Evaluation of a state‐wide effort to improve COVID‐19 infection control in Massachusetts nursing homes

Abstract

Background During the deadly 2020 SARS‐CoV‐2 surge in nursing homes (NHs), Massachusetts (MA) initiated a multicomponent infection control intervention to mitigate its spread. Methods We aimed to assess the intervention's impact by comparing the weekly risk of PCR‐confirmed infections among MA NH residents to those in neighboring New England states, all managed similarly by a single NH provider. We studied 2085 residents in 20 MA NHs and 4493 residents in 45 comparator facilities. The intervention included: (1) A 28‐item infection control checklist of best practices, (2) incentive payments to NHs contingent on scoring ≥24 on the checklist, meeting 6 core competencies, testing residents and staff for SARS‐COV‐2 RNA, uploading data, and enabling virtual visits; (3) on‐site and virtual infection control consultations for deficient facilities; (4) 6 weekly webinars; (5) continuous communication with the MA Department of Public Health; and (6) access to personal protective equipment, temporary staff, and SARS‐CoV‐2 testing. Weekly rates of infection were adjusted for county COVID‐19 prevalence. Results The adjusted risk of infection started higher in MA, but declined more rapidly in its NHs compared to similarly managed facilities in other states. The decline in infection risk during the early intervention period was 53% greater in MA than in Comparator States (state‐by‐time interaction HR = 0.47; 95% CI 0.37–0.59). By the late intervention period, the risk of infection continued to decline in both groups, and the change from baseline in MA was marginally greater than that in the Comparator States (interaction HR 0.80; 95% CI 0.64–1.00). Conclusions The MA NH intervention was associated with a more rapid reduction in the rate of SARS‐CoV‐2 infections compared to similarly managed NHs in neighboring states. Although several unmeasured factors may have confounded our results, implementation of the MA model may help rapidly reduce high rates of infection and prevent future COVID‐19 surges in NHs.

The Massachusetts COVID‐19 initiative provides evidence for a practical, multi‐faceted, participatory implementation process

“…Hebrew SeniorLife (HSL), the largest nonprofit provider of senior health care and living communities in New England, and the Massachusetts Senior Care Association (MSCA), partnered to implement a multicomponent infection control intervention in nursing homes across MA. 12 , 14 The intervention was grounded in evidence‐based practices, based upon key elements identified by the Centers for Disease Control and Prevention (CDC) 15 and the Centers for Medicare and Medicaid Services (CMS). 16 A core component of this initiative was a 28‐item checklist of infection control practices, staffing plans, use of PPE, clinical care, and communication practices (staff, residents, families).…”

“…In addition to positive survey performance, the payment was contingent upon the upload of key data, follow‐through on SARS‐CoV‐2 testing, the provision of technology for virtual visits; and the use of payments for additional staff supplies and reconfiguration of living spaces to enable cohorting of residents. 12 , 14 Another implementation strength was the approach to increasing staff knowledge and competence. The project utilized a multi‐faceted, multi‐level approach aimed at staff, clinicians, and leadership that engaged stakeholders as active participants in the implementation of the intervention.…”

“…The study took place in NHs that were all part of the same long‐term care system, thereby mitigating the risk of confounders associated with divergent management approaches. 12 To promote balance between resident samples, new admissions were not included, because some NHs were not admitting new residents, and there was also the possibility that new admissions would be recovering from previous SARS‐CoV‐2 infections, which would influence their response to the intervention. The investigators examined a pragmatic measure of effectiveness, weekly infection by SARS‐CoV‐2, extracted from the NH tracking logs, to evaluate the impact of the intervention.…”

“…They compared weekly rates of infection, confirmed with polymerase chain reaction (PCR) testing, among 2085 residents in 20 MA NHs to 4493 residents in 45 facilities in neighboring New England states (Rhode Island, New Hampshire, and Connecticut), the comparison group. 12 Careful attention was paid to the selection of co‐variates that are known to increase SARS‐CoV‐2 infection risk. These included bed size, staffing, SARS‐CoV‐2 prevalence in the nursing homes' surrounding community, and whether the resident was planned to have a short‐stay or long‐term stay.…”

“…Lipschitz and colleagues have offered a model for successful state and provider partnerships to mitigate infection risk by providing education, supplies, staffing, and financial support. 12 They also offer a prototype for future implementation and evaluation of initiatives to prevent and control infectious disease outbreaks and the value of supporting staff and leadership participation in the process.…”