COVID-19 Vaccination Among Skilled Nursing Facility Staff: Challenges and Strategies Identified by Administrators.

COVID-19 vaccinations are critical for mitigating outbreaks and reducing mortality for skilled nursing facility (SNF) residents and staff, yet uptake among SNF staff varies widely and remains suboptimal. Understanding which strategies are successful for promoting staff vaccination, and examining the relationship between vaccination policies and staff retention/turnover is key for identifying best practices. We conducted repeated interviews with SNF administrators at 3-month intervals between July 2020 and December 2021 (n = 156 interviews). We found that COVID-19 vaccines were initially met with both enthusiasm and skepticism by SNF staff. Administrators reported strategies to increase staff vaccine acceptance, including incentives, one-on-one education, and less stringent personal protective equipment requirements. Federal and state vaccination mandates further promoted vaccine uptake. This combination of mandates with prioritization of the vaccine by SNFs and their leadership was successful at increasing staff vaccination acceptance, which may be critical to increase staff booster uptake from its current suboptimal levels.

Containment of COVID-19 outbreak at a veterans affairs community living center.

Asymptomatic and pre-symptomatic staff and residents likely contribute to widespread transmission of COVID-19 in long-term care settings. Here, we describe the successful containment of a COVID-19 outbreak on one floor of a 163-bed Veterans Affairs (VA) Community Living Center (CLC). Testing using nasopharyngeal swabs with a rapid turn-around-time identified 3 of 28 (11%) residents and 2 of 41 (5%) healthcare personnel (HCP) with COVID-19. Both HCP likely worked on the floor while pre-symptomatic. When one HCP reported a cough to the secondary (employee) screening clinic, she was erroneously advised to work. Protocols to limit the risk for HCP to import COVID-19 were reinforced with Community Living Center staff as well as with personnel in secondary screening. Further, the CLC implemented an expanded screening tool that assessed residents for typical and atypical symptoms of COVID-19. No further cases of COVID-19 were detected on the CLC floor in the subsequent 6 weeks. Swift recognition and response helped contain the outbreak and prevent further COVID-19 infections among other residents and staff.

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.

Effectiveness of Coronavirus Disease 2019 (COVID-19) mRNA Vaccines Against Infection During an Outbreak of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Beta (B.1.351) Variant in a Skilled Nursing Facility: Virginia, March-April 2021.

In April 2021, we assessed mRNA vaccine effectiveness (VE) in the context of a COVID-19 outbreak in a skilled nursing facility. Among 28 cases, genomic sequencing was performed on 4 specimens on 4 different patients, and all were classified by sequence analysis as the Beta (B.1.351) variant. Adjusted VE among residents was 65% (95% confidence interval: 25-84%). These findings underscore the importance of vaccination for prevention of COVID-19 in skilled nursing facilities.

Estimating COVID-19 Vaccine Effectiveness for Skilled Nursing Facility Healthcare Personnel, California, USA.

We estimated real-world vaccine effectiveness among skilled nursing facility healthcare personnel who were regularly tested for SARS-CoV-2 infection in California, USA, during January‒March 2021. Vaccine effectiveness for fully vaccinated healthcare personnel was 73.3% (95% CI 57.5%-83.3%). We observed high real-world vaccine effectiveness in this population.

Lessons learned from COVID-19 outbreak in a skilled nursing facility, Washington State.

Long-term care facilities have been identified as a local epicenter of disease among populations vulnerable to coronavirus disease 2019 (COVID-19). A skilled nursing facility in Washington State was the first major site of COVID-19 infections in the United States. Many lessons were learned during the events surrounding this outbreak, including how to develop, and the importance of, a coordinated response between emergency medical services and local area hospitals. As these events came early in the U.S. pandemic, unfortunately, disease spread and mortality was high. However, these events also resulted in rapid mobilization of the regional response to the COVID-19 pandemic. Understanding the events surrounding this outbreak demonstrate some of the challenges involved in responding to acute infectious illnesses within these unique environments and associated vulnerable populations.

Investigation of a Severe Acute Respiratory Syndrome Coronavirus 2 Delta (B.1.617.2) Variant Outbreak Among Residents of a Skilled Nursing Facility and Vaccine Effectiveness Analysis: Maricopa County, Arizona, June-July 2021.

