State Policy Actions to Support Long-Term Care Facilities During COVID-19 Response

October 21, 2020|5:16 p.m.| ASTHO Staff

As COVID-19 emerged and spread in the U.S., those working and residing in long-term care facilities (LTCF) have experienced a significant burden of COVID-19 cases and deaths. As of Oct. 8, deaths associated with LTCF account for 40% of total COVID-19 deaths in the U.S. LTCF are at increased risk for outbreaks due to limited infection prevention and control capacity, staff who travel to work at multiple facilities—and during the COVID-19 pandemic—limited access to PPE. Additionally, residents at LTCF are more susceptible to infectious disease outbreaks, such as COVID-19, due to aging, high rates of underlying chronic diseases, and congregant living environments.

Federal and state policymakers have responded throughout the pandemic through funding, policy, legislative, and regulatory means to address the rapidly evolving response environment. Federal resources so far include: funds to hire additional staff, implement infection control mentorship programs, increase testing, and provide additional services such as technology solutions to maintain connections between residents and their families.

Many states have also responded by introducing policies, legislation, or regulatory action to help support LTCF in their COVID-19 response. These legislative and regulatory actions typically last for the duration of the declared public health emergency. Select state examples are described below.

Allocating Resources
During the pandemic, one in five LTCFs reported staff or severe PPE shortages. New Jersey responded by enacting a bill that will allow the health commissioner to dedicate a percentage of the state stockpile of PPE and any PPE received from the federal strategic national stockpile to LTCF. The Minnesota Department of Health developed a COVID-19 toolkit and a five-point plan to expand testing, prioritize PPE allocation, ensure adequate staffing, and leverage existing partnerships.

Enhancing Capacity
Maintaining appropriate staffing levels is critical for preventing and controlling the spread of infectious diseases. To support LTCF in recruiting, training, and maintaining appropriate staff capacity, the Massachusetts state Medicaid program established a temporary 10% payment rate increase for all nursing home facilities and an additional 15% payment rate increase for those facilities that cohort residents with COVID-19 to support increased infection control and supply costs. New Jersey enacted similar legislation that will allow a temporary rate adjustment of 10% to increase staff wages and provide supplementary pay for certified nursing aides. New Jersey also introduced a bill that would allow LTCF employees to accrue paid sick leave. Michigan created the Rapid Response Staffing Resource to provide short term staffing assistance to LTCF facing staffing shortages. Indiana and Florida created a temporary personal care attendant program to allow on-the-job training program for nursing assistants to work in nursing homes.

Infection Control
LTCF are required by the Centers for Medicaid and Medicare Services (CMS) to establish and maintain an infection prevention and control program. LTCF are also required by CMS to report COVID case and death data among residents and staff, as well as PPE data and access to COVID-19 testing, to the Centers for Disease Control and Prevention’s (CDC) National Healthcare Safety Network. During the COVID-19 pandemic, many LTCFs have been challenged in their ability to protect residents and staff through proven infection control measures. To address these challenges, Texas deployed Special Infection Control Assessment teams to conduct on-site assessments at troubled LCTF. Minnesota introduced a bill that requires LTCF to establish and maintain proven infection control capacity in alignment with the state’s COVID-19 response plan. New Jersey introduced legislation known as “Sally’s Law” that will establish testing and visitation requirements for LTCF in response to an infectious disease outbreak. The New Jersey Department of Health issued an executive directive that requires LTCF to have one or more individuals with training in infection prevention and control employed or contracted to provide on-site management of the infection prevention and control program.

Looking Ahead
State and territorial health leaders have a key role in supporting LTCF throughout the COVID-19 response through policy actions that will help guide public health preparedness, containment, and mitigation strategies.

To support these efforts, state and territorial health agencies may consider working with LTCF partners and stakeholders to develop and execute plans that include:

  • Testing strategies for residents, staff, and visitors in accordance with current guidelines.
  • Implement contact tracing strategies for residents and staff.
  • Maintain adequate PPE supplies; and develop or operationalize tools such as a COVID-19 LTCF readiness checklist (examples include those developed by CDC and Kansas).

As the COVID-19 virus continues to spread across the country, state and territorial health leaders have the opportunity to continue working with or establish multi-sector teams to develop targeted recommendations and guidelines that further support LTCF response efforts across LTCF partners, stakeholders, and state agency offices in Medicaid, minority health, and rural health. Additionally, states and territories may partner with quality improvement organizations, state surveyors, and ombudsman programs to identify areas where policy approaches might improve testing strategies, build staffing and resource capacity, and improve infection prevention and control practices.


Ashley Ottewell, MPH, is the senior analyst of healthcare-associated infections and antimicrobial resistance at ASTHO
Kate Heyer, MPH, is the director of emerging infections at ASTHO