Trends in COVID‐19 Cases, Related Deaths, and Staffing Shortage in Nursing Homes By Rural and Urban Status

RESEARCH OBJECTIVE: Initial efforts to understand the impact of COVID‐19 on nursing home (NHs) staffing levels indicated considerable increases in staffing shortages occurred during the first few months of the COVID‐19 pandemic. In response, this study built upon initial staffing reports by examining the long‐term consequence of the pandemic on staffing shortages in US NHs by rural/urban status using the most recently compiled NH COVID‐19 data (May 2020–February 2021). The specific aim of this study was to examine trends in COVID‐19 cases, related deaths, and staffing shortages in NHs by rural and urban status and over time. STUDY DESIGN: This cross‐sectional time‐series study compiled four data sources, including: the NH COVID‐19 files and provider information files from Centers for Medicare and Medicaid Services, the Area Health Resource Files from Health Resources and Services Administration, and the New York Times county‐level COVID‐19 data. We plotted the proportion of NHs with at least one COVID‐19 case, one related death, and four types of staff shortages (aides, licensed nurses, medical providers, and other staff) by rural/urban status from 5/25/20 to 2/28/21 to visualize the weekly trends over time. Then, weekly data were combined into four periods with 10 weeks of the aggregated data in each period. Our main analyses estimated the likelihood of having at least one case of COVID‐19 infection, related death, or at least one week of staffing shortage in rural NHs compared to urban NHs over four time periods using generalized linear mixed models with state‐fixed effects. POPULATION STUDIED: We identified a total 59,515 aggregated cases combined from all four periods, involving 15,139 unique NHs that submitted at least one‐week report during the study period. PRINCIPAL FINDINGS: Findings suggest that staffing shortage trends varied by both time and location. Rural areas experienced an increasing proportion of NHs with staffing shortages until mid‐November, 2020, and then a gradual decrease afterwards, corresponding with trends in COVID‐19 cases. Conversely, the proportion of NHs reporting staffing shortages in urban areas was relatively stable over time. The interaction effect between period and rural/urban status in adjusted models revealed a significantly higher likelihood of having at least one COVID‐19 case, related death, and shortages in aides, licensed nurses, and other staff in rural NHs in later periods than in the earlier one, compared to changes in urban NHs over time. The proportion of NHs with medical provider shortage was about 10% which was lower than other types of staff shortages and unchanged during the study period in both rural and urban NHs. CONCLUSIONS: Our findings suggest that direct care provider staffing shortages in rural NHs were greatly accelerated over time with a surge in COVID‐19 cases. IMPLICATIONS FOR POLICY OR PRACTICE: The COVID‐19 pandemic may have significantly strained rural NHs that are already burdened with healthcare human resource infrastructural deficits. Findings highlight the needs to develop effective strategies that maximize rural NH workforce crisis resilience, including enhanced recruitment and retention incentives, and targeted resource allocation to prepare for short‐ and long‐term consequences of natural disasters such as COVID‐19 pandemic.