BACKGROUND: Short-term rehabilitation units present unique infection control challenges because of high turnover and medically complex residents. In June 2021, the Maricopa County Department of Public Health was notified of a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Delta outbreak in a skilled nursing facility short-term rehabilitation unit. We describe the outbreak and assess vaccine effectiveness (VE). METHODS: Facility electronic medical records were reviewed for residents who spent > 1 night on the affected unit between June 10 and July 23, 2021, to collect demographics, SARS-CoV-2 test results, underlying medical conditions, vaccination status, and clinical outcomes. Coronavirus disease 2019 VE estimates using Cox proportional hazards models were calculated. RESULTS: Forty (37%) of 109 short-stay rehabilitation unit residents who met inclusion criteria tested positive for SARS-CoV-2. SARS-CoV-2-positive case-patients were mostly male (58%) and White (78%) with a median age of 65 (range, 27-92) years; 11 (27%) were immunocompromised. Of residents, 39% (10 cases, 32 noncases) received 2 doses and 9% (4 cases, 6 noncases) received 1 dose of messenger RNA (mRNA) vaccine. Among nonimmunocompromised residents, adjusted 2-dose primary-series mRNA VE against symptomatic infection was 80% (95% confidence interval, 15-95). More cases were hospitalized (33%) or died (38%) than noncases (10% hospitalized; 16% died). CONCLUSIONS: In this large SARS-CoV-2 Delta outbreak in a high-turnover short-term rehabilitation unit, a low vaccination rate and medically complex resident population were noted alongside severe outcomes. VE of 2-dose primary-series mRNA vaccine against symptomatic infection was the highest in nonimmunocompromised residents. Health departments can use vaccine coverage data to prioritize facilities for assistance in preventing outbreaks.

Prevalence Rates and Characteristics of Malnutrition, Frailty, and Other Nutrition and Muscle Mass-Related Conditions Document Potential Quality of Care Gap for Medicare Patients in US Skilled Nursing Facilities.

Changes to the payment structure of the United States (U.S.) healthcare system are leading to an increased acuity level of patients receiving short-term skilled nursing facility care. Most skilled nursing facility patients are older, and many have medical conditions that cannot be changed. However, conditions related to nutrition/muscle mass may be impacted if there is early identification/intervention. To help determine the diagnosis and potential impact of nutrition/muscle mass-related conditions in skilled nursing facilities, this study evaluated 2016-2020 US Medicare claims data. Methods aimed to identify a set of skilled nursing facility claims with one or more specific diagnoses (COVID-19, malnutrition, sarcopenia, frailty, obesity, diabetes, and/or pressure injury) and then to determine length of stay, discharge status, total charges, and total payments for each claim. Mean values per beneficiary were computed and between-group comparisons were performed. Results documented that each year, the total number of Medicare skilled nursing facility claims declined, whereas the percentage of claims for each study diagnosis increased significantly. For most conditions, potentially related to nutrition/muscle mass, Medicare beneficiaries had a shorter length of skilled nursing facility stays compared to those without the condition(s). Furthermore, a lower percentage of these Medicare beneficiaries were discharged home (except for those with claims for sarcopenia and obesity). Total claim charges for those with nutrition/muscle mass-related conditions exceeded those without (except for those with sarcopenia). We conclude that although the acuity level of patients in skilled nursing facilities continues to increase, skilled nursing facility Medicare claims for nutrition/muscle mass-related conditions are reported at lower levels than their likely prevalence. This represents a potential care gap and requires action to help improve patient health outcomes and skilled nursing facility quality metrics.

Effects of the COVID-19 pandemic on hip fracture volume, disposition, and readmission rates.

Our study aimed to assess the effects COVID had on the incidence of hip fractures. Hip fracture cases (from March 1 to September 1) were compared in 2018, 2019, and 2020. Data were analyzed for surgical volume, discharge location, and readmission rates. There was a statistically significant decrease in hip fractures during 2020 (P < 0.01) and a decrease in patients placed in skilled nursing facilities (P = 0.04), with no increase in 30-day readmission (P = 0.776). Findings suggest that COVID-19 has impacted the volume and composition of hip fracture cases. Although additional research on the subsequent survival impact is necessary, these placement patterns of hip fracture patients into facilities may be an opportunity to optimize cost and care.

