Understanding the factors that have contributed to high penetration rates of COVID-19 in select nursing homes is essential to the development of strategies and policies that will help prevent and mitigate future disease outbreaks. Recently published studies from academics at Brown University, Harvard University, and the University of Chicago have suggested that there are a few key characteristics that can be associated with higher penetration rates of COVID-19 in U.S. nursing homes. Some of the identified factors are to be expected, but certain factors that did not have a significant bearing on COVID-19 cases may be surprising.
First, let’s look at the factors that were found to contribute to an increased likelihood of a nursing home having a documented COVID-19 case.
Facility Size and Location
David Grabowski, PhD, a professor of health care policy at Harvard Medical School, and colleagues conducted an analysis of 9,395 nursing homes to examine the association between certain characteristics and the likelihood of having a documented COVID-19 case. Larger facility size and urban location were both significantly related to increased probability of having a COVID-19 case.
With regard to facility size, the study found that while smaller facilities are less likely to have outbreaks, the outbreaks at small facilities affect more patients per bed. This is likely reflective of a number of characteristics of smaller facilities, such as higher patient turnover and the possibility that isolating COVID-positive residents is more difficult for smaller facilities.
Speaking on his own research, Dr. Vincent Mor, a Brown University School of Public Health professor, reported “the spread is affected more by the facility size and community prevalence due to the virus’ characteristics. Simply put, nursing facilities faced a perfect storm of an opportunistic virus, a vulnerable population base, resources shortages born of years of underfunding, and current policies that favored an acute care focus over all other care settings.”
Non-Chain Status
Skilled nursing properties that are part of a larger chain are more integrated and therefore more likely to have the resources to allow a quicker and more systematic response across their nursing homes. This includes access to resident and staff testing and access to PPE. Nursing home chains are also more likely to have a Chief Medical Officer, who can provide guidance to facilities on best practices for infection control.
Percentage of African American Residents
In early May of this year, evidence began circulating that African Americans were disproportionately being affected by COVID-19, compared with whites and other ethnic groups. This was also evident in seniors housing properties, with studies showing that the likelihood of having a COVID-19 outbreak in seniors housing and skilled nursing properties is correlated with the proportion of African Americans residing in the property.
Nursing homes are more likely to draw upon and employ staff from the neighborhoods in which they are located. This is also the case for the residents/patients in those properties. Hence, nursing homes often reflect the demographic characteristics of the neighborhood in which they are located. As people in predominantly non-white neighborhoods are most affected by the pandemic, these factors are also putting nursing homes in these areas at the most risk.
Tamara Konetzka, PhD, a health economics and health services research professor with the University of Chicago, presented her team’s findings to the Senate Select Committee on Aging on May 21, 2020. The first key result “found a strong and consistent relationship between race and the probability of COVID-19 cases and deaths. Nursing homes with the lowest percent white residents were more than twice as likely to have COVID-19 cases or deaths as those with the highest percent white residents.”
The study’s findings confirm that the patterns of COVID-19 infections and deaths in nursing homes are consistent with wider racial and socioeconomic disparities. Nursing homes serving traditionally underserved populations are bearing the worst outcomes of the pandemic.
Five-Star Rating Not Significantly Related
Given the asymptomatic spread of the virus, inadequate testing, and the fact that nursing homes cater to both post-acute, rehabilitative patients as well as highly vulnerable high-acuity patients in need of long-term care, it may seem inevitable that many of these congregate setting communities would become infected with the virus. In addition, there have been challenges with acquiring the appropriate amount of personal protection equipment, which has made it that much more difficult to keep patients safe. It may seem likely, therefore, that lower quality ratings should result in higher infection rates. Traditional quality metrics, however, such as the Centers for Medicare and Medicaid Services (CMS) five-star rating system, have been shown not to be a reliable predictor of COVID-19 infection rates.
This finding prompted some pushback from CMS, however, which argued that “facilities that had a one-star quality rating were more likely to have large numbers of COVID-19 cases than facilities with a five-star quality rating.” While CMS is correct in their assertion, Konetzka’s findings indicate that variations in COVID-19 infection and mortality rates do not correlate to star-rating alone. CMS’ position falls short of a full explanation.
Further, both the direction and strength of the relationship between star ratings and COVID-19 cases across and within states is inconsistent. Konetzka notes, “In some states, such as Illinois, nursing homes with higher quality ratings (four or five stars) were marginally less likely to have a case of COVID-19, but in other states, such as New Jersey, higher quality homes were marginally more likely to experience a case.”
Relationship between Nursing Home Quality and COVID-19 Cases and Deaths
Ownership Structure Not a Factor
Lastly, Konetzka’s study looked for meaningful differences based on for-profit or not-for-profit status. The findings indicated that there was the same probability – 36% – of a for-profit nursing home and a not-for-profit nursing home having a COVID-19 case in their respective community.
The bottom line is that standard quality measures alone are not enough to distinguish which nursing homes have higher propensity for COVID-19 cases and deaths. Instead, early research indicates that factors such as location, which can reflect community vulnerabilities, facility size, and access to testing and personal protective equipment are more likely to have an impact.
The enormity of this pandemic, coupled with the intrinsic susceptibility of the nursing home setting and population, means that even the highest-quality nursing homes are not impervious to the virus.
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