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COVID-19: Beyond Tomorrow
May 22, 2020

Nursing Home Care in Crisis in the Wake of COVID-19

Author Affiliations
  • 1Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
  • 2Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island
  • 3Providence Veterans Administration Medical Center, Providence, Rhode Island
JAMA. 2020;324(1):23-24. doi:10.1001/jama.2020.8524

The coronavirus disease 2019 (COVID-19) pandemic has devastated US nursing homes. Thousands of facilities nationwide have reported cases of COVID-19 among residents and staff.1 Although less than 0.5% of the total US population (approximately 1.5 million people) live in nursing homes, nursing home residents have accounted for approximately 25% of the documented deaths due to COVID-19. Some states (such as Massachusetts and Pennsylvania) and some European countries (such as France and Ireland) have reported that residents of nursing homes account for 50% of the deaths.1 Virtually all nursing homes are in full lockdown mode with residents unable to see their families or participate in communal meals or activities. Many staff are concerned they will contract the virus, and severe staff shortages exist because many workers are unable or unwilling to work in conditions characterized by insufficient testing and personal protective equipment (PPE).

COVID-19 has exposed long-standing issues in how nursing home services are structured and financed. Nursing homes predominantly care for 2 groups: short-term postacute care patients with Medicare coverage and long-term residents with Medicaid coverage. Medicare is a relatively generous payer, whereas Medicaid often pays below the cost of caring for these frail and medically complex individuals. Thus, the economics of nursing home care hinges on admitting enough short-term Medicare beneficiaries to cross-subsidize the care of long-term residents with Medicaid coverage. Nursing homes that are predominantly dependent on the lower Medicaid reimbursement are poorly resourced, have lower staffing levels, are located in poorer neighborhoods, have the most quality problems, and are most likely to close.2

Currently, few nursing homes are admitting short-term Medicare beneficiaries. Hospitals are not performing elective procedures like joint replacements so patients who would ordinarily require postacute care are not being referred to nursing homes. An increasing number of hospitalized patients are recovering from COVID-19 and are medically stable enough for postacute rehabilitative care, but most nursing homes are not admitting these patients because of an inability to care for them safely. Some nursing homes are facing bankruptcy due to decreased Medicare revenue and the increased costs of managing patients with COVID-19.

The Days Ahead

Given this crisis, owners, payers, and clinicians need to come together to provide resources and support to nursing homes. To date, nursing homes have received some short-term stimulus funding but much more help is needed.

Staff who are infected but asymptomatic may bring COVID-19 into nursing homes that have been on lockdown for weeks. Nursing homes require rapid COVID-19 testing and continued surveillance of all staff and residents. The virus spreads from the community to nursing homes via staff without sufficient PPE. The federal government recently announced that all US nursing homes would receive 1 week of PPE. Although a good start, the sector will need additional PPE for many weeks because universal precautions must be in place to account for patients with COVID-19 and staff who are asymptomatic. Nursing home staff will need to be trained and supported in good infection control. Additional pay and support for staff, along with short-term programs to supplement this workforce, will be necessary.

For long-term residents, advance care planning and palliative care must be priorities. For patients needing postacute care, nursing homes should not be mandated or otherwise coerced to admit patients with COVID-19 who are discharged from the hospital. The majority of nursing homes do not have the staff, PPE, or a physical layout to safely care for recovering patients with COVID-19 after hospitalization. Specialized postacute care settings for COVID-19 care are needed around the country.3 In some instances, this will be part of an existing facility, but in others, these are new temporary spaces built in convention centers, arenas, or closed facilities. Ideally, hospital staff will be involved in managing and delivering care in such specialized COVID-19 facilities. For example, a large hospital system in Boston, Massachusetts, is operating a 250-bed skilled nursing facility unit in the city’s convention center.

Road to Tomorrow

The first question is when will nursing homes be able to open safely. Given the asymptomatic spread of COVID-19, nursing homes will not be able to reopen until they have access to accurate and rapid COVID-19 surveillance testing. Right now, nursing homes are working under the assumption that everyone has COVID-19. This makes the safe admission of new patients nearly impossible and the care of existing residents challenging. In addition to testing, staff will need adequate PPE and strong infection control protocols in place. With universal testing and meticulous infection control, nursing homes could begin to admit new patients without COVID-19 from the hospital and ease lockdown restrictions on long-term residents.

