COVID-19, care homes and infection management: It’s time for outcomes measures

May 15, 2020 / By Richard Fuller, MS

In a prior blog, we highlighted the results of our research into patient outcomes, potentially preventable admissions (PPAs) and emergency room visits (PPVs)1among nursing home residents. In that research, we argued that the existing system of quality measurement in nursing homes is divorced from what we should expect from a system intended to drive quality and guide users to higher quality care. A recent study echoes this limitation whereby nursing home quality scores are not predictive of inspection results2. In this instance, the quality measures and nursing homes are in Canada, but there is common reliance on process measures and an absence of direct measures of adverse outcomes from infections.

The emergence of COVID-19 and the ensuing global pandemic has ravaged long-term care facilities in all nations. The precise share of COVID-19 mortality experienced by care homes has not been rigorously confirmed (not least because of differences in defining what counts as a care-home related COVID-19 death), but there is good reason to believe that the majority of COVID-19 related deaths will be centered upon care homes. Pennsylvania reports nursing/care home related deaths which, at time of writing, total 67 percent of deaths in the state. Using this broader measure of care homes (assisted living plus nursing homes) and counting mortality both occurring in the care home and after subsequent transfer to hospital, it is becoming clear that the number of care-home related deaths is closer to the 50 percent+ cautioned by the WHO3 than the 27 percent being estimated by the Kaiser foundation just two weeks ago4.

This has once more placed care homes under the spotlight, with articles highlighting the correlation of past failures of infection control for flu and pneumonia in care homes and the rapid spread of COVID-195. Infection control in nursing homes has been a consistent cause for concern with the CMS rewriting quality measures in 2015 to promote increased emphasis on the adoption of infection control standards and practices. These revised regulations arose out of failings attributed to the spread of Clostridioides-difficile (C-Diff) and MDROs (multi-drug resistant organisms)6. The terms of participation with Medicare require as of November 2019, that each nursing home7 designate a person as the infection control preventionist (IP). These are good moves towards the improvement of care practices known to have been historically deficient8,9 but, as with the regulation of hospitals, initiatives to improve processes should be accompanied with measurements to show improvements in outcomes.

When we move on from COVID-19, there will undoubtedly be a reassessment of the importance of infection control and infection control practices in care homes. We have already seen CMS initiate a commission to look at nursing home response to COVID-19 and, more generally, management of infectious disease10. One of the proposed tasks for the commission is to develop ways to better ensure “compliance with infection control policies in response to COVID-19.” Given that the last round of wholesale rule changes was intended to enhance infection control, surely the time has come for care homes to learn what has already been learned in hospitals: The only way to focus on the implementation and effectiveness of infection control is to focus on the outcomes.

Richard Fuller, MS, is an economist with 3M Clinical and Economic Research.


  1. Fuller RL, Goldfield NI, Hughes JS, McCullough EC. Nursing Home Compare Star Rankings and the Variation in Potentially Preventable Emergency Department Visits and Hospital Admissions. Popul Health Manag. Published online July 2018:pop.2018.0065. doi:10.1089/pop.2018.0065
  2. Mashouri P, Taati B, Quirt H, Iaboni A. Quality Indicators as Predictors of Future Inspection Performance in Ontario Nursing Homes. J Am Med Dir Assoc. Published online October 29, 2019. doi:10.1016/j.jamda.2019.09.007
  3. WHO Europe: Up to Half of Deaths in Care Homes | Voice of America – English. Accessed May 4, 2020.
  4. Apr 23 PCP, 2020. State Reporting of Cases and Deaths Due to COVID-19 in Long-Term Care Facilities. The Henry J. Kaiser Family Foundation. Published April 23, 2020. Accessed May 4, 2020.
  5. Hundreds of nursing homes in coronavirus hotspots violated infection-control rules repeatedly – The Washington Post. Accessed May 4, 2020.
  6. Dick AW, Bell JM, Stone ND, Chastain AM, Sorbero M, Stone PW. Nursing home adoption of the National Healthcare Safety Network Long-term Care Facility Component. Am J Infect Control. 2019;47(1):59-64. doi:10.1016/j.ajic.2018.06.018
  7. Unroe KT, Ouslander JG, Saliba D. Nursing Home Regulations Redefined: Implications for Providers. J Am Geriatr Soc. 2018;66(1):191-194. doi:10.1111/jgs.15128
  8. Stone PW, Herzig CTA, Agarwal M, Pogorzelska-Maziarz M, Dick AW. Nursing Home Infection Control Program Characteristics, CMS Citations, and Implementation of Antibiotic Stewardship Policies: A National Study. Inq J Med Care Organ Provis Financ. 2018;55:46958018778636. doi:10.1177/0046958018778636
  9. Hammerschmidt J, Manser T. Nurses’ knowledge, behaviour and compliance concerning hand hygiene in nursing homes: a cross-sectional mixed-methods study. BMC Health Serv Res. 2019;19(1):547. doi:10.1186/s12913-019-4347-z
  10. CMS Announces Independent Commission to Address Safety and Quality in Nursing Homes | CMS. Accessed May 5, 2020.