"It's Not a Sprint, It's a Marathon": Stages of Managing a Nursing Home Throughout the Pandemic.

OBJECTIVES: To qualitatively examine the impact of COVID-19 on nursing homes over the course of the pandemic from the perspective of nursing home administrators. DESIGN: In-depth, semi-structured interviews with nursing home administrators, repeated 3 months apart for a total of 4 each from July 2020 through December 2021. SETTINGS AND PARTICIPANTS: Administrators from a total of 40 nursing homes from 8 health care markets across the United States. METHODS: Interviews were conducted virtually or via phone. The research team identified overarching themes using applied thematic analysis, and iteratively coded transcribed interviews. RESULTS: Nursing home administrators across the United States reported challenges of managing nursing homes during a pandemic. We found their experiences could generally be categorized into 4 stages, not necessarily coinciding with surge levels of the virus. The initial stage was characterized by fear and confusion. The second stage, by a "new normal," a term administrators used to report feeling better prepared for an outbreak and how residents, staff, and families began to adjust to life with COVID. Administrators started using the phrase "a light at the end of the tunnel" to describe the third stage, characterized by the hope associated with the availability of vaccinations. The fourth stage was marked by "caregiver fatigue" as nursing homes experienced numerous breakthrough cases. Some challenges, like staffing issues and uncertainty about the future, were reported throughout the pandemic, as was a continued mission to keep residents safe. CONCLUSIONS AND IMPLICATIONS: As the ability of nursing homes to provide safe, effective care faces unprecedented and continued challenges, the insights reported here from longitudinal perspectives of nursing home administrators may help policy makers develop solutions to encourage high-quality care. Knowing how the needs for resources and support vary across the progression of these stages has the potential to be helpful in addressing these challenges.

Nursing home infection control strategies during the COVID-19 pandemic.

BACKGROUND: The American Rescue Plan Act of 2021 awarded $500 million toward scaling "strike teams" to mitigate the impact of Coronavirus Disease 2019 (COVID-19) within nursing homes. The Massachusetts Nursing Facility Accountability and Support Package (NFASP) piloted one such model during the first weeks of the pandemic, providing nursing homes financial, administrative, and educational support. For a subset of nursing homes deemed high-risk, the state offered supplemental, in-person technical infection control support. METHODS: Using state death certificate data and federal nursing home occupancy data, we examined longitudinal all-cause mortality per 100,000 residents and changes in occupancy across NFASP participants and subgroups that varied in their receipt of the supplemental intervention. RESULTS: Nursing home mortality peaked in the weeks preceding the NFASP, with a steeper increase among those receiving the supplemental intervention. There were contemporaneous declines in weekly occupancy. The potential for temporal confounding and differential selection across NFASP subgroups precluded estimation of causal effects of the intervention on mortality. CONCLUSIONS: We offer policy and design suggestions for future strike team iterations that could inform the allocation of state and federal funding. We recommend expanded data collection infrastructure and, ideally, randomized assignment to intervention subgroups to support causal inference as strike team models are scaled under the direction of state and federal agencies.

Perspectives of nursing home administrators across the United States during the COVID-19 pandemic.

OBJECTIVE: To characterize the experiences of nursing home administrators as they manage facilities across the United States during the COVID-19 pandemic. DATA SOURCES AND STUDY SETTING: We conducted 156 interviews, consisting of four repeated interviews with administrators from 40 nursing homes in eight health care markets across the country from July 2020 through December 2021. STUDY DESIGN: We subjected the interview transcripts to a rigorous qualitative analysis to identify overarching themes using a modified grounded theory approach to applied thematic analysis. DATA COLLECTION METHODS: In-depth, semi-structured qualitative interviews were conducted virtually or by phone, and audio-recorded, with participants' consent. Audio recordings were transcribed. PRINCIPAL FINDINGS: Interviews with nursing home administrators revealed a number of important cross-cutting themes. In interviewing each facility's administrator four times over the course of the pandemic, we heard perspectives regarding the stages of the pandemic, and how they varied by the facility and changed over time. We also heard how policies implemented by federal, state, and local governments to respond to COVID-19 were frequently changing, confusing, and conflicting. Administrators described the effect of COVID-19 and efforts to mitigate it on residents, including how restrictions on activities, communal dining, and visitation resulted in cognitive decline, depression, and weight loss. Administrators also discussed the impact of COVID-19 on staff and staffing levels, reporting widespread challenges in keeping facilities staffed as well as strategies used to hire and retain staff. Administrators described concerns for the sustainability of the nursing home industry resulting from the substantial costs and pressures associated with responding to COVID-19, the reductions in revenue, and the negative impact of how nursing homes appeared in the media. CONCLUSIONS: Findings from our research reflect nursing home administrator perspectives regarding challenges operating during COVID-19 and have substantial implications for policy and practice.

