Excess Mortality Among Assisted Living Residents With Dementia During the COVID-19 Pandemic.

OBJECTIVE: To evaluate whether assisted living (AL) residents with Alzheimer's disease and related dementias (ADRD) experienced a greater rate of excess all-cause mortality during the first several months of the COVID-19 pandemic compared to residents without ADRD, and to compare excess all-cause mortality rates in memory care vs general AL among residents with ADRD. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: Two cohorts of AL residents enrolled in Medicare Fee-For-Service who resided in 9-digit ZIP codes corresponding to US AL communities of ≥25 beds during calendar year 2019 or 2020. METHOD: By linking Medicare claims and Vital Statistics data, we examined the weekly excess all-cause mortality rate, comparing the rate from March 12, 2020, to December 31, 2020, to the rate from January 1, 2019, to March 11, 2020. We adjusted for demographics, chronic conditions, AL community size, and county fixed effects. RESULTS: Of the 286,350 residents in 2019 and the 273,601 in 2020 identified in these cohorts, approximately 31% had a diagnosis of ADRD. Among all AL residents, the excess weekly mortality rate in 2020 was 49.1 per 100,000 overall during the pandemic. Compared to residents without ADRD, residents with ADRD experienced 33.4 more excess deaths per 100,000 during the pandemic. Among residents with ADRD, those who resided in memory care communities did not experience a statistically significant different mortality rate than residents who lived in general AL. CONCLUSIONS AND IMPLICATIONS: AL residents with ADRD were more vulnerable to mortality during COVID-19 than residents without ADRD, a finding similar to those reported in other settings such as nursing homes. Additionally, the study provides important new information that residents with ADRD in memory care communities may not have been at differential risk of COVID-19 mortality when compared to residents with ADRD in general AL, despite prior research suggesting they have more advanced dementia.

Dementia and COVID-19 infection control in assisted living in seven states.

BACKGROUND: Assisted living (AL) is the largest residential long-term care provider in the United States, including for persons with Alzheimer's disease and related dementias. Despite recognizing the challenge of infection control for persons with dementia, this study of 119 AL communities is the first to describe dementia-relevant COVID-19 infection control across different types of AL communities, and to discuss implications for the future. METHODS: From a parent study sampling frame of 244 AL communities across seven states, 119 administrators provided data about COVID-19 infection control practices and resident behaviors. Data were collected from July 2020 through September 2021. Communities were differentiated based on the presence of beds/units dedicated for persons living with dementia, as being either dementia-specific, mixed, or integrated. Data obtained from administrators related to feasibility of implementing seven infection control practices, and the extent to which residents themselves practiced infection prevention. Analyses compared practices across the three community types. RESULTS: Less than half of administrators found it feasible to close indoor common areas, all community types reported a challenge organizing group activities for safe distancing, and more than half of residents with dementia did not wear a face covering or maintain physical distance from other residents when indicated. Dementia-specific AL communities were generally the most challenged with infection control during COVID-19. CONCLUSION: All AL community types experienced infection control challenges, more so in dementia-specific communities (which generally provide care to persons with more advanced dementia and have fewer private beds). Results indicate a need to bolster infection prevention capacity when caring for this especially vulnerable population, and have implications for care in nursing homes as well.

COVID-19 Perspectives of Assisted Living and Health Care Providers in Seven States

Thirty percent of COVID-19 deaths in long-term care were in assisted living (AL), indicating challenges providing care. This project recruited AL administrators and medical and mental health care providers in a seven-state stratified random sample of 250 communities;it asked what was most challenging responding to COVID-19, what was successful, how to have better dealt with COVID-19, and how others could have helped. The most common challenge was addressing residents’ psychosocial needs, explained as “No contact - no hugging. The seniors require touch. It's something we've always done, and we can't do;we're required not to do it.” Successes included infection prevention, and in hindsight, administrators discussed staffing. Related to external entities, one commented, “Come in the building and see what we're doing. Don't sit behind a freaking screen and act like you know what we're doing.” Providers stressed patient access to care and social isolation. Implications will be discussed.

