ABSTRACT
Background: The COVID-19 pandemic has profoundly affected skilled nursing facilities (SNFs). Our objective was to understand SNF staff perspectives on the unintended effects of isolation protocols and suggestions for future outbreaks. Methods: Qualitative analysis of semi-structured interviews from caregivers (n=17) from seven SNFs. Interviews focused on the impact of isolation on caregiving, SNF residents' cognitive and physical health, and best practices. Virtual interviews were recorded and transcribed. Qualitative framework analysis using a modified care preparedness model was used to identify themes related to the impact of COVID-19 isolation. Results: Caregivers observed withdrawal, irritability, depression, and lack of motivation among residents. Staff noted increased confusion in cognitively impaired residents and observed that cognitively intact residents displayed more symptoms of depression. Most participants related residents' emotional changes to lack of family visitation and loneliness. SNFs connected residents with families using technology and modified visits. Staff also developed creative programming to engage residents while maintaining physical distancing, such as a mobile ice cream cart. Challenges included less hands-on caregiving due to fear of COVID-19 transmission, staff turnover, personal protective equipment (PPE) shortages, and COVID-19 outbreaks. Many participants also noted inadequate administrative support and hoped for more aid and flexibility. Staff reported that increasing family communication and physical and psychological therapy interventions worked well for residents. Staff who perceived early initiation of infection control measures (e.g., closing admittance, frequent testing, maintaining PPE supplies) and/or had highly involved administrators (e.g., open door policy, visible on the floor) felt better equipped to care for residents. Most also noted strong coworker camaraderie. Staff recommendations for quantifying the effects of isolation included tracking physical and cognitive measures longitudinally to identify changes in resident status. For future epidemics, staff emphasized the need for communication and preparation with ample supplies and staff. Conclusions: This analysis includes suggestions for preparation, communication, enforcement of infection control policies for future outbreaks.
ABSTRACT
BACKGROUND: Skilled nursing facility (SNF) patients are medically complex with multiple, advanced chronic conditions. They are dependent on caregivers and have experienced recent acute illnesses. Among SNF patients, the rate of mortality or acute care use is over 50% within 90 days of discharge, yet these patients and their caregivers often do not receive the quality of transitional care that prepares them to manage serious illnesses at home. METHODS: The study will test the efficacy of Connect-Home, a successfully piloted transitional care intervention targeting seriously ill SNF patients discharged to home and their caregivers. The study setting will be SNFs in North Carolina, USA, and, following discharge, in patients' home. Using a stepped wedge cluster randomized trial design, six SNFs will transition at randomly assigned intervals from standard discharge planning to the Connect-Home intervention. The SNFs will contribute data for patients (N = 360) and their caregivers (N = 360), during both the standard discharge planning and Connect-Home time periods. Connect-Home is a two-step intervention: (a) SNF staff create an individualized Transition Plan of Care to manage the patient's illness at home; and (b) a Connect-Home Activation RN visits the patient's home to implement the written Transition Plan of Care. A key feature of the trial includes training of the SNF and Home Care Agency staff to complete the transition plan rather than using study interventionists. The primary outcomes will be patient preparedness for discharge and caregiver preparedness for caregiving role. With the proposed sample and using a two-sided test at the 5% significance level, we have 80% power to detect a 18% increase in the patient's preparedness for discharge score. We will employ linear mixed models to compare observations between intervention and usual care periods to assess primary outcomes. Secondary outcomes include (a) patients' quality of life, functional status, and days of acute care use and (b) caregivers' burden and distress. DISCUSSION: Study results will determine the efficacy of an intervention using existing clinical staff to (a) improve transitional care for seriously ill SNF patients and their caregivers, (b) prevent avoidable days of acute care use in a population with persistent risks from chronic conditions, and (c) advance the science of transitional care within end-of-life and palliative care trajectories of SNF patients and their caregivers. While this study protocol was being implemented, the COVID-19 pandemic occurred and this protocol was revised to mitigate COVID-related risks of patients, their caregivers, SNF staff, and the study team. Thus, this paper includes additional material describing these modifications. TRIAL REGISTRATION: ClinicalTrials.gov NCT03810534 . Registered on January 18, 2019.