COVID-19 Deaths in Long-Term Care Facilities in the US: An Urgent Call for Equitable and Integrated Health Systems and an All-Hazards Approach to the Next Crisis

The COVID-19 pandemic unjustly impacted aging people worldwide, particularly vulnerable residents living in congregate settings. In the United States, which marked the highest number of COVID-19 deaths in the world, at least 170,148 such deaths occurred in long-term care facilities (LTCFs) by December 2023.¹ LTCFs include nursing homes (NHs) and assisted living facilities (ALFs). Of infected ALF residents, 21.2% died, compared to 2.5% of the general public. Yet, the actual COVID-19 morbidity and mortality in ALFs exceeded official reporting.²

From public health and human rights perspectives, we previously described an integrated public health, emergency management, and health care supersystem with systematic and operational solutions³ to the pervasive and systemic failures⁴ that led to this crisis. Building upon that base, we present in this editorial conceivable root causes and a proposal for preventive, integrated health systems using an all-hazards approach to emergency preparedness. An all-hazards approach generally addresses natural, human-caused, and accidental crises including emerging infectious diseases. Additionally, climate change is one of the greatest global challenges to health: accelerating natural disasters requires continuously improving all-hazards crisis prevention systems. Our conceptual foundation is central to the Federal Emergency Management Agency (FEMA) and Centers for Medicare and Medicaid Services (CMS) preparedness doctrine. We present equitable evidence-based options and best practices to protect LTCF residents and staff before the next crisis.

First, ALFs are based on a social services/hospitality model founded on residents’ autonomy and individual choice.⁵ They are not required to follow the protective CMS Emergency Preparedness Final Rule (EP final Rule), including Appendix Z that emphasizes emerging infectious diseases. At the state level, ALF emergency preparedness regulations vary, unlike NHs that are standardized by federal regulation. Nationally and internationally, ALF staff training and licensed nurse availability vary widely.^5,6 According to the Joint Commission, ALFs are transitioning from a hospitality to a health care business model, with nearly half of their residents living with Alzheimer’s disease or dementia.^6,7

Second, LTCFs, including NHs, are not “well integrated into governmental disaster planning,” potentially resulting only in “paper compliance”⁴ with the EP Final Rule. Moreover, NHs must follow the EP Final Rule or face regulatory consequences, including the loss of CMS reimbursement. The EP Final Rule is based on established FEMA doctrine: an all-hazards-based risk assessment drives emergency plan development, procedures and training, and crisis simulation, all focused on business continuity.

Third, the residents of congregate LTCFs are influenced by multilayered health determinants, concepts developed in the 1970s⁸ and continuing to evolve. Some social, environmental, organizational, economic, and commercial factors in LTCFs may be beyond the individual resident’s control.

Below we present options and best practices that can help to achieve integrated health systems for better preparedness in LTCFs.^4,6,9 We advocate the integration of LTCFs, including NHs and ALFs, into a coordinated system of public health, emergency management, and health care disciplines, focused through a public health and human rights lens: a prevention-oriented and evidence-based population approach that aims for equity.^3,9

Federal Level

Immediately at the onset of a hazard (e.g., a novel pathogen), the federal government should secure personal protective equipment for potentially impacted people, matching estimations of the exposure modalities (e.g., transmission pathways) with appropriate infection prevention and control precautions. To set the standards in disaster management (e.g., infectious disease prevention and control), the CMS and the Centers for Disease Control and Prevention of the Department of Health and Human Services (HHS) should align with the Occupational Safety and Health Administration (OSHA) of the Department of Labor and states with primacy. These agencies should harmonize guidelines for the HHS Administration for Strategic Preparedness and Response and the Department of Homeland Security/FEMA to advise state, local, tribal, and territorial governments.

State Level

State agencies license and regulate LTCFs. Therefore, state laws should require ALFs to comply with the EP Final Rule. In essence, align ALFs with NHs in the same infectious disease prevention and control system, along with the all-hazards approach. The State of Minnesota, for instance, amended the state law requiring ALFs to comply with the EP Final Rule in 2019—before the COVID-19 pandemic. Given that many NHs mandated to follow the EP Final Rule were also unsuccessful in protecting their residents and staff against COVID-19, LTCF staff should be trained in appropriate infectious disease prevention and control field practices, in addition to other required legal mandates.

Local/Regional Level

Because “all disasters are local,” all LTCFs should be included in the local emergency operations planning led by the Healthcare Coalitions (local healthcare and responder entities that are organized in states). Instances of public health leadership occurred at the local health department level in the State of Virginia during the COVID-19 pandemic. When an outbreak notice was received, a county health department provided cross-jurisdictional assistance to LTCFs, including NHs and ALFs; epidemiological analysis, infectious disease prevention and control systems, and environmental health surveys that focused on sanitation, hygiene, and sanitizer types. The Healthcare Coalition invited LTCFs to regional crisis simulations. Such comprehensive planning and response, performed under the National Incident Management System utilizing the proven Incident Command System, requires extensive local/regional and state jurisdictional coordination.

LTCF Level

Residents’ life and health determinants depend upon competent management and operations by the LTCFs. They should adopt and implement commercially available emergency preparedness plans and/or third-party accreditation systems. LTCFs are largely for-profit organizations in the US. There is an opportunity to advance sustainable shared benefits in private-public partnerships, which require accountability, “goodwill,” and “capacity to manage effective organizational integration.”^10(p15) All options can be organized under the continuity of business incentives, benefiting private and public entities.

Life and health are basic human rights. The systemic failure to protect human life and health during the COVID-19 pandemic,^3,4,9 with the above-discussed possible root causes, teaches us to strengthen all-hazards preparedness by fully integrating LTCFs into health systems with robust emergency management systems that protect the basic human rights of all people, including those who spend the last part of their lives in LTCFs.

Acknowledgments

The authors appreciate constructive comments from Michael R. Reich on previous versions of the manuscript, anonymous editors for their constructive comments, inputs from interviewed legislative, public health, and emergency management officials, and assistance from the librarians of Grand Canyon University.