The Case for Malnutrition Quality Measures and Nutrition-Focused Quality Improvement Programs (QIPs) in US Skilled Nursing Facilities.

As skilled nursing in the United States moves to a value-based model, malnutrition care remains a critical gap area that is associated with multiple poor health outcomes, including hospital readmissions and declines in functional status, psychosocial well-being, and quality of life. Malnutrition is often undiagnosed/untreated, even though it impacts up to half of skilled nursing facility (SNF) residents, and COVID-19 infections/related symptoms have likely further increased this risk. In acute care, malnutrition quality measures have been both developed/tested, and nutrition-focused quality improvement programs (QIPs) have been shown to reduce costs and effectively improve care processes and patient outcomes. Less is known about such quality initiatives in SNF care. This perspective paper reviewed malnutrition-related quality measures and nutrition-focused QIPs in SNFs and nursing home care. It identified that although the Centers for Medicare & Medicaid Services (CMS) has had a nursing home Quality Assurance and Performance Improvement (QAPI) program for 10 years and has had SNF quality measures for nearly 20 years, there are no malnutrition-specific quality measures for SNFs and very few published nutrition-focused QIPs in SNFs. This represents an important care gap that should be addressed to improve resident health outcomes as SNFs more fully move to a value-based care model.

Assessment of the impact of patient/family video visitation on depression severity scores at a hospital-based skilled nursing facility

Background: The COVID-19 global pandemic resulted in regulations severely restricting patient visitation in Skilled Nursing Facilities (SNF). Lack of family visitation can have a negative impact on patients such as loneliness, social isolation, and feelings of depression. Therefore, prompting this facility act to reduce the barriers for this, often fragile, patient population, at high risk for depression. Purpose: The purpose of this quality improvement (QI) project was to improve the resources provided by a hospital-based SNF to prevent or lessen depression in patients, related to restricted family visitation, through implementation of a patient-family video visitation initiative. Methods: This QI project used a before and after design to implement a technology-based patient/family video visitation initiative aimed at preventing or decreasing depression severity in patients cared for in a hospital-based SNF during the COVID-19 pandemic. Video visitation was implemented using an I-pad and the Microsoft Teams platform to allow for face-to-face visitation. PHQ-9 scores and patient/family satisfaction with video visitation were measured before and after the intervention. Conclusion: The initiation of a technology-based, patient-family visitation resource by the SNF resulted in patients scoring in the minimal depression category before and after the intervention, supporting the use of video visitation to prevent depression or worsening depression due to prolonged isolation of patients. The initiative illuminated the organizational and feasibility factors to be considered and mitigated when introducing new technology and processes into an already strained health care setting. Lessons learned and similar positive outcomes, can be expanded to many health settings faced with long lengths of patient stays where family members have regulatory, organizational, or personal barriers to visitation. (PsycInfo Database Record (c) 2022 APA, all rights reserved)

Telehealth Use and Hospital Readmission Rates in Long-term Care Facilities in Southeastern Minnesota During the COVID-19 Pandemic.

Objective: To determine whether the length of a telehealth visit predicted the risk of hospital readmission at 30 days in skilled nursing facilities (SNFs) in southeastern Minnesota during the coronavirus disease 2019 pandemic. Patients and Methods: This was a retrospective cohort study conducted in SNFs located in southeastern Minnesota from March 1, 2020 through July 15, 2020. The primary outcomes included hospitalization within 30 days of a video visit, and the secondary outcome was the number of provider video visits during the stay at an SNF. The primary predictor was the duration of video visits, and we collected the data regarding other known predictors of hospitalization. We used the χ2 test for categorical variables and multivariate conditional logistic regression. Results: We included 722 patients (mean age, 82.8 years [SD, 10.8 years]). Of those, 76 SNF residents (10.5%) were rehospitalized within 30 days. The average length of a video visit was 34.0 minutes (SD, 22.7 minutes) in admitted residents compared with 30.0 minutes (SD, 15.9 minutes) in nonadmitted residents. After full adjustment, there was no difference in the video visit duration between admitted and nonadmitted residents (odds ratio, 1.01; 95% CI, 0.99-1.03). The number of subsequent provider video visits was 2.26 (SD, 1.9) in admitted residents vs 1.58 (SD, 1.6), which was significant after adjustment (odds ratio, 1.17; 95% CI, 1.02-1.34). Conclusion: There was no difference in the length of video visits for hospitalized SNF residents vs those who were not hospitalized within 30 days of a video visit. There were more visits in residents with hospital readmission. This may reflect the acuity of care for patients requiring a hospital stay. More research is needed to determine the ideal use of telehealth during the coronavirus disease 2019 pandemic in the postacute and long-term care environment.

