Increased risk of SARS-CoV-2 infection and COVID-19 death among older patients at long-term care hospitals in Korea.

Introduction: Long-term care hospitals are known to be vulnerable to SARS-CoV-2 infection and death given their numerous older chronic disease patients. However, the actual effect of long-term care hospital admission is not well known in Korea; hence, this study sought to analyze the effect of long-term care hospitalization on SARS-CoV-2 infection and COVID-19 death by correcting for patients' characteristics. Methods: This cross-sectional study used the data from K-COV-N cohort, which is linked to the National Health Insurance Service and the Korea Disease Control and Prevention Agency; it analyzed 70,373 individuals aged ≥60 years, who had been tested for COVID-19 between January 1 and May 30, 2020 (KDCA-NHIS-2020-1-601). Patients admitted to a long-term care hospital were defined as those with a confirmed history of hospitalization within 30 days of the COVID-19 testing date. The final data analysis was performed in December 2022. Logistic regression analysis of the national data was employed to determine the association between long-term care hospital admission, the risk of SARS-CoV-2 infection, and death from COVID-19. The odds ratios for SARS-CoV-2 infection and death from COVID-19 were calculated by adjusting for sex, age, residential area, health insurance premium, disability, and the Charlson Comorbidity Index. Results: Older patients at long-term care hospitals had a high risk of SARS-CoV-2 infection (OR:2.91, 95% CI:2.33-3.64) and death from COVID-19 (OR:3.58, 95% CI:2.13-6.02). A difference in SARS-CoV-2 infection risk was observed based on residential area, health insurance premium (economic level), and disability; no difference was observed for COVID-19 mortality risk. Discussion: Admission to a long-term care hospital itself could be a risk factor for SARS-CoV-2 infection and the consequent high mortality risk after adjusting for sex, age, disability, and comorbidities. Patients are at high risk of infection through contact with workers, leading to death; therefore, quarantine policies for workers must be strengthened.

Potentially avoidable hospitalizations for older patients transferred from long-term care hospitals: a nationwide cross-sectional analysis of potential healthcare consequences.

Multiple chronic disorders and disabilities among older patients in long term care hospitals (LTCH) tends to increase the healthcare burden by causing overcrowding, particularly in emergency departments. Therefore, access to timely and adequate healthcare for LTCH patients is an increasingly important issue, and potentially avoidable hospitalizations (PAHs) and hospitalizations during non-office hours can result as indicators of emergency department overcrowding. The study aimed to evaluate PAHs and hospitalizations during non-office hours in emergency departments for older patients transferred from LTCH compared to patients living at home. We performed a cross-sectional study using the National Emergency Department Information System database from January 2018 to December 2019, in South Korea, with older patients (≥ 65 years) who visited nationwide emergency departments. Adjusted odds ratio (aOR) and 95% confidence interval (CI) for indicators of overcrowding as PAHs and hospitalizations during non-office hours were calculated by logistic regression. Among the 2,177,663 older patients who visited the emergency departments, 98,434 patients were living in LTCH and 2,079,229 patients were living at home. The older patients living in LTCH was associated with PAHs (aOR: 1.90, 95% CI 1.87-1.94) and hospitalizations during non-office hours (aOR: 1.76, 95% CI 1.73-1.78). LTCH patients showed more hospital visits, extended stay in the emergency department, greater prevalence of chronic diseases, greater rates of transfer as well as higher admission rates and mortality as compared to the patients living at home. The LTCH older patients were associated with the indicators of emergency department overcrowding, which impacts health care quality in hospitals. Introduction of policy and training programs for LTCH staff are recommended to manage vulnerable groups in advance.

Type D personality, cognitive illness perception, depression, approach coping, and self-management among older adults in long-term care hospitals: Structural equation modeling.

