Long-term care facilities in US account for over 50% coronavirus deaths in 6 states, put 1.3M lives at risk

Long-term care facilities in US account for over 50% coronavirus deaths in 6 states, put 1.3M lives at risk
(Getty Images)

Long-term care facilities for older adults have especially been at high risk for transmission of COVID-19 and they account for a significant share of cases and deaths in many states. In six states — Delaware, Massachusetts, Oregon, Pennsylvania, Colorado, and Utah — deaths in long-term care facilities account for over 50% of all COVID-19 deaths, according to an analysis.

Long-term care facility deaths as a share of total deaths in the state vary widely between states — from 8% in South Carolina, 34% in Mississippi to 58% in Delaware. In Massachusetts and Oregon, deaths in long-term care facilities represent 55% of the coronavirus deaths in each, as of April 23, 51% in Pennsylvania, 50% in Colorado and Utah, say researchers from Kaiser Family Foundation (KFF), a non-profit headquartered in San Francisco. New York (3,505) and New Jersey (2,050) reported the highest number of deaths, accounting for over half of the total reported long-term care facility deaths.

According to the US Centers for Disease Control and Prevention (CDC), there are an estimated 15,600 nursing homes in the US with 1.3M residents. Nursing homes, skilled nursing facilities and assisted living facilities are collectively known as long-term care facilities. They provide multiple services, both medical and personal care, to people who are unable to manage independently in the community.

Hints of what nursing homes and their residents and staff are going through have emerged from the states that have started publicly sharing data about them. 

In Massachusetts, for example, where regular data is being provided by the Department of Public Health, about 83% of the nursing homes — 322 of 389 — had at least one case of COVID-19 as of May 3. So far, 13,447 residents/healthcare workers of long-term care facilities have COVID-19. Further, 2,368 deaths have been recorded across these facilities, which represent 59% of the deaths in Massachusetts. The overall data on confirmed cases and deaths for Massachusetts show that 68,087 have been infected with COVID-19, and 4,004 have died.

The new analysis shows that in 23 states that publicly reported death data as of April 23, there have been over 10,000 deaths due to COVID-19 in long-term care facilities, including residents and staff. This represents 27% of deaths due to coronavirus in those states, say researchers. 

Nationwide, among the states reporting data, analysis shows that nearly 50,775 cases have been reported in at least 4,000 facilities, accounting for 11% of coronavirus cases in 29 states.

Cases and deaths due to COVID-19 in long-term care facilities (Kaiser Family Foundation)

"Our data finds that there have been over 50,000 reported cases (in long-term care facilities). Long-term care facilities account for over half of the deaths in six states. High case and death rates may be attributed to a number of factors, including high rates of testing within long-term care facilities and low rates of testing of the general public. The total cases and deaths from reporting states account for over half (53%) of all cases, and 81% of all deaths," says the study. It adds, "Given that not all states are reporting data yet and the continual lag in testing, the counts of cases and deaths are an undercount of the true number of cases and deaths in long-term care facilities."

Long-term care facility cases also account for a notable share of overall cases in states. Over one-fifth of cases in Oklahoma and Minnesota are in long-term care facilities. Illinois, South Carolina and Tennessee have the lowest shares of cases attributable to long-term care facilities (5%). North Dakota was the only state to report fewer than 100 cases in their facilities. 

"The number of long-term care facilities with known cases varies widely across states, with New Jersey (438) and Pennsylvania (407) reporting the highest number of facilities and Maine (3), Iowa (12) and New Mexico (12) reporting the lowest number of facilities,” say experts.

As of April 23, 36 states were reporting some level of data about coronavirus cases and deaths in long-term care facilities, with wide variation in types of data being reported, long-term care facility definitions, the inclusion of residents/staff and frequency of updates. Nine states report fully comprehensive data on cases and deaths at the facility level, including Illinois and Oregon. Other states including Michigan, Mississippi and Pennsylvania report data at the country level, citing privacy concerns about reporting at the facility level. Three states provide data on facilities only, with New Mexico providing a list of facilities with reported cases, and Arizona and Maine reporting a total number of facilities. 

There is also some variation in the types of facilities that states include in their long-term care facility counts. Five states report data on nursing homes only, while the remaining states report on long-term facilities more generally. The researchers explain that state definitions of “long-term care facilities” can include a range of settings, including assisted living facilities, personal care homes and intermediate care facilities. 

States also vary in their inclusion of residents versus staff in the reporting of cases and deaths. Eight states report data on residents only, 17 states report data on residents and staff together, and the remaining states do not specify who is included in their data. 

According to the US Centers for Disease Control and Prevention, there are an estimated 15,600 nursing homes in the US with 1.3M residents (Getty Images)

Experts caution that failure to count COVID-19 deaths in care facilities could dramatically skew US numbers. The CDC estimates that the majority of long-term care services users were aged 65 and over in 2015-2016. Among nursing home residents, 81.4% of short-stay residents and 85.1% of long-stay residents were aged 65 and above. Among nursing home residents, 32.2% of short-stay residents and 43.5% of long-stay residents were aged 85 and over, says the CDC. At least one-quarter of service users had Alzheimer's disease or dementia, arthritis, heart disease or hypertension, among other illnesses, say experts.

“With the clustering of people who are frail and have multiple other illnesses like heart disease, stroke, chronic lung disease and diabetes, the risk of severe illness and death from COVID-19 is much higher in nursing homes,” Thomas Perls, professor of medicine at Boston University, writes in The Conversation.   

“Yet, the US does not know how many people are dying from COVID-19 in part because the government is only just now requiring nursing homes to start reporting numbers of presumed and confirmed cases and deaths to the CDC,” he says, adding that the missing cases could “dramatically skew” the national death count. 

On April 19, 2020, the Centers for Medicare & Medicaid Services (CMS) released guidance that would require nursing homes to report cases of coronavirus directly to the CDC. A preliminary analysis by the CDC shows that 6,160 deaths happened in a nursing home/long term care facility.

“There is wide variety in how states are currently collecting and reporting data, and it is unclear when the federal data will become available, what form it will take, and how comparable it will be across states. It is unclear how and when nationwide detailed facility-level data will be made available to the public and how often the data will be updated. Data currently available from states provides an incomplete picture, but can be used to direct attention to the issue and help inform policy solutions to help mitigate the number of deaths going forward," the KFF report says. 

Perls estimates that among nursing home residents, the reproductive number is likely to be higher than 5.7. This implies that on average, a person infected with COVID-19 could lead to an additional five people becoming infected with the novel coronavirus. “I believe it is likely that the majority of nursing homes throughout the US and beyond have or will soon have multiple residents and staff who are COVID-19 positive. One large nursing home operator in Britain estimates that two-thirds of its homes have outbreaks," he writes.

Perls recommends that to get an accurate count, veterans’ homes, assisted living centers, group homes and other senior housing facilities must be required to report their past and current COVID-19 cases and deaths as well. “There is plenty we still do not know about for why nursing home residents have borne the brunt of this pandemic," he warns. 

As of May 4, over 1,158,041 coronavirus cases have been reported from across the US and 67,682 have died in the COVID-19 pandemic, shows the Johns Hopkins tracker.

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