Long-Term Care Administrator Perspectives on an Essential Family Caregiver Policy.

OBJECTIVES: Characterize the implementation, benefits, and challenges of an Essential Family Caregiver (EFC) program, a novel policy implemented in long-term care (LTC) settings during the COVID-19 pandemic in Indiana. Characterize LTC administrator perspectives on family/caregiver involvement in the LTC setting. DESIGN: Semi-structured qualitative interviews. SETTING AND PARTICIPANTS: Administrators from 4 Indiana LTC facilities. METHODS: In this qualitative study, a convenience sample of 4 LTC administrators was recruited. Each participant completed 1 interview during January to May 2021. Following transcription, a thematic analysis approach with 2 cycles of qualitative coding identified relevant themes. RESULTS: Four LTC administrators participated, representing both urban and rural nonprofit nursing homes. Participants spoke positively of the program despite implementation challenges including perceived infection risk, policy interpretation, and logistical challenges. The psychological impact of isolation for nursing home residents was emphasized as a critical consideration alongside physical health concerns. LTC administrators desired to support resident well-being while maintaining good standing with regulatory agencies. CONCLUSIONS AND IMPLICATIONS: Based on a limited sample, Indiana's EFC policy was viewed favorably by LTC administrators as a tool to balance resident and family psychosocial needs with infection-related health risks. LTC administrators desired a collaborative approach from regulators as they worked to implement a novel policy. Consistent with participant desire for broader caregiver access to residents, more recent policymaking has reflected growing recognition of the critical role of family members not only as companions but also as care providers, even in a structured care environment.

Exploring the intersection of structural racism and ageism in healthcare.

The American Geriatrics Society (AGS) has consistently advocated for a healthcare system that meets the needs of older adults, including addressing impacts of ageism in healthcare. The intersection of structural racism and ageism compounds the disadvantage experienced by historically marginalized communities. Structural racism and ageism have long been ingrained in all aspects of US society, including healthcare. This intersection exacerbates disparities in social determinants of health, including poor access to healthcare and poor outcomes. These deeply rooted societal injustices have been brought into the forefront of the collective public consciousness at different points throughout history. The COVID-19 pandemic laid bare and exacerbated existing inequities inflicted on historically marginalized communities. Ageist rhetoric and policies during the COVID-19 pandemic further marginalized older adults. Although the detrimental impact of structural racism on health has been well documented in the literature, generative research on the intersection of structural racism and ageism is limited. The AGS is working to identify and dismantle the healthcare structures that create and perpetuate these combined injustices and, in so doing, create a more just US healthcare system. This paper is intended to provide an overview of important frameworks and to guide future efforts to both identify and eliminate bias within healthcare delivery systems and health professions training with a particular focus on the intersection of structural racism and ageism.

COVID-19 disease trajectories among nursing home residents.

INTRODUCTION: Older adults are at greater risk of both infection with and mortality from COVID-19. Many U.S. nursing homes have been devastated by the COVID-19 pandemic, yet little has been described regarding the typical disease course in this population. The objective of this study is to describe and identify patterns in the disease course of nursing home residents infected with COVID-19. SETTING AND METHODS: This is a case series of 74 residents with COVID-19 infection in a nursing home in central Indiana between March 28 and June 17, 2020. Data were extracted from the electronic medical record and from nursing home medical director tracking notes from the time of the index infection through August 31, 2020. The clinical authorship team reviewed the data to identify patterns in the disease course of the residents. RESULTS: The most common symptoms were fever, hypoxia, anorexia, and fatigue/malaise. The duration of symptoms was extended, with an average of over 3 weeks. Of those infected 25 died; 23 of the deaths were considered related to COVID-19 infection. A subset of residents with COVID-19 infection experienced a rapidly progressive, fatal course. DISCUSSION/CONCLUSIONS: Nursing home residents infected with COVID-19 from the facility we studied experienced a prolonged disease course regardless of the severity of their symptoms, with implications for the resources needed to care for and support of these residents during active infection and post-disease. Future studies should combine data from nursing home residents across the country to identify the risk factors for disease trajectories identified in this case series.