Medicare Skilled Nursing Facility Use and Spending Before and After Introduction of the Public Health Emergency Waiver During the COVID-19 Pandemic.

Importance: In response to the COVID-19 pandemic, Medicare introduced a public health emergency (PHE) waiver in March 2020, removing a 3-day hospitalization requirement before fee-for-service beneficiaries could receive skilled nursing facility (SNF) care benefits. Objective: To assess whether there were changes in SNF episode volume and Medicare spending on SNF care before and during the PHE among long-term care (LTC) residents and other Medicare beneficiaries. Design, Setting, and Participants: This retrospective cohort study used Medicare fee-for-service claims and the Minimum Data Set for Medicare beneficiaries who were reimbursed for SNF care episodes from January 2018 to September 2021 in US SNFs. Exposures: The prepandemic period (January 2018-February 2020) vs the PHE period (March 2020-September 2021). Main Outcomes and Measures: The main outcomes were SNF episode volume, characteristics, and costs. Episodes were defined as standard (with a preceding 3-day hospitalization) or waiver (with other or no acute care use). Results: Skilled nursing facility care was provided to 4 299 863 Medicare fee-for-service beneficiaries. Medicare beneficiaries had on average 130 400 monthly SNF episodes in the prepandemic period (mean [SD] age of beneficiaries, 78.9 [11.0] years; 59% female) and 108 575 monthly episodes in the PHE period (mean [SD] age of beneficiaries, 79.0 [11.1] years; 59% female). All waiver episodes increased from 6% to 32%, and waiver episodes without preceding acute care increased from 3% to 18% (from 4% to 49% among LTC residents). Skilled nursing facility episodes provided for LTC residents increased by 77% (from 15 538 to 27 537 monthly episodes), primarily due to waiver episodes provided for residents with COVID-19 in 2020 and early 2021 (62% of waiver episodes without preceding acute care). Skilled nursing facilities in the top quartile of waiver episodes were more often for-profit (80% vs 68%) and had lower quality ratings (mean [SD] overall star rating, 2.7 [1.4] vs 3.2 [1.4]; mean [SD] staffing star rating, 2.5 [1.1] vs 3.0 [1.2]) compared with SNFs in the other quartiles. Monthly Medicare spending on SNF care was $2.1 billion before the pandemic and $2.0 billion during the PHE. For LTC residents, monthly SNF spending increased from $301 million to $585 million while spending on hospitalizations remained relatively stable. Conclusions and Relevance: This cohort study found that the PHE waiver for SNF care was associated with a marked increase in the prevalence of SNF episodes without a preceding hospitalization, especially in the first year of the COVID-19 pandemic. The waiver was used primarily among certain types of facilities and for LTC residents with COVID-19. Although the effect of the waiver cannot be differentiated from that of the pandemic, overall SNF care costs did not increase substantially; for LTC residents, the waiver was applied primarily for COVID-19 care, suggesting the waiver's successful implementation.

Differences In Nursing Home Staff COVID-19 Testing Rates And Odds Of Vaccination Across Work Shifts.

COVID-19 vaccination and regular testing of nursing home staff have been critical interventions for mitigating COVID-19 outbreaks in US nursing homes. Although implementation of testing has largely been left to nursing home organizations to coordinate, vaccination occurred through a combination of state, federal, and organization efforts. Little research has focused on structural variation in these processes. We examined whether one structural factor, the primary shift worked by staff, was associated with differences in COVID-19 testing rates and odds of vaccination, using staff-level data from a multistate sample of 294 nursing homes. In facility fixed effects analyses, we found that night-shift staff had the lowest testing rates and lowest odds of vaccination, whereas day-shift staff had the highest testing rates and odds of vaccination. These findings highlight the need to coordinate resources and communication evenly across shifts when implementing large-scale processes in nursing homes and other organizations with shift-based workforces.

