- Thank you for Helping Us Celebrate 35 Years of Medicare Advocacy
- Covid-19 and Nursing Home Residents: Increased Loneliness and Isolation
- Experts Spotlight Systemic Racism in U.S. Nursing Homes and Call for Action
- Some Good COVID News from Navajo Nation
Thank you to all who joined us at the 8th Annual National Voices of Medicare Summit & Sen. Jay Rockefeller Lecture
Thank you to everyone who made the 2021 Summit a success! We thank the Sen. Jay Rockefeller Lecturer, Dr. Donald Berwick, presenters, sponsors, attendees, Center for Medicare Advocacy board members, and the Summit planning committee. Watch for our annual Summit Reflections, summarizing the event, coming soon.
A reminder that if you registered for this year’s Summit – whether or not you attended – we ask that you fill out our follow-up survey at: https://www.esurveyspro.com/s/474780/CMA-Summit-Registrant-2021.
We look forward to meeting with all of you again next year!
Many nursing home residents who have not contracted or died from COVID-19 have also suffered negative consequences during the pandemic. Loneliness and isolation have taken a significant toll on residents. A study of long-stay residents in Connecticut’s 244 nursing homes finds that, compared with residents in the same four-month period (March 9-July 31) in 2017-2019, residents in 2020 experienced increased depression, unplanned weight loss, and incontinence, as well as deterioration in cognitive function. The researchers at Mathematica who did the study found no differences in serious pressure ulcers, activities of daily living, recent falls, urinary tract infections, or use of antipsychotic or anti-anxiety medications.
The study’s authors identify selection bias in the assessment data that could have affected their findings. They note that the 10 percent of residents living in Connecticut nursing facilities in March 2020 who died could have experienced declines in their mental and physical functioning that were not recorded in the data and that, as a result, the study may have underestimated the negative health effects of the pandemic on residents.
The Center notes that Mathematica’s analysis may understate the negative effects of the pandemic for another reason. Analysis of resident outcomes depends on the accuracy of resident assessment data. A recent study found that skilled nursing facilities (SNFs) under-reported the three quality measures they studied, which are three of the six measures where the Mathematica researchers found no decline in Connecticut nursing home residents.
Comparing pressure ulcer rates reported by SNFs with pressure ulcer rates from patients who were readmitted to the hospital from the SNFs, Integra Med Analytics found that SNFs under-reported three quality measures – pressure ulcers, urinary tract infections (UTIs), and falls. The researchers found “low correlations between self-reported and hospital-based measures for pressure ulcers, UTIs and falls at .02, .04 and .09 respectively, indicating that the self-reported measures were inconsistent with hospital-based diagnoses.”
Integra Med Analytics reports, “The median ratio of the self-reported and hospital-based pressure ulcer rates was 0.48, indicating that over half of SNFs under-reported by at least a factor of two.” The researchers describe their analysis as “a conservative measure of under-reporting; the hospital data only included patients that were re-admitted to the hospital in the numerator and any SNF patients with pressure ulcers that were not re-admitted to the hospital weren’t counted.”
The consequences of under-reporting were significant. One facility studied by the company “had a low self-reported UTI rate of less than 1 in 1,000 which is in the first percentile of the self-reported rates. However, 5.8% of this SNF’s admissions were re-hospitalized with a UTI, which is in the 86th percentile for the hospital-based measure.”
 Michael Levere, Patricia Rowan, Andrea Wysocki, “The adverse events of the COVID-19 pandemic on nursing home resident well-being,” Journal of the American Medical Directors Association (2021), https://www.jamda.com/article/S1525-8610(21)00306-6/pdf
 Integra Med Analytics, Underreporting in Nursing Home Quality Measures (Aug. 2020), https://www.nursinghomereporting.com/post/underreporting-in-nursing-home-quality-measures.
COVID-19 deaths in long-term care facilities account for one-third of the nation’s death toll – even though only five percent of the cases have occurred in these facilities. “People in nursing homes”, as Robert Espinoza, Vice President of Policy at PHI, states, “were at ‘ground zero’ of the pandemic.”
