The whole thing felt like a charade.
It was mid-March and Tyson Belanger was standing beside the medical checkpoint at the entrance to Shady Oaks Assisted Living, the long-term care facility he owns in Bristol. Before entering the building, employees had their temperatures checked and answered a series of health-related questions. The checkpoint was established according to the best medical advice, but it reminded Belanger of the ineffective beak masks physicians wore in the 17th century to avoid the plague or the folk medicine of ritual theater, an archetypal performance for the purposes of healing. He knew that the checkpoint could not detect pre-symptomatic or asymptomatic carriers of the virus, and, consequently, any one of the employees walking past him that day could carry the virus right through the front door.
That night he woke up and was unable to fall back asleep. He had 48 employees who cycled into and out of the facility for different shifts and he knew a medical checkpoint wasn’t enough to protect his residents. Belanger had been tracking the progress of the virus since the first reports came out of Wuhan. In late February he’d followed news reports of the outbreak at Life Care Center nursing home in Kirkland, Washington, where dozens of residents died of the disease.
“What we watched there was so devastating and horrific, it really looked like a nightmare that was coming true,” he says.
He had seen nightmares come true in the past. A former Marine infantry officer who served three tours in Iraq, he participated in the invasion of Baghdad in 2003 and the intense clearing of Fallujah in November 2004. In 2005, in the aftermath of Hurricane Katrina, he filled up his pickup truck with supplies and drove down to New Orleans where he’d witness the apocalyptic site of a major U.S. city evacuated and shut down.
Between his public and military service, he’d also earned an undergraduate degree from Yale and a Ph.D. in political science from Harvard. He planned to turn his dissertation into a book, but in 2016 his father’s health was failing, and Belanger switched careers to buy Shady Oaks Assisted Living from his parents. He moved into the house next door and began running the facility, which his family has owned for 44 years. Running the place and caring for its residents became his life’s mission. Belanger’s grandmothers have both lived in the residence and he says his mother may soon require its care. (His father died in January 2018.)
Now, in the middle of the night, he thought back to what he’d learned in Iraq and New Orleans. He’d witnessed the terrible instability that can follow an unexpected paradigm shift. But he’d also seen a pattern of things getting very bad for a period of weeks or months and then getting better as people learned and adjusted to the new realities of their world.
“One crushing feeling that I had from my time in the Marines was that irreversibility of death and how much learning could happen if you could just survive the first few months of contact,” the 45-year-old says. There’s a story in military circles about a “guy who’s on his first patrol and makes a mistake and gets harmed and doesn’t have a chance to learn anything. I didn’t want that to be us.”
Belanger needed more time to protect his 36 residents — time to put in place new safety procedures; time to let hospital staff adjust to the surge and better handle the virus; time to let U.S. testing ramp up after a badly botched beginning. Over the next few days, Belanger struck upon a concept as old as warfare: a modern moat. He would ask select employees to live at the assisted-living facility for two months in exchange for a significant added pay. Two months, Belanger believed, would serve as a bridge, getting his residents through the worst of the crisis.
He called the idea “the bubble” and began discussing it with others on March 14. Belanger hadn’t heard of other homes employing this strategy, though he would later identify two others in the U.S. and one in France that had come up with the idea independently. The concept wasn’t based on any medical research, but there was an intuitiveness to the strategy that recalls what's known as the parachute paradigm in medicine: we know parachutes reduce one’s chance of dying if you jump out of an airplane, even though that conclusion has never been studied in a randomized control study.
Despite its simplicity as a concept, it was clear the bubble would be difficult and highly expensive to implement. Belanger didn’t care. “I’m responsible for these lives,” he says. He knew the virus was coming for homes like his and he was going to fight back. He thought, “Not us, not our home, not our residents. Not if I could help it.”
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On March 18, Gov. Ned Lamont announced the state’s first coronavirus fatality. The victim was a man in his 80s who lived at Benchmark Senior Living at Ridgefield Crossing. It was the beginning of the nightmare Belanger had foreseen.
More than two dozen more residents of that Ridgefield facility were a tiny fraction of the devastation wrought in senior-care facilities as the virus swept through the state. Together, nursing homes and assisted-living facilities have accounted for more than 3,000 deaths, or 72 percent of Connecticut’s 4,300-plus COVID fatalities, as of early July.
Nationwide, more than 51,000 residents and employees of long-term care facilities have died, representing more than 40 percent of the total death toll in the U.S., The New York Times found in an analysis published in late June.