Association of State COVID-19 Vaccine Mandates With Staff Vaccination Coverage and Staffing Shortages in US Nursing Homes.

Importance: Several states implemented COVID-19 vaccine mandates for nursing home employees, which may have improved vaccine coverage but may have had the unintended consequence of staff departures. Objective: To assess whether state vaccine mandates for US nursing home employees are associated with staff vaccination rates and reported staff shortages. Design Setting and Participants: This cohort study performed event study analyses using National Healthcare Safety Network data from June 6, 2021, through November 14, 2021. Changes in weekly staff vaccination rates and reported staffing shortages were evaluated for nursing homes in states with mandates after the mandate announcement compared with changes in facilities in nonmandate states. An interaction between the mandates and county political leaning was considered. Data analysis was performed from February to March 2022. Exposures: Weeks after announcement of a state's COVID-19 vaccine mandate. Main Outcomes and Measures: Weekly percentage of all health care staff at a nursing home who received at least 1 COVID-19 vaccine dose, and a weekly indicator of whether a nursing home reported a staffing shortage. Results: Among 38 study-eligible states, 26 had no COVID-19 vaccine mandate for nursing home employees, 4 had a mandate with a test-out option, and 8 had a mandate with no test-out option. Ten weeks or more after mandate announcement, nursing homes in states with a mandate and no test-out option experienced a 6.9 percentage point (pp) increase in staff vaccination coverage (95% CI, -0.1 to 13.9); nursing homes in mandate states with a test-out option experienced a 3.1 pp increase (95% CI, 0.5 to 5.7) compared with facilities in nonmandate states. No significant increases were detected in the frequency of reported staffing shortages after a mandate announcement in mandate states with or without test-out options. Increases in vaccination rates in states with mandates were larger in Republican-leaning counties (14.3 pp if no test-out option; 4.3 pp with option), and there was no evidence of increased staffing shortages. Conclusions and Relevance: The findings of this cohort study suggest that state-level vaccine mandates were associated with increased staff vaccination coverage without increases in reported staffing shortages. Vaccination increases were largest when mandates had no test-out option and were also larger in Republican-leaning counties, which had lower mean baseline vaccination rates. These findings support the use of state mandates for booster doses for nursing home employees because they may improve vaccine coverage, even in areas with greater vaccine hesitancy.

Staffing Patterns in US Nursing Homes During COVID-19 Outbreaks.

Importance: Staff absences and departures at nursing homes may put residents at risk and present operational challenges. Objective: To quantify changes in nursing home facility staffing during and after a severe COVID-19 outbreak. Design Setting and Participants: In this cohort study, daily staffing payroll data were used to construct weekly measures of facility staffing, absences, departures, and use of overtime and contract staff among US nursing homes experiencing a severe COVID-19 outbreak that started between June 14, 2020, and January 1, 2021. Facility outbreaks were identified using COVID-19 case data. An event-study design with facility and week fixed effects was used to investigate the association of severe outbreaks with staffing measures. Exposures: Weeks since the beginning of a severe COVID-19 outbreak (4 weeks prior to 16 weeks after). Main Outcomes and Measures: Total weekly staffing hours, staff counts, staff absences, departures, new hires, overtime and contract staff hours measured for all nursing staff and separately by staff type (registered nurses, licensed practical nurses, certified nursing assistants), facility self-reported staff shortages, and resident deaths. Results: Of the included 2967 nursing homes experiencing severe COVID-19 outbreaks, severe outbreaks were associated with a statistically significant drop in nursing staffing levels owing to elevated absences and departures. Four weeks after an outbreak's start, around when average new cases peaked, staffing hours were 2.6% (95% CI, 2.1%-3.2%) of the mean below preoutbreak levels, despite facilities taking substantial measures to bolster staffing through increased hiring and the use of contract staff and overtime. Because these measures were mostly temporary, staffing declined further in later weeks; 16 weeks after an outbreak's start, staffing hours were 5.5% (95% CI, 4.5%-6.5%) of the mean below preoutbreak levels. Staffing declines were greatest among certified nursing assistants, primarily owing to smaller increases in new hires of this staff type compared with licensed practical nurses and registered nurses. Conclusions and Relevance: In this cohort study of nursing homes experiencing severe COVID-19 outbreaks, facilities experienced considerable staffing challenges during and after outbreaks. These results suggest the need for policy action to ensure facilities' abilities to maintain adequate staffing levels during and after infectious disease outbreaks.

