What Kind of Nursing Homes Have Had the Fewest COVID-19 Cases?

More than a year into the pandemic, over 533,000 people have died from COVID-19 in the US. Of those deaths, a staggering 81 percent (434,317) were of people ages 65 and older, and 20 percent of deaths (106,701) occurred in nursing homes or other long-term care facilities. Several reasons explain these high rates: elderly people are more likely to have other illnesses putting them at higher risk of dying from COVID-19, their aging immune systems are not as strong as younger people’s, and many live in congregate settings like nursing homes, where the virus can spread rapidly. To understand how to better protect elderly people in a future pandemic, this study compared rates of COVID-19 cases, nursing home admission and readmission rates, and deaths among residents of nontraditional small nursing homes and traditional nursing homes.

The best-known type of nontraditional, small house nursing home is the Green House model, which operates 300 homes across 32 states, each housing only 10 to 12 residents. In addition to their small size, Green House homes also feature consistent, universal staff assignment (meaning the facilities try to assign the same staff to the same residents and that staff perform a wide range of responsibilities in addition to their nursing role, like cleaning and cooking), private rooms and bathrooms, smaller overall space, and a central entry. Green House homes have also been proven to have other benefits, such as improving residents’ quality of life and reducing preventable hospitalizations.

The researchers compared COVID-19 data among residents in Green House and other nontraditional small nursing homes that replicate the Green House design and operational practices to two other groups: traditional nursing homes with fewer than 50 beds and those with 50 beds or more. They gathered data from the Centers for Medicare & Medicaid Services and from administrators of nontraditional small house nursing homes on the number of occupied beds, the number of residents with a positive COVID-19 test, the number of people admitted or readmitted to the nursing home with COVID-19, and the number of resident deaths in the period from January 20 to July 31, 2020.

The study found COVID-19 incidence and mortality rates were lower in the nontraditional small nursing homes than in either small or large traditional nursing homes. Other characteristics of nontraditional small nursing homes may have led to this result. For example, the Green House nursing homes are less likely to be operated by for-profit firms and typically pay their certified nursing assistants more, which may result in better care for patients. Green House nursing homes also serve fewer African American residents, who have a higher mortality risk for COVID-19, and fewer residents who are bedfast or have a catheter.

Key findings

• The median rate of COVID-19 cases and admission and readmission rates per 1,000 resident days is 0 for Green House and nontraditional small nursing homes and for traditional nursing homes with fewer than 50 beds, compared with 6 for traditional nursing homes with more than 50 beds.
• The median mortality rates per 100 COVID-19 positive residents is 0 for Green Homes and nontraditional small nursing homes, 10 for traditional nursing homes with fewer than 50 beds, and 12.5 for traditional homes with 50 or greater beds.

Policy implications

• The researchers suggest the Green House model may be a promising option for transforming long-term care and preventing elderly deaths in a future pandemic. However, more research is needed to understand some of the model’s components, and more funding would be needed to scale this model.