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As the post-pandemic world reflects on lessons learned from COVID-19, an important stream of scholarship is examining how public policies and organizational management affect outcomes during periods of crisis. In “Steering, Rowing, and Bailing Water: The Role of Government Regulation and Ownership in COVID-19 Outcomes in Nursing Homes,” forthcoming this summer in International Public Management Journal, SPA Professors Anna Amirkhanyan and Kenneth Meier, along with SPA PhD candidate William G. Prince and Miyeon Song (Chung-Ang University), explore these relationships in the context of nursing homes.

Their study, using a large-N quantitative analysis of U.S. nursing homes, considers the effects of government regulation, ownership, and several distinct management strategies on facilities’ capacity to curb the threats posed by the pandemic. Their findings stress the importance of transparency and efforts to mitigate informational asymmetry between nursing homes, their clients, and the parties (Medicare/Medicaid/private insurance providers) who pay for their care. 

“It seems that during a major global public health crisis, vulnerable clients, on average, fare better in government and nonprofit, rather than for-profit, facilities,” said Amirkhanyan. “Our study shows that during the first year of the pandemic, nursing home residents were significantly less likely to get sick and less likely to die of COVID-19 in public and nonprofit nursing homes.”

The paper relates this sector-related performance boost to the nature of public vs. private ownership. Ownership type, tied to structure, mission and resources, determines the level of institutional pressure to incentivize cost savings over quality, or vice versa. In addition, public and nonprofit ownership may strengthen accountability pressures and increase access to local government or community resources or support. 

“Accountability matters,” said Amirkhanyan. “Nonprofit boards and stakeholders may have provided additional oversight mechanisms to encourage greater focus on resident safety and welfare. Interestingly, however, our interviews conducted with nursing home administrators suggest that they perceive no major sector differences.”

The authors also discovered an important link between more restrictive state regulations––those broadly targeting institutions and individual behavior via school and business closures and stay-at-home orders, etc.––and COVID-19 cases and deaths in long-term care facilities, strengthening the evidence for such public health interventions.

“COVID-19 restrictions imposed by states aimed at containing the spread of infection in the community, including masking, social distancing, and limiting public gatherings, are associated with fewer COVID-19 cases among nursing home residents,” said Amirkhanyan. “These policies likely result in less exposure to nursing home staff and administrators, more reliable levels of staffing, consistent use of specialized equipment, fewer visitations, and more resources dedicated to core functions.”

The study’s findings also suggest that higher staffing levels helped certain facilities limit resident COVID-19 cases and deaths. As the virus spread, and the need for staff care and expertise grew, so did the associated risks and stress for workers, leading to retention problems.

“Staffing is an essential component of nursing homes' ability to provide adequate care during both normal operations and crises,” said Prince. “Facility administrators reported extreme difficulty in keeping experienced nursing staff at the start of the pandemic. For many, the personal costs of continuing to work were too high, leaving many facilities understaffed. Our findings emphasize that adequate support and incentives to skilled workers may have life-saving implications in the next crisis.”

However, the management strategies under investigation showed only modest effects on COVID-19 outcomes.

“Facilities with lower levels of COVID-19 cases tended to be managed by those who shared power and carefully managed their staff by soliciting feedback, resolving staff conflicts, and delegating decision-making,” noted Amirkhanyan. “This likely means that managers who effectively delegate day-to-day operating problems to capable staff can better focus on responding to environmental threats. Additionally, COVID-19 deaths were lower in facilities where managers expressed more resistance towards government regulation. This potentially suggests that, despite breeding managerial dissatisfaction, stricter public policies can effectively curb the influences of the pandemic.”

Prince, who expects to earn his doctoral degree in public administration and policy, appreciated the chance to consider these pressing public management questions with such decorated academics.

"I consider myself incredibly fortunate to have the opportunity to work alongside Anna and Ken,” he said. “Not only are they talented researchers, but they are dedicated to sharing their skills and insights with their students. This experience has been invaluable to me as I prepare for a career as a scholar."