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Severe Staffing And Personal Protective Equipment Shortages Faced By Nursing Homes During The COVID-19 Pandemic

Affiliations
  1. Brian E. McGarry ([email protected]) is an assistant professor in the Department of Medicine, University of Rochester, in Rochester, New York.
  2. David C. Grabowski is a professor of health care policy at Harvard Medical School, in Boston, Massachusetts.
  3. Michael L. Barnett is an assistant professor of health policy and management at the Harvard T. H. Chan School of Public Health, in Boston, Massachusetts.
PUBLISHED:Free Accesshttps://doi.org/10.1377/hlthaff.2020.01269

Abstract

The coronavirus disease 2019 (COVID-19) pandemic continues to devastate US nursing homes. Adequate personal protective equipment (PPE) and staffing levels are critical to protect nursing home residents and staff. Despite the importance of these basic measures, few national data are available concerning the state of nursing homes with respect to these resources. This article presents results from a new national database containing data from 98 percent of US nursing homes. We find that more than one in five nursing homes reports a severe shortage of PPE and any shortage of staff. Rates of both staff and PPE shortages did not meaningfully improve from May to July 2020. Facilities with COVID-19 cases among residents and staff, as well as those serving more Medicaid recipients and those with lower quality scores, were more likely to report shortages. Policies aimed at providing resources to obtain additional direct care staff and PPE for these vulnerable nursing homes, particularly in areas with rising community COVID-19 case rates, are needed to reduce the national COVID-19 death toll.

TOPICS

Coronavirus disease 2019 (COVID-19) has devastated nursing homes, both globally and in the US. By the end of July 2020 more than 60,000 deaths had occurred in US nursing homes and other long-term care facilities, accounting for nearly half of all COVID-19-related fatalities nationwide.1 Many staff members have also contracted COVID-19, with more than 760 staff deaths from the virus occurring as of July 26, 2020.2 Efforts to stem the virus are also taking a huge toll on nursing home residents. Nursing homes endured weeks of a federally mandated all-out lockdown with no visitation, communal dining, or activities allowed starting in March in most facilities. Only recently have these restrictions begun to be relaxed, and only on a limited basis in certain states. Similar difficulties have been reported for nursing homes in Europe.

Although our knowledge of COVID-19 is still evolving, strict infection control is considered a fundamental component of ensuring the safety of residents and staff in nursing homes. The standard of care for infection control in nursing homes is illustrated by a set of “core practices” endorsed by the Centers for Disease Control and Prevention (CDC), including adequate access to personal protective equipment (PPE) and staffing.3

The CDC suggests that nursing homes must “provide supplies necessary to adhere to recommended infection prevention and control practices.”3 Adequate access to PPE includes supplies such as masks, gowns, goggles, gloves, and hand sanitizer. Many nursing homes have reported shortages of PPE, which has led to the use of lower-grade equipment or the reuse of equipment across patients with and without COVID-19.4,5 In response to this shortage, the federal government promised to provide two weeks’ supply of PPE to all US nursing homes back in May.5 However, many nursing homes have reported that they did not receive adequate PPE through this initiative.5

The CDC has also called for nursing homes to “develop (or review existing) plans to mitigate staffing shortages from illness or absenteeism.”3 Many nursing homes struggled with staffing before COVID-19,6 and shortages have reportedly been magnified because many staff members are unable or unwilling to work in these conditions.7

It is widely accepted that these key practices outlined by the CDC can prevent or mitigate the spread of COVID-19 in nursing homes. However, there has been little national evidence about the state of these practices in nursing homes because of the lack of data. As part of recent federal COVID-19 nursing home data collection efforts, the Centers for Medicare and Medicaid Services (CMS) has begun collecting data from nearly every nursing home in the country regarding COVID-19 and its impact on residents and staff. This article reports some of the first results from these federal data by describing nursing home access to PPE and staffing and examining the facility characteristics associated with shortages in these areas.

