The Relative Importance of Hospital Discharge and Patient Composition in Changing Post-Acute Care Utilization and Outcomes Among Medicare Beneficiaries.

Background: The COVID-19 pandemic changed care delivery. But the mechanisms of changes were less understood. Objectives: Examine the extent to which the volume and pattern of hospital discharge and patient composition contributed to the changes in post-acute care (PAC) utilization and outcomes during the pandemic. Research design: Retrospective cohort study. Medicare claims data on hospital discharges in a large healthcare system from March 2018 to December 2020. Subjects: Medicare fee-for-service beneficiaries, 65 years or older, hospitalized for non-COVID diagnoses. Measures: Hospital discharges to Home Health Agencies (HHA), Skilled Nursing Facilities (SNF), and Inpatient Rehabilitation Facilities (IRF) versus home. Thirty- and ninety-day mortality and readmission rates. Outcomes were compared before and during the pandemic with and without adjustment for patient characteristics and/or interactions with the pandemic onset. Results: During the pandemic, hospital discharges declined by 27%. Patients were more likely to be discharged to HHA (+4.6%, 95% CI [3.2%, 6.0%]) and less likely to be discharged to either SNF (-3.9%, CI [-5.2%, -2.7%]) or to home (-2.8% CI [-4.4%, -1.3%]). Thirty- and ninety-day mortality rates were significantly higher by 2% to 3% points post-pandemic. Readmission were not significantly different. Up to 15% of the changes in discharge patterns and 5% in mortality rates were attributable to patient characteristics. Conclusions: Shift in discharge locations were the main driver of changes in PAC utilization during the pandemic. Changes in patient characteristics explained only a small portion of changes in discharge patterns and were mainly channeled through general impacts rather than differentiated responses to the pandemic.

Perspectives of Physicians with Experience in Nursing Home Care on Telehealth Use During the COVID-19 Public Health Emergency.

BACKGROUND: Despite expanded access to telehealth services for Medicare beneficiaries in nursing homes (NHs) during the COVID-19 public health emergency, information on physicians' perspectives on the feasibility and challenges of telehealth provision for NH residents is lacking. OBJECTIVE: To examine physicians' perspectives on the appropriateness and challenges of providing telehealth in NHs. PARTICIPANTS: Medical directors or attending physicians in NHs. APPROACH: We conducted 35 semistructured interviews with members of the American Medical Directors Association from January 18 through January 29, 2021. Outcomes of the thematic analysis reflected perspectives of physicians experienced in NH care on telehealth use. MAIN MEASURES: The extent to which participants used telehealth in NHs, the perceived value of telehealth for NH residents, and barriers to telehealth provision. KEY RESULTS: Participants included 7 (20.0%) internists, 8 (22.9%) family physicians, and 18 (51.4%) geriatricians. Five common themes emerged: (1) direct care is needed to adequately care for residents in NHs; (2) telehealth may allow physicians to reach NH residents more flexibly during offsite hours and other scenarios when physicians cannot easily reach patients; (3) NH staff and other organizational resources are critical to the success of telehealth, but staff time is a major barrier to telehealth provision; (4) appropriateness of telehealth in NHs may be limited to certain resident populations and/or services; (5) conflicting views about whether telehealth use will be sustained over time in NHs. Subthemes included the role of resident-physician relationships in facilitating telehealth and the appropriateness of telehealth for residents with cognitive impairment. CONCLUSIONS: Participants had mixed views on the effectiveness of telehealth in NHs. Staff resources to facilitate telehealth and the limitations of telehealth for NH residents were the most raised issues. These findings suggest that physicians in NHs may not view telehealth as a suitable substitute for most in-person services.

Discharge to post-acute care and other predictors of prolonged length of stay during the initial COVID-19 surge: a single site analysis.

