Contact tracing, a strategy long-used to contain the spread of infectious diseases by identifying and isolating people exposed to an infection, has become a crucial state tool to curb COVID-19. But the pandemic requires significant ramping up of contact tracing capacity and funding. Experts estimate 30 contact tracers are needed for every 100,000 Americans – a total of 98,460 workers nationwide – far short of states’ current tracer workforces.
As the death toll in nursing homes rises and COVID-19 testing capacity slowly expands, states are each crafting new testing policies to prevent and contain outbreaks in long-term care facilities, where more than half of coronavirus deaths have occurred in many states.
While the US Centers for Disease Control and Prevention (CDC) has issued general recommendations for testing nursing homes’ staff and 1.3 million residents, governors are issuing executive orders with precise testing mandates that include deadlines and penalties for noncompliance, including loss of operating licenses if nursing homes do not meet testing requirements.
On May 19, 2020, the CDC updated its general principles guiding nursing home testing and recommended that all facilities perform a universal, baseline COVID-19 test in residents and staff based on their available “resources and goals” when at least one infection occurs. Nursing homes should then test all residents weekly until all residents test negative. Before a nursing home can reopen to visitors, the federal government recommends daily screenings of staff (taking temperatures and asking about symptoms) and weekly testing of all staff.
States Issue their Own Testing Guidelines
Faced with COVID-19 nursing home deaths, states are mandating specific testing strategies – in some cases stricter than the federal government’s recommendations – though many states still struggle with limited tests and personal protective equipment (PPE) supplies.
New York: Because asymptomatic facility staff are believed to introduce many coronavirus infections into nursing homes, New York Gov. Andrew Cuomo issued an executive order mandating twice-weekly testing of the state’s 185,000 nursing home staff, in addition to the blanket, baseline testing of nursing home staff and residents after an infection. The facilities must arrange for the testing – though employees can use free state testing sites – and report results to the state or risk losing their operating licenses.
New Jersey: New Jersey’s health commissioner signed an executive directive that requires all long-term care facilities, including nursing homes, assisted living residences, comprehensive personal care homes, residential health care facilities, or dementia care homes to provide COVID-19 baseline testing of all staff and residents by May 26, 2020. Those who test negative must be retested within three to seven days after the baseline testing, and any additional testing should follow CDC’s guidelines on Testing for Coronavirus in Nursing Homes. Failure to comply with the guidelines could result in loss of a facility’s operating license.
Maine recently tripled its test kit supply after it purchased $750,000 worth of tests, using federal relief funds, from Maine-based IDEXX, a veterinary biomedical company that repurposed to produce COVID-19 tests. Maine’s testing capacity increased from 2,300 a week to more than 7,000. Before the IDEXX supply became available, facility-wide testing in nursing homes occurred only if there were a minimum of three reported COVID-19 cases in the nursing home. Nirav D. Shah, director of Maine’s CDC, told NASHP the increased testing capacity now allows testing of all nursing home staff or residents after one individual tests positive. When asked about conducting blanket, pre-emptive universal testing in all Maine nursing homes, he explained, “Maine is reviewing that type of expanded testing protocol, but based on input from medical directors at congregate care facilities, an approach that focuses on staff or some other form of targeted testing is under review.”
West Virginia: In April, Gov. Jim Justice issued an executive order, directing the West Virginia Department of Health and Human Resources and the West Virginia National Guard to “immediately” test every nursing home resident and staff member throughout the state. His order places the onus on state and national guard officials – not nursing homes – to perform the tests. Residents and staff members who have previously been tested will be retested to ensure the most up-to-date results possible.
Pennsylvania: Two weeks ago, Gov. Tom Wolf recommended all nursing home employees, patients, and clients at facilities that have had reported cases to be tested once a week for COVID-19. At facilities that have not had reported any cases, Wolf recommended facilities consider testing 20 percent of staff and residents weekly.
Maryland: Gov. Larry Hogan ordered all Maryland nursing home residents and staff to be tested for the coronavirus by state “strike teams” regardless of whether or not they have exhibited any symptoms of the virus. An earlier order had mandated testing in only symptomatic workers and residents. Nursing homes will be prioritized based on an imminent outbreak or a current rising threat of an outbreak. The order also requires nursing homes to have a physician, nurse practitioner, physician’s assistant or registered nurse evaluate all residents on a daily basis. Failure to comply is a misdemeanor punishable by one-year imprisonment and/or a $5,000 fine.
