Mapping and Identifying Community Risk Factors for COVID‐19 Nursing Home Deaths

RESEARCH OBJECTIVE: Although emerging research has identified facility‐level or community‐level risk factors for nursing home COVID‐19 infection cases, little research has been conducted to understand the risk factors for nursing home COVID‐19 death rates. This study has two aims: 1) identify geographic clusters with high nursing home COVID‐19 death rates; 2) understand facility‐level and community‐level risk factors for facilities residing within the hot spots versus those not in the hot spots. STUDY DESIGN: This is a cross‐sectional research design. We utilized nursing home COVID data from Centers for Medicare & Medicaid Services (as of November 13th, 2020) linked with Brown University's LTCfocus data and Nursing Home Compare, along with zip code‐level data from American Community Survey. Geospatial hot spot analysis (Getis‐Ord Gi*) was applied to identify statistically significant hot spots of COVID‐19 death rates in nursing homes. We compared facility‐level and community‐level factors associated with COVID death rates by performing multivariate regressions stratified by whether the nursing home was located in the hot spot area identified. POPULATION STUDIED: The sample included 15,341 nursing homes. PRINCIPAL FINDINGS: 322 zip code areas were identified as having a significantly high level of nursing home COVID death rates at the 95% confidence level. We found statistically significant clustering of COVID‐19 death rates in nursing homes in Northeastern United States (New Jersey, Massachusetts, Connecticut, and New York), South Carolina, Georgia, Florida, Kentucky, and parts of Texas, Mississippi and Louisiana. The hot spot areas tend to be communities with lower household income, higher household sizes, and higher unemployed rates. Regression results indicated common facility‐level risk factors as low total nursing staffing levels, high proportion of Medicaid residents, and low deficiency/quality ratings. Significant zip code‐level factors included household income, average household size, unemployed rate, and proportion of Hispanic residents. However, among nursing homes residing in hot spot zip code areas, total nursing staffing levels (β = −0.04, p < 0.001) and proportion of Medicaid residents (β = 0.03, p < 0.001) had greater effects on death rates. CONCLUSIONS: Nursing homes located in communities of lower social‐economic status were hit the hardest in terms of having high death rates. Among nursing homes located in hot spot communities, nurse staffing and facility resources (i.e. proportion of Medicaid) play more critical roles in preventing further damage to residents. IMPLICATIONS FOR POLICY OR PRACTICE: Policymakers should target resources to nursing homes in the hot spot areas identified, particularly nursing homes with low staffing and high Medicaid census in those areas.