Assisted Living Administrators’ Mental and Emotional Health During the COVID-19 Pandemic

Little is known about assisted living (AL) administrators’ mental and emotional health, particularly during a global pandemic in which most of their residents are highly vulnerable to infection, hospitalization, and death. Considering that administrator turnover and burnout have been associated with negative outcomes such as decreased quality of resident care, low staff morale, and reduced financial solvency, this study examined how AL administrators described their mental and emotional state throughout the first year of the COVID-19 pandemic. Using thematic analysis, our team coded 18 qualitative interviews conducted from May-August 2021. The themes included declining physical health due to stress, feelings of inadequacy and self-doubt, and increased burnout. Many administrators described increased staffing challenges as directly impacting their daily stress levels. Some administrators described feeling guilty and doubting their interpretation or implementation of regulations, particularly in incidents that further distanced residents from peers and loved ones. A few administrators described their disposition or personality changing due to what they experienced during the pandemic. One administrator stated, “I'm not an anxiety person, but I feel anxiety about a lot of things. In fact, my doctor has talked to me about starting some medications to help with that.” Multiple administrators made comments such as, “I don't know that there could be a more stressful position than executive director of assisted living…the COVID pandemic reinforced that. This is rough.” Understanding AL administrators’ mental and emotional health during a public health crisis allows for understanding, supporting, and retaining critical leaders in long-term care communities.

Experiences of Rural and Urban Assisted Living Communities in Oregon During COVID-19 Pandemic

This study presents findings on the impact of the COVID-19 pandemic as reported by a representative sample of Oregon assisted living communities (AL) between December 2020 and March 2021. Of the 559 AL eligible to participate, 346 completed eleven questions related to their experiences since March 2020. These questions covered topics such as access to personal protective equipment (PPE) and accurate information, communication with and support from government agencies, ability to find staff and new residents, ability to address pandemic-related concerns of residents’ families and staff, use of virtual visits and telehealth for residents, and visitor restrictions. Response categories ranged from 0 (strongly disagree) to 4 (strongly agree) and we coded “agree” and “strongly agree” responses as having experienced that issue. Among responding AL, 42% were located in rural or frontier areas. We present three findings. First, most AL experienced adverse impact due to COVID-19, especially regarding issues likely to be outside of their control compared to those within their control. Second, while almost all urban-based AL reported that their residents used virtual communication technologies and tools for telemedicine/telehealth (96%) or virtual social visits (96%), rural AL were less likely to report so (90% and 92%, respectively). Finally, rural AL experienced significantly greater staffing difficulties (75%) compared to their urban counterparts (82%). In sum, while all AL would benefit from better regulatory guidance on policies and access to PPE, rural AL might especially benefit from additional, context-specific resources.

COVID-19 Response In U.S. Assisted Living Settings: Key Stakeholder Perspectives

Unique regulatory requirements and scope of services within assisted living (AL) pose distinctive challenges to COVID-19 response. To identify COVID-19 issues specific to AL, we recruited stakeholders with expertise in AL operations, policy, practice, and research (n=42) to participate in remote interviews between July and September 2020. Using thematic analysis, we derived the following overarching themes: 1) Policymakers lack an understanding of the AL context;2) AL administrators were left to coordinate guidelines with little support;3) AL organizations faced limited knowledge of and disparate access to resources;4) State-level regulatory requirements conflicted with COVID-19 guidelines resulting in confusion;and 5) AL operators struggled to balance public health priorities with promoting their residents’ wellbeing. To develop evidence-informed policy and avoid unintended consequences, AL operators, direct care workers, residents, and clinicians practicing in these settings should have opportunities to provide feedback through the policy development process, both state and national.

Seven-State Study of Assisted Living and Healthcare Providers’ Responses to COVID-19

COVID-19 has inordinately affected assisted living (AL), such that the proportion of fatalities to cases has been 21% in AL versus 2.5% for the general population. Understanding how AL administrators and medical and mental health providers have responded to COVID-19 can inform health care going forward. Using a seven-state stratified random sample of 250 communities, administrators were interviewed and providers completed questionnaires regarding COVID-19 practices. Preliminary data indicate that 79%, 44%, and 62% of administrators reported serving meals in rooms to segregate residents, using telemedicine, and providing extra pay for staff, respectively. Perceived use/effectiveness of practices differed based on dementia case-mix (e.g., face coverings, social distancing). Providers reported less access to patients (82%), more telehealth (63%), and less ability to provide care (43%). However, they uniformly reported high confidence in AL staff ability to prevent (94%) and respond to outbreaks (96%). Discussion will summarize points important for future care.