BACKGROUND: During the initial surge of coronavirus disease 2019 (COVID-19), health-care utilization fluctuated dramatically, straining acute hospital capacity across the USA and potentially contributing to excess mortality. METHODS: This was an observational retrospective study of patients with COVID-19 admitted to a large US urban academic medical center during a 12-week COVID-19 surge in the Spring of 2020. We describe patterns in length of stay (LOS) over time. Our outcome of interest was prolonged LOS (PLOS), which we defined as 7 or more days. We performed univariate analyses of patient characteristics, clinical outcomes and discharge disposition to evaluate the association of each variable with PLOS and developed a final multivariate model via backward elimination, wherein all variables with a P-value above 0.05 were eliminated in a stepwise fashion. RESULTS: The cohort included 1366 patients, of whom 13% died and 29% were readmitted within 30 days. The LOS (mean: 12.6) fell over time (P < 0.0001). Predictors of PLOS included discharge to a post-acute care (PAC) facility (odds ratio [OR]: 11.9, 95% confidence interval [CI] 2.6-54.0), uninsured status (OR 3.2, CI 1.1-9.1) and requiring intensive care and intubation (OR 18.4, CI 11.5-29.6). Patients had a higher readmission rate if discharged to PAC facilities (40%) or home with home health agency (HHA) services (38%) as compared to patients discharged home without HHA services (26%) (P < 0.0001). CONCLUSION: Patients hospitalized with COVID-19 during a US COVID-19 surge had a PLOS and high readmission rate. Lack of insurance, an intensive care unit stay and a decision to discharge to a PAC facility were associated with a PLOS. Efforts to decrease LOS and optimize hospital capacity during COVID-19 surges may benefit from focusing on increasing PAC and HHA capacity and resources.

Relating Acute Care Rehabilitation Use and Discharge Disposition Among Individuals Hospitalized for COVID-19

Research Objectives To examine the extent to which acute care rehabilitation predicts discharge to post-acute care (PAC) in hospitalized COVID-19 patients. To identify social determinants that influence discharge to PAC for hospitalized COVID-19 patients. Design Secondary analysis of de-identified electronic health record (EHR) data obtained from 14 hospitals during January 2020 through April 2021. The dependent variable was discharge disposition (post-acute care or home). Independent variables included age, sex, ethnic/race minority status, presence of significant other, education level, income, insurance type, rural-urban-frontier residence, acute care occupational therapy (OT) and physical therapy (PT), ICU stay. Descriptive statistics and binary logistic regression were employed. Setting Fourteen acute care hospitals that are part of a single health network in Colorado. Participants 5,654 individuals were admitted and diagnosed with COVID-19 during the observation window. To be included in our analyses, cases had to meet the following criteria: survival to discharge, discharged to home or PAC, complete data for variables of interest. After applying these criteria, 979 individuals were excluded resulting in a final sample size of 4,675 individuals. Interventions Receipt of acute care OT or PT. Main Outcome Measures The primary outcome (dependent variable) was discharge disposition, which we categorized as "discharged to Post-Acute Care (PAC)" or "home". Results Age (Odds ratio, OR = 1.03), Medicare (OR = 2.21), receipt of acute care OT (OR = 3.41), receipt of acute care PT (OR = 5.05), and ICU stay (OR = 1.49) significantly predicted discharge to inpatient PAC. Sex, race/ethnicity, significant other status, residence type, education level, and income level were not significant predictors of discharge disposition. Conclusions Individuals who were older, Medicare beneficiaries, received OT or PT, and had an ICU stay were the most likely hospitalized COVID-19 patients to be discharged to inpatient PAC. Contrary to pre-pandemic studies that demonstrate the influence of significant others, residence location (e.g., rural), income, and education level have on discharge disposition, our findings suggest these factors mattered less in the context of COVID-19. Author(s) Disclosures The authors have no conflicts.

Evaluation of the predictive factors of the short-term effects of a multidisciplinary rehabilitation in COVID-19 survivors.

