This report reviews relevant national and state studies of how coronavirus has spread through nursing homes, and recommends practical strategies to reduce infection rates and deaths. It also details policy recommendations for state and federal officials, health insurance plans, public health agencies, and other local medical facilities, all of whom play vital roles in preparing for and responding to such crises. Residents in U.S. nursing homes account for approximately 40 percent of all COVID-19 related deaths, even as they account for less than one percent of the entire population. The U.S. faces a COVID-19 pandemic now, and will undoubtedly face other infectious disease outbreaks in the future, including annual bouts with influenza. This makes lasting reform urgent.
Traditional nursing homes usually have two residents per room, high staff turnover, and multiple staff who rotate in and out of more than one facility. Such workers in many cases receive no health insurance or paid sick leave. With those dynamics, nursing homes often have chronic infection control deficiencies and staff shortages. Many of the solutions and recommendations outlined here are in fact long overdue.
The Research Speaks: Factors Affecting COVID-19 Resident Cases and Deaths
Available evidence about the factors affecting facility resident cases and deaths varies at the national and state levels, but two major national studies provide relevant data. The Abrams et al (2020) study of 30 states found a statistically significant relationship between a higher percentage of Black residents and facilities having at least one COVID-19 case—a finding highlighting the systemic inequities that have emerged. Among other findings, it also concludes that when a facility had at least one case, the size of the COVID-19 outbreak had a statistically significant relationship to increased facility size, and for-profit status. While this study did not address nurse staffing levels, another study, McGarry et al (2020), did and showed that about 20 percent of nursing homes reported shortages of staff or severe shortages of PPE (personal protective equipment). Taking both studies together, it appears that:
- Large nursing homes, with a high proportion of Black residents, were most likely to have at least one case. Outbreak size in these nursing homes was related to facility size and being for-profit.
- Nursing homes with shortages of staff and PPE were more likely to experience COVID-19 cases. Nursing homes with these shortages were also more likely to have low quality scores and more residents on Medicaid.
By November 2020, two states, Connecticut and New Jersey, had completed comprehensive studies of the COVID-19 pandemic’s effects on nursing home residents, and came to differing conclusions about the causes of their high cases and death rates among residents. Other states, such as Michigan and New York, have conducted studies that focus on individual aspects of the pandemic’s effects on residents. Other states’ reports, such as those for Arizona, Colorado, and Virginia, have focused on specific aspects of how to deal with the pandemic.
A report on Connecticut points to facility-specific factors predicting rates of infection in long term care facilities, including nursing staff ratios, wider community rates, residents receiving certain off-site medical treatments, size and occupancy rates. The report’s recommendations cluster around major themes, including (1) more person-centered care, (2) improved infection control systems and procedures, (3) higher requirements for staffing levels than Connecticut currently has, (4) improved state agency response and coordination with LTSS providers, (5) improved facility procedures, and (6) increased payment rates to nursing homes to cover the cost of certain quality improvements.
New Jersey Study
A May assessment in New Jersey did “not observe any strong or reliable patterns” between nursing home COVID-19 cases/deaths and a range of the potential facility-related factors: size and ownership status, quality star ratings, deficiencies during quality surveys, or staff levels. Instead, it found that the intensity of COVID-19 cases in New Jersey is related to rates in nursing homes’ surrounding communities. The report’s recommendations focused on (1) strengthening emergency responses, (2) stabilizing facilities, (3) requiring minimum nursing staff ratios that align with the needs of nursing home residents (4) prohibiting professional administrative staff from counting toward these ratios, (5) increasing reporting and accountability, and (6) building a better LTSS system.
Recommendations for Quality Improvement
In a detailed final section on solutions, this report recommends that policymakers, health plans, and providers consider changes in care for facility residents and in the structure of nursing homes, better staffing patterns and quality assurance, and aligning payment with accountability for quality of care and quality of life. Read about those recommendations in the full report.