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Changes in Health and Quality of Life in US Skilled Nursing Facilities by COVID-19 Exposure Status in 2020

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  How did health and quality of life in US skilled nursing facilities (SNFs) change during the COVID-19 pandemic?

Findings  In this retrospective observational study that included data from 2 985 864 long-term care resident-years in 15 477 SNFs in 2018-2020, SNFs with active COVID-19 cases experienced significant increases in mortality and functional decline during the first year of the pandemic compared with the prepandemic period, while significant increases in weight loss and depressive symptoms occurred in SNFs with active COVID-19 and SNFs with no known COVID-19 cases.

Meaning  Among skilled nursing facilities in the US from January to November 2020, adverse changes occurred in some health and quality of life measures during the first year of the pandemic and prior to the availability of COVID-19 vaccination, compared with the prepandemic period of January to November 2018 and 2019, even among facilities that did not have known COVID-19 cases.


Importance  During the COVID-19 pandemic, the US federal government required that skilled nursing facilities (SNFs) close to visitors and eliminate communal activities. Although these policies were intended to protect residents, they may have had unintended negative effects.

Objective  To assess health outcomes among SNFs with and without known COVID-19 cases.

Design, Setting, and Participants  This retrospective observational study used US Medicare claims and Minimum Data Set 3.0 for January through November in each year beginning in 2018 and ending in 2020 including 15 477 US SNFs with 2 985 864 resident-years.

Exposures  January through November of calendar years 2018, 2019, and 2020. COVID-19 diagnoses were used to assign SNFs into 2 mutually exclusive groups with varying membership by month in 2020: active COVID-19 (≥1 COVID-19 diagnosis in the current or past month) or no-known COVID-19 (no observed diagnosis by that month).

Main Outcomes and Measures  Monthly rates of mortality, hospitalization, emergency department (ED) visits, and monthly changes in activities of daily living (ADLs), body weight, and depressive symptoms. Each SNF in 2018 and 2019 served as its own control for 2020.

Results  In 2018-2019, mean monthly mortality was 2.2%, hospitalization 3.0%, and ED visit rate 2.9% overall. In 2020, among active COVID-19 SNFs compared with their own 2018-2019 baseline, mortality increased by 1.60% (95% CI, 1.58% to 1.62%), hospitalizations decreased by 0.10% (95% CI, −0.12% to −0.09%), and ED visit rates decreased by 0.57% (95% CI, −0.59% to −0.55%). Among no-known COVID-19 SNFs, mortality decreased by 0.15% (95% CI, −0.16% to −0.13%), hospitalizations by 0.83% (95% CI, −0.85% to −0.81%), and ED visits by 0.79% (95% CI, −0.81% to −0.77%). All changes were statistically significant. In 2018-2019, across all SNFs, residents required assistance with an additional 0.89 ADLs between January and November, and lost 1.9 lb; 27.1% had worsened depressive symptoms. In 2020, residents in active COVID-19 SNFs required assistance with an additional 0.36 ADLs (95% CI, 0.34 to 0.38), lost 3.1 lb (95% CI, −3.2 to −3.0 lb) more weight, and were 4.4% (95% CI, 4.1% to 4.7%) more likely to have worsened depressive symptoms, all statistically significant changes. In 2020, residents in no-known COVID-19 SNFs had no significant change in ADLs (−0.06 [95% CI, 0.12 to 0.01]), but lost 1.8 lb (95% CI, −2.1 to −1.5 lb) more weight and were 3.2% more likely (95% CI, 2.3% to 4.1%) to have worsened depressive symptoms, both statistically significant changes.

Conclusions and Relevance  Among skilled nursing facilities in the US during the first year of the COVID-19 pandemic and prior to the availability of COVID-19 vaccination, mortality and functional decline significantly increased at facilities with active COVID-19 cases compared with the prepandemic period, while a modest statistically significant decrease in mortality was observed at facilities that had never had a known COVID-19 case. Weight loss and depressive symptoms significantly increased in skilled nursing facilities in the first year of the pandemic, regardless of COVID-19 status.

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Article Information

Corresponding Author: Michael L. Barnett, MD, MS, Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, 677 Huntington Ave, Kresge 411, Boston, MA 02115 (mbarnett@hsph.harvard.edu).

