BACKGROUND/OBJECTIVES
Nursing homes have experienced a disproportionate share of COVID‐19 cases and deaths. Early analyses indicated that baseline quality was not predictive of nursing home cases, ...but a more nuanced study of the role of nurse staffing is needed to target resources and better respond to future outbreaks. We sought to understand whether baseline nurse staffing is associated with the presence of COVID‐19 in nursing homes and whether staffing impacts outbreak severity.
DESIGN
We analyzed Centers for Medicare & Medicaid Services (CMS) facility‐level data on COVID‐19 cases and deaths merged with nursing home and county characteristics. We used logistic regressions to examine the associations of staffing levels from Nursing Home Compare with the outcomes of any COVID‐19 cases and, conditional on at least one case, an outbreak. Among facilities with at least one case, we modeled count of deaths using hurdle negative binomial‐2 regressions.
SETTING
All nursing homes in the CMS COVID‐19 Nursing Home Dataset with reports that passed the CMS Quality Assurance Check as of June 25, 2020.
PARTICIPANTS
Residents of nursing homes that met COVID‐19 reporting requirements.
MEASUREMENTS
A nursing home is defined as having at least one case is if one or more confirmed or suspected COVID‐19 case among residents or staff is reported. Conditional on at least one case, we examine two outcomes: an outbreak, defined as confirmed cases/certified beds >10% or total confirmed and suspected cases/beds >20% or >10 deaths, and the total number of deaths attributed to COVID‐19 among residents and staff.
RESULTS
A total of 71% of the 13,167 nursing homes that reported COVID‐19 data as of June 14 had at least one case among residents and/or staff. Of those, 27% experienced an outbreak. Higher registered nurse‐hours are associated with a higher probability of experiencing any cases. However, among facilities with at least one case, higher nurse aide (NA) hours and total nursing hours are associated with a lower probability of experiencing an outbreak and with fewer deaths. The strongest predictor of cases and outbreaks in nursing homes is per capita cases in the county.
CONCLUSION
The prevalence of COVID‐19 in the community remains the strongest predictor of COVID‐19 cases and deaths in nursing homes, but higher NA hours and total nursing hours may help contain the number of cases and deaths.
Background/Objectives
The coronavirus disease 2019 (COVID‐19) pandemic has taken a disproportionate toll on long‐term care facility residents and staff. Our objective was to review the empirical ...evidence on facility characteristics associated with COVID‐19 cases and deaths.
Design
Systematic review.
Setting
Long‐term care facilities (nursing homes and assisted living communities).
Participants
Thirty‐six empirical studies of factors associated with COVID‐19 cases and deaths in long‐term care facilities published between January 1, 2020 and June 15, 2021.
Measurements
Outcomes included the probability of at least one case or death (or other defined threshold); numbers of cases and deaths, measured variably.
Results
Larger, more rigorous studies were fairly consistent in their assessment of risk factors for COVID‐19 outcomes in long‐term care facilities. Larger bed size and location in an area with high COVID‐19 prevalence were the strongest and most consistent predictors of facilities having more COVID‐19 cases and deaths. Outcomes varied by facility racial composition, differences that were partially explained by facility size and community COVID‐19 prevalence. More staff members were associated with a higher probability of any outbreak; however, in facilities with known cases, higher staffing was associated with fewer deaths. Other characteristics, such as Nursing Home Compare 5‐star ratings, ownership, and prior infection control citations, did not have consistent associations with COVID‐19 outcomes.
Conclusion
Given the importance of community COVID‐19 prevalence and facility size, studies that failed to control for these factors were likely confounded. Better control of community COVID‐19 spread would have been critical for mitigating much of the morbidity and mortality long‐term care residents and staff experienced during the pandemic. Traditional quality measures such as Nursing Home Compare 5‐Star ratings and past deficiencies were not consistent indicators of pandemic preparedness, likely because COVID‐19 presented a novel problem requiring extensive adaptation by both long‐term care providers and policymakers.
