Risk factors for Veteran food insecurity: findings from a National US Department of Veterans Affairs Food Insecurity Screener.

OBJECTIVE: Food insecurity is associated with numerous adverse health outcomes. The US Veterans Health Administration (VHA) began universal food insecurity screening in 2017. This study examined prevalence and correlates of food insecurity among Veterans screened. DESIGN: Retrospective cross-sectional study using VHA administrative data. Multivariable logistic regression models were estimated to identify sociodemographic and medical characteristics associated with a positive food insecurity screen. SETTING: All US Veterans Administration (VA) medical centres (n 161). PARTICIPANTS: All Veterans were screened for food insecurity since screening initiation (July 2017-December 2018). RESULTS: Of 3 304 702 Veterans screened for food insecurity, 44 298 were positive on their initial screen (1·3 % of men; 2·0 % of women). Food insecurity was associated with identifying as non-Hispanic Black or Hispanic. Veterans who were non-married/partnered, low-income Veterans without VA disability-related compensation and those with housing instability had higher odds of food insecurity, as did Veterans with a BMI < 18·5, diabetes, depression and post-traumatic stress disorder. Prior military sexual trauma (MST) was associated with food insecurity among both men and women. Women screening positive, however, were eight times more likely than men to have experienced MST (48·9 % v. 5·9 %). CONCLUSIONS: Food insecurity was associated with medical and trauma-related comorbidities as well as unmet social needs including housing instability. Additionally, Veterans of colour and women were at higher risk for food insecurity. Findings can inform development of tailored interventions to address food insecurity such as more frequent screening among high-risk populations, onsite support applying for federal food assistance programs and formal partnerships with community-based resources.

Frequency and Predictors of Suboptimal Prescribing Among a Cohort of Older Male Residents with Urinary Tract Infections.

BACKGROUND: Unnecessary antibiotic treatment of suspected urinary tract infections (UTI) is common in long-term care facilities (LTCFs). However, less is known about the extent of suboptimal treatment, in terms of antibiotic choice, dose, and duration, after the decision to use antibiotics has been made. METHODS: We described the frequency of potentially suboptimal treatment among residents with an incident UTI (the first during the study with none in the year prior) in Department of Veterans Affairs (VA) community living centers (CLCs; 2013-2018). Time trends were analyzed using Joinpoint regression. Residents with UTIs receiving potentially suboptimal treatment were compared with those receiving optimal treatment, to identify resident characteristics predictive of suboptimal antibiotic treatment, using multivariable unconditional logistic regression models. RESULTS: We identified 21 938 residents with an incident UTI treated in 120 VA CLCs, of whom 96.0% were male. Potentially suboptimal antibiotic treatment was identified in 65.0% of residents and decreased 1.8% annually (P < .05). Potentially suboptimal initial drug choice was identified in 45.6% of residents, suboptimal dose frequency in 28.6%, and longer than recommended duration in 12.7%. Predictors of suboptimal antibiotic treatment included prior fluoroquinolone exposure (adjusted odds ratio, 1.38), chronic renal disease (1.19), age ≥85 years (1.17), prior skin infection (1.14), recent high white blood cell count (1.08), and genitourinary disorder (1.08). CONCLUSION: Similar to findings in non-VA facilities, potentially suboptimal treatment was common but improving in CLC residents with an incident UTI. Predictors of suboptimal antibiotic treatment should be targeted with antibiotic stewardship interventions to improve UTI treatment.

Poor clinical outcomes associated with suboptimal antibiotic treatment among older long-term care facility residents with urinary tract infection: a retrospective cohort study.