Willingness of Long-Term Care Staff to Receive a COVID-19 Vaccine: A Single State Survey.

OBJECTIVES: To plan for coronavirus infectious disease 2019 (COVID-19) vaccine distribution, the Indiana Department of Health surveyed nursing home and assisted living facility staff. DESIGN: Cross-sectional analysis of an anonymous survey sent via text message link to personal cell phones and emails. SETTING AND PARTICIPANTS: Nursing home and assisted living facility staff in Indiana. MEASURES: Staff characteristics including age, gender, race, ethnicity, role in the facility, experience in long-term care, and geographic location of facility were self-reported along with prior infection and willingness to receive an approved vaccine as soon as it is available. Responses were weighted to represent staff statewide. Weighted frequencies and logit regression estimated characteristics associated with vaccine willingness. RESULTS: There were 8,243 responses to the survey. For nursing home staff (survey delivered via 23,232 working phone numbers), there was a 33% response rate). There were 2,372 (29%) in nurse aide or similar roles and 1,602 nurses providing direct clinical care (19%). Overall, 45% of respondents indicated they would receive an approved COVID-19 vaccine as soon as available. Of those unwilling to take the vaccine when first available, 44% would consider in the future. Concerns about side effects was the primary reason for vaccine hesitancy (70%). Characteristics associated with increased willingness were age over 60, male, and white race (P < .0001). No statistically significant differences were observed among staff self-reporting prior SARS-CoV-2 infection. CONCLUSIONS AND IMPLICATIONS: The willingness to receive the COVID-19 vaccine immediately or in the future may be as high as 69%, but varies among subgroups of nursing home staff which has implications for distribution. Educating staff on the vaccine may be critical for increasing uptake. Widespread vaccination holds the promise of protection against serious illness and death and a return of visitors and activities that support improved quality of life. This promise will not be realized without strong uptake of the vaccines.

Community Coronavirus Disease 2019 Activity Level and Nursing Home Staff Testing for Active Severe Acute Respiratory Syndrome Coronavirus 2 Infection in Indiana.

OBJECTIVES: To assess whether using coronavirus disease 2019 (COVID-19) community activity level can accurately inform strategies for routine testing of facility staff for active severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. DESIGN: Cross-sectional study. SETTING AND PARTICIPANTS: In total, 59,930 nursing home staff tested for active SARS-CoV-2 infection in Indiana. MEASURES: Receiver operator characteristic curves and the area under the curve to compare the sensitivity and specificity of identifying positive cases of staff within facilities based on community COVID-19 activity level including county positivity rate and county cases per 10,000. RESULTS: The detection of any infected staff within a facility using county cases per 10,000 population or county positivity rate resulted in an area under the curve of 0.648 (95% confidence interval 0.601‒0.696) and 0.649 (95% confidence interval 0.601‒0.696), respectively. Of staff tested, 28.0% were certified nursing assistants, yet accounted for 36.9% of all staff testing positive. Similarly, licensed practical nurses were 1.4% of staff, but 4.7% of positive cases. CONCLUSIONS AND IMPLICATIONS: We failed to observe a meaningful threshold of community COVID-19 activity for the purpose of predicting nursing homes with any positive staff. Guidance issued by the Centers for Medicare and Medicaid Services in August 2020 sets the minimum frequency of routine testing for nursing home staff based on county positivity rates. Using the recommended 5% county positivity rate to require weekly testing may miss asymptomatic infections among nursing home staff. Further data on results of all-staff testing efforts, particularly with the implementation of new widespread strategies such as point-of-care testing, is needed to guide policy to protect high-risk nursing home residents and staff. If the goal is to identify all asymptomatic SARS-Cov-2 infected nursing home staff, comprehensive repeat testing may be needed regardless of community level activity.