Autonomy, identity, and design in the COVID-19 era

This chapter examines the state of response and likely long-term implications across the continuum of place types for older adults, from independent housing to skilled nursing, with a focus on how physical settings and technological systems can empower autonomy and identity. It does so by adopting a person-environment (P-E) exchange framework as articulated by Chaudhury and Oswald (J Aging Stud 51:100821, 2019) This framework is structured in three sections: components of P-E interaction, P-E processes, and environment-related outcomes. Components of P-E interaction include individual characteristics, social factors, physical/built environments, and technological systems with this chapter focusing on the last two. These components form a milieu within which the dialectic interaction between agency and belonging occurs and ultimately informs assessments regarding autonomy and identity. Emergent themes discussed in this chapter include a heightened emphasis on inclusive housing models, age-friendly integration of technology, environmental flexibility in design and programming, and enhanced support for the needs of caregivers. Examining place change through an integrative P-E framework offers a lens to understanding what implications to agency and belonging might be tied to modifications in the physical and technological environment in response to COVID-19 and how that might inform outcomes related to autonomy and identity among older adults. The environmental responses to COVID-19 will accelerate the ability of independent housing to serve individuals longer in their homes and should promote a radical embrace of small house approaches to skilled care, thereby challenging assisted living as a place type altogether. (PsycInfo Database Record (c) 2023 APA, all rights reserved)

(Re)designing the continuum of care for older adults: The future of long-term care settings

This book broadens the visioning on new care environments that are designed to be inclusive, progressive, and convergent with the needs of an aging population. The contents cover a range of long-term care (LTC) settings in a single collection to address the needs of a wide audience. Due to the recent COVID-19 pandemic, rethinking the spatial design of care facilities in order to prepare for future respiratory and contagious pathogens is one of the prime concerns across the globe, along with social connectedness and autonomy in care settings. This book contributes to the next generation of knowledge and understanding of the growing field of the design of technology, programs, and environments for LTC that are more effective in infection prevention and control as well as social connectedness. To address these issues, the chapters are organized in four sections: Part I: Home- and community-based care;Part II: Facility-based care;Part III: Memory care and end-of-life care;and Part IV: Evidence-based applied projects and next steps. (Re)designing the Continuum of Care for Older Adults is an essential resource for researchers, practitioners, educators, policymakers, and students associated with LTC home and healthcare settings. With diverse topics in theory, substantive issues, and methods, the contributions from notable researchers and scholars cover a range of innovative programming, environments, and technologies which can impact the changing needs and support for older adults and their families across the continuum of care. (PsycInfo Database Record (c) 2023 APA, all rights reserved)

"It's Not a Sprint, It's a Marathon": Stages of Managing a Nursing Home Throughout the Pandemic.

OBJECTIVES: To qualitatively examine the impact of COVID-19 on nursing homes over the course of the pandemic from the perspective of nursing home administrators. DESIGN: In-depth, semi-structured interviews with nursing home administrators, repeated 3 months apart for a total of 4 each from July 2020 through December 2021. SETTINGS AND PARTICIPANTS: Administrators from a total of 40 nursing homes from 8 health care markets across the United States. METHODS: Interviews were conducted virtually or via phone. The research team identified overarching themes using applied thematic analysis, and iteratively coded transcribed interviews. RESULTS: Nursing home administrators across the United States reported challenges of managing nursing homes during a pandemic. We found their experiences could generally be categorized into 4 stages, not necessarily coinciding with surge levels of the virus. The initial stage was characterized by fear and confusion. The second stage, by a "new normal," a term administrators used to report feeling better prepared for an outbreak and how residents, staff, and families began to adjust to life with COVID. Administrators started using the phrase "a light at the end of the tunnel" to describe the third stage, characterized by the hope associated with the availability of vaccinations. The fourth stage was marked by "caregiver fatigue" as nursing homes experienced numerous breakthrough cases. Some challenges, like staffing issues and uncertainty about the future, were reported throughout the pandemic, as was a continued mission to keep residents safe. CONCLUSIONS AND IMPLICATIONS: As the ability of nursing homes to provide safe, effective care faces unprecedented and continued challenges, the insights reported here from longitudinal perspectives of nursing home administrators may help policy makers develop solutions to encourage high-quality care. Knowing how the needs for resources and support vary across the progression of these stages has the potential to be helpful in addressing these challenges.