Facility characteristics and costs associated with meeting proposed minimum staffing levels in skilled nursing facilities.

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.

Implementation of a national testing policy in Dutch nursing homes during SARS-CoV-2 outbreaks.

BACKGROUND: To evaluate how a national policy of testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) regardless of symptoms was implemented during outbreaks in Dutch nursing homes in the second wave of the pandemic and to explore barriers and facilitators to serial testing. METHODS: We conducted a mixed-method study of nursing homes in the Netherlands with a SARS-CoV-2 outbreak after 15 September 2020. Direct care staff and management from 355 healthcare organizations were invited to participate in a digital survey. A total of 74 out of 355 (20.9%) healthcare organizations participated and provided information about 117 nursing homes. We conducted 26 in-depth interviews on the outbreak and the testing strategy used. We also conducted four focus group meetings involving managers, physicians, nurses, and certified health assistants. Recordings were transcribed and data were thematically analyzed. RESULTS: One hundred and four nursing homes (89%) tested residents regardless of their symptoms during the outbreak, and 85 nursing homes (73%) tested the staff regardless of their symptoms. However, interviews showed testing was sometimes implemented during later stages of the outbreak and was not always followed up with serial testing. Barriers to serial testing regardless of symptoms were lack of knowledge of local leaders with decisional making authority, lack of a cohort ward or skilled staff, and insufficient collaboration with laboratories or local public health services. Important facilitators to serial testing were staff willingness to undergo testing and the availability of polymerase chain reaction (PCR) tests. CONCLUSIONS: Serial testing regardless of symptoms was only partially implemented. The response rate of 21% of nursing home organizations gives a risk of selection bias. Barriers to testing need to be addressed. A national implementation policy that promotes collaboration between public health services and nursing homes and educates management and care staff is necessary.

Integrating Principles of Safety Culture and Just Culture Into Nursing Homes: Lessons From the Pandemic.

Decades of concerns about the quality of care provided by nursing homes have led state and federal agencies to create layers of regulations and penalties. As such, regulatory efforts to improve nursing home care have largely focused on the identification of deficiencies and assignment of sanctions. The current regulatory strategy often places nursing home teams and government agencies at odds, hindering their ability to build a culture of safety in nursing homes that is foundational to health care quality. Imbuing safety culture into nursing homes will require nursing homes and regulatory agencies to acknowledge the high-risk nature of post-acute and long-term care settings, embrace just culture, and engage nursing home staff and stakeholders in actions that are supported by evidence-based best practices. The response to the COVID-19 pandemic prompted some of these actions, leading to changes in nursing survey and certification processes as well as deployment of strike teams to support nursing homes in crisis. These actions, coupled with investments in public health that include funds earmarked for nursing homes, could become the initial phases of an intentional renovation of the existing regulatory oversight from one that is largely punitive to one that is rooted in safety culture and proactively designed to achieve meaningful and sustained improvements in the quality of care and life for nursing home residents.

Lessons learned in preventing COVID-19 within a skilled nursing facility during the early pandemic.

OBJECTIVE: Guided by the vulnerable population framework, the aim was to describe the risks and protective strategies for COVID-19 spread and infections in a Skilled Nursing Facility (SNF). METHOD: We conducted a retrospective cohort (March 1st-August 31st, 2020) study. Data were collected from internal COVID-19 documents and resident electronic health records. Data were summarized and analyzed using descriptive statistics, relative risk calculations, and cases charted by week onset. RESULTS: There were 325 residents who lived in and 296 staff who worked at the SNF during the study period. There was a total of 2 confirmed cases among residents and 4 confirmed cases among staff. Cases were isolated and all were living at their baseline health status at the end of the study. CONCLUSION: Understanding the vulnerability to and protective strategies for COVID-19 within SNFs could strengthen resident care, resiliency among the SNF community, and improve health policies.

Repeat positive SARS-CoV-2 RNA testing in nursing home residents during the initial 9 months of the COVID-19 pandemic: an observational retrospective analysis.

