Assisted living facilities are now eligible for emergency funding through the same federal relief program as hospitals and nursing homes, but they won’t be subject to similar COVID-19 data reporting requirements, raising questions about how coronavirus cases will be tracked and how safety standards will be upheld in these settings.
This spring, Congress created the $175 billion Provider Relief Fund to help offset the coronavirus-related financial losses of hospitals, nursing homes and community-based providers, and the Department of Health and Human Services recently announced that assisted living facilities, which serve older adults who don’t need constant attention and are mostly private-pay, could apply for its next round of funding. The deadline was Sept. 13.
Separately, nursing homes are required to report data on COVID-19 in their facilities — including case and death counts, personal protective equipment supplies and testing capacity — to the federal government, while the Trump administration has moved to make a voluntary data reporting program for hospitals mandatory and said facilities that fail to report this information risk losing payment from Medicare and Medicaid.
Yet assisted living sites are primarily regulated by states, not federal health agencies, meaning they will now receive relief funding — amounting to 2 percent of their annual gross revenue from resident care — without being required to meet federal reporting rules designed to monitor patients’ safety and keep outbreaks in check.
Assisted living facilities are “a provider group moving under the radar — they have a lot of older people living there, but they’re not subject to the same protections as people in nursing homes,” said Karyn Schwartz, a senior fellow at the Kaiser Family Foundation. “Congress hasn’t had a hook to make requirements of them, because they don’t receive Medicare or Medicaid funding” directly, though most states allow Medicaid to pay for some health services in these facilities.
Nursing homes and skilled nursing facilities, which have been granted about $7.4 billion in Provider Relief funding thus far, are now being held to a different standard. Two days after assisted living facilities became eligible for funding, HHS announced it would distribute $2 billion to nursing homes over four months, with payments tied to their ability to keep new COVID-19 infection and mortality rates low among residents.
Nursing homes don’t need to apply for funding through this incentive program, HHS said; the agency will use the data these facilities are already reporting to dole out payments.
The HHS decision to make assisted living facilities eligible for provider relief came after months of lobbying from senior living trade associations, which say assisted living facilities have been hit hard by coronavirus outbreaks and faced significant PPE shortages and testing delays, but unlike nursing homes, have received little government support. That’s been changing recently; for example, the Trump administration said it would include assisted living sites in its distribution of 150 million rapid COVID-19 tests.
“There is no question that assisted living residents and staff have been especially impacted by COVID-19, and thousands have tragically lost their lives,” the American Health Care Association and National Center for Assisted Living said in an emailed statement. The Provider Relief Fund announcement represents a “positive first step.”
Even so, it’s unclear what standards, if any, will be set for assisted living facilities that receive federal funding. All providers must report to HHS how they spend relief fund payments, and an HHS spokesperson said they’ll have to comply with any reporting requirements “specified in future directions issued by the Secretary.”
If HHS decides to require assisted living sites to report additional data or meet other requirements at a later time, however, it’s unclear how the agency would compel them to do so once the funds are already out the door. Some states do require facilities to report COVID-19 data, though, and the Centers for Disease Control and Prevention’s National Healthcare Safety Network has a voluntary portal for long-term care sites to report coronavirus data.
AHCA/NCAL said it encouraged long-term care providers to prioritize reporting COVID-19 data to local and state agencies over the CDC’s portal because states can then share this data with the federal government and “we support transparency, but not a duplication of efforts.”
Yet only 18 states publish data on COVID-19 in assisted living facilities, and reporting is spotty, according to a recent Kaiser Family Foundation analysis. For example, some states report cases among residents and staff separately, while others combine case counts or exclude staff. Five states only publish active cases, and six include data from facilities for seniors that are not assisted living sites or nursing homes, the analysis shows.
It’s a problem that the picture of COVID-19 in assisted living communities is so murky given the devastating toll the virus has taken on older adults, said Dr. Tamara Konetzka, a professor and researcher of health economics and long-term care at the University of Chicago. As of Sept. 10, more than half of all COVID-19 deaths in 22 states were in long-term care sites, according to The COVID Tracking Project.
Konetzka said she thinks it’s a net positive that assisted living sites are eligible for federal relief funding, but that “it should be mandatory” for them to report COVID-19 data.
“From a public health perspective, the data are everything,” Konetzka said. “We can't figure out exactly who needs help and where the problem areas are, and study what works and what doesn't work unless we have that data.”
Schwartz also raised questions about how fairly the relief payments will be distributed, given the funding formula is tied to an assisted living facility’s revenue rather than its level of need or how hard its community has been hit by the coronavirus. While federal relief payments must be used to cover higher health care costs and decreased revenue tied to COVID-19, the revenue-based model means assisted living facilities that charge residents more to live there will be eligible for more funding.
“With assisted living facilities, there’s a wide variation in how much they cost and what they’re like,” Schwartz said. “It’s not clear why you’d do it that way.”