Senior-care employees, many of whom average around $15 an hour, often work in multiple facilities, increasing their chances of exposure to the virus. They work in difficult conditions sometimes with ineffective personal protective equipment and poorly thought-out infection control. As asymptomatic or presymptomatic carriers, they likely brought the virus with them from facility to facility unknowingly. Even with proper PPE, residents often share rooms and staff have close contact with them, frequently helping them do things like eat, walk and go to the bathroom. Once COVID gets into a facility it often infects 50 percent of the residents and kills as many as one in four of them.
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To establish the bubble, Belanger moved out of his house and into his office, and he converted the house for staff members to live there. He bought RVs and set them up in the parking lot. Employees were being asked to work 60-80 hours a week and to be away from loved ones for an extended period of time in the midst of a crisis. In return, Belanger paid certified nursing assistants $15,000 per month, while nurses received $20,000 a month, about five times more than their normal salaries. Belanger’s gross weekly payroll would balloon to more than three times its pre-pandemic level. To pay for it all, he ultimately received a $343,000 loan from the Paycheck Protection Program and raised more than $200,000 in donations. Even so, he still needed to contribute more than $250,000 from his personal savings.
On March 22 at 6 p.m.,17 staff members joined Belanger on the Shady Oaks campus. The bubble had been established.
One of those staff members was a veteran nurse named Faith Brouker. When she first heard about the concept she thought it was an overreaction. Even so, she agreed to become what Belanger called a “bubble guardian,” those workers who remained at the facility. Brouker’s children are grown, but her elderly mother lives with her and her husband. Her decision to enter the bubble was a family decision.
Within weeks, as Brouker heard from friends and colleagues who worked in nursing homes and assisted-living homes, she felt a sense of relief that she was not working in the terrible conditions she was hearing about, and that she was not in danger of bringing the virus to either her patients or carrying it from them home to her family.
“Thank God we did what we did,” she recalls thinking. “Thank God for Tyson.”
As for Belanger, as the effectiveness of the bubble became clear, he tried to get the word out to other nursing homes and assisted-living facilities that were still COVID free. He believed that if they bubbled up they could still save lives. He wrote an op-ed for the Hartford Courant that was published on April 3, urging the state to provide funding to help other long-term care facilities establish their own bubbles. He also shared his strategy, hoping other homes in Connecticut and beyond would act on it. He did local press interviews and made a YouTube video trying to get the message out. By early May he attracted national attention when he penned an op-ed in The New York Times that ran on May 3 and was interviewed on MSNBC and CNN.
“Thousands of people could have been saved if we could have made this manifest throughout Connecticut. Think of how proud we would have been if we were the only state that had done this and really protected its seniors."
Even in early May he argued it wasn’t too late to enact bubbles, as a third of long-term care facilities within Connecticut, and many more throughout the country, were still COVID free. And he believed that homes with cases could isolate sick residents and create a bubble for others at the facility. The cost was so steep it would likely require government intervention, but Belanger believed it was worth the investment. “If Connecticut pays $25,000 per week in matching payroll funds to all of its roughly 365 nursing homes and assisted-living centers for six weeks, this would cost taxpayers nearly $55 million,” he wrote. “Not every home or caregiver will agree to do it, but we should provide the financial support to make it financially viable for all.”
Belanger’s bubble at Shady Oaks became well known in Connecticut and beyond. He was hailed as a hero for the extraordinary steps he was taking. But that wasn’t his goal. He wanted to show that it was ordinary, that it was a strategy to protect the most vulnerable, and that many more facilities could implement the bubble with the proper support.
“If you had a magic pill that would reduce the fatalities of coronavirus in Connecticut by 70 percent, wouldn’t you spend the money on it?” he says. "But no one was interested. It’s my personal regret that I was unsuccessful at motivating that level of protection for our seniors and caregivers.”
He adds, “Thousands of people could have been saved if we could have made this manifest throughout Connecticut. Think of how proud we would have been if we were the only state that had done this and really protected its seniors. It would be a mark of distinction across the country and maybe would have inspired other people to try something similar.”
At the time he wrote that first op-ed for the Courant in early April, Connecticut only had 335 confirmed COVID-19 deaths and just 36 of Connecticut’s 216 nursing homes had residents with COVID-19. Thousands more fatalities, a majority of them residents at senior-care facilities, were on the way.
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In early June, Lamont ordered an outside review of how the pandemic had been handled by the state's nursing homes and assisted-living facilities. “There is a chance there could be a second surge and we want to be ready,” Lamont said during a press conference announcing the plan.
Whatever change the report suggests, creating new bubbles is unlikely to be one of the solutions.
Dr. Patrick Coll, of the UConn Center on Aging and UConn Health’s medical director of senior health, says that Belanger’s bubble strategy made sense when he did it. “It was clear that staff were at risk for bringing the virus into the facility, and if you go back to March and April and early May, we weren’t testing staff,” he says. But now, Coll says senior facilities are conducting regular testing for both staff and residents. At the Seabury Retirement Community in Bloomfield where Coll is the medical director, they are testing all staff on a weekly basis.
