key: cord-0928911-bvs84mow authors: Zimmerman, Sheryl; Dumond-Stryker, Carol; Tandan, Meera; Preisser, John S.; Wretman, Christopher J.; Howell, Abigail; Ryan, Susan title: Nontraditional Small House Nursing Homes Have Fewer COVID-19 Cases and Deaths date: 2021-01-26 journal: J Am Med Dir Assoc DOI: 10.1016/j.jamda.2021.01.069 sha: 3bb9068d664b912ab6b550009b5486490d13e09d doc_id: 928911 cord_uid: bvs84mow Objectives Green House and other small nursing home (NH) models are considered “nontraditional” due to their size (10-12 beds), universal caregivers, and other home-like features. They have garnered great interest regarding their potential benefit to limit COVID-19 infections due to fewer people living, working, visiting, and being admitted to Green House/small NHs, and private rooms and bathrooms, but this assumption has not been tested. If they prove advantageous compared to other NHs, they may constitute an especially promising model as policy makers and providers reinvent NHs post-COVID. Design This cohort study compared rates of COVID-19 infections, COVID-19 admissions/readmissions, and COVID-19 mortality, among Green House/small NHs to rates in other NHs between 1/20/20-7/31/20. Setting and Participants All Green House homes that held a skilled nursing license and received Medicaid or Medicare payment were invited to participate; other small NHs that replicate Green House physical design and operational practices were eligible if they had the same licensure and payer sources. Of 57 organizations, 43 (75%) provided complete data, which included 219 NHs. Comparison NHs (referred to as “traditional NHs”) were up to five most geographically proximate NHs within 100 miles that had <50 beds and ≥50 beds for which data were available from the Centers for Medicare & Medicaid Services (CMS). Because Veterans Administration organizations are not required to report to CMS, they were not included. Methods Rates per 1000 resident days were derived for COVID-19 cases and admissions, and per 100 COVID-19 positive cases for mortality. A log-rank test compared rates between Green House/small NHs and traditional NHs with <50 beds and ≥50 beds. Results Rates of all outcomes were significantly lower in Green House/small NHs than in traditional NHs that had <50 beds and ≥50 beds (log-rank test p<0.025 for all comparisons). The median (middle value) rates of COVID-19 cases per 1000 resident days were 0 in both Green House/small NHs and NHs <50 beds, while they were 0.06 in NHs ≥50 beds; in terms of COVID-19 mortality, the median rates per 100 positive residents were 0 (GH/small NHs), 10 (<50 beds), and 12.5 (≥50 beds). Differences were most marked in the highest quartile: 25% of Green House/small NHs had COVID-19 case rates per 1000 resident days higher than 0.08, with the corresponding figures for other NHs being 0.15 (<50 beds) and 0.74 (≥50 beds). Conclusions and Implications COVID-19 incidence and mortality rates are less in Green House/small NHs than rates in traditional NHs with <50 and ≥50-beds, especially among the higher and extreme values. Green House/small NHs are a promising model of care as NHs are reinvented post-COVID. Since the onset of the Severe Acute Respiratory Syndrome Coronavirus 2 pandemic (COVID-37 19) in the United States, long-term care residents have represented a disproportionate share of 38 cases and deaths. As of January 8, 2021, 6% of COVID-19 cases, and 38% of COVID-19 39 deaths, have been attributed to long-term care. 1 These rates reflect the medical conditions of 40 this population that put them at risk, as well as the congregate nature of long-term care that 41 increases the spread of infection. 2 42 Short-term remedies related to the congregate nature of long-term care include using personal 43 protective equipment, restricting visitors, and instituting screening. 3 Longer-term remedies may 44 ward off threats when the next pandemic arises, centered on nursing home (NH) quality, 4 45 staffing, 5 and physical design. 6, 7 Presumably, smaller NHs reduce risk because there are fewer 46 residents (including new admissions), staff, and visitors who may spread infection. 47 Non-traditional small house NHs have garnered great interest in the wake of COVID-19. 8 The 48 most well-known model of this type, the Green House model, has 300 NHs across 32 states. 9 Components of Green House homes that may be critical for infection prevention and control are 50 that they house only 10-12 residents, and have consistent and universal staff assignment 51 (thereby limiting ancillary staff), private rooms and bathrooms, smaller overall space, and a 52 central entry. Research on Green House NHs has found their benefits include better resident 53 quality of life, fewer hospital readmissions, better quality indicators, reduced Medicare spending, 54 and perhaps less staff turnover. 10 55 Given the potentially advantageous components of Green House/small NHs for infection 56 prevention and control, this project collected data related to the number of COVID-19 cases and 57 deaths among residents in Green House/small NHs, and examined them in comparison to 58 larger NHs (<50 beds and ≥50 beds). Both categorizations "<50 beds" and "≥50 beds" omitted 59 Green House/small NHs, and so refer to traditional model NHs. It also compared rates of 60 COVID-19 admissions/readmissions. Data specific to COVID-19 in Green House/small NHs are 61 not publicly available and have not been previously analyzed, meaning results provide novel 62 findings and implications. 