BACKGROUND: Antibiotic use is associated with several antibiotic-related harms in vulnerable, older long-term care (LTC) residents. Suboptimal antibiotic use may also be associated with harms but has not yet been investigated. The aim of this work was to compare rates of poor clinical outcomes among LTC residents with UTI receiving suboptimal versus optimal antibiotic treatment. METHODS: We conducted a retrospective cohort study among residents with an incident urinary tract infection (UTI) treated in Veterans Affairs LTC units (2013-2018). Potentially suboptimal antibiotic treatment was defined as use of a suboptimal initial antibiotic drug choice, dose frequency, and/or excessive treatment duration. The primary outcome was time to a composite measure of poor clinical outcome, defined as UTI recurrence, acute care hospitalization/emergency department visit, adverse drug event, Clostridioides difficile infection (CDI), or death within 30 days of antibiotic discontinuation. Shared frailty Cox proportional hazard regression models were used to compare the time-to-event between suboptimal and optimal treatment. RESULTS: Among 19,701 LTC residents with an incident UTI, 64.6% received potentially suboptimal antibiotic treatment and 35.4% experienced a poor clinical outcome. In adjusted analyses, potentially suboptimal antibiotic treatment was associated with a small increased hazard of poor clinical outcome (aHR 1.06, 95% CI 1.01-1.11) as compared with optimal treatment, driven by an increased hazard of CDI (aHR 1.94, 95% CI 1.54-2.44). CONCLUSION: In this national cohort study, suboptimal antibiotic treatment was associated with a 6% increased risk of the composite measure of poor clinical outcomes, in particular, a 94% increased risk of CDI. Beyond the decision to use antibiotics, clinicians should also consider the potential harms of suboptimal treatment choices with regards to drug type, dose frequency, and duration used.

Facilitators and Barriers to Antibiotic Stewardship: A Qualitative Study of Pharmacists' Perspectives.

Background: The Veterans Affairs (VA) is a leader in the implementation and advancement of antibiotic stewardship programs throughout the nation. The Centers for Disease Control and Prevention (CDC) has also led national antibiotic stewardship efforts and has outlined core elements to improve antibiotic use in hospitals, long-term care, and outpatient settings. Many facilities still face challenges to the implementation and maintenance of successful programs, particularly in nonacute care settings. The objective of this study was to identify barriers and facilitators to antibiotic stewardship within the VA medical centers through qualitative interviews with pharmacists. Methods: Eight semi-structured telephone interviews were conducted with pharmacists from 6 VA medical centers within VA New England Healthcare System. Pharmacist respondents were either pharmacy champions (for medical centers with established programs) or pharmacists with responsibilities in making antibiotic recommendations (locations without established programs). All interviews were audio recorded and transcribed verbatim. NVivo 8 was used for data coding and analysis. Results: Pharmacists from all 8 medical centers were contacted for interviews and pharmacists from 6 medical centers agreed to interviews (75% VA New England medical center participation). Three main themes regarding antibiotic stewardship were identified from the interviews with pharmacists. Respondents described the importance of (1) a supportive organizational culture, (2) protected time for antibiotic stewardship, and (3) a cohesive organizational structure in the success of antibiotic stewardship programs. Conclusions: Our findings support the CDC core elements for antibiotic stewardship, in particular the importance of leadership commitment in the creation of a culture that supports antibiotic stewardship and in ensuring staff are given sufficient time for antibiotic stewardship efforts. Although a strong supportive culture has been built, strategies focused on fostering increased protected time for antibiotic stewardship and a cohesive organizational structure may be helpful in advancing and sustaining successful antibiotic stewardship programs that improve patient outcomes.

Evacuation and Health Care Outcomes Among Assisted Living Residents After Hurricane Irma.