Providing care for patients recovering from COVID-19 will require differentiating postacute care from long-term care. The COVID-19 pandemic has demonstrated that hospital systems should continue to embrace, support, and be accountable for postacute care delivery. Over the past 5 years hospitals increasingly have been developing preferred relationships with postacute care centers and clinicians.4 This trend should be reinforced via alternative payment models like accountable care organizations and bundled payment models. These models will provide the necessary flexibility for COVID-19 care, for example, by encouraging telemedicine and other delivery innovations but also by giving nursing homes access to medical expertise, like infection control, that has heretofore been missing.

To date, Medicare’s experience with bundled payment for surgical procedures and accountable care organizations has suggested modest savings without any change in outcomes such as hospital readmission or mortality.5 When savings have been achieved, they have largely been extracted from postacute care. For the care of high-need patients such as those with COVID-19 (ie, those that require oxygen, isolation, or intensive clinical care), hospitals would need to move beyond simply eliminating low-value postacute care toward improving clinical management of these postacute patients in a meaningful way. The hope is that these payment models would be evaluated on quality measures that were more sensitive to postacute care considerations for high-need patients such as those with COVID-19.

Long-term nursing home residents recovering from COVID-19 will require extensive medical and social care. Medicaid must begin to pay a higher rate commensurate with the costs of delivering high-quality long-term care to frail older adults. In many states, this will require greater federal contributions. However, this will not be sufficient to ensure access to high-quality medical care for these individuals. Because Medicare still covers medical services for these long-term nursing home residents, models are needed that integrate medical care with the social needs of patients recovering from COVID-19.

Two examples of such models include Medicare Advantage Institutional Special Needs Plans and nursing home–led accountable care organizations. Although these models are only in a small proportion of nursing homes nationwide, they provide Medicare dollars to invest in onsite clinical services for long-term residents that can improve the health and quality of care of these residents while ideally leading to decreased use of costly emergency department care and hospitalizations.

For either of these care models to succeed in improving care for elderly residents at ongoing risk of contracting COVID-19, more physicians and nurse practitioners must shift away from the traditional individual primary care model and embrace managing the health of this patient population, serving as their primary care clinicians and collaborating with nursing staff and therapists. Only by addressing the clinical workforce caring for this population can fundamental changes be realized. Nursing homes will have to attract health care professionals who want long-term relationships with their frail patients.

More engagement of physicians and nurse practitioners in leadership positions in health care systems to provide population health to this challenging population is going to be key for any innovation to work because financing reform without delivery system reform is not going be successful. An increasing share of primary care delivered to residents in nursing homes is being provided by specialist clinicians, many of whom are nurse practitioners.6 This shift has coincided with a reduction in hospital transfers among long-term residents, which helps to make the new financing models viable because reducing hospitalizations makes possible more primary care and other services enhancing quality of life.7

Conclusions

Nursing homes are in crisis because of the COVID-19 pandemic. These facilities need immediate support from policy makers and clinicians including testing, PPE, and support for staff. When nursing homes are able to reopen, this need for clinical support will not end. Value-based payment models that meaningfully engage clinicians in both postacute care and long-term nursing home care should help nursing homes provide safe and appropriate care for patients recovering from COVID-19 and for other patients who require short-term or long-term nursing home care.

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Article Information

Corresponding Author: David C. Grabowski, PhD, Department of Health Care Policy, Harvard Medical School, 180 Longwood Ave, Boston, MA 02115 (grabowski@hcp.med.harvard.edu).

Published Online: May 22, 2020. doi:10.1001/jama.2020.8524

Conflict of Interest Disclosures: Dr Grabowski reported receiving research support from the National Institute on Aging, the Agency for Healthcare Research and Quality, the Arnold Foundation, and the Warren Alpert Foundation; serving on a scientific advisory committee for and receiving personal fees from naviHealth; receiving personal fees from the Medicare Payment Advisory Commission, Vivacitas, CareLinx, Compass Lexecon, Abt Associates, Analysis Group, and the Research Triangle Institute. Dr Mor reported receiving research support from the National Institute on Aging, the VA Health Services Research and Development Service, and the Seqeris Corporation via Insight Therapeutics Inc; and chairing a scientific advisory board for and receiving personal fees from naviHealth.