In Washington State, where 61 percent of COVID-19 deaths have occurred in nursing homes, Gov. Jay Inslee ordered widespread testing at all skilled nursing facilities across the state and tasked the Department of Health to come up with a plan to test every nursing home resident and staff member regularly. That will require 37,000 tests, officials report, which doubles the number of tests currently required.
Florida: Earlier this month, Florida’s health department issued an order requiring all nursing home staff and residents to be tested for COVID-19 when there has ben a reported COVID-19 case in the facility. This order specifically included nursing home staff who are not in the building at the time of the baseline screening — otherwise the facility faces fines or risks having its license revoked. The order, issued by Florida’s Agency for Health Care Administration, requires the state’s 3,800 facilities to make all staff and residents – including asymptomatic staff, some of whom have refused to be tested for fear they would lose their jobs – available for testing by the Florida Department of Health and the National Guard. Officials in Florida say a shortage of test kits continues to deter testing at facilities that do not have reported cases, despite CDC guidelines.
Texas faces a similar problem. Gov. Greg Abbott recently ordered health officials to conduct universal testing in all nursing homes, mirroring CDC guidelines, and enlisted state and local public health officials, including local fire department staff, to perform testing. Because of staffing and testing limitations, officials from the Texas Health and Human Services Commission said they do not know when testing will be completed. As of last week, universal testing had occurred in about 190 of 1,224 licensed nursing facilities, according to a Texas Department of Health and Human Services statement. “At this time, cost estimates are still being calculated, and it’s expected costs will be reimbursable by the federal government,” according to the statement. “The state will be working with nursing facilities and officials around the state to assist with capturing costs and ensuring they are able to seek reimbursement.”
Universal Nursing Home Testing Is a First Step
As states struggle to confront the pandemic’s death toll in their nursing homes, leaders acknowledge that persistent test and PPE shortages are hindering their efforts, and a one-time, universal testing, funded in large part by federal relief funds, offers a first step toward controlling a pandemic that they are only beginning to understand.
Utah, which is currently working to test all nursing home staff in compliance with CDC recommendations, exemplifies what many states face. In the Utah Targeted Recommendations in Support of Long-Term Care Facilities during the COVID-19 Pandemic report to the governor, released May 18, 2020, health experts point out that there continues to be delays and significant under-testing in rural nursing homes. “Some (nursing home facilities) are electing not to engage in widespread testing, leading to under-reporting and this has contributed to the undetected spread of the disease in some facilities,” the report’s authors wrote. The task force recommends Utah:
- Require and provide testing kits, PPE, and staff to prioritize comprehensive, widespread and frequent testing of direct care staff and nursing home residents;
- Provide comprehensive contact tracing of all positive nursing home cases;
- Prioritize antibody testing for nursing home staff as it becomes available; and
- Prioritize rapid COVID-19 testing for nursing home staff as it becomes available.
As states face reduced tax revenue and inevitable shortfalls due to economic fallout from COVID-19, officials question if there will be additional federal relief funds forthcoming to cover future testing needs.
- The current baseline tests capture a snapshot of COVID-19 infections in a nursing home facility at one point in time, but a minimum of weekly testing of staff has been recommended moving forward.
- Additionally, nursing homes make up less than half of congregate care facilities in many areas. As states address the nursing facility risk through universal testing, many are developing similar testing strategies for other congregate settings.
“A failure to aggressively address these issues now could result in high costs related to COVID-19 treatment and management, and long-term care facilities could become a reservoir of SARS COV-2 which could accelerate a second wave of the pandemic,” Utah’s task force members warned in their report.
Confronted with a shortage of test kits, rising COVID-19 cases, and pressure to reopen, many states are designing innovative contact tracing initiatives that use private and public health expertise, volunteers, and traditional phone calls to reach individuals who have been exposed to the coronavirus so they can self-isolate to stop the spread of infection.
Updated June 12, 2020
Last week, states received a minimum of $1.25 billion from the Coronavirus Aid, Relief, and Economic Security Act (CARES Act, Title V) to use at their discretion to address issues related to the pandemic. These dollars may be used to fund necessary COVID-19-related expenses that have not been addressed in their most recently passed state budgets and are limited to expenses that occur between March 1 to Dec. 30, 2020.