Study Data And Methods

Data Sources

The primary data for this study were acquired from the CMS COVID-19 Nursing Home Data database. This publicly available file provides information submitted by nursing homes to the CDC’s National Healthcare Safety Network Long-term Care Facility COVID-19 Module about the impact of COVID-19 on staff and residents, as well as shortages of staff, PPE, and testing.2 We used data from two reporting periods each lasting four weeks: the first spanned May 18–June 14, 2020 (study period 1), and the second spanned June 24–July 19, 2020 (study period 2). In the early study window, 87 percent of nursing homes submitted data for all four weeks, whereas 94 percent of nursing homes submitted data for all four weeks in the later window. For facilities with multiple submissions within a study period, we used the most recent data available.

Facility information was obtained from the 2017 Certification and Survey Provider Enhancement Reports system through the National Institute on Aging–funded LTCFocus.org website and the 2020 Nursing Home Compare Provider Info file.8,9 County-level data on the seven-day average of new COVID-19 cases (per 100,000 population) were obtained from the publicly available New York Times Coronavirus (Covid-19) Data in the United States repository.10

Study Sample

Our primary study sample included all Medicare- and Medicaid-certified nursing homes in the US that submitted responses to staffing and PPE questions during at least one of the weekly reporting periods in the two study windows detailed earlier. In addition, we examined all Medicare- and Medicaid-certified nursing homes in the US to compare characteristics of the facilities with and without submitted data.

Outcomes And Measures

We examined shortages in two categories: staffing and PPE (including hand sanitizer, which is not strictly “equipment” but is key for proper infection control practices). These categories are based on the set of questions that CMS required nursing homes to submit answers for, in addition to other COVID-19 data. Nursing homes were considered to have a shortage of staff if they reported a shortage (defined simply as “shortage” in survey questions) in any of the following staff categories: nurses (registered nurses and licensed practical nurses), clinical staff (physicians, physician assistants, and advanced practice nurses), aides (certified nursing assistants, nurse aides, medication aides/technicians), and other (including staff not involved in direct resident care, such as food or environmental service staff). Nursing homes were classified as having a shortage of PPE if they reported less than a one-week supply of any of the following equipment types: N95 respirators, surgical masks, eye protection (face shields, goggles), gowns, gloves, and alcohol-based hand sanitizer. For all outcomes, we used the most recently available data within the two four-week study windows for each facility.

We defined our outcomes on staff or PPE shortage as having a shortage in any category because of the interdependence of the individual components for high-quality care. Having a shortage of any type of staff affects every aspect of clinical care, whereas a shortage of any PPE element can break infection control protocols. We considered shortages in PPE to be “severe” because positive answers to these questions represent an extremely limited capacity to respond to a COVID-19 outbreak. In contrast, the staff shortage questions were worded more generally and did not indicate magnitude.

The following nursing home characteristics were obtained from the Nursing Home Compare data: total number of beds, profit status, overall five-star quality score (a composite measure of multiple quality, staffing, and compliance indicators assessed annually by Medicare), and staffing-related five-star quality score (which provides information about facilities’ staffing levels before the pandemic). Certification and Survey Provider Enhancement Reports data were used to obtain information on the percentage of facility revenue that comes from Medicaid (categorized into quartiles among all nursing homes), the percentage of residents who are non-White race (categorized into quartiles), and whether the facility is part of a chain. In addition, we included the incidence of new COVID-19 cases (measured as a seven-day average of new cases per 100,000 population) in the county where the facility is located for the seven-day period ending June 14, 2020, for the first study window or July 19, 2020, for the second. New case rates were categorized into quartiles. We also captured whether the facility reported any confirmed or suspected COVID-19 cases among residents or staff by the end of the relevant study window, as reported by facilities in the CMS COVID-19 Nursing Home Data database.

