A Proactive Nursing Home Risk Stratification Model for Disaster Response: Lessons Learned from COVID-19 to Optimize Resource Allocation


      A coordinated emergency management response to disaster management in nursing homes is desperately needed globally.
      During the most recent COVID-19 pandemic, aside from a few exemplary countries, most countries have struggled to protect their nursing home populations. Timely and appropriate allocation of resources to nursing homes during disaster response is a challenging yet crucial task to prevent morbidity and mortality of residents.
      The responsibility for the management of nursing homes during the pandemic was multifaceted, and responsibilities lay at the national, jurisdictional, and regional levels. Success in managing COVID-19 in nursing homes required all these levels to be aligned and supportive, ideally through management by an emergency response leadership team. However, globally there is a paucity of effective management strategies.
      This article uses the example of the COVID-19 pandemic to propose a risk stratification system to ensure timely and appropriate allocation of resources to nursing homes during disaster preparation and management. Nursing homes should be risk-stratified according to 4 domains: risk of intrusion, capability for outbreak containment, failure in organizational capability, and failure in the availability of community and health care supports. Risk stratification should also consider factors such as current levels of community transmission, if applicable, and geographic location of nursing homes and services.
      Early identification of nursing homes at risk for infectious disease, or disasters, and targeted allocation of resources might help reduce the number of outbreaks, lower the mortality, and preserve community supports such as acute hospital services. The next step is to debate this concept to validate the selected variables and then develop and pilot test a risk stratification tool for use.


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        • Jain B.
        • Cheong E.
        • Bugeja L.
        • Ibrahim J.
        International transferability of research evidence in residential long-term care: A comparative analysis of aged care systems in 7 nations.
        J Am Med Dir Assoc. 2019; 20: 1558-1565
        • World Health Organization, Regional Office for Europe
        Statement – Invest in the overlooked and unsung: build sustainable people-centred long-term care in the wake of COVID-19 [press release].
        (Available at:)
        • Comas-Herrera A.
        • Zalakain J.
        • Lemmon E.
        • et al.
        Mortality associated with COVID-19 in care homes: International evidence. London: International Long-Term Care Policy Network.
        (Available at:) (Published 2020. Accessed April 23, 2021)
        • Emanuel E.J.
        • Persad G.
        • Upshur R.
        • et al.
        Fair allocation of scarce medical resources in the time of COVID-19.
        N Engl J Med. 2020; 382: 2049-2055
        • Willoughby M.
        • Kipsaina C.
        • Ferrah N.
        • et al.
        Mortality in nursing homes following emergency evacuation: A systematic review.
        J Am Med Dir Assoc. 2017; 18: 664-670
        • World Health Organization
        Ethics and COVID-19: Resource allocation and priority-setting. Geneva: World Health Organization.
        (Available at:)
        • Auyeung T.W.
        • Chan F.H.W.
        • Chan T.Y.
        • et al.
        COVID-19 and older adults: Experience in Hong Kong.
        Asian J Gerontol Geriatr. 2020; : 15
        • Jefferies S.
        • French N.
        • Gilkison C.
        • et al.
        COVID-19 in New Zealand and the impact of the national response: A descriptive epidemiological study.
        Lancet Public Health. 2020; 5: e612-e623
        • Amnesty International
        As if expendable: The UK Government's failure to protect older people in care homes during the COVID-19 pandemic. London: Amnesty International.
        (Available at:)
        • Royal Commission into Aged Care Quality and Safety
        Aged care and COVID-19: a special report. Canberra: Commonwealth of Australia.
        (Available at:) (Published 2020. Accessed April 23, 2021)
        • The COVID Tracking Project
        The long-term care COVID tracker.
        (Available at:)
        • Beach M.
        Diaster basics.
        Disaster Preparedness and Management. F.A. Davis Company, Philadelphia2010: 1-20
        • Eagar K.
        • Westura A.
        • Snoek M.
        • et al.
        How Australian residential aged care staffing levels compare with international and national benchworks.
        Centre for Health Service Development, Australian Health Services Institute, University of Wollongong, Wollongong, New South Wales, Australia2019
        • Royal Commission into Aged Care Quality and Safety
        Interim report: Neglect. Canberra: Australian Government.
        (Available at:) (2019. Accessed April 23, 2021)
        • Hershkovich O.
        • Gilad D.
        • Zimlichman E.
        • Kreiss Y.
        Effective medical leadership in times of emergency: A perspective.
        Disaster Mil Med. 2016; 2: 4
        • Anderson D.C.
        • Grey T.
        • Kennelly S.
        • O'Neill D.
        Nursing home design and COVID-19: Balancing infection control, quality of life, and resilience.
        J Am Med Dir Assoc. 2020; 21: 1519-1524
        • Phillips B.D.
        Inclusive emergency management for people with disabilities facing disaster.
        in: Kelman I. Stough L. Disability and Disaster: Explorations and Exchanges. Palgrave Macmillan US, New York2015: 31-49
        • Gaugler J.E.
        • Bain L.J.
        • Mitchell L.
        • et al.
        Reconsidering frameworks of Alzheimer's dementia when assessing psychosocial outcomes.
        Alzheimers Dement (N Y). 2019; 5: 388-397
        • Department of Health
        Coronavirus (COVID-19) at a glance—19 October 2020. Canberra: Australian Government.
        (Available at:)
        • Prime Minister Scott Morrison
        Interview with Michael Rowland, ABC News Breakfast. In: Rowland M, editor. ABC News Breakfast.
        (Available at:)
        • Mody L.
        • Bradley S.F.
        • Huang S.S.
