In nursing homes and assisted living communities, minorities suffer most from Covid-19, research says

Older racial and ethnic minority residents in nursing homes and assisted living communities in the United States and their caregivers have been hit hardest by the Covid-19 pandemic, according to new research by the University of Rochester Medical Center.

The findings, based on newly mandated weekly data from the Centers for Medicare and Medicaid Services of more than 15,500 nursing homes, came from two studies published Monday in the Journal of the American Geriatrics Society.

The research discovered a disproportionate impact on racial and ethnic minorities in nursing homes across every state.

Nursing homes with disproportionately higher numbers of racial and ethnic minority residents when compared to their communities reported 2 to 4 times as many new Covid-19 cases and deaths per facility than other nursing homes, according to a study led by Yue Li, a professor of public health sciences. The numbers are for the week of May 25.

Disparities of this magnitude, Li said, suggest that longstanding, fundamental inequalities in nursing homes resulting from segregated facilities with limited resources and poorest quality of care are being “exacerbated by the pandemic.”

A study of the incidence of Covid-19 in US assisted living communities, led by Helena Temkin-Greener, who also is a professor of public health sciences, showed a four-fold higher case fatality rate in these communities compared to the counties in which they are located.

“As in the nursing home study, we also see that assisted living communities with more minority residents have more cases, and we confirm that communities with a higher proportion of residents with dementia, chronic obstructive pulmonary disease, and obesity, experienced more COVID-19 cases,” Temkin-Greener said.

Those findings were based on data from seven of 13 states that publicly reported Covid-19 data from nursing homes and residential care settings through May 29, 2020.

Communities need ‘same attention’ as nursing homes

Unlike nursing homes, assisted living communities are not subject to federal regulation; they are regulated by the states “with varying degrees of rigor,” Temkin-Greener said.

Several factors leave them “ill prepared” to deal with a pandemic, the study found.

For example, assisted living communities are often financially challenged, care for increasingly sick residents, operate under limited oversight, and experience staff and PPE shortages. The workers providing daily care are often personal care aides rather than certified nursing assistants or registered nurses, and receive little if any training in the use of PPE, according to the study.

Nursing homes have recently been mandated to collect and report data on Covid-19, including cases and deaths, to the Centers for Medicare and Medicaid Services However, there is no such system for assisted living communities, researchers said.

Temkin-Greener and her collaborators were able to combine state-reported data for more than 4,600 assisting living communities in Colorado, Connecticut, Georgia, North Carolina, New York, Ohio, and South Carolina with a 2019 national inventory of assisted living communities and Medicare beneficiary data for residents of those communities.

They found that:

  • Whereas the percentage of Covid deaths ranged from 3.32% of the overall number of cases in North Carolina to 9.26% in Connecticut, the percentage of Covid deaths in assisted living communities in those states ranged from 12.89% to 31.59% — even though fewer than 10% of assisted living communities reported being affected by the pandemic.
  • Assisted living communities with higher proportions of Black and Hispanic residents had more Covid-19 cases — but not more deaths.
  • Assisted living communities with a greater proportion of residents with dementia, COPD, and obesity had significantly more cases and deaths related to Covid-19.

And yet, assisted living communities have been relatively overlooked by the federal response to Covid-19 compared to nursing homes, the researchers said.

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For example, the federal government has allocated more than $10 billion to specifically assist nursing homes with the pandemic, including support for testing, PPE, and staff shortages. However, federal assistance to assisted living communities has been limited to those communities serving Medicaid eligible residents — which is only about 16% of assisted living communities — even though they care for very similar populations and share many of the same pandemic-related challenges as nursing homes.

“Relying on (assisted living) communities to muster a rigorous response to the COVID-19 pandemic largely on their own is clearly unrealistic,” the researchers conclude.

“Assisted living communities and their residents urgently need local, state, and the federal governments to pay at least the same level of attention as that given to nursing homes.”

‘Systemic inequalities’ fuel toll among minorities

By July 30, 362,000 people in virtually every US nursing home were infected with the virus, representing about 8% of all cases in the country, the study found. At least 62,000 nursing home residents had died of Covid-19, representing 41% of all Covid-19 deaths nationally.

The Centers for Medicare and Medicaid Services’ Nursing Home COVID-19 Public File used by Li’s team includes weekly counts of cases and deaths among nursing home residents and staff, as well as facility capacity, staff, and supplies of PPE, as reported by individual nursing homes to the Centers for Disease Control. The researchers used the first available weekly count (May 25-31) and compared it to several other databases.

Of the 12,576 nursing homes whose data passed the Centers for Medicare and Medicaid Services’ quality assurance checks, those with higher proportions of racial/ethnic minority residents tended to be larger, for-profit facilities affiliated with a chain. They also had more Medicaid residents and lower registered nurse and total nurse staffing hours, and were located in counties with more Covid-19 cases and deaths as of May 31.

The number of weekly new Covid-19 confirmed cases among residents increased from an average of 0.4 cases per facility among nursing homes with a low proportion of racial/ethnic minority residents to 1.5 cases per facility for the homes with the highest proportion.

The predicted counts of cases and deaths per facility were 2 to 4 times higher in nursing homes with the highest proportions of racial/ethnic minority residents.

These disparities in rates of Covid-19 cases and deaths mirror pre-pandemic studies showing that nursing homes with lower resources and higher concentrations of racial/ethnic minorities have poorer outcomes, Li’s team reported.

Nursing home literature for several decades has indicated that nursing homes remain highly segregated, and that racial and ethnic minority residents tend to be cared for in a small number of facilities located in communities of color with poorest quality of care and highly restricted resources, his team found.

Nursing home staff from these communities — especially staff of color who make up over 50% of nursing home direct care workforces — are more likely to live in crowded households and neighborhoods, travel to and from work by public transportation, and be low paid with few or no benefits such as paid sick leave, “all placing them at higher risks of COVID-19 infection as well as inadvertent cross-infection with patients,” the researchers reported.

“Immediate actions are needed to ensure that as the pandemic continues to evolve, racial/ethnic minority nursing home residents, and the front line workers caring for them, do not bear an additional later or sufferings due to systemic inequalities,” the researchers concluded.

Although 22% of all nursing homes reported shortages of staff, and 25% reported shortages of PPE for the reporting week, “we did not find evidence of dramatic disparities in these self-reported shortages across nursing homes,” Li’s team said.

However, the team found that nursing homes dominated by racial and ethnic minority residents were more likely to face other institutional issues such as poor testing capacity, as well as inadequate staff knowledge and training in infection control and prevention. They recommended that Centers for Medicare and Medicaid Services’ weekly reports be expanded to include these additional items.