Persistent challenges of COVID-19 in skilled nursing facilities: The administrator perspective.

INTRODUCTION

Skilled nursing facilities (SNFs) have borne enormous burdens from COVID‐19, accounting for 40% of COVID‐19 deaths in the United States (US).1, 2 Moreover, SNFs have faced tremendous operational, clinical, and financial hurdles during the pandemic.3, 4, 5, 6, 7, 8, 9, 10 Despite broad recognition of such problems, there is little systematic evidence about the experience of SNFs from the perspective of SNF leadership. In this study, we assessed SNF administrator views of challenges after the first wave of COVID‐19 cases and what they anticipated for the future.

METHODS

We conducted a nationally representative survey of 223 SNF administrators by phone and online, July 22 through September 11, 2020. The sample was drawn from a comprehensive listing of Medicare‐ or Medicaid‐certified SNFs in the United States (Nursing Home Compare). The study was approved as exempt by Harvard TH Chan School of Public Health's Office of Regulatory Affairs and Research Compliance.

The questionnaire included open‐ended questions to elicit administrator views of their greatest challenges in the past 30 days and predicted challenges in the event of future COVID‐19 waves. It also asked closed‐ended questions about issues previously identified as important for resilience: staffing, supplies, and screening.3, 4, 5, 6, 7, 8, 9, 10

The completion rate among administrators who could be reached by telephone was 96%; response rate at the SNF level was 23%. To compare respondents to all SNFs with respect to facility characteristics and COVID‐19‐specific characteristics (e.g., community case counts), the dataset was merged with Medicare COVID‐19 Nursing Home Database, the National Institute on Aging‐funded LTCFocus.org database, and the New York Times coronavirus database. Respondents were similar to all SNFs across characteristics except that respondents were less likely to be in for‐profit facilities (64% vs. 70%). To mitigate non‐response bias, we weighted the data by profit status.

RESULTS

The top recent challenge, identified by 52% of administrators, was staffing. More than 40% noted challenges with COVID‐19 protocol implementation (46%), including keeping up with changing requirements, and procuring supplies like personal protective equipment (PPE) (41%) (Table 1). More than a quarter noted testing problems (30%) and disruption to communal activities (29%), while few brought up morale (16%) or finances (15%) as the biggest challenges. Approximately two‐thirds of administrators (63%) anticipated that staffing would remain among the greatest challenge in future waves and 45% said the same of supplies. Substantially fewer administrators noted other issues.

TABLE 1

Biggest COVID‐19 challenges in past 30 days as viewed by SNF administrators

Challenge	% Respondents saying it was one of biggest challenges in past 30 days	% Respondents predicting it would be one of biggest challenges for next wave of cases
Staffing	52%	63%
Staffing shortages	52%	63%
COVID‐19 protocols and requirements	46%	26%
Keeping up with changing requirements	20%	17%
Implementing new protocols and requirements	19%	5%
Staff education and protocol adherence	14%	5%
Supplies	41%	45%
Personal protective equipment (PPE)	37%	42%
General and other supplies	6%	7%
Testing	30%	17%
Testing result delays/testing turnaround	13%	8%
Staff testing	7%	2%
Testing supplies	3%	2%
Resident testing	1%	1%
General testing issues	11%	6%
Visitation and communal activities	29%	20%
Loss of visitation or communal activities	17%	11%
Managing visitors and visitation processes	12%	11%
Morale	16%	20%
Resident/patient morale	12%	14%
Staff morale	9%	14%
Finances	15%	14%
Financial challenges and new expenses	11%	10%
Census	8%	9%
Other	16%	17%
COVID spread or rates in the community	8%	9%
Clinical decline of residents	2%	1%
Other	7%	8%

Note: Responses of “do not know” or refusals on any question were <3%. SNFs could suggest any number of sub‐categories (non‐shaded rows), therefore the items within each larger category (Staffing, COVID‐19 Protocols and Requirements, Supplies, Testing, Visitation and Communal Activities, Morale, Finances and Other) may not add up to the sum of their component sub‐categories.

When asked closed‐ended questions, 47% agreed they had staffing shortages, including 15% who said this affected clinical care (data not shown). Shortages occurred despite multiple efforts to extend resources: extending hours at regular (80%) or higher pay (76%); using non‐clinical staff for tasks (63%) and per diem contracting (40%). Approximately half (52%) said their facility had a shortage of at least one essential supply identified (e.g., N‐95 masks, alcohol‐based sanitizer), including 35% who said this impacted quality of care. Substantial fractions said there had been no screening of staff or residents in the past 30 days (27% and 42%, respectively).

When asked what would occur if there were another wave of COVID‐19, only a third of administrators (33%) said their facility would be “very likely” to have adequate staffing. The vast majority (85%) said their facility would be “very likely” to have shortages of at least one essential supply. Administrators were more optimistic about screening. Two‐thirds (65%) and three‐quarters (72%) felt they would be “very likely” to have adequate screening for staff and residents respectively.

DISCUSSION

Results show that even months into the pandemic, many administrators felt SNFs faced problems across multiple domains and these would likely continue. These findings suggest that policy to date has not adequately supported SNFs during COVID‐19 and improvements are needed.

Administrator views would suggest the first policy priority is to retain SNF staff, a long‐standing challenge exacerbated by COVID‐19.12, 13 Possible approaches include using federal relief funds for staff hazard pay, updating regulations to enable surge staffing pools for COVID‐19 hot spots, and providing targeted support to SNFs with outbreaks to help control spread among staff and residents. A second priority is to address gaps in supplies. A possible approach includes a national, centralized strategy for SNF PPE procurement. Third, respondents called for keeping new policies and regulations as clear, consistent and coordinated as possible in order to relieve SNFs from excessive administrative burdens while they try to focus on clinical care. Such conclusions are consistent with prior policy discussions but highlight the perspective of administrators.4, 14, 15

Study limitations include smaller sample size, the risk of non‐response bias, and social desirability bias in responses. Nonetheless, results provide a novel and important perspective for SNF policy discussions.

FINANCIAL DISCLOSURES

This work was supported by an Acceleration Grant from the Harvard TH Chan School of Public Health. Dr. Barnett was also supported by the National Institute on Aging (K23 AG058806‐01).

CONFLICT OF INTEREST

Gillian SteelFisher's husband is a minority owner of a company that does consulting work for Eli Lilly. David Grabowski serves as a paid consultant to Vivacitas and CareLinx.

AUTHOR CONTRIBUTIONS

All authors have read and approved of the submission of this manuscript. All authors contributed to the study design and concept, as well as the acquisition, analysis and interpretation of data. Gillian K. SteelFisher and Michael L. Barnett drafted the manuscript. All authors contributed to critical revisions of the manuscript for intellectual content. Michael L. Barnett was responsible for statistical analysis, alongside the independent survey fielding firm, SSRS. Michael L. Barnett obtained funding and provided study supervision.

SPONSOR'S ROLE

This work was supported by an Acceleration Grant from the Harvard TH Chan School of Public Health. Dr. Barnett was also supported by the National Institute on Aging (K23 AG058806‐01). Harvard University and 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.