This infographic highlights what states need to consider when providing pregnancy-related services to Medicaid enrollees through telehealth during the pandemic. Links to more tools and resources are listed below the infographic.
States can use the following flexibilities and tools to increase access to pregnancy-related services via telehealth:
- Medicaid State Plan Disaster Relief State Plan Amendment: States can use these streamlined templates to add telehealth services.
- State Medicaid and CHIP Telehealth Toolkit
- Medicaid and CHIP Telehealth Toolkit Checklist for States
- Section 1135 Waiver Flexibilities: States can use this waiver to waive provider enrollment and prior authorizations requirements to expand access to telehealth services.
- The Office of Civil Rights at the Department of Health and Human Services issued guidance that allows for enforcement discretion for noncompliance with HIPAA regulatory requirements related to providers and telehealth (e.g., using non-HIPAA compliant systems like Zoom).
- Information letters can provide guidance on billing and covered services to managed care organizations.
- NASHP blog: States Rapidly Build their Telehealth Capacity to Deliver Opioid Use Disorder Treatment, April, 2020
In early March, Washington State experienced the nation’s first COVID-19 nursing home* outbreak, and the state quickly developed a response plan to address outbreaks at other nursing homes. Candace Goehring is director of Residential Care Services in Washington State’s Department of Social and Health Services (DSHS), the agency that regulates and performs complaint investigations into nursing facilities. She took time to answer questions from the National Academy for State Health Policy about the state’s COVID-19 nursing home response plan.
States must be sound stewards of taxpayer dollars and the need to do so now is particularly acute as states confront financial landscapes devastated by the pandemic. Federal investments are providing relief to unemployed workers, small businesses, schools and universities, hospitals, and other health care providers. Additional funding is directed to governors to parse out in a manner that further mitigates need. Their challenge is understanding that need in light of direct grants to providers so funds – whether from federal appropriation, state general funds, or other grants – can be put to the most effective use.
In several states, nursing home staff and residents make up nearly half of residents who have died from COVID-19, including 55 percent of deaths caused by the coronavirus in Massachusetts. While hospitals’ personal protective equipment (PPE) shortages have been highlighted, less attention has been paid to the critical need for PPE and infection control expertise at nursing homes. In response, states are launching rapid-response initiatives to assess and stabilize patients and provide infection control recommendations and support.
With few places to self-isolate, limited access to disinfectant supplies, and overcrowded shelters that reduce residents’ ability to physically distance themselves, individuals experiencing homelessness are at unique risk for COVID-19. Recent estimates suggest that up to 40 percent of homeless individuals, many of whom have underlying health conditions, may become infected.
As COVID-19 cases increase, states, with federal support, are adopting a variety of approaches to safeguard homeless individuals, including creating temporary shelters and renting hotel and motel rooms.
Coronavirus Aid, Relief, and Economic Security Act (CARES Act) and Department of Housing and Urban Development (HUD) appropriations help states build and operate emergency shelters, provide hotel and motel vouchers, and provide essential services to people experiencing homelessness.
Additionally, some states are requesting authorization under 1135 waivers to use Medicaid funding to assist individuals experiencing homelessness.
- Illinois and Oregon have applied for 1135 waivers to create new isolation and quarantine systems for those who cannot quarantine at home.
- Massachusetts requested federal funding to use hotels as temporary housing for individuals experiencing homelessness and to help cover the cost of sanitation products to keep the temporary housing clean.
- North Carolina asked to use Medicaid dollars to cover housing-related services, including temporary housing, housing application assistance and transfers, and moving expenses for homeless individuals who are ready to be discharged from hospitals.
Other state Medicaid offices are seeking flexibility to waive administrative requirements to address homelessness during the pandemic:
- Arkansas submitted an 1115 waiver application asking for the flexibility to use federal funding to cover temporary housing assistance for its high-risk homeless population.
- Washington State proposed targeted Medicaid funding to provide temporary shelter for homeless individuals who are currently under institutional care, so that hospitals can discharge these individuals and free up more space for COVID-19 patients.
