United States – Resources to support community and institutional Long-Term Care responses to COVID-19

LTCcovid Country Profile – Printable Version

1.00. Brief overview of the Long-Term Care system

In the United States, there are five major types of LTC services: adult day centre, home health agencies, nursing homes, hospices, and residential living facilities. As of 2016, there were approximately 15,300 nursing homes and 28,900 residential care (‘assisted living’) facilities. Approximately 24 in every 1,000 people aged 65+ use nursing homes, and 15 in every 1,000 people aged 65+ live in residential care. 75 in every 1000 people aged 65+ use home health agencies for at-home services (source: Vital and Health Statistics).

Update for: United States Last updated: February 11th, 2022

1.01. Population size and ageing context

As of 2019, approximately 16.5% of Americans were aged 65 and older, constituting more than 54 million people in a population of 320+ million (source: https://www.census.gov/topics/population/older-aging.html). Moreover, the number of people aged 65 and older is expected to double in the next 40 years (source: https://www.urban.org/policy-centers/us-population-aging).

Update for: United States Last updated: February 11th, 2022

1.02. Long-Term Care system governance

The governance of LTC in the United States is complex and uncoordinated, primarily because of the state variations regarding fund allocation and aging populations. There is a shortage of an appropriate, nationwide system to address the health and social care needs of the population, whilst fragmented and under-resourced systems are common. Federal services tend to be scattered across agencies with minimal collaboration. Various LTC programs are often operating independently (De Biasi et al. 2020).

Federal level attempts at financing reform have either ended in failure or produced small changes to the financing arrangements. Demands for reforms have increased particularly in light of the pandemic (Dawson et al. 2021).

References:

De Biasi, A. et al. Creating an Age-Friendly Public Health System (2020). Innovation in Aging, Volume 4, Issue 1, https://doi.org/10.1093/geroni/igz044

Dawson, W. D., Boucher, N. A., Stone, R., & Van Houtven, C. H. (2021). COVID-19: The Time for Collaboration Between Long-Term Services and Supports, Health Care Systems, and Public Health Is Now. The Milbank Quarterly, 99(2), 565–594. https://doi.org/10.1111/1468-0009.12500

Update for: United States Last updated: February 11th, 2022

1.03. Long-term care financing arrangements and coverage

In 2018 LTC expenditure represented 0.8% of Gross Domestic Product in the United States (source: https://stats.oecd.org/Index). The financing of LTC in the United States is a continuous and growing challenge. Medicaid is the primary payer for formal LTC services, accounting for over half of national spending in 2017, however it is means-tested: it requires proof of need and exhaustion of individual financial resources (e.g. low-income status and/or limited savings). In 2016, the majority of Medicaid LTC funding was spent on home and community-based services (57%), but several states still apply their Medicaid dollars primarily to institutional care. Coverage and spending on LTC schemes also vary significantly by state (source: Long-term care financing in the US).

Some states fund home and community-based services through Medicaid waivers, and some even allow for self-directed Medicaid funds for payment of informal carers (sources: van Houtven et al. 2020; Vital and Health Statistics). An estimated 7.4 million Americans own private LTC insurance policy (around 15% of persons 65 and over).

References:

Van Houtven, CH., Boucher NA, Dawson WD (2020) The Impact of COVID-19 Outbreak on Long Term Care in the United States. Country report in LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE, 24th April 2020. Retrieved from: Article from ltccovid.org

Update for: United States Last updated: February 15th, 2022

1.06. Care coordination

Despite Medicaid and Medicare’s central role in the funding of LTC services, the LTC and health care sectors are not integrated. Differences in how medical care and LTC are paid for, and prioritized in each state, as well as the ownership of healthcare organizations (i.e. hospitals) compared to the LTC sector, hampers coordination of services as well as opportunities for a joint care delivery system (Dawson et al. 2021).

References:

Update for: United States Last updated: February 11th, 2022

1.07. Information and monitoring systems

While states differ in their collection of data, federal evaluations of LTC services and needs use the Center for Disease Control’s (CDC) recently renamed National Post-Acute and Long-Term Care Studies (NPALS). Information and statistics on adult day centre services and participants as well as residential care communities can be accessed dating back to 2012 on the CDC website (source: https://www.cdc.gov/nchs/npals/reports.htm).

Update for: United States Last updated: February 11th, 2022

1.08. Care home infrastructure

The Center for Disease Control (CDC) studies LTCFs with regards to the following categories: adult day services centres, nursing homes, residential care communities, hospices and home-health agencies. State-by-state information on the number of each kind of LTCF, the number of people they serve, ownership (i.e. for-profit or governmental), certification, staffing, and services provided can be found in the CDC’s National Post-Acute and LTC Study (source: https://www.cdc.gov/nchs/data/nsltcp/2016_CombinedNSLTCPStateTables_opt.pdf).

