PROJECT SUMMARY/ABSTRACT
The COVID-19 pandemic highlighted the vulnerability of the nearly 1.4 million nursing home (NH) residents
to respiratory healthcare associated infections (HAI) such as COVID-19. By August 2020, there were nearly
200,000 confirmed cases of COVID-19 with more than 50,000 reported resident deaths. NH residents are
vulnerable to respiratory HAI because of multiple comorbidities and physical and cognitive frailty. These
vulnerabilities are compounded by an institutional environment of common caregivers, shared living spaces,
and a setting with a history of being under-resourced and ill-prepared to manage infection outbreaks. While
COVID-19 related NH infections and mortality continue to increase nationwide, no one has reported on the
impact of COVID-19 on NHs’ capacity to respond to the pandemic and to understand the impact of their
response on clinical, functional, and psychosocial resident outcomes jointly.
We are proposing a longitudinal mixed-methods study with the goal to develop knowledge and
recommendations to improve US NHs’ ability to respond to respiratory HAI outbreaks. We have unique access
to data recorded by the Quality Improvement Program for Missouri (QIPMO), a state-sponsored cooperative
program. In March 2020, QIPMO began documenting NH COVID-19 infections and support provided to
Missouri NHs. By June, there were over 2,400 documented QIPMO encounters providing us an unprecedented
opportunity to study how NHs responded to COVID-19. In aim 1, we will use QIPMO data, state key informant
interviews, and interviews with over 300 leaders and staff from 24 purposively sampled NHs to assess diverse
NH pandemic responses, including enactment of federal guidance. In aim 2, using an interrupted time-series
analysis, we will leverage statistical data from the Minimum Data Set (MDS) to determine the effects of the
COVID-19 response on NH resident clinical, functional, and psychosocial outcomes. In aim 3, we will converge
findings from aims 1 and 2 to identify relationships between contextual differences in NH responses and
resident health outcomes to describe practices and strategies that either mitigated or contributed to adverse
outcomes. Finally, in aim 4 we will convene an expert panel to review and recommend updates to current NH
HAI guidelines and identify new practices and strategies to enhance NHs’ capacity to respond to infectious
disease outbreaks including identifying implementation barriers, final dissemination plans and future
intervention development.
The likelihood that COVID-19 will become endemic and create needs for ongoing management is growing.
Understanding how NHs’ responses influenced outcomes, including long-term resident effects, will inform
future intervention development for US NHs to systematically prepare and manage infectious disease
outbreaks. This study addresses the AHRQ priority to better prepare NHs for prevention and management,
specifically high-risk respiratory HAI illnesses like COVID-19.