In addition to using Medicaid authority, states are employing other resources to help individuals experiencing homelessness. In California, with a homeless population of nearly 130,000, Gov. Gavin Newsom dedicated $150 million to support local efforts to house individuals living on the street. In his April 3, 2020 address, Newsom outlined a plan to move individuals experiencing homelessness into temporary shelters, including hotels, motels, and travel trailers. The first phase of the plan, involving sheltering homeless patients testing positive for COVID-19, has already begun, with the state leasing 7,000 of 15,000 rooms needed. As of April 11, 2020, 1,813 of these rooms had been filled.
Washington State, hit early and hard by the virus, is also moving to open additional housing facilities for individuals experiencing homelessness. In mid-March, the Washington Department of Commerce announced that it was allocating $30 million to support the homeless population, with each county receiving $250,000, with the remainder distributed based on the county’s number of homeless individuals. Counties are using this funding to rent motel and hotel rooms and are focusing their efforts on individuals who have tested positive for COVID-19.
Kitsap County in western Washington recently opened two facilities to shelter homeless individuals who test positive for COVID-19 and those awaiting test results. In Seattle, the city’s Human Services Department, in partnership with other local public health departments, is working to expand shelter capacity by finding new spaces, such as the Seattle Center Exhibition Hall, to house residents from the city’s most crowded shelters. The department is also working on deploying hygiene and sanitation resources, such as public toilets and hand-washing stations, throughout the city. The Seattle Navigation Team is providing outreach to high-risk individuals experiencing homelessness to connect them to housing, sanitation kits, and medical treatment.
The Maine State Housing Authority, the Maine Department of Health and Human Services (DHHS), and the University of Southern Maine have teamed up to open a temporary shelter for homeless adults in a university gym. Located in Portland, the new shelter will house 50 individuals and alleviate some of the crowding in the city’s existing shelters to allow for physical distancing during the emergency. Individuals in the shelter are required to be screened for COVID-19 symptoms regularly and they receive food from the university’s food service contractor. Funding for supplies, including beds, comes from DHHS and MaineHousing. The University of Maine System also signed a memorandum of agreement with the Maine Emergency Management Agency that allows the system’s facilities, supplies, and employees to be used as needed to address the pandemic.
As the pandemic response continues to unfold, it will be critical to highlight how states use the flexibility granted under their new waivers, and whether and to what extent these dollars are used to address homelessness. Additionally, though 1135 waivers are only available for the duration of the public health emergency, states may identify new, creative ways to appropriately use Medicaid funding for supportive housing programs that combine rental subsidies with wrap-around services to help people stay stably housed. In California, for example, the governor hopes to continue to provide homeless services at the hotels and motels the state is renting out, and the current agreements allow for individuals to extend leases after the pandemic subsides.
As safe and stable housing clearly promote health, states and the federal government have both invested in programs that help historically disenfranchised individuals find housing and access health care and supportive services to improve equity. Though temporary during the pandemic, current state initiatives may generate new and valuable partnerships between the health and housing sectors. With the rise of COVID-19 and its health and economic consequences, it is more important than ever that health and housing sectors work in tandem to break down siloes and deploy resources in a coordinated way to meet the needs of those who experience homelessness.
The COVID-19 pandemic is shining a light on well-established racial disparities in health care access and quality, and in social and economic factors affecting health status and outcomes. The racial inequities exposed by case identification and death rates data give states opportunities to improve their responses and interventions.
As state and local data becomes available, Louisiana and Illinois governors have highlighted racial disparities in COVID-19 cases and deaths. This aligns with governors’ recent public statements about equity – 22 governors mentioned the need for educational, economic, and social equity in their state of the state addresses earlier this year.
State public health agencies are working around the clock to inform the public about the pandemic by regularly monitoring and reporting data, which is one of their core functions. An analysis by the National Academy for State Health Policy (NASHP) of state public health websites found that 25 states (AL, AR, AZ, CA, CT, GA, ID, IL, IN, LA, MA, MD, MI, MN, MS, NY, NC, OH, OK, SC, TN, TX, VA, WA, and WI) and Washington, DC are reporting COVID-19 data by race and/or ethnicity.
Among the findings:
- Six states report case data (laboratory-confirmed positive cases), three report mortality data, and 17 report both cases and mortality by race and/or ethnicity.
