Over the next few weeks, we will look at the challenges currently facing long-term care facilities and identify solutions to improve quality of care. This blog will take a closer look at how the COVID-19 crisis amplified the challenges to delivering long-term care.
For those who have followed the harrowing stories of COVID-19’s impact in nursing homes, news reports over the past couple of months have taken a dramatic turn for the better. Cases and deaths are down, vaccines are widely available for residents and staff, and pandemic-related visitor restrictions are slowly lifting, particularly in communities where case rates are low.
We hope these trends mark the beginning of a permanent turnaround from 2020, when people living and working in nursing homes were disproportionately affected by COVID-19. As of November 2020, deaths in long-term care facilities, including nursing homes, accounted for 40 percent of all deaths nationwide, with rates reaching 70 percent in several states. Close living quarters put residents at higher risk of infection, and the vulnerability of older residents with chronic health conditions put them at a higher risk of death. Shortages of personal protective equipment were also at fault, especially in the earliest stage of the pandemic.
But poor quality of care in nursing homes and substandard infection-control procedures played a significant role in the spread of the virus. Both concerns had been long-standing and presented a challenge before the onset of the pandemic. COVID-19 just made the problems and the need for solutions more urgent. Improving the quality of nursing home care to improve residents’ outcomes and preventing the spread of infectious diseases like COVID-19 require a multipronged approach.
The factors that led to more than a million COVID-19 cases in long-term care facilities are not random. Key drivers of nursing home quality needed improvement well before the pandemic, and the failure to address this need contributed to widespread, highly publicized problems. Here are the three most glaring issues facing nursing homes:
- Staffing levels. Decades of research demonstrate that one of the strongest factors driving nursing home quality is having enough staff with the right training to address residents’ needs. Higher nurse staffing ratios are strongly correlated with better quality outcomes, including fewer pressure ulcers, fewer infections, less weight loss, and lower mortality rates. Recent studies of COVID-19 outbreaks in nursing facilities, including a Mathematica report for the state of Connecticut, found that higher staffing ratings on CMS’s Nursing Home Compare were strongly associated with fewer COVID-19 cases and deaths per licensed bed.
- Infection-control practices. Before the COVID-19 pandemic, infection-control deficiencies were widespread. The Government Accountability Office found that 82 percent of nursing homes were cited for deficiencies in infection control in one or more years from 2013 through 2017. Every study that examined the association between community prevalence of COVID-19 and nursing home outbreaks found a correlation; the communities with the highest infection rates also had the highest rates of nursing home cases. These findings highlight the importance of strong infection control to keep pathogens from entering facilities and to contain their spread if they do.
- Facility size and design. Several studies found that large facilities with more beds were associated with an increased likelihood of having any COVID-19 cases, higher case and death counts, and increased severity of outbreaks. A California study found that the COVID-19 case and death rates were higher for larger nursing homes (with more than 99 licensed beds) than for smaller facilities.
These issues can be remedied by adopting a range of solutions at both the federal and state level. A value-driven approach might help incentivize improvement to nursing home quality and should be paired with other rewards for participating in managed care plans and provider groups that help improve care and quality of life. Our next blog will focus on value-based payment solutions.