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1.
J Am Geriatr Soc ; 70(4): 1198-1207, 2022 Apr.
Article in English | MEDLINE | ID: covidwho-1673190

ABSTRACT

BACKGROUND: Federal minimum nurse staffing levels for skilled nursing facilities (SNFs) were proposed in 2019 U.S. Congressional bills. We estimated costs and personnel needed to meet the proposed staffing levels, and examined characteristics of SNFs not meeting these thresholds. METHODS: This was a cross-sectional analysis of 2019Q4 payroll data, the Hospital Wage Index, and other administrative data for 14,964 Medicare and Medicaid-certified SNFs. We examined characteristics of SNFs not meeting proposed minimum thresholds: 4.1 total nursing hours per resident day (HPRD); 0.75 registered nurse (RN) HPRD; 0.54 licensed practical nurse (LPN) HPRD; and 2.81 certified nursing assistant (CNA) HPRD. For SNFs falling below the thresholds, we calculated the additional HPRD needed, along with the associated full-time equivalent (FTE) personnel and salary costs. RESULTS: In 2019, 25.0% of SNFs met the minimum 4.1 total nursing HPRD, while 31.0%, 84.5%, and 10.7% met the RN, LPN, and CNA thresholds, respectively. Only 5.0% met all four categories. In adjusted analyses, factors most strongly associated with SNFs not meeting the proposed minimums were: higher Medicaid census, larger bed size, for-profit ownership, higher county SNF competition; and, for RNs specifically, higher community poverty and lower Medicare census. Rural SNFs were less likely to meet all categories and this was explained primarily by county SNF competition. We estimate that achieving the proposed federal minimums across SNFs nationwide would require an estimated additional 35,804 RN, 3509 LPN, and 116,929 CNA FTEs at $7.25 billion annually in salary costs based on current wage rates and prepandemic resident census levels. CONCLUSIONS: Achieving proposed minimum nurse staffing levels in SNFs will require substantial financial investment in the workforce and targeted support of low-resource facilities. Extensive recruitment and retention efforts are needed to overcome supply constraints, particularly in the aftermath of the COVID-19 pandemic.


Subject(s)
COVID-19 , Skilled Nursing Facilities , Aged , Cross-Sectional Studies , Humans , Medicare , Pandemics , United States , Workforce
2.
J Am Geriatr Soc ; 70(1): 19-28, 2022 01.
Article in English | MEDLINE | ID: covidwho-1526377

ABSTRACT

BACKGROUND: After the first of three COVID-19 vaccination clinics in U.S. nursing homes (NHs), the median vaccination coverage of staff was 37.5%, indicating the need to identify strategies to increase staff coverage. We aimed at comparing the facility-level activities, policies, incentives, and communication methods associated with higher staff COVID-19 vaccination coverage. METHODS: Design. Case-control analysis. SETTING: Nationally stratified random sample of 1338 U.S. NHs participating in the Pharmacy Partnership for Long-Term Care Program. PARTICIPANTS: Nursing home leadership. MEASUREMENT: During February 4-March 2, 2021, we surveyed NHs with low (<35%), medium (40%-60%), and high (>75%) staff vaccination coverage, to collect information on facility strategies used to encourage staff vaccination. Cases were respondents with medium and high vaccination coverage, whereas controls were respondents with low coverage. We used logistic regression modeling, adjusted for county and NH characteristics, to identify strategies associated with facility-level vaccination coverage. RESULTS: We obtained responses from 413 of 1338 NHs (30.9%). Compared with facilities with lower staff vaccination coverage, facilities with medium or high coverage were more likely to have designated frontline staff champions (medium: adjusted odds ratio [aOR] 3.6, 95% CI 1.3-10.3; high: aOR 2.9, 95% CI 1.1-7.7) and set vaccination goals (medium: aOR 2.4, 95% 1.0-5.5; high: aOR 3.7, 95% CI 1.6-8.3). NHs with high vaccination coverage were more likely to have given vaccinated staff rewards such as T-shirts compared with NHs with low coverage (aOR 3.8, 95% CI 1.3-11.0). Use of multiple strategies was associated with greater likelihood of facilities having medium or high vaccination coverage: For example, facilities that used ≥9 strategies were three times more likely to have high staff vaccination coverage than facilities using <6 strategies (aOR 3.3, 95% CI 1.2-8.9). CONCLUSIONS: Use of designated champions, setting targets, and use of non-monetary awards were associated with high NH staff COVID-19 vaccination coverage.