Update for: United States Last updated: February 11th, 2022

1.10. Workforce conditions: pay, employment conditions, qualification levels, shortages

According to data published by the US Department of Health and Human Services, in 2015-2016 there were almost 1.5 million nursing employee full-time equivalents (FTEs) working across the five sectors of long-term care in the United States. This includes registered nurses (RNs), licensed practical or vocational nurses (LPNs or LVNs), and healthcare aides, as well as approximately 35,000 social work FTEs. The majority (63.3%, or 945,700 FTEs) work in nursing homes, 20.0% are residential care community employees, 9.7% are employed by home health agencies, 5.7% are employed by hospices, and 1.3% are adult day services centre employees. Employment conditions and required qualifications vary a great deal across the sectors; a breakdown of employment rates in each sector can be found beginning on page 18 of the CDC report.

Nursing home workforce

The nursing home workforce is composed of nursing assistants, licensed practical/vocational nurses, and registered nurses. Nursing assistants provide hands-on care with daily activities such as eating, toileting, dressing, and toileting. Licensed practical or vocational nurses administer medications or wound treatments while registered nurses oversee the overall nursing care of nursing home residents.

According to a report, 9 out of 10 nursing assistants who work in nursing homes are women. One in three has a child under the age of 18 at home and about 15% have a child under the age of five. Less than half of nursing assistants have completed education beyond high school. Approximately 54% of all nursing assistants in nursing homes are people of color, 36% of which are Black of African American. Additionally, 20% of nursing assistants are immigrants.

Update for: United States Last updated: February 11th, 2022 Contributors: William Byrd | Nerina Girasol |

1.11. Role of unpaid carers and policies to support them

The US system relies heavily on informal (unpaid) caregivers: 75% of those needing LTC rely solely on informal caregivers and approximately 41 million Americans are unpaid caregivers (Upadhyay and Weiner, 2019). These demands are also disproportionately experienced by women, individuals of low socioeconomic status, and minority racial and ethnic populations. Over the past 10 years some States used provisions in the Affordable Care Act to redistribute some Medicaid funds towards at-home, informal caregiving, nationally this shift has been small (van Houtven et al. 2020).

References:

Upadhyay P. and Weiner J. (2019) Long-Term Care financing in the United States. Leonard Davis Institute of Health Economics, Issue Brief 23(1). University of Pennsylvania.

Van Houtven, CH., Boucher NA, Dawson, WD. (2020). The Impact of COVID-19 Outbreak on Long Term Care in the United States. Country report in LTCcovid.org, International Long-Term Care Policy Network, CPEC-LSE, 24th April 2020. Retrieved from: Article from ltccovid.org

Update for: United States Last updated: February 16th, 2022

1.14. Pandemic preparedness of the Long-term care sector

The LTC sector in the United States was unprepared for the pandemic; some reports have described it as disastrous and staggering. One key challenge during COVID-19 faced by the LTC sectors was the fundamental (mis)structuring of financial arrangements, which determine the reimbursement, regulatory framework, and design of the services delivered. These arrangements determine which sectors would have enough resources and systems in place (e.g. PPE, infection control training) to respond to the pandemic (source: Dawson et al., 2021; NYTimes).

Lessons on pandemic preparedness can be drawn from experiences from natural disasters, according to authors of a recent study (Peterson et al., 2021). This study explored the experiences of LTC facilities: Nursing Homes (NH) and Assisted Living Communities (ALCs) in Florida, following hurricane Irma in 2017. The findings showed that despite federal disaster preparedness regulations and experience with disasters like hurricanes, NHs and ALCs in Florida experienced issues that highlighted response gaps, highlighting that adequate preparedness goes beyond simply putting in place regulations. The study highlights the importance of lLTC organisations building and maintaining connections with those who can provide support, including relationships with emergency managers and community organisations.

References:

Peterson, L. J., Dobbs, D., June, J., Dosa, D. M., & Hyer, K. (2021). “You Just Forge Ahead”: The Continuing Challenges of Disaster Preparedness and Response in Long-Term Care. 5(4), 1–13. https://doi.org/10.1093/geroni/igab038

Update for: United States Last updated: February 11th, 2022 Contributors: Daisy Pharoah | Joanna Marczak |

2.01. Impact of the COVID-19 pandemic on the country (total population)

As of early March 2021, the United States had identified 29.5 million cases of COVID-19, and over 530,000 deaths. As of this date, the United States has been the country hit hardest by the pandemic per capita.