Association Between the Patient Driven Payment Model and Therapy Utilization and Patient Outcomes in US Skilled Nursing Facilities.

Importance: In October 2019, Medicare changed its skilled nursing facility (SNF) reimbursement model to the Patient Driven Payment Model (PDPM), which has modified financial incentives for SNFs that may relate to therapy use and health outcomes. Objective: To assess whether implementation of the PDPM was associated with changes in therapy utilization or health outcomes. Design Setting and Participants: This cross-sectional study used a regression discontinuity (RD) approach among Medicare fee-for-service postacute-care patients admitted to a Medicare-certified SNF following hip fracture between January 2018 and March 2020. Exposures: Skilled nursing facility admission after PDPM implementation. Main Outcomes and Measures: Main outcomes were individual and nonindividual (concurrent and group) therapy minutes per day, hospitalization within 40 days of SNF admission, SNF length of stay longer than 40 days, and discharge activities of daily living score. Results: The study cohort included 201 084 postacute-care patients (mean [SD] age, 83.8 [8.3] years; 143 830 women [71.5%]; 185 854 White patients [92.4%]); 147 711 were admitted pre-PDPM, and 53 373 were admitted post-PDPM. A decrease in individual therapy (RD estimate: -15.9 minutes per day; 95% CI, -16.9 to -14.6) and an increase in nonindividual therapy (RD estimate: 3.6 minutes per day; 95% CI, 3.4 to 3.8) were observed. Total therapy use in the first week following admission was about 12 minutes per day (95% CI, -13.3 to -11.3) (approximately 13%) lower for residents admitted post-PDPM vs pre-PDPM. No consistent and statistically significant discontinuity in hospital readmission (0.31 percentage point increase; 95% CI, -1.46 to 2.09), SNF length of stay (2.7 percentage point decrease in likelihood of staying longer than 40 days; 95% CI, -4.83 to -0.54), or functional score at discharge (0.04 point increase in activities of daily living score; 95% CI, -0.19 to 0.26) was observed. Nonindividual therapy minutes were reduced to nearly zero in late March 2020, likely owing to COVID-19-related restrictions on communal activities in SNFs. Conclusions and Relevance: In this cross-sectional study of SNF admission after PDPM implementation, a reduction of total therapy minutes was observed following the implementation of PDPM, even though PDPM was designed to be budget neutral. No significant changes in postacute outcomes were observed. Further study is needed to understand whether the PDPM is associated with successful discharge outcomes.

Association Between the Patient Driven Payment Model and Therapy Utilization and Patient Outcomes in US Skilled Nursing Facilities