Statistical Analysis

We estimated the national rate of staff and PPE shortages, as well as the national rate of specific shortage types, across the two study windows. We examined variation in any staff and PPE shortages at these two points, using bivariate comparisons and multivariate modeling. Specifically, we estimated linear probability models for each outcome that included the facility characteristics described here and state-level fixed effects to capture variation in state policies and responses. For all variables, we included categories for missing values so that only facilities with missing outcome data for PPE or staff shortages were excluded from multivariate analyses. Separate models were estimated for each period. All models used robust standard errors clustered at the county level. Finally, we examined geographic variation in the rate of overall shortages in the most recent period by calculating county-level averages (weighted by facility bed size) and mapping the results. Maps of shortage rates in the initial study window are in the online appendix.11

Limitations

Our study had several limitations. The CMS COVID-19 Nursing Home Data make up a novel database and may therefore be subject to measurement error. Early reports of the initial reporting period indicated that errors existed in the death and case counts.12 However, the shortage variables are plausibly less subject to such reporting errors, as these variables are based on straightforward yes-or-no questions asked of nursing homes. Furthermore, staff and PPE shortages are likely easier for nursing home administrators to track than COVID-19 death counts, given that deaths may often occur outside the nursing homes and testing is not universal. To assess the internal validity of the shortage data, we calculated the number of facilities with inconsistent responses to the PPE questions; specifically, we examined the number of facilities that reported both not having any of a particular PPE type and having a one-week supply of the same type, which is not possible. Fewer than 0.5 percent of facilities had this type of conflicting response, and these respondents were conservatively classified as not having a PPE shortage in our analyses. Although these checks are reassuring, the surveys are self-reported by nursing homes, and it is still possible that facilities underreported shortages, potentially to avoid undesired scrutiny.

This study was also limited by the wording of the shortage questions. For example, a one-week supply of PPE represents a severe shortage of supplies, but no additional questions were available to detect the magnitude of shortages. As such, PPE shortages should be viewed as a lower bound of clinically significant shortages at the time. In contrast, staff shortage questions asked only about any shortage and did not quantify the extent of these deficits. Staff shortages are therefore subject to bias if respondents had systematic differences in their interpretation of the broad wording in the question.

Another limitation was that the state of the COVID-19 pandemic moves very quickly. Therefore, the state of nursing homes in mid-July 2020 might not reflect shortages later in 2020. Nevertheless, this survey represents the largest and most recent data set that was available about the state of nursing homes navigating the pandemic.

Finally, our analysis only demonstrated associations between nursing home characteristics and the prevalence of shortages. Our results should be interpreted as descriptive, not causal.

Study Results

Of the 15,388 nursing homes identified in our data, 15,035 (98 percent) had submitted staff and PPE shortage data to the CDC database in at least one of the weekly reporting periods during study period 2 (June 24–July 19, 2020) (appendix exhibit A1).11 Nursing homes without submitted data (n = 353) were more likely to be small (that is, with 1–50 beds), be unaffiliated with a chain, have the highest and lowest quartiles of Medicaid revenue share, have the lowest overall and staffing five-star quality scores, have high proportions of non-White residents, and be located in a county with the highest quartile of new COVID-19 cases.

At the end of study period 1 (ending June 14, 2020), 20.7 percent of nursing homes with submitted data reported a severe PPE shortage, recording one week or less of available supply, with shortages of N95 respirators and gowns being the most common types (13.4 percent and 12.6 percent of all nursing homes, respectively; exhibit 1). A total of 20.8 percent of facilities reported a staff shortage, with 15.1 percent, 17.2 percent, and 9.2 percent indicating a shortage of nurses, nurse aides, and other staff, respectively.

Exhibit 1 National rates of personal protective equipment (PPE) and staff shortages in US nursing homes, May–July 2020

Shortage typeStudy period 1
Study period 2
Percent95% CIPercent95% CI
Any PPE shortage (n = 14,509a and 15,036b)20.7(20.0, 21.4)19.1(18.4, 19.7)
 N95 respirators13.4(12.9, 14.0)14.4(13.9, 15.0)
 Surgical masks6.1(5.7, 6.5)8.3(7.9, 8.8)
 Eye protection5.8(5.4, 6.2)7.8(7.4, 8.2)
 Gowns12.6(12.1, 13.2)10.9(10.4, 11.4)
 Gloves3.7(3.4, 4.0)4.2(3.9, 4.6)
 Hand sanitizer4.9(4.6, 5.3)4.3(4.0, 4.7)
Any staff shortage (n = 14,519a and 15,042b)20.8(20.1, 21.5)21.9(21.3, 22.6)
 Nurses15.1(14.5, 15.7)16.0(15.4, 16.6)
 Clinical staff2.7(2.5, 3.0)2.6(2.4, 2.9)
 Nurse aides17.2(16.6, 17.9)18.5(17.9, 19.1)
 Other9.2(8.8, 9.7)9.3(8.9, 9.8)

SOURCE Authors’ calculations using Centers for Medicare and Medicaid Services COVID-19 Nursing Home Data database. NOTE CI is confidence interval.

aFor study period 1, May 18–June 14, 2020.

bFor study period 2, June 24–July 19, 2020.

