From April to August 2020, 45% of U.S. COVID deaths occurred in long-term care (LTC) facilities, even though LTC residents made up only 0.45% of the population. This stark disparity revealed that nursing homes were particularly vulnerable during the pandemic, with high transmission and fatality rates in these congregate settings. Skilled Nursing Facilities (SNFs), commonly known as nursing homes, represented about 80% of LTC COVID deaths, making them the deadliest place to live during COVID. While vaccine rollouts in 2021 reduced the death rate in LTC facilities, by then, 11% of SNF residents had already died from COVID, a significant increase over pre-pandemic mortality rates.
Infection Control: A Longstanding Challenge
The pandemic’s devastation in LTC facilities highlighted longstanding challenges. For years, SNFs struggled to control infections due to limited resources and outdated oversight systems. Even before COVID, nursing homes were prone to frequent outbreaks of respiratory and skin infections, including serious conditions like MRSA. Data from a 2017 study shows that 74% of the country’s influenza-related morbidity and mortality occurred in LTC facilities. When COVID hit, CMS and state public health agencies had not prioritized infection control resources for LTCs, leaving them ill-prepared to protect their vulnerable residents.
Despite decades of advocacy from patient groups, geriatricians, and survey directors, little reform had been enacted to address these risks. However, in April 2022, the National Academies of Science, Engineering, and Medicine released the report “The National Imperative to Improve Nursing Home Quality.” This 600-page document outlined necessary changes to prevent future mass fatalities, sparking the formation of the Moving Forward Coalition, an alliance of advocacy groups, industry leaders, and survey specialists committed to reforming CMS oversight.
California’s Proactive Approach
In addition to the coalition movement for reform during the COVID-19 pandemic, some states like California deviated from the standard CMS Quality and Safety Survey System to pilot a new approach using real-time data and risk-based algorithms to pinpoint the nursing homes with the highest risk for an outbreak and send surveyors and infection control teams to the
facilities. Thanks to this new targeted approach, California had the lowest COVID-19 fatality ratio in the continental U.S. despite having the greatest number of nursing homes in the entire nation. Since then, Maryland also added a bi-directional data approach to determine where and when to send public health teams and resources to LTC facilities. As a result, Maryland’s COVID-19 fatality ratio dropped from 14% per week to 2% per week. These efforts of state public health quality and safety oversight survey systems and the growing reform movement of LTC facilities have shown it’s time to create a nationwide movement to use real-time data and risk-based analytics to determine where to intervene early with public health experts in these high-risk facilities.
The Need for Reform in the U.S. Quality and Safety Survey System
According to the World Health Organization, the aging population, which represents 15-30% of the global demographic, is expected to double by 2050, intensifying the need for safe, effective LTC care. Infection control in LTCs is critical as healthcare-associated infections (HAIs) account for one in ten global deaths in these facilities. The current oversight system in the U.S., based on outdated methodologies and inadequate funding, has struggled to keep pace with increasing workloads and technological needs, resulting in significant backlogs in complaint investigations and predictable inspection patterns. Without modernization, the system cannot support the needs of LTC facilities or adequately prevent mass outbreaks.
To receive Medicare funding, LTC facilities must meet CMS safety standards, but enforcement is hindered by funding shortfalls and technological gaps. State survey agencies often rely on the outdated ASPEN (Automated Survey Process Environment) system, designed in the 1990s, which lacks internet or mobile capabilities, making real-time data collection impossible and response times dangerously slow. When surveyors do inspect LTC facilities, delays in processing findings can lead to extended periods without oversight, creating opportunities for infection risks to escalate.
Leveraging Data to Improve Outcomes
The California case study demonstrated that there are more proactive ways to use past and real-time data on LTC facilities to determine where the highest-risk facilities are.
California data scientists took several datasets to create an algorithm of risk which became over 80% accurate by the fall of 2020. Maryland also used a similar life-saving system later in the pandemic. The states that have used data and algorithms like these during the pandemic have used them daily to determine whether a LTC facility is at high, medium, or low risk. High-risk facilities are the first to receive visits from surveyors and infection control teams. Medium-risk facilities receive an immediate phone call or tele-visit to see if there are resources or technical assistance needed. And low-risk facilities are still surveyed once every 15 months as per CMS requirements, but they are prioritized last. With a diminishing public health workforce, using risk-based strategies like these with data can help use public health nurses and surveyors in more impactful ways. If states had more freedom to be innovative and use data more proactively, rather than relying on the current CMS annual schedule, we can save lives in these facilities that have had long-standing health disparities.
Data on state infectious disease outbreaks like influenza and COVID-19 is collected through the states and the CDC. All states send influenza and COVID-19 LTC facility outbreak and case fatality ratio data to CDC where it is publicly available for use.
A Call to Action
With over 370,000 deaths in LTC facilities between 2020 and 2021, the need for change is clear. Social determinants of health data can help guide resource allocation, identifying areas most in need of proactive intervention. The CMS has taken steps toward more targeted inspections, but significant reform is essential to rebuild trust, improve safety, and protect the vulnerable aging population in these settings.
The greatest health disparity in LTCs stems from inadequate infection control. By developing a modern, data-integrated oversight system, we can reduce infectious disease outbreaks, prevent excess deaths, and ensure that our most vulnerable citizens are not the first casualties of future pandemics. The tools are available—the time to act is now.
About Heidi Steinecker
Heidi Steinecker is a principal health and human services consultant at Resultant and has more than 20 years of leadership in healthcare delivery and public health policy. Heidi provided valuable leadership in California’s COVID-19 response and has worked globally to strengthen healthcare systems. She is currently completing her Doctorate of Public Health with a focus on global health security at the Medical College of Wisconsin.