COVID-19 devastated the U.S., destroying many of the nation’s 15,600 nursing homes. In the early months of the pandemic, more than a third of those who died were nursing home residents. More than half of all deaths associated with COVID-19 occurred in nursing homes in at least 18 states.

Traditionally operated outside the public eye, nursing homes are now being scrutinized. Some wonder if the current healthcare system should or will survive. Many of the facilities that run on the household service model have had to abandon neighborhoods and reduce their exposure to the public. They changed the way they provide care and how patients are exposed. Organizing care in this way required significant changes.

A quarter of the documented deaths due to COVID-19 were caused by nursing home residents, despite more than 0.5% of the US population living in nursing homes. The death rate for residents of nursing homes is reported to be 50% in some states and some European countries.

Visitation and the lasting lessons while returning to normalcy
Due to lockdown procedures, residents could not visit their families or participate in communal meals or activities at almost all nursing homes. Because many workers are unwilling or unable to work in pandemic conditions, there are severe staff shortages. Care providers sought to minimize the exposure to COVID during the onset of the pandemic. In doing so, they severely restricted access from the outside and limited access to patients.

The first question facing nursing homes as the pandemic subsides is when they can reopen. At the height of the pandemic, nursing homes operated under the assumption that everyone had COVID-19. This makes the safe admission of new patients nearly impossible and the care of existing residents challenging. In addition to testing, staff needed adequate PPE and robust infection control protocols to be in place. With universal testing and meticulous infection control, nursing homes began to admit new patients without COVID-19 and ease lockdown restrictions on long-term residents.

As a result of the pandemic years, the nursing home industry has changed dramatically in the U.S. The average facility size was over 100 beds in 2018. According to research, nursing home COVID-19 infection rates strongly correlate with nursing home size. Exposure to infected teams and outbreaks in nursing homes with more extensive staff and residents is more likely.

A study of trends during the pandemic found that COVID-19 cases were much more likely to occur in facilities with a larger size, an urban location, and a higher proportion of African American residents.

Another study focused on Connecticut with 216 nursing homes, reporting the following results:

  • The number of COVID-19 deaths per licensed bed was higher in larger nursing homes.
  • About 60 percent more deaths occurred per licensed bed in for-profit nursing homes than nonprofit nursing homes.
  • Nursing homes owned by chains had about 40 percent fewer deaths than privately owned nursing homes.
  • The COVID-19 death rate was lower in nursing homes with higher staffing ratings.
  • Rates of COVID-19 deaths were not related to Quality ratings.

The majority of nursing home buildings are older
Nursing homes are often old, outdated, poorly designed, and unattractive to consumers. The COVID-19 pandemic revealed serious design and layout issues that contributed to the rapid and uncontrolled spread of the virus. Despite CMS having fire and life safety regulations and assessing deficiencies in nursing homes that don’t meet these standards, these standards have been violated frequently. The design standards for infection control have been largely ignored.

Post-COVID models have evolved
The majority of nursing home residents do not have private rooms. Nursing home residents usually share bathrooms and live in rooms with two to four beds. Medicare and Medicaid will cover only shared spaces, so private rooms will require a personal payment, which is higher. A number of nursing homes changed their organizational structure and service model as a result of the pandemic. Behavioral models have been updated to reflect the post-pandemic world.

Facility design reform is needed
To improve health, improve infection control, and prepare for pandemics, alternative models are needed. Seniors’ quality of life depends on a multitude of factors, including proximity to their home community, integration of health care and social services, urban design and neighborhood amenities, private rooms and bathrooms for each resident, circulation, and ventilation to prevent infections, transitional rooms, outdoor areas and spaces for exercising, and staff space, among many others. Several nations pioneered small modern nursing home clusters, such as Norway, Denmark, and the United States. Facilities of this type offer home-like environments, private rooms, bathrooms, and outdoor therapeutic spaces, as well as environmental and safety features that ensure residents’ safety.

The clustered neighborhood design has become a model for nursing homes worldwide, where each cluster has 8-12 residents and a private room. Consequently, more personal attention can be provided while limiting the spread of viruses. There are living, dining, and kitchen areas in each group of rooms as well as areas for the residents’ families and nursing staff. Architectural factors have been shown to significantly improve residents’ quality of life and care in nursing homes.

In the U.S., several small homes that follow the “household model” have been successful, but they offer a small proportion of nursing home beds. Although there is no formal definition of “small,” communities with 20 residents or fewer have become commonplace. Among the well-known and established projects, Green House is the most visible and well funded. There are approximately 300 Green House homes in the country, which are usually built in clusters of five units. The homes have between ten and twelve residents, each with a private bath. Multi-floor buildings with individual houses are also examples of urban variations.

In many modern home designs, fireplaces are featured in living rooms and open kitchens are where meals are prepared and shared. In addition to nurses and doctors, cross-trained staff members are employed as nurse aides, cooks, cleaners, and social workers. A lower rate of staff turnover is apparent. Their cross-training allows them to handle multiple aspects of daily life, including cooking, cleaning, and recreation. Both the public and policymakers are concerned with the fact that smaller homes have been proven to provide high levels of satisfaction for residents, families, and workers. They provide a better quality of life and care than traditional nursing homes, and, most importantly, contain and prevent illness during a pandemic.

There was a comparison of the infection rates and death rates associated with COVID-19 in 229 smaller nursing homes that participated in Medicare and Medicaid with traditional nursing homes that were geographically nearby. There are two types of conventional nursing homes: smaller traditional nursing homes with 50 beds and larger traditional nursing homes with 50 beds. Despite their size variations, conventional homes generally had multiple residents per room and a more divided staff. A tracking period spanning January 20, 2020, and July 31, 2020, was used to compare smaller homes with typical homes of both sizes.

It was a stunning result. Nursing homes with 50 or more beds had a 12.5% median death rate per 100 residents. In contrast, nursing homes with 49 or fewer beds had a 10% median death rate. In newer homes, however, there was a death rate of 0% per 100 residents. A zero death rate does not mean there were no deaths; instead, the number was so low that the median is mathematically zero.

Infection rates were equally dramatic. As part of the infection rate analysis, positive COVID-19 cases, as well as re-admissions following COVID-19 hospitalization, were included. The numbers per 1,000 residents are expressed in percentage terms. In light of the low ratios on that scale, the researchers decided to compare the 75th percentiles of COVID-19 cases in each group. In smaller, newer nursing homes, the 75th percentile rates of COVID-19 patients were twice as high as those in traditional homes with 50 beds and 50 beds, respectively.

Modern homes are more than just large and stylish. There are fewer admissions, private bedrooms, and fewer staff members in these homes. A nursing home’s physical plant structure must be restructured in light of these factors to prevent another long-term care epidemic from occurring.

Our nation should review the building design requirements for nursing homes in order to ensure the safety of nursing home residents. A good design does not guarantee safety, quality of life, or quality of care, but the evidence suggests it plays a significant role.

There are several federal, state, and local regulations that apply to nursing homes. The standards must be rethought in light of the pandemic. The most established of these are smaller, newly designed style homes. The homes can accommodate no more than 12 beds and are arranged in clusters to maximize efficiency and provide professional support. It would be helpful to analyze existing, successful models.