Nursing Facilities and Covid-19 – It’s Not Inevitable

The nursing home industry claims that outbreaks of COVID-19 in nursing facilities are largely the result of geography and that once coronavirus gets into a building, it inevitably spreads throughout the facility.  Increasing evidence documents that the industry is wrong on both counts.

In a Message to his members, the American Health Care Association’s President and CEO Mark Parkinson wrote in June, in an explanation of How Did We Get Here?:

It wasn’t a matter of bad operators getting COVID-19 and good operators not getting it. The facts indicate that your Five-Star rating, profit vs. not for profit status, or prior deficiency history are not predictors of whether COVID-19 gets in your buildings. The most important factor in determining whether COVID-19 ends up in a building is the surrounding community of where the building is located. If you are located in New York, you likely ended up with COVID-19 in your building. If you are located in the rural Midwest, you are less likely to have COVID-19 in your building.  It depends on the outbreak in the surrounding community, which impacts the number of carriers without symptoms.[1]

Geography is not the sole determinant of COVID-19.  Facilities providing higher quality of care are less likely to experience COVID-19 outbreaks.  An analysis of West Virginia nursing facilities by the Centers for Disease Control and Prevention (CDC) finds that “the odds of a COVID-19 outbreak were 87% lower among 2- to 3-star-rated facilities and 94% lower among 4- to 5-star-rated facilities.”[2] 

Individual nursing facilities also give lie to the “geography is destiny” myth.  An article in the Washington Post describes the Maryland Baptist Aged Home, the oldest black-owned nursing facility in the state serving primarily low-income Black and Latinx adults.  As of the July 24 article, the Baltimore facility had remained entirely COVID-free during the pandemic, even as 338 people in its zip code, and more than 13,000 residents and staff in Maryland, had been infected.[3]  The Maryland Baptist Aged Home, with 29 residents, has had a full-time infection control nurse on staff for 10 years and has not been cited with an infection control deficiency in four years.

Similarly, containment of COVID-19 is more successful in some facilities than in others.  As the Center for Medicare Advocacy reported in August,[4] multiple studies find that nursing facilities with higher nurse staffing levels are more successful in containing COVID-19 than facilities with lower staffing levels.  For example, an analysis of all 215 Connecticut nursing facilities with confirmed COVID-19 cases and deaths as of April 16, 2020 finds that every 20 minutes per resident day of increased staffing by registered nurses was associated with 22% fewer confirmed cases of COVID-19 and 26% fewer COVID-19 deaths.[5]

An analysis of nursing facilities in New York State also found that, compared to facilities without labor unions, facilities with unions had a 30% lower mortality rate from COVID-19 and a 42% “relative decrease in COVID-19 infection rates” among residents.[6]  Facilities with unions were located in counties with higher rates of COVID-19 than facilities without unions, countering the industry argument that zip code determines COVID-19 infection rates.

Conclusion

The Center for Medicare Advocacy does not contend that the location of a facility has absolutely no effect on COVID-19 infection rates in nursing facilities.  However, it is not the sole factor.  While the Kaiser Family Foundation reported in July that hotspots of COVID-19 witnessed an increased in COVID-19 in their nursing facilities, its data actually showed that the increase in COVID-19 in facilities was considerably lower than the COVID-19 increase in the state.[7]  In Florida, for example, COVID-19 increased by 96% in the state between June 24 and July 9, but COVID-19 increased by 51% in nursing facilities for the same 10-day period.  In the other hotspot state, Texas, COVID-19 increased by 89% in the state and by 47% in nursing facilities during the same period.[8] 

We cannot allow to go unchecked the nursing home industry’s argument that COVID-19 in the community always means COVID-19 in facilities and that facilities are without responsibility for containing the virus. High staffing levels, good infection control practices, and sufficient testing and personal protective equipment are all critical factors determining whether COVID-19 gets into nursing facilities and whether it spreads.

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[1] American Health Care Association, “We Won’t Back Down” (Jun. 2020), https://files.constantcontact.com/64f0b60b701/f86b03a3-a859-4098-b6d0-3866c56672d5.pdf, discussed in “American Health Care Association’s CEO Issues Message to Members: ‘We Won’t Back Down,’” (CMA Alert, Jul. 16, 2020), https://medicareadvocacy.org/american-health-care-associations-ceo-issues-message-to-members-we-wont-back-down/. Parkinson cited David Grabowski, Professor of Health Policy, Harvard Medical School, as a key researcher finding that COVID-19 is a function of geography.  At a presentation on October 6, 2020 at a webinar sponsored by the Alliance for Health Care Reform, Professor Grabowski reiterated the claim that geography is key.  Addressing which nursing homes have COVID, he said “Where you are, not who you are.”  Later, in response to a question, he acknowledged that the number of staff can be a way to prevent a huge outbreak. 
[2] David P. Bui, et al, “Association Between CMS Quality Ratings and COVID-19 Outbreaks in Nursing Homes – West Virginia, March 17-June 11, 2020,” CDC Morbidity and Mortality Report (Sep. 18, 2020), MMWR Morb Mortal Wkly Rep 2020; 69:1300-1304, https://www.cdc.gov/mmwr/volumes/69/wr/pdfs/mm6937a5-H.pdf.
[3] Rebecca Tan, “In Baltimore, a struggling, black-owned nursing home keeps covid-19 at bay,” Washington Post (Jul. 24, 2020), https://www.washingtonpost.com/local/baltimore-nursing-home-covid-free/2020/07/23/31bddade-c78a-11ea-b037-f9711f89ee46_story.html.
[4] See CMA, “Studies Find Higher Nurse Staffing Levels in Nursing Facilities Are Correlated With Better Containment of COVID-19” (CMA Alert, Aug. , 2020).
[5] Yue Li, H Temkin-Greener, S Gao, X. Cai, “COVID-19 infections and deaths among Connecticut nursing home residents: facility correlates,” Journal of American Geriatrics Society (2020), https://onlinelibrary.wiley.com/doi/epdf/10.1111/jgs.16689.
[6] Adam Dean, Atheendar Verkataramani, and Simeon Kimmel, “Mortality Rates From COVID-19 Are Lower In Unionized Nursing Homes,” Health Affairs (published Sep. 10, 2020), https://www.healthaffairs.org/doi/10.1377/hlthaff.2020.01011, discussed in CMA, “Study Finds Lower Mortality Rates in Unionized New York State Nursing Facilities” (CMA Alert, Sep. 17, 2020), https://medicareadvocacy.org/study-finds-lower-mortality-rates-in-unionized-new-york-state-nursing-facilities/.  
[7] Priya Chidambaram, “Rising Cases in Long-term Care Facilities Are Cause for Concern,” Kaiser Family Foundation Data Note (Jul. 21, 2020), https://www.kff.org/coronavirus-covid-19/issue-brief/rising-cases-in-long-term-care-facilities-are-cause-for-concern/.
[8] Id. Table 1.