Overall shortage rates were relatively unchanged at the conclusion of study period 2 (ending July 19, 2020), with 19.1 percent and 21.9 percent of nursing homes reporting shortages of PPE and staff, respectively. N95 respirators (14.4 percent) and gowns (10.9 percent) continued to be the most common types of PPE shortages, although the percentage of nursing homes reporting gown shortages fell relative to the first study period. Nurse aides (18.5 percent), nurses (16.0 percent), and other staff (9.3 percent) continued to be the most common staff shortage categories.

In unadjusted comparisons, facilities reporting any PPE shortage in both study periods were more likely to be for-profit and chain affiliated and to report COVID-19 cases among staff and residents (exhibit 2). After adjustment, being for profit (8.1-percentage-point increase [study period 1; p<0.001] and 8.3-percentage-point increase [study period 2; p<0.001] relative to nonprofit facilities) and having COVID-19 cases among residents (3.2-percentage-point increase [study period 1; p<0.001] and 3.1-percentage-point increase [study period 2; p<0.001] relative to facilities without cases among residents) and staff (2.5-percentage-point increase [study period 1; p=0.003] and 2.3-percentage-point increase [study period 2; p=0.007] relative to facilities without cases among staff) continued to be associated with higher rates of any PPE shortages. Regression estimates also indicated that facilities with the highest five-star staffing scores were less likely (5.1-percentage-point decrease [p=0.002] relative to one-star facilities) to report a PPE shortage during study period 1. Finally, being chain affiliated was associated with a relative increase (1.7 percentage points [p=0.025]) in the likelihood of reporting a PPE shortage in study period 2.

Exhibit 2 Personal protective equipment (PPE) shortages in US nursing homes, by facility characteristics, May–July 2020

Facility characteristicsStudy period 1
Study period 2
Unadjusted (%)Adjusted difference (percentage points)Unadjusted (%)Adjusted difference (percentage points)
Profit status
 Nonprofit15.6Ref14.3Ref
 Government owned14.00.313.61.8
 For profit23.08.1***21.18.3***
Number of beds
 1–5020.1Ref18.7Ref
 51–10021.0−0.919.4−0.1
 101–15020.7−0.519.30.9
 151–20020.7−1.218.60.3
 More than 20020.0−0.917.00.4
Part of chain
 No18.9Ref17.0Ref
 Yes21.91.020.71.7**
Percent of revenue from Medicaid (quartiles)
 1 (lowest)18.3Ref17.8Ref
 221.91.720.01.3
 321.71.119.71.0
 4 (highest)20.70.319.01.0
Percent of residents who are non-White (quartiles)
 1 (lowest)20.9Ref21.0Ref
 221.10.719.1−1.5
 319.70.018.6−1.6
 4 (highest)21.41.318.2−2.0
Five-star overall quality score
 120.1Ref18.4Ref
 221.70.819.10.0
 321.10.519.30.4
 421.20.719.81.2
 519.60.918.81.7
Five-star staffing score
 117.9Ref15.4Ref
 220.3−118.10.1
 322.6−0.121.31.7
 423.00.421.41.3
 516.4−5.1***16.3−2.6
County COVID-19 new case rate (quartiles)
 1 (lowest)21.6Ref20.2Ref
 221.00.219.5−0.4
 319.5−0.318.7−0.8
 4 (highest)20.6−0.517.70.3
Any COVID-19-positive residents
 No18.4Ref16.9Ref
 Yes22.73.2***20.23.1***
Any COVID-19-positive staff
 No18.5Ref16.9Ref
 Yes21.92.5***19.62.3***

SOURCE Authors’ calculations using Centers for Medicare and Medicaid Services COVID-19 Nursing Home Data database. NOTES Study periods 1 and 2 are defined in the notes to exhibit 1. Adjusted differences were calculated using linear regression models that included all characteristics listed in this exhibit in addition to state fixed effects. Missing information for any of the facility characteristics was captured with a “missing” category not reported here. Full regression results are in appendix exhibit A2 (see note 11 in text).

