What do we know about COVID-19 in Michigan’s nursing homes?
Michigan is currently reporting more than 2,300 COVID-19 cases in nursing homes. According to the Michigan Department of Health and Human Services, the number of deaths is 748. That’s nearly 15% of the state’s COVID deaths.
But information about how well Michigan’s nursing homes have controlled the spread of COVID-19 has been limited.
The case count, broken down by facility, shows only active cases—that is, the number of cases a facility counts on a given day, not a cumulative tally. The information on infections has also been limited to residents. It does not include staff. And visitors to the state’s public portal won't see the number of COVID-19 deaths at nursing homes reported there. MDHHS says it does not post the number because of inconsistencies in reporting. The agency says 748 is likely an under count.
But changes underway at the state and federal levels may increase transparency around long-term care.
Michigan is adjusting its data-gathering efforts to reflect requirements from the Centers for Medicare and Medicaid Services (CMS). Released in April, these CMS rules went into effect on May 17.
A spokesperson for CMS said some of the information it’s collecting would be made publicly available by the end of May. Meanwhile, Michigan is working on a plan to test residents and staff at all long-term care facilities, which would likely improve the accuracy of the reported data.
How Michigan stacks up against other states
According to data collected by researchers at the Kaiser Family Foundation, Michigan reports less information about COVID in long-term care facilities than most other states.
“Something that is unusual in Michigan is they actually reported a lower number of cases and facilities this week than they did last week,” said Priya Chidambaram, a health policy analyst for the Kaiser Family Foundation who’s been studying how states report long-term care data.
Again, she’s referring to Michigan’s practice of only publishing active cases in facilities. A facility’s case count may have been 100 one week, and 50 the next. If you visited the site during that second week, you would have only seen the smaller number.
Michigan is one of only three states limiting its case counts to active infections, though it’s possible other states are doing the same (the uncertainty comes from unclear labeling of data).
Michigan is also one of a few states posting data only from skilled nursing facilities, which excludes other long-term care facilities, like homes for the aged. Many states post separate case numbers for residents and staff; Michigan only reports residents.
The KFF data also show that 37 states post deaths. Michigan does not.
New reporting requirements
To be clear, MDHHS has more information than it’s releasing to the public. It’s recording deaths, levels of personal protective equipment, bed availability, and other figures. Soon, to comply with the new CMS standards, it will be collecting even more data, though it’s unclear how much will be published.
One reason it doesn’t currently share more information with the public may be that the data is unreliable.
Katherine Commey, who’s working on developing long-term care reporting strategies with MDHHS, says some facilities struggled to adjust to the reporting system when the state first started collecting data in April. Nursing homes and hospitals alike report information to MDHHS through a system called EMResource, but until the pandemic, hospitals were more familiar with it.
That “learning curve” has been the “largest hurdle” to clear as the department strives to collect accurate data from long-term care facilities, says Commey. For example, it hadn’t been specified whether daily admissions includes all patients that come from the hospital, or just those who are new to the facility.
“That’s why we have, in the most recent weeks, been focusing on updating our reporting requirements at the state level to align with those recently released federal reporting standards,” said Commey, referring to the new CMS standards.
CMS is requiring that skilled nursing facilities (though not other long-term care facilities, which don’t receive both Medicare and Medicaid funding) report suspected and confirmed cases among residents and staff, total deaths among residents and staff, PPE supplies, ventilator capacity, beds and census, access to testing, staffing shortages, and other information.
MDHHS hasn’t said how much of this data it will publish when it re-launches the portal by May 25.
As for CMS, it will be publishing facility-specific data for some of these categories, including cases and deaths, by the end of May. But Chidambaram, the policy analyst from KFF, says we should expect delays.
“Nursing homes have a lot going on right now. State health departments have a lot going on right now. The transition time might be more than just this week or two that CMS has indicated,” she said.
One thing KFF is not tracking is the amount of testing happening at long-term care facilities. Regular testing would give states more reason to be confident in the accuracy of their data. But only a handful of states, like Maine, have a universal testing strategy for these facilities.
Michigan is still coming up with a plan.
Cathy Sunlin, the vice president of regulatory services at the Health Care Association of Michigan, which represents skilled nursing facilities, says state officials consider universal testing at all long-term care facilities a priority.
“It's a necessary component in the fight against COVID, because that's really the way that we can identify where the virus is at and isolate it to stop transmission,” she said.
Sunlin is part of a work group at MDHHS developing a testing strategy at skilled nursing facilities. She and Melissa Samuel, HCAM’s president and CEO, say that doing so for all of Michigan’s 458 skilled nursing facilities, 292 homes for the aged, and 4,211 adult foster care facilities has been a challenge.
Local health officials echo the sentiment. As we reported Thursday, in the absence of a unifying state or national plan, cities and counties in Michigan have had to rely on their own creativity to adapt to shortages in testing materials. Detroit, for example, turned to a perinatal research group based in the city to collect swabs and transport media.
Oakland County is monitoring its long-term care facilities’ testing progress, according to a spokesperson. For facilities without medical staff, the county has been coordinating with local paramedics and fire departments to test residents and staff. A spokesperson for the Macomb County health department said all the county’s nursing facilities have tested residents; half have tested staff too.
The closest thing to a statewide effort involves the Michigan National Guard. With support from the Michigan State Police and MDHHS, the National Guard completed testing at seven facilities in the Upper Peninsula, and on May 15 started working its way through more populous counties, including Oakland, Wayne, Macomb, and Kent.
A spokesperson for the National Guard said testing will continue through the end of May.
Pay attention to the nursing homes themselves
But facilities can only report accurate data if they’re testing staff and residents regularly — and it’s unclear if that’s happening.
Dr. Lona Mody is a professor of internal medicine, geriatrics, and palliative care at the University of Michigan. She says long-term care facilities “should come up with a plan to test their residents and staff on a certain frequency” — for example, once a week, which is what CMS recommends.
Mody believes that for the sake of future pandemic preparedness, we should all be paying attention to exactly how long-term care facilities are responding to this crisis, and not just what the state is requiring them to report.
On March 11, the day after Michigan’s first cases were reported, Mody and fellow researchers sent out a survey to nearly all the state’s 458 skilled nursing facilities. In 2007 she had led a study about facilities’ pandemic preparedness plans, and she wanted to see if they had improved. She found that they had.
A majority of the new survey’s 130 respondents said they had a pandemic response plan in place. Many of them had stockpiled PPE. Also since 2007, nursing homes had strengthened communication with hospitals and state and local health officials, creating an ecosystem that may have streamlined the transfer of patients between facilities in the last months.
The results show that nursing homes were aware that a pandemic was inevitable. But they may not have been prepared for how suddenly and powerfully the wave crashed. Many homes couldn’t contain outbreaks, likely due to shortages of PPE and the struggle to quickly build isolation units.
Noting the possibility of a second surge of COVID-19 infections in the fall, Mody says that along with testing, it’s critical that nursing facilities have clear plans for isolating infection and providing adequate PPE.
“They should be prepared to step up to the challenge,” she said.