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.

Perspectives of nursing home administrators across the United States during the COVID-19 pandemic.

OBJECTIVE: To characterize the experiences of nursing home administrators as they manage facilities across the United States during the COVID-19 pandemic. DATA SOURCES AND STUDY SETTING: We conducted 156 interviews, consisting of four repeated interviews with administrators from 40 nursing homes in eight health care markets across the country from July 2020 through December 2021. STUDY DESIGN: We subjected the interview transcripts to a rigorous qualitative analysis to identify overarching themes using a modified grounded theory approach to applied thematic analysis. DATA COLLECTION METHODS: In-depth, semi-structured qualitative interviews were conducted virtually or by phone, and audio-recorded, with participants' consent. Audio recordings were transcribed. PRINCIPAL FINDINGS: Interviews with nursing home administrators revealed a number of important cross-cutting themes. In interviewing each facility's administrator four times over the course of the pandemic, we heard perspectives regarding the stages of the pandemic, and how they varied by the facility and changed over time. We also heard how policies implemented by federal, state, and local governments to respond to COVID-19 were frequently changing, confusing, and conflicting. Administrators described the effect of COVID-19 and efforts to mitigate it on residents, including how restrictions on activities, communal dining, and visitation resulted in cognitive decline, depression, and weight loss. Administrators also discussed the impact of COVID-19 on staff and staffing levels, reporting widespread challenges in keeping facilities staffed as well as strategies used to hire and retain staff. Administrators described concerns for the sustainability of the nursing home industry resulting from the substantial costs and pressures associated with responding to COVID-19, the reductions in revenue, and the negative impact of how nursing homes appeared in the media. CONCLUSIONS: Findings from our research reflect nursing home administrator perspectives regarding challenges operating during COVID-19 and have substantial implications for policy and practice.

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.

Where is the Evidence on Acoustic Considerations for Dementia Care Settings: A Scoping Review...American Congress of Rehabilitation Medicine (ACRM) 99th Annual Conference, November 8-11, 2022, Chicago, Illinois

To provide up to date evidence on the acoustic considerations for dementia care settings, to support healthspan and quality of life. Scoping Review. Institutionalized settings to include assisted living, nursing homes, rehabilitation centers, skilled nursing facilities, and other supported care environments. Individuals living with dementia. Per the nature of a scoping review, we are considering multiple levels of evidence and several aspects of the intervention of interest, to include the following: auditory environment, acoustic environment, or sound-based intervention or observation. Cognitive, behavioral, or other health related outcomes relative to participants with dementia. The initial search was carried out by a librarian and yielded 1671 articles for screening after duplicates were removed. Title and screening was carried out among 4 independent reviewers via Covidence review software. Of the initial 1671 articles, 101 were included for full text review. Full text review screening is ongoing. This will be followed by data extraction and the development of a thematic summary of the available evidence. We plan to complete this review prior to reporting at the conference. We anticipate our findings to provide preliminary insight into the importance of acoustic environments and interventions in supporting the day-to-day functional needs of older adults living with dementia in supported contexts. This preliminary insight will be used to guide future, high level evidence, needed to further elucidate this aspect of care. N/A.

Dual impacts of Medicare payment reform and the COVID-19 pandemic on therapy staffing in skilled nursing facilities.