- States use a variety of categories to report race and ethnicity data. For example, Louisiana reports race data for the following categories: American Indian/Alaska Native, Asian, black, Native Hawaiian/Pacific Islander, other, unknown, and white. Louisiana reports ethnicity data as either Hispanic/Latino or non-Hispanic/Latino. Connecticut reports Hispanic, non-Hispanic white, non-Hispanic black, non-Hispanic Asian, non-Hispanic other, and non-Hispanic unknown.
- Eighteen states report a large proportion of unknown (or missing) race/ethnicity.
- Fourteen states illustrate racial or ethnic disparities where the percentage of deaths or cases for one population is disproportionately high, compared to the demographic breakdown of the state. For example, Mississippi reported that 72 percent of its deaths from COVID-19 have been in the African American population, despite the fact that African Americans make up only 38 percent of the state’s overall population.
State health secretaries and legislators also are emphasizing the importance of identifying disparities to understand and respond to the pandemic and promote health equity. Recently, Massachusetts’ Health and Human Services Secretary, MaryLou Sudders said, “I want to be clear, obtaining racial and ethnic data on cases of COVID-19 is crucial for examining where and on whom the burden of illness and death is falling…It’s actually essential for the commonwealth response to the pandemic and important information for all of us to understand.”
There are additional opportunities for states to monitor and address COVID-19 disparities. Gov. Andrew Cuomo of New York has committed to collecting more comprehensive data about COVID-19 in minority communities. Publicly reporting COVID-19 testing, hospitalization, and recovery by race and ethnicity could further allow state and local policymakers, providers, and other stakeholders to monitor and ensure equity in access to resources for prevention and treatment in order to improve outcomes.
State and city leaders can harness COVID-19 data to tailor their current responses to the pandemic and continue to identify strategies to meet the health and health-related social needs of communities of color. States use race/ethnicity data in a number of ways, including targeting or soliciting funding, tailoring stakeholder outreach and engagement, informing public health initiatives, and strengthening governmental processes to address disparities strategically and comprehensively.
In response to data in her state, Gov. Gretchen Whitmer established the Michigan Coronavirus Task Force on Racial Disparities to develop recommendations for addressing disparities “right now as we work to mitigate the spread of COVID-19 in Michigan.” Task Force chair, Lt. Gov. Garlin Gilchrist II, tweeted, “COVID-19 is a constant reminder of how dangerous racial disparities and inequality are for people of color. 14% of our population is Black, but more than 40% of deaths are in Black communities. I’m working alongside @GovWhitmer to make Michigan a leader in addressing this.”
City leaders also are taking action. Chicago Mayor Lori E. Lightfoot announced a multi-pronged strategy to “address systemic health inequities within the COVID-19 crisis.” Specifically, the mayor in collaboration with nonprofit partners is:
- Establishing a Racial Equity Rapid Response Team to engage community members;
- Conducting regional briefings in targeted communities and with street outreach workers; and
- Calling for more detailed data collection.
Importantly, the city’s health department signed a public health order enhancing data-sharing requirements for certain facilities to support COVID-19 tracking.
States can incorporate lessons into their existing state initiatives to ensure access to coverage and address health equity through accountable health models, Medicaid managed care contract language for social determinants of health, unique data-sharing agreements, and workforce strategies. As the Coronavirus Aid, Relief and Economic Security Act (CARES Act) funding is made available to states and hospitals, leaders can use the funds to support communities and populations disproportionally affected by COVID-19 due to structural and social inequities. States’ efforts to address health equity will continue throughout and beyond this pandemic. NASHP will continue to track states’ public reporting of COVID-19 by race and ethnicity.
