By Jason Bloome
The United States healthcare system is deluged by seniors with COVID-19 who require respiratory treatments: which includes the use of respirators, ventilators, inhalation therapy, oxygen, and other treatments. The elderly in skilled nursing homes are a population especially vulnerable to developing serious illness or dying as a result of COVID-19. In 2017, there were 15,483 skilled nursing homes in the United States providing care to approximately 1.3 million residents. In the future, all CDC models predict a shortage of skilled nursing home beds and, in this time of COVID-19, there is a role to play for small 4-6 bed residential assisted living homes.
Many families concerned about COVID-19 are afraid of placing loved ones in skilled nursing homes1 where many seniors transfer from hospitals for short-term rehabilitation. Every year, more than 2 million seniors on Medicare are discharged to skilled nursing homes for rehabilitation services.2 In order to qualify for rehabilitation covered by Medicare in a skilled nursing home, a senior must have a hospital inpatient stay of at least three days and require occupational, speech/language or physical therapy at least five days a week or skilled nursing care seven days a week. Although Medicare can pay for up to 100 days for rehabilitation, the average rehabilitation stay is 25 days.3
Some seniors, after rehabilitation, can no longer return home and require long-term custodial care (e.g. require help with dressing, bathing, incontinence, have dementia and/or are non-ambulatory and need help in and out of bed, etc.). For these patients, hospital social workers and case managers can offer families an alternative: bypass the skilled nursing homes with direct hospital discharge to small 4-6 bed residential assisted living homes (also known as board and care homes) where short-term rehabilitation is offered in the same setting where the senior will receive long-term custodial care. Although no care setting is impervious to viruses, families concerned about COVID-19 might prefer the advantages small residential care homes have over large 100+ bed skilled nursing homes. In California, there are approximately 5,800 small residential 4-6 bed assisted living homes licensed by Community Care Licensing, a division of the California Department of Social Services.4
Residential assisted living homes cannot accept incoming patients who test positive for COVID-19.
Residential assisted living homes are licensed to provide 24-hour custodial care. They do not have nurses and cannot accept patients who require skilled nursing care (e.g. require help with g-tubes, intravenous tubes, g-tubes, tracheostomies, etc.)or patients, including those with COVID-19, on ventilators and respirators. As cases increase, residential assisted living homes will not have bed capacity reduced by incoming patients who test positive for COVID-19.
Skilled nursing homes are one of the few settings, outside of hospitals, that can provide respiratory services for COVID-19 patients. About 16 percent of residents in skilled nursing facilities across the United States received respiratory treatment in 2017.5 When skilled nursing homes accept more patients with COVID-19, the risk of infection increases for current and incoming patients without COVID-19.6 Increasing the number of skilled nursing homes beds for patients with COVID-19 will also reduce the available supply of beds for incoming patients who do not have COVID-19.
Residential assisted living homes can incorporate good infection control measures.
Infection control measures are easier to implement in small 4-6 bed residential assisted living homes where there are few residents, a smaller volume of traffic generated by family visitations and less surface areas to sanitize than in large skilled nursing homes. Having less patients facilitates efforts by residential assisted living staff to monitor residents for possible signs of COVID-19 which include high temperatures, coughing and respiratory issues, and to put into place newly issued CDC and WHO guidelines for assisted living homes compiled by the California Assisting Living Association.7
Skilled nursing homes are often cited for having poor infection control measures. It is estimated that more than 2 million infections occur in skilled nursing homes each year.8 Infection control deficiencies are the most common reported violation (39%), followed by food sanitation (36%) and accident environments (34%). In 2017, more than 63% of skilled nursing homes in California were cited for one or more deficiencies related to infection control.9 Poor infection control measures can hasten the spread of COVID-19 among residents in skilled nursing homes.
Residential assisted living homes are small and have fewer patients than skilled nursing homes which impacts the quality of care and decreases the likelihood of the community spread of infections.