This study aimed to construct a structural equation model to explore the relationship between Type D personality, cognitive illness perception, depression, approach-coping, and self-management. The study was conducted at two long-term care hospitals with 300 or more beds in Korea. Participants were 287 older patients from whom data were collected from February 17 to March 10, 2021, using a structured questionnaire comprising items on the following variables: Type D personality, cognitive illness perception, depression, approach coping, and self-management. Type D personality (ß=-.601, p=.001), cognitive illness perception (ß =.692, p <.001), depression (ß =-.204, p =.011), and approach-coping (ß =.326, p <.001) explained 78.8% of the total variance of self-management, highlighting their impact on how patients accept and manage a disease and their relevance to the self-management of older adults in long-term care hospitals.

Standardized assessment of depression symptoms in post-acute care: A screening threshold approach.

BACKGROUND: Depression symptoms have impacts on quality of life, rehabilitation and treatment adherence, and resource utilization among patients in post-acute care (PAC) settings. The PHQ-2 and PHQ-9 are instruments for the assessment of depression, previously used in PAC settings, that have tradeoffs in terms of measurement depth versus respondent/assessor burden. Therefore, the present study tested a gateway version of the protocol (PHQ-2 to 9). METHODS: In 143 PAC settings in 14 U.S. markets across 10 states from November 2017 to August 2018, facility and research nurses administered the PHQ-2 to communicative patients (n = 3010). Nurses administered the full PHQ-9 if the patient screened positive for either of the two cardinal symptoms assessed by the PHQ-2 (depressed mood and anhedonia). We assessed the prevalence and frequency of depression symptoms using the PHQ-2 to 9, associations between depression screening results and patient characteristics and clinical conditions, and feasibility indicators. RESULTS: More than 1 in 4 patients (28%) screened positive on the PHQ-2. Only 6% of those completing the full PHQ-9 had a score indicating "minimal" severity. The average score (M = 11.9) met the threshold for moderate depression. Positive PHQ-2 screening was associated with age, female gender, disposition at discharge, septicemia/severe sepsis, and dependence for ADLs of toileting and lying to sitting mobility. Age was also associated with full PHQ-9 scores; patients ages 45-64 had the highest mean score. Length of stay was not associated with PHQ-2 screening results or full PHQ-2 to 9 scores. Missing data were minimal (<2.4%). The average time to complete was 2.3 min. Interrater reliability and percent agreement were excellent. CONCLUSIONS: These findings suggest the feasibility of a gateway scoring approach to standardized assessment of depression symptoms among PAC patients, and that depression symptoms are relatively common among this inpatient population.

Dietitians View of Foodservice Sanitary Practices and Demands in Long-Term Care Hospitals.

This study aimed to investigate the current state of foodservice management and demands for improvement in long-term care hospitals. The survey was performed in experienced dietitians working at 25 hospitals. General characteristics, status of sanitary management (document management, self-assessment of importance and performance), necessity and ranking of sanitary management items were investigated. Approximately 2.5 dietitians worked in each hospital, but only 7 (28.0%) hospitals employed clinical dietitians. From the questionnaire, the scores of the importance in sanitary management and performance were 4.5 ± 0.7 and 4.3 ± 0.9, respectively, and were significantly different (p = 0.000). Participants also reported "special therapeutic diets management" and "compliance with standards of refrigerating time, food, method management" had the lowest importance and performance, respectively. The result of Importance-Performance Analysis revealed a significant positive correlation between importance and performance (R2 = 0.427). However, items such as "performing hand hygiene" and "compliance with standards of refrigerating time, food, method" and etc. had low importance recognition with low performance. All participants reported "preparing sanitary management standards was necessary" is necessary and "development of sanitary management manual" is the most important. These findings suggest that sanitary management is important in food service management of long-term care hospitals, and improving awareness is required. Developing a hospital foodservice hygiene manual would ensure better safety and quality for patient care and public health.

Clarifying differences in viewpoints between multiple healthcare professionals during discharge planning assessments when discharging patients from a long-term care hospital to home.