References
1.
Chidambaram  P. Kaiser Family Foundation Issue Brief: state reporting of cases and deaths due to COVID-19 in long-term care facilities. Accessed April 26, 2020. https://www.kff.org/medicaid/issue-brief/state-reporting-of-cases-and-deaths-due-to-covid-19-in-long-term-care-facilities/
2.
Grabowski  DC. 2019 Senate finance committee hearing: not forgotten: protecting Americans from abuse and neglect in nursing homes. Accessed January 19, 2020. https://www.finance.senate.gov/imo/media/doc/Grabowski%20Senate%20Finance%20testimony%20FINAL.pdf
3.
Grabowski  DC, Joynt Maddox  KE.  Postacute care preparedness for COVID-19: thinking ahead.   JAMA. Published online March 25, 2020. doi:10.1001/jama.2020.4686 PubMedGoogle Scholar
4.
Mor  V, Rahman  M, McHugh  J.  Accountability of hospitals for Medicare beneficiaries’ postacute care discharge disposition.   JAMA Intern Med. 2016;176(1):119-121. doi:10.1001/jamainternmed.2015.6508PubMedGoogle ScholarCrossref
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Barnett  ML, Mehrotra  A, Grabowski  DC.  Postacute care—the piggy bank for savings in alternative payment models?   N Engl J Med. 2019;381(4):302-303. doi:10.1056/NEJMp1901896PubMedGoogle ScholarCrossref
6.
Teno  JM, Gozalo  PL, Trivedi  AN, Mitchell  SL, Bunker  JN, Mor  V.  Temporal trends in the numbers of skilled nursing facility specialists from 2007 through 2014.   JAMA Intern Med. 2017;177(9):1376-1378. doi:10.1001/jamainternmed.2017.2136PubMedGoogle ScholarCrossref
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McCarthy  EP, Ogarek  JA, Loomer  L,  et al.  Hospital transfer rates among US nursing home residents with advanced illness before and after initiatives to reduce hospitalizations.   JAMA Intern Med. 2019;180(3):385-394. doi:10.1001/jamainternmed.2019.6130PubMedGoogle ScholarCrossref
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    2 Comments for this article
    EXPAND ALL
    Home Care as a Safe Alternative in Post-Acute and Long-Term Care
    Claudio Oliveira, MD, PhD | Home Doctor
    I read with great interest the Viewpoint by Dr Grabowski (1) about the high mortality rates due to COVID-19 among nursing home residents, representing 25% of deaths from COVID-19 in the US. Percentages are even higher in some US states and European countries. The concern with the safety of patients and professionals at these facilities is extremely relevant.

    In Brazil, a country heavily impacted by the pandemic, much of post-acute care, rehabilitation, and long-term chronic patient care is provided at home, covering approximately 1 million admission per year (2). This modality of treatment includes drug administration, enteral nutrition, wound
    care, rehabilitation, oxygen therapy, respiratory support, and more complex therapies like parenteral nutrition and invasive or non-invasive mechanical ventilation. Home care is available in both public and private health sectors and has been distinguished by humanized care, patients' reintegration into society, and a low incidence of infections (3).

    Our single institution provides home care to 2,400 patients (64% are elderly). Brazil has the second highest number of COVID-19 cases in the world; however, despite this challenging scenario, our institution reported only 28 cases (0.01%) and 7 deaths to date. These numbers reinforce the idea that, in addition to its social advantages, home care protects patients and lessens the risk of virus and other infections. Patients naturally remain in home isolation and are treated by a team of professionals in a directed way. This, together with proper use of PPE and implementation of innovations (e.g. telemedicine), is key for safe care in an epidemic context (4).

    During the 2-month period of the pandemic so far, we have observed a 15% increase in the number of patients treated at home, mainly with the following actions: 1) dehospitalizing non-COVID-19 patients and leading to an increase in the number of available hospital beds; 2) dehospitalizing COVID-19 patients, whether in the stable or in the rehabilitation phase of the disease; 3) preventing hospitalization of non-critical COVID-19 cases, through at-home oxygen monitoring, oxygen supplementation, medical follow-up, and medical emergency care available 24x7.

    The current pandemic has led us to reflect deeply on how to provide the best health care by creating safe treatment options outside hospital walls. New alternatives have been rapidly implemented worldwide. Shifting post-acute and chronic care to the household environment with the implementation of technology and new payment models may be one of the ways (3,5).

