Research Brief

More Staffers: More COVID-19 Exposures and More Nursing Home Deaths

Reliance on part-timers raises headcounts and dangers to patients

Devastating COVID-19 outbreaks in nursing facilities led some states to permanently raise staffing requirements, on the belief that more hours of hands-on care could help prevent deaths.

But research suggests that exactly how facilities staff these necessary care hours can dramatically affect the risk of COVID-19 outbreaks faced by residents and staff. Increasing the number of workers in and out of a facility daily greatly increases the risk of COVID-19 among residents and staff, as well as resulting death rates for both, according to a paper published in Health Affairs by University of Rochester’s Brian E. McGarry, UCLA Anderson’s Ashvin D. Gandhi and Harvard’s David C. Grabowski and Michael Lawrence Barnett.

Using data from about 7,000 facilities from the summer of 2020, the researchers found COVID-19 case rates per 100 beds 92% higher in facilities with the highest numbers of unique workers than the case rates of the quarter of facilities with the fewest workers. Death rates among residents were 133% higher comparatively in the highest quartile and 69% higher among staff.

Reducing Number of Part-timers Can Reduce Exposure

Throughout the industry, nursing facilities rely heavily on part-time workers, and that allows employers to raise staffing levels during the busiest parts of the day and pay fewer workers during slack hours. About a quarter of the nursing assistants surveyed by the nonprofit Paraprofessional Healthcare Institute took part-time jobs that rarely offer benefits like health insurance and paid sick days because they could not find full-time positions. Another study found that more than 60% of workers in long-term care facilities held double- or triple-duty caregiver roles, often taking shifts at multiple facilities.

The findings suggest that using fewer workers to achieve a given staff-to-resident ratio at facilities is an important factor in protecting residents and staff. All facility workers can potentially bring COVID-19 inside, as each is subjected to possible exposure from multiple sources every day when they return to their normal lives. Employees in jobs without patient contact, like administration or janitorial, can spark outbreaks by spreading it to care staff.

The researchers noted that the findings don’t imply that nursing homes should have lower staffing per resident.

Allowing Remote Work Could Help Protect Residents

“Rather,” they wrote, “our findings suggest that when facilities with the same staffing ratios are being compared, nursing homes that can provide those staff hours with fewer unique staff members will be better able to protect their residents from COVID-19.”

The Health Affairs study suggested that replacing part-time staff with fewer full-time equivalents, as well as allowing noncare employees to work from home when possible, could reduce disease and death. Small-home models, where eight to 12 residents live with permanent staff, possibly would better prevent outbreaks, they suggested.

Several prominent studies have linked higher rates of nursing care hours per resident to facilities with better COVID-19 outbreak control and fewer deaths. However, this research typically does not look at how many individual workers are providing those hours of care.

Rather than tallying total hours of care by job role (a traditional research approach for evaluating staffing level), the Health Affairs study authors looked at the number of employed people likely to enter and leave the business daily.

The researchers calculated the average number of employees at each facility each day in the fourth quarter of 2019, before staffing levels were affected by COVID-19 outbreaks. They then divided the facilities into groups based on the average number of daily staff members. They found wide variation in staff numbers, even among facilities with similar numbers of beds.

For instance, facilities in the fifth decile for bed size had a median of 50 employees per day with an overall range of 13 to 219 employees per day.

The study covered COVID-19 cases between June 7, 2020, ahead of COVID’s second wave, and Sept. 20, 2020. Testing more traditional measures of staffing, the study found no clear correlations to COVID-19 outbreaks. Overall staff size was a more important predictor of COVID-19 outcomes than ratios of direct care staff to residents or staff skill mix.

This finding suggests that the factors determining the quality of resident care are not necessarily the same as those influencing successful infection control practices.

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About the Research

McGarry, B.E., Gandhi, A.D., Grabowski, D.C. & Barnett, M.L. (2021). Larger Nursing Home Staff Size Linked to Higher Number of COVID-19 Cases in 2020. Health Affairs, 40(8), 1261-1269.

Van Houtven, C.H., DePasquale, N. & Coe, N.B. (2020). Essential Long‐Term Care Workers Commonly Hold Second Jobs and Double‐ or Triple‐Duty Caregiving Roles. Journal of the American Geriatrics Society, 68(8): 1657–1660. doi: 10.1111/jgs.16509

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