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/.