Comprehensive discharge planning provided by interprofessional collaboration is critical for discharging patients from hospitals to home. For effective interprofessional discharge planning, the evaluation that clarifies the differences in assessment viewpoints between various healthcare professionals is needed. This study aimed to clarify the assessment viewpoints of multiple healthcare professional groups when discharging patients from a long-term care hospital (LTCH) to home. We reviewed 102 medical records from an LTCH in Japan, extracted descriptions of discharge planning assessments written by 3 doctors, 13 nurses, 3 physical therapists, 13 care workers, and 2 social workers, linked these to the International Classification of Functioning, Disability and Health, and conducted the statistical analysis. Doctors and nurses significantly focused on "Body Functions". Physical therapists and care workers significantly focused on "Activities and Participation". Social workers significantly focused on "Environmental Factors". We also identified the factors less or missing from assessments in the clinical field of the LTCH. Our findings could be contributed as a base of knowledge to foster a better understanding of different healthcare professionals' assessment viewpoints. The further development of comprehensive discharge planning assessment tools, service programs, and research on discharge planning methods that could contribute to effective interprofessional discharge planning is needed.

Can post-exposure prophylaxis for COVID-19 be considered as an outbreak response strategy in long-term care hospitals?

In the context of the ongoing global outbreak of coronavirus disease 2019 (COVID-19), management of exposure events is a concern. Long-term care hospitals (LTCHs) are particularly vulnerable to cluster outbreaks because facilities for patient isolation and healthcare personnel to care for these patients in isolation are difficult to arrange in a large outbreak situation. Although several drugs have been proposed as treatment options, there are no data on the effectiveness and safety of post-exposure prophylaxis (PEP) for COVID-19. After a large COVID-19 exposure event in an LTCH in Korea, PEP using hydroxychloroquine (HCQ) was administered to 211 individuals, including 189 patients and 22 careworkers, whose baseline polymerase chain reaction (PCR) tests for COVID-19 were negative. PEP was completed in 184 (97.4%) patients and 21 (95.5%) careworkers without serious adverse events. At the end of 14 days of quarantine, all follow-up PCR tests were negative. Based on our experience, further clinical studies are recommended for COVID-19 PEP.

Effects of the organizational culture type, job satisfaction, and job stress on nurses' happiness: A cross-sectional study of the long-term care hospitals of South Korea.

AIM: It was aimed to explore the effects of the long-term-care (LTC) hospital-nurse organizational culture type, job satisfaction, and job stress on nurses' happiness. METHODS: Included were 226 participants who were randomly selected among the nurses who were working in 17 LTC hospitals with ≥100 beds, located in five cities in South Korea. A multiple regression analysis was carried out in order to examine the factors affecting the happiness of the nurses. RESULTS: The happiness of the LTC hospital nurses was not high. Regarding the factors affecting their happiness, a higher feeling of happiness was evident when the estimation of their subjective health status was healthier, when they were in an organization with hierarchy-oriented culture properties, when they expressed a higher job satisfaction regarding autonomy, and when the number of task requests was lower. Among these factors, autonomy-based job satisfaction exerts the greatest effect. CONCLUSION: Based on these results, the development of personal health improvement programs for nurses' happiness should be required. In addition, hospitals need to be stably operated and managed to ensure organizational safety and the nurse managers should encourage the nurses to carry out their tasks with autonomy.

Hospital patients with severe wounds: early evidence on the impact of Medicare payment changes on treatment patterns and outcomes.

AIMS: This study examines the effects of recent changes in Medicare long-term care hospital (LTCH) payments on treatment patterns and outcomes for severe wound patients discharged from short-term acute care hospitals (STACHs). MATERIALS AND METHODS: The rolling implementation of a new Medicare payment policy was used to develop a difference-in-difference model. The study population consisted of Medicare beneficiaries subjected to the payment policy changes and hospitalized for stage 3, 4, or unstageable wounds; non-healing surgical wounds; and fistula. Using 2015-Q1-2017 Medicare claims data, changes in outcomes were examined for severe wound patients exposed to the new policy (treatment) and those that were not (comparison). All outcomes were modeled using linear regressions and adjusted for patient clinical characteristics. Analysis was conducted in a full sample and a sample with high-LTCH-use propensity. RESULTS: Severe wound patients exposed to the new policy experienced 4.1 and 7.5 percentage point (pp) reductions in LTCH use relative to the comparison group in the full sample and high-LTCH-propensity sample, respectively (p < .01 and p = .039). No statistically significant change was found in 60-day mortality or Medicare spending after the policy change in the treatment group as compared to the comparison group (p > .10). However, among severe wound patients who are exposed to the new policy in the high-LTCH-propensity sample, readmission and post-discharge sepsis rates increased after the policy change relative to the comparison group (readmission rate = 8.1 pp, p = .075; sepsis rate = 7.0 pp, p = .033). LIMITATIONS: The findings are based on data from a limited timeframe around the policy change and, thus, provide only early evidence on the effects of the new policy. CONCLUSION: The new LTCH payment policy is associated with no changes in Medicare spending and mortality, but higher readmissions and post-discharge sepsis rates among severe wound patients with a high likelihood to use an LTCH.

