COVID-19 Long-Term Care Deaths and Cases Are at An All-Time Low, Though A Rise In LTC Cases In A Few States May Be Cause for Concern

Since December 2020, the US has fully vaccinated over 1.4 million residents in long-term care facilities (LTCF) and over 1 million LTCF staff. Since then, weekly deaths in nursing homes have continued to fall, much of which has been attributed to the high rates of vaccination among nursing home residents. LTCFs include a range of facilities, including nursing homes, assisted living facilities, and other congregate care facilities for people with disabilities or older adults. This data note looks at state-reported LTCF data from 41 states plus Washington DC to assess what has happened to new deaths and cases in LTCFs in the four months since vaccinations began on December 21^st, 2020. We also examine how recent changes in deaths and cases in LTCFs have shifted the nature of the pandemic outside of LTCFs. Data in this analysis is as of the week of April 11^th, 2021. See methods for more details.

COVID-19 Deaths in Long-Term Care Facilities

Of the 39 states (38 states plus DC) for which we can trend COVID-19 deaths in LTCFs, 21 states reported an all-time low death rate in April 2021. Five states reported zero LTCF deaths per 100,000 state residents in April 2021, a rounded value that represents a very small number of LTCF deaths in those states (Table 1 and Appendix Table 1). Across all states analyzed, LTCF deaths per 100,000 state residents hit an all-time low of 0.2 deaths per 100,000 state residents in April 2021, a steep decrease from the peak of 2.8 deaths per 100,000 US residents in April 2020 and a rate of 1.9 per 100,000 as vaccinations were being rolled out in January 2021. California, Colorado, Mississippi, Tennessee, and Montana reported zero LTCF deaths per 100,000 state residents in April 2021. This is a rounded value that represents a small number of LTCF deaths in those states. Of the 17 states that did not report the lowest number of LTCFs deaths per 100,000 in April 2021 over the course of the pandemic, 13 reported the lowest rate in April since vaccinations began in December 2020. These 17 states reported an average rate of 2.1 deaths per 100,000 in January 2021, which declined to 0.3 deaths per 100,000 in April 2021. See Appendix Table 1 for detailed data.

Since vaccinations began in mid-December 2020, the number of COVID-19 deaths in LTCFs across all states in this analysis has declined by 89% as of April 2021, from 1.7 deaths per 100,000 state residents to 0.2 deaths per 100,000 state residents (Table 1 and Appendix Table 1). Percent decline is calculated by taking the difference between average weekly deaths in December 2020 and average weekly deaths in April 2021 and dividing that difference by the average weekly deaths in December 2020.  Among the 39 states for which we can trend COVID-19 deaths between December 2020 and April 2021, 38 states reported a decline in deaths per 100,000 state residents, ranging from a decline of 68% in Virginia to 100% in Kentucky, with an average drop of 84%. Iowa was the only state that reported higher average weekly LTCF deaths in April 2021 than December 2020 (24% increase). It is possible that this number reflects unknown reporting changes or data reconciliation, especially because the trend in Iowa has been unstable, with increases and decreases reported since October 2020. Notably, Iowa’s LTCF deaths per 100,000 was lower in April 2021 than January and February 2021.

Both nationally and in most states, the share of deaths attributed to LTCFs has dropped since the start of vaccinations in December 2020 (Table 1), indicating a faster decline in death rates in LTCFs than in the community. To a large extent, deaths due to COVID-19 have been concentrated in LTCFs throughout the pandemic.  Previous analysis indicates that the share of COVID-19 deaths attributed to LTCFs peaked in June 2020, when about 49% of all COVID-19 deaths in the US were in LTCFs. Since then, the share of deaths attributed to LTCFs dropped slowly to 42% for the week of December 20^th, 2020, when LTCF residents began receiving vaccines. By mid-April, 2021, LTCFs accounted for 34% of total, cumulative COVID-19 deaths, an eight-percentage point drop since the start of vaccinations. This pattern held in most states. However, four states reported a higher share of deaths in LTCFs in April 2021 compared to December 2020 (CO, IN, OK, OR). Increases in these states were modest, ranging from one to four percentage points, reflecting a slightly faster decrease in community deaths than LTCF deaths.

COVID-19 Cases in Long-Term Care Facilities

Similar to LTCF deaths, average new weekly cases in LTCFs hit an all-time low in April 2021, with two states (Kansas and Mississippi) reporting zero new LTCF cases per 100,000 state residents that month (Table 2 and Appendix Table 2). Across the 39 states (38 states plus DC) included in this analysis, average new weekly cases in LTCFs were just 1.6 per 100,000 in April 2021, compared to a peak of 20.3 in December 2020. Of the 39 states, 28 states reported the lowest average weekly new case rate in April 2021 since the start of the pandemic. Of the remaining 11 states, 3 reported the lowest average weekly rate in April 2021 since vaccinations began in December 2020. See Appendix Table 2 for detailed data.

