Hari Sharma is an assistant professor of health management and policy in the University of Iowa College of Public Health. His research focuses on health economics, costs, quality of care, and disparities. He is also interested in public reporting and the 5-star rating system for nursing homes.

As of May 3, 2020, the Iowa Department of Public Health reported that 28 long-term care facilities in the state have COVID-19 outbreaks. At least three residents of a long-term care facility must test positive for COVID-19 to meet the IDPH’s definition of an outbreak. Sharma answered several questions about the current coronavirus crisis and the unique challenges nursing homes face.

Q: What are some of the factors that make a nursing home or other long-term care facility more susceptible to an infectious disease outbreak?

A: Long-term care facilities, nursing homes in particular, are vulnerable to infectious diseases outbreaks because they house a large number of older residents with multiple chronic conditions in a closely confined place. In addition to the vulnerability of the residents, facilities are often poorly equipped to handle outbreaks of diseases such as COVID-19. Even though there are rules on how to approach infection prevention and control, these facilities may have staff shortages or employees that are poorly trained. There’s a high turnover of staff in these facilities, and any experience/training of staff in handling such outbreaks may not continue from year to year.

Many residents in these facilities congregate for meals and other events, potentially exposing themselves to others who may be infected. Moreover, there is also a risk of staff infecting residents. In a nursing home, housekeeping staff, dietary staff, nurse aides, licensed practical nurses, and registered nurses are some of the staff that cater to many residents within the facility, and if they are not careful, they could very well be the medium of transmission.

Q: What are some of the main steps that nursing homes can take to prevent and control COVID-19 and other disease outbreaks?

A: COVID-19 is a challenge for all health care providers, and nursing homes are no different. In the short term, nursing homes should focus on testing both residents and staff for COVID-19, isolating residents with symptoms, and providing support for residents in isolation. Older residents already feel isolated and further isolation can be detrimental to their health. So, nursing homes should provide support in some ways to these isolated residents. Nursing homes should also work closely with area hospitals to ensure that residents in need are taken to the hospital on a timely fashion.

On a longer term basis, there are many steps nursing homes can take to better prepare themselves for infectious disease outbreaks. First, we need adequate staffing at nursing homes. If we have staff shortages during an outbreak, both the residents and staff will be vulnerable to such outbreaks.

Second, nursing homes need to not only train their staff on the infection prevention and control policies, but also assess the implementation of the policies. Training staff is not enough because we have seen facilities getting cited for poor infection control again and again. For example, nursing homes usually have a policy on cleaning/disinfecting equipment after each use, but we still see facilities getting cited for not doing so. Given the high turnover of staff, training on a regular basis is also important.

Finally, nursing homes should be better prepared to isolate many residents at once and work with area hospitals more closely to hospitalize residents in need in a timely manner. I do not think we were expecting a contagious disease at the level of COVID-19, but we should be prepared for it going into the future.

Q: How frequently are nursing homes in Iowa inspected, and are reports and ratings available to the public?

A: Nursing homes in Iowa and in the U.S. are inspected every 9 to 15 months. During these inspections, facilities are assessed on hundreds of quality measures, from staffs’ handling of infection control policies to resident quality of care. The details of these reports are available on state and federal websites.

Nursing homes also get star ratings based on their performance in inspections, resident quality of care, and staffing. Despite a plethora of information, it is difficult for residents to judge whether a facility is of good quality; in many instances, a nursing home could perform well in one dimension but not so much in another. In general, nursing homes rated 4-5 stars are considered good quality nursing homes. However, I do want to mention that these star ratings may not say much about the nursing homes’ preparedness for infectious disease outbreaks such as COVID-19.

Q: In an ideal world, what supports and resources do long-term care facilities need to provide the best care to their residents?

A: Nursing homes and long-term care facilities in general have seen low reimbursements from Medicaid for decades. If these facilities are to improve staffing, expand their training of staff on various issues including infection control, and evaluate whether the policies prescribed in the manuals are implemented, they need more funding.

Stigmatizing long-term care facilities or the workers in these facilities is not helpful either. Caring for our older population is challenging, especially during an outbreak of disease such as COVID-19, and we should focus on finding ways to support these facilities and workers. While providing more resources to nursing homes and other long-term care facilities is important, we also need to ensure that these facilities are doing their part. Thousands of facilities keep getting cited for the same quality problems year after year, and we need a more aggressive approach to citing and penalizing facilities that get cited repeatedly.