OBJECTIVE: Functional impairments after coronavirus disease 2019 (COVID-19) constitute a major concern in rehabilitative settings; however, evidence assessing the efficacy of rehabilitation programs is lacking. The aim of this study was to verify the clinical characteristics that may represent useful predictors of the short-term effectiveness of multidisciplinary rehabilitation. METHODS: In this real-practice retrospective pre-post intervention cohort study, the short-term effectiveness of a multidisciplinary patient-tailored rehabilitation program was assessed through normalized variations in the Functional Independence Measure in post-acute care patients who had overcome severe COVID-19. Biochemical markers, motor and nutritional characteristics, and the level of comorbidity were evaluated as predictors of functional outcome. Length of stay in the rehabilitation ward was also considered. RESULTS: Following rehabilitation, all participants (n = 53) reported a significant decrease in the level of disability in both motor and cognitive functioning. However, neither motor and nutritional characteristics nor comorbidities played a significant role in predicting the overall positive change registered after rehabilitation. CONCLUSIONS: The results support the existing sparse evidence addressing the importance of an early rehabilitation program for patients who received intensive care and post-acute care due to severe COVID-19.

Correlation of long-term care facility vaccination practices between seasons and resident types.

BACKGROUND: Influenza vaccination varies widely across long-term care facilities (LTCFs) due to staff behaviors, LTCF practices, and patient factors. It is unclear how seasonal LTCF vaccination varies between cohabitating but distinct short-stay and long-stay residents. Thus, we assessed the correlation of LTCF vaccination between these populations and across seasons. METHODS: The study design is a national retrospective cohort using Medicare and Minimum Data Set (MDS) data. Participants include U.S. LTCFs. Short-stay and long-stay Medicare-enrolled residents age ≥ 65 in U.S. LTCFs from a source population of residents during October 1^st-March 31^st in 2013-2014 (3,042,881 residents; 15,683 LTCFs) and 2014-2015 (3,143,174, residents; 15,667 LTCFs). MDS-assessed influenza vaccination was the outcome. Pearson correlation coefficients were estimated to assess seasonal correlations between short-stay and long-stay resident vaccination within LTCFs. RESULTS: The median proportion of short-stay residents vaccinated across LTCFs was 70.4% (IQR, 50.0-82.7%) in 2013-2014 and 69.6% (IQR, 50.0-81.6%) in 2014-2015. The median proportion of long-stay residents vaccinated across LTCFs was 85.5% (IQR, 78.0-90.9%) in 2013-2014 and 84.6% (IQR, 76.6-90.3%) in 2014-2015. Within LTCFs, there was a moderate correlation between short-stay and long-stay vaccination in 2013-2014 (r = 0.50, 95%CI: 0.49-0.51) and 2014-2015 (r = 0.53, 95%CI: 0.51-0.54). Across seasons, there was a moderate correlation for LTCFs with short-stay residents (r = 0.54, 95%CI: 0.53-0.55) and a strong correlation for those with long-stay residents (r = 0.68, 95%CI: 0.67-0.69). CONCLUSIONS: In LTCFs with inconsistent influenza vaccination across seasons or between populations, targeted vaccination protocols for all residents, regardless of stay type, may improve successful vaccination in this vulnerable patient population.

Ethnic, clinical, and pharmacological predictors of high social dependence in COVID-19 patients admitted to post-acute care

The COVID-19 epidemic affected both acute hospitals and post-acute care, which experienced various degrees of overcrowding. We evaluated all the patients admitted to a post-acute care facility during the second wave of the epidemic to detect features possibly associated with social frailty. We analyzed the socio-demographic characteristics and comorbidities of the patients and the pattern of their previous hospitalization as available in their discharge letter. In addition, we evaluated their clinical features and tests on admission to post-acute care. We found that COVID-19 patients without social problems had distinctive features. Those with a higher need for specific pharmacological treatments during their stay in an acute hospital were less likely to be admitted to post-acute care for concomitant social problems (p < 0.05 for all types of medication). They were also more likely to be native (p = 0.02), obese (p = 0.009), and with hypertension (p = 0.03). Patients with social problems usually stayed longer and were less frequently discharged home with a negative swab (p = 0.0009). In COVID-19 patients, recognition of distinctive features predicting that their need for a longer hospital stay is due to social problems can lead to more appropriate discharge and to more appropriate use of post-acute care.

