Coronavirus outbreaks, deaths opaque at MT senior care centers

As COVID-19 outbreaks plague hundreds of Montana senior care facilities, details of those outbreaks — including how many people have died — are hard to come by.

This fall, the Village Health & Rehabilitation experienced the largest known COVID-19 outbreak among nursing homes in the state, with 116 of the 145 residents at the time having contracted the virus in a little over a month, according to Centers for Medicare and Medicaid Services (CMS) database. Village Health is a 193-bed facility.

Village Health noted on Nov. 24 that its positive case count was back at zero. But the facility declined to confirm the number of residents who have died from COVID-19. The most recent CMS data show that 18 residents had died due to COVID-19 as of Nov. 15, or almost half of Missoula County's total deaths, at 42 as of Friday.

Data in the CMS database are irregular and only offer case counts for federally-licensed skilled nursing homes. It's also often at least two weeks out of date. Additionally, the federal mandate that requires the four nursing homes in Missoula, including Village Health, to report facility-level COVID-19 data doesn’t apply to the roughly 200 state-licensed personal care and assisted living homes that fall under state oversight.

Meanwhile, the state Department of Corrections is reporting data specific to locations. The University of Montana issues a daily COVID-19 count to the local health department and public. And other states, such as Georgia, provide daily updates with detailed information about specific cases and outcomes at care facilities.

These facilities house people among the most vulnerable to complications and death from the novel coronavirus.

The lack of information in Missoula and across Montana paints an incomplete picture of cases at nursing homes and assisted living facilities at a time infections are soaring across the state — and hospitalizations and deaths along with them. It also has raised questions about the current severity of the outbreak at a time public health experts say knowing where the virus is spreading is critical in preventing future outbreaks.

“We think you can be more strategic on your interventions if you know where exposures actually occur,” Jeffrey Klausner, a physician and epidemiologist at the University of California, Los Angeles, told Science Magazine.

More transparency elsewhere

People who are elderly are more vulnerable to complications or death from the respiratory virus. Residents at nursing homes and other long-term care facilities account for about 1% of the U.S. population, but they represent 40% of COVID-19 deaths, according to the COVID Tracking Project.

A number of other states regularly release data about nursing homes and other care facilities, arguing that providing the names of facilities with COVID-19 cases is necessary for public health. And other agencies in Montana are reporting case counts in other settings, either voluntarily or because of a mandate.

In Montana, Gov. Steve Bullock required public schools to report cases. The Department of Corrections reports cases by facility. Locally, Missoula City-County Health Department Director Ellen Leahy worked with the University of Montana to provide an overall snapshot of cases among staff and students. University faculty have called for even greater transparency, but the snapshot is part of the health department's daily update.

Other states have had a scattered approach to reporting, but a number of states have released facility-level information. Florida, South Carolina, Illinois and Oregon are among the states that report data on cases and deaths at the facility level. And Georgia publishes a daily report of COVID-19 cases in nursing homes, assisted living communities and personal care homes with the name of the facility, resident cases, deaths, recoveries, and staff cases.

The Centers for Disease Control and Prevention’s field epidemiology manual states that communicating with the public and providing "timely, accurate information and answers about the outbreak’s effects" to media during a public health investigation is essential for maintaining the trust of the public and can greatly influence the public's decision to follow health authorities’ recommendations during an outbreak.

"The ability to contain and stop the outbreak might hinge on established relationships and coordination with key partners and stakeholders," the manual states.

Scattered information in Montana

The Montana Department of Public Health and Human Services has not published facility-level data on nursing home cases, although it does publish a summary on its website with the total combined number of COVID-19 cases and deaths among staff and residents across the state for all senior care facilities. The department is still in the process of reviewing a records request from the Missoulian to publicly publish facility-level data on a regular basis for all state and federally licensed facilities.

The state's summary is typically updated weekly, and the most recent report dates back to Nov. 27. According to that report, 97% of the state's long-term care facilities and 51% of the state's assisted living facilities had reported COVID-19 cases. Almost 252 residents had died from COVID-19 since the beginning of the pandemic, or 38% of the state's total 657 deaths as of the Nov. 27 report.

