Staffing in nursing homes matters when combating COVID-19

Liz Seegert


senior wearing a mask
Photo: Elvert Barnes via Flickr

Why are some nursing homes doing so much better at containing the coronavirus among residents and staff than others? Testing, adequate protective gear and the ability to isolate infected residents are all important factors. Another key contributor is sufficient staffing, according to a recent research letter in JAMA.

Nursing homes that rated better on staffing had fewer COVID-19 cases than those facilities with poorer staffing ratings. Approximately 27% of deaths due to coronavirus disease 2019 (COVID-19) have occurred among residents of nursing homes, researchers noted in the August 10 letter. (The New York Times estimated closer to 40% if workers are included.) It seems like a no-brainer that more staff might result in fewer cases.

It also turns out that facilities that rated more highly in staffing, inspections, and quality control in CMS’ Nursing Home Compare database also had fewer certified beds. Interestingly, quality measures and inspections did not show the same association.

Researchers from the Harvard School of Public Health, Beth Israel Deaconess Medical Center, Boston, and the London School of Economics’ Department of Health Policy evaluated whether facilities highly rated by CMS for health inspections, quality measures and nurse staffing had fewer COVID-19 cases than facilities with lower ratings. Using data from eight state health departments (California, Connecticut, Florida, Illinois, Maryland, Massachusetts, New Jersey, and Pennsylvania), researchers determined the total number of COVID-19 cases occurring in facilities between January 1 and June 30.

Since data is not reported consistently across states, they were limited to grouping nursing homes into three categories: those with 10 or fewer, 11 to 30, or more than 30 COVID-19 cases.

Of the 4,254 nursing homes analyzed, all (100%) had star ratings for health inspection; 4,241 (99.7%), quality measures; and 4,225 (99.3%), nurse staffing domains. Within each domain, 1,451 (34.1%) were considered high performing for health inspection; 2,974 (70.1%) for quality measures; and 1,517 (35.9%) for nurse staffing.

High-performing facilities — also with fewer certified beds — were less likely to have had more than 30 COVID-19 cases than were low-performing facilities across each domain. Facilities with high ratings on nurse staffing were less likely to have more than 30 COVID-19 cases versus facilities with 11 to 30, and versus facilities with 10 or fewer cases, than were low-performing nursing homes. There was no significant association between high- versus low-performing nursing homes in the health inspections or quality measures domains with COVID-19 cases.

“These findings suggest that poorly resourced nursing homes with nurse staffing shortages may be more susceptible to the spread of COVID-19,” researchers concluded. “Although guidance on best practices on infection control is important, which has been the primary strategy used by CMS to date, policies that provide immediate staffing support may be more effective at mitigating the spread of COVID-19.”

The analysis only looked at data from eight states. The authors point out, however, that these were among the states with the greatest burden of COVID-19 cases during the period studied.

Nursing home staffing during the COVID-19 crisis has been a problem across the United States, according to Toby Edelman, senior policy attorney at the Center for Medicare Advocacy. According to recent CMS data, 15.7% of all nursing homes nationwide reported a shortage of nurses, she wrote. Shortages ranged from just 1% in California to nearly 30% in Alabama. Shortages of nurses, clinical staff and aides were reported in 234 homes across 40 states, with Texas reporting the greatest shortages across all staffing categories, followed by Ohio.

“There is no dispute that nurses are essential to providing high quality of care for nursing home residents. Insufficient numbers of nurses, both licensed (RNs, LPNs) and paraprofessionals (certified nurse assistants) have been a problem in nursing homes for decades,” Edelman said in an email. “As the HHS inspector general recently confirmed, many facilities still don’t meet even the relatively modest requirements for licensed nurses that have existed in federal law since 1987.”

“We need to learn, from the tragedy of COVID-19, we must improve nurse staffing levels in nursing facilities,” she added.

Recruiting and retaining quality nurses and other skilled employees to care for America’s increasing older population has long been a significant challenge, said Katie Smith Sloan, president and CEO of LeadingAge, an association of aging service providers that includes non-profit long-term care facilities. “Even before the coronavirus pandemic, workforce shortages were severe.”

Smith cited multiple factors, from shifting demographics and a full-employment economy (until recently) to societal biases toward aging and our country’s reluctance to fund Medicaid, which is the primary public source of financing for the nation’s nursing homes, as contributing to the problem.

There are multiple examples of how providers are grappling with and addressing their needs for additional staff. With community spread a significant factor in virus transmission, Westminster Canterbury in Chesapeake Bay, Vir., developed a program aimed at certain employees who pre-pandemic had worked multiple jobs at numerous employers. They now provide incentives for the employees to work solely for the company.

“We said you have to tell us if you have another job that deals with the public and stop,” said Ben Unkle, Westminster’s president and CEO. The company then “makes them whole” by giving these employees enough hours, including overtime, if necessary, to replace the pay they were receiving elsewhere.

The program currently applies to about 60 people, “mostly frontline workers,” Unkle said. “These people need two jobs to make ends meet despite our move to higher voluntary wages.” He adds that there is no lack of work to be done; staff can be reassigned to dining services, security, administrative or wherever there’s a need.

Meanwhile, help from the federal government is still falling short, according to Sloan. “We need action from both the Administration and from Congress. At the federal level, we need a coordinated, federal response to this pandemic, not the patchwork approach that’s resulted in a maze of different and often conflicting approaches to deal with virus mitigation and requirements on testing, nursing home visitation, at federal, state and local levels.”

Providers are coping with unprecedented staff stress, shortages, costly extra shifts, and paying competitive wages and hero bonuses to protect older adults, Sloan said. With the latest round of COVID-19 funding stalled in Congress, her organization is advocating for a dedicated fund of $100 billion devoted to caring for older Americans.

“It’s time to put older adults and their care providers at the front of the line, right alongside hospitals for life-saving resources like PPE and testing,” she said.

Journalists may want to explore how their local nursing homes are coping with staffing shortages. Among the questions to ask:

  • How does the facility’s reality compare with the CMS staffing data?
  • Are any local facilities reporting few or no cases of virus? What do facility leaders attribute to this success?
  • What about facilities that have high rates of infection? Are they short-staffed, or are other issues contributing to outbreaks?

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Liz Seegert

Liz Seegert

Liz Seegert is AHCJ’s health beat leader for aging. She’s an award-winning, independent health journalist based in New York’s Hudson Valley, who writes about caregiving, dementia, access to care, nursing homes and policy. As AHCJ’s health beat leader for aging,