How to use the dashboard

On the dashboard (Figure 1), there is a large map with 48 states in the middle, which users can zoom in on or pan. Below the main map, there are five highlighted states and territories, including Alaska, Hawaii, Puerto Rico and Virgin Island, Guam and Northern Mariana, and American Samoa, which have fixed sizes. On the map, colors represent the number of policies in each state, with yellow indicating the fewest and blue indicating the most. Circles indicate COVID-19 burden, with largest representing severe COVID-19 burden and the smallest representing no cases or deaths. Green circles indicate no cases or deaths, while red circles signify at least 1 case or death (see published manuscript for detailed information). Additionally, for nursing home COVID-19 burden, gray circles indicate that there is no available data at that time. Users are also encouraged to hover over the circles in the map to view detailed policy counts for each policy subtype in each state.

The dashboard was designed to be interactive for users. On the top left corner (Area 1 on Figure 1), users can select dates or play an animation using the buttons. The animation allows for viewing policy trends during the pandemic. Users are also able to select different healthcare settings in Area 2, allowing users to view policies enacted for specific healthcare settings. In the Area 3, users are able to select one type of COVID-19 burden. It is strongly recommended that users select nursing home COVID-19 burden if focusing on nursing home policies. In the Area 4, users can select each policy type and subtype, which will result in a change in map view.

Figure 1. Overview of the COVID-19 PAC policy dashboard  

COVID-19 PAC policy dataset documentation

Policy Identification

For this dataset, the Council of State Government’s (CSG) website, “2020-2021 State Executive Orders – COVID-19 Resources for State Leaders,”¹ was the initial source for identifying state/territory-based COVID-19 policies since the state/territory executive orders were already consolidated and classified. Firstly, PAC-related policies were identified under the CSG classification of “Assisted Living/Nursing Home/Long-Term Care Facilities”. Building on the work of others,² these policies were then organized in our dataset under one of five broad categories: 1) preventing virus transmission, 2) expanding facility/agency capacity, 3) relaxing administrative requirements, 4) reporting COVID-19 data, and 5) admission/discharge policies. These policies were then further divided into smaller more specific subcategories (n = 38) guided by the policy intention.

A subsequent Google search was conducted, revealing limitations of the CSG website. The CSG website did not identify COVID-19 policies aimed at healthcare settings in general, as well as extensions and line-by-line modifications of already-identified policies. A detailed internet search was conducted for each U.S. state and territory (50 U.S. states, District of Columbia, Puerto Rico, U.S. Virgin Islands, Guam, Northern Mariana Islands and American Samoa). Policies collected previously from the CSG website were verified for accuracy and end dates of policies were added, considering any extensions. New policies that were identified during the search, as well as modifications to previously-collected policies, were added to the dataset. We also identified policies aimed generally at healthcare settings (not naming nursing homes or home healthcare agencies specifically) that fit our predetermined categories and subcategories. Searches were conducted in the order of a state/territory’s FIPS code using terms such as “[state/territory name]” in combination with “COVID-19 policies”, “executive orders”, “public health orders” and “governor office news briefings”. Through these searches, we learned that individual states/territories have their own methods of organizing and archiving COVID-19-specific policies; some states/territories had very organized archives by date and are searchable by topic, while others removed any policies relating to a previous gubernatorial administration if an election had occurred. If policies were not archived on the official government site, we attempted to locate the policies in place during a previous administration on other websites or on the internet archive (via Wayback Machine).  

Policy Categorization

Executive Orders and Public Health Orders provided specific information regarding which policies were enacted and what time period they were effect. Government Office News Briefings were useful in identifying policies for states that did not archive their orders; the briefings also provided additional context to specific political actions and their intended outcomes. Collectively, this information was used to create a dataset of policies addressing COVID-19 mitigation in post-acute care settings that takes into consideration policies aimed at healthcare settings in general and includes the actual date in which a policy is no longer in effect.

For each policy, the following data was collected in Excel³: start date, end date, policy type, policy sub-type, application to healthcare setting(s), source, website link, and comments. The start dates of each policy were stated in executive orders and public health orders or when a new policy was enacted to replace a prior policy. The end dates of specific policies were listed based on their original end date. Policy extensions were added as a different row and highlighted to differentiate them from the original policy. This process followed until a final expiration date occurred due to either non-renewal of the policy or replacement by a new policy. Modifications were treated as new policies (new Excel row) if the wording of the policy changed appreciably. Furthermore, if a policy was allowed to expire and was not included in an extension within 2 weeks (allowing for any backdating), any subsequent extension was added as a new row and was treated as a new policy to account for the time gap. In the final dataset, the extensions were collapsed into the original policy, date ranges for each extension were added in a comment, and the original policy received a new end date. The application of the policy was determined as either “General”, “Nursing Homes”, “Home Health” or “Both Nursing Homes & Home Health”. Policies that address healthcare settings as essential businesses, but do not explicitly mention nursing homes or home healthcare agencies were listed as “General”. Policies that specifically address nursing homes were listed as “Nursing Homes” and policies that specifically address home healthcare agencies were listed as “Home Health”. Policies that address both nursing homes and home healthcare agencies were categorized as “Both Nursing Homes & Home Health”. One team member categorized and another team member confirmed the categorization; if categorization differed, discussion with other team members occurred until consensus was reached. The source was listed as the title of the specific policy or news briefing being referenced; a link to the source was also listed. Comments included a brief description of the specific policy that supports its categorization under a specific policy type and subtype. Overall, 1,400 policies were included in the final policy dataset (Figure 2).

Figure 2. Categorization of COVID-19 mitigation policies by healthcare setting