        Keeping the "home" in nursing home: Implications for infection prevention.
        JAMA Intern Med. 2013; 173: 853-854
        • Montoya A.
        • Cassone M.
        • Mody L.
        Infections in nursing homes: Epidemiology and prevention programs.
        Clin Geriatr Med. 2016; 32: 585-607
        • Gaspard P.
        • Mosnier A.
        • Simon L.
        • et al.
        Gastroenteritis and respiratory infection outbreaks in French nursing homes from 2007 to 2018: Morbidity and all-cause lethality according to the individual characteristics of residents.
        PLoS One. 2019; 14: e0222321
        • Australian Bureau of Statistics
        Disability, Ageing and Carers, Australia: Summary of Findings, 2015: A profile of people living in residential aged care in Australia. Canberra: Australian Bureau of Statistics.
        (Available at:)
        • Montoya A.
        • Mody L.
        Common infections in nursing homes: A review of current issues and challenges.
        Aging Health. 2011; 7: 889-899
        • Strausbaugh L.J.
        • Joseph C.L.
        The burden of infection in long-term care.
        Infect Control Hosp Epidemiol. 2000; 21: 674-679
        • Bielza R.
        • Sanz J.
        • Zambrana F.
        • et al.
        Clinical characteristics, frailty, and mortality of residents with COVID-19 in nursing homes of a region of Madrid.
        J Am Med Dir Assoc. 2020; 22: 245-252
        • Salcher-Konrad M.
        • Jhass A.
        • Naci H.
        • et al.
        COVID-19 related mortality and spread of disease in long-term care: a living systematic review of emerging evidence [preprint].
        (Available at:) (Published 2020. Accessed August 19, 2021)
        • Chatterjee P.
        • Kelly S.
        • Qi M.
        • Werner R.M.
        Characteristics and quality of US nursing homes reporting cases of coronavirus disease 2019 (COVID-19).
        JAMA Netw Open. 2020; 3: e2016930
        • Abrams H.R.
        • Loomer L.
        • Gandhi A.
        • Grabowski D.C.
        Characteristics of U.S. nursing homes with COVID-19 Cases.
        J Am Geriatr Soc. 2020; 68: 1653-1656
        • Stall N.M.
        • Jones A.
        • Brown K.A.
        • et al.
        For-profit long-term care homes and the risk of COVID-19 outbreaks and resident deaths.
        CMAJ. 2020; 192: E946-E955
        • Sun C.L.F.
        • Zuccarelli E.
        • Zerhouni E.G.A.
        • et al.
        Predicting coronavirus disease 2019 infection risk and related risk drivers in nursing homes: A machine learning approach.
        J Am Med Dir Assoc. 2020; 21: 1533-1538
        • Tsai T.C.
        • Jha A.K.
        • Gawande A.A.
        • et al.
        Hospital board and management practices are strongly related to hospital performance on clinical quality metrics.
        Health Aff (Millwood). 2015; 34: 1304-1311
        • Anderson R.A.
        • McDaniel Jr., R.R.
        RN participation in organizational decision making and improvements in resident outcomes.
        Health Care Manage Rev. 1999; 24: 7-16
        • Ouslander J.G.
        • Grabowski D.C.
        COVID-19 in nursing homes: Calming the perfect storm.
        J Am Geriatr Soc. 2020; 68: 2153-2162
        • Sugg M.M.
        • Spaulding T.J.
        • Lane S.J.
        • et al.
        Mapping community-level determinants of COVID-19 transmission in nursing homes: A multi-scale approach.
        Sci Total Environ. 2021; 752: 141946
        • Adlakha D.
        • Sallis J.F.
        Activity-friendly neighbourhoods can benefit non-communicable and infectious diseases.
        Cities Health. 2020;
        • Iijima Y.
        • Tanaka S.
        • Ohishi H.
        Multiple outbreaks of gastroenteritis due to a single strain of genotype GII/4 norovirus in Kobe.
        Japan. Jpn J infect Dis. 2008; 61: 419-422
        • Murata A.
        • Matsuda S.
        Association between ambulance distance to hospitals and mortality from acute diseases in Japan: National database analysis.
        J Public Health Manag Pract. 2013; 19: E23-E28
        • Peterson L.
        • Hyer K.
        • Brown L.M.
        Building resilience in nursing homes in disasters.
        in: Cefalu C.A. Disaster Preparedness for Seniors: A Comprehensive Guide for Healthcare Professionals. Springer, New York2014: 104-117
        • Stall N.M.
        • Farquharson C.
        • Fan-Lun C.
        • et al.
        A hospital partnership with a nursing home experiencing a COVID-19 outbreak: Description of a multiphase emergency response in Toronto, Canada.
        J Am Geriatr Soc. 2020; 68: 1376-1381
        • Department of Health
        COVID-19 Outbreaks in Australian Residential Aged Care Facilities: National Snapshot. Canberra: Australian Government.
        (Available at:)
        • Malikov K.
        • Huang Q.
        • Shi S.
        • et al.
        Temporal associations between community incidence of COVID-19 and nursing home outbreaks in Ontario, Canada.
        J Am Med Dir Assoc. 2020; 22: 260-262
        • Gnanasambantham K.
        • Aitken G.
        • Morris B.
        • et al.
        Developing a clinical screening tool for identifying COVID-19 infection in older people dwelling in residential aged care services.
        Australas J Ageing. 2021; 40: 48-57
        • McGarry B.E.
        • SteelFisher G.K.
        • Grabowski D.C.
        • Barnett M.L.
        COVID-19 test result turnaround time for residents and staff in US nursing homes.
        JAMA Intern Med. 2021; 181: 556-559