Review and inspirations of the payment mechanism of Long-Term Care Hospital of Medicare of the United States / 中华医院管理杂志

A type of designated hospitals in Medicare is referred to as Long-Term Care Hospital (LTCH). LTCH is one of Post-Acute Care settings(I. e. Intermediate care)and the only facilities certified by length of stays. This article reviewed the milestones and payment methods of Medicare Long-Term Care Hospital payment system, for perfection of the medical insurance and construction of China′s intermediate care system.

Longitudinal associations of nursing staff turnover with patient outcomes in long-term care hospitals in Korea.

AIMS: To describe the characteristics of long-term care hospitals in 2010-2013 and to examine the longitudinal associations of nursing staff turnover with patient outcomes. BACKGROUND: The number of long-term care hospitals has exploded in Korea since the national long-term care insurance was launched in 2008. The care quality deviation across long-term care hospitals is large. METHODS: This was a longitudinal secondary data analysis using the Health Insurance Review and Assessment Service's data. RESULTS: From 2010 to 2013, the nursing staff turnover rate decreased. The number of patients per registered nurse increased while that per total nursing staff and skill mix decreased. All adverse patient outcomes decreased. Higher nursing staff turnover and lower RN proportions were associated with adverse patient outcomes. CONCLUSIONS: Since the launch of the long-term care insurance, total nursing staffing, turnover rate and patient outcomes have improved, while the skill mix has decreased. Systematic efforts to decrease nursing staff turnover should be implemented for better long-term care patient outcomes. IMPLICATIONS FOR NURSING MANAGEMENT: In addition to maintaining high levels of nurse staffing and skill mix, supportive work environments and competitive wages and benefits could reduce turnover, and ultimately adverse patient outcomes. Health care policy should separate nursing staffing levels for registered nurses and certified nursing assistants.

Confidence in delegation and leadership of registered nurses in long-term-care hospitals.

BACKGROUND AND AIMS: Effective delegation improves job satisfaction, responsibility, productivity and development. The ageing population demands more nurses in long-term-care hospitals. Delegation and leadership promote cooperation among nursing staff. However, little research describes nursing delegation and leadership style. We investigated the relationship between registered nurses' delegation confidence and leadership in Korean long-term-care hospitals. METHODS: Our descriptive correlational design sampled 199 registered nurses from 13 long-term-care hospitals in Korea. Instruments were the Confidence and Intent to Delegate Scale and Multifactor Leadership Questionnaire. RESULTS: Confidence in delegation significantly aligned with current-unit clinical experience, length of total clinical-nursing experience, delegation-training experience and leadership. Transformational leadership was the most statistically significant factor influencing delegation confidence. IMPLICATIONS FOR NURSING MANAGEMENT: When effective delegation integrates with efficient leadership, staff can deliver optimal care to long-term-care patients.