Update for: United States Last updated: July 29th, 2021

2.02. Deaths attributed to COVID-19 among people using long-term care

This covers cumulative deaths in US care homes (nursing facilities, assisted living facilities, and other long-term care facilities) from January 1, 2020, through to March 29, 2021. Information about deaths in care homes comes from three sources: the Center for Medicare and Medicaid Services (CMS), the Kaiser Family Foundation (KFF), and the COVID Tracking Project (CTP) produced by The Atlantic Magazine. As of March 7, 2021, COVID Tracking Project has stopped collecting data. We derived COVID-19 mortality estimates by starting with state-level figures, which were reported directly by each of the sources (Sources: https://data.cms.gov/stories/s/COVID-19-Nursing-Home-Data/bkwz-xpvg/; https://www.kff.org/coronavirus-covid-19/issue-brief/state-covid-19-data-and-policy-actions/#long-term-care-cases-deaths; https://covidtracking.com/). We started with state-level figures to address inconsistencies between the three data systems in the number of recorded COVID-19 deaths. Because the sources draw from different sources, their state totals differ. By starting at the state level, we were able to pick the ‘best’ estimate of care home COVID-19 deaths from each state from among the three data systems. To obtain the ‘best’ estimate of care home COVID-19 deaths, we selected the highest number of deaths recorded for each state from among the three sources. The ‘best’ estimate was a cumulative number of 185,269 COVID-19 related deaths in care homes. Based on this data, care home COVID-19 related deaths account for 34% of all COVID-19 related deaths.

The number of residents in care homes was approximated by adding the residents in nursing facilities from the Center for Medicare and Medicaid Services data and the number of residents in assisted living facilities taken from a report by the National Center for Assisted Living, to get 1,937,345. Therefore, the total number of COVID-19 related deaths in care homes represents 9.56% of this population.

Update for: United States Last updated: August 2nd, 2021

2.04. Impacts of the pandemic on access to care for people who use Long-Term Care

Reductions in access to care for people living in the community

Qualitative interviews with professionals supporting people living with dementia and their family carers in four US states showed that, during the shelter-in-place periods in March to May 2020, fear of contracting COVID-19 led to reluctance in using medical care and respite care services. Concerns about restrictions to visiting and inability to provide care also led to reluctance to consider moving to care homes. When carers did seek services, they found that these were less available (or in the case of day care services, not at all). Carers also reported shortages of key supplies, including incontinence products and groceries. However, this study also showed how existing staff in Care Ecosystem programmes adapted their ways of working to provide additional support, including helping family carers learn how to use technology, practical in-home activity ideas, and help them navigate access to information and resources (Merrilees et al., 2022).

References:

Merrilees J., Robinson-Teran J. Allawala M., et al. (2022). Responding to the needs of persons living with dementia and their caregivers during the COVID-19 pandemic: Lessons from the Care Ecosystem, Innovation in Aging, 2022;, igac007, https://doi.org/10.1093/geroni/igac007

Update for: United States Last updated: March 3rd, 2022 Contributors: Adelina Comas-Herrera |

2.05. Impacts of the pandemic on the health and wellbeing of people who use Long-Term Care

A study of 224 nursing homes in Connecticut (US) found significant deterioration among residents in a broad range of physical and mental health measures. This study used Minimum Data Set assessments to measure outcomes for nursing home residents between March and July 2020 to compare to outcomes observed in 2017-2019. The study found that nursing home resident outcomes such as depression, unplanned substantial weight loss, episodes of incontinence and cognitive function worsened during that period. Weight loss, which is considered a good indicator for physical deterioration, was greater for residents who had contracted COVID-19. Other outcomes, such as severe pressure ulcers or activities of daily living scores did not show significant changes (Levere et al., 2021).

References:

Levere M., Rowan P., Wysocki A. (2021) The adverse effect of the COVID-19 pandemic on nursing home resident well-being. J Am Med Dir Assoc 2021; https://doi.org/10.1016/j.jamda.2021.03.010

Update for: United States Last updated: January 10th, 2022

2.07. Impacts of the pandemic on unpaid carers

Many unpaid carers in the United States increased their care commitment as reduced community services were available. Carers reported experiencing delayed access to medical care and expressed financial concerns. Carers also reported increased stress, conflicts, isolation and other negative implications (https://ltccovid.org/wp-content/uploads/2021/01/Lorenz_Comas_COVID_impact_unpaidcarers_preprint.pdf; https://ucsur.pitt.edu/files/center/covid19_cg/COVID19_Full_Report_Final.pdf; https://ucsur.pitt.edu/files/center/covid19_cg/COVID19_Full_Report_Final.pdf; https://www.usagainstalzheimers.org/covid-19-surveys; https://academic.oup.com/psychsocgerontology/article/76/4/e241/5895926).

Update for: United States Last updated: January 6th, 2022

2.08. Impacts of the pandemic on people working in the Long-Term Care sector

Impacts on community-based workers:

A qualitative study of the experiences of 33 home health workers in New York City carried out from March to April 2020 found that workers felt invisible even though they were on the frontline of the COVID-19 pandemic, had high risk of virus transmission and were forced to make difficult decisions between their work and personal lives, exacerbating existing inequities. The majority of respondents were women of color. The respondents were aware that, due to lack of Personal Protection Equipment and relying on public transport, they were at high risk of infection and they also posed a risk to the people they provided care to and own their families. As well as anxiety about COVID risks, the respondents were also concerned about the implications of the pandemic for their already precarious financial situation (Sterling et al., 2020).

