More on Quality and Safety

COVID-19 toll in nursing homes linked to staffing levels and quality

Low-resource facilities and those with high concentrations of socioeconomically challenged residents experience poorer outcomes.

Jeff Lagasse, Associate Editor

Residents of long-term care facilities with lower nurse staffing levels, poorer quality scores, and higher concentrations of disadvantaged residents suffer from higher rates of confirmed COVID-19 cases and deaths, finds new research in the Journal of the American Geriatrics Society.

This highlights that there are disparities in the system whereby low-resource facilities and those with high concentrations of socioeconomically challenged residents experience poorer health outcomes. These disparities are only exacerbated by the pandemic.


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Residents of long-term care facilities have been shown to be highly vulnerable to respiratory disease outbreaks, such as influenza or other common human coronaviruses. Current evidence suggests that COVID-19 disproportionately impacts older adults and individuals with chronic health conditions.

These factors are more concentrated in nursing homes, where residents are characterized by advanced age, more frequent and complex chronic-disease patterns, and highly impaired physical, cognitive and immune system functions, putting these populations at greater risk for more severe COVID-19 infections.

This phenomenon first came to light in a skilled nursing facility in the Seattle area in February during the early stages of the pandemic, where more than half of the residents in the facility became infected and a third died. Since that time, 50,000 coronavirus-related deaths, approximately 40% of the total, have been linked to nursing homes across the U.S.

The new study examines nursing home-level data published on the Connecticut Department of Health and Human Services website. At the time it was conducted, Connecticut was one of the few states that made this information publicly available. This information was compared to data from the Center for Medicare and Medicaid Services' Nursing Home Compare website, which tracks quality, staffing and health outcomes for nursing homes nationwide.

What this showed was that long-term care facilities with higher concentrations of disadvantaged residents, including Medicaid residents and racial and ethnic minorities, lower nurse staffing levels (particularly of registered nurses), and lower scores on CMS five-star quality measures had higher rates of confirmed COVID-19 cases and deaths. Higher nurse-staffing ratios in particular were strongly associated with fewer cases and deaths.

Nursing levels are especially key, since there was a strong link between staffing levels and coronavirus cases, suggesting that such personnel are key to an institution's ability to effectively respond to an outbreak – likely because RNs are a major factor in the assessment and provision of medical care, including the early identification of emergencies and life-threatening situations.


Similar patterns in nursing homes have since been observed in other states, including California. In April, the federal Centers for Disease Control and Prevention required all nursing homes to submit COVID-19 data. A preliminary analysis of the CDC data showed similar associations between nursing home quality and staffing and coronavirus infection rates and deaths.

The authors suggest that the findings should be used to recalibrate the nation's efforts to control infection rates in nursing homes. Efforts to date have concentrated in facilities located in areas with high infection rates. The authors contend that, going forward, regulators and state nursing home inspectors should also target homes with lower RN staffing levels and quality ratings.

Twitter: @JELagasse

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