Advancing Clinical Trials in Nursing Homes: A Proposed Roadmap to Success.

An effective clinical research effort in nursing homes to address prevention and treatment of COVID-19 faced overwhelming challenges. Under the Health Care Systems Research Network-Older Americans Independence Centers AGING Initiative, a multidisciplinary Stakeholder Advisory Panel was convened to develop recommendations to improve the capability of the clinical research enterprise in US nursing homes. The Panel considered the nursing home as a setting for clinical trials, reviewed the current state of clinical trials in nursing homes, and ultimately developed recommendations for the establishment of a nursing home clinical trials research network that would be centrally supported and administered. This report summarizes the Panel's recommendations, which were developed in alignment with the following core principles: build on available research infrastructure where appropriate; leverage existing productive partnerships of researchers with groups of nursing homes and nursing home corporations; encompass both efficacy and effectiveness clinical trials; be responsive to a broad range of stakeholders including nursing home residents and their care partners; be relevant to an expansive range of clinical and health care delivery research questions; be able to pivot as necessary to changing research priorities and circumstances; create a pathway for industry-sponsored research as appropriate; invest in strategies to increase diversity in study populations and the research workforce; and foster the development of the next generation of nursing home researchers.

Pro-active monitoring and social interventions at community level mitigate the impact of coronavirus (COVID-19) epidemic on older adults' mortality in Italy: A retrospective cohort analysis.

BACKGROUND: The COVID-19 epidemic in Italy has severely affected people aged more than 80, especially socially isolated. Aim of this paper is to assess whether a social and health program reduced mortality associated to the epidemic. METHODS: An observational retrospective cohort analysis of deaths recorded among >80 years in three Italian cities has been carried out to compare death rate of the general population and "Long Live the Elderly!" (LLE) program. Parametric and non-parametric tests have been performed to assess differences of means between the two populations. A multivariable analysis to assess the impact of covariates on weekly mortality has been carried out by setting up a linear mixed model. RESULTS: The total number of services delivered to the LLE population (including phone calls and home visits) was 34,528, 1 every 20 day per person on average, one every 15 days during March and April. From January to April 2019, the same population received one service every 41 days on average, without differences between January-February and March-April. The January-April 2020 cumulative crude death rate was 34.8‰ (9,718 deaths out of 279,249 individuals; CI95%: 34.1-35.5) and 28.9‰ (166 deaths out of 5,727 individuals; CI95%:24.7-33.7) for the general population and the LLE sample respectively. The general population weekly death rate increased after the 11th calendar week that was not the case among the LLE program participants (p<0.001). The Standardized Mortality Ratio was 0.83; (CI95%: 0.71-0.97). Mortality adjusted for age, gender, COVID-19 weekly incidence and prevalence of people living in nursing homes was lower in the LLE program than in the general population (p<0.001). CONCLUSIONS: LLE program is likely to limit mortality associated with COVID-19. Further studies are needed to establish whether it is due to the impact of social care that allows a better clients' adherence to the recommendations of physical distancing or to an improved surveillance of older adults that prevents negative outcomes associated with COVID-19.

Hybrid simulation modelling of networks of heterogeneous care homes and the inter-facility spread of Covid-19 by sharing staff.

Although system dynamics [SD] and agent-based modelling [ABM] have individually served as effective tools to understand the Covid-19 dynamics, combining these methods in a hybrid simulation model can help address Covid-19 questions and study systems and settings that are difficult to study with a single approach. To examine the spread and outbreak of Covid-19 across multiple care homes via bank/agency staff and evaluate the effectiveness of interventions targeting this group, we develop an integrated hybrid simulation model combining the advantages of SD and ABM. We also demonstrate how we use several approaches adapted from both SD and ABM practices to build confidence in this model in response to the lack of systematic approaches to validate hybrid models. Our modelling results show that the risk of infection for residents in care homes using bank/agency staff was significantly higher than those not using bank/agency staff (Relative risk [RR] 2.65, 95% CI 2.57-2.72). Bank/agency staff working across several care homes had a higher risk of infection compared with permanent staff working in a single care home (RR 1.55, 95%CI 1.52-1.58). The RR of infection for residents is negatively correlated to bank/agency staff's adherence to weekly PCR testing. Within a network of heterogeneous care homes, using bank/agency staff had the most impact on care homes with lower intra-facility transmission risks, higher staff-to-resident ratio, and smaller size. Forming bubbles of care homes had no or limited impact on the spread of Covid-19. This modelling study has implications for policy makers considering developing effective interventions targeting staff working across care homes during the ongoing and future pandemics.

Protecting Nursing Home Residents and Staff from COVID-19.

Two new tools from the AHRQ help facilitate observational audits.

More Nursing Home Staff Linked to More COVID-19 Cases.

According to this study: A higher number of nursing home staff members was associated with a higher number of COVID-19 cases, independent of the size of the facility.Decreasing the number of staff members but not the number of direct care hours could help improve patient safety.

A systematic review of long-term care facility characteristics associated with COVID-19 outcomes.