Incidence and Outcomes of SARS-CoV-2 in Post-Acute Skilled Nursing Facility Care.

OBJECTIVES: To examine the risk of contracting SARS-CoV-2 during a post-acute skilled nursing facility (SNF) stay and the associated risk of death. DESIGN: Cohort study using Minimum Data Set and electronic health record data from a large multistate long-term care provider. Primary outcomes included testing positive for SARS-CoV-2 during the post-acute SNF stay, and death among those who tested positive. SETTING AND PARTICIPANTS: The sample included all new admissions to the provider's 286 SNFs between January 1 and December 31, 2020. Patients known to be infected with SARS-CoV-2 at the time of admission were excluded. METHODS: SARS-CoV-2 infection and mortality rates were measured in time intervals by month of admission. A parametric survival model with SNF random effects was used to measure the association of patient demographic factors, clinical characteristics, and month of admission, with testing positive for SARS-CoV-2. RESULTS: The sample included 45,094 post-acute SNF admissions. Overall, 5.7% of patients tested positive for SARS-CoV-2 within 100 days of admission, with 1.0% testing positive within 1-14 days, 1.4% within 15-30 days, and 3.4% within 31-100 days. Of all newly admitted patients, 0.8% contracted SARS-CoV-2 and died, whereas 6.7% died without known infection. Infection rates and subsequent risk of death were highest for patients admitted during the first and third US pandemic waves. Patients with greater cognitive and functional impairment had a 1.45 to 1.92 times higher risk of contracting SARS-CoV-2 than patients with less impairment. CONCLUSIONS AND IMPLICATIONS: The absolute risk of SARS-CoV-2 infection and death during a post-acute SNF admission was 0.8%. Those who did contract SARS-CoV-2 during their SNF stay had nearly double the rate of death as those who were not infected. Findings from this study provide context for people requiring post-acute care, and their support systems, in navigating decisions around SNF admission during the SARS-CoV-2 pandemic.

Defining the Role and Value of Physicians Who Primarily Practice in Nursing Homes: Perspectives of Nursing Home Physicians.

OBJECTIVE: To identify the perceptions of physicians with expertise in nursing home care on the value of physicians who primarily practice in nursing homes, often referred to as "SNFists," with the goal of enriching our understanding of specialization in nursing home care. DESIGN: Qualitative analysis of semistructured interviews. SETTING AND PARTICIPANTS: Virtual interviews conducted January 18-29, 2021. Participants included 35 physicians across the United States, who currently or previously served as medical directors or attending physicians in nursing homes. METHODS: Interviews were conducted virtually on Zoom and professionally transcribed. Outcomes were themes resulting from thematic analysis. RESULTS: Participants had a mean 19.5 (SD = 11.3) years of experience working in nursing homes; 17 (48.6%) were female; the most common medical specializations were geriatrics (18; 51.4%), family medicine (8; 22.9%), internal medicine (7; 20.0%), physiatry (1; 2.9%), and pulmonology (1; 2.9%). Ten (28.6%) participants were SNFists. We identified 6 themes emphasized by participants: (1) An unclear definition and loose qualifications for SNFists may affect the quality of care; (2) Specific competencies are needed to be a "good SNFist"; (3) SNFists are distinguished by their unique practice approach and often provide services that are unbillable or underreimbursed; (4) SNFists achieve better outcomes, but opinions varied on performance measures; (5) SNFists may contribute to discontinuity of care; (6) SNFists remained in nursing homes during the COVID-19 pandemic. CONCLUSIONS AND IMPLICATIONS: There is a strong consensus among physicians with expertise in nursing home care that SNFists provide higher quality care for residents than other physicians. However, a uniform definition of a SNFist based on competencies in addition to standardized performance measures are needed. Unbillable and underreimbursed services create disincentives to physicians becoming SNFists. Policy makers may consider modifying Medicare reimbursements to incentivize more physicians to specialize in nursing home care.

