COVID-19 Rates in Nursing Homes Can Plummet with Funding, PPE — But Long-Term Sustainability in Doubt

By adhering to infection control processes, particularly the use of personal protective equipment (PPE) and cohorting residents, skilled nursing facilities have significantly reduced their weekly COVID-19 infection and mortality rates, a new study has determined.

The study was published in the Journal of the American Geriatrics Society earlier this month, examining 360 nursing homes in the state of Massachusetts and how the state’s response affected their COVID-19 outcomes.

As in many other states, nursing homes in the Bay State rapidly emerged as hot spots for the virus, with more than half of the state’s deaths occurring among residents and staff.


Gov. Charlie Baker made $130 million in additional funding available for two months to nursing homes to improve their infection control processes on April 27, the study noted. The funding was contingent on nursing home compliance with a new set of criteria that included mandatory testing of residents and staff and a 28-point infection-control checklist.

The plan by the governor allowed for a 50% increase in payments to nursing homes for that two-month time frame if they passed unannounced state inspection audits by scoring 24 or higher on the checklist while meeting six core competencies, testing 90% of residents and staff for COVID-19 by a given date, uploading data weekly, and providing technology for virtual resident visits.

That was part of the overall program for Massachusetts, which had six components to its intervention:

  • The infection-control checklist
  • The two-month payment incentive
  • Onsite and virtual consultation on infection control
  • Weekly webinars
  • Ongoing question-and-answer communication from regulators at MassHealth, the state’s Medicaid program, and the Massachusetts Department of Public Health (DPH)
  • PPE, staffing, and testing resources

The Massachusetts Senior Care Association — the state’s affiliate of the national nursing home trade group American Health Care Association (AHCA) — and the senior care non-profit Hebrew SeniorLife organized a Central Command team, with 123 facilities with infection control deficiencies designated as “special focus” sites.

These facilities were targeted with on‐site and virtual consultations; all 360 nursing homes in the study were offered weekly webinars and answers to questions regarding infection control procedures, as well as information about resources for acquiring PPE, backup staff, and COVID-19 testing.

While both staff and resident COVID-19 infection rates began higher in the special focus facilities, they “rapidly declined to the same low level in both groups,” according to the study, which was written by Hebrew SeniorLife chief academic officer Lewis Lipsitz, Alida Lujan of the Massachusetts Institute of Technology, Alyssa Dufour of Hebrew SeniorLife, Gary Abrahams of the Massachusetts Senior Care Association, Helen Magliozzi of the Massachusetts Senior Care Association, Laurie Herndon of Hebrew SeniorLife and Mohammad Dar of MassHealth.

During the first six weeks of the nine-week intervention period, the cumulative COVID‐19 infection rate rose from 46% to 55% of all Massachusetts nursing home residents, and the mortality rate rose from 24% to 26% of all residents with COVID‐19 infections. But both rates leveled and stayed fairly steady in the remaining three weeks, with weekly hospitalization falling from 2.1% of the average daily census to 1.3% by week five; that rate stayed at 1.2% to 1.4% after that point.

The study also found that in both groups of Massachusetts facilities, mortality declined in parallel, reaching fewer than 2 deaths per 1,000 residents per week by the end of the intervention — or half the average rate reported for Cleveland, Detroit, and New York nursing homes in 2019.

The authors noted that the state’s outcomes were hard to attribute solely to the interventions, since infection and mortality rates declined statewide and community spread is one of the strongest risk factors.

“Nevertheless, our analysis did show significant correlations between adherence to best infection control practices and reductions in infection and mortality rates, even when county prevalence was taken into account,” they wrote. “One concern is the possibility of backsliding during the last week of the intervention when the number of infections among residents and staff and audit failure rates began to increase.”

They also noted that though many of the infection control processes included in the state’s checklist are being implemented nationally in Singapore, this is not true in the U.S.

In addition, many other authors have noted the need for changes in the way the U.S. pays for long-term care, they noted. One of the most important lessons was the fact that facilities need “clear and consistent PPE guidance from state and federal authorities that is well aligned and adaptable when shortages are present,” including the right use, appropriate donning and doffing procedures, and ways to optimize usage to prevent shortages. They also called for the requirement and funding of an infection preventionist position in nursing homes.

“We do not know whether improvements in infection control processes can be sustained without payment incentives,” they wrote.