Importance: Evacuation has been found to be associated with adverse outcomes among nursing home residents during hurricanes, but the outcomes for assisted living (AL) residents remain unknown. Objective: To examine the association between evacuation and health care outcomes (ie, emergency department visits, hospitalizations, mortality, and nursing home visits) among Florida AL residents exposed to Hurricane Irma. Design, Setting, and Participants: Retrospective cohort study using 2017 Medicare claims data. Participants were a cohort of Florida AL residents who were aged 65 years or older, enrolled in Medicare fee-for-service, and resided in 9-digit zip codes corresponding to US assisted living communities with 25 or more beds on September 10, 2017, the day of Hurricane Irma's landfall. Propensity score matching was used to match evacuated residents to those that sheltered-in-place based on resident and AL characteristics. Data were analyzed from September 2022 to February 2024. Exposure: Whether the AL community evacuated or sheltered-in-place before Hurricane Irma made landfall. Main Outcomes and Measures: Thirty- and 90-day emergency department visits, hospitalizations, mortality, and nursing home admissions. Results: The study cohort included 25 130 Florida AL residents (mean [SD] age 81 [9] years); 3402 (13.5%) evacuated and 21 728 (86.5%) did not evacuate. The evacuated group had 2223 women (65.3%), and the group that sheltered-in-place had 14 556 women (67.0%). In the evacuated group, 42 residents (1.2%) were Black, 93 (2.7%) were Hispanic, and 3225 (94.8%) were White. In the group that sheltered in place, 490 residents (2.3%) were Black, 707 (3.3%) were Hispanic, and 20 212 (93.0%) were White. After 1:4 propensity score matching, when compared with sheltering-in-place, evacuation was associated with a 16% greater odds of emergency department visits (adjusted odds ratio [AOR], 1.16; 95% CI, 1.01-1.33; P = .04) and 51% greater odds of nursing home visits (AOR, 1.51; 95% CI, 1.14-2.00; P = .01) within 30 days of Hurricane Irma's landfall. Hospitalization and mortality did not vary significantly by evacuation status within 30 or 90 days after the landfall date. Conclusions and Relevance: In this cohort study of Florida AL residents, there was an increased risk of nursing home and emergency department visits within 30 days of Hurricane Irma's landfall among residents from communities that evacuated before the storm when compared with residents from communities that sheltered-in-place. The stress and disruption caused by evacuation may yield poorer immediate health outcomes after a major storm for AL residents. Therefore, the potential benefits and harms of evacuating vs sheltering-in-place must be carefully considered when developing emergency planning and response.

Winter Storm Uri Reduced Availability of Daily Direct-Care Nurse Staff in Texas Nursing Homes.

We examined the effect of Winter Storm Uri on daily direct-care nurse staffing levels in 1,173 Texas nursing homes (NHs) from February 13th to 19th, 2021. We used data from Payroll-Based Journaling and the Care Compare website. Linear mixed effects models were used to estimate the linear and non-linear change in staffing. During Winter Storm Uri, Texas NHs experienced a linear decrease in daily staffing levels with subsequent non-linear increase for registered nurses (RNs; p < .001) and certified nursing assistants (CNAs; p < .001), and staffing increased linearly for licensed practical nurses (LPNs; p < .001). Compared to 1 week before the storm, Texas NHs reported lower staffing levels across all three types of staff, but most dramatically among LPNs and CNAs. In supplemental analyses, urban and lower quality NHs fared slightly poorer than rural and higher-quality NHs. Winter storms pose a particular challenge to NHs and their ability to maintain direct-care nurse staffing levels.

Hospice Aide Visits among Nursing Home Residents During the Early Months of the COVID-19 Pandemic.

OBJECTIVE: Hospice aides are vital in delivering care to patients and family members at the end of life. The COVID-19 pandemic resulted in disruptions in hospice care delivery, especially in long-term care settings. We aim to provide a description of hospice aide visits among nursing home residents enrolled in hospice during the first 9 months of 2020, as compared with the same months in 2019. DESIGN: Observational cohort study. SETTING AND PARTICIPANTS: 153,109 and 152,077 long-stay nursing home residents enrolled in hospice in 2019 and 2020, respectively. METHODS: On a monthly basis, we reported estimated probabilities of not having visits from hospice aides and adjusted visit minutes among those who had hospice aide visits for the 2019 and 2020 cohort, respectively. The regression models accounted for resident sociodemographic and clinical characteristics and nursing home fixed effects. The analyses were conducted at the national and state level, separately. RESULTS: More than half of residents did not have any visits from hospice aides in 2020 from April and onward. Among residents who had hospice aide visits, the 2020 cohort had reduced visits in March and onward, with the greatest difference being 155 minutes less in April (95% CI: -163.4, -146.5). State-level analyses suggested that multiple factors besides community spread or state policies might contribute to the reduced presence of hospice aides. CONCLUSIONS AND IMPLICATIONS: Our findings highlight the toll of the pandemic on hospice care delivery in nursing homes and the need for hospice care to be better incorporated into emergency preparedness planning.

