Hospice Aide Visits Among Nursing Home Residents During the Early Months of the COVID-19 Pandemic

Objective Hospice aides are vital in delivering care to patients and family members at the end-of-life. The COVID-19 pandemic resulted in disruptions in hospice care delivery, especially in long-term care settings. We aim to provide a description of hospice aide visits among nursing home residents enrolled in hospice during the first nine months of 2020, as compared with the same months in 2019. Design Observational cohort study Setting and Participants 153,109 and 152,077 long-stay nursing home residents enrolled in hospice in 2019 and 2020, respectively. Methods On a monthly basis, we reported estimated probabilities of not having visits from hospice aides, and adjusted visit minutes among those who had hospice aide visits for the 2019 and 2020 cohort, respectively. The regression models accounted for resident sociodemographic and clinical characteristics and nursing home fixed effects. The analyses were conducted at the national- and state- level, separately. Results More than half of residents did not have any visits from hospice aides in 2020 from April and onward. Among residents who had hospice aide visits, the 2020 cohort had reduced visits in March and onward, with the greatest difference being 155 minutes less in April [95% CI: -163.4, -146.5]. State-level analyses suggested that multiple factors besides community spread or state policies might contribute to the reduced presence of hospice aides. Conclusions and Implications Our findings highlight the toll of the pandemic on hospice care delivery in nursing homes and the need for hospice care to be better incorporated into emergency preparedness planning.

Antimicrobial Prescribing in the Telehealth Setting: Framework for stewardship during a period of rapid acceleration within primary care.

Antibiotic resistance is a global public health threat. The use of telehealth in primary care presents unique barriers to antimicrobial stewardship, including limited physical examination and changes to the patient-provider relationship. Since the COVID-19 pandemic, there is a need to identify novel antimicrobial stewardship strategies with an explosion in the use of telehealth within primary care. Our review proposes a tailored, sustainable approach to antimicrobial prescribing in the telehealth setting based on the CDC's Core Elements of Outpatient Antibiotic Stewardship: commitment, action for policy and practice; tracking and reporting; and education and expertise. The rapid growth of telehealth for all types of primary care visits (not just antibiotic use) is outpacing knowledge associated with strategies for antimicrobial stewardship. Improving antibiotic use within primary care settings is critical as telehealth will remain a priority whether the COVID-19 pandemic recedes, particularly within patient populations with limited access to healthcare.

Risk factors for Veteran food insecurity: findings from a National US Department of Veterans Affairs Food Insecurity Screener.

OBJECTIVE: Food insecurity is associated with numerous adverse health outcomes. The US Veterans Health Administration (VHA) began universal food insecurity screening in 2017. This study examined prevalence and correlates of food insecurity among Veterans screened. DESIGN: Retrospective cross-sectional study using VHA administrative data. Multivariable logistic regression models were estimated to identify sociodemographic and medical characteristics associated with a positive food insecurity screen. SETTING: All US Veterans Administration (VA) medical centres (n 161). PARTICIPANTS: All Veterans were screened for food insecurity since screening initiation (July 2017-December 2018). RESULTS: Of 3 304 702 Veterans screened for food insecurity, 44 298 were positive on their initial screen (1·3 % of men; 2·0 % of women). Food insecurity was associated with identifying as non-Hispanic Black or Hispanic. Veterans who were non-married/partnered, low-income Veterans without VA disability-related compensation and those with housing instability had higher odds of food insecurity, as did Veterans with a BMI < 18·5, diabetes, depression and post-traumatic stress disorder. Prior military sexual trauma (MST) was associated with food insecurity among both men and women. Women screening positive, however, were eight times more likely than men to have experienced MST (48·9 % v. 5·9 %). CONCLUSIONS: Food insecurity was associated with medical and trauma-related comorbidities as well as unmet social needs including housing instability. Additionally, Veterans of colour and women were at higher risk for food insecurity. Findings can inform development of tailored interventions to address food insecurity such as more frequent screening among high-risk populations, onsite support applying for federal food assistance programs and formal partnerships with community-based resources.

Disaster Vulnerability in Long-Term Care: The Importance of Social and Organizational Connections

The risks to older adults in nursing homes (NHs) and assisted living communities (ALCs) exposed to disasters are evident in prior research. However, little research has been conducted to understand the factors related to facilities’ vulnerability. This research examined NH and ALC experiences during Hurricane Irma in 2017. Qualitative interviews were conducted with representatives of facilities (N=100), transcripts were analyzed using Atlas.ti version 8. Team members met to reach consensus on codes and major themes and subthemes, which they analyzed using a conceptual model designed to identify factors related to the disaster vulnerability in long-term care (LTC). We found physical factors (e.g. location, physical characteristics) are important, but physical strength is not enough. Multiple social/organizational factors are critical. Results indicate managing a major disaster and protecting LTC residents involve social and organizational connections across a range of groups from staff and family members to emergency mangers and neighborhood associations.

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.