In addition to hitting long-term care facilities the hardest, COVID-19 also highlighted racial and ethnic disparities within these care settings. The Centers for Disease Control and Prevention (CDC) reports that evidence suggests some racial and ethnic minority groups were disproportionately affected by COVID-19, and that long-standing systemic health and social inequities have put many people from these groups at increased risk of getting sick and dying from COVID.
Mr. Espinoza is one of several co-authors of a new article titled “Addressing Systemic Racism in Nursing Homes: A Time for Action”, published in the Journal of Post-Acute and Long-Term Care Medicine (JAMDA). Espinoza and his co-authors assert that these disparities are a result of longstanding “structural, interpersonal and cultural racism” in the United States. They found that the proportion of Black residents in a nursing home was correlated with an increased probability of a COVID-19 outbreak anywhere from 45% to 300%. The authors examine two characteristics of nursing home environments that contribute to these disturbing statistics – a “racially segregated care system”, and a “racially stratified workforce”.
In the care system setting, the authors explore why Black Americans are disproportionately more likely to rely on nursing home care. In speaking with the Center for Medicare Advocacy, Mr. Espinoza explains,
“we really don’t have a strong home and community-based services system, and that forces many people of color – who don’t have the income to live in assisted living or hire their own caregiver out-of-pocket – to go into nursing homes. Black and Latinx people of color in particular are more likely to end up in nursing homes.”
The article also highlights that Black individuals are also cared for in facilities that are often for-profit, serve a primarily Medicaid population, have lower levels of nurse staff, and have lower resident outcomes.
The 1.3-1.7 million direct care workers in long-term care settings also suffer from the impacts of systemic racism. The workforce is largely comprised of low-paid, ethnic minorities who are primarily female, and who are largely relegated to the “bottom of the health care occupational ladder”. Direct care workers are paid so little, in fact, that almost 20% live in poverty and more than half rely on some form of public assistance. Furthermore, the authors point out that long-term care settings are “essentially institutions where low-paid people of color care for a primarily White clientele under the supervision of primarily White managers.”
The authors recommend policy and practice recommendations to address the impacts of systemic racism in the long-term care environment, which range from investing in segregated neighborhoods to build wealth, examining public financing of nursing homes to increase Medicaid payments, and increasing direct-care worker wages. For Mr. Espinoza, an important key is racial disparity data. “It starts with collecting data on outcomes within the workforce,” he argues. “And then it means targeted strategies to support people of color and women and immigrant workers to make sure that they can rise up that career ladder.”
 KFF, “State COVID-19 Data and Policy Actions” (Apr. 6, 2021). Retrieved April 06, 2021, from https://www.kff.org/coronavirus-covid-19/issue-brief/state-covid-19-data-and-policy-actions/
 CDC, “Health equity considerations and racial and ethnic minority groups” (Feb. 12, 2021). Retrieved April 06, 2021, from https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/race-ethnicity.html
 Sloane, P. D., Yearby, R., Konetzka, R. T., Li, Y., Espinoza, R., & Zimmerman, S. (2021). Addressing systemic racism in nursing homes: A time for action. Journal of the American Medical Directors Association, 22(4), 886-892. doi:10.1016/j.jamda.2021.02.023
The New York Times reported some welcome news this week regarding COVID-19 cases in Navajo Nation: Due to a successful vaccination campaign in which half the population is already vaccinated, as well as strict adherence to mitigation measures, Navajo Nation had zero cases and zero deaths in a 24 hour period.
This is particularly striking as Navajo Nation previously had one of the worst rates of COVID-19 cases in the United States. Early reporting from the pandemic showed that American Indians and Alaska Natives were 3-5 times more likely to be diagnosed with the COVID-19 than non-Hispanic whites, and their mortality rate was almost twice as high.
Despite the recent welcome news, the article cautioned that warning signs were ahead; there was a confirmed case in Navajo Nation of the highly contagious and more lethal COVID-19 variant first seen in the U.K., as well as the general concern among health officials of a possible looming surge in cases.
The Center for Medicare Advocacy (the Center), continues to highlight COVID-19 data and resources showing the higher burden of illness from COVID-19 in communities of color. The Center aims to call attention to the ongoing, harmful health disparities exposed by the pandemic.