The COVID-19 pandemic has had a significant impact on the United States (US), resulting in 6,176,518 hospitalizations and 1,132,507 deaths as of June 3, 2023.1 Older adults and individuals with comorbidities, such as cardiovascular disease, chronic respiratory disease, and/or chronic kidney disease, experienced worse outcomes and a higher COVID-19 mortality rate compared to populations without comorbidities.2 It is important to note that as individuals age, the severity of chronic conditions worsens, and functional disabilities progress. Consequently, many individuals become unable to perform daily self-care tasks, necessitating assistance from others. As they require more assistance in managing their medical conditions and performing self-care tasks, some seek long-term care (LTC) in different settings depending on personal preference, affordability, and care need. LTC can be provided by informal, unpaid caregivers like family members or professional hired caregivers like home health aides or Registered Nurses. LTC is designed to meet the health care and social needs of individuals who typically have one or more ongoing health conditions or have a need for assistance with daily living tasks like toileting, bathing, and transferring, among others.

For some older adults, home care is appropriate, while others transition to nursing homes or other types of LTC facilities to meet their health and personal care needs.3 Given the continuing growth of the aging population, ensuring high-quality care and providing diverse options for care modalities are critical concerns for individuals, families, caregivers, policymakers, and governments.

In general, there are two different nursing home care models in the US: Green Houses (GHs) and traditional nursing homes (NHs). These facilities differ in terms of physical structure, size, and care approach. GH homes, designed to resemble houses or apartments, create a home-like setting for residents, promoting a sense of belonging and community participation.4,5 The GH model emphasizes a more intimate environment, with small households and private rooms for residents, home-like furnishings and amenities, communal space, and outdoor space where residents can socialize and engage in activities. GHs are typically smaller in scale, housing 10–12 residents on only one or more levels. This allows caregivers to provide additional personalized care to residents while also fostering closer bonds between residents and caregivers.4,5 In contrast, traditional NHs in the US have an average of 108 beds, accommodating a larger number of residents.4,6 They are often housed in larger, multistory buildings with long corridors and a centralized nursing station, resembling the layout of traditional medical institutions.

Although traditional NHs and GHs provide the same level of skilled nursing care and related therapies, the care approach differs between the two. The GH care model empowers caregivers called Shahbazim7,8 who provide direct resident care including cleaning, laundry, meal preparation, staff scheduling, and other activities.8 The GH care model is person-centered and caregivers are cross-trained to provide various types of care to residents, including personal assistance, nursing care, and household tasks.8,9 This care model promotes residents’ independence and autonomy. The higher staff-to-resident ratio in GHs allows for meaningful relationships between residents and caregivers to be formed.9,8 These relationships extend to interactions among residents, family, and friends, creating a sense of community in GHs.

In contrast, traditional NHs often follow a more task-oriented approach to care. With lower staff-to-resident ratios, it may be challenging to provide individualized attention to residents, leaving less room for intimate personal relationships between caregivers and care recipients. Caregivers in traditional NHs typically specialize in specific tasks such as nursing and personal care. Others provide facility cleaning and meal preparation. This increases the number of people entering the nursing facilities with the focus being primarily on meeting residents' medical and basic care needs rather than fostering relationships as in the GH.8

Based on the significant differences between GHs and traditional NHs, one would expect variations in residents’ health outcomes. The COVID-19 pandemic may actuate more differences between the two models. COVID-19 case and mortality data collected by the Centers for Medicare & Medicaid Services (CMS) offer the opportunity to examine the impact of the nursing home care model (GHs vs. traditional NHs) on COVID-19 outcomes.

Previous GH studies primarily focus on NH characteristics, quality ratings, staffing levels, access to personal protective equipment (PPE), and individual and structural risk factors associated with COVID-19 case and mortality rates.10, 11, 12, 13, 14 However, only two studies have quantified the differences in case and mortality rates between GHs and traditional NHs. Zimmerman and colleagues15 reported lower case and mortality rates in GHs compared to NHs, but their study was limited to a six-month period and preceded vaccine interventions. Another study by Young and colleagues16 also found lower COVID-19 incidence and mortality rates in GHs compared to traditional NHs, but their study was limited to New York State and did not explore multivariate models.

To bridge these gaps, this study aims to better understand the difference in COVID-19 case and mortality rates in GHs and traditional NHs across the US utilizing multivariate models. We hypothesize that residents in GHs will have lower case and mortality rates compared to those in traditional NHs.