The relationship between exposure to Hurricane Harvey and mortality among nursing home residents.

BACKGROUND: Nursing home (NH) residents are vulnerable to mortality after natural disasters. We examined NH residents' excess all-cause mortality associated with Hurricane Harvey, a unique disaster with long-lasting flooding effects. We also explored how mortality differed between short-stay and long-stay residents and by chronic conditions. METHODS: We conducted a retrospective observational study of Texas NH residents, comparing 30- and 90-day mortality among residents exposed to Hurricane Harvey in August 2017 to residents not exposed in the same location and time period during the previous 2 years. Data came from the Minimum Data Set Assessments and the Medicare Beneficiary Summary File. We used linear probability models to examine the association between hurricane exposure and mortality, adjusting for resident demographics, clinical acuity, and NH fixed effects. Models were stratified by short-stay and long-stay status. We also described differences in mortality by residents' chronic conditions. RESULTS: In 2017, 18,479 Texas NH residents were exposed to Hurricane Harvey. Exposure to Hurricane Harvey was not significantly associated with 30-day mortality. However, 7.6% (95% CI: 7.2, 7.9) of long-stay residents died 90 days after exposure to Harvey, compared to 6.3% (95% CI: 6.0, 6.7) during 2015. Apparently, this effect was driven by chronic obstructive pulmonary disease (COPD) as approximately 9.2% of these residents died within 90 days after Harvey landing compared to 7.2% in 2015 (p < 0.01). CONCLUSIONS: Hurricane exposure appears to have significant consequences for mortality among long-stay NH residents, which appear to materialize over the long-term (90 days post-hurricane in our study) and may not be apparent immediately (30 days post-hurricane in our study). NH residents with COPD may be particularly vulnerable to increased mortality risk following hurricane exposure. The results highlight the need to pay special attention to mortality risk in NH residents, particularly those with COPD, following hurricane exposure.

Assessment of Regional Nursing Home Preparedness for and Regulatory Responsiveness to Wildfire Risk in the Western US.