Learning about sites of care for older adults: a jigsaw educational session for medical students.

Choosing the appropriate site of care for patients is a vital clinical skill when caring for older adults. For better patient safety and smoother transitions of care, we need improved curricula to train clinicians about the system of sites and services where older adults receive care. Here we present an innovative introduction for medical trainees to the complexities of long-term and post-acute care for geriatric patients. Students participated in a team-based 'jigsaw' learning activity, in which each team researched a particular site of care and then taught a larger group of their peers about that site. It was subsequently converted to a virtual format due to COVID-19. The activity was assessed using students' written feedback and satisfaction scores. Students enjoyed the interactivity and hands-on approach, giving the activity an average score of 3.9 out of 5 (1 = 'poor'; 5 = 'excellent'). The jigsaw provided an engaging, case-based foundation for learning about sites of care and was well-received by students.

Retirement Center Worker Sleep Health Assessment During the COVID-19 Pandemic.

BACKGROUND: Sleep health disturbances can increase risks for workplace injury, error, and poor worker health. Essential workers have reported sleep disturbances since the COVID-19 pandemic onset, which may jeopardize their health and safety. The aims of this project were to assess sleep health among Continuing Care Retirement Community (CCRC) workers, examine potential differences between worker types, and describe the self-perceived impact of COVID-19 on workers' workload and sleep. METHODS: Through an academic-practice partnership, this needs assessment used a cross-sectional design that collected self-report data during fall 2020 from CCRC workers. Guided by the Workplace Health Model, survey questions included work characteristics, sleep health, and COVID-19 impact on sleep and workload. FINDINGS: Ninety-four respondents completed the survey across multiple departments. Respondents (n = 34, 36.2%) reported sleeping below recommended hours on workdays. The majority scored above the population mean on Patient-Reported Outcomes Measurement (PROMIS) measures of sleep disturbance (n = 52, 55.3%), sleep-related impairment (n = 49, 52.1%), and fatigue (n = 49, 52.1%). Differences in workday total sleep time and fatigue were noted among shift workers versus nonshift workers, with shift workers reporting less sleep and more fatigue. Shorter sleep duration was noted among respondents working shifts 10 or more hours compared with those working 8 hours. Pandemic-related workload increase was reported by 22.3% (n = 21) of respondents, with 17% (n = 16) noting more than one type of workload change. Since COVID-19 onset, 36.2% (n = 34) reported no sleep changes and 35.1% (n = 33) reported sleeping less. A medium, positive relationship was found between increased changes in work due to COVID-19 and increased difficulties sleeping (r = .41, n = 73, p = .000). CONCLUSION/APPLICATION TO PRACTICE: Proper sleep health is essential to workplace safety and worker health. By assessing sleep health during a crisis, occupational health nurses can identify opportunities to support worker health and safety, through sleep education, monitoring for sleepiness and fatigue, ensuring countermeasures are available (e.g., caffeine), and assessing for opportunities to change organizational policies.

Increased Anxiety and Depression Symptoms in Post-Acute Care Patients with Stroke during the COVID-19 Pandemic.