Small residential assisted living homes are usually 4-5-bedroom houses which have 4-6 residents. In homes where some residents have private rooms, staff care for only 3 or 4 seniors.
Skilled nursing homes have high patient densities and high occupancy rates which can increase the risk for community spread of COVID-19. In 2017, four out of five skilled nursing home beds in the nation were filled, with some states having occupancy rates as high as 90% (e.g. New York). In California, the occupancy rates of skilled nursing homes in 2017 was 85%.10
The number of beds in skilled nursing homes impacts the quality of care with smaller homes, according to the Center for Medicare and Medicaid Services, having higher star ratings than larger nursing homes.11 In 2017, the average size of California skilled nursing homes was 99 beds.12
Residents in residential assisted living homes require less care than residents in skilled nursing homes.
Residential assisted living home residents, on average, require less help with activities of daily living than skilled nursing home residents. Skilled nursing homes have short and long-term residents who require skilled nursing care (e.g. require help with g-tubes, i.v.s’, g-tubes, tracheostomies, etc.) and long-term custodial care residents. On average, skilled nursing homes have sicker populations than residents in residential assisted living homes. 13 In settings with sicker residents the spread of COVID-19 is particularly dangerous.
Residential assisted living homes have better staff to resident ratios than skilled nursing homes.
The Centers for Medicare and Medicaid Services (CMS) correlates higher quality of care with care settings that have high staff to resident ratios. Most small residential assisted living homes have 2 staff caring for 4-6 residents.
Medicare does not have a minimum standard for staff to resident ratios in skilled nursing homes but it does require that an RN must be present for eight hours a day, and an RN or LPN must always be present at a facility. In April 2019, CMS changed the way they assessed skilled nursing home staffing by using published payroll records instead of depending on skilled nursing homes self-reporting. They found more than half of all skilled nursing facilities met the expected level of staffing less than 20% of the time during a one-year study and, as a consequence, downgraded 1,638 skilled nursing homes on Nursing Home Compare to 1-star—their lowest rating. Most homes were downgraded because their payroll records did not show any registered nurse hours for periods of four days or more or because they failed to produce payroll records or provide data that could be verified by an audit.14 An analysis of the payroll data found the average weekend staffing time per resident day was just 17 minutes for registered nurses, nine minutes for licensed practical nurses, and 12 minutes for nurses’ aides. 15 CMS found in skilled nursing homes with lower staffing levels there were more infection control violations.16
Residential assisted living homes have a lower rate of depression than skilled nursing homes.
Given the choice, most seniors would prefer to receive care at home, or, if this option is not possible, in a community-based care setting rather than in an institution. Small residential assisted living homes provide a familiar environment for people transferring from their own homes.
Residing long-term in a skilled nursing home can affect a resident’s mental well-being which can exact a toll on their physical well-being as well. The percent of residents with depression in skilled nursing homes (49%) is twice as high as for residential assisted living homes (25%).17 Frequent family and friend visits can often help alleviate depression for skilled nursing home residents but, due to COVID-19, many states are beginning to restrict and even prohibit family visits.
Residential assisted living homes are less expensive than skilled nursing homes.
As COVID-19 cases increase throughout the nation and cities close non-essential businesses, families face fiscal uncertainty and budget constraints. The cost of long-term care settings for loved ones will be an important consideration.
The average nationwide cost for a residential assisted living home is $3,000-$3,500 for a shared room and $4,051 for a private room. Private paid skilled nursing homes, on average, are $7,513/month for a shared room and $8,517 for a private room—about twice the cost of residential assisted living homes.18
Social workers should inform families about the option of bypassing skilled nursing homes for patients who require rehabilitation and long-term custodial care.
