Advocates Push Back on Geography as Driver of Nursing Home Outbreaks — and Detail Drastic Measures for Keeping COVID at Bay

COVID-19 outbreaks in skilled nursing facilities are affected by more than geography, and nursing home operators have tools and actions they can take to mitigate the spread of the virus in their facilities, the Center for Medicare Advocacy (CMA) argued in a report released on Thursday.

“Since the start of the pandemic, one of the most widely shared explanations for the devastation that we’ve seen in our nursing homes has been that where a facility is located will define how much they’re able to protect residents from COVID,” Cinnamon St. John, a health and aging policy fellow at CMA, who authored the report, said in remarks on a webinar marking its release on Thursday. “But when you look at the data, and examine the world of research around this topic, and speak to those who are out there, battling this disease every day, which my report has done, it becomes clear that this simple explanation just does not stand on its own.”

CMA is a non-profit law organization that advocates on behalf of Medicare beneficiaries.


The CMA report drew from Centers for Medicare & Medicaid Services (CMS) COVID-19 data set through December 27, 2020, as well as data from the CMS Care Compare Database. It also used interviews with nursing home administrators in Los Angeles County, Calif.; Maricopa County, Ariz.; and Hartford County, Conn.

The group in particular called out an August article published in the Journal of the American Geriatrics Society by Rebecca Gorges and R. Tamara Konetzka, which concluded that community spread was a top predictor of outbreaks, despite staff playing a key role in how those outbreaks played out.

“This argument, however, is certainly neither ironclad nor the entire story,” the CMA report said.


In the report, St. John examined a variety of factors that played a part in the severity and effect of COVID-19 outbreaks in nursing homes, including CMS overall star ratings, ownership, personal protective equipment (PPE) and the availability of COVID-19 testing for residents and staff. It also provided a range of actions and policy recommendations centered around leadership and staffing, physical plant standards, and protocols for infection prevention and control and following public health guidance.

The report found SNFs with a five-star rating from CMS were 18% more effective at preventing COVID-19 infections — logging total resident infections that were 7 percentage points lower than three-, two-, and one-star SNFs. Specifically, five-star facilities reported an average infection rate of 38% of residents, compared with 43% on average for four-star facilities and 45% for three-, two-, and one-star facilities.

Chart showing the average % of residents infected with COVID-19, grouped by CMS overall star rating
Source: Center for Medicare Advocacy

In terms of quality, nursing homes in the top 10 percentiles by COVID-19 cases per 1,000 residents had an average CMS quality rating of 3.8. Those in the bottom ten percentiles had an average quality rating of 3.5.

Staffing ratings showed a particularly notable disparity, with a 9.7% difference between those in the top ten percentiles by COVID-19 cases per 1,000 residents and those in the bottom ten percentiles. Facilities that performed the best by this metric had an average CMS staffing star rating of 3.4; those that performed the worst had an average staffing star rating of 3.1.

There was also a wide gulf between best- and worst-performing facilities in terms of testing; just 0.5% of the top performing facilities reported a shortage in staff testing capacity, while 1.4% of the bottom performing facilities did the same. For nursing staff shortages, there was a similarly notable gap; 18.4% of top-performing facilities by COVID-19 cases per 1,000 residents reported a shortage of nursing staff, while 21% of the worst-performing facilities reported this shortage.

There was one interesting, counterintuitive finding: Of the top-performing facilities by COVID-19 cases per 1,000 residents, 21.2% reported a shortage of nurse aides, while just 20.4% of those worst-performing facilities reported this shortage.

“Though the level of infection found in the surrounding community does undoubtedly create additional challenges for nursing homes battling to keep COVID-19 at bay, as this data makes clear, a facility’s location does not equate to a facility’s fate,” the report argued.

The August 2020 study by Rebecca Gorges and R. Tamara Konetzka, which studied data from 13,167 nursing homes that reported COVID‐19 data as of June 14, 2020, had several conclusions that were similar; it found that higher nurse-aide (NA) hours and total nursing hours were associated with a lower probability of experiencing an outbreak, and were correlated with fewer deaths.

