May 7, 2020

Skilled Nursing Facilities in Rural Communities: Opportunities for partnering on COVID-19 response efforts

Guest blog post by Dr. Meg Ann Traci, RTC:Rural Knowledge Broker


The devastating and disproportionate rates of novel coronavirus (COVID-19) cases and deaths in institutional settings continues to be part of the national crisis. With data from the 23 states that publicly report data on deaths within long term care facilities, such as nursing homes, skilled nursing facilities and assisted living facilities, the Kaiser Family Foundation estimates more than one in four COVID-19 related deaths in those states (27%) occurred in such settings. The threat within these medical and personal care settings put people with disabilities and others unable to maintain and manage independence in the community, at increased risk. In rural areas, the threat to such institutionalized populations is likely even greater.

Data on Skilled Nursing Facilities

Provider of Services data extracted from the Centers for Medicare and Medicaid Services (CMS), accessed through the Health Resources and Service’s Administration’s (HRSA) data explorer tool, reveal that of the 15,110 Medicaid and Medicare approved skilled nursing facilities (SNF) across the United States, nearly one in three are located in rural* counties.

Table 1: Urban/rural distribution of skilled nursing facilities

UrbanMetropolitan72.6%
RuralMicropolitan/Noncore27.4%

*We define “rural and urban counties” using the Office of Management and Budget classification; whereas urban = metropolitan counties, and rural = micropolitan and noncore counties.

There are higher rates of institutionalized populations in rural vs urban areas, and those living in institutional settings are more likely to report disabilities than the general population. Those statistics, noted with the rates of non-institutionalized populations of people with disabilities living in rural, point to a need to ensure current efforts to address COVID-19 response and guidance in rural communities is not overlooked.

U.S. Skilled Nursing Facilities Density

The map below shows the density of skilled nursing facilities across the U.S.

Map of the US showing locations of skilled nursing facilities. Text description in body of post.
This map of the United States shows the dispersion of skilled nursing facilities across all U.S. counties. Counties are designated as metropolitan, micropolitan, and noncore. Nearly a third of skilled nursing facilities are located in rural counties, whereas rural includes micropolitan and noncore counties, using the Office of Management and Budget classification definition.  Map produced May 2020 using CMS Provider of Services data from HRSA. https://data.hrsa.gov/data/about

The map above suggests the scale of outreach efforts needed to support skilled nursing facilities. Notably, The Centers for Medicaid and Medicare (CMS) and the Centers for Disease Control and Prevention (CDC) have released directed guidance and provisions for community response in all states, including:

Skilled nursing facilities benefit from community partner support to adopt these recommendations, practices, and resources (e.g., funding and resources being organized across federal agencies) using a whole community approach in local response and recovery efforts, particularly in rural.

Centers for Independent Living (CILs) are community partners positioned to reach people with disabilities in both urban and rural areas and to coordinate with other community emergency response efforts. CILs provide information and referral, independent living skills training, peer counseling, and individual and systems advocacy supports to people with disabilities, many of whom have needs for long term services and supports that can be met in skilled nursing facilities and in less restrictive and community settings.

 In its report (May 24, 2019), Preserving Our Freedom: Ending Institutionalization of People with Disabilities During and After Disasters, the  National Council on Disability recommended that CILs play important roles in emergency management and disaster response. This states “Disaster case management for housing, community living, and related needs must begin no later than one week after an Individual Assistance Disaster Declaration is declared by the President” (p. 63). On March 27, 2020, the President enacted the COVID-19 Aid, Relief, and Economic Security Act (CARES Act) that included $85 million for CILs “…to respond to the COVID-19 pandemic and the surge of needs of individuals with disabilities to access or reconnect with the services and supports they need to remain safely in their community.” CILs may use allocated funds to support needed staff, technology such as remote service delivery technology and equipment, and COVID-19 related supplies such as personal protective equipment, personal care necessities and life sustaining food. CILs may partner with community organizations on these response activities.

Additionally, CILs were among the community partners who supported transition and diversion services resulting in more than 75,000 individuals transitioning to the community from nursing homes through the Money Follows the Person Program (MFP) (January 2008 to December 2016). CIL work involved tracking community resources for accessible communications, transportation, housing, and health care to share as options with interested nursing home residents to consider and use in transition and independent living plans. As a result of MFP and related work, many CILs have a unique capacity to provide transition and diversion services that could be used in emergency response efforts to COVID-19 outbreaks in nursing homes and similar settings (e.g., as part of a strike team) and during emergency recovery and response periods where there may be an increased demand for transition services among nursing home residents.

Future directions

12.3 million people in the U.S. with long term services and supports (LTSS) needs reside in the community, and 1.7 million reside in institutions (Kaye, 2018).  The logistics of LTSS often involve personal assistance and direct care services and the use of durable medical equipment. These arrangements require specific guidance on disinfecting commonly used living surfaces, maintaining social distancing, and staying in the community under shelter-in-place, quarantine, isolation, evacuation, and hospital overflow conditions. Continued work and specific long-term care rebalancing efforts are needed to strengthen and extend the emergency operations framework and planning for pandemics and to do so in ways that will support people with disabilities who live in community and in institutional settings. Attention to strategies and resources needed for rural states and communities to be successful is recommended in this work given the lack of infection control experts and resources in rural areas and the higher population rates of non-institutionalized people with disabilities and the density of skilled nursing facilities in rural areas.


References:

Kaye, H. S. (2018). Maintaining the Right to Community Living: Long-Term Services & Supports in Challenging Times. Paper presented at the Academy Health Annual Research Meeting, Seattle, WA.

Acknowledgements

This guest blog post was submitted by Meg Ann Traci, Ph.D., University of Montana Research Associate Professor, and Knowledge Broker for RTC:Rural.

The map was created by Arin Leopold, RCT:Rural student research assistant, and Lillie Greiman, RTC: Rural Project Director.