BACKGROUND: Implementation of new skilled nursing facility (SNF) Medicare payment policy, the Patient Driven Payment Model (PDPM), resulted in immediate declines in physical and occupational therapy staffing. This study characterizes continuing impacts of PDPM in conjunction with COVID-19 on SNF therapy staffing and examines variability in staffing changes based on SNF organizational characteristics. METHODS: We analyzed Medicare administrative data from a national cohort of SNFs between January 2019 and March 2022. Interrupted time series mixed effects regression examined changes in level and trend of total therapy staffing minutes/patient-day during PDPM and COVID-19 and by type of staff (therapists, assistants, contractors, and in-house staff). Secondary analyses examined the variability in staffing by organizational characteristics. RESULTS: PDPM resulted in a -6.54% level change in total therapy staffing, with larger declines for assistants and contractors. Per-patient staffing fluctuated during COVID-19 as the census changed. PDPM-related staffing declines were larger in SNFs that were: Rural, for-profit, chain-affiliated, provided more intensive therapy, employed more therapy assistants, and admitted more Medicare patients before PDPM. COVID-19 resulted in larger staffing declines in rural SNFs but smaller early declines in SNFs that were hospital-based, for-profit, or received more relief funding. CONCLUSIONS: SNFs that historically engaged in profit-maximizing behaviors (e.g., providing more therapy via lower-paid assistants) had larger staffing declines during PDPM compared to other SNFs. Therapy staffing fluctuated during COVID-19, but PDPM-related reductions persisted 2 years into the pandemic, especially in rural SNFs. Results suggest specific organizational characteristics that should be targeted for staffing and quality improvement initiatives.

Sharing Lessons From Successes: Long-term Care Facilities That Weathered the Storm of COVID-19 and Staffing Crises

Purpose: To identify leadership styles and staffing strategies in Missouri long-term care (LTC) facilities that stood out among their peers as "positive deviants" with regard to COVID-19 infections and staffing shortages. Methods: Statewide survey of all LTC facilities to identify exemplar facilities with stable staffing and low rates of COVID-19. Interviews with senior leaders were conducted in 10 facilities in the state to understand the strategies employed that led to these "positive outliers." A result-based educational program was designed to describe their actions and staff reactions. Results: Exemplar leaders used transformational leadership style. Top reasons for their success were as follows: (1) trusting and supportive staff relationships;(2) positive presence and communication;and (3) use of consistent staffing assignments. Strong statewide participation was noted in the educational programs.

Need for inpatient rehabilitation and skilled nursing services in COVID-19 patients post hospitalization: a retrospective cohort study.

BACKGROUND: The need for rehabilitation and skilled nursing services for coronavirus disease 2019 (COVID-19) survivors has been speculated from the beginning of the pandemic. However, real-world data describing utilization of these services post COVID-19 hospitalization and the factors associated with the same is limited. This retrospective cohort study on COVID-19 patients aims to identify the patients discharged to inpatient rehabilitation or nursing facilities post-hospitalization and the factors associated with the same. METHODS: A retrospective cohort study on COVID-19 patients during second wave of the pandemic in the state of Michigan. Primary outcome was discharge disposition. Binary logistic regression was conducted to identify the factors associated with discharge to a facility. RESULTS: A total of 559 COVID-19 patients [median age 64 years, interquartile range (IQR) 53-73 years, 48.5% males (n=271), 67.6% Blacks (n=378)] were included in the study. During hospitalization, 17.4% of the patients (n=97) died. Around 65% (n=365) patients were discharged home whereas 12.5% (n=70) were discharged to a facility for inpatient rehabilitation/nursing services. Older patients, males, those with longer hospital stay, and patients who needed new percutaneous endoscopic gastrostomy (PEG) tube, tracheostomy, initiation of hemodialysis or continuous renal replacement therapy (CRRT), or had an acute stroke during admission were more likely to be discharged to a facility post-hospitalization. CONCLUSIONS: About 12.5% of hospitalized COVID-19 patients needed discharge to a facility for inpatient rehabilitation/nursing services. Knowledge of the factors associated with discharge to a facility can optimize discharge planning, efficient resource allocation, and improve long-term COVID-19 care.

Connect-Home transitional care from skilled nursing facilities to home: A stepped wedge, cluster randomized trial.