Families depend on healthcare professionals to give them good advice during a time of crisis and, as the nation is mobilizing to combat COVID-19, hospital social workers and case managers are on the frontlines. News reports about the insidious spread of COVID-19 has every family thinking twice before placing a loved one who requires long-term custodial care in a skilled nursing home. For patients who require rehabilitation about to be discharged from hospitals to skilled nursing homes, hospital social workers and case managers can offer families an alternative: bypass the skilled nursing home with direct discharge to a residential assisted living home where rehabilitation services can be imported into the same setting that provides long-term custodial care. Small 4-6 bed residential assisted living homes have many advantages when compared to skilled nursing homes, and their own part to play as COVID-19 forces us to leverage all parts of our healthcare system.
Jason Bloome is owner of Connections – Care Home Consultants, an information and referral agency to care homes in Southern California. He has helped families place loved ones in care homes for more than 30 years. More information at carehomefinders.com.
1. Dan Berry, “92 Years Old, Scared and Pleading to Come Home”, New York Times, March 22, 2020, https://www.nytimes.com/2020/03/19/nyregion/coronavirus-nursing-home.html
2. Judith Graham, “Making Smarter Decisions About Where to Recover After Hospitalization”, Kaiser Health News, April 11, 2019, https://khn.org/news/making-smarter-decisions-about-where-to-recover-after-hospitalization/#:~:text=
4. California Community Care Licensing Data Tables, https://www.ccld.dss.ca.gov/carefacilitysearch/DownloadData
5. Priya Chidambaram, “Data Note: “How might Coronavirus Affect Residents in Nursing Facilities?”, Kaiser Family Foundation, March 13, 2020: https://www.kff.org/medicaid/issue-brief/data-note-how-might-coronavirus-affect-residents-in-nursing-facilities/
6. Jack Healey and Serge Kovalesky, “The Coronavirus Rampage Through A Suburban Nursing Home’, New York Times, March 21, 2020, https://www.nytimes.com/2020/03/21/us/coronavirus-nursing-home-kirkland-life-care.html
7. Allen Flores Consulting Group, “Coronavirus Preparedness Plan”, March 13, 2020, https://caassistedliving.org/pdf/resources/coronavirus.pdf
8. Montoya A, Mody L. “Common infections in nursing homes: a review of current issues and challenges”. Aging Health. 2011. Dec; 7(6): 889-899.
9. Chidambaram, Data Note.
10. Chidambarum, Data Note.
11. Christina Boccuti et al., “Reading the Stars: Nursing Home Quality Star Ratings, Nationally and by State”, Kaiser Family Foundation, May 2015, https://www.kff.org/report-section/reading-the-stars-nursing-home-quality-star-ratings-nationally-and-by-state-issue-brief/
12. State Health Facts, “Average Number of Certified Skilled Nursing Home Beds”, Kaiser Family Foundation, 2017, https://www.kff.org/other/state-indicator/average-number-of-certified-nursing-facility-beds/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D
13. National Center for Health Statistics Series 3, Number 43, “Long Term Care Providers and Services Users in the United States: 2015-2016” ,CDC, Page 24, February 2019, https://www.cdc.gov/nchs/data/series/sr_03/sr03_43-508.pdf
14. Jordan Rau and Elizabeth Lucus, “Neglect Unchecked: Short Staff Nursing Homes See Drop in Medicare Ratings”, Kaiser Family Foundation, May 3, 2019, https://khn.org/news/short-staffed-nursing-homes-see-drop-in-medicare-ratings/
15. David Fangli et. al., “Daily Nursing Home Staffing Highly Variable, Often Below Reported CMS Expectations”, Health Affairs, Volume 28, No. 7, July 2019, https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2018.05322
16. Jordan Rau, “As Coronavirus Looms Many Skilled Nursing Homes Are Falling Short on Infection Prevention”, WLRN, National Public Radio as reported in Kaiser Health News, March 3, 2019, https://www.npr.org/sections/health-shots/2020/03/04/812162416/as-coronavirus-looms-many-nursing-homes-fall-short-on-infection-prevention
17. CDC, “QuickStats: Percentage of Users of Long-Term Care Services with a Diagnosis of Depression, by Provider Type — National Study of Long-Term Care Providers, United States, 2011 and 2012”,