**p0.05

***p0.01

With respect to staffing, facilities that were government owned, had higher Medicaid revenue shares, had lower five-star overall and staffing-specific quality scores, and had staff and resident COVID-19 cases were more likely to report shortages in both study periods in unadjusted analyses (exhibit 3). After adjustment, government ownership (4.7-percentage-point increase [study period 1; p=0.006] and 3.9-percentage-point increase [study period 2; p=0.024] relative to nonprofit facilities), having greater Medicaid revenue shares (for example, 5.2- and 5.1-percentage-point increases in study periods 1 and 2 [p<0.001 for both] between facilities in the highest versus lowest quartiles, respectively), and having COVID-19 cases among the staff (1.9-percentage-point increase [study period 1; p=0.022] and 3.8-percentage-point increase [study period 2; p<0.001] relative to facilities without cases among the staff) continued to be significant predictors of a reported shortage in both periods. In addition, there was a clear gradient across both general facility quality scores and scores specific to prior staffing levels, with higher-rated facilities being less likely to report a shortage. Facilities with an overall five-star score were 6.4 percentage points (study period 1; p<0.001) and 7.5 percentage points (study period 2; p<0.001) less likely to report a shortage relative to one-star facilities; nursing homes with a five-star staffing score were 5.7 percentage points (study period 1; p=0.001) and 5.4 percentage points (study period 2; p=0.002) less likely.

Exhibit 3 Staff shortages in US nursing homes, by facility characteristics, May–July 2020

Facility characteristicsStudy period 1
Study period 2
Unadjusted (%)Adjusted difference (percent points)Unadjusted (%)Adjusted difference (percent points)
Profit status
 Nonprofit19.4Ref19.6Ref
 Government owned24.54.7***25.53.9**
 For profit20.90.822.41.0
Number of beds
 1–5019.9Ref19.6Ref
 51–10020.7−0.922.3−0.2
 101–15020.9−1.723.0−1.0
 151–20021.1−2.621.3−2.1
 More than 20022.4−4.1**20.5−3.4
Part of chain
 No21.3Ref22.4Ref
 Yes20.7−1.421.9−2.5***
Percent of revenue from Medicaid (quartiles)
 1 (lowest)17.2Ref17.8Ref
 220.00.922.12.1**
 322.13.1***22.92.8***
 4 (highest)24.55.2***25.55.1***
Percent of residents who are non-White (quartiles)
 1 (lowest)21.3Ref21.7Ref
 220.90.222.30.5
 321.10.622.5−0.5
 4 (highest)21.31.122.90.3
Five-star overall quality score
 127.1Ref28.9Ref
 223.5−1.924.9−1.9
 320.3−4.8***21.8−4.6***
 419.1−5.4***20.2−5.6***
 516.3−6.4***16.3−7.5***
Five-star staffing score
 127.2Ref29.5Ref
 221.9−2.323.1−2.0
 319.7−2.320.4−2.4
 419.3−2.820.3−2.5
 517.0−5.7***17.2−5.4***
County COVID-19 new case rate (quartiles)
 1 (lowest)22.6Ref20.1Ref
 220.5−1.021.1−1.5
 319.9−2.123.11.0
 4 (highest)20.1−1.023.40.8
Any COVID-19-positive residents
 No19.4Ref21.1Ref
 Yes22.02.2***22.41.2
Any COVID-19-positive staff
 No19.0Ref19.5Ref
 Yes21.91.9**22.53.8***

SOURCE Authors’ calculations using Centers for Medicare and Medicaid Services COVID-19 Nursing Home Data database. NOTES Study periods 1 and 2 are defined in the notes to exhibit 1. Adjusted differences were calculated using linear regression models that included all characteristics listed in this exhibit in addition to state fixed effects. Missing information for any of the facility characteristics was captured with a “missing” category not reported here. Full regression results are in appendix exhibit A3 (see note 11 in text).