    REFERENCES

    1. Grabowski DC, Mor V. Nursing Home Care in Crisis in the Wake of COVID-19. JAMA. Published online May 22, 2020. doi:10.1001/jama.2020.8524
    2. Censo NEAD-FIPE de atenção domiciliar 2017/2018. www.neadsaude.org.br/outros.
    3. Cuxart Mèlich A, Estrada Cuxart O. Hospital at Home: An Opportunity for Change. Med Clin (Barc) 2012 Apr 7;138(8):355-60.
    4. McGoldrick, Mary MS, RN, CRNI Personal Protective Equipment Removal, Home Healthcare Now: May/June 2020 - Volume 38 - Issue 3 - p 170-171 doi: 10.1097/NHH.0000000000000879
    5. Ramon Martınez Riera J, Gras-Nieto E. Home care and covid-19. before, in and after the state of alarm. Enfermeria Clinica (2020), doi: https://doi.org/10.1016/j.enfcli.2020.05.003
    CONFLICT OF INTEREST: None Reported
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    Mistaken Emphasis on Proportion Nursing Home Deaths Make Up of Total COVID-19 Deaths
    James Scanlan, JD | Attorney at Law
    Grabowsky and Mor describe what appears to be a serious financial and staffing crisis in nursing homes caused by COVID-19. But in doing so, they discuss the high proportion of COVID-19 deaths that have occurred in nursing homes, which some are calling a crisis. The high proportion that deaths of nursing home residents make up of total COVID-19 deaths should not be regarded as an indicator of COVID-19 risk in nursing homes and certainly not as a crisis, particularly since improvements in health care-based COVID-19 care will tend to increase that proportion.

    The rarer an
    outcome the greater tend to be relative differences between rates at which more and less susceptible groups experience the outcome (though the smaller tend to be relative differences between rates at which the groups avoid the outcome); correspondingly, the rarer an outcome, the larger tends to be the proportion the more susceptible group makes up of persons experiencing the outcome (and avoiding the outcome) [1,2].  Reducing deaths from COVID-19, including among nursing home residents, will tend to increase the relative difference between rates at which nursing home residents and others die from COVID-19 (while reducing relative differences between rates at which such groups fail to die from COVID-19); correspondingly, it will tend to increase the proportion nursing home residents make up of persons who die from COVID-19 (and persons who do not die from COVID-19).

    Data in Tables A.2 and A.3 (at 85-88) of reference 3 illustrate the point. Among seriously ill COVID-19 patients in the United Kingdom, mortality rates of persons over 65 and persons 20 to 64 were 44.6% and 8.6% for men and 33.3% and 3.18% for women. The ratio of the older group’s mortality rate to the younger group’s morality rate was therefore 5.2 among men and 10.5 among women. Thus, if care were improved such as to give male patients the same chance of recovery as female patients, among male patients the relative difference between the mortality rates of the older group and the younger group would increase (though the relative difference between the groups’ survival rates would decrease). The data would correspondingly show that the proportion older patients make up of men who died would increase (as would the proportion they make up of men who survived).

    The mistaken emphasis on the proportion nursing home residents make up of persons dying from COVID-19, rather the proportion of nursing home residents persons who die from the disease, may be compared to the mistaken emphasis given the so-called feminization of poverty – that is, an increase in the proportion persons in female headed families made up of the poor – without understanding that reductions in poverty, including the poverty of persons in female-headed families, tends to increase the proportion persons in such families make up of the poor (and the non-poor). See references 1 and 2.

    Unfortunately, the frequent mention of the proportion nursing home residents make up of persons who die from COVID-19 may contribute to the financial and staffing problems facing nursing homes.

    References:

    1. Scanlan JP. Race and mortality revisited. Society 2014;51(4):327-346.
    http://link.springer.com/article/10.1007%2Fs12115-014-9790-1#page-1

    2. Scanlan JP. Race and mortality. Society 2000;37(2):19-35.
    http://www.jpscanlan.com/images/Race_and_Mortality.pdf

    3. Public Health England. Disparities in the risk and outcomes of COVID-19. May 2020. https://www.gov.uk/government/publications/covid-19-review-of-disparities-in-risks-and-outcomes
    CONFLICT OF INTEREST: None Reported
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