IMPORTANCE: Use of postacute care is common and costly in the United States, but there is significant uncertainty about whether the choice of postacute care setting matters. Understanding these ...tradeoffs is particularly important as new alternative payment models push patients toward lower-cost settings for care. OBJECTIVE: To investigate the association of patient outcomes and Medicare costs of discharge to home with home health care vs discharge to a skilled nursing facility. DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study used Medicare claims data from short-term acute-care hospitals in the United States and skilled nursing facility and home health assessment data from January 1, 2010, to December 31, 2016, on Medicare beneficiaries who were discharged from the hospital to home with home health care or to a skilled nursing facility. To address the endogeneity of treatment choice, an instrumental variables approach used the differential distance between the beneficiary’s home zip code and the closest home health agency and the closest skilled nursing facility as an instrument. EXPOSURES: Receipt of postacute care at home vs in a skilled nursing facility. MAIN OUTCOMES AND MEASURES: Readmission within 30 days of hospital discharge, death within 30 days of hospital discharge, improvement in functional status during the postacute care episode, and Medicare payment for postacute care and total payment for the 60-day episode. RESULTS: A total of 17 235 854 hospitalizations (62.2% women and 37.8% men; mean SD age, 80.5 7.9 years) were discharged either to home with home health care (38.8%) or to a skilled nursing facility (61.2%) during the study period. Discharge to home was associated with a 5.6-percentage point higher rate of readmission at 30 days compared with discharge to a skilled nursing facility (95% CI, 0.8-10.3; P = .02). There were no significant differences in 30-day mortality rates (−2.0 percentage points; 95% CI, 0.8-10.3; P = .12) or improved functional status (−1.9 percentage points; 95% CI, –12.0 to 8.2; P = .71). Medicare payment for postacute care was significantly lower for those discharged to home compared with those discharged to a skilled nursing facility (−$5384; 95% CI, –$6932 to –$3837; P < .001), as was total Medicare payment within the first 60 days after admission (−$4514; 95% CI, –$6932 to –$3837; P < .001). CONCLUSIONS AND RELEVANCE: Among Medicare beneficiaries eligible for postacute care at home or in a skilled nursing facility, discharge to home with home health care was associated with higher rates of readmission, no detectable differences in mortality or functional outcomes, and lower Medicare payments.
Approximately 40% of all COVID-19 deaths in the United States have been linked to long-term care facilities.1 Early in the pandemic, as the scope of the problem became apparent, the nursing home ...sector generated significant media attention and public alarm. A New York Times article in mid-April referred to nursing homes as "death pits"2 because of the seemingly uncontrollable spread of the virus through these facilities. This devastation continued during subsequent surges,3 but there is a role for policy to change this trajectory. The circumstances that led to this tragedy, often referred to as a "perfect storm,"4 started with the attributes of the novel coronavirus itself. The coronavirus that causes COVID-19 is airborne, can be spread asymptomatically, and is particularly risky for older adults with underlying health conditions. It is therefore no surprise that nursing home residents, who fit that risk profile almost by definition, are at high risk for serious complications from COVID-19. Rapid spread of the virus is difficult to control owing to features of the nursing home setting. Nursing homes house, in close quarters, large numbers of residents needing hours of hands-on care on a daily basis. Rooms are often shared by two or more residents. The congregate nature of the setting combined with the need for care make social isolation impossible. Finally, asymptomatic spread means that residents and staffcan cause an outbreak without knowing it. This was especially lethal early in the pandemic, when there was less known about asymptomatic transmission.
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Werner and Konetzka explored the trends in the use of post-acute care , hospital and post-acute care among Medicare beneficiaries from 2000 to 2015. They used multivariable regression to predict ...risk-adjusted annual outcomes adjusted for age, sex, race and 31 Elixhauser comorbidities. The use of institutional post-acute care increased between 2000 to 2015 and was accompanied by increasing length of post-acute care stays through 2014. The trends did not seem to change when payment reform was implemented under the Affordable Care Act. It remains uncertain whether the use of post-acute care benefits patients as there is little evidence.
Approximately two decades ago, federally mandated public reporting began for U.S. nursing homes through a system now known as Nursing Home Compare. The goals were to provide information to enable ...consumers to choose higher quality nursing homes and to incent providers to improve the quality of care delivered. We conduct a systematic review of the literature on responses to Nursing Home Compare and its effectiveness in meeting these goals. We find evidence of modest but meaningful response by both consumers and providers. However, we also find evidence that some improvement in scores does not reflect true quality improvement, that disparities by race and income have increased, that risk-adjustment of the measures is likely inadequate, and that several key domains of quality are not represented. Our results support moderate success of Nursing Home Compare in achieving intended goals but also reveal the need for continued refinement.