Impacts on nursing home staff:

Qualitative analysis from an electronic survey of 152 nursing home staff from 32 states carried out from 11th May to 4th June 2020 found that staff were working under complex and stressful circumstances. Respondents reported burnout and described enormous emotional, physical and mental burdens of having to taken heavier workloads and learning new roles and processes. They expressed concern about the situation experienced by residents, which added to the emotional toll and fears about becoming infected and infecting their families as a result. Respondents also expressed feeling demoralised as a result of negative media coverage of nursing homes and feeling that hospital staff were given much more praise, resources and recognition (White et al., 2021).

References:

Sterling M.R., Tseng E., Poon A. et al. (2020) Experiences of Home Health Care workers in New York City during the Coronavirus-2019 pandemic. JAMA Intern Med. 180(11):1453-1459. doi:10.1001/jamainternmed.2020.3930

White E.M., Fox Wetle T., Reddy A. and Baier R.R. (2021) Front-line nursing home staff experiences during the COVID-19 pandemic. JAMDA 22(1):199-203. https://doi.org/10.1016/j.jamda.2020.11.022

Update for: United States Last updated: January 10th, 2022

2.10. Financial and other impacts of the pandemic on Long-Term Care providers

Impact on workforce shortages

Data from the Bureau of Labor Statistics, reported by the KFF Health Systems Tracker shows that the number of people working in Long-Term Care Facilities has declined by substantial between February 2020 and November 2021. The number of people employed in community elder care facilities declined by 11.1%, from 976,100 employees to 867,700. The number of people working in nursing care facilities decreased by 15.0%, from 1.59 million to 1.35. This builds on a previous trend, employment on nursing homes had been declining at an average of 0.09% per month between 2017 and early 2020.

Increased wages

The KFF Health Systems Tracker also reports that average earnings rose by over 14.7% between February 2020 and October 2021, from $669.90 to $768.56 per week. Wages of home healthcare workers rose by 13.8% from $586.46 to $667.28.

Update for: United States Last updated: January 5th, 2022

3.01. Brief summary of the overall pandemic response (not specific to Long-Term Care)

The United States has been the country hit hardest by the pandemic per capita. Public health responses have primarily been delineated by state and local government, but general stay-at-home and mask-wearing orders have been in place across the country since March 2020 (Source: https://www.cdc.gov/nchs/nvss/vsrr/covid_weekly/index.htm).

Update for: United States Last updated: September 8th, 2021

3.02. Governance of the Long-Term Care sector's pandemic response

The United States, according to the Global Health Security Index, was considered to be the country most prepared in the world for a pandemic, and studies as to why its failures were so extreme are underway. President Trump declared COVID-19 a public health emergency on February 3, 2021. Jurisdiction regarding stay-at-home orders, travel quarantines, and sheltering in place is given to the individual states, which led to what is a considered a highly-politicized divide in local and regional responses and mandates (Source: https://ltccovid.org/wp-content/uploads/2020/04/USA-LTC-COVID-situation-report-24-April-2020.pdf).

Update for: United States Last updated: September 8th, 2021

3.02.01. National or equivalent Covid-19 Long-Term Care taskforce

Both President Trump and President Biden crafted national COVID-19 taskforces, with experts from varying backgrounds. President Biden’s new taskforce explicitly prioritizes the need to “protect older Americans and others at high-risk.” While this has not resulted in an explicit federal social care taskforce, the President’s program has responded to this need by introducing a COVID-19 Racial and Ethnic Disparities Task Force to address major inequities which have come to particular light within the LTC sector (Source: https://www.whitehouse.gov/priorities/covid-19/).

Update for: United States Last updated: September 9th, 2021

3.03. Monitoring Covid-19 impacts in the Long-Term Care sector: data and information systems

There are multiple on-going studies and information systems tracking the impact of the pandemic on LTC users. The official government data system for tracking COVID-19 in nursing facilities and other LTCFs is through the Center for Disease Control’s (CDC) National Healthcare Safety Network (Source: https://www.cdc.gov/nhsn/ltc/covid19/index.html). In coordination with the federal agency for health insurance programs, the Center for Medicare and Medicaid Services (CMS), this Network has produced a Nursing Home COVID-19 Public File to which over 15,000 certified nursing facilities nationwide are expected to report related data weekly. The CMS can impose financial penalties if facilities do not report, and compliance has thus been nearly 100% (Sources: https://ltccovid.org/wp-content/uploads/2021/02/LTC_COVID_19_international_report_January-1-February-1-1.pdf; https://data.cms.gov/stories/s/COVID-19-Nursing-Home-Data/bkwz-xpvg/). Other, independent information systems tracking the impact of the pandemic in LTCFs include the Kaiser Family Foundation (KFF) and The Atlantic Magazine’s COVID Tracking Project (CTP) (Source: https://www.kff.org/coronavirus-covid-19/issue-brief/state-covid-19-data-and-policy-actions/#long-term-care-cases-deaths; https://covidtracking.com/).

