Impact of COVID-19 on Care Transitions and Health Outcomes for Vulnerable Populations in Nursing Homes and Home Healthcare Agencies (ACROSS-CARE)

The "Impact of COVID-19 on Care Transitions and Health Outcomes for Vulnerable Populations in Nursing Homes and Home Healthcare Agencies (ACROSS-CARE)" study will address the impact of COVID-19 on care transitions and health outcomes of elderly, vulnerable patients (e.g., persons of color, rural residents) and identify health disparities and effective practices to mitigate them.

Columbia University School of Nursing is conducting the study in partnership with the RAND Corporation, and each institution's IRB has approved the study. 

The National Institutes of Health's National Institute on Aging, National Institute of Allergy and Infectious Diseases, and National Institute on Minority Health and Health Disparities are funding this research (R01AG074492).


The COVID-19 pandemic has disproportionately impacted elderly persons of color who experience higher rates of severe consequences including death.1 As the pandemic has evolved, rural communities have also been severely affected, in part due to their high-risk populations and limited health care infrastructure.2,3 Thus, both elderly persons of color and rural residents are vulnerable. The substantial risk for COVID-19 in these vulnerable populations can be partially explained by a higher prevalence of underlying health problems as well as other social determinants of health (SDoH).4-8

Home health agencies and nursing homes provide essential post-acute care to elderly vulnerable populations. When HHAs and NHs provide best practices in infection prevention and control, they can reduce the risk of nosocomial infections and related hospitalizations, therefore reducing overcrowding in hospitals.

We have previously shown that IPC programs in many HHAs and NHs are suboptimal (R01NR016865 and R01 NR013687), and that having recommended IPC infrastructure and policies in place is associated with better patient outcomes.9-15 Furthermore, with the pandemic, care transitions between hospitals and both HHAs and NHs have been disrupted, with patients not receiving necessary hospital and post-acute care for non-COVID-19 diagnoses.16

However, we do not know if the disruptions in care have had a differential impact on vulnerable patients who historically have limited access to high-quality care. Nor do we know how HHAs and NHs have responded to the pandemic, including how their IPC programs have changed and the impact of these changes on patient outcomes.

Study Goals

Building upon our previous work and guided by the NIMHD framework,17 we will conduct qualitative interviews and a national survey of HHAs and NHs. We will sample from the core HHAs and NHs from our pre-COVID-19 surveys and augment with new facilities as needed. We will link our prior surveys and the new 2022 survey to examine changes in IPC programs and determine if these changes differed in facilities predominately serving vulnerable populations.

Next, we will use longitudinal (2013 to 2022) CMS data to characterize how select urgent and elective hospital admissions and discharge dispositions to HHAs and NHs changed with COVID-19 and whether these changes differed for vulnerable populations. Finally, we will link our pre-COVID surveys and the 2022 survey with longitudinal CMS data to model the health outcomes (i.e., COVID-19 cases, infections, rehospitalizations, and mortality) of elderly Medicare beneficiaries, controlling for the local COVID-19 environment.

Study Aims

  1. Describe how HHA and NH IPC programs have changed in response to the COVID-19 pandemic across the nation, and examine if these changes vary for facilities serving a large proportion of vulnerable populations.
  2. Characterize how COVID-19 disrupted hospital admissions and subsequent discharges to HHAs and NHs, and determine if the disruptions disproportionately affected vulnerable populations.
  3. Quantify the impact of COVID-19 on inpatient, HHA and NH health outcomes and the effectiveness of IPC programs in HHAs and NHs in reducing the impact of the pandemic in vulnerable and non-vulnerable elderly populations.


  1. Oppel RA et al. The Fullest Look Yet at the Racial Inequity of Coronavirus. New York Times. July 5, 2020.
  2. Rural Communities. Centers for Disease Control and Prevention. Last updated July 7, 2021.
  3. COVID-19 Stats: COVID-19 Incidence, by Urban-Rural Classification — United States, January 22–October 31, 2020. MMWR. 2020;69:1753. 
  4. Graham G. Racial and Ethnic Differences in Acute Coronary Syndrome and Myocardial Infarction Within the United States: From Demographics to Outcomes. Clin Cardiol. 2016;39(5):299-306. 
  5. Rodriguez-Gutierrez R et al. Racial and Ethnic Differences in 30-Day Hospital Readmissions Among US Adults With Diabetes. JAMA Network Open. 2019;2(10):e1913249.
  6. Gu A et al. Racial and Ethnic Differences in Antihypertensive Medication Use and Blood Pressure Control Among US Adults With Hypertension: The National Health and Nutrition Examination Survey, 2003 to 2012. Circ Cardiovasc Qual Outcomes. 2017;10(1).
  7. Social Determinants of Health: Know What Affects Health, Centers for Disease Control and Prevention. Updated August 13, 2020. Accessed November 13, 2020.
  8. Tai DBG et al. The Disproportionate Impact of COVID-19 on Racial and Ethnic Minorities in the United States. Clin Infect Dis. 2020 Jun 20:ciaa815.
  9. Stone PW et al. Nursing Home Infection Control Program Characteristics, CMS Citations, and Implementation of Antibiotic Stewardship Policies: A National Study. Inquiry. 2018;55:46958018778636.
  10. Agarwal M et al. Changes in US Nursing Home Infection Prevention and Control Programs from 2014 to 2018. J Am Med Dir Assoc. 2020;21(1):97-103. 
  11. Shang J et al. Infection Prevention and Control Policies and Staffing: A National Survey of Home Health Agencies in the United States. Infec Control Hosp Epidemiol. 2020;41(S1):S301.
  12. Chastain AM. Infection Prevention in Home Health Care: A National Study, Lessons Learned. Presented at HCA-NY Quality & Technology Symposium, November 13, 2019, Suffern, NY.
  13. Pogorzelska-Maziarz M, Chastain AM. Changing Landscape of IPC and Quality Improvement in Home Healthcare. Presented at 46th Annual APIC Conference, June 12, 2019, Philadelphia.
  14. Shang J et al. A Mixed-Methods Study of Health Information Technology in U.S. Home Health Agencies. Presented at 18th International Conference on Communication in Healthcare, September 9, 2020, virtual.
  15. Stone PW et al. Integration of Palliative Care and Infection Management at the End of Life in U.S. Nursing Homes. J Pain Symptom Manage. 2019;58(3):408-416.e401.
  16. Birkmeyer JD et al. The Impact Of The COVID-19 Pandemic On Hospital Admissions In The United States. Health Aff. (Millwood). 2020;39(11):2010-2017.
  17. Alvidrez J et al. The National Institute on Minority Health and Health Disparities Research Framework. Am J Public Health. 2019;109(S1):S16-s20.
Columbia School of Nursing
RAND Corporation