IMPORTANCE: It is important to understand differences in coronavirus disease 2019 (COVID-19) deaths by nursing home racial composition and the potential reasons for these differences so that limited ...resources can be distributed equitably. OBJECTIVE: To describe differences in the number of COVID-19 deaths by nursing home racial composition and examine the factors associated with these differences. DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study of 13 312 nursing homes in the US used the Nursing Home COVID-19 Public File from the Centers for Medicare and Medicaid Services, which contains COVID-19 cases and deaths among nursing home residents as self-reported by nursing homes beginning between January 1, 2020, and May 24, 2020, and ending on September 13, 2020. Data were analyzed from July 28 to December 18, 2020. EXPOSURES: Confirmed or suspected COVID-19 infection. Confirmed cases were defined as COVID-19 infection confirmed by a diagnostic laboratory test. Suspected cases were defined as signs and/or symptoms of COVID-19 infection or patient-specific transmission-based precautions for COVID-19 infection. MAIN OUTCOMES AND MEASURES: Deaths associated with COVID-19 among nursing home residents. Death counts were compared by nursing home racial composition, which was measured as the proportion of White residents. RESULTS: Among 13 312 nursing homes included in the study, the overall mean (SD) age of residents was 79.5 (6.7) years. A total of 51 606 COVID-19–associated deaths among residents were reported, with a mean (SD) of 3.9 (8.0) deaths per facility. The mean (SD) number of deaths in nursing homes with the lowest proportion of White residents (quintile 1) vs nursing homes with the highest proportions of White residents (quintile 5) were 5.6 (9.2) and 1.7 (4.8), respectively. Facilities in quintile 1 experienced a mean (SE) of 3.9 (0.2) more deaths than those in quintile 5, representing a 3.3-fold higher number of deaths in quintile 1 compared with quintile 5. Adjustment for the number of certified beds reduced the mean (SE) difference between these 2 nursing home groups to 2.2 (0.2) deaths. Controlling for case mix measures and other nursing home characteristics did not modify this association. Adjustment for county-level COVID-19 prevalence further reduced the mean (SE) difference to 1.0 (0.2) death. CONCLUSIONS AND RELEVANCE: In this study, nursing homes with the highest proportions of non-White residents experienced COVID-19 death counts that were 3.3-fold higher than those of facilities with the highest proportions of White residents. These differences were associated with factors such as larger nursing home size and higher infection burden in counties in which nursing homes with high proportions of non-White residents were located. Focusing limited available resources on facilities with high proportions of non-White residents is needed to support nursing homes during potential future outbreaks.
Nursing home residents are vulnerable to disproportionate harm during disasters and health emergencies, as evidenced by the recent impact of COVID-19 and extreme weather events. Evaluation of these ...disasters shows that the nursing homes in question were often in compliance with relevant regulations around emergency planning. However, advance planning for disasters cannot anticipate every contingency, leading to the need for flexibility and quick adaptation on the part of nursing home leaders. In addition, disasters often involve larger, regional problems and situations that individual providers cannot solve. We suggest that policy makers need to prioritize development and expectations around leadership skills in nursing home management and better integrate the long-term care sector into local, state, and federal public health planning for future pandemics and other disasters.
Objective
To estimate and contrast the relationships between nurse staffing and health outcomes in nursing homes with low and high dementia census, to understand the association of staffing hours ...with dementia care quality.
Data Sources and Study Setting
A national sample of nursing homes during 2017–2019 (pre‐COVID). Data included the Payroll‐Based Journal, Medicare Claims, Nursing Home Care Compare, and Long‐Term Care Focus.
Study Design
Retrospective, regression analyses. We estimated separate linear models predicting six long‐term facility‐level outcomes. Independent variables included staffing hours per resident‐day (HPRD) interacted with the facility percentage of dementia residents, controlling for other resident and facility characteristics.
Data Collection/Extraction Methods
Hospital‐based nursing homes, those with fewer than 30% dementia residents, and missing data were excluded.
Principal Findings
We found that registered nurses and certified nurse assistants HPRDs were likely to exhibit positive returns in terms of outcomes throughout most of the range of HPRD for both high and low‐census dementia facilities, although, high‐ and low‐dementia facilities differed in most outcome rates at all staffing levels. Average predicted antipsychotics and activities of daily living as functions of HPRD were worse in higher dementia facilities, independent movement, and hospitalizations did not differ significantly, and Emergency Rooms and pressure sores were worse in lower dementia facilities. Average marginal effects were not statistically different CI included zero between the high and low dementia facilities for any outcome.
Conclusions
These findings suggest that increasing staffing will improve outcomes by similar increments in both low‐ and high‐dementia facilities for all outcomes. However, at any given level of staffing, absolute differences in outcomes between low‐ and high‐dementia facilities remain, suggesting that additional staffing alone will not suffice to close these gaps. Further studies are required to identify opportunities for improvement in performance for both low‐ and high‐dementia census facilities.
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