BACKGROUND: Nursing homes are high-risk COVID-19 settings with residents who are typically older and have multiple comorbidities. SARS-CoV-2 testing occurs frequently in nursing homes, with public health guidance suggesting that repeat testing is generally not warranted in the 90 days following initial positive test results. Interpretation of repeat positive tests beyond 90 days is challenging and the consequences of decisions following these tests are significant. METHODS: We utilized a surveillance system for COVID-19 to identify Connecticut nursing home residents who tested positive for SARS-CoV-2 by RNA-based testing ≥ 90 days after initial positive results. We analyzed statewide nursing home testing data over a 9-month period, from the first Connecticut nursing home case identified on March 15 through December 15, 2020, when nursing home COVID-19 vaccinations began in Connecticut. FINDINGS: We identified 156 residents (median age 75 years) with positive RNA-based PCR tests occurring ≥90 days after an initial positive test. Residents with repeat positives tests represented approximately 2.6% (156/6,079) of nursing home residents surviving beyond 90 days of their initial SARS-CoV-2 diagnosis statewide since the start of the pandemic, with a median time to repeat positivity of 135 days (range 90-245 days). Deaths were reported in 12.8% (20/156) of residents following the repeat positive test, with 80% (16/20) having one or more intervening negative RT-PCR tests prior to the repeat positive test. INTERPRETATION: Our analysis suggests that repeat positive testing in nursing home populations may exceed those reported in younger age groups. Repeat positive tests beyond 90 days may accompany severe outcomes, and should be prospectively investigated with genomic, virologic and additional data, when feasible. Data shed light on the duration of protective immunity following natural infection in this subset of largely elderly and medically frail individuals. FUNDING: This work was conducted in the context of the Connecticut DPH COVID-19 response and not supported by specific funding.

Building community and resilience in Massachusetts nursing homes during the COVID-19 pandemic.

During the COVID-19 pandemic, frontline nursing home staff faced extraordinary stressors including high infection and mortality rates and ever-changing and sometimes conflicting federal and state regulations. To support nursing homes in evidence-based infection control practices, the Massachusetts Senior Care Association and Hebrew SeniorLife partnered with the Agency for Healthcare Research and Quality AHRQ ECHO National Nursing Home COVID-19 Action Network (the network). This educational program provided 16 weeks of free weekly virtual sessions to 295 eligible nursing homes, grouped into nine cohorts of 30-33 nursing homes. Eighty-three percent of eligible nursing homes in Massachusetts participated in the Network, and Hebrew SeniorLife's Training Center served the vast majority. Each cohort was led by geriatrics clinicians and nursing home leaders, and coaches trained in quality improvement. The interactive sessions provided timely updates on COVID-19 infection control best practices to improve care and also created a peer-to-peer learning community to share ongoing challenges and potential solutions. The weekly Network meetings were a source of connection, emotional support, and validation and may be a valuable mechanism to support resilience and well-being for nursing home staff.

Infection control response to an outbreak of OXA-23 carbapenemase-producing carbapenem-resistant Acinetobacter baumannii in a skilled nursing facility in Utah.

BACKGROUND: Antibiotic-resistant Acinetobacter species are a growing public health threat, yet are not nationally notifiable, and most states do not mandate reporting. Additionally, there are no standardized methods to detect Acinetobacter species colonization. METHODS: An outbreak of carbapenem-resistant Acinetobacter baumannii (CRAB) was identified at a Utah ventilator unit in a skilled nursing facility. An investigation was conducted to identify transmission modes in order to control spread of CRAB. Culture-based methods were used to identify patient colonization and environmental contamination in the facility. RESULTS: Of the 47 patients screened, OXA-23-producing CRAB were detected in 10 patients (21%), with 7 patients (15%) having been transferred from out-of-state facilities. Of patients who screened positive, 60% did not exhibit any signs or symptoms of active infection by chart review. A total of 38 environmental samples were collected and CRAB was recovered from 37% of those samples. Whole genome sequencing analyses of patient and environmental isolates suggested repeated CRAB introduction into the facility and highlighted the role of shared equipment in transmission. CONCLUSIONS: The investigation demonstrated this ventilated skilled nursing facility was an important reservoir for CRAB in the community and highlights the need for improved surveillance, strengthened infection control and inter-facility communication within and across states.