Minority long-term care residents, staff bear heavy COVID burden

Adding to mounting evidence of racial health inequities in the United States, two University of Rochester in New York studies published yesterday in the Journal of the American Geriatrics Society show that minority residents and caregivers in nursing homes and assisted living facilities have suffered the most amid the COVID-19 pandemic.

The studies include data from 7 of the 13 states that reported cases and deaths to the Centers for Medicare and Medicaid Services through May 29: Colorado, Connecticut, Georgia, North Carolina, New York, Ohio, and South Carolina.

Testing capacity, infection prevention protocols

In a modeling study on disparities in coronavirus infections and deaths in 12,576 nursing homes the week of May 25, researchers found that facilities with low proportions of minority residents had, on average, 0.4 new COVID-19 residents each week (0 cases in 93% of facilities), versus 1.5 in those with higher proportions of minorities (0 in 78.9%).

In multivariable regression analysis, the likelihood of one or more new resident cases was 76% higher in the high-proportion minority group. Likewise, COVID-19 weekly deaths were 0.1 in the low-proportion group, versus 0.4 in the high-proportion group.

Weekly new coronavirus cases in staff members were 0.3 in low-proportion nursing homes, compared with 1.3 in those with high proportions. Self-reported shortages of staff and personal protective equipment (PPE) did not significantly differ between the two groups.

But "it is likely that nursing homes predominated by racial/ethnic minority residents face more of other institution-wide issues, such as poor testing capacity, and inadequate staff knowledge and training in infection control and prevention," Yue Li, PhD, lead author of the study, said in a University of Rochester news release.

Nursing home staff in communities of color, who provide most of the direct patient care in such facilities, are more likely than whites to live in crowded homes, rely on public transportation to get to and from work, have low pay, and lack benefits, the authors said.

Assisted living centers 'ill prepared'

A second study evaluated 2,542 COVID-19 infections and 675 deaths in assisted living centers. Statewide case-fatality rates ranged from 3.3% in North Carolina to 9.3% in Connecticut, in contrast with 12.9% and 31.6% among assisted living residents in those two states.

Of assisted living centers with one or more COVID-19 cases, mid-sized communities had fewer overall cases than smaller ones. And facilities with higher proportions of minorities and residents with dementia, chronic obstructive pulmonary disease, and obesity had the most coronavirus cases—but not deaths.

In the news release, the authors said that the pandemic has worsened disparities between facilities with divergent levels of resources and quality of care. Assisted living facilities, they said, are usually "ill prepared" to care for sicker residents and often have limited oversight, inexperienced or low-level staff, and PPE shortages. They are also subject to only state—not federal—regulations, which may or may not be rigorous.

They added that the federal government has given funding meant to address testing, PPE, and staff shortages only to the roughly 16% of assisted living facilities that serve Medicaid-eligible residents.

"Relying on [assisted living] communities to muster a rigorous response to the COVID-19 pandemic largely on their own is clearly unrealistic," the authors concluded. "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."

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