Excess Mortality Attributable to COVID-19 Among Assisted Living Residents

This study examines the excess mortality attributable to COVID-19 among a national cohort of assisted living (AL) residents. To do this, we compare the weekly rate of all-cause mortality during 1/1/20-8/11/20 with the same weeks in 2019 and calculated adjusted incidence rate ratios (IRRs) and 95% confidence intervals (CIs). All-cause mortality rates, nationally, were 14% higher in 2020 compared with 2019 (mean, 2.309 vs. 2.020, respectively, per 1000 residents per week;adjusted IRR, 1.169;95% CI 1.165-1.173). Among the 10 states with the highest community spread, the excess mortality attributable to COVID-19 was 24% higher, with 2.388 deaths per 1000 residents per week in 2020 during January-August vs 1.928 in 2019 (adjusted IRR, 1.241;95% CI 1.233-1.250). These results suggest that AL residents suffered excess mortality due to COVID-19.

"What Keeps Me Awake at Night": Assisted Living Administrator Responses to COVID-19.

BACKGROUND AND OBJECTIVES: Assisted living (AL) constitutes an important sector of residential long-term care, yet there has been limited research about the impact of the coronavirus disease 2019 (COVID-19) pandemic in this setting. This qualitative study sought to understand the impact of the early stages of the pandemic (February-August 2020) from AL administrators' perspectives. RESEARCH DESIGN AND METHODS: Semistructured phone interviews were conducted with 40 AL administrators in Oregon. A stratified sampling method emphasizing rurality, profit status, Medicaid acceptance, and memory care designation was used to maximize variation in perspectives. We asked 8 questions aimed at understanding the impact of the COVID-19 pandemic on their roles and AL residents and their families, as well as AL operations, such as staffing and resource procurement. Audio-recorded interviews were transcribed and analyzed using an iterative thematic analysis. RESULTS: We identified 3 themes that characterize AL administrators' response to COVID-19: emotion and burnout management, information management, and crisis management. Based on their experiences, administrators made suggestions for managing future crises. DISCUSSION AND IMPLICATIONS: Our findings demonstrate the slow-burning but devastating impact of the COVID-19 pandemic in AL communities similar to recent findings in nursing homes. Coupled with the limited resources, perceived external pressures, and the ongoing pandemic, many administrators were managing but not thriving in these domains. AL as a care setting, and the role of administrators, requires more scholarly and policy attention, especially regarding emergency preparedness and response.

Coronavirus Disease 2019 Regulatory Response in United States-Assisted Living Communities: Lessons Learned.

Coronavirus disease 2019 (COVID-19) has disproportionately affected residents, their families, staff, and operators of congregate care settings. Assisted living (AL) is a type of long-term care setting for older adults who need supportive care but not ongoing nursing care and emphasizes a social model of care provision. Because AL is a type of long-term care, it has at times been referenced along with nursing homes in discussions related to COVID-19 but not recognized for its different care practices that pose unique challenges related to COVID-19; in that manner, it has largely been left out of the COVID-19 discourse, although ~812,000 older adults live in AL. To identify COVID-19 issues specific to AL, stakeholders with expertise in AL operations, policy, practice, and research (n = 42) were recruited to participate in remote interviews between July and September 2020. Using a thematic analysis, we derived the following overarching themes: (1) Policymakers are disconnected from and lack an understanding of the AL context; (2) AL administrators were left to coordinate, communicate, and implement constantly changing guidelines with little support; (3) AL organizations faced limited knowledge of and disparate access to funding and resources; (4) state-level regulatory requirements conflicted with COVID-19 guidelines resulting in uncertainty about which rules to follow; and (5) AL operators struggled to balance public health priorities with promoting their residents' quality of life and well-being. To develop evidence-informed policy and avoid unintended consequences, AL operators, direct care workers, residents, and clinicians practicing in these settings should have opportunities to provide feedback throughout the policy development process, both state and national.