BACKGROUND: Skilled nursing facility (SNF) patients and their caregivers who transition to home experience complications and frequently return to acute care. We tested the efficacy of the Connect-Home transitional care intervention on patient and caregiver preparedness for care at home, and other patient and caregiver-reported outcomes. METHODS: We used a stepped wedge, cluster-randomized trial design to test the intervention against standard discharge planning (control). The setting was six SNFs and six home health offices in one agency. Participants were 327 dyads of patients discharged from SNF to home and their caregivers; 11.1% of dyads in the control condition and 81.2% in the intervention condition were enrolled after onset of COVID-19. Patients were 63.9% female and mean age was 76.5 years. Caregivers were 73.7% female and mean age was 59.5 years. The Connect-Home intervention includes tools, training, and technical assistance to deliver transitional care in SNFs and patients' homes. Primary outcomes measured at 7 days included patient and caregiver measures of preparedness for care at home, the Care Transitions Measure-15 (patient) and the Preparedness for Caregiving Scale (caregiver). Secondary outcomes measured at 30 and 60 days included the McGill Quality of Life Questionnaire, Life Space Assessment, Zarit Caregiver Burden Scale, Distress Thermometer, and self-reported number of patient days in the ED or hospital in 30 and 60 days following SNF discharge. RESULTS: The intervention was not associated with improvement in patient or caregiver outcomes in the planned analyses. Post-hoc analyses that distinguished between pre- and post-pandemic effects suggest the intervention may be associated with increased patient preparedness for discharge and decreased number of acute care days. CONCLUSIONS: Connect-Home transitional care did not improve outcomes in the planned statistical analysis. Post-hoc findings accounting for COVID-19 impact suggest SNF transitional care has potential to increase patient preparedness and decrease return to acute care.

Between a Rock and a Hard Place: COVID-19 Lessons Learned From Providers Rounding at Skilled Nursing Facilities in the Rural Midwest.

On March 11, 2020, coronavirus disease 2019 (COVID-19) was classified as a pandemic, setting in motion unprecedented practice changes across the healthcare industry. Never was this more evident than in Skilled Nursing Facilities (SNFs). SNFs were tested on multiple fronts, requiring innovation and perseverance at levels never before seen. Lessons learned from this setting to better prepare for the next pandemic include: updating and standardizing infection control and prevention policies, ensuring the supply chain keeps up with demand, updating infrastructure, creating a work environment that promotes well-being, and having clear communication plans.

The Advanced Practice Registered Nurse Leadership Role in Nursing Homes: Leading Efforts Toward High Quality and Safe Care.

This article highlights the critical role of advanced practice registered nurses in the care of older adults living in nursing homes. This population is one of the frailest, marginalized, and often neglected in the United States. The COVID-19 pandemic impact on nursing homes resulted in a stunning number of infections and subsequent resident deaths. This is a shameful reminder of the many challenges and gaps in the nursing home industry including inadequate staffing, high staff turnover, improper isolation technique, and lack of fundamental knowledge of how to adequately implement infection prevention and control processes. Strong advanced practice registered nurse leadership may have mitigated some of these factors.

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.

Quality of care among skilled nursing facilities: A mixed methods investigation of person-centered care and workplace environment