Update for: United States Last updated: September 9th, 2021

3.06. Support for care sector staff and measures to ensure workforce availability

A survey of 11,920 nursing homes (NH) in May 2020 found that 15.9% reported shortages of licensed nurse staff, 18.4% of nurse aides, 2.5% of clinical staff and 9.8% of other staff. The study found that staff shortages were associated with COVID-19 related factors: NHs with any case of COVID-19 among residents or staff were more likely to experience staff shortages. NHs with more supplies of Personal Protection Equipment (PPE) were less likely to report staff shortages. Also, NHs with higher staffing levels (particularly higher ratios of registered nurses) were less likely to report shortages (Xu et al., 2020).

Increased wages

The KFF Health Systems Tracker reports that average earnings rose by over 14.7% between February 2020 and October 2021, from $669.90 to $768.56 per week. Wages of home healthcare workers rose by 13.8% from $586.46 to $667.28. This is in the context ongoing declines in the numbers of people working in this sector, which accelerated during the pandemic.

References:

Xu, H., Intrator, O., & Bowblis, J. R. (2020). Shortages of Staff in Nursing Homes During the COVID-19 Pandemic: What are the Driving Factors?. Journal of the American Medical Directors Association, 21(10), 1371–1377. https://doi.org/10.1016/j.jamda.2020.08.002)

Update for: United States Last updated: January 6th, 2022

3.06.01. Surge staffing and other measures to support care homes with outbreaks or critical staff shortages

Practical support for understaffed care homes:

During December 2021 the National Guard has been deployed to nursing homes across the United States to enable nursing homes with critically low numbers of staff to continue to operate. There is an acute shortage of staff in nursing homes across the country (a pre-pandemic problem).

In Minnesota 400 guard members with no previous experience in care have undergone rapid training before being sent to provide temporary support to nursing homes facing severe staffing shortages homes. The 75 hour training programme has been provided over 8 days, online and in person, by the Minnesota Department of Health and Minnesota National Guard medical staff, through sixteen Minnesota State community and technical colleges, the Guard members quality as emergency certified nursing assistants (CNA) and termporary nursing aides. This is in addition to an initiative to recruit, train and deploy at least 1,000 new certified nursing assistants for Long-Term Care Facilities in Minnesota by the end of January and an expansion of the emergency staffing pool so that short-term emergency temporary staff can be deployed to open up additional long-term care beds for people who are ready to be discharged from hosptial.

In October 2021 a provider survey found that 23,000 nursing home positions were unfilled in Minnesota, 8,000 more than in March of the same year.

Infection Prevention and Control strike teams:

In the United States a federal strike team initiative offered technical assistance and recommendations to facilities experiencing large outbreaks, with a focus on controlling the outbreak. The strike teams were deployed to nursing homes with outbreaks of 30 or more cases and typically included infection prevention specialists, epidemiologists and public health experts.

Analysis of the reports from the strike teams visits to 96 nursing homes in 30 states between July and November 2020, had support from federal strike teams. These nursing homes faced challenges related to staffing, lack of Personal Protection Equipment (PPE), COVID-19 testing and implementation of COVID-19 Infection Prevention and Control (IPC).

The American Rescue Plan Act of 2021 has made available $500 million through the Centers for Disease Control and Prevention (CDC)’s Epidemiology and Laboratory Capacity (ELC) Cooperative Agreement, for the Nursing Home & Long-Term Care Facility Strike Team and Infrastructure Project. The funds can be used on temporary staff and also to procure needed laboratory equipment, PPE, and technology to help reporting.

Virtual support:

In the United States there were also many examples of community health teams supporting nursing home staff, for example via telemedicine.

Update for: United States Last updated: February 18th, 2022

3.07. Infection Prevention and Control measures in the Long-Term Care sector: guidance, support and implementation

Guidance

Guidance for LTCFs in the United States regarding COVID-19 infection prevention and control is regularly provided and updated by the Center for Disease Control and Prevention (CDC). The instructions (e.g. on PPE, distancing, quarantining) can be found here: CDC/Covid-19.

Technical support in managing outbreaks and Infection Prevention and Control (IPC)

In the United States a federal strike team initiative offers technical assistance and recommendations to Long-Term Care facilities experiencing large outbreaks, with a focus on controlling the outbreak. The strike teams were deployed to nursing homes with outbreaks of 30 or more cases and typically included infection prevention specialists, epidemiologists and public health experts.

Layout of the facilities and lack of space
Critical staff shortages and staff burnout, lack of staff trained in IPC
Delays in test results
PPE shortages
Rapidly changing guidance and lack of established lines of communications with agencies that issue guidance

Training in IPC

The Centres for Disease Control and Prevention and the Centers for Medicare & Medicaid Services (CMS) developed and made available a free online course: “Nursing Home Infection Preventionist Training Course” in March 2019 and in October 2020 launched project Firstline, a set of resources on IPC that includes short training videos for nursing homes.