Subject(s)
COVID-19 Vaccines/administration & dosage , COVID-19/prevention & control , Nursing Homes , Nursing Staff/statistics & numerical data , Vaccination/statistics & numerical data , Adult , Case-Control Studies , Female , Humans , Male , Middle Aged , Motivation , Reward , United States
3.
J Am Med Dir Assoc ; 22(11): 2240-2244, 2021 11.
Article in English | MEDLINE | ID: covidwho-1373103

ABSTRACT

OBJECTIVES: Little is known about how the COVID-19 pandemic has affected rehabilitation care in post-acute and long-term care. As part of a process to assess research priorities, we surveyed professionals in these settings to assess the impact of the pandemic and related research needs. DESIGN: Qualitative analysis of open-ended survey results. SETTING AND PARTICIPANTS: 30 clinical and administrative staff working in post-acute and long-term care. METHODS: From June 24 through July 10, 2020, we used professional connections to disseminate an electronic survey to a convenience sample of clinical and administrative staff. We conducted an inductive thematic analysis of the data. RESULTS: We identified 4 themes, related to (1) rapid changes in care delivery, (2) negative impact on patients' motivation and physical function, (3) new access barriers and increased costs, and (4) uncertainty about sustaining changes in delivery and payment. Rapid changes: Respondents described how infection control policies and practices shifted rehabilitation from group sessions and communal gyms to the bedside and telehealth. Negative impact: Respondents felt that patients' isolation, particularly in residential care settings, affected their motivation for rehabilitation and their physical function. Access and costs: Respondents expressed concerns about increased costs (eg, for personal protective equipment) and decreased patient volume, as well as access issues. Uncertainty: At the same time, respondents described how telehealth and Medicare waivers enabled new ways to connect with patients and wondered whether waivers would be extended after the public health emergency. CONCLUSIONS AND IMPLICATIONS: Survey results highlight rapid changes to rehabilitation in post-acute and long-term care during the height of the COVID-19 pandemic. Because staff vaccine coverage remains low and patients vulnerable in residential care settings, changes such as infection precautions are likely to persist. Future research should evaluate the impact on care, outcomes, and costs.


Subject(s)
COVID-19 , Pandemics , Aged , Humans , Long-Term Care , Medicare , SARS-CoV-2 , United States
4.
J Am Med Dir Assoc ; 22(1): 199-203, 2021 01.
Article in English | MEDLINE | ID: covidwho-977126

ABSTRACT

OBJECTIVE: The Coronavirus disease 2019 (COVID-19) pandemic is an unprecedented challenge for nursing homes, where staff have faced rapidly evolving circumstances to care for a vulnerable resident population. Our objective was to document the experiences of these front-line health care professionals during the pandemic. DESIGN: Electronic survey of long-term care staff. This report summarizes qualitative data from open-ended questions for the subset of respondents working in nursing homes. SETTING AND PARTICIPANTS: A total of 152 nursing home staff from 32 states, including direct-care staff and administrators. METHODS: From May 11 through June 4, 2020, we used social media and professional networks to disseminate an electronic survey with closed- and open-ended questions to a convenience sample of long-term care staff. Four investigators identified themes from qualitative responses for staff working in nursing homes. RESULTS: Respondents described ongoing constraints on testing and continued reliance on crisis standards for extended use and reuse of personal protective equipment. Administrators discussed the burden of tracking and implementing sometimes confusing or contradictory guidance from numerous agencies. Direct-care staff expressed fears of infecting themselves and their families, and expressed sincere empathy and concern for their residents. They described experiencing burnout due to increased workloads, staffing shortages, and the emotional burden of caring for residents facing significant isolation, illness, and death. Respondents cited the presence or lack of organizational communication and teamwork as important factors influencing their ability to work under challenging circumstances. They also described the demoralizing impact of negative media coverage of nursing homes, contrasting this with the heroic public recognition given to hospital staff. CONCLUSIONS AND IMPLICATIONS: Nursing home staff described working under complex and stressful circumstances during the COVID-19 pandemic. These challenges have added significant burden to an already strained and vulnerable workforce and are likely to contribute to increased burnout, turnover, and staff shortages in the long term.


Subject(s)
Burnout, Professional/psychology , COVID-19/nursing , Nurse's Role , Nurse-Patient Relations , Nursing Homes/organization & administration , Nursing Staff/psychology , COVID-19/epidemiology , Female , Humans , Infectious Disease Transmission, Patient-to-Professional/prevention & control , Male , Personal Protective Equipment/statistics & numerical data , Personnel Turnover
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