Nursing homes admitting a COVID-positive patient during the peak months of the pandemic was associated with six additional cases and 1.5 additional deaths over the next 15 weeks, according to a study published Monday in JAMA Internal Medicine.

The new findings add fuel to the fire for critics of state policies that incentivized nursing homes to admit COVID-positive patients, or restricted their ability to deny such patients, according to lead author Brian McGarry, PhD, assistant professor and health services researcher at the University of Rochester.

“They are significant,” he told McKnight’s Long-Term Care News Monday. “I think that they suggest that there were substantial increases of COVID risk as a result of those COVID admissions. I think with the benefits of hindsight, it’s clear that those policies that encouraged nursing homes to take COVID-positive patients were probably not the right policies.”

Nursing home residents were among the earliest and hardest hit populations in the country during the pandemic. More than 2 million residents have caught COVID and more than 170,000 residents have died from the virus, according to CDC data.

State government often reacted with a complex web of policies intended to curtail the spread of COVID and reduce the risk of hospitals overflowing their peak capacity. Another JAMA study in April already confirmed that the number of these policies was not correlated with reduced spread. 

The new data suggests that states should have weighed the risks for nursing home residents more heavily alongside the risk of hospital crowding, McGarry said.

Misleading incentives

Worries about excess hospital demand motivated some states to incentivize nursing homes to admit COVID-positive patients that would otherwise have needed to stay in hospitals — or, in some states such as New York, at emergency field hospitals. 

Much of the political backlash to state COVID policies have focused on the five states that  instructed nursing homes they could not deny a patient admission solely for being COVID-positive. Those states were New York, New Jersey, Pennsylvania, Michigan and California.

One such opinion was also published in JAMA in a companion commentary to Monday’s study.

“There are some actions that are so foolish and so consequential that they beg for outrage,” wrote James Goodwin, MD, senior associate director of the Sealy Center on Aging at the University of Texas Medical Branch, and Huiwen Xu, PhD, assistant professor at UTMB. “No individual with the slightest knowledge of nursing homes could have forced nursing homes to admit patients with COVID-19. The majority of nursing homes were totally unprepared to quarantine patients with COVID-19, with inadequate staff, space, personal protective equipment, and training and protocols.”

McGarry noted strong backlash to these policies, but said equal attention should be paid to states that merely incentivized nursing homes to take on COVID-positive admissions. Both policies gave nursing homes a signal that such policies were approved by leading authorities.

Nursing homes did not have access to the same infrastructure as hospitals, McGarry confirmed, which should have been considered before setting such policies. 

“A number of other states used those financial incentives and I think those flew under the radar,” he told McKnight’s. “Clearly, money talks and that sends an equally strong signal to nursing homes that, ‘We appreciate you taking these patients — we want you to.’”

What now?

McGarry said that one upside to the incentive policies was that it put additional funding into long-term care. The study confirmed that excess cases and deaths following a COVID-positive admission were worse when a facility had insufficient resources for proper staffing and safety measures.

Another major problem facing nursing homes — during the peak of the pandemic and to this day — is the need to care for two different populations, McGarry said.

“Part of the root of this problem is that we use nursing homes to serve two distinct populations — one being long-stay residents for whom the nursing home is their home … and the other patient population is the post-acute rehab patients who in this instance were better served in a more medicalized environment,” he explained. “There’s a real tension there … there’s a knee-jerk reaction to say that a nursing home should be more like a hospital … but that shouldn’t necessarily be at the expense of long-stay residents who benefit from a comfortable, home-like environment.”

Both McGarry and the UTMB commentators pointed to the Green House model as an example for how providers can cater to residents with fewer residents per room and less potential for staff spreading illness.

Increasing staffing overall should be another key priority for policymakers and providers, the commentators wrote — noting that lower staffing rates were associated with more infections and deaths. They suggested that increased staffing requirements “should be accompanied by increased reimbursement.”