Importance: It is uncertain whether emergency preparedness and regulatory oversight for US nursing homes are aligned with local wildfire risk. Objective: To evaluate the likelihood that nursing homes at elevated risk of wildfire exposure meet US Centers for Medicare & Medicaid Services (CMS) emergency preparedness standards and to compare the time to reinspection by exposure status. Design, Setting, and Participants: This cross-sectional study of nursing homes in the continental western US from January 1, 2017, through December 31, 2019, was conducted using cross-sectional and survival analyses. The prevalence of high-risk facilities within 5 km of areas at or exceeding the 85th percentile of nationalized wildfire risk across areas overseen by 4 CMS regional offices (New Mexico, Mountain West, Pacific/Southwest, and Pacific Northwest) was determined. Critical emergency preparedness deficiencies cited during CMS Life Safety Code Inspections were identified. Data analysis was performed from October 10 to December 12, 2022. Main Outcomes and Measures: The primary outcome classified whether facilities were cited for at least 1 critical emergency preparedness deficiency during the observation window. Regionally stratified generalized estimating equations were used to evaluate associations between risk status and the presence and number of deficiencies, adjusted for nursing home characteristics. For the subset of facilities with deficiencies, differences in restricted mean survival time to reinspection were evaluated. Results: Of the 2218 nursing homes in this study, 1219 (55.0%) were exposed to elevated wildfire risk. The Pacific/Southwest had the highest percentage of both exposed (680 of 870 [78.2%]) and unexposed (359 of 486 [73.9%]) facilities with 1 or more deficiencies. The Mountain West had the largest difference in the percentage of exposed (87 of 215 [40.5%]) vs unexposed (47 of 193 [24.4%]) facilities with 1 or more deficiencies. Exposed facilities in the Pacific Northwest had the greatest mean (SD) number of deficiencies (4.3 [5.4]). Exposure was associated with the presence of deficiencies in the Mountain West (odds ratio [OR], 2.12 [95% CI, 1.50-3.01]) and the presence (OR, 1.84 [95% CI, 1.55-2.18]) and number (rate ratio, 1.39 [95% CI, 1.06-1.83]) of deficiencies in the Pacific Northwest. Exposed Mountain West facilities with deficiencies were reinspected later, on average, than unexposed facilities (adjusted restricted mean survival time difference, 91.2 days [95% CI, 30.6-151.8 days]). Conclusions and Relevance: In this cross-sectional study, regional heterogeneity in nursing home emergency preparedness for and regulatory responsiveness to local wildfire risk was observed. These findings suggest that there may be opportunities to improve the responsiveness of nursing homes to and regulatory oversight of surrounding wildfire risk.

Mortality among Nursing Home Residents Enrolled in Hospice and Hospice Utilization Post-Hurricane Irma.

Background: Nursing home (NH) residents are vulnerable to increased mortality after a natural disaster such as hurricanes but the specific vulnerability of NH residents on hospice and the impact on admission to hospice are unknown. Objectives: Exposure to Hurricane Irma (2017) was used to evaluate increased mortality among Florida NH residents by hospice status compared with the same time period in a nonhurricane year. Difference in hospice utilization rates poststorm for short- and long-stay NH residents was also examined. Setting/Subjects: Subject were all Florida NH residents of age 65 years and older utilizing fee-for-service Medicare claims data exposed to Hurricane Irma in 2017 compared with a control group of residents residing at the same NHs in 2015. Analysis: Mortality rates were calculated by hospice status, rates of hospice enrollment, and the corresponding odds ratios (ORs). Results: Hurricane exposure was associated with an increase in mortality 30 days poststorm (OR = 1.12, 95% confidence interval [CI]: 1.00-1.26) but not 90 days poststorm (OR = 1.02, 95% CI: 0.95-1.10) for residents on hospice. For the rate of hospice enrollment poststorm among residents previously not on hospice, there was an increase in odds of enrollment among long-stay residents in 30 days (OR = 1.15, 95% CI: 1.02-1.23) and 90 days (OR = 1.12, 95% CI: 1.05-1.20) but not short-stay residents within 30 (OR = 1.02, 95% CI: 0.91-1.15) and 90 days (OR = 1.07, 95% CI: 0.99-1.15). Conclusion: Mortality in NH residents on hospice care increased in the aftermath of Hurricane Irma. In addition, NH residents not on hospice were more likely to be referred to hospice in the 30 days after the storm.

Nursing Home Compare Star Rating and Daily Direct-Care Nurse Staffing During Hurricane Irma.

OBJECTIVES: Nursing homes (NHs) are affected by major hurricanes and other natural disasters. To mitigate adverse effects of a major hurricane, NHs often increase their direct-care nurse staffing levels to meet the needs of their residents. However, the quality rating of the NH may affect the resources available to obtain and retain staff. This data brief provides estimates of direct-care nurse staffing levels by quality star rating during Hurricane Irma. DESIGN: Retrospective cohort study from September 3, 2017, to September 10, 2017. SETTING AND PARTICIPANTS: 570 Florida NHs that sheltered in place during Hurricane Irma. METHODS: We stratified NHs by their NH Compare overall quality star rating and then measured change in direct-care nurse staffing levels for registered nurses, licensed practical nurses, and certified nursing assistants. RESULTS: We found that the NH Compare overall star rating was positively associated with a greater staffing level response during Hurricane Irma among registered nurses, licensed practical nurses, and certified nursing assistants. This change was largest for 5-star facilities and smallest for 1-star facilities. CONCLUSIONS AND IMPLICATIONS: Higher-quality NHs may be more responsive and have the resources to be more responsive, to increased needs during a natural disaster. Our findings may serve as a platform for ongoing discussion on the role of the federal, state, and local governments in ensuring minimum staffing standards during natural disasters.

