Sunday, May 10, 2020

Nursing Homes and Covid-19

I think most people understand that Covid-19 is most dangerous to those that are older. I think that they also understand that older people in nursing homes are the most vulnerable population to the virus.

However, I don't think many people understand how much the deaths from those in nursing homes are affecting the death totals from Covid-19.

The numbers are astounding.

The latest CDC data indicates that there are 1,350,000 people residing in 15,500 nursing homes in the United States.

There are an additional 812,000 senior citizens residing in residential care communities.

Based on this data, seniors in nursing homes make up about .4% of the population of the United States. If we include senior residential communities that number is a little over .6%

Compare those numbers to the percentage of deaths from Covid-19 in various states as a percentage of all Covid-19 deaths.

Minnesota                81%

New Hampshire      77%

Rhode Island           76%

Pennsylvania           68%

Delaware                  65%

Washington             62%

Massachusetts         60%

Oregon                      60%

Colorado                   58%

New Jersey               53%

Here are a couple of those states in graphic form comparing nursing home with all other deaths from Covid-19.



Since New York has the most deaths from Covid-19 you might wonder what the percentage of deaths of nursing home residents has been in that state. This is particularly true since New York's Governor Cuomo made the dubious decision to mandate that nursing homes take infected Covid-19 patients into these facilities. This was intended to relieve pressure on hospitals but it resulted in the virus ravaging many vulnerable people in the close confines of the nursing home environment. 

Similar orders were put in place in Pennsylvania and New Jersey and you can see in the numbers above the high death rates that resulted in those states among nursing home residents.

Even worse, New York did little to insure that nursing homes had the personal protective equipment to deal with the Covid-19 cases they were required to take. Although Cuomo mandated that the nursing homes take the Covid-19 patients the state provided little in support to these facilities.

Cuomo faced criticism at a recent briefing for saying that providing masks and gowns to nursing homes is “not our job” because the homes are privately owned.

New York is officially reporting that nursing home residents make up 25.2% of its Covid-19 deaths. However, this number excludes any nursing homes residents who died in the hospital. That means this includes only deaths that actually occurred in the nursing home. New York is the only state that is reporting deaths this way.

It makes you wonder what the actual percentage is? You have to think it has to be at least 50% as well.

New York also did not mandate testing in nursing homes or follow the lead of other states such as Florida, Tennessee and Wisconsin in dispatching National Guard teams to support nursing homes in conducting testing, triage and care.

Florida, despite an older population that New York, has had only 43% of its Covid-19 deaths from nursing homes. Tennessee is at 36%.

Of course, doesn't it say it all when a nursing home death rate of around 40% is considered a "good" number? 

All in all, it is estimated that more than half of the Covid-19 deaths in the United States are of nursing home residents.

It is important to also keep all of this data in perspective. The fact is that when someone needs to go into a nursing home they almost certainly have pre-existing medical conditions and they also typically need assistance in one or more aspects of daily living.

For example, the CDC's most recent report found that the percentage of nursing home residents that needed assistance in these aspects of daily living were as follows:

Eating                                                   59.9%

Bathing                                                 96.7%

Dressing                                                92.7%

Toileting                                                89.3%

Walking of Locomotion                      92.0%

Transferring In or Out of Bed           86.8%

It should also be considered that most nursing home stays are relatively brief.

This study from 2010 which looked at 8,433 study participants from 1992 to 2006 found that 65% of nursing home residents died within one year of nursing home admission and 53% died within six months.

The median length of stay was five months.


Considering all of the challenges to nursing homes in the current environment, what I found very interesting in the April jobs report was that Nursing & Residential Care Facilities saw a loss of 113,000 jobs between March and April.  This was very close to the 135,000 job losses in hospitals over the last month. The loss of those jobs in nursing and other senior facilities is even more significant considering that hospitals employ many more people.

All of this in the middle of a pandemic that is disproportionately affecting nursing home residents?

How do you explain it?

This appears to be the result of the cutback in elective medical procedures and surgeries. Many of these patients are discharged to a skilled nursing unit in a nursing home to recover and rehabilitate for a period of time before going home. The ban on elective procedures is also taking a bite out of the revenues of nursing homes at the same time they are confronted with the challenges of Covid-19. Yet another unintended consequence of the lockdowns.

What can we take from all of this?

If we are serious about limiting the loss of life from Covid-19 the number one focus has to be on nursing home populations. There is nothing else that is remotely close when you look at the numbers.

I actually saw someone on Twitter who suggested that it might actually make sense to have the federal government offer to pay nursing home personnel four times their normal pay to stay locked in with the residents in order to insure that no new infections come in from the outside. Since nursing homes have generally been locked down for the last two months (no visitors, etc)  most infections recently have had to come from staff going in and out each day. Locking everyone down might be the only way to stop the spread in nursing homes. Paying this wage premium might be a better use of money than paying trillions of dollars to people to not work.

More practically, nursing homes need massive support with personnel, testing and personal protective equipment. It would seem to me that it would make sense to also use Hydroxychloroquine with these populations since it is cheap and readily available. It might even make sense to do double-blind studies of its utility as a prophylactic medication in these facilities to see if the drug confers some preventive benefits. Looking at the data, targeted measures like these would clearly have the biggest impact on lowering the death rate from Covid-19.

I don't know all the right answers on this but I do know that overall Covid-19 death rates are not going to come down until nursing home death rates come down.

Of course, it also must be remembered that the death rates among nursing home residents never comes down. That was the case before Covid-19 and that also will be the case after Covid-19 is long gone.

There is a reason that nursing homes have the name they do.

That is why we need to insure that we have all preventive and protective measures in place and that the care that is given in nursing homes is delivered professionally and compassionately with these valuable and vulnerable populations of older Americans.

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