Skilled nursing facilities (SNFs) across the United States strive to provide a high quality of care for their residents. Person-centered care is often seen as a domain of quality of care as it individualizes care to the resident. Along with attending to care needs, direct care professionals (DCPs) must navigate aspects of their workplace environment, such as staff burnout and engagement, that influence the quality of care provided. Additionally, recently SNFs have experienced the impact of the coronavirus disease 2019 (COVID-19) pandemic, which was an unprecedented event that produced challenges for SNFs and influenced care practices due to increased regulations and change in social interactions and safeguards. Therefore, the aim of the current study was to examine multiscale influences on the quality of care in SNFs (e.g., person-centered approaches, workplace characteristics), reflecting the long-term goal to improve quality of care and resident outcomes in SNFs.An exploratory mixed methods approach was utilized for data collection, analysis, and interpretation. Eleven SNFs in Iowa were recruited for this study. The recruited SNFs represented varied SNF characteristics (e.g., bed count, staffing hours) and Accountable Care Organization (ACO) affiliation was also considered during recruitment. Administrators from the SNFs participated in interviews (N=11), during which the researcher gauged perceptions of person-centered care (PCC), staff burnout and engagement, management and leadership principles, views of resident outcomes, and staff training. DCPs completed surveys (N=83) to assess perceptions of PCC, staff burnout, and engagement. Additionally, Centers for Medicare and Medicaid Services data were utilized to assess SNF characteristics (e.g., profit status, bed count) and Minimum Data Set resident outcomes (e.g., falls, urinary tract infections).The impact of the COVID-19 pandemic on SNFs constituted the primary focus in the first study. Results indicated resident outcomes that were worse than the national average increased from 2019 to 2020 and then decreased from 2020 to 2021. Slopegraphs were employed to provide visualizations of trends in resident outcomes over time. Thematic analysis revealed administrators reported SNFs were impacted by the pandemic by staff concern regarding COVID-19, financial strain, resident isolation, new regulations and protocols, and staffing challenges (e.g., turnover, shift coverage). DCPs reported SNFs were impacted by the pandemic by limited or no family/friend visits;required masks and personal protective equipment (PPE);resident death;staffing challenges;and resident isolation. Lastly, DCPs reported that the COVID-19 pandemic impacted their day-to-day work and burnout a great deal;however, overall DCPs reported low to moderate feelings of burnout. Care practices, regulations and policies, staffing issues, and establishing a new normal are important implications based on the findings from this study.Identifying associations between resident outcomes and PCC, burnout, engagement, and SNF characteristics was the focus of the second study. Results indicated PCC was positively correlated with engagement and negatively correlated with burnout. Scatterplots produced visualizations of trends between resident outcomes and PCC, burnout, and engagement. Themes from administrators and DCPs were identified surrounding common contributors to burnout (e.g., low wages, short staffing), factors influencing staff engagement (e.g., events, providing one-on-one care), and implementation of PCC (e.g., care planning, involving the resident). Lastly, clustering of SNFs that were associated with PCC, burnout, engagement, and resident outcomes were discerned based on profit status, Accountable Care Organization affiliation, and bed count. (PsycInfo Database Record (c) 2022 APA, all rights reserved)

Changes in Therapy Utilization at Skilled Nursing Facilities Under Medicare's Patient Driven Payment Model.

OBJECTIVES: The Patient Driven Payment Model (PDPM) was implemented in October 2019 to reimburse skilled nursing facilities (SNFs) based on Medicare patients' clinical and functional characteristics rather than the volume of services provided. This study aimed to examine the changes in therapy utilization and quality of care under PDPM. DESIGN: Quasi-experimental design. SETTING AND PARTICIPANTS: In total, 35,540 short stays by 27,967 unique patients in 121 Oregon SNFs. METHODS: Using Minimum Data Set data from January 2019 to February 2020, we compared therapy utilization and quality of care for Medicare short stays before and after PDPM implementation to non-Medicare short stays. RESULTS: The number of minutes of individual occupational therapy (OT) and physical therapy (PT) per week for Medicare stays decreased by 19.3% (P < .001) and 19.0% (P < .001), respectively, in the first 5 months of PDPM implementation (before the COVID-19 pandemic). The number of group OT and PT minutes increased by 1.67 (P < .001) and 1.77 (P < .001) minutes, respectively. The magnitude of PDPM effects varied widely across stays with different diagnoses. PDPM implementation was not associated with statistically significant changes in length of SNF stay (P = .549), discharge to the community (P = .208), or readmission to the SNF within 30 days (P = .684). CONCLUSIONS AND IMPLICATIONS: SNFs responded to PDPM with a significant reduction in individual OT and PT utilization and a smaller increase in group OT and PT utilization. No changes were observed in length of SNF stay, rates of discharge to the community, or readmission to the SNF in the first 5 months of PDPM implementation. Further research should examine the relative effects of individual and group therapy and their impact on the quality of SNF care.

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.