This cross-sectional study assesses whether implementation of the Patient Driven Payment Model is associated with changes in therapy utilization or health outcomes. Key Points Question Was the Patient Driven Payment Model (PDPM), implemented in October 2019, associated with rehabilitation therapy utilization and health outcomes of patients admitted to skilled nursing facilities (SNFs)? Findings In this cross-sectional study of 201 084 patients admitted to an SNF after hip fracture between January 2018 and March 2020, those admitted post-PDPM received about 13% fewer therapy minutes than those admitted pre-PDPM, but the likelihood of rehospitalization and functional scores at discharge remained unchanged. Meaning Implementation of PDPM was associated with a reduction in the volume of therapy use without changes in subsequent hospitalization risk or discharge functional scores. Importance In October 2019, Medicare changed its skilled nursing facility (SNF) reimbursement model to the Patient Driven Payment Model (PDPM), which has modified financial incentives for SNFs that may relate to therapy use and health outcomes. Objective To assess whether implementation of the PDPM was associated with changes in therapy utilization or health outcomes. Design, Setting, and Participants This cross-sectional study used a regression discontinuity (RD) approach among Medicare fee-for-service postacute-care patients admitted to a Medicare-certified SNF following hip fracture between January 2018 and March 2020. Exposures Skilled nursing facility admission after PDPM implementation. Main Outcomes and Measures Main outcomes were individual and nonindividual (concurrent and group) therapy minutes per day, hospitalization within 40 days of SNF admission, SNF length of stay longer than 40 days, and discharge activities of daily living score. Results The study cohort included 201 084 postacute-care patients (mean [SD] age, 83.8 [8.3] years;143 830 women [71.5%];185 854 White patients [92.4%]);147 711 were admitted pre-PDPM, and 53 373 were admitted post-PDPM. A decrease in individual therapy (RD estimate: −15.9 minutes per day;95% CI, −16.9 to −14.6) and an increase in nonindividual therapy (RD estimate: 3.6 minutes per day;95% CI, 3.4 to 3.8) were observed. Total therapy use in the first week following admission was about 12 minutes per day (95% CI, −13.3 to −11.3) (approximately 13%) lower for residents admitted post-PDPM vs pre-PDPM. No consistent and statistically significant discontinuity in hospital readmission (0.31 percentage point increase;95% CI, −1.46 to 2.09), SNF length of stay (2.7 percentage point decrease in likelihood of staying longer than 40 days;95% CI, −4.83 to −0.54), or functional score at discharge (0.04 point increase in activities of daily living score;95% CI, −0.19 to 0.26) was observed. Nonindividual therapy minutes were reduced to nearly zero in late March 2020, likely owing to COVID-19–related restrictions on communal activities in SNFs. Conclusions and Relevance In this cross-sectional study of SNF admission after PDPM implementation, a reduction of total therapy minutes was observed following the implementation of PDPM, even though PDPM was designed to be budget neutral. No significant changes in postacute outcomes were observed. Further study is needed to understand whether the PDPM is associated with successful discharge outcomes.

Nursing Homes and COVID-19: A Crisis on Top of a Crisis

The COVID-19 pandemic has caused a staggering number of deaths and a great deal of suffering in U.S. nursing homes. The spread of the virus across the country introduced a new emergency to a long-term care sector that had already been in a state of crisis for multiple decades. Nursing homes have been underfunded and understaffed for years, often delivering inadequate care to their vulnerable residents, and they are financed and regulated separately from the rest of the U.S. health care system. During the pandemic, policy responses at both the federal and state levels were often slow and inadequate, partly due to a frayed infrastructure that is the result of years of inattention from policy-makers. We review the state of nursing home care in the United States and the impacts of the pandemic, and we argue that a package of broader policy and delivery reforms should be implemented to improve the care of older adults that could help to prevent future tragedy.

A systematic review of long-term care facility characteristics associated with COVID-19 outcomes.

BACKGROUND/OBJECTIVES: The coronavirus disease 2019 (COVID-19) pandemic has taken a disproportionate toll on long-term care facility residents and staff. Our objective was to review the empirical evidence on facility characteristics associated with COVID-19 cases and deaths. DESIGN: Systematic review. SETTING: Long-term care facilities (nursing homes and assisted living communities). PARTICIPANTS: Thirty-six empirical studies of factors associated with COVID-19 cases and deaths in long-term care facilities published between January 1, 2020 and June 15, 2021. MEASUREMENTS: Outcomes included the probability of at least one case or death (or other defined threshold); numbers of cases and deaths, measured variably. RESULTS: Larger, more rigorous studies were fairly consistent in their assessment of risk factors for COVID-19 outcomes in long-term care facilities. Larger bed size and location in an area with high COVID-19 prevalence were the strongest and most consistent predictors of facilities having more COVID-19 cases and deaths. Outcomes varied by facility racial composition, differences that were partially explained by facility size and community COVID-19 prevalence. More staff members were associated with a higher probability of any outbreak; however, in facilities with known cases, higher staffing was associated with fewer deaths. Other characteristics, such as Nursing Home Compare 5-star ratings, ownership, and prior infection control citations, did not have consistent associations with COVID-19 outcomes. CONCLUSION: Given the importance of community COVID-19 prevalence and facility size, studies that failed to control for these factors were likely confounded. Better control of community COVID-19 spread would have been critical for mitigating much of the morbidity and mortality long-term care residents and staff experienced during the pandemic. Traditional quality measures such as Nursing Home Compare 5-Star ratings and past deficiencies were not consistent indicators of pandemic preparedness, likely because COVID-19 presented a novel problem requiring extensive adaptation by both long-term care providers and policymakers.