Accepted for Publication: August 10, 2022.

Published Online: August 29, 2022. doi:10.1001/jama.2022.15071

Author Contributions: Dr Barnett had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Barnett, Epstein, Joynt Maddox.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Barnett, Joynt Maddox.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Barnett, Waken, Zheng, Orav.

Obtained funding: Barnett, Epstein, Joynt Maddox.

Administrative, technical, or material support: Epstein, Joynt Maddox.

Supervision: Barnett, Joynt Maddox.

Conflict of Interest Disclosures: Dr Barnett reported receiving support from the National Institute on Aging, the Agency for Healthcare Research and Quality, and the Retirement Research Foundation. Dr Grabowski reported receiving personal fees from AARP, the Analysis Group, GRAIL LLC, Health Care Lawyers PLC, the Medicare Payment Advisory Commission, and RTI International outside the submitted work. Dr Joynt Maddox reported receiving grants from the National Heart, Lung, and Blood Institute, the National Institute on Aging, and the National Institute of Nursing Research; research support from Humana Inc; and personal fees for serving on the health policy advisory council of Centene Corp. No other disclosures were reported.

Funding/Support: This work was supported by grants K23 AG058806 and R01 AG060935 from the National Institute on Aging of the National Institutes of Health (Drs Barnett, Epstein, Grabowski, Orav, and Joynt Maddox).

Role of the Funder/Sponsor: The National Institute on Aging had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: Dr Joynt Maddox is an Associate Editor of JAMA, but she was not involved in any of the decisions regarding review of the manuscript or its acceptance.