**p0.05

***p0.01

Some differences were noted between the two study periods. Larger facilities (that is, those with 200 or more beds) were less likely to report a staff shortage (−4.1 percentage points [p=0.033] relative to facilities with 50 or fewer beds) during study period 1. This difference was no longer significant during study period 2 at the 95 percent significance level. Being part of a chain was associated with a lower likelihood of a staff shortage in study period 2 (−2.5 percentage points; p=0.002), and having COVID-19 cases among residents was associated with a greater likelihood (2.2 percentage points [p=0.005]) in study period 1.

There was considerable variation across counties reporting PPE (exhibit 4) and staff (exhibit 5) shortages during the June 24–July 19, 2020 reporting period (study period 2). For example, in 25 percent of counties with data, 32 percent of nursing homes reported less than a one-week supply of at least one PPE category. In 10 percent of counties, 66 percent of nursing homes reported such a shortage. PPE shortages were distributed throughout the country, but clusters of high shortage rates were notable in northern New England, Iowa, Alabama, North Carolina, West Virginia, and Tennessee. Twenty-five percent of counties had at least 44 percent of nursing homes reporting a staff shortage; 12 percent of counties had 75 percent of more of their nursing homes operating short staffed. High rates of staff shortages were clustered in portions of the South and Midwest, especially Louisiana, Alabama, eastern Texas, and Georgia. Geographic shortage patterns were similar in study period 1 (appendix exhibits A4 and A5).11

Exhibit 4 Geographic distribution of personal protective equipment (PPE) shortages in US nursing homes, June 24–July 19, 2020

Exhibit 4
SOURCE Authors’ calculations using the Centers for Medicare and Medicaid Services COVID-19 Nursing Home Data database. NOTE County shortage rates reflect the percentage of facilities within a county reporting a PPE shortage, weighted by number of beds in facilities.

Exhibit 5 Geographic distribution of staff shortages in US nursing homes, June 24–July 19, 2020

Exhibit 5
SOURCE Authors’ calculations using the Centers for Medicare and Medicaid Services COVID-19 Nursing Home Data database. NOTE County shortage rates reflect the percentage of facilities within a county reporting a staff shortage, weighted by number of beds in facilities.

Discussion

We found that roughly one in five facilities faced a staff shortage or a severe shortage of PPE in early July 2020.

Using the most comprehensive survey of nursing homes during the COVID-19 pandemic to date, we found that roughly one in five facilities faced a staff shortage or a severe shortage of PPE in early July 2020. Despite a slight decrease in facilities with any PPE shortage driven by the higher availability of gowns, overall PPE and staff shortages had not meaningfully improved since late May 2020. In many counties, the majority of facilities faced shortages of staff or PPE. PPE shortages were magnified among nursing homes with COVID-19 cases among the staff or residents and for-profit facilities. Staff shortages were greater in facilities with COVID-19 cases, particularly among staff members; in those serving a high proportion of disadvantaged patients on Medicaid; and in those with lower quality scores, including prepandemic staffing scores. Given the disproportionate burden of morbidity and mortality faced by nursing home residents, the magnitude of these shortfalls poses a major threat to public health, especially in areas with the highest proportions of nursing homes with severe shortages, many of which experienced surges in COVID-19 activity in July and August 2020.

These results provide a detailed view of the specific challenges faced by nursing homes during the height of pandemic in many areas nationwide. For example, PPE shortages were most pronounced for N95 respirators and gowns, whereas staff shortages were most commonly reported for nurses and nurse aides. Overall shortages were also more common among facilities with COVID-19 cases among the staff or residents. It is predictable that facilities with active COVID-19 cases would be more likely to experience shortages because those facilities are likely the ones using PPE at the highest rates and with sick staff members who have to quarantine. However, this association highlights the importance of pandemic preparedness for nursing homes in areas of the country that faced a second surge of COVID-19 in the summer of 2020. Many of these areas, such as South Carolina, Georgia, and Alabama, had a high concentration of counties where the majority of nursing homes faced shortages even before the second surge of COVID-19 began in late June.

