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. 2024 Aug 1;7(8):e2429613.
doi: 10.1001/jamanetworkopen.2024.29613.

Modeling Nursing Home Harms From COVID-19 Staff Furlough Policies

Sarah M Bartsch  1   2   3 , Colleen Weatherwax  1   2   3 , Bruce Leff  4 , Michael R Wasserman  5 , Raveena D Singh  6 , Kavya Velmurugan  1   2   3 , Danielle C John  1   2   7 , Kevin L Chin  1   2   3 , Kelly J O'Shea  1   2   3 , Gabrielle M Gussin  6 , Marie F Martinez  1   2   3 , Jessie L Heneghan  1   2   3 , Sheryl A Scannell  1   2   3 , Tej D Shah  1   2   3 , Susan S Huang  6 , Bruce Y Lee  1   2   3   7
Affiliations

Modeling Nursing Home Harms From COVID-19 Staff Furlough Policies

Sarah M Bartsch et al. JAMA Netw Open. .

Abstract

Importance: Current guidance to furlough health care staff with mild COVID-19 illness may prevent the spread of COVID-19 but may worsen nursing home staffing shortages as well as health outcomes that are unrelated to COVID-19.

Objective: To compare COVID-19-related with non-COVID-19-related harms associated with allowing staff who are mildly ill with COVID-19 to work while masked.

Design, setting, and participants: This modeling study, conducted from November 2023 to June 2024, used an agent-based model representing a 100-bed nursing home and its residents, staff, and their interactions; care tasks; and resident and staff health outcomes to simulate the impact of different COVID-19 furlough policies over 1 postpandemic year.

Exposures: Simulating increasing proportions of staff who are mildly ill and are allowed to work while wearing N95 respirators under various vaccination coverage, SARS-CoV-2 transmissibility and severity, and masking adherence.

Main outcomes and measures: The main outcomes were staff and resident COVID-19 cases, staff furlough days, missed care tasks, nursing home resident hospitalizations (related and unrelated to COVID-19), deaths, and costs.

Results: In the absence of SARS-CoV-2 infection in the study's 100-bed agent-based model, nursing home understaffing resulted in an annual mean (SD) 93.7 (0.7) missed care tasks daily (22.1%), 38.0 (7.6) resident hospitalizations (5.2%), 4.6 (2.2) deaths (0.6%), and 39.7 (19.8) quality-adjusted life years lost from non-COVID-19-related harms, costing $1 071 950 ($217 200) from the Centers for Medicare & Medicaid Services (CMS) perspective and $1 112 800 ($225 450) from the societal perspective. Under the SARS-CoV-2 Omicron variant conditions from 2023 to 2024, furloughing all staff who tested positive for SARS-CoV-2 was associated with a mean (SD) 326.5 (69.1) annual furlough days and 649.5 (95% CI, 593.4-705.6) additional missed care tasks, resulting in 4.3 (95% CI, 2.9-5.9) non-COVID-19-related resident hospitalizations and 0.7 (95% CI, 0.2-1.1) deaths, costing an additional $247 090 (95% CI, $203 160-$291 020) from the CMS perspective and $405 250 (95% CI, $358 550-$451 950) from the societal perspective. Allowing 75% of staff who were mildly ill to work while masked was associated with 5 additional staff and 5 additional resident COVID-19 cases without added COVID-19-related hospitalizations but mitigated staffing shortages, with 475.9 additional care tasks being performed annually, 3.5 fewer non-COVID-19-related hospitalizations, and 0.4 fewer non-COVID-19-related deaths. Allowing staff who were mildly ill to work ultimately saved an annual mean $85 470 (95% CI, $41 210-$129 730) from the CMS perspective and $134 450 (95% CI, $86 370-$182 540) from the societal perspective. These results were robust to increased vaccination coverage, increased nursing home transmission, increased importation of COVID-19 from the community, and failure to mask while working ill.

Conclusion and relevance: In this modeling study of staff COVID-19 furlough policies, allowing nursing home staff to work with mild COVID-19 illness was associated with fewer resident harms from staffing shortages and missed care tasks than harms from increased COVID-19 transmission, ultimately saving substantial direct medical and societal costs.

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Conflict of interest statement

Conflict of Interest Disclosures: Ms Singh reported receiving grants from the National Institutes of Health (NIH) during the conduct of the study and receiving grants from the NIH outside the submitted work. Ms Gussin reported receiving grants from the NIH during the conduct of the study and receiving grants from the NIH outside the submitted work. Dr Huang reported receiving grants from the Agency for Healthcare Research and Quality (AHRQ) and the NIH during the conduct of the study and receiving grants from the Centers for Disease Control and Prevention, the NIH, and the AHRQ and support from Xttrium Laboratories for clinical studies in which participating nursing homes and hospital patients received contributed antiseptic product outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Resident Tasks Needed and Potential Harm if Not Received
Figure 2.
Figure 2.. Estimated Impact of Nursing Home Staff Furlough Policies Compared With Current Understaffing Levels on Nursing Home Operational Outcomes
Simulated nursing home staff furlough policies allowed different proportions of staff who were mildly ill to work while wearing N95 respirators. Note difference in axis scales across panels.
Figure 3.
Figure 3.. Estimated Impact of Nursing Home Staff Furlough Policies Compared With Current Staffing Levels on COVID-19–Related and Non–COVID-19–Related Resident Outcomes and Costs
Simulated nursing home staff furlough policies allowed different proportions of staff who were mildly ill to work while wearing N95 respirators. Note the difference in axis scales across panels. The third-party payer included combined direct medical costs for residents and staff. CMS indicates Centers for Medicare & Medicaid Services.
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