In the first half of 2020, Médecins Sans Frontières (MSF) started working with nursing homes in Michigan by providing health education training on infection control measures to help prevent the spread of COVID-19 in these facilities. Feedback from the training was particularly positive from the non-medical staff (such as those working in the kitchen) who were less likely to have had any previous training on ways in which to protect themselves and the residents (source: MSF, 2020).

Update for: United States Last updated: February 6th, 2022 Contributors: Daisy Pharoah |

3.07.01. Measures in relation to transfers to and from hospital, from community to care homes and between settings

In New York, following a hugely controversial directive from New York State’s Health Department on March 25, 2020, approximately 6,300 recovering coronavirus patients were transferred from hospitals into nursing homes throughout April (the peak of New York’s pandemic surge). The policy was defended by the Governor’s office, which argued that not only was this based on federal guidance, but that the devastation in nursing and long-term care facilities had more to do with the infection rates amongst staff. Regardless, the policy was overturned by mid-May and replaced with a new mandate such that patients could not enter nursing homes without a negative COVID test. News sources also counted over 2,700 “readmissions” of patients sent back from hospital to nursing homes they had previously lived in during that time. The executive board of The Society for Post-Acute and Long-Term Care Medicine (AMDA) estimated that 5,000 deaths in nursing homes and LTCFs are a direct result of that order (https://apnews.com/article/new-york-andrew-cuomo-us-news-coronavirus-pandemic-nursing-homes-512cae0abb55a55f375b3192f2cdd6b5; https://apnews.com/article/5ebc0ad45b73a899efa81f098330204c).

Update for: United States Last updated: September 9th, 2021

3.07.02. Approach to isolation of people with confirmed or suspected Covid-19 infections in care homes

Guidance:

The Centers for Disease Control guidelines encourage suspected and confirmed cases amongst new and returning residents of LTCFs to be placed in a designated, in-house COVID-care unit.

Evidence on isolation approaches:

Tiered cohorting to separate positive, exposed, and unexposed residents

This study describes a rapidly deployed point-prevalence testing and 3-tiered cohorting in an urban skilled nursing facility (SNF) in Chicago with over 200 beds spread over 4 floors, including a memory-care unit floor. Three resident cohorts were created: positive (red), negative-cleared (green), and negative exposed (yellow).

On COVID-19 positive floors, sharing rooms was permitted, whereas on COVID-19 negative-exposed floors, residents were placed in their own rooms. The memory floor was separated into positive and negative cohorts, because off-floor relocation was believed to potentially cause more harm than benefit given the care needs of residents with dementia. Initial testing (n=120) identified 43 negative-exposed residents and 77 positive residents. Of those residents who were negative, testing performed 1 week later revealed 12 residents had converted to positive. Ten of the 12 who converted were on the memory-care unity (Collison et al., 2020)

Cohorting positive or exposed residents in specific units

A study by Dora et al. (2021) reported on the serology results following an outbreak in a skilled nursing facility (SNF) at the Veterans Affairs Greater Los Angeles Healthcare System West Los Angeles (WLA) campus where residents were serially tested and positive residents were cohorted.

From 28 to 30 March 2020, symptom based testing identified 3 COVID-19 cases. In response, all remaining patients (n=96) underwent testing. Between 29 March and 6 April, 16 additional cases were identified. These 16 and the original 3 patients were transferred to the acute care hospital for treatment or a designated COVID-19 recovery unit (CRU) located within the SNF. No further cases were identified upon additional testing. An additional 9 patients from the community who were diagnosed with COVID-19 were transferred to the CRU by 5 June. When tested 46-76 days later, 24 of 26 positive residents available for testing were seropositive. None of the 124 negative residents had confirmed seropositivity.

Another study describes the interruption of a potential outbreak of COVID-19 in a 120 bed hospital affiliated long-term care facility in Florida using a point prevalence testing containment strategy. Universal prevalence testing was undertaken every 14 days for 6 weeks, starting on April 8, 2020. A cohort unit was established to avoid placing unexposed residents into a shared space with exposed residents. This included private rooms with a private bathroom. All positive confirmed cases were transferred to the hospital for complete medical evaluation and airborne isolation. The cohort unit did not see any conversions to positive. Over 6 weeks the spread of the disease was contained shown by the prevalence decreasing from 5.4% to 3.6% to 0.4%. From April 7 – May 6, a total of 9 patients were positive at the facility (Eckardt et al., 2020).