Association Between State Regulations Supportive of Third-party Services and Likelihood of Assisted Living Residents in the US Dying in Place.

Importance: Older adults are increasingly residing in assisted living residences during their last year of life. The regulations guiding these residential care settings differ between and within the states in the US, resulting in diverse policies that may support residents who wish to die in place. Objective: To examine the association between state regulations and the likelihood of assisted living residents dying in place. The study hypothesis was that regulations supporting third-party services, such as hospice, increase the likelihood of assisted living residents dying in place. Design, Setting, and Participants: This retrospective cohort study combined data about assisted living residences in the US from state registries with an inventory of state regulations and administrative claims data. The study participants comprised 168 526 decedents who were Medicare beneficiaries, resided in 8315 large, assisted living residences (with ≥25 beds) across 301 hospital referral regions during the last 12 months of their lives, and died between 2017 and 2019. Descriptive analyses were performed at the state level, and 3-level multilevel models were estimated to examine the association between supportive third-party regulations and dying in place in assisted living residences. The data were analyzed from September 2021 to August 2022. Exposures: Supportive (vs "silent," ie, not explicitly mentioned in regulatory texts) state regulations regarding hospice care, private care aides, and home health services, as applicable to licensed/registered assisted living residences across the US. Main Outcomes and Measures: Presence in assisted living residences on the date of death. Results: The median (IQR) age of the 168 526 decedents included in the study was 90 (84-94) years. Of these, 110 143 (65.4%) were female and 158 491 (94.0%) were non-Hispanic White. Substantial variation in the percentage of assisted living residents dying in place was evident across states, from 18.0% (New York) to 73.7% (Utah). Supportive hospice and home health regulations were associated with a higher odds of residents dying in place (adjusted odds ratio [AOR], 1.38; 95% CI, 1.24-1.54; P < .001; and AOR, 1.21; 95% CI, 1.10-1.34; P < .001, respectively). In addition, hospice regulations remained significant in fully adjusted models (AOR, 1.46; 95% CI, 1.25-1.71). Conclusions and Relevance: The findings of this cohort study suggest that a higher percentage of assisted living residents died in place in US states with regulations supportive of third-party services. In addition, assisted living residents in licensed settings with regulations supportive of hospice regulations were especially likely to die in place.

Home-delivered meals for people with dementia: Which model delays nursing home placement? - Protocol for a feasibility pilot.

BACKGROUND: Home-delivered meals promote food security, socialization, and independence among homebound older adults. However, it is unclear which of the two predominant modes of meal delivery, daily-delivered vs. drop-shipped, frozen meals, promotes community living for homebound older adults with dementia. Our objective is to present the protocol for a pilot multisite, two-arm, pragmatic feasibility trial comparing the effect of two modes of meal delivery on nursing home placement among people with dementia. We include justifications for individual randomization with different consent processes and waivers for specific elements of the trial. METHODS: 236 individuals with dementia on waiting lists at three Meals on Wheels programs' in Florida and Texas will be randomized to receive either: 1) meals delivered multiple times per week by a Meals on Wheels volunteer or paid driver who may socialize with and provide an informal wellness check or 2) frozen meals that are mailed to participants' homes every two weeks. We will evaluate and refine processes for recruitment and randomization; assess adherence to the intervention; identify common themes in participant experience; and test processes for linking participant data with Medicare records and nursing home assessment data. We will conduct exploratory analyses examining time to nursing home placement, the primary outcome for the larger trial. CONCLUSION: This pilot will inform the follow-on large-scale, definitive pragmatic trial. In addition, the justifications for individual randomization with differing consent procedures for elements of a pragmatic trial provide a model for future trialists looking to develop ethical and feasible pragmatic studies enrolling people with dementia.