In general, Coll says there is a silver lining to the tragedy that occurred within these facilities. “Be it good or bad, nursing homes have gotten a lot of attention over the past several months, and hopefully that can be leveraged."
Lisa Freeman, executive director of the Connecticut Center for Patient Safety, agrees that COVID's spread through senior homes has highlighted the need for more attention for this aspect of health care. “Way too many people died from the virus and probably shouldn’t have,” she says. “While this was one particularly aggressive virus, infections are prevalent in nursing homes, even though they may not be as visible or as devastating.”
She adds, “we’ve learned from this disaster,” but it’s clear that “we’re not putting enough money into our elderly care. The reward for having survived a long life isn’t what it should be, and that to me is the tragedy of this, the sadness of this.”
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Shady Oaks was not the only long-term care facility in the state untouched by the scourge of COVID. In June, a Connecticut Health Investigative team found that 41 out of Connecticut’s 214 nursing homes had remained COVID free throughout the surge. But the administrators of these homes could not account for why, and it’s likely luck played a role in this outcome for many of them.
Belanger does not believe his facility would have been so lucky. In Bristol, four of five nursing homes had COVID outbreaks with more than 250 infections and 60 deaths. While he was in the bubble, Belanger learned of six staff members who would have been exposed to the virus through family members or other job commitments had they been commuting to and from Shady Oaks.
That didn’t mean things inside the bubble were easy. Staff worked long hours and at times dealt with depression and loneliness, but they bonded with each other and the residents. “We became their family and they became our family,” says Brouker, the nurse. Like people dealing with the challenges of the shutdown everywhere, they found creative ways to stay connected safely. Her husband would make dinner and drop off a portion for her, then park across the parking lot from the RV where she lived. She’d grab the food and talk with him on the phone as they ate the same meal at the same time.
And the bubble wasn’t a prison or an impenetrable fortress. People both left it and were introduced into it with precautions. One employee left to attend a funeral and was reintroduced with a combination of quarantining and testing. A resident was brought home from a rehab facility and was introduced into the bubble the same way.
The bubble had been scheduled to end in early May, but Belanger was still worried there wasn’t enough testing available at that point to open safely, so he asked residents to stay until the end of May, by which point all the bubble guardians had left and resumed commuting to work.
In the future, even if there is a spike of cases in the state, Belanger does not expect to have to re-enter the bubble. He plans on protecting against COVID with weekly testing and by requiring his staff to wear personal protective equipment. He has since been able to purchase facemasks and other protective gear in sufficient quantity to feel comfortable. If a resident tests positive, they will be quickly isolated and moved to another facility to receive care. None of these methods are perfect, but they follow a concept in risk reduction he learned at Harvard called layering.
In June this new system was put to the test when a staff member at Shady Oaks tested positive for COVID-19. She was asymptomatic and began self-quarantining as soon as she learned she had COVID, and it did not spread to the facility. “We’ve had four rounds of tests since then. All residents and other staff have been negative. We believe our frequent testing helped us catch the danger early,” Belanger says. “We also believe that our use of KN-95 respirators saved the staff member from transmitting the disease for the days she worked positive and did not yet know it. We see from the updated Connecticut reporting on nursing homes and assisted livings that this is a common event throughout the state. Staff members catch COVID, work in homes, but tests catch it early.” He adds, “the danger of COVID is still here and real. Testing and KN-95s really help.”
Though it seems unlikely to be necessary, Belanger will consider entering a new bubble if these other strategies prove ineffective. He believes others should be equally open to the option. “I just want this on the stockpile of tools, the stockpile of approaches when someone has a COVID surge,” he says.
He keeps thinking about residents who died at other facilities throughout Connecticut and beyond. Many of them were veterans of World War II and those who served on the home front in factories. They lived through so much only to die alone and confused and in almost total isolation. Belanger also thinks about the staff who bravely tended to those patients in such horrific conditions, and who, in some cases, made the ultimate sacrifice.
And he knows that if he hadn’t done what he did in March, he likely would have regretted it for the rest of his life. “It was a massive undertaking, but it was a question of what way I want to live the rest of my life? Do I want to look back at this time and realize that we lost 25, 30, 40 percent of our residents to this awful disease? That’s the way it has cut through some of the homes. I’d so much rather spend money and do the human solution rather than just muddle through. And the human solution was, as long as we’re here, we’re going to be safe.”
He adds, “Beyond all that it comes back to this deep, heartfelt question, do you care enough to do the right thing? And to me, the right thing is to do everything you possibly can to protect your residents.”