We are beginning to learn which nursing homes are most likely to be hit with COVID-19.  And while studies are preliminary and based on very limited data, they tell a troubling story: Location and the race of residents matter a lot. But they also tell a surprising story: Quality (at least as measured by Medicare),   the share of Medicaid residents, and a facility’s business model tell us little about whether a facility is likely to have an outbreak.

First, the not-surprising news: Facilities are most likely to be hit with COVID-19 if they are located in communities where the disease is widespread. Separate research by David Grabowski at Harvard Medical School and Vince Mor at Brown University found close connections between the location of facilities and their experience with COVID-19. Here is a nice summary from Provider magazine.

Location, location, location

In short, larger nursing homes in communities with lots of cases were more likely to have an outbreak. The reason: There were more opportunities for someone to bring in the disease and spread it throughout the facility. This could be a staffer, new resident, or—in the days before facilities were closed to outsiders– a visitor. “It’s about where you are and not who you are,” says Grabowski.

Mor calls it “a function of traffic…If you’re in an environment where there are a lot of people in the community who have COVID, the patients in the building are more likely to have COVID….If you are a larger facility…there is more traffic… and more likelihood that someone will be coming in from the outside with COVID.”

One interesting question about this location, location, location story: What will happen as outbreaks of COVID-19 migrate away from big cities like New York and Chicago and into more rural states with fewer big cities? For example, Mississippi, Alabama, Virginia, Minnesota, North Carolina, and West Virginia all saw their cases increase by 15 percent of more over the past week.

Will nursing home cases migrate with the virus, or will the relatively small absolute numbers of outside cases protect facility residents?  David thinks nursing home cases will move with the disease. When communities where aides live have outbreaks, those aides (often with no symptoms) inevitably will bring COVID-19 into the facilities where they work. At least they will until there is sufficient and rapid testing and necessary personal protective equipment.

No meaningful relationships

Now, the more surprising news: Another study by Tamara Konetzka of the University of Chicago looked at other potential links between key characteristics of nursing homes and COVID-19 cases and deaths. Here is what she found: There is “no meaningful relationship” between nursing home quality (as measured by Medicare’s Nursing Home Compare tool) and COVID-19 cases or deaths. There is no real difference between for-profit facilities and not-for-profits, and only a “weak relationship” between the number of Medicaid residents in a facility and the number of cases.

In some states, such as Illinois, higher rated facilities were slightly less likely to have COVID-19 cases. But in states such as New Jersey, they were marginally more likely to have cases.

Tamara’s work on quality also makes me wonder:  Is this a COVID-19 story or a Nursing Home Compare story? Is part of the problem that Medicare is measuring the wrong things when it rates nursing home quality? Is it missing key factors that affect the well-being and safety of residents?  I raised this issue in a blog six years ago, and many of Medicare Compare’s problems persist.

Race matters

But Tamara found one “strong and consistent” relationship: Nursing homes with larger percentages of white residents were far less likely to have COVID-19 cases or deaths than facilities with more non-white residents. The difference is striking: Facilities with the largest number of non-white residents were twice as likely to have either COVID-19 cases or deaths.

In part, she may be seeing the same phenomenon as Mor and Grabowski. In big cities with many of the early COVID-19 cases, black And Hispanic residents suffered outsized numbers of cases and deaths.  And, as Tamara notes, people tend to stay in nursing homes that are located in their own communities—the same neighborhoods where staff may live, and where COVID-19 was widespread. Add it up, and you get nursing homes in African-American neighborhoods with substantial COVID-19 cases.

There is much we still don’t know about COVID-19 and nursing homes. And the data may change as the disease moves away from cities like New York. But we are getting some important early clues about why many older adults are dying in some nursing homes and not in others.