Overlooked and Undercounted: The Growing Impact of COVID-19 on Assisted Living Facilities

To collect data on COVID-19 cases and deaths in ALFs, we reviewed public reporting of COVID-19 surveillance data displayed on applicable state-run websites in all states, and collected numbers of cases and deaths for ALFs in states where this data is reported separately from cases and deaths in LTC facilities generally, in order to exclude nursing facilities from our analysis. Not all states report COVID-19 data for LTC facilities, and some only report this data for nursing homes. For this analysis, we collected state data on COVID-19 cases and deaths between June 5 and June 8, 2020, and between August 3 and August 6, 2020.

We included COVID-19 case and death data for each state (n=13) that reported for ALFs specifically, as well as other states (n=6) that report ALF data separately from nursing facilities, but do so within a larger category that includes ALFs along with other non-nursing home facility types, such as residential care facilities, personal care homes, and adult care facilities. We included these congregate facilities because assisted living facilities represent a large share of their total residents in many states. We intentionally excluded states reporting in broader categories that include nursing homes because these numbers are reported to CMS separately and our goal is to understand the impact of COVID-19 in assisted living facilities to the extent this is possible with current data limitations.

In order to compare increases in COVID-19 cases and deaths overall to increases in cases and deaths occurring in ALFs over the study period, we calculated the percent increases in cases and deaths occurring between June 8 and August 6, 2020 in the 11 states reporting cumulative ALF data in both the beginning and end of the study period, using the state data section of the KFF COVID-19 Coronavirus Tracker.

Notably, states vary widely in reporting data for cases and deaths. Among the 18 states that report ALF cases, 2 states report aggregate cases for residents and staff, 14 states report cases for residents and staff separately, and 2 states report cases for residents only. Among the 14 states that report ALF deaths, 7 states report deaths for residents and staff separately and 7 states report deaths for residents only. Since June, Connecticut and Texas, which were previously reporting cases and deaths for residents only, are now reporting staff cases, but not staff deaths (Texas) and cases and deaths for residents and staff separately (Connecticut). Most states in our analysis (n=14) report cumulative case and death data, however five states (Florida, North Carolina, North Dakota, Tennessee, Utah) report only active cases, which may lead to a significant undercount of cases and deaths that are no longer active. Within the two-month period, North Carolina switched from reporting cumulative cases to active cases.

States differ slightly in how many cases constitute a facility “outbreak” which triggers reporting – some states report data for facilities with just one active case, others begin reporting when two or more cases are reported by facilities. States also differ in whether they report suspected COVID-19 cases and deaths, in addition to confirmed cases – some only report cases confirmed via diagnostic test. For the purpose of this analysis, we have included both suspected and confirmed COVID-19 cases and deaths reported. Additionally, four states (Massachusetts, Rhode Island, Utah, and California) report ranges of cases and/or deaths, versus specific counts. For these states, we used the median of the reported range, or 5 in the case of “5 or above” reported, and 31 for “greater than 30”.

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