Long-term Care Work Conditions Pose COVID-19 Risk

Christina Bennett

May 27, 2020

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

Up to 70% of workers in long-term care facilities in the United States feel obligated to work when sick, according to the results of a new study.

In low-wage sectors like this one, the numbers of workers without health insurance and without sick leave are generally higher than average, said Steven Wallace, PhD, from the UCLA Fielding School of Public Health and the UCLA Center for Health Policy Research in Los Angeles, who was not involved in the study.

"If workers feel they cannot afford to take time off when they are sick — whether it is due to low wages, no sick leave, or a feeling of obligation to not let patients and coworkers down in understaffed settings — they are more likely to ignore symptoms, which could lead to exposing patients to COVID-19, along with other illnesses," he told Medscape Medical News.

That is a recipe for the disaster that we are seeing all too often in nursing homes around the country.

"That is a recipe for the disaster that we are seeing all too often in nursing homes around the country," he said.

It is "particularly dangerous" for the 61% of workers who reported having caregiving responsibilities for children and adult relatives, and could possibly bring COVID-19 home from work, Wallace pointed out.

The study also showed that an estimated one in six workers involved in direct patient care at long-term-care facilities in the United States have a second job.

These long-term-care workers work an average of nearly 20 hours per week at their second job and have an average annual gross personal income of $30,000 to $34,999, and an average household income of $40,000 to $44,999.

The study was conducted to explore the overlooked risk factor for transmission of the virus posed by long-term care workers, said lead investigator Courtney Harold Van Houtven, PhD, from the Department of Population Health Sciences at Duke University and the Duke-Margolis Center for Health Policy in Durham, North Carolina.

Risk Factors for Transmission

The study was published online in the Journal of the American Geriatrics Society and coincides with the original date for the now-canceled American Geriatrics Society (AGS) 2020 Annual Scientific Meeting.

The findings come from a secondary analysis of data from the Work, Family and Health Study collected in 2012 from 30 nursing home facilities in the Northeastern United States and 1007 participants.

In the study cohort of 958 workers who provided direct patient care, 70% were certified nursing assistants, 20% were licensed practical nurses (LPNs), and 10% were registered nurses (RNs).

Personal and household incomes were significantly lower for nursing assistants than for LPNs and RNs (P < .001), and nursing assistants were more likely to be Hispanic (P < .001) or foreign born (P < .01).

"Certified nursing assistants have, since 2010, really been making just slightly more than minimum wage," Van Houtven told Medscape Medical News. "There have been no policies to change it."

Although the data are from 2012, the employment situation for these workers remains much the same today, said Wallace.

In fact, the workers in the study cohort might have been "better off" than the average worker because they reported working for the same employer for an average of nearly 9 years. A 2009 study showed that nursing assistants have an average tenure of 2 years.

The most important change that could be put in place to mitigate some of the study findings "would be to extend paid sick leave to all workers in the country," Wallace said.

In a recent COVID-19 policy statement, the AGS advocates for paid sick leave for workers at long-term care facilities.

In response to the pandemic, there have been changes that could indirectly increase worker's pay and benefits. These include funding through the CARES Act and increased reimbursement from Medicaid in select states, Van Houtven said. However, it is unlikely that workers will see improvements.

"There are so many reductions in average daily census and so much threat to the finances of these facilities that I think it's likely that additional funds are being used to either pay for the increased costs of taking care of a COVID patient or they're trying to just stem their losses," she said.

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