A case study on the response to an outbreak of COVID-19 in a long-term care facility (LTCF) in West Virginia. The facility is a free-standing structure with a 100-bed capacity, providing long-term care, skilled nursing, and hospice care. On March 22, 2020, an index case was identified. Within 36 hours, 21 of 98 residents initially tested were identified as positive. The facility has six separate units with four nursing stations. The designated isolation unit was chosen due to no shared common space with other units and a private nursing station. Each resident room had its own ventilation, recirculating air. As of August 20, 2020, the facility has had 52 residents test positive. The resident rate of infection (53%) and mortality (5%) are better than reported world averages for LTCFs (Shrader et al., 2020).

Isolation of positive residents in private rooms

A study conducted in 123 West Virginia in nursing homes in April 21 through May 8, 2020 reported on a universal testing strategy and isolation in private rooms. In nursing homes with active outbreaks, all persons received testing who had previously tested negative or had not been tested. All patients with positive test results were isolated in private rooms. Following universal testing, nursing homes screened residents daily and tested anyone with signs or symptoms of COVID-19. If additional cases were identified, testing was performed for close contacts. In total, 42 COVID-19 cases were identified in 28 nursing homes. Of these cases, 11 were residents. The 42 cases represented 20 single cases from 20 facilities and 22 outbreak associated cases, representing new outbreaks in eight facilities. In six of the eight nursing homes with newly identified outbreaks where cohorting of residents with positive test results was implemeneted, daily symptom screening of all residents and staff members for 28 days found that further transmission did not occur (McBee et al., 2020).

Isolation in negative pressure isolation spaces

A case study reports on the design, implementation, and validation of an isolation space at a skilled nursing facility (SNF) in Lancaster, Pennsylvania, with 114 beds. One hall was the subject of this study which consisted of 6 double occupancy rooms and one single occupancy room, all with single bathrooms.

The negative pressure isolation space was created on April 6, 2020, by modifying an existing HVAC system of the SNF. These modifications were not resource intensive and were rapidly established. As of June 23, 14 confirmed positive residents had been treated in the negative isolation space and the facility had utilised the isolation space for a total of 21 individuals. No transmission between residents isolated to the space occurred, not did any transmission to other residents occur (Miller et al., 2021).

References:

Collison, M., Beiting, K. J., Walker, J., Huisingh-Scheetz, M., Pisano, J., Chia, S., Marrs, R., Landon, E., Levine, S., & Gleason, L. J. (2020). Three-Tiered COVID-19 Cohorting Strategy and Implications for Memory-Care. Journal of the American Medical Directors Association, 21(11), 1560–1562. https://doi.org/10.1016/j.jamda.2020.09.001

Dora V, A., Winnett, A., Fulcher, J. A., Sohn, L., Calub, F., Lee-Chang, I., Ghadishah, E., Schwartzman, W. A., Beenhouwer, D. O., Vallone, J., Graber, C. J., Goetz, M. B., & Bhattacharya, D. (2021). Using Serologic Testing to Assess the Effectiveness of Outbreak Control Efforts, Serial Polymerase Chain Reaction Testing, and Cohorting of Positive Severe Acute Respiratory Syndrome Coronavirus 2 Patients in a Skilled Nursing Facility. CLINICAL INFECTIOUS DISEASES, 73(3), 545–548. https://doi.org/10.1093/cid/ciaa1286

Eckardt, P., Guran, R., Hennemyre, J., Arikupurathu, R., Poveda, J., Miller, N., Katz, R., & Frum, J. (2020). Hospital affiliated long term care facility COVID-19 containment strategy by using prevalence testing and infection control best practices. American Journal of Infection Control. https://doi.org/10.1016/j.ajic.2020.06.215

McBee, S. M., Thomasson, E. D., Scott, M. A., Reed, C. L., Epstein, L., Atkins, A., & Slemp, C. C. (2020). Notes from the Field: Universal Statewide Laboratory Testing for SARS-CoV-2 in Nursing Homes – West Virginia, April 21-May 8, 2020. MMWR. Morbidity and Mortality Weekly Report, 69(34), 1177–1179. https://doi.org/10.15585/mmwr.mm6934a4

Miller, S. L., Mukherjee, D., Wilson, J., Clements, N., & Steiner, C. (2021). Implementing a negative pressure isolation space within a skilled nursing facility to control SARS-CoV-2 transmission. American Journal of Infection Control, 49(4), 438–446. https://doi.org/10.1016/j.ajic.2020.09.014

Shrader, C. D., Assadzandi, S., Pilkerton, C. S., & Ashcraft, A. M. (2020). Responding to a COVID-19 Outbreak at a Long-Term Care Facility. Journal of Applied Gerontology?: The Official Journal of the Southern Gerontological Society, 733464820959163. https://doi.org/10.1177/0733464820959163

Update for: United States Last updated: January 13th, 2022 Contributors: William Byrd |

3.07.03. Visiting and unpaid carer policies in care homes

In the United States visitation guidelines fall into the decision-making power of the different states. States can decide whether they want to issue guidelines across the state or to provide them on an ‘individual facility basis’. A review found that most states leave care homes to make final decision on safe opening procedures (https://ltccovid.org/wp-content/uploads/2021/01/Care-home-visiting-policies-international-report-19-January-2021-1.pdf).