Barnett  ML , Grabowski  DC .  Nursing homes are ground zero for COVID-19 pandemic.   JAMA Health Forum. 2020;1(3):e200369-e200369. doi:10.1001/jamahealthforum.2020.0369Google ScholarCrossref
Shen  K , Loomer  L , Abrams  H , Grabowski  DC , Gandhi  A .  Estimates of COVID-19 cases and deaths among nursing home residents not reported in federal data.   JAMA Netw Open. 2021;4(9):e2122885. doi:10.1001/jamanetworkopen.2021.22885PubMedGoogle ScholarCrossref
Levere  M , Rowan  P , Wysocki  A .  The adverse effects of the COVID-19 pandemic on nursing home resident well-being.   J Am Med Dir Assoc. 2021;22(5):948-954.e2. doi:10.1016/j.jamda.2021.03.010PubMedGoogle ScholarCrossref
Guidance for infection control and prevention of Coronavirus disease (COVID-19) in nursing homes. Centers for Medicare & Medicaid Services. 2020;Updated March 10, 2021. Accessed June 21, 2022. https://www.cms.gov/files/document/qso-20-14-nh-revised.pdf
Abbasi  J .  Social isolation—the other COVID-19 threat in nursing homes.   JAMA. 2020;324(7):619-620. doi:10.1001/jama.2020.13484PubMedGoogle ScholarCrossref
Paulin  E . Is isolation killing America’s nursing home residents? AARP. September 3, 2020. Accessed June 21, 2022. https://www.aarp.org/caregiving/health/info-2020/covid-isolation-killing-nursing-home-residents.html
Simard  J , Volicer  L .  Loneliness and isolation in long-term care and the COVID-19 pandemic.   J Am Med Dir Assoc. 2020;21(7):966-967. doi:10.1016/j.jamda.2020.05.006PubMedGoogle ScholarCrossref
McGarry  BE , Grabowski  DC , Barnett  ML .  Severe staffing and personal protective equipment shortages faced by nursing homes during the COVID-19 pandemic: study examines staffing and personal protective equipment shortages faced by nursing homes during the COVID-19 pandemic.   Health Aff (Millwood). 2020;39(10):1812-1821. doi:10.1377/hlthaff.2020.01269PubMedGoogle ScholarCrossref
Patel  SY , Mehrotra  A , Huskamp  HA , Uscher-Pines  L , Ganguli  I , Barnett  ML .  Variation in telemedicine use and outpatient care during the COVID-19 pandemic in the United States.   Health Aff (Millwood). 2021;40(2):349-358. doi:10.1377/hlthaff.2020.01786PubMedGoogle ScholarCrossref
Patel  SY , Mehrotra  A , Huskamp  HA , Uscher-Pines  L , Ganguli  I , Barnett  ML .  Trends in outpatient care delivery and telemedicine during the COVID-19 pandemic in the US.   JAMA Intern Med. 2021;181(3):388-391. doi:10.1001/jamainternmed.2020.5928PubMedGoogle ScholarCrossref
Baum  A , Schwartz  MD .  Admissions to Veterans Affairs hospitals for emergency conditions during the COVID-19 pandemic.   JAMA. 2020;324(1):95-99.Google ScholarCrossref
Smulowitz  PB , O’Malley  AJ , Khidir  H , Zaborski  L , McWilliams  JM , Landon  BE .  National trends in ED visits, hospital admissions, and mortality for Medicare patients during the COVID-19 pandemic.   Health Aff (Millwood). 2021;40(9):1457-1464. doi:10.1377/hlthaff.2021.00561PubMedGoogle ScholarCrossref
Prasad  NK , Englum  BR , Turner  DJ ,  et al.  A nation-wide review of elective surgery and COVID-surge capacity.   J Surg Res. 2021;267:211-216. doi:10.1016/j.jss.2021.05.028PubMedGoogle ScholarCrossref
Intrator  O , Hiris  J , Berg  K , Miller  SC , Mor  V .  The residential history file: studying nursing home residents’ long-term care histories.   Health Serv Res. 2011;46(1 pt 1):120-137.Google Scholar
Goodwin  JS , Li  S , Zhou  J , Graham  JE , Karmarkar  A , Ottenbacher  K .  Comparison of methods to identify long term care nursing home residence with administrative data.   BMC Health Serv Res. 2017;17(1):376. doi:10.1186/s12913-017-2318-9PubMedGoogle ScholarCrossref
Long-term care facilities (LTCF) component. National Healthcare Safety Network, Centers for Disease Control and Prevention. Accessed June 21, 2022. https://www.cdc.gov/nhsn/ltc/index.html
COVID-19 nursing home data. Centers for Medicare & Medicaid Services. Accessed June 21, 2022. https://data.cms.gov/stories/s/COVID-19-Nursing-Home-Data/bkwz-xpvg/
Barnett  ML , Joynt Maddox  KE , Orav  EJ , Grabowski  DC , Epstein  AM .  Association of skilled nursing facility participation in a bundled payment model with institutional spending for joint replacement surgery.   JAMA. 2020;324(18):1869-1877. doi:10.1001/jama.2020.19181PubMedGoogle ScholarCrossref
Barnett  ML , Wilcock  A , McWilliams  JM ,  et al.  Two-year evaluation of mandatory bundled payments for joint replacement.   N Engl J Med. 2019;380(3):252-262. doi:10.1056/NEJMsa1809010PubMedGoogle ScholarCrossref