New cases in LTCFs dropped by 92% between December 2020 and April 2021, a pattern that is reflected in state-level data as well (Table 2 and Appendix Table 2). Nearly all states (36 of 39 states) included in the analysis reported a greater than 80% drop in LTCF cases in this time period. The remaining three states reported a drop of greater than 50%.

Reflecting a potentially troubling trend of increasing community spread, eight states reported increases in LTCF cases from March to April 2021 (Table 2 and Appendix Table 2). These increases ranged from a 6% increase in New Hampshire to over 150% in Connecticut and Michigan. The other five states that saw increases from March to April 2021 were Idaho (9%), Louisiana (31%), New Jersey (36%), Ohio (78%), and Alabama (81%). These increases may be a result of increased cases in the state overall, which has been attributed to rising infections among younger people due to “pandemic fatigue” and the rise of the B.1.1.7 variant. Research suggests a strong connection between increased cases in the community and increased cases in LTCFs. None of the states reported both an increase in LTCF cases and deaths between March and April 2021, so it remains to be seen whether these increased LTCF cases will lead to increased LTCF deaths.

Methods

This analysis is based on data as of the week of April 11th, 2021 from 41 states plus Washington DC, for a total of 42 states. The remaining nine states were excluded because they do not directly report data on cases and deaths in long-term care facilities, their data is sourced from sporadically released media reports, or there were data quality or availability issues in trending data over time. For example, some states have periodically reconciled their data, leading to large jumps that reflect reporting and data quality rather than actual cases or deaths. Within the 42 states included in this analysis, we were able to trend long-term care cases in 38 states plus DC and deaths in 38 states plus DC. We included states for which we could reliably trend at least six months of data, using the earliest reliable period reported in the state as the starting point for that state’s trend. States vary in which facilities they include in LTCF reporting and whether they include residents and staff in case and death counts. For all states, we trended the subset of facilities and populations that provide the longest reliable trend line. For example, our data for Delaware excludes staff cases because that data was not reported consistently; in Michigan, this analysis excludes cases and deaths in Adult Foster Care facilities since these cases and deaths were only added for recent weeks. For this reason, this analysis should not be used to identify state-level or national data on total long-term care cases and deaths. The most recent data on total cases and deaths in long-term care facilities can be located here. See below for details on how each indicator in the Tables and Appendix were calculated. Average Weekly Long-Term Care Deaths/Cases Per 100,000 State Residents: These data represent trends in long-term care deaths and cases in states overtime in the context of total state population. Total state population data is from 2019 estimates from the US Census Bureau. The first week of available long-term care data for each state was not included in this analysis since the first week of data does not reflect a single week of deaths and cases, but rather all deaths and cases that have occurred up to that point. New deaths and cases were calculated for each week thereafter, and then averaged for all of the weeks within the month. Weeks where states reported large increases or any decreases due to reporting changes or data reconciliation were not included in the calculations of monthly averages. These average new deaths and cases were converted to represent deaths and cases per 100,000 state residents to allow for easier comparison across states. Totals for each table were calculated by dividing total new deaths and new cases per month by the total state populations for the states represented in each month of data and converting values to represent totals per 100,000 state residents. Change in Average Weekly LTCF Deaths/Cases Per 100,000 State Residents Since December 2020: The change in LTCF deaths and cases per 100,000 state residents since December 2020 was calculated by taking the difference between the new LTCF deaths/cases in April 2021 and December 2020. Percent Change In LTCF Deaths/Cases Since December 2020: Percent change is calculated by taking the difference between average weekly deaths in December 2020 and average weekly deaths in April 2021 and dividing that difference by the average weekly deaths in December 2020. Percentage Point Change in Share of COVID-19 Deaths Attributed to LTCFs Since December 2020: This value was calculated by calculating the share of deaths attributed to long-term care facilities the week of December 20th, 2020 and subtracting this from the share of deaths attributed to long-term care facilities the week of April 11th, 2021. Shares of deaths were calculated by dividing total long-term care COVID-19 deaths by total COVID-19 deaths in the state at that time. Total deaths for each time period was pulled from KFF COVID tracker. This indicator is not calculated for Iowa, New York, Ohio, or Wisconsin since those states had major increases or decreases in reported deaths after December 20th, 2020. Any changes in the share of deaths between December 2020 and April 2021 would have been impacted by these major reporting changes and would not have accurately reflected the pandemic’s evolving impact on long-term care facilities. This analysis relies on state-reported data instead of federal data since federal data does not include non-nursing home settings. COVID-19 has disproportionately impacted all types of long-term care settings, such as assisted living facilities and group homes. Thus, the state-reported data is more likely to capture the full burden of deaths in long-term care facilities. Additionally, federal data cannot be trended from March-May 2020, and therefore misses early months of the pandemic when there were outbreaks in LTCFs.