COVID-19 Across the LTC Landscape: Heterogeneity and Disparities

Once it dawned on us that a pandemic was underway, those of us involved in geriatric care knew that long-term care facilities were going to be in trouble.  And yes, we knew that the usual racial and socioeconomic disparities in outcomes would appear.  But we didn’t know exactly how much trouble, nor did we know exactly how the disparities would play out.  At least for my county of Alameda, for the pre-vaccination phase of the pandemic, we now have answers.

Through the month of January 2021, we had 508 COVID-19 deaths in long-term care facilities (LTCFs) compared with 505 community deaths.  As expected, most of our LTCF pre-vaccination deaths – 71% – were in skilled nursing facilities (SNFs), but 29% were in residential care facilities for the elderly (RCFEs) or continuing care retirement communities (CCRCs).  What I had not anticipated was how dramatically the socioeconomic gradients would show up in our data.  Nor had I anticipated how painful it would be to watch as infections and deaths mounted among staff.

The Alameda County analyses are now available in a paper that David Farrell and I published in Gerontology and Geriatric Medicine (, about which more in a moment, but first I’d like to back up to the events of March 2020. 

It’s worth repeating that the CALTCM leadership was remarkably prescient and swift.  By March 5th, Mike Wasserman, Dan Osterweil, and Albert Lam decided to offer CALTCM’s expertise to the California Department of Public Health.  At the CDPH suggestion that CALTCM organize an educational webinar, Dolly Greene, Jay Luxenberg, and Mike Wasserman did just that on March 9th.  Meanwhile I was oblivious, visiting family and running a marathon on March 7th in Albany, Georgia, which unbeknownst to us was awash with incubating infections – the state’s epicenter.  Flying back to California that evening, I thought the passenger wiping down overhead buttons was over-reacting.  I spent the next two days with other HealthImpact board members at our annual retreat -- my last time in a small closed room without a mask, my last hugs with colleagues.

In short order, reality got me up to speed.  On March 9th, the contaminated Grand Princess Cruise ship docked in Oakland.  Three days later, the Alameda-Contra Costa Medical Association (ACCMA) met with our local health officers, and on March 19th I found myself with the title of COVID-19 Medical Director for the ACCMA.  A thousand and one virtual meetings promptly followed.

County-wide agonies of PPE and testing aside, I knew that our frail older adults were most vulnerable.  A local foundation (Stupski) agreed, so we were able to organize regular LTCF-focused “huddles” between county agencies and delivery systems, as well as meetings of SNFists and SNF medical directors and meetings of palliative care clinicians.  The spring surge subsided, and by the time of the summer surge we had recruited LTC guru David Farrell to county service.  The local African-American Response Coalition emerged as a valuable ally, and by autumn I had official volunteer status, a county email address, and access to local and state COVID-19 data.  

Although I knew only a few of the medical directors, nurses, and unlicensed staff who became infected, I knew many of the facilities, so reviewing the cases and death certificates felt personal and painful.  That first winter surge didn’t have to be as bad as it was.  I don’t have a military background, but I couldn’t help thinking of ground wars in past centuries that were lost due to logistics.

Our paper covers an array of topics, of which here are two:

“Data on decedents’ age, race, education, and country of birth reflected a hierarchy of wealth and socioeconomic status from CCRCs to RCFEs to SNFs. … Our population approach to multiple LTCF types can serve as a corrective to the endemic fragmentation of news, policy, and research regarding various levels of long-term care and to the relative paucity of research on non-SNF settings. These data challenge the impression that different levels of care hold clinically distinct populations; rather, a person’s place in the long-term care system may depend as much on family wealth and support as on medical conditions and function.” 

“Of the 12 COVID-19 deaths among staff, all were people of color, 10 were Asian immigrants, and 10 were unlicensed. … For our SNFs in particular, a mostly immigrant, mostly female workforce cares for a resident population that is mostly poor people of color.”

I would love to hear how our local experience compares with yours.  Our second paper, now in press, will focus on the inevitability of COVID-19 data noise, gaps, and undercounts in LTCFs.  Meanwhile, omicron is still rampant, and CLIA waivers for rapid testing divide the “haves and the have nots” among our 500 RCFEs and ARFs as many PCR turn-around times are so long as to be useless.  David Farrell has been driving around the county dropping off bundles of the OTC rapid home testing kits so at the very least the CLIA waiver “have nots” have something for their staff to test themselves.  Our delivery systems huddles continue.  Resilience is a good thing to have.

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