Clinical Nutrition Services of a Long-term Care Hospital in Korea / 대한지역사회영양학회지

OBJECTIVES: The purpose of this study was to investigate how clinical nutrition services is provided at a long term care hospital in Korea and to investigate job satisfaction levels of the clinical dietitians. METHODS: Survey questionnaire was sent to dietitians working at a long term care hospital in Korea. The participating hospitals (n=240) were randomly selected from 1,180 long- term care hospitals using a stratified sampling method. A total of 134 long term care hospital s and 223 dietitians completed the survey of clinical nutrition service s and job satisfaction questionnaires The job satisfaction questionnaire included 27 job satisfaction questions on task, stability vision, working conditions, and relationship areas. RESULTS: The average nutritional screening rate was 17.9% and the rate of computerized nutritional screening system was 9.7% in the participating hospitals. Nutritional intervention rate was only 3.2% of all patients. KOIHA (Korea Institute for Healthcare Accreditation) accreditated hospitals showed only 50% performance rate of nutrition service evaluation area. This shows that after achieving KOIHA accredition, many hospitals do not emphasize the performance of nutritional services. The job satisfaction scores in all four areas ranged from 2/5 to 3/5, implying generally low job satisfaction level in hospital dietitians. Linear regression analysis results showed that the "hospital adequacy grade" type was a significant predictor of job satisfaction level for two areas (working conditions & relationship). CONCLUSIONS: There is a need to provide proper standardized clinical nutrition services as a primary treatment and we observed large variations in the quality of nutritional service s in long term care hospitals. Therefore, government and local hospitals have to work on implementing nutritional programs and policies for improved service and care.

Are we asking the right question about postacute settings of care?

This issue of Archives includes an article by Mallinson et al that compares the outcomes of patients with hip fracture who received rehabilitation services in 3 different postacute settings: skilled nursing facilities, inpatient rehabilitation facilities, or home health. Except in 1 instance, Mallinson found no setting-specific effects and noted that the issue of defining an optimum postacute rehabilitation program is complex and requires more investigation. Mallinson's findings are interesting in their own right but raise a more fundamental issue. This commentary observes that rehabilitation patients typically use multiple postacute settings, not just 1 setting of care, for the same episode of care. This commentary asks whether we should be examining episode outcomes and not just setting-specific outcomes, especially in the face of bundled payment and value-based payment reforms in the Affordable Care Act.

Effects on Long-Term Care Hospital Staff Mixing Level after Implementing Differentiated Inpatient Nursing Fees by Staffing Grades / 간호행정학회지

PURPOSE: The purpose of this study was to examine trends in number of nursing staff and skill mix. METHODS: Nursing staff and skill mix were measured using the number of nursing staff including nurse aids and registered nurses per bed. Descriptive and panel data regression analyses were conducted using data on long-term care hospitals which included yearly series data from 2006 to 2010 for 119 hospitals. RESULTS: The number of nursing staff per bed increased significantly but percentage of registered nurses decreased significantly from 2007 to 2010. The regression model explained this variation as much as 35% and 44%. CONCLUSION: The results showed that in long-term care hospitals there were more nurse aids employed instead of registered nurses after the implemention of differentiated inpatient nursing fees. Thus clarifying the job descriptions for nurses and nurse aids is needed and appropriate hospital incentive policies should be implemented.

Long-Term Care Hospital and the Role of Neurologist

Korea health care system and public welfare system have been changed slowly and developed step by step. It makes efforts to promote the welfare of the people, but does not provide good benefits for geriatric patients. In 2008, it was incompletely set up the long term care system in Korea. And the Law on Long-Term Care Insurance for Elderly was officially announced in Nov. 2011 and the law for dementia, Dementia Management Act, was drafted in Feb. 2012. Though there were many laws, the concept of long-term care hospital and geriatric care facility is still obscure. In long-term care hospital, there are big expansion of the number of beds and institutions in Korea. Over a half of the patients in long-term care hospitals are suffered from mixed neurological diseases. Especially, dementia is the comorbid state with other chronic geriatric diseases. In view of the aging population, the role of neurologist will continue to grow. So neurologists need more special training for the needed skills and competencies, and the specific care settings program in long-term care hospital. In this review, the history and current state of long-term care hospital, related laws, and the role of neurologist will be discussed.

The effect of a nutritional education program on the nutritional status of elderly patients in a long-term care hospital in Jeollanamdo province: health behavior, dietary behavior, nutrition risk level and nutrient intake.