BACKGROUND/OBJECTIVES: The coronavirus disease 2019 (COVID-19) pandemic has taken a disproportionate toll on long-term care facility residents and staff. Our objective was to review the empirical evidence on facility characteristics associated with COVID-19 cases and deaths. DESIGN: Systematic review. SETTING: Long-term care facilities (nursing homes and assisted living communities). PARTICIPANTS: Thirty-six empirical studies of factors associated with COVID-19 cases and deaths in long-term care facilities published between January 1, 2020 and June 15, 2021. MEASUREMENTS: Outcomes included the probability of at least one case or death (or other defined threshold); numbers of cases and deaths, measured variably. RESULTS: Larger, more rigorous studies were fairly consistent in their assessment of risk factors for COVID-19 outcomes in long-term care facilities. Larger bed size and location in an area with high COVID-19 prevalence were the strongest and most consistent predictors of facilities having more COVID-19 cases and deaths. Outcomes varied by facility racial composition, differences that were partially explained by facility size and community COVID-19 prevalence. More staff members were associated with a higher probability of any outbreak; however, in facilities with known cases, higher staffing was associated with fewer deaths. Other characteristics, such as Nursing Home Compare 5-star ratings, ownership, and prior infection control citations, did not have consistent associations with COVID-19 outcomes. CONCLUSION: Given the importance of community COVID-19 prevalence and facility size, studies that failed to control for these factors were likely confounded. Better control of community COVID-19 spread would have been critical for mitigating much of the morbidity and mortality long-term care residents and staff experienced during the pandemic. Traditional quality measures such as Nursing Home Compare 5-Star ratings and past deficiencies were not consistent indicators of pandemic preparedness, likely because COVID-19 presented a novel problem requiring extensive adaptation by both long-term care providers and policymakers.

Delivering Hospice Care During the COVID-19 Pandemic: Meeting Nursing Home Residents' Needs.

This discussion article highlights the challenges of providing hospice care in nursing homes since the start of the COVID-19 (coronavirus disease 2019) pandemic and illuminates practice changes needed in nursing homes. The article provides an overview of the expectations of hospice care, explains the differences in delivering hospice care during the COVID-19 pandemic, examines social isolation and emotional loneliness and the role of familial caregivers, and describes policy changes related to the COVID-19 affecting hospice care delivery in nursing homes. This article answers the following questions: (1) How did residents receiving hospice care have their needs met during the COVID-19 pandemic? (2) What areas of nursing home care need to be improved through governmental policy and restructuring? This article also summarized the lessons learned as a result of the COVID-19 pandemic and provided practical implications for nursing, specific to changes in hospice care deliveries for nursing home residents.

Application of the Haddon matrix to COVID-19 prevention and containment in nursing homes.

COVID-19 has exacted a disproportionate toll on the health of persons living in nursing homes. Healthcare providers and other decision-makers in those settings must refer to multiple evolving sources of guidance to coordinate care delivery in such a way as to minimize the introduction and spread of the causal virus, SARS-CoV-2. It is essential that guidance be presented in an accessible and usable format to facilitate its translation into evidence-based best practice. In this article, we propose the Haddon matrix as a tool well-suited to this task. The Haddon matrix is a conceptual model that organizes influencing factors into pre-event, event, and post-event phases, and into host, agent, and environment domains akin to the components of the epidemiologic triad. The Haddon matrix has previously been applied to topics relevant to the care of older persons, such as fall prevention, as well as to pandemic planning and response. Presented here is a novel application of the Haddon matrix to pandemic response in nursing homes, with practical applications for nursing home decision-makers in their efforts to prevent and contain COVID-19.

Nursing home staff perceptions of challenges and coping strategies during COVID-19 pandemic in China.

BACKGROUND: First-line nursing staff are responsible for protecting residents, the most vulnerable population, from COVID-19 infections. They are at a high risk of being infected with COVID-19 and experience high levels of psychological distress. AIMS: To explore the challenges and coping strategies perceived by nursing staff during the COVID-19 pandemic in China. METHODS: In April,2020, we conducted a qualitative study using in-depth semi-structured interviews with nursing staff. Participants were selected from seven nursing homes in three cities in Hunan Province, China. RESULTS: A total of 21 nursing staff participated in the study, including seven nurse managers, seven registered nurses and seven nursing assistants. Three main themes were identified. Different groups encountered different sources of stress and adopted various coping strategies to fulfil their responsibilities. CONCLUSIONS: Nursing home staff were underprepared for dealing with COVID-19-related challenges. Educational programs to improve the ability to deal with COVID-19 prevention and control are needed.

From Cruddiness to Catastrophe: COVID-19 and Long-term Care in Ontario.

Over 80% of Canadian COVID-19 first wave deaths occurred in long-term care homes. Focussing on Ontario, I trace the antecedents of the COVID-19 crisis in long-term care and document experiences of frontline staff and family members of residents during the pandemic. Following Povinelli, I argue that the marginalization of both residents and workers in Ontario's long-term care system over two decades has eroded possibilities for recognition of their personhood. I also question broader societal attitudes toward aging, disability and death that make possible the abandonment of the frail elderly.

Reimagining care homes: can the COVID-19 pandemic act as a catalyst for enhancing staff status and education?

During the first wave of the coronavirus disease 2019 (COVID-19) pandemic, older people were discharged from hospitals to care homes to release NHS beds. This influx of new residents whose COVID-19 status was largely unknown added to the many challenges already experienced by care homes, with serious consequences including an increased number of deaths among residents. The social care sector has been fragile for several years and the pandemic has brought the challenges experienced by care homes to the forefront, prompting renewed calls for improved funding and reform. This article describes the ongoing challenges and additional challenges caused by the pandemic in the care home sector. The authors argue for urgent reform to enhance the status and education of care home staff, move towards registration of the social care workforce in England, and achieve integration of health and social care services for older people.