Nursing homes: A true COVID-19 epicenter

Beyond the curve: Dr. Peter Lurie's COVID-19 blog

I was reflecting the other day on how this country has been dealing—or not dealing—with the COVID-19 pandemic and what we would look back on with regret when it’s finally over. There’s no shortage of candidates. Downplaying the virus, blaming the Chinese, flubbing the testing, turning mask-wearing into some kind of macho litmus test, hawking fake cures, etc., etc. But one major, somewhat underappreciated, mistake was how long it took the United States to recognize the horrific toll COVID-19 was wreaking on nursing homes, and how much this was contributing to the burden of the pandemic.

Of course, we expected that our 15,600 nursing homes would be especially vulnerable to the coronavirus because of the ages and underlying medical conditions of their residents. And that’s on top of the crowded conditions and sometimes substandard care that characterize them. But that less than one percent of our citizens would account for more than forty percent of our deaths from the virus? This was, and still is, shocking.

It's no consolation that the United States was not alone. Europe, particularly Belgium, leads the world in per capita deaths, partly because tens of thousands of older people died in their nursing homes. Around the world, public health officials left nursing homes out of their pandemic preparedness plans and the mathematical models used to guide their responses.

Here in the United States, the very first outbreak of COVID-19 occurred in a Washington state nursing home in February and killed at least 35 residents. This should have set off louder alarm bells. It’s inexcusable that the federal government didn’t start tracking the death toll in nursing homes until more than two months later, in mid-May, when we were already deep into the pandemic. When it finally did, the feds estimated that almost 26,000 residents and workers had already perished from the coronavirus at nursing homes.

The well-known aphorism in business and government that “you can’t manage what you don’t measure” should have been the government’s mantra. But even after the infection’s outsized impact on nursing homes was finally recognized, relatively little of the nation’s emergency funding and supplies was directed to these homes. And assisted living facilities, which sustained an additional estimated 7,000 deaths from COVID-19, got no federal help at all because they’re not regulated by the federal government.

Many of the nursing homes really needed help. A Government Accounting Office (GAO) report published in May found that most homes it surveyed had been cited for deficiencies in their prevention and control of infections during the five-year period from 2013 to 2017. Half the cited homes were repeat offenders.

Their violations involved failing to follow basic practices such as isolating sick residents and using masks and other personal protective equipment to control the spread of infections. These measures can be critical, GAO pointed out, to preventing the spread of infectious diseases such as COVID-19.

The coronavirus pandemic has also highlighted the perilous financial state of our nation’s nursing homes. Even before it struck, many of these facilities were losing money and struggling to attract new residents.

Their fiscal situation has worsened during the past decade with the increasing takeover of nursing homes by private equity and other investment firms who see the properties as cash cows. Many investors drain the profits from these homes by charging their operators high rents and consulting fees and by pressuring them to buy their products and services at inflated prices from companies the investors own. This leaves the properties with “staggering bills and razor-thin margins,” the New York Times reported.

These takeovers likely led to a greater vulnerability to the pandemic because, as researchers at the Wharton School and other institutions found earlier this year, after investment groups take over, staffing is typically cut, usually from front-line nursing care, and the overall quality of care declines.

Moreover, families who believe their loved ones died unnecessarily in nursing homes from poor management or neglect may find a giant barricade at the courthouse door. At least 23 states have considered providing businesses or healthcare providers with some degree of legal immunity from lawsuits. And Senate Republicans have sought to include a national immunity provision in its Congressional pandemic relief package. CSPI wrote to Congress in April and again in July opposing industry’s attempt to obtain these national “liability shields.”

Still, it is heartening that some nursing homes seem to have avoided COVID-19 infections and deaths. As of early June, about half of nursing homes reported a suspected or confirmed case of COVID-19 and only one in five facilities reported a death from the virus, according to an analysis of federal data by the Associated Press.

Unfortunately, nursing homes also reflect the health disparities that have characterized the pandemic more broadly. Those with the lowest percentage of white residents were more than twice as likely to have COVID-19 cases or deaths as those with the highest percentage of white residents.

One can learn from this catastrophe by observing what Hong Kong did after its nursing homes were hit hard by the Severe Acute Respiratory Syndrome (SARS) outbreak in 2003. The city, which has roughly the same population as New York City, required each home to have a trained infection-control officer, to maintain at least a month’s supply of face masks and personal protection equipment, and to isolate residents with contagious infections in special hospital wards, not in the nursing homes. The result? As of the beginning of July, no one in a Hong Kong nursing home had died from COVID-19.

Maybe if this country had gotten a handle much earlier on the major sources of COVID-19 infections, with nursing homes, other health care facilities, prisons, and meatpacking facilities receiving concerted attention, combined with the public conscientiously wearing masks and respecting social distance, we would be more like Europe now instead of stuck in the mess we’re in.

This post was co-written by David Schardt and Peter Lurie.