seniors—the majority of whom are people of color. The programs provide essential services like at-home nursing care, physical and emotional therapy, meals, and transportation that are on-par with the support received by residents in senior homes.

Out of the nearly 10,000 seniors served by MSSP, only three have died of Covid-19 so far, says Claire Ramsey, a senior staff attorney at Justice in Aging, a nonprofit that advocates for low-income seniors. “This is a way safer way to provide care,” she comments. Chodos notes that seniors who receive care in their homes also have lower rates of depression, and experience slower cognitive and physical decline. And home care is also usually what seniors would prefer, says Unroe: “People should be cared for where they want to be cared for. Almost anyone would say that is in their homes.”

Advocates say that nursing homes are necessary, but they shouldn’t be the default care solution for seniors who need some assistance. “There should be a continuum of care, and institutional care should really be reserved for people who need it, who can’t be successful and safe in their own homes,” says Ramsey.

But the economic effects of Covid-19 are forcing states to cut budgets; both California and New York have proposed cuts to programs that provide low-income seniors with at-home help that keeps them out of institutions. In the Golden State, Governor Gavin Newsom’s revised budget will eliminate both CBAS and MSSP and reduce the hours of in-home care MediCal funds by 7 percent. New York state already has decided to limit eligibility to the Consumer Directed Personal Assistance Program, which pays for home nursing aides for disabled or chronically ill New Yorkers. Ramsey says that without these programs, many seniors will have no choice but to move into long-term care facilities. “You are literally going to have more people die if you do this,” she adds.

Another worry is that even if seniors aren’t forced into high-risk living situations, other cuts could jeopardize their overall health. California’s proposed budget would also cut eligibility for MediCal and eliminate optional MediCal benefits like podiatry, physical therapy, and diabetes prevention programs. Those benefits are important for keeping people healthy and alive, regardless of the threat from the novel coronavirus. “One of the things we’re very worried about is how bad these are cumulatively for people,” says Ramsey. “It’s really death by 1,000 cuts.”

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