That study found that higher registered nurse hours were associated with a higher probability of experiencing any cases, which could possibly be related to the increase of traffic in and out of a facility, the authors noted in their discussion. However, the UChicago study found that the factor with the greatest effect on outbreaks was where the virus was circulating in a community.

“The prevalence of COVID‐19 in the community remains the strongest predictor of COVID‐19 cases and deaths in nursing homes, but higher NA hours and total nursing hours may help contain the number of cases and deaths,” Gorges and Konetzka concluded at the time.

Keeping COVID-19 out

Rev. Dr. Derrick DeWitt Sr., the director and chief financial officer of the Maryland Baptist Aged Home in Baltimore, spoke during the webinar about how he kept COVID-19 out of his facility.

The Maryland Baptist Aged Home has 30 residents and 42 full- and part-time employees who have been free from COVID-19 infection, and DeWitt has been praised widely in the wake of the pandemic for that accomplishment.

His success involved acting early. But he also noted that the operator was “excessive and extreme in our measures.”

“Even before the pandemic, I took a lot of criticism by having a full-time infection control and quality assurance nurse in such a small facility,” he said. “But we knew that infection was going to be the thing that either made us or closed us. If we kept infection out, we would have success in remaining open as we have for 100 years.”

DeWitt had to take a pay cut to hire the infection control nurse, but did so based on the premise that infection control could not be a “side duty” in a health care facility. When the pandemic struck, infection control took center stage, and according to DeWitt, the work of the infection control nurse formed the basis of how Maryland Baptist responded.

That response necessitated going “above and beyond the guidelines.”

“Everything that she had in the book, I said: Let’s multiply this times 10 and do it,” DeWitt said.

That included stockpiling PPE immediately before shortages emerged, and closing the facility to visitors on February 28, 2020.

It also meant making drastic changes to how employees approached work.

“We told our employees: Don’t take public transportation, wear masks at home, and limit your exposure to your family,” DeWitt said. “It’s very extreme measures, right? We’re invasive. And our questionnaire doesn’t just ask: Have you had contact with people? We want to know: When you left the facility, what did you do, and who did you do it with? We were very intrusive. We’re checking social media. I’ve suspended workers for 14 days with no pay because they went to a party during the pandemic. These are some extreme measures.”

To offset the challenges of not taking public transit, Maryland Baptist provided supplemental transportation to prevent employees having to take the bus and the train. It also hired more activities personnel to try to combat the toll of isolation on residents.

But it also faced some challenges implementing these measures. DeWitt emphasized strongly the need to focus on care and not funds — while noting those funds for care need to be sufficient.

“It’s got to be about the care and less about the money,” he said. “The other way to look at it is that the money that we get from Medicare, Medicaid, is not enough to provide the quality of care that’s needed. A lot of the measures that we’ve done, it was at great financial sacrifice.”

Maryland Baptist Home has a registered nurse on every shift, for instance, which helped maintain quality assurance related to care. That coverage on top of the additional activities personnel poses a fiscal challenge.

“A lot of problems that I see with Medicare, Medicaid, those types of payment models especially for non-profits — the margins are so tight that it’s hard to focus and to put in a lot of these measures that will lead to the safety of our residents,” DeWitt said.

He also pointed out the disproportionate toll of COVID-19 on nursing homes where people of color live, relative to other nursing homes, as an example of the need to account for the fact that long-term care facilities differ by community. That study, also by Gorges and Konetzka, found that several factors played a role, with the larger size and poorer quality of nursing homes in those areas — combined with overall higher community case counts in those areas — a particular issue.

“I want to be careful in saying that it is important to note that nursing homes could have done everything right and still have been affected negatively by this pandemic,” he said. “But I think that we have to begin to look a the models of larger facilities … it’s hard to control infection, once it’s entered your facility, if you have a large facility, a large workforce. We have to begin to look at smaller, community, neighborhood-type facilities that are designed based on the differences in those communities, centered around long-term care.”

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