For-profit nursing homes reported substantially higher rates of PPE shortages than other facilities, but not staffing shortages. This is especially concerning, given that the vast majority of nursing homes in the US are for profit and given that a substantial literature from before the pandemic documented lower quality of care at for-profit nursing homes compared with nonprofit facilities.1315 Our results are not able to speak to a specific mechanism that might drive this association. However, it is plausible that for-profit facilities had a stronger financial disincentive than others to make large investments in PPE, given the uncertainty of how the pandemic might evolve in the US.

It is also notable that the most prominent staff shortages were for nurses and nurse aides, as opposed to clinicians or other staff. Shortages in these staffing categories were common before COVID-19, but the pandemic is straining an overstretched workforce that is already contending with low pay and demanding work environments. This point is supported by the finding that nursing homes with lower staffing quality scores before the pandemic were more likely to report current shortages. Nurses and nurse aides are on the front lines of care delivery, with daily or even hourly contact with residents. These shortages could have a major impact not just on nursing homes’ ability to adhere to standard infection control protocols but also on their capacity to provide necessary ongoing care not directly related to COVID-19.

It is concerning, although not unexpected, that more disadvantaged or lower-quality nursing homes, such as those with a higher percentage of revenue from Medicaid or those with lower star ratings, have worse staff shortages. These are facilities whose profit margins will be necessarily lower because of the underpayment of Medicaid for nursing home costs. Although nursing homes across the spectrum of quality and patient mix reported shortages, we observed a fairly stark disparity, with 29 percent of one-star nursing homes reporting a shortage compared to 16 percent of five-star nursing homes. This disparity illustrates that policies to address shortages will need to account for the heavier burden among nursing homes serving more disadvantaged populations. Without more policy attention and additional investment, nursing homes serving disadvantaged populations may struggle to meet even the most basic needs of their residents, regardless of COVID-19 status.

Although the most effective way to prevent COVID-19 outbreaks within nursing homes may be to reduce the community prevalence of coronavirus infections, our results have a number of nursing home–specific policy implications. First, too many nursing homes lack a minimally sufficient supply of PPE to adequately protect themselves from COVID-19. This shortage persisted over a period of almost two months. Given that nearly half of all deaths from COVID-19 in the US have come from nursing home residents, this must be a policy priority if policy makers intend to save as many lives as possible.

The most vulnerable nursing homes are at the highest risk for shortages that put the health of residents and staff at risk.

Second, as in most crises, the most vulnerable nursing homes are at the highest risk for shortages that put the health of their residents and staff at risk. Although there is no quick fix for the complex problems faced by nursing homes with more disadvantaged populations, additional targeted financial support for direct patient care and supplies, coupled with appropriate oversight to ensure that funds are used for the intended purposes, as a part of future stimulus packages could help prevent COVID-19 from being both a financial and a clinical crisis for these facilities.

Third, there is clearly substantial geographic heterogeneity in the shortages faced by nursing homes. Some states, such as Alabama, need to prioritize their nursing homes’ resilience to outbreaks more than others, particularly as the geographic distribution of COVID-19 hot spots continues to evolve.

Fourth, these data are extremely valuable, and CMS should continue its commitment to gathering information on nursing homes’ available resources and disseminating it publicly. However, as facilities improve their data reporting capacities, CMS should also update its survey questions to reflect the current realities of the pandemic. The current set of questions reflects an extreme of scarcity that might not apply for long and that misses other important factors such as the degree of staff shortages or testing turnaround times.

Conclusion

Many nursing homes in the US are poorly prepared to prevent and manage COVID-19 outbreaks, given a lack of essential PPE and staff. Despite intense policy attention and mounting mortality, the shortages did not meaningfully improve from May to July 2020. Unless these shortages are prioritized by policy makers, long-term care residents will continue to be at a great disadvantage in the pandemic.

ACKNOWLEDGMENTS

David Grabowski serves as a paid consultant to Vivacitas and CareLinx. He also serves on the Scientific Advisory Committee of NaviHealth. Michael Barnett acknowledges funding from the National Institute on Aging (Grant No. K23 AG058806-01). An unedited version of this article was published online August 20, 2020, as a Fast Track Ahead Of Print article. That version is available in the appendix.

NOTES

   
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