​Where a nursing facility is located has a great deal to do with whether its residents have a case of COVID-19, said a panel of researchers in a May 7 webinar. According to preliminary research presented, larger facilities located in urban areas with large populations, particularly in counties with a higher prevalence of COVID-19 cases, were more likely to have reported cases.

Characteristics that were not associated with a facility having a COVID case included Five-Star Rating on Nursing Home Compare; whether or not a facility had a prior violation with infection; or whether it was for-profit, part of a chain, or having a high Medicaid census. These factors had no correlation with whether the facility had cases of COVID-19, said the researchers.

“It’s about where you are and not who you are,” said David Grabowski, PhD, professor of health care policy, Department of Health Care Policy, Harvard Medical School. “What we’re seeing in our data is it tends to be larger facilities—urban facilities in areas with more cases—that tend to be the facilities with COVID cases.”

The finding was supported by preliminary research presented by Vincent Mor, PhD, IMPACT principal investigator, professor, Florence Pierce Grant University, and professor of health services, policy and practice, Brown University School of Public Health.

In a partnership with Genesis HealthCare, Mor’s team used real-time electronic medical record data to track epidemiology of COVID-19 in nursing centers across 30 states. The preliminary analysis was consistent with Grabowski’s findings that larger facilities in urban communities with COVID cases are more likely to have outbreaks.

Both Grabowski, using data from 20 states, and Mor’s team data from Genesis investigated what differentiated facilities with COVID-19 from those without COVID-19. The Genesis facilities, in Mor’s preliminary analysis, found those that had a positive COVID case, compared with the facilities that did not have a positive case, have more total number of beds and were located in counties that had a higher number of positive COVID cases per hundred thousand. Both Grabowski and Mor indicated that these characteristics were strongly differentiating.

“So it’s a function of traffic; that is, if you’re in an environment where there are a lot of people in the community who have COVID, the patients in the building are more likely to have COVID: It’s as important,” Mor said. “If you are a larger facility versus a smaller facility, there is more traffic. Larger facilities simply have more staff, more people coming in and out of them. That’s more traffic and more likelihood that someone will be coming in from the outside with COVID.”

Grabowski added, “This is a system problem, not a bad apple problem.” He went on to say that the system has not adequately supported nursing homes during this pandemic.

Mor’s team also found a strong correlation between the number of skilled nursing facility (SNF) cases in the building that test positive and the number of positive cases in that county.

The researchers reported that even while nursing facilities are in lockdown, the COVID-19 virus is spreading and pointed to the asymptomatic presentation of the virus and the lack of testing as factors.

“As we know, it is spreading via asymptomatic and pre-symptomatic cases, and what we’ve learned is that in facilities that have been closed for weeks, we are seeing cases emerge,” said Grabowski. “Those cases are emerging because of staff who don’t know that they have the virus are coming in to work.”

The reality of the problem played out in a SNF in Massachusetts, said Grabwoski. The facility went into lockdown in mid-March. In early April, the facility was scheduled to become an all-COVID-19 facility—all the long-stay residents were to be moved out. Every resident in the building was tested for COVID-19, and over half tested positive with no symptoms, he said. About 60 percent of the staff were also tested, and of those, 40 percent tested positive.

“So this shows you it is coming into buildings,” said Grabowski. “It’s not about symptoms. It’s going to come into these buildings through asymptomatic staff, and like this [facility] in Massachusetts, the outcomes are often dire.”

Regarding the lack of testing, the researchers called for a system to test and monitor staff and residents. “We’re not going to get a handle on COVID-19 [facilities] until we get a systematic testing and surveillance system,” Grabowski said.

In addition to calling on federal leaders to implement testing all over the country for all residents and staff, the researchers called for adequate access to personal protective equipment, infection control personnel and infrastructure, hazard pay, practicing good cohorting, COVID-specialized post-acute care facilities, and investment in home- and community-based services to be included in policies to support nursing facility residents and staff.

The researchers highlighted the need for national data, including number of cases and fatalities for residents and staff. As previously reported, the Centers for Medicare & Medicaid Services has released a QSO memo addressing the interim final rule requiring SNFs to report to National Healthcare Safety Network (NHSN) on COVID-19, as well as to provide notifications to residents, their representatives, and families. The American Health Care Association/National Center for Assisted Living said these requirements were to go into effect with the publication in the Federal Register of the interim final rule on May 8. 

The research findings were presented during a webinar titled, “COVID-19 in Nursing Homes: Pragmatic Research Responses to the Crisis,” hosted by The National Institute on Aging (NIA) Imbedded Pragmatic AD/ADRD Clinical Trials (IMPACT) Collaboratory.

The NIA IMPACT Collaboratory works to build the nation’s capacity to conduct pragmatic clinical trials of interventions embedded within health care systems for people living with dementia and their care partners. To learn more, visit https://impactcollaboratory.org.

To listen to the webinar, go to https://impactcollaboratory.org/special-grand-rounds-covid-19-in-nursing-homes-pragmatic-research-responses-to-the-crisis/.