|States Publicly Reporting COVID-19 Data by Race/Ethnicity*|
|State||Data Reported||Categories Used to Define Race/Ethnicity|
|AL||Cases**||Race: Asian, Black, White, Other/Unknown
Ethnicity: Hispanic/Latino, Not Hispanic/Latino, Unknown
|AR||Cases and Mortality||Black, White, American Indian, Asian, Pacific Islander, Multiracial, Other, Missing|
|AZ||Cases and Mortality||White Non-Hispanic, Hispanic or Latino, Native American, Black Non-Hispanic, Asian/Pacific Island, Other Non-Hispanic, Unknown|
|CA||Cases and Mortality||Latinos, Whites, African Americans/Blacks, Asians, Multiracial, American Indians or Alaska Natives, Native Hawaiians or Pacific Islanders, Other|
|CT||Cases and Mortality||Hispanic, Non-Hispanic White, Non-Hispanic Black, Non-Hispanic Asian, Non-Hispanic Other, Non-Hispanic Unknown|
|DC||Cases and Mortality||Race: Unknown, White, Black/African American, Asian, American Indian/Alaska Native, Other/Multiracial, Refused During the Interview
Ethnicity: Unknown, Hispanic or Latinx, NOT Hispanic or Latinx, Refused During Interview
|GA||Cases||Race: Black or African American, White, American Indian/Native American, Asian, Multiracial, Native Hawaiian/Pacific Islander, Other, Unknown
Ethnicity: Hispanic/Latino, Non-Hispanic/Latino, Unknown
|ID||Mortality||Race: White, Black, American Indian/Alaska Native, Asian/Pacific Islander, Other Race/Multiple Race, Race Information Pending
Ethnicity: Non-Hispanic, Hispanic, Ethnicity information Pending
|IL||Cases and Mortality||White, Black, Hispanic, Asian, American Indian or Alaska Native, Native Hawaiian or Other Pacific Islander, Other, Left Blank|
|IN||Cases and Mortality||Race: White, Black or African American, Asian, Other, Unknown
Ethnicity: Not Hispanic or Latino, Hispanic or Latino, Unknown
|LA||Mortality||Race: American Indian/Alaska Native, Asian, Black, Native Hawaiian/Pacific Islander, Other, Unknown, White
Ethnicity: Hispanic/Latino, Non-Hispanic/Latino
|MA||Cases and Mortality||Hispanic, Non-Hispanic White, Non-Hispanic Black/African American, Non-Hispanic Asian, Non-Hispanic Other, Unknown, Missing|
|MD||Cases and Mortality||African-American, Asian, White, Other, Data not Available|
|MI||Cases and Mortality||Race: American Indian or Alaska Native, Asian/Pacific Islander, Black or African American, Caucasian, Multiple Races, Other, Unknown
Ethnicity: Hispanic/Latino, Non-Hispanic/Latino, Other, Unknown
|MN||Cases and Mortality||Race: White, Black, Asian, Native Hawaiian/Pacific Islander, American Indian/Alaska Native, Other, Unknown/Missing
Ethnicity: Hispanic, Non-Hispanic, Unknown/Missing
|MS||Cases and Mortality||Black or African American, White, Other|
|NY||Mortality||Hispanic, Black, White, Asian|
|NC||Cases and Mortality||Race: American Indian/Alaska Native, Asian, Black or African American, Native Hawaiian or Pacific Islander, White, Other
Ethnicity: Hispanic, Non-Hispanic
|OH||Cases and Mortality||Race: White, Black, Other, Unknown
Ethnicity: Non-Hispanic or Non-Latino, Hispanic, Latino, Unknown
|OK||Cases and Mortality||Race: American Indian/Alaska Native Only, Asian Only, Black Only, White Only, Other/Multiple Races
Ethnicity: Hispanic or Latino (can be any race)
|SC||Cases||Race: African American, White, Asian, American Indian or Alaska Native, Unknown, Other|
|TN||Cases||Race: White, Black or African American, Other/Multiracial, Asian, Pending
Ethnicity: Not Hispanic or Latino, Hispanic, Pending
|TX||Cases||Asian, Black, Hispanic, Other, Unknown, White|
|VA||Cases||Race: Black or African American, White, Other, Not Reported|
|WA||Cases and Mortality||Hispanic, Non-Hispanic American Indian or Alaska Native, Non-Hispanic Asian, Non-Hispanic Black, Non-Hispanic White, Non-Hispanic Native American or Other Pacific Islander, Non-Hispanic Multiracial, Non-Hispanic Other Race, Unknown|
|WI||Cases and Mortality||Race: American Indian, Asian or Pacific Islander, Black, White, Multiple or Other Races, Unknown
Ethnicity: Hispanic or Latino, Not Hispanic or Latino, Unknown
*As of April 12, 2020. View an updated interactive map highlighting state efforts to track COVID-19 case and death rates by race and ethnicity here.
** Cases in this table refer to laboratory-confirmed positive COVID-19 cases.
Support for this work was provided by the Robert Wood Johnson Foundation. The views expressed here do not necessarily reflect the views of the foundation.