Underrepresented Populations Suffer Most from COVID-19 in Nursing Homes, Assisted Living Communities

Sep. 21, 2020

Older residents from underrepresented racial and ethnic backgrounds and their caregivers bear the severest brunt from COVID-19 across the entire spectrum of US nursing homes and assisted living communities, University of Rochester Medical Center researchers report in two groundbreaking studies in the Journal of the American Geriatrics Society.

For example, nursing homes with disproportionately higher numbers of residents from underrepresented racial and ethnic backgrounds reported two to four times as many new COVID-19 cases and deaths per facility than other nursing homes for the week of May 25, according to a study led by Yue Li, Ph.D., professor of Public Health Sciences.

The findings – the first to be reported based on newly mandated, weekly data reported from 15,587 U.S. nursing homes to the Centers for Medicare and Medicaid Services (CMS) – are also the first to document the disproportionate impact on residents from underrepresented racial and ethnic backgrounds in nursing homes across all states.

 Disparities of this magnitude, Li says, 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 first-ever empirical study involving the incidence of COVID-19 in US assisted living communities showed a four-fold higher case fatality in these communities, compared to the counties in which they are located. The study was led by Helena Temkin-Greener, Ph.D., M.S., professor of Public Health Sciences.

“As in the nursing home study, we also see that assisted living communities with more underrepresented 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 says.

The findings are 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.

Assisted living 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 says.

Several factors leave them “ill prepared” to deal with a pandemic, the study reports. For example, assisted living communities are often financially challenged, care for increasingly sicker 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.

Moreover, “unlike nursing homes, which have recently been mandated to collect and report data on COVID-19 --including cases and deaths--to the CMS, there’s no system at all to report such data for assisted living communities,” Temkin-Greener says.

Hence the lack of previous studies. Temkin-Greener and her collaborators were able to combine state-reported data for 4,685 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, which the researchers had prepared as part of another project.

They found that:

  • Whereas the percentage of COVID deaths ranged from 3.32 percent of the overall number of cases in North Carolina to 9.26 percent in Connecticut, the percentage of COVID deaths in assisted living communities in those states ranged from 12.89 percent to 31.59 percent – even though fewer than 10 percent 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 note. 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 ALs has been limited to those communities serving Medicaid eligible residents, or 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 AL 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 higher nursing home 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. At least 62,000 nursing home residents died of COVID-19, representing 41% of all COVID-19 deaths nationally.  

The CMS 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 CMS quality assurance checks, those with higher proportions of residents from underrepresented racial/ethnic backgrounds tended to be larger for-profit facilities affiliated with a chain, had more Medicaid residents and lower RN and total nurse staffing hours, and were located in counties with more COVID-19 cases and deaths as of May 31, with lower socio-economic status, and with higher competition for nursing home care.

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 residents from underrepresented racial/ethnic backgrounds to 1.5 cases per facility for the highest proportion homes.

The predicted counts of cases and deaths per facility were two to four times higher in nursing homes with the highest proportions of residents from underrepresented racial/ethnic backgrounds.

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 residents from racial/ethnic backgrounds have poorer outcomes, Li’s team reports. In addition, nursing home literature for several decades has indicated that nursing homes remain highly segregated, and that residents from underrepresented racial/ethnic backgrounds 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.

Nursing home staff from these communities--especially staff of color who make up over 50 percent 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 report.

Thus, “immediate actions are needed to ensure that as the pandemic continues to evolve, nursing home residents from underrepresented racial/ethnic backgrounds, and the frontline workers caring for them, do not bear an additional later or sufferings due to systemic inequalities.”

Although 22 percent of all nursing homes reported shortages of staff, and 25 percent 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 notes. However, “it is likely that nursing homes predominated by residents from underrepresented racial/ethnic backgrounds face more of other institution-wide issues, such as poor testing capacity, and inadequate staff knowledge and training in infection control and prevention.”

They recommend that CMS’ weekly reports be expanded to include data collection for these “additional and more nuanced items.”

Other collaborators on the assisted living study included Li; Xueya Cai, a research associate professor in biostatistics and computational biology; and Wenhan Guo and Yunjiao Mao, Ph.D. students in health services research and policy. Temkin-Greener, Cai and Xi Cen ‘19, former PhD student, now a research associate and health economist at IMPAQ International collaborated on the nursing home study.

The nursing home study was supported with funding from the National Institutes of Health and the Agency for Healthcare Research and Quality. The assisted living community study was also supported with funding from the Agency for Healthcare Rese