Why The 'Kevin Bacon' Factor Is Key To Understanding How COVID Spread In Nursing Homes

Adrina Rodriguez talks with a nurse through a window in April as she visits her father at the Gateway Care and Rehabilitation Center in Hayward where 19 residents have died of COVID-19. (Justin Sullivan/Getty Images)

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To make ends meet, Martha Tapia works 64 hours a week at two different Orange County nursing homes. She is one of the thousands of certified nursing assistants who perform the intimate and physical work of bathing, dressing and feeding the nation's fragile elderly.

"We do everything for them. Everything you do for yourself, you have to do for the residents," Tapia said.

And she's also one of many in that relatively low-paid field, predominantly women of color, who move between facilities.

In March, when the coronavirus began racing through nursing homes the federal government banned visitors. But infections kept spreading. UCLA professors Keith Chen and Elisa Long decided to examine the people still entering nursing homes — the workers.

"The people who we can infer work in this nursing home, what other nursing homes do they work at?" Chen said.

Using location data when the visitor ban was in place from 30 million smartphones helped them "see" the movements of people into and out of nursing homes. The data showed a lot of nursing home workers are — like Tapia — working at more than one. Chen says the data suggests that one source of the spread of infections is staff who work in multiple nursing homes.

"When you learn that over 20 of your workers are also spending time in other nursing homes, that should be a real red flag," Chen said.

THE TOLL

More than 84,000 residents and staff of nursing homes and other long-term care facilities have died from COVID-19, representing 40% of all coronavirus fatalities in the U.S., according to Kaiser Family Foundation's most recent analysis. In Los Angeles County the toll is more than 2,100 making up 30% of all coronavirus deaths in the county.

The UCLA team created maps of movement and found that on average each nursing home is connected to seven others through staff movement. Limiting nursing home workers to one home could mean fewer COVID-19 infections - but that would hurt underpaid, largely minority women.

After each of her shifts, Tapia worries she'll bring the coronavirus home to her granddaughter. She tries to take precautions, even buying N95 masks from nurses. She knows it's not just patients who are at risk. Nursing home workers like Tapia are also contracting COVID-19 — in California alone, 152 of them have died since the pandemic began.

At the nursing home she works at in the morning, she gets an N95 mask that she has to re-use and leave there. At her other nursing home job, in the afternoons, she only gets a blue surgical mask.

"They say they cannot give us N95 [masks]," she says, because she works in the 'general area' where residents haven't tested positive for the coronavirus.

She doesn't want to work at multiple nursing homes but her rent is $2,200 a month and her low pay and limited hours at each nursing home make multiple jobs a necessity.

"I don't want to get sick. But we need to work. We need to eat, we need to pay rent. That's just how it is," Tapia said.

STAFF CONNECTIONS = INFECTIONS

The UCLA study also found that some areas of the country had a much higher overlap among nursing homes than others.

"There are some facilities in Florida, in New Jersey, where they're sharing upwards of 50 to 100 workers," Long said. "This is over an eleven week time period, but that's a huge number of individuals that are moving between these facilities, all of these are potential sources of COVID transmission."

They also found the more shared workers a nursing home had, the more COVID-19 infections among the residents.

"Not only does it matter how connected your nursing home is, but what really matters is how connected your connections are," said Long.

They refer to these highly connected nursing homes as each state's 'Kevin Bacon of nursing homes.'

"We found that if you're going to see a nursing home outbreak anywhere it's likely to spread to the Kevin Bacon of nursing homes in each state," Chen said.

The team hopes that local health departments could use similar cell phone data methods as an early warning system. Using the test results from the 'Kevin Bacon' of nursing homes as an indicator would be the first step.

"As soon as you detect an outbreak in one nursing home, you can immediately prioritize those other nursing homes that you know are increased risk," Chen said.

PRIORITIZE MASKS AND HANDWASHING

The California Association of Health Facilities represents most nursing homes in the state. In response to the study, the group said they can't prevent workers like Martha Tapia from taking jobs elsewhere, and they can't pay them more, because California doesn't pay them enough through Medicaid reimbursements.

Mike Dark doesn't buy that argument. He's an attorney with the California Advocates for Nursing Home Reform — and he says the state already tried paying nursing homes more in 2006.

"If the state were to steer more money to facilities in the short term, as an emergency measure, and earmark that money for better pay for a CNA so that they could not work in as many facilities, we know from past experience that money tends to go into the pockets of the executives and administrators who run these places," Dark said.

He agrees that health workers like Martha Tapia should be paid more, but cautions against the idea that is being floated in some policy circles - limiting workers to one nursing home.

"Then you can wind up depriving some of the crucial health caregivers that we have in these facilities of their livelihoods, which can't be a good solution," he said.

Instead, he says regulators need to focus on the basics, since we know that infection control measures work, especially in one hundred of California nursing homes with ongoing outbreaks.

"Right now there's poor access to [personal protective equipment] there's still erratic compliance with things like handwashing requirements," he said. "If we spent more time addressing those key issues there would be much less concern about the spread between facilities."