International COVID-19 palliative care guidance for nursing homes leaves key themes unaddressed

Background: COVID-19 mortality disproportionally affects nursing homes, creating enormous pressures to deliver high-quality end-of-life care. Comprehensive palliative care should be an explicit part of both national and global COVID- 19 response plans. Aims: To identify, review and compare national and international COVID-19 guidance for nursing homes concerning palliative care, issued by government bodies and professional associations in low-, middle-, and high-income countries. Methods: We performed a directed documentary and content analysis of newly developed or adapted COVID-19 guidance documents from across the world. Documents were collected via expert consultation and independently screened against prespecified eligibility criteria. We applied thematic analysis and narrative synthesis techniques. Results: We identified 21 eligible documents covering both nursing homes and palliative care;from the World Health Organisation (n = 3), and 8 individual countries: United States (n = 6), Canada (n = 1), the Netherlands (n = 2), Ireland (n = 1), United Kingdom (n = 3), Switzerland (n = 3), New Zealand (n = 1), Belgium (n = 1). International documents focused primarily on infection prevention and control, including only a few sentences on palliative-care-related topics. Palliative care themes most frequently mentioned across documents were end-of-life visits, advance care planning documentation, and clinical decision- making towards the end of life (focusing on hospital transfers). Conclusion: There is a dearth of comprehensive international COVID-19 guidance on palliative care for nursing homes. Most have a limited focus both regarding breadth of topics and recommendations made. Key aspects of palliative care, that is, symptom management, staff education and support, referral to specialist services or hospice, and family support, need greater attention in future guidelines.

Clinical outreach to older adults in the community during COVID: A description of unmet health-related needs

Background: Shelter-in-place orders and service disruptions due to the COVID-19 pandemic created a risk of unmet healthrelated needs among older adults and those with disabilities, such as the ability to obtain medications or receive healthcare. To mitigate these risks, primary care clinics performed outreach calls to identify and address unmet needs. We examined the association with unmet needs and healthcare utilization. Methods: Four primary care clinics completed outreach calls, each with differing with at-risk populations: home-based, safety-net adult, academic geriatrics and safety-net HIV. Examined needs included medication refills, medical supplies, food insecurity, and telehealth capability. Utilization included urgent care, ER visits and hospitalizations, measured 3 months prior and 3 months after the call. We also report on COVID diagnosis and death in the 3 months after the outreach call. We show descriptive statistics and will use Poisson regression models to examine associations. Results: Thus far, we analyzed 165 of 500 total outreach calls. Mean age was 84.1, with 18% of patients >95, 71% female, 40% white, 33% Asian, 12% Black, and 15% Latinx. Forty five percent had both Medicare and Medi-Cal, 33% had Medicare and supplemental insurance, and 17% had Medicare only. Comorbid conditions were frequent: 69% had hypertension, 37% had dementia, 30% had depression. Unmet needs and care utilization are presented in Table 1. Conclusion: The pandemic has disrupted health and social care among older adults. Evaluation of associations between unmet needs and use of urgent healthcare services can inform future planning during crises to better meet the needs of community dwelling older adults.