63 Sample. All operating Green House homes that held a skilled nursing license and received 65 Medicaid or Medicare payment were invited to participate, as was one additional small house 66 organization (with 10 NHs) that may be joining the Green House network because its operation 67 mirrors that of Green House homes. Given that COVID-19 rates vary by location and relate to 68 community prevalence, 5 and 27.0, respectively -meaning that one-quarter of NHs of each type had rates higher than 122 these. 123 The Figure the asterisks indicate extreme values. In addition to demonstrating that even outlier rates for 128 Green House/small NHs are markedly lower than those in other NHs, it appears that NHs <50 129 beds have generally lower COVID-19 case rates than NHs ≥50 beds, but such is not the case in 130 relation to COVID-19 mortality rates or admissions. 131 Discussion 132 NH quality has been criticized for decades, and concern has increased markedly following the 133 ravages of COVID-19. Stakeholders agree we must capitalize on the opportunity offered by 134 COVID-19 to transform our system of long-term care, but the path to necessary changes -135 financing, accountability, workforce, regulation 12 --suggest an arduous and contentious road. 136 Green House/small NHs, which already are widely in favor, may constitute a promising future. 137 Their model already exists, and in addition to being advantageous in relation to COVID-19, they 138 benefit resident quality of life, improve satisfaction, reduce hospital readmissions and Medicare 139 spending, and result in better quality indicators. 10,13 140 The median incidence of COVID-19 cases in Green House/small NHs was significantly less 141 than that in NHs ≥50 beds: 0 versus 2.19 cases per 100 resident years (e.g., 100 residents each 142 followed for one year). Given the low rates overall, differences were even more notable among 143 the higher and extreme values: while only one-quarter of Green House/small NHs had rates per 144 100 resident years higher than 2.92, the corresponding rates for traditional NHs <50 beds and 145 ≥50 beds, respectively, were 5.48 and 27.0. While small size is known to limit the proportion of 146 COVID-19 cases, 6 Green House/small NHs are beneficial above and beyond the mere benefit of 147 size, perhaps due to their private bedrooms and bathrooms, limited ancillary staff, and fewer 148 admissions; in fact, traditional NHs <50 beds were not as advantaged in terms of COVID-19 149 admissions as were Green House/small NHs. 150 In terms of COVID-19 mortality, the median rates per 100 COVID positive residents were 0 151 (Green House/small NHs), 10 (<50 beds), and 12.5 (≥50 beds); thus, the benefit of Green 152 House/small NHs remains in terms of mortality. In this regard, the potential advantage of small 153 size may be to psychosocial well-being. Families may be more able to have socially-distanced 154 outdoor visits, and having consistent, universal staff may allow for the maintenance of social 155 relationships. Notably, residents in Green House homes receive significantly more hours per 156 day of care from certified nursing assistants than do residents in traditional nursing homes. 14 157 Others have reported that visitor restrictions increase loneliness, depression, physical 158 deterioration, and cognitive decline, 15 and so Green House/small NHs may convey an important 159 psychosocial advantage. However, NHs <50 beds were not advantaged in the higher and 160 extreme values compared to NHs ≥50 beds (their mortality rates at 75% and 90% percentile 161 were markedly higher), which may speak to other critical differences. 162 Differences exist between Green House/small NHs and other NHs that are less clearly related 163 to infection-prevention and psychosocial well-being, and which may in part relate to COVID-19 164 differences. One such driver may be for-profit status, which has repeatedly been found to relate 165 to lower NH quality. Green House NHs are much less likely to be for-profit than are NHs across 166 the country (18% compared to 69%), [16] [17] [18] and tend to pay their certified nursing assistants more 167 than do other NH 19 (which may result in fewer staff working in more than job). In addition, 168 resident case-mix differs between Green House and other NHs which may partly explain 169 COVID-19 differences, including that they have fewer African American residents who are at 170 higher mortality risk, and fewer residents who are bedfast and catheterized. [20] [21] [22] Such 171 differences would be most consequential in terms of explaining differences in COVID-19 172 mortality rates. 173 Clearly, more research is needed on the model of Green House/small NHs, including 174 consideration of components that could not be adjusted in analyses. Other limitations are that 175 the accuracy of the CMS data cannot be affirmed, and analyses used data only through 7/31/20. The decision to not extend analyses beyond that date was in part based on the fact that some 177 Green House/small NHs and other NHs were changing their models of care such as becoming widely researched (compared to other small NHs), largely with funding from The Robert Wood 183 Johnson Foundation. 23 AARP recently highlighted this model as an option to transform long-term 184 care, while noting that its adoption has been limited, in part due to financing, regulatory, and 185 workforce challenges. 17 Hope may be on the horizon, however, given universal recognition that 186 beyond the pandemic, we must transform how our nation provides and finances long-term 187 care. 24 188 COVID-19 incidence and mortality rates are less in Green House/small NHs than rates in 190 traditional NHs with <50 and ≥50-beds, especially among the higher and extreme values. 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