By Thomas Goldsmith

It’s a statistic that could easily fly by at a time when the number of statewide COVID-related deaths have passed 8,300.

But there are good reasons to take a deeper look at the 200 North Carolina residential-care residents who have been listed as COVID-related deaths each week beginning with Dec. 22 as recorded in state Department of Health and Human services data.

Each week’s total amounts to about one in four of the total 817 deaths tied to COVID among assisted living residents since the beginning of the pandemic in 2020.

The grim statistics are driving some regulators’ and academics’ increased concern about COVID-related deaths in assisted living facilities, in addition to those in the more medically intensive nursing homes.

Researchers have suggested reasons to ramp up the attention paid to deaths in assisted living settings, where residents are generally healthier and therefore, thought to fare better generally than those in nursing homes.

Nursing homes vs assisted living
Although the types of U.S. long-term care facilities are sometimes confused, nursing homes and assisted living centers serve different functions for fragile older people and their families.

Assisted living facilities in North Carolina grew out of the former county rest-home system, are regulated by the state Department of Health and Human Services, and generally take care of personal and health care needs of people with less intensive medical conditions.

Skilled nursing facilities, commonly known as “nursing homes,” concentrate on residents’ medical care with additional services and are strictly regulated by the federal Center for Medicare and Medicaid Services.

Sources: NC DHHS and the Centers for Medicare and Medicaid Services 

For one thing, more than half of assisted living residents — about 53 percent are 85 or older, while 42 percent of skilled nursing facility residents are in the same age group, according to research in the Journal of American Medical Directors Association by Cheryl Zimmerman, distinguished professor at UNC School of Social Work; UNC geriatrician Dr. Philip Sloane; and colleagues.

“More so, many have the chronic underlying conditions implicated in COVID-19: 34% have heart disease, 17% have diabetes, and 15% have lung disease, and more than a quarter have between four and 10 chronic health conditions,” the authors wrote. “Thus, the assisted living population is at high risk for being affected by COVID-19 and suffering serious outcomes.”

On the national level, U.S. Sen. Elizabeth Warren (D-Mass.) and colleagues commissioned a July report that explored the incidence of COVID in assisted living centers.

“The fatality rate for diagnosed cases (in assisted living), while highly sensitive to the testing rate, is nearly six times the national average, and is comparable to — or even higher than — the fatality rate for nursing home residents with COVID-19,” the report says.

COVID-related concerns listed by 11 major assisted living providers surveyed for the Warren report included high levels of hospitalization for COVID patients in assisted living, the lack of federal testing requirements, inadequate sick-leave policies that put staff and residents at increased risk of infection, and practical and financial obstacles to ensuring supplies of personal protective equipment or PPE.

In addition, congressional researchers found that public and private health-care officials lack full information because assisted living providers aren’t required to match the skilled nursing facilities’ strict requirements for reporting cases and deaths to federal regulators at the Centers for Medicare and Medicaid Services.

More attention in North Carolina has gone to the 2,877 fatalities —  or 10.4 percent of  the state’s deaths — recorded among 27,867 cases in skilled nursing facilities. However, an NC Health News review shows that about 6.7 percent of the state’s assisted living residents die once they have contracted COVID-19. That compares to a 10.7 rate of skilled nursing facility residents with COVID.

“I know that it’s difficult to keep it out of facilities despite many providers’ best efforts,” said Jeff Horton, executive director of the NC Senior Living Association, a trade group.

As of Jan. 15, NC DHHS figures for assisted living centers showed nearly as many current outbreaks in assisted living facilities, at 334, as in skilled nursing facilities, which had 356.

In the context of overall surges in COVID-19 cases, public health and industry officials have pointed out the correlation between increasing COVID-19 cases in the community and in long-term care. Adam Sholar, president of the North Carolina Health Care Facilities Association told NC Health News that community level of the disease ranks as the most significant factor driving an outbreak in a facility.

Horton cited the same cause: “If you look at the numbers regarding percentages of positive tests and hotspots around the state, including the number of cases and deaths related to COVID, there is a correlation to deaths and outbreaks in long-term care.”

However, some distinctive aspects of COVID-19 in long-term care may help assisted living providers guard against more serious complications, according to a Centers for Disease Prevention and Control report and other sources.

Federal regulators advised assisted living providers to push against the increases in community transmission by quickly identifying cases and reacting early to residents or staff who have or may have the disease.

“Experience with outbreaks in nursing homes has demonstrated that residents with COVID-19 may not report common symptoms such as fever or respiratory symptoms,” the CDC report said. “Some may not report any symptoms.

“Unrecognized asymptomatic and pre-symptomatic infections likely contribute to transmission in these settings.”

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Thomas Goldsmith

Thomas Goldsmith worked in daily newspapers for 33 years before joining North Carolina Health News. Goldsmith is a native Tar Heel who attended the UNC-Chapel Hill, and worked at newspapers in Tennessee...