Nursing Homes & Assisted Living Facilities Account for 38% of COVID-19 Deaths

A startling statistic has profound implications for the way we’ve managed the coronavirus pandemic.

By Gregg Girvan and Avik Roy

(Due to high demand, this article has been updated seven times—most recently on January 30, 2021—to reflect the most recent statistics. For historical data on nursing home and assisted living facility deaths, please visit this page.)

Based on an original analysis of state-by-state COVID-19 fatality reports, it is clear that for most of the pandemic, the most underappreciated aspect of the novel coronavirus pandemic has been its effect on a specific population of Americans: those living in nursing homes and assisted living facilities.

The disease caused by SARS-CoV-2 affects the elderly far more severely, on average, than younger individuals.

But it turns out that among those who are elderly, deaths are concentrated even further among those living in long term care facilities. This has implications for both those who live in such facilities and those who don’t.

Northeastern nursing homes and assisted living facilities are hardest hit. The cohort of northeastern states, including Connecticut, Massachusetts, New Jersey, and Rhode Island, have experienced the greatest share of nursing home and assisted living fatalities, as a share of the number of residents in those communities. This is in part due to policy decisions by those states that discharged seniors with active COVID-19 infections from hospitals to long-term care facilities. (Source: G. Girvan & A. Roy; Graphic: A. Roy / FREOPP)

Five categories of long-term care providers

There are five core categories of long-term care providers, of which two are our focus: nursing homes and assisted living facilities (sometimes called residential care communities). Adult day care centers, home health care, and hospices are not part of our analysis.

• Nursing homes. Nursing homes, also known as skilled nursing facilities or SNFs, include 24-hour supervision, nursing care, three meals a day, and assistance with activities of daily living. Nursing home residents are usually people with long-term physical, medical, or mental conditions requiring 24-hour supervision, but can also include patients recently discharged from a hospital who need such care temporarily.
• Assisted living facilities. Assisted living facilities, sometimes called residential care homes or personal care homes, are similar to nursing homes, but for individuals who don’t require full-time medical care on-site. They offer meals and assistance with activities of daily living.
• Adult day service centers. Adult day service centers, sometimes called adult day care, are usually only open during normal business hours, and offer a lighter menu of services for those needing some assistance.
• Home health care. Home health care, often delivered through agencies, offer services similar to those of nursing homes but in an individual’s home.
• Hospices. Hospices are long-term care facilities for those with terminal illnesses (e.g., those with 6 months or less to live).

According to the Centers for Disease Control and Prevention, 2.1 million people live in nursing homes or residential care facilities, representing 0.6% of the U.S. population. And yet residents in such facilities account for 38 percent of all deaths from COVID-19, for states that report such statistics.

For more on reopening the economy while the pandemic endures, read FREOPP’s white paper, “A New Strategy for Bringing People Back to Work During COVID-19,” by Lanhee Chen, Bob Kocher, Avik Roy, and Bob Wachter.

Missouri does not break out deaths by residential categories. But among the 304,148 U.S. COVID-19 deaths captured by our analysis, 115,902, or 38 percent, were nursing or residential care home residents. Based on long-term care usage and demographics in the states, including Missouri, we also estimate nationally that the share of fatalities from nursing home and residential care facilities is 38 percent, and 41 percent outside of New York State.

These figures are lower than our analysis released in late July, when nursing or residential care home resident peaked at 45% of all COVID-19 deaths. As states have prioritized protecting such residents, mortality rates within facilities have decreased relative to the rest of the population.

Our calculations are available in an online spreadsheet for public review. We estimate the national share of nursing and residential care home COVID-19 fatalities in three ways:

• Estimate 1 (38.3%): Among states reporting nursing home fatalities, death from COVID-19 has struck 5.8% of U.S. residents of nursing homes and residential care facilities. We estimate that 2.1 million Americans over 65 live in nursing homes and residential care facilities; by extrapolating 5.8% across the entire U.S. nursing and residential care home population, we estimate that nursing homes account for 38.3% of COVID-19 fatalities.
• Estimate 2 (38.1%): This is our most simplistic estimate. Among states reporting nursing and residential care home fatalities from COVID-19, nursing homes account for 38.1% of those deaths. If we simply assume that this share holds true in non-reporting states, we get to a national share of 38.1% (i.e., identical to the share in reporting states).
• Estimate 3 (40.5%): This estimate excludes New York State, which is an outlier in terms of its reported share of COVID-19 deaths in nursing homes. New York State counts as hospital deaths those of nursing home residents who die in a hospital, a tactic that reduces their long-term care death count by thousands. New York’s lower share of COVID-19 deaths in nursing homes is also the result of so many New York deaths outside of long-term care facilities (i.e., a much larger denominator).

Long-term care deaths also a problem outside the U.S.

The U.S. is not an outlier in terms of its nursing home-related COVID-19 fatalities. A study by researchers at the International Long Term Care Policy Network of fatalities in a range of high-income countries found that 46 percent of reported COVID-19 fatalities took place in nursing homes. In terms of deaths per million residents, the worst-performing countries were Belgium and Spain, with 547 and 442 deaths per million occurring in care homes, respectively.

There are idiosyncrasies in the way that U.S. states and other countries report nursing home fatalities; we will continue to monitor the best ways to reconcile international comparisons.

Reorienting the COVID-19 policy response

The policy implications of these figures are significant, and suggest substantial flaws in the way that we have managed the COVID-19 pandemic. Much more attention must be paid to the risk of SARS-CoV-2 infection in nursing homes, especially through nursing home staff who work at multiple facilities. Nursing homes must use best practices for testing and cleanliness.

Thankfully, the CDC’s recommendation to prioritize limited quantities of COVID-19 vaccines for residents and staff in long-term care facilities along with front-line health care workers acknowledges the heightened risk nursing home residents face.

The risk of death from COVID-19 is far higher in the elderly than in younger Americans. According to data from the Centers for Disease Control and Prevention, those older than 65 are 26 times as likely to die of COVID-19 than those aged 25 to 54. Note that not all COVID-19 deaths reported elsewhere are counted by CDC, and that not all CDC-counted deaths were caused by COVID-19; some of these individuals died from other causes, but tested positive for SARS-CoV-2 antibodies. If we assume that there will be 150,000 total deaths from COVID-19 in the U.S., the odds of an individual under 25 dying from COVID-19 are around 1.5 per million, or 1 in 669,000. (Graphics: A. Roy / FREOPP.)

On the flip side, it would appear that elderly individuals who do not live in nursing homes may be at a somewhat lower, while still significant, risk for hospitalization and death due to COVID-19. States and localities should consider reorienting their policy responses away from younger and healthier people, and toward the elderly, and especially elderly individuals living in nursing homes and other long-term care facilities.