Covid cases are rising rapidly among US nursing home residents and staff, causing shortages in admissions, exacerbating bed shortages at hospitals in turn, and in some cases requiring the national guard to be called in.
The Omicron wave has sent many staff home sick at care facilities and rehabilitation centers that offer round-the-clock medical care. As a result, hospitals that would normally release patients into such stepped-down care are now holding off, creating a backlog of patients stuck in hospital.
“Things are condition critical today. Individuals can’t find an empty or staffed bed out there,” said David Grabowski, professor of health care policy at Harvard Medical School.
“It really puts hospitals in a difficult position,” he said, noting that they can’t admit new patients until they find a spot at a care facility for those patients well enough to be transferred. “That’s a huge problem, because they’re occupying a bed that would otherwise go to a new patient.”
There were more than 31,500 cases among nursing home residents in the week ending 9 January, nearly as many as last winter’s peak, according to the Centers for Medicare and Medicaid Services.
Cases among staff are even higher – more than double last year’s highest record, with more than 57,000 confirmed cases in the week of 9 January, a tenfold increase in just three weeks.
The rapid rise in infections compounds existing worker shortages, with 234,000 caregivers having exited the industry during the pandemic so far – a 15% reduction in the workforce in only two years.
In Wisconsin, the shortages are so acute that more than 200 members of the national guard will be trained to work as nursing aides.
“Right now, the only thing that is on their minds is the essential of, ‘How do we stay open without shortchanging our patients?’” said Leemore Dafny, professor at Harvard Business School.
Yet the acute care offered by some nursing homes is “a really important release valve for the hospitals”, she said, adding that without it hospitals may become even more overwhelmed: “It causes this ricochet effect.”
Care facilities, already buffeted by the pandemic, are a little-acknowledged part of the health system, particularly for patients who don’t need hospital-level care but aren’t yet ready to go home.
“Nursing homes, including the post-acute care parts, have just always been kind of secondary to hospitals, and I think that comes back to bite us. Because it turns out they’re a pretty essential link in the chain,” said R Tamara Konetzka, professor of public health sciences at the University of Chicago.
“Nursing homes throughout the early part of the pandemic were really the epicenter of the tragedy of Covid-19,” Konetzka said. At various times, they accounted for 30% to 50% of the total deaths in their areas.
Residents of nursing homes have had some of the highest fatality rates of the pandemic, because of their close living quarters and the increased susceptibility of residents to Covid-19.
The pandemic was also brutal on staff. “They put themselves at risk. Cases among staff have been among the highest” among workers, Grabowski said. At one point in the pandemic, he said, being a nursing home worker was the most dangerous job in America, based on the death rates.
Nursing homes had already struggled with understaffing for decades, and the pandemic amplified those problems. Workers feared getting sick and bringing the virus home to vulnerable family members. Some struggled to find child care during school and daycare closures. Others became disabled, and still others died. Some, meanwhile, found they could work elsewhere for equal or better pay.
Yet having enough staff during nursing-home outbreaks can be a defining factor in how well residents do, according to research from Konetzka, Grabowski, and others.
“You really need enough staff to try to stem the outbreak,” Konetzka said. Nursing home staff test patients regularly, move those who are positive into isolation areas, and provide care both for Covid and any underlying conditions.
Admissions to nursing homes remain below pre-pandemic levels. The pandemic has seen some patients defer care and hospitals delay scheduled procedures, such as hip replacements, that would require a stay in a step-down facility.
Many patients were worried by headlines about high rates of cases and deaths in nursing homes, as well as isolation and loneliness.
“There was a real reluctance to enter a nursing home during the pandemic,” Grabowski said.
Omicron has so far led to significantly lower deaths than previous Covid waves, though deaths can be a lagging indicator, following cases and hospitalizations by a few weeks. High vaccination rates among residents – 87% are fully immunized – may keep fatalities low.
“The original vaccine effort was one of the real success stories during the pandemic when it comes to nursing homes,” Grabowski said.
However, there is high turnover in care facilities, both of staff and residents. “Even if you got everybody vaccinated the first time around, a few months later, there are going to be different people there,” Konetzka said.
Residents of nursing homes are also at generally higher risk of breakthrough infections, in part because the vaccines don’t work as well to spark lasting immune systems of older adults. Boosters can help, Konetzka said, but “that’s also not been very organized or systematic.”
Staff vaccination rates are lower, too, at 81%. That means one in five nursing-home employees are unvaccinated, putting them at higher risk of passing the virus on to residents and getting ill themselves. Even if staff are out for a few days, it puts pressure on the entire system.
But staff vaccination rates may soon increase with the federal vaccine mandate for facilities accepting Medicaid and Medicare, which could help reduce soaring cases and shortages.