This study aimed to explore the quality and stability of post-acute care for patients with stroke, including their functional outcomes, mental health and medical care in Taiwan during the COVID-19 pandemic. In this retrospective case-control study-based on propensity score matching-we assessed 11 patients admitted during the pandemic period (in 2021) and 11 patients admitted during the non-pandemic period (in 2020). Functional outcomes, including the scores of the modified Rankin Scale, Barthel Index, EuroQoL-5 Dimension, Lawton-Brody instrumental activities of daily living, Berg Balance Scale, 5-metre walking speed and 6-min walking distance, were determined. Data on the length of acute care, length of post-acute care, destination after discharge and 14-days readmission were used to evaluate the quality of medical care. The Wilcoxon signed-rank test was used to compare functional performance before and after rehabilitation. The pandemic group showed no significant improvement in the scores of EuroQoL-5 Dimension, a self-reported health status assessment (p = 0.13), with the anxiety or depression dimension showing a negative effect (r = 0.21). Post-acute care programmes can efficiently improve the functional performance of patients with stroke during the COVID-19 pandemic in Taiwan. Mental health should therefore be simultaneously maintained while rehabilitating physical function.

Racial Disparities in 30-Day Outcomes Following Index Admission for COVID-19.

We investigated racial disparities in a 30-day composite outcome of readmission and death among patients admitted across a 5-hospital health system following an index COVID-19 admission. A dataset of 1,174 patients admitted between March 1, 2020 and August 21, 2020 for COVID-19 was retrospectively analyzed for odds of readmission among Black patients compared to all other patients, with sequential adjustment for demographics, index admission characteristics, type of post-acute care, and comorbidities. Tabulated results demonstrated a significantly greater odds of 30-day readmission or death among Black patients (18.0% of Black patients vs. 11.3% of all other patients; Univariate Odds Ratio: 1.71, p = 0.002). Sequential adjustment via logistic regression revealed that the odds of 30-day readmission or death were significantly greater among Black patients after adjustment for demographics, index admission characteristics, and type of post-acute care, but not comorbidities. Stratification by type of post-acute care received on discharge revealed that the same disparity in odds of 30-day readmission or death existed among patients discharged home without home services, but not those discharged to home with home services or to a skilled nursing facility or acute rehab facility. Collectively, the findings suggest that weighing comorbidity burdens in post-acute care decisions may be relevant in addressing racial disparities in 30-day outcomes following discharge from an index COVID-19 admission.

Management of post-acute COVID-19 patients in geriatric rehabilitation: EuGMS guidance.

PURPOSE: To describe a guidance on the management of post-acute COVID 19 patients in geriatric rehabilitation. METHODS: The guidance is based on guidelines for post-acute COVID-19 geriatric rehabilitation developed in the Netherlands, updated with recent insights from literature, related guidance from other countries and disciplines, and combined with experiences from experts in countries participating in the Geriatric Rehabilitation Special Interest Group of the European Geriatric Medicine Society. RESULTS: This guidance for post-acute COVID-19 rehabilitation is divided into a section addressing general recommendations for geriatric rehabilitation and a section addressing specific processes and procedures. The Sect. "General recommendations for geriatric rehabilitation" addresses: (1) general requirements for post-acute COVID-19 rehabilitation and (2) critical aspects for quality assurance during COVID-19 pandemic. The Sect. "Specific processes and procedures", addresses the following topics: (1) patient selection; (2) admission; (3) treatment; (4) discharge; and (5) follow-up and monitoring. CONCLUSION: Providing tailored geriatric rehabilitation treatment to post-acute COVID-19 patients is a challenge for which the guidance is designed to provide support. There is a strong need for additional evidence on COVID-19 geriatric rehabilitation including developing an understanding of risk profiles of older patients living with frailty to develop individualised treatment regimes. The present guidance will be regularly updated based on additional evidence from practice and research.

Inpatient Hospital Costs for COVID-19 Patients in the United States.