But even the weekly updates mean the data are quickly obsolete because of the fast-spreading nature of the virus. The outbreak among residents at Village Health, for instance, started soon after one staff member tested positive the week ending Sept. 20 and three more staff members tested positive the week ending Oct. 4. In a little over a month, 80% of the facility's residents at the time had contracted the virus, as well as 61 staff, according to CMS data. Village Health said the facility had zero active cases as of Nov. 24.

Other information from state and federal sources can be scattershot or difficult to decipher. For example, Village Health reported a rising death toll among residents throughout October, totaling nine deaths on Nov. 1, but a CMS update on Nov. 8 listed zero total deaths. Those numbers have since been updated in the most recent CMS data to reflect 18 deaths of residents at the facility due to COVID-19 as of Nov. 15.

The Missoula City-County Health Department issues Health Officer Orders to any facility that experiences an outbreak (which is defined as one case) to mandate additional protocols for minimizing the spread of COVID-19.

Those orders, which the Missoulian requested, show that Senescence Care, Rosetta Homes, The Springs at Missoula, BeeHive Homes of Missoula, and the Auberge at Missoula Valley have experienced at least one case in the past two months, as of Nov. 6. It is unknown how many cases have occurred at each of those facilities in the absence of reporting mandates for state-licensed facilities.

In Missoula, Leahy said all facilities must report cases to their local health department. However, the local health department is not reporting facility-level information to the public. Leahy said the county’s attorney cited the government health care information act and Health Insurance Portability and Accountability Act of 1996, known as HIPAA, which is intended to protect patients’ privacy, as the reason for its lack of disclosure.

However, the Reporters Committee for Freedom of the Press points out that there are HIPAA exceptions that allow the release of protected health information, including an exception that allows covered entities to disclose protected health information if it “is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public” and the disclosure is to “a person or persons reasonably able to prevent or lessen the threat."

Community spread in Missoula

As of Nov. 25, Missoula County was at an average of 69 cases per 100,000 residents, well above the rate of 25 cases per a 100,000 population that the Harvard Global Health Institute flags as a "red zone," beyond which a locality may tip into uncontrolled spread.

The county’s death toll and average number of hospitalizations are also on the rise.

In mid-November, Village Health said that it would admit positive COVID-19 patients into its COVID-19 unit as they are discharged from hospitals in an effort to ensure hospital beds remain open. However, Village Health only accepted one positive patient to date, and last week, a Goodman Group spokesperson said Village Health will only accept residents that have tested negative at the hospital or are post-COVID and have met the CDC criteria for release from isolation. The Goodman Group manages Village Health.

Leahy said that nursing homes are a high-risk setting and that controlling an outbreak is difficult, even when facilities are taking proper precautions and completing surveillance testing.

“The people that have been struggling to safely take care of people at the same time preventing further spread have a very, very difficult job,” Leahy said.

The challenge is compounded by the rise of infections in the community, and in Missoula, cases are soaring. University of Chicago health researcher Tamara Konetzka recently told the Associated Press that infections in the community have a direct effect on its nursing homes and other care facilities.

“Trying to protect nursing-home residents without controlling community spread is a losing battle,” Konetzka told the AP. “Someone has to care for vulnerable nursing-home residents, and those caregivers move in and out of the nursing home daily, providing an easy pathway for the virus to enter.”

When it comes to reporting COVID-19 cases to the public, though, Leahy contended that nursing homes are different than other institutions such as schools and universities because nursing homes are not public places where people unknowingly enter.

“They’re not even allowed to have visitors, so there’s really no immediate concern to the public,” Leahy said.

Although Leahy said cases at nursing homes pose no immediate concern to the public, she also said recently that increased cases among older populations mean more hospitalizations and a strain on healthcare infrastructure, which she called a “worrisome trend” for Missoula County and other nearby areas that utilize Missoula’s hospitals.

Leahy confirmed that senior care facilities in Missoula have faced staffing shortages due to staff isolations and quarantines, and said that at one point, the health department called the National Guard to help fill staffing shortages at one of the county’s larger facilities. She did not identify the facility. She said staffing issues were addressed without enlisting the Guard’s help.

Editor's note: Dee Strauss, executive director of The Village, is married to Jim Strauss, publisher of the Missoulian.