Minimum data set (MDS) 3.0 resident assessment instrument (RAI) manual. Centers for Medicare & Medicaid Services. Accessed June 21, 2022. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual
Jenny Wei  Y-J , Chen  C , Fillingim  RB ,  et al.  Uncontrolled pain and risk for depression and behavioral symptoms in residents with dementia.   J Am Med Dir Assoc. 2021;22(10):2079-2086.e5. doi:10.1016/j.jamda.2021.05.010PubMedGoogle ScholarCrossref
Chronic conditions data warehouse. Centers for Medicare & Medicaid Services. Accessed June 21, 2022. https://www.ccwdata.org/.
Kim  DH , Schneeweiss  S , Glynn  RJ , Lipsitz  LA , Rockwood  K , Avorn  J .  Measuring frailty in Medicare data: development and validation of a claims-based frailty index.   J Gerontol A Biol Sci Med Sci. 2018;73(7):980-987. doi:10.1093/gerona/glx229PubMedGoogle ScholarCrossref
Goodman  RA , Lochner  KA , Thambisetty  M , Wingo  TS , Posner  SF , Ling  SM .  Prevalence of dementia subtypes in United States Medicare fee-for-service beneficiaries, 2011-2013.   Alzheimers Dement. 2017;13(1):28-37. doi:10.1016/j.jalz.2016.04.002PubMedGoogle ScholarCrossref
Jarrín  OF , Nyandege  AN , Grafova  IB , Dong  X , Lin  H .  Validity of race and ethnicity codes in Medicare administrative data compared with gold-standard self-reported race collected during routine home health care visits.   Med Care. 2020;58(1):e1-e8. doi:10.1097/MLR.0000000000001216PubMedGoogle ScholarCrossref
Find & compare nursing homes, hospitals and other providers near you. Medicare.gov. Accessed June 21, 2022. https://www.medicare.gov/NursingHomeCompare/Data/About.html
Shaping long-term care in America Project. Yale University School of Public Health. Accessed June 21, 2022. https://ltcfocus.org.
Joynt Maddox  KE , Orav  EJ , Zheng  J , Epstein  AM .  How do frail Medicare beneficiaries fare under bundled payments?   J Am Geriatr Soc. 2019;67(11):2245-2253. doi:10.1111/jgs.16147PubMedGoogle ScholarCrossref
Bales  CW , Ritchie  CS .  Sarcopenia, weight loss, and nutritional frailty in the elderly.   Annu Rev Nutr. 2002;22:309-323. doi:10.1146/annurev.nutr.22.010402.102715PubMedGoogle ScholarCrossref
Clegg  A , Young  J , Iliffe  S , Rikkert  MO , Rockwood  K .  Frailty in elderly people.   Lancet. 2013;381(9868):752-762. doi:10.1016/S0140-6736(12)62167-9PubMedGoogle ScholarCrossref
LeBlanc  ES , Rizzo  JH , Pedula  KL ,  et al; Study of Osteoporotic Fractures Research Group.  Long-Term weight trajectory and risk of hip fracture, falls, impaired physical function, and death.   J Am Geriatr Soc. 2018;66(10):1972-1979. doi:10.1111/jgs.15532PubMedGoogle ScholarCrossref
Hall  AJ , Wikswo  E , Pringle  K , Gould  LH , Parashar  UD .  Vital signs: foodborne norovirus outbreaks—United States, 2009–2012.   MMWR Morb Mortal Wkly Rep. 2014;63(22):491-495.Google Scholar
Salem-Schatz  S , Griswold  P , Kandel  R ,  et al.  A statewide program to improve management of suspected urinary tract infection in long-term care.   J Am Geriatr Soc. 2020;68(1):62-69. doi:10.1111/jgs.16261PubMedGoogle ScholarCrossref
Ponnada  S , Guerrero  DM , Jury  LA ,  et al.  Acquisition of Clostridium difficile colonization and infection after transfer from a Veterans Affairs hospital to an affiliated long-term care facility.   Infect Control Hosp Epidemiol. 2017;38(9):1070-1076. doi:10.1017/ice.2017.140PubMedGoogle ScholarCrossref
Karanika  S , Grigoras  C , Flokas  ME ,  et al.  The attributable burden of Clostridium difficile infection to long-term care facilities stay: a clinical study.   J Am Geriatr Soc. 2017;65(8):1733-1740. doi:10.1111/jgs.14863PubMedGoogle ScholarCrossref
Kane  RL , Huckfeldt  P , Tappen  R ,  et al.  Effects of an intervention to reduce hospitalizations from nursing homes: a randomized implementation trial of the INTERACT program.   JAMA Intern Med. 2017;177(9):1257-1264. doi:10.1001/jamainternmed.2017.2657PubMedGoogle ScholarCrossref
Ingber  MJ , Feng  Z , Khatutsky  G ,  et al.  Initiative to reduce avoidable hospitalizations among nursing facility residents shows promising results.   Health Aff (Millwood). 2017;36(3):441-450. doi:10.1377/hlthaff.2016.1310PubMedGoogle ScholarCrossref
Grabowski  DC , O’Malley  AJ .  Use of telemedicine can reduce hospitalizations of nursing home residents and generate savings for Medicare.   Health Aff (Millwood). 2014;33(2):244-250. doi:10.1377/hlthaff.2013.0922PubMedGoogle ScholarCrossref
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