INTRODUCTION: Reliable cost and resource use data for COVID-19 hospitalizations are crucial to better inform local healthcare resource decisions; however, available data are limited and vary significantly. METHODS: COVID-19 hospital admissions data from the Premier Healthcare Database were evaluated to estimate hospital costs, length of stay (LOS), and discharge status. Adult COVID-19 patients (ICD-10-CM: U07.1) hospitalized in the US from April 1 to December 31, 2020, were identified. Analyses were stratified by patient and hospital characteristics, levels of care during hospitalization, and discharge status. Factors associated with changes in costs, LOS, and discharge status were estimated using regression analyses. Monthly trends in costs, LOS, and discharge status were examined. RESULTS: Of the 247,590 hospitalized COVID-19 patients, 49% were women, 76% were aged ≥ 50, and 36% were admitted to intensive care units (ICU). Overall median hospital LOS, cost, and cost/day were 6 days, US$11,267, and $1772, respectively; overall median ICU LOS, cost, and cost/day were 5 days, $13,443, and $2902, respectively. Patients requiring mechanical ventilation had the highest hospital and ICU median costs ($47,454 and $41,510) and LOS (16 and 11 days), respectively. Overall, 14% of patients died in hospital and 52% were discharged home. Older age, Black and Caucasian race, hypertension and obesity, treatment with extracorporeal membrane oxygenation, and discharge to long-term care facilities were major drivers of costs, LOS, and risk of death. Admissions in December had significantly lower median hospital and ICU costs and LOS compared to April. CONCLUSION: The burden from COVID-19 in terms of hospital and ICU costs and LOS has been substantial, though significant decreases in cost and LOS and increases in the share of hospital discharges to home were observed from April to December 2020. These estimates will be useful for inputs to economic models, disease burden forecasts, and local healthcare resource planning.

Trends in Post-Acute Care Utilization During the COVID-19 Pandemic.

OBJECTIVE: To examine the effect of the COVID-19 pandemic on post-acute care utilization and spending. DESIGN: We used a large national multipayer claims data set from January 2019 through October 2020 to examine trends in posthospital discharge location and spending. SETTING AND PARTICIPANTS: We identified and included 975,179 hospital discharges who were aged ≥65 years. METHODS: We summarized postdischarge utilization and spending in each month of the study: (1) the percentage of patients discharged from the hospital to home for self-care and to the 3 common post-acute care locations: home with home health, skilled nursing facility (SNF), and inpatient rehabilitation; (2) the rate of discharge to each location per 100,000 insured members in our cohort; (3) the total amount spent per month in each post-acute care location; and (4) the percentage of spending in each post-acute care location out of the total spending across the 3 post-acute care settings. RESULTS: The percentage of patients discharged from the hospital to home or to inpatient rehabilitation did not meaningfully change during the pandemic whereas the percentage discharged to SNF declined from 19% of discharges in 2019 to 14% by October 2020. Total monthly spending declined in each of the 3 post-acute care locations, with the largest relative decline in SNFs of 55%, from an average of $42 million per month in 2019 to $19 million in October 2020. Declines in total monthly spending were smaller in home health (a 41% decline) and inpatient rehabilitation (a 32% decline). As a percentage of all post-acute care spending, spending on SNFs declined from 39% to 31%, whereas the percentage of post-acute care spending on home health and inpatient rehabilitation both increased. CONCLUSIONS AND IMPLICATIONS: Changes in posthospital discharge location of care represent a significant shift in post-acute care utilization, which persisted 9 months into the pandemic. These shifts could have profound implications on the future of post-acute care.

Post-acute care management of a patient with COVID-19 using remote cardiorespiratory monitoring.

Hospital discharge planning can be complex and hospital space is often limited. Patients, including those with COVID-19, can have prolonged symptoms after discharge and often require ongoing monitoring. Furthermore, prolonging hospital stays primarily for monitoring can expose patients to iatrogenic and infectious risks. The patient's overall condition and their home support system factor into the decisions of when and where to discharge patients. Innovations in remote patient monitoring (RPM) now allow for more options in the discharge process. This case report presents a patient with severe COVID-19 pneumonia where RPM was used at discharge to improve home monitoring and clinical follow-up. Additional experience with RPM is necessary to refine its role in post-acute care monitoring.

Recovery from Coronavirus Disease 2019 among Older Adults in Post-Acute Skilled Nursing Facilities.