The Difference LTC Corporate Ownership Makes in Collaborations With Emergency Operation Centers During Disasters

Collaboration between nursing homes (NHs) and assisted living communities (ALCs) with state and local entities (e.g., emergency operation centers (EOCs)) is critical during a disaster. The corporate structure of NHs and ALCs can make a difference in their ability to collaborate with these entities during a disaster. This mixed-method study examines differences in satisfaction with collaboration with state and local entities during Hurricane Irma in Florida in 2017 between corporate-owned NHs (N=24), larger (25+ beds) ALCs (N=38) and smaller ALCs (N=30). We also explore collaboration in Florida NHs (N=35) and ALCs (N=123) specific to COVID19. Scaled 1-5 survey data results indicate that small ALCs are the least satisfied (M=2.90) with EOC collaboration, compared to NHs (M=3.04) and larger ALCs (M=3.33) during Irma. Smaller ALCs were more dissatisfied with COVID19 mandates compared to larger ALCs and NHs. Ways to improve collaboration during a disaster, especially for smaller ALCs, will be discussed.

Infection Control Citations in Nursing Homes: Compliance and Geographic Variability.

OBJECTIVES: To report the initial compliance with new infection control regulations and geographic disparities in nursing homes (NHs) in the United States. DESIGN: Retrospective cohort study from November 27, 2017 to November 27, 2019. SETTING AND PARTICIPANTS: In total, 14,894 NHs in the continental United States comprising 26,201 inspections and 176,841 deficiencies. METHODS: We measured the cumulative incidence of receiving F880: Infection Prevention and Control deficiencies, geographic variability of F880 citations across the United States, and the scope and severity of the infection control deficiencies. RESULTS: A total of 6164 NHs (41%) in the continental United States received 1 deficiency for F880, and 2300 NHs (15%) were cited more than once during the 2-year period. Geographic variation was evident for F880 deficiencies, ranging from 20% of NHs in North Carolina to 79% of NHs in West Virginia. Between 0% (Vermont) and 33% (Michigan) of states' NHs were cited multiple times over 2 years. Facilities receiving 2 or more F880 deficiencies were more reliant on Medicaid, for-profit, and served more acute residents. Infection Prevention and Control deficiencies were of similar severity but of greater scope in NHs that were cited multiple times. CONCLUSIONS AND IMPLICATIONS: As the coronavirus disease 2019 pandemic challenges hospitals with an increased surge of patients from the community, NHs will be asked to accept convalescing patients who were previously infected with the virus. NHs will need to rely on infection control practices to mitigate the effects of the virus in their facilities. Particular attention to NHs that have fared poorly with repeat infection control practices deficiencies might be a good first step to improving care overall and preventing downstream morbidity and mortality among the highest-risk patients.

Association Between Exposure to Hurricane Irma and Mortality and Hospitalization in Florida Nursing Home Residents.

Importance: Nursing home residents are at heightened risk for morbidity and mortality following an exposure to a disaster such as a hurricane or the COVID19 pandemic. Previous research has shown that nursing home resident mortality related to disasters is frequently underreported. There is a need to better understand the consequences of disasters on nursing home residents and to differentiate vulnerability based on patient characteristics. Objective: To evaluate mortality and morbidity associated with exposure to Hurricane Irma, a Category 4 storm that made landfall on September 10, 2017, in Cudjoe Key, Florida, among short-stay (<90-day residence) and long-stay (≥90-day residence) residents of nursing homes. Design, Setting, and Participants: Cohort study of Florida nursing home residents comparing residents exposed to Hurricane Irma in September 2017 to a control group of residents residing at the same nursing homes over the same time period in calendar year 2015. Data were analyzed from August 28, 2019, to July 22, 2020. Exposure: Residents who experienced Hurricane Irma were considered exposed; those who did not were considered unexposed. Main Outcome and Measures: Outcome variables included 30-day and 90-day mortality and first hospitalizations after the storm in both the short term and the long term. Results: A total of 61 564 residents who were present in 640 Florida nursing home facilities on September 7, 2017, were identified. A comparison cohort of 61 813 residents was evaluated in 2015. Both cohorts were mostly female (2015, 68%; 2017, 67%), mostly White (2015, 79%; 2017, 78%), and approximately 40% of the residents in each group were over the age of 85 years. Compared with the control group in 2015, an additional 262 more nursing home deaths were identified at 30 days and 433 more deaths at 90 days. The odds of a first hospitalization for those exposed (vs nonexposed) were 1.09 (95% CI, 1.05-1.13) within the first 30 days after the storm and 1.05 (95% CI, 1.02-1.08) at 90 days; the odds of mortality were 1.12 (95% CI, 1.05-1.18) at 30 days and 1.07 (95% CI, 1.03-1.11) at 90 days. Among long-stay residents, the odds of mortality for those exposed to Hurricane Irma were 1.18 (95% CI, 1.08-1.29) times those unexposed and the odds of hospitalization were 1.11 (95% CI, 1.04-1.18) times those unexposed in the post 30-day period. Conclusions and Relevance: The findings of this study suggest that nursing home residents are at considerable risk to the consequences of disasters. These risks may be underreported by state and federal agencies. Long-stay residents, those who have resided in a nursing home for 90 days or more, may be most vulnerable to the consequences of hurricane disasters.