Long-term care operators located in areas of high COVID-19 prevalence are hamstrung when it comes to keeping SARS-CoV-2 infections from infiltrating their facilities, the country’s top long-term care researchers contend after an exhaustive review of pandemic studies.

Image of Tamara Konetzka, Ph.D., of the University of Chicago
Tamara Konetzka, Ph.D., of the University of Chicago

Better control of community COVID-19 spread would have mitigated much of the morbidity and mortality experienced by nursing home facilities and assisted living communities during the pandemic, they concluded in a new study published today in the Journal of the American Geriatrics Society.

“Long-term care facilities must be recognized as integral components of the health care system and prioritized for assistance and resources as needed,” the research team wrote. “Despite the need for long-term care providers to improve, our review revealed little that providers could have done to prevent an outbreak when in a hotspot.”

The authors include industry experts R. Tamara Konetzka, Ph.D. of the University of Chicago; Elizabeth M. White APRN, Ph.D.; Vincent Mor, Ph.D. and Alexander Pralea of Brown University; and David Grabowski, Ph.D., of Harvard Medical School. 

Their review — a search for verifiable evidence on the facility characteristics tied to COVID-19 cases and deaths — considered the results of 36 studies published between Jan. 1, 2020, and June 15, 2021. The goal was to fill a critical knowledge gap in what influences a facility’s success in preventing and controlling COVID-19 outbreaks.

The data consistently showed that nursing homes and assisted living facilities with a larger number of beds located in areas of high COVID-19 prevalence tended to have the most COVID-19 cases and deaths.

Outcomes also varied by facility racial composition, but these differences were explained in part by facility size and community COVID-19 prevalence, the researchers noted.

There was a notable blip in the findings that suggested the influence of effective facility staffing. Although facilities with higher nurse staff counts were more likely to experience outbreaks, higher nurse staffing levels were linked to fewer deaths in facilities and lower case counts once outbreaks occurred.

Facility ownership was not consistently linked to COVID-19 outcomes, a departure from past research findings. Nor were Nursing Home Compare Five-Star Quality Ratings and infection control citation measures, the authors added. These traditional quality measurements do not consistently indicate pandemic preparedness because they were not designed to address the new pandemic challenges, and would require extensive adaptation to do so, Konetzka and colleagues concluded.

“If we let the virus rage … “

The results present a more complete understanding of COVID-19 in nursing homes, building on that of early pandemic studies. Two major studies released last year also implicated facility size and location in resident cases and deaths.

Today’s findings remained consistent across all studies reviewed, and highlight the infection control challenges nursing home operators and clinicians continue to face, the researchers wrote.

“These results tell us that it is exceedingly difficult to protect nursing home residents if we let the virus rage in the surrounding community,” Konetzka said in a statement accompanying the study’s release.

Misguided policies

The authors ding policymakers for missing early opportunities to help reduce community spread, and for not prioritizing the highest-risk long-term care facilities for personal protective equipment distribution, early testing to identify outbreaks and staffing reserve assistance. 

The Centers for Medicare & Medicaid Services mistakenly has pushed punitive policies based on the assumption that long-term care facilities could control outbreaks independent of community prevalence, Konetzka and colleagues wrote.

“Our review suggests that such policies were misguided, given that the strongest predictor of COVID-19 outcomes was facility location,” they argue. “Anecdotal and qualitative evidence suggests that such policies may have had the inadvertent effects of diverting critical resources away from facilities most in need.”

Administrators have since been shouldered with undue administrative and regulatory burdens when their focus needed to be on crisis management, they added.

New approaches needed

Future efforts to control spread to and within long-term care facilities require new solutions from both long-term care providers and policymakers, the researchers concluded. 

The findings don’t exonerate long-term care operators from concerns about infection control and care quality. But “the overwhelming importance of community COVID-19 prevalence in predicting long-term care cases and deaths suggests that mitigation policies should not solely focus on facility actions,” Konetzka and colleagues wrote. 

The evidence presents a widespread and unique challenge, especially in the face of inadequate supply chains for PPE and rapid testing, they suggested.

“The fate of residents and staff of long-term care facilities is inextricably linked to the fate of the communities in which they are located. Policies to address future crises need to recognize these linkages and provide a more integrated response,” the authors concluded.

In related news:

BREAKING: 16,000 COVID deaths missed in nursing homes

Nursing home COVID cases rise four-fold in surge states, resident deaths double, data shows

Race and location — not star ratings — tied to COVID-19 deaths, say investigators

Data on COVID-19 in nursing homes is key to stopping spread; race a factor in facility outbreaks: expert

McKnight’s Senior Living COVID-19 coverage

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