Surging Coronavirus More Dangerous for Nursing Homes With Black, Latino Residents

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As the coronavirus surges again, it is especially dangerous for people in nursing homes caring for more Black and Latino residents, according to a new analysis from the California Health Care Foundation.

Researchers found that skilled nursing facilities with a greater share of Black and Latino residents had higher rates of COVID-19 cases and deaths — and that disparity is growing.

“We asked [our] advisory group, how do you explain this disparity?” said Dr. Bruce Spurlock, executive director of Cal Hospital Compare, and a study co-author. “And nobody really knows. And that's kind of the part that we really need to figure out.”

A Shift Over Time

Skilled nursing facilities have borne much of the weight of the pandemic. More than one quarter of reported COVID-related deaths in California have happened in nursing homes, even though their residents make up less than half a percent of the state’s population.

Beyond demographics, the new study analyzed state and federal data about ownership status, size, type of patient, staffing levels and geography to identify factors associated with the hardest-hit nursing homes.

And those factors changed as the pandemic wore on. Back in May, “you could tell that the larger the facility, the for-profit facilities, were doing worse than the smaller and nonprofit facilities,” Spurlock said.

By late summer, he said, facilities struggling to control the virus were in counties with high COVID-19 rates.

“Age, gender, race and ethnicity were a much bigger predictor of who was doing worse in the August time frame,” Spurlock said.

Nursing home residents over 85, and men, have been more vulnerable to the virus throughout California. And while Latinos account for about 60% of California’s positive coronavirus tests, they represent less than 40% of the state’s population. But across the state, COVID-positive tests for Blacks have been a disproportionately small part of the total.

Lower Risk in Bay Area Nursing Homes

All together, the research suggests a story of how the coronavirus has moved through skilled nursing facilities statewide. That story is slightly different in the Bay Area.

Outbreaks the region experienced during late spring and summer tracks with the study’s overall conclusions about nursing homes. Windsor Vallejo, a Contra Costa County care home operated by a limited liability corporation, saw 100 cases of the coronavirus in May. A month earlier, corporate-owned Gateway Care and Rehabilitation Center in Hayward saw at least 65 cases of COVID-19. Complaints from family members have so far prompted a lawsuit and an investigation by the Alameda County district attorney.

But Bay Area nursing homes have fewer Latino residents than the rest of the state. The region’s nursing homes are generally smaller than the state average, and fewer are run by corporations for profit. About a third of Marin County nursing homes are nonprofit, for example.

“The report is great. My response to it is 'duh,’ ” said Scott Akrie, whose father Costell tested positive for coronavirus while at Gateway and died within weeks. Akrie, who is suing Gateway, points out that the facility has been repeatedly cited by state regulators and sued, so far with little consequence. “Just because these people are elderly, they are not forgotten souls that can be taken for granted.”

County by county, as the coronavirus surges, health officers are now are modifying orders related to long-term care homes. In Santa Clara County, the latest guidelines keep visitors to care home residents outside as much as possible, and require visitors present a negative test within 72 hours of a socially distanced visit indoors.

In Alameda County, where the Centers for Disease Control and Prevention reports the case rate per capita has risen 24% in the last week, seven nursing homes report COVID-19 outbreaks as of Dec. 2. Nine facilities currently report outbreaks in Santa Clara County, where the case rate has risen more than 50% in the last week.

Some Recommendations Easier Than Others

Researchers make several recommendations to stanch the spread of the virus in nursing homes. Some are tactical; actions that could be taken immediately, like asking the Department of Public Health to enforce testing and training requirements week after week. Some are more complex: The authors suggest that the Department of Health Care Services should demand more financial transparency from all related entities controlling nursing homes, which would require amending law and regulation.

The California Department of Public Health says it has used predictive analysis to identify facilities that seem to be headed for trouble, and follows up with facilities in outbreak to address urgent needs. In a statement, CDPH says it has prioritized mitigation and infection control, as well as the investigation of complaints and incidents that nursing homes themselves report, over routine inspections and enforcement.

Nursing homes with higher levels of staffing have fared better throughout the pandemic, but staffing levels remain “a very controversial area,” according to Spurlock. Federal and state rules set minimum hour requirements for nurses, assistants and other staffers at skilled nursing facilities. In the Bay Area, patient advocates allege that understaffing has contributed to outbreaks, especially in Alameda County.

In a statement, the California Association of Health Facilities calls staffing a “critical” problem for the nursing homes it represents, pointing out that when a worker tests positive and must quarantine, other workers must often work double shifts.

“It’s incredibly difficult to find staff right now and require them to work in a dangerous environment,” said California Association of Health Facilities spokeswoman Deborah Pacyna.

Researchers recommend that regulators require facilities to meet the staffing standards they’re supposed to. They also suggest designating family members as “essential workers” as the pandemic continues. Doing that would permit relatives into facilities, which could boost care and minimize isolation and anxiety in a time of crisis.

The authors also put forward a more involved proposal to restructure the state’s low-income health subsidy, to boost nursing home salaries and staffing even further than it does now. Such a move would prompt debate and require litigation.

“Any suggestion that staff levels should be increased needs to be coupled with additional state reimbursement for wages,” said Pacyna.

“With staffing, we know the changes to make” that would help, said Spurlock. “With health equity, we still are unsure about what actions that we need to take to reduce the disparity.”

Among the researchers’ health equity-related recommendations is that vaccines should be directed toward skilled nursing facilities most at-risk, which right now means facilities with higher numbers of Black and Latino residents.

As of now, federal and state guidelines prioritize vaccines for health care workers on the front lines most at risk of contracting COVID-19. California counties are still developing their specific plans for distributing vaccines that are sure to be in short supply. And Spurlock acknowledges that this recommendation is a controversial one. But he says that the evidence points toward a need for change, and for multiple, large-scale solutions being enacted simultaneously.

“The pandemic has really ripped open some vulnerabilities in a population that's extremely dangerous, that something like this can go through very rapidly and ravage people that are near and dear to our hearts,” Spurlock said. “I don't think we're going back.”