COVID-19 Infections and Deaths Among Connecticut Nursing Home Residents: Facility Correlates

Yue Li, PhD; Helena Temkin-Greener, PhD; Gao Shan, MS; Xueya Cai, PhD


J Am Geriatr Soc. 2020;68(9):1899-1906. 

In This Article

Abstract and Introduction


Background/Objectives: To determine the associations of nursing home registered nurse (RN) staffing, overall quality of care, and concentration of Medicaid or racial and ethnic minority residents with 2019 coronavirus disease (COVID-19) confirmed cases and deaths by April 16, 2020, among Connecticut nursing home residents.

Design: Cross-sectional analysis on Connecticut nursing home (n = 215) COVID-19 report, linked to other nursing home files and county counts of confirmed cases and deaths. Multivariable two-part models determined the associations of key nursing home characteristics with the likelihood of at least one confirmed case (or death) in the facility, and with the count of cases (deaths) among facilities with at least one confirmed case (death).

Setting: All Connecticut nursing homes (n = 215).

Participants: None.

Intervention: None.

Measurements: Numbers of COVID-19 confirmed cases and deaths among residents.

Results: The average number of confirmed cases was eight per nursing home (zero in 107 facilities), and the average number of confirmed deaths was 1.7 per nursing home (zero in 131 facilities). Among facilities with at least one confirmed case, every 20-minute increase in RN staffing (per resident day) was associated with 22% fewer confirmed cases (incidence rate ratio [IRR] = .78; 95% confidence interval [CI] = .68–.89; P < .001); compared with one- to three-star facilities, four- or five-star facilities had 13% fewer confirmed cases (IRR = .87; 95% CI = .78–.97; P < .015), and facilities with high concentration of Medicaid residents (IRR = 1.16; 95% CI = 1.02–1.32; P = .025) or racial/ethnic minority residents (IRR = 1.15; 95% CI = 1.03–1.29; P = .026) had 16% and 15% more confirmed cases, respectively, than their counterparts. Among facilities with at least one death, every 20-minute increase in RN staffing significantly predicted 26% fewer COVID-19 deaths (IRR = .74; 95% CI = I .55–1.00; P = .047). Other focused characteristics did not show statistically significant associations with deaths.

Conclusion: Nursing homes with higher RN staffing and quality ratings have the potential to better control the spread of the novel coronavirus and reduce deaths. Nursing homes caring predominantly for Medicaid or racial and ethnic minority residents tend to have more confirmed cases.


As of April 28, 2020, there were nearly 3 million confirmed cases of coronavirus disease 2019 (COVID-19) and 202,597 deaths globally, with 960,916 confirmed cases and 49,170 deaths in the United States.[1] Residents of long-term care (LTC) facilities were shown to be highly vulnerable to respiratory disease outbreaks, such as those of influenza or other common human coronaviruses.[2,3] Current evidence suggests that COVID-19 disproportionately affects older adults and persons with chronic health conditions, leading to higher attack rates and more severe adverse outcomes, such as deaths, among them.[4–6] Nursing home residents are characterized by advanced age, more frequent and complex chronic disease patterns, and highly impaired physical, cognitive, and immune system functions that together put them at the greatest risk of severe COVID-19 infections.[7–9]

After the identification of the first confirmed COVID-19 case in a skilled nursing facility in Seattle, Washington, on February 28, a case investigation conducted by the Public Health–Seattle and King County and the Centers for Disease Control and Prevention (CDC)[7] reported that as of March 18, a total of 167 confirmed COVID-19 cases affecting nursing home residents, care providers, and visitors were found to be linked epidemiologically to that facility, and that more than one-half of infected residents were hospitalized and one-third dead. By April 23, 4,069 LTC facilities in 36 states had been hit by COVID-19, and more than 10,000 deaths of LTC residents and staff were reported in 23 states.[10]

Research is urgently needed to understand COVID-19 transmissions in LTC facilities and to identify important facility characteristics that may be associated with the spread of the novel coronavirus and case fatality among residents. Strong evidence and broad consensus exist that higher nurse staffing levels in nursing homes, especially higher registered nurse (RN) hours, improve safety of care and resident outcomes.[11–14] Residents in nursing homes with better quality of care were also shown to have better health outcomes such as reduced risks of pressure ulcers and mortality.[15–17] Moreover, it is widely reported that nursing homes caring for a disproportionately high number of disadvantaged residents, including Medicaid residents and racial or ethnic minority residents, tend to have more limited financial and clinical resources that lead to poorer quality and safety outcomes for their residents.[18–23] However, COVID-19 is a novel, rapidly evolving pandemic, and evidence regarding COVID-19–related outcomes and their variation among nursing homes is lacking.

This study describes variations in COVID-19–confirmed cases and deaths among residents in Connecticut nursing homes through April 16, 2020, and it evaluates their associations with important nursing home characteristics. We test the hypotheses that nursing homes with higher RN staffing level and better overall quality of care have fewer confirmed cases and deaths, whereas facilities in which Medicaid-paid residents and racial/ethnic minority residents predominate have worse COVID-19 outcomes.