CMS guidance on care home visiting from September 2020 can be found here: https://www.cms.gov/files/document/qso-20-39-nh.pdf. As of March 10, 2021, President Biden relaxed the federal guidelines (recommendations) on nursing and long-term care home visiting policies for the first time since September 2020 (https://www.nytimes.com/2021/03/10/us/politics/coronavirus-nursing-homes.html).

Update for: United States Last updated: September 8th, 2021

3.09. Access to Personal Protection Equipment (PPE) in the Long-Term Care sector

An electronic survey of 152 nursing home staff from 32 states, including direct care staff and administrators carried out from the 11th May to the 4th June 2020 showed that by then availability of PPE had improved compared to the earlier part of the pandemic. However, there were still shortages, resulting in extended reuse of PPE and supplementation with homemade PPE. Staff in management roles spending large amounts of time (and money) to obtain sufficient supplies of PPE, having to rely on unconventional suppliers.

Update for: United States Last updated: January 2nd, 2022

3.10. Use of technology to compensate for difficulties accessing in-person care and support

A recent study by Schuster and Cotten (2022) explored the use of ICTs across 70 LTC facilities (12 nursing homes and 58 assisted living facilities) in South Carolina during the pandemic. 61% of the LTC facility administrators surveyed reported an increase in technology spending at their facility, although the main method of purchase was through facility funds (with only 45% reporting funding through Medicaid or Medicare services). Roughly 42% of residents used the technology provided by facilities and a quarter were unable to use the ICTs (owing to health or other impairments). Overall, the study found that the key benefit of ICTs was promoting feelings of connectedness to family, friends, and other residents. Barriers to ICT use by residents included a shortage of staff to assist with ICT use and technology that didn’t work.

References:

Schuster, A. M., & Cotten, S. R. (2022). COVID-19’s Influence on Information and Communication Technologies in Long-Term Care: Results From a Web-Based Survey With Long-Term Care Administrators. JMIR Aging 2022;5(1):E32442 Https://Aging.Jmir.Org/2022/1/E32442, 5(1), e32442. https://doi.org/10.2196/32442

Update for: United States Last updated: February 17th, 2022

3.11. Vaccination policies for people using and providing Long-Term Care

The United States’ federal effort to get nursing and long-term care home residents vaccinated, known as the Pharmacy Partnership for Long-Term Care Program, partnered with pharmacies such as Walgreens and CVS to set up vaccination clinics in and around LTCFs. The federal program used a statistical formula that has significantly overestimated how many doses would be needed for long-term care facilities, leading some states such as Oklahoma and Maine to redistribute the federally-provided vaccinations to those 65 and older living at home. A map containing the number of doses distributed from this Long-Term Care Program specifically was shared on the CDC website.

On March 11th 2021, President Biden’s administration announced an updated timeline for vaccination across the country, making all adults eligible for vaccination by May 1st due to the success of vaccination rates of the highest priority groups.

On 18th August 2021, President Biden announced that the week of 20th September booster shots would start being administered to individuals who had had the second dose eight months before, the first citizens that will be eligible will be healthcare providers, residents in nursing homes and other older people. The President also announced that COVID-19 vaccinations would be mandatory for all Long-Term Care workers for Medicare and Medicaid services.

Due to the raising infections and deaths in nursing home facilities in Omicron wave in the US, there has been a renewed push to get more residents and staff members vaccinated and boosted. In December 2021, a federal appeals court revived in 26 U.S. states a COVID-19 mandate issued by President Biden’s administration requiring healthcare workers to get vaccinated if they work in facilities that receive federal funding.

Update for: United States Last updated: January 18th, 2022

3.12. Measures to support unpaid carers

Policy measures:

During the pandemic Medicaid allowed more people with care needs to hire family members as paid carers.

Home-based tele-health has been expanded and the Care Act requires a caregiver to be registered within people’s health records.

Some US guidance includes unpaid carers in the vaccination priority list.

Care Ecosystem programmes: adapting to support unpaid carers and people with dementia

Qualitative interviews with professionals supporting people living with dementia and their family carers in four US states with established Care Ecoystem programmes showed that, during the shelter-in-place periods in March to May 2020, fear of contracting COVID-19 led to reluctance in using medical care and respite care services. Concerns about restrictions to visiting and inability to provide care also led to reluctance to consider moving to care homes. When carers did seek services, they found that these were less available (or in the case of day care services, not at all). Carers also reported shortages of key supplies, including incontinence products and groceries. Staff from the existing However, this study also showed how existing staff (mainly Care Team Navigators) adapted their ways of working to provide additional support, including helping family carers learn how to use technology, practical in-home activity ideas, and help them navigate access to information and resources (Merrilees et al., 2022).

References:

Update for: United States Last updated: March 3rd, 2022