This study was conducted to assess improvements in nutritional status following the application of nutrition education to elderly patients in a long-term care hospital. The study was carried out from January to May 2009, during which a preliminary survey, a pretest, the application of nutrition education, and a post-test were applied in stages. The number of subjects at pretest was 81, and the number of participants included in the final analysis was 61 (18 men, 43 women), all of whom participated in both the nutrition education program and the post-test. The survey consisted of general demographic items, health behaviors, dietary behaviors, the Nutrition Screening Initiative checklist, and nutrient intake assessment (24 hour recall method). The nutrition education program lasted for four weeks. It included a basic education program, provided once a week, and mini-education program, which was offered daily during lunch times. The survey was conducted before and after the education program using the same assessment method, although some items were included only at pretest. When analyzing the changes in elderly patients after the nutritional education program, we found that, among subjective dietary behaviors, self-rated perceptions of health (P < 0.001) and of depression (P < 0.001) improved significantly and that dietary behavior scores also improved significantly (P < 0.001), while nutritional risk levels decreased. In terms of nutrient intake, subjects' intake of energy, protein, fat, carbohydrate, calcium, phosphorus, iron, vitamin A, thiamin, riboflavin, niacin, and vitamin C all increased significantly (P < 0.001). These results indicated that nutritional education is effective in improving the nutritional status of elderly patients. We hope that the results of this study can be used as preliminary data for establishing guidelines for nutrition management tailored to elderly patients in long-term care hospitals.

Improving Service Quality in Long-term Care Hospitals: National Evaluation on Long-term Care Hospitals and Employees Perception of Quality Dimensions.

OBJECTIVES: To investigate predictors for specific dimensions of service quality perceived by hospital employees in long-term care hospitals. METHODS: Data collected from a survey of 298 hospital employees in 18 long-term care hospitals were analysed. Multivariate ordinary least squares regression analysis with hospital fixed effects was used to determine the predictors of service quality using respondents' and organizational characteristics. RESULTS: The most significant predictors of employee-perceived service quality were job satisfaction and degree of consent on national evaluation criteria. National evaluation results on long-term care hospitals and work environment also had positive effects on service quality. CONCLUSION: The findings of the study show that organizational characteristics are significant determinants of service quality in long-term care hospitals. Assessment of the extent to which hospitals address factors related to employeeperceived quality of services could be the first step in quality improvement activities. Results have implications for efforts to improve service quality in longterm care hospitals and designing more comprehensive national evaluation criteria.

The effect of a nutritional education program on the nutritional status of elderly patients in a long-term care hospital in Jeollanamdo province: health behavior, dietary behavior, nutrition risk level and nutrient intake

This study was conducted to assess improvements in nutritional status following the application of nutrition education to elderly patients in a long-term care hospital. The study was carried out from January to May 2009, during which a preliminary survey, a pretest, the application of nutrition education, and a post-test were applied in stages. The number of subjects at pretest was 81, and the number of participants included in the final analysis was 61 (18 men, 43 women), all of whom participated in both the nutrition education program and the post-test. The survey consisted of general demographic items, health behaviors, dietary behaviors, the Nutrition Screening Initiative checklist, and nutrient intake assessment (24 hour recall method). The nutrition education program lasted for four weeks. It included a basic education program, provided once a week, and mini-education program, which was offered daily during lunch times. The survey was conducted before and after the education program using the same assessment method, although some items were included only at pretest. When analyzing the changes in elderly patients after the nutritional education program, we found that, among subjective dietary behaviors, self-rated perceptions of health (P < 0.001) and of depression (P < 0.001) improved significantly and that dietary behavior scores also improved significantly (P < 0.001), while nutritional risk levels decreased. In terms of nutrient intake, subjects' intake of energy, protein, fat, carbohydrate, calcium, phosphorus, iron, vitamin A, thiamin, riboflavin, niacin, and vitamin C all increased significantly (P < 0.001). These results indicated that nutritional education is effective in improving the nutritional status of elderly patients. We hope that the results of this study can be used as preliminary data for establishing guidelines for nutrition management tailored to elderly patients in long-term care hospitals.