OBJECTIVES: To examine functional outcomes of post-acute care for coronavirus disease 2019 (COVID-19) in skilled nursing facilities (SNFs). DESIGN: Retrospective cohort. SETTING AND PARTICIPANTS: Seventy-three community-dwelling adults ≥65 years of age admitted for post-acute care from 2 SNFs from March 15, 2020, to May 30, 2020. MEASURE(S): COVID-19 status was determined from chart review. Frailty was measured with a deficit accumulation frailty index (FI), categorized into nonfrail, mild frailty, and moderate-to-severe frailty. The primary outcome was community discharge. Secondary outcomes included change in functional status from SNF admission to discharge, based on modified Barthel index (mBI) and continuous functional scale scored by physical (PT) and occupational therapists (OT). RESULTS: Among 73 admissions (31 COVID-19 negative, 42 COVID-19 positive), mean [standard deviation (SD)] age was 83.5 (8.8) and 42 (57.5%) were female, with mean FI of 0.31 (0.01) with no differences by COVID-19 status. The mean length of SNF stay for rehabilitation was 21.2 days (SD 11.1) for COVID-19 negative with 20 (64.5%) patients discharged to community, compared to 23.0 (SD 12.2) and 31 (73.8%) among patients who tested positive for COVID-19. Among those discharged to the community, all groups improved in mBI, PT, and OT score. Those with moderate-to-severe frailty (FI >0.35) had lower mBI scores on discharge [92.0 (6.7) not frail, 81.0 (15.4) mild frailty, 48.6 (20.4) moderate-to-severe frailty; P = .002], lower PT scores on discharge [54.2 (3.9) nonfrail, 51.5 (8.0) mild frailty, 37.1 (9.7) moderate-to-severe frailty; P = .002], and lower OT score on discharge [52.9 (3.2) nonfrail, 45.8 (9.4) mild frailty, 32.4 (7.4) moderate or worse frailty; P = .001]. CONCLUSIONS AND IMPLICATIONS: Older adults admitted to a SNF for post-acute care with COVID-19 had community discharge rates and functional improvement comparable to a COVID-19 negative group. However, those who are frailer at admission tended to have lower function at discharge.

Physical Therapy for Hospitalized Patients With COVID-19 in Isolation: Feasibility and Pilot Implementation of Telehealth for Delivering Individualized Therapy.

OBJECTIVE: To optimize the ability of hospitalized patients isolated because of coronavirus disease 2019 (COVID-19) to participate in physical therapy (PT). DESIGN: This was a prospective quality improvement trial of the feasibility and acceptability of a "hybrid" in-person and telerehabilitation platform to deliver PT to hospitalized adults. SETTING: Inpatient wards of a tertiary care, multispecialty academic medical center in the greater New York City metropolitan area. PARTICIPANTS: A convenience sample of 39 COVID-19-positive adults (mean age, 57.3y; 69% male) all previously community dwelling agreed to participate in a combination of in-person and telerehabilitation sessions (N=39). INTERVENTIONS: Initial in-person evaluation by physical therapist followed by twice daily PT sessions, 1 in-person and 1 via a telehealth platform meeting Health Insurance Portability and Accountability Act confidentiality requirements. The communication platform was downloaded to each participant's personal smart device to establish audiovisual contact with the physical therapist. MAIN OUTCOME MEASURES: We used the 6-clicks Activity Measure of Post-Acute Care (AM-PAC) to score self-reported functional status premorbidly and by the therapist at baseline and discharge. RESULTS: Functional status measured by AM-PAC 6-clicks demonstrated improvement from admission to discharge. Barriers to participation were identified and strategies were planned to facilitate use of the platform in the future. CONCLUSIONS: A consistent and structured protocol for engaging patient participation in PT delivered via a telehealth platform was successfully developed. A process was put in place to allow for further development, recruitment, and testing in a randomized trial.