Infection Control Citations in Nursing Homes: Compliance and Geographic Variability.

OBJECTIVES: To report the initial compliance with new infection control regulations and geographic disparities in nursing homes (NHs) in the United States. DESIGN: Retrospective cohort study from November 27, 2017 to November 27, 2019. SETTING AND PARTICIPANTS: In total, 14,894 NHs in the continental United States comprising 26,201 inspections and 176,841 deficiencies. METHODS: We measured the cumulative incidence of receiving F880: Infection Prevention and Control deficiencies, geographic variability of F880 citations across the United States, and the scope and severity of the infection control deficiencies. RESULTS: A total of 6164 NHs (41%) in the continental United States received 1 deficiency for F880, and 2300 NHs (15%) were cited more than once during the 2-year period. Geographic variation was evident for F880 deficiencies, ranging from 20% of NHs in North Carolina to 79% of NHs in West Virginia. Between 0% (Vermont) and 33% (Michigan) of states' NHs were cited multiple times over 2 years. Facilities receiving 2 or more F880 deficiencies were more reliant on Medicaid, for-profit, and served more acute residents. Infection Prevention and Control deficiencies were of similar severity but of greater scope in NHs that were cited multiple times. CONCLUSIONS AND IMPLICATIONS: As the coronavirus disease 2019 pandemic challenges hospitals with an increased surge of patients from the community, NHs will be asked to accept convalescing patients who were previously infected with the virus. NHs will need to rely on infection control practices to mitigate the effects of the virus in their facilities. Particular attention to NHs that have fared poorly with repeat infection control practices deficiencies might be a good first step to improving care overall and preventing downstream morbidity and mortality among the highest-risk patients.

"You Just Forge Ahead": The Continuing Challenges of Disaster Preparedness and Response in Long-Term Care.

BACKGROUND AND OBJECTIVES: Protecting nursing home and assisted living community residents during disasters continues to be a challenge. The present study explores the experiences of long-term care facilities in Florida that were exposed to Hurricane Irma in 2017. RESEARCH DESIGN AND METHODS: We used an abductive approach, combining induction and deduction. Interviews and focus groups beginning in May 2018 were conducted by telephone and in person with 89 administrative staff members representing 100 facilities (30 nursing homes and 70 assisted living communities). Analyses identified themes and subthemes. Findings were further analyzed using the social ecological model to better understand the preparedness and response of nursing homes and assisted living communities to Hurricane Irma. RESULTS: 3 main themes were identified including: (1) importance of collaborative relationships in anticipating needs and planning to shelter in place or evacuate; (2) efforts required to maintain safety and stability during an unprecedented event; and (3) effects, repercussions, and recommendations for change following the disaster. DISCUSSION AND IMPLICATIONS: Preparing for and managing disasters in nursing homes and assisted living communities involves actions within multiple environments beyond the residents and facilities where they live. Among these, community-level relationships are critical.

Emergency Department Use Among Assisted Living Residents After Hurricane Irma.

OBJECTIVES: Nursing home residents are especially vulnerable to adverse outcomes after a hurricane. Prior research suggests that emergency department (ED) visits increase among community-residing older adults after natural disasters. However, little is known about the impact of hurricanes on the large population of older adults residing in assisted living (AL) settings, particularly the influence of storms on the rates and causes of ED visits. We examined whether rates of ED use for injuries and other medical reasons increased after Hurricane Irma in 2017 among AL residents in Florida. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: Samples of 30,358 Medicare fee-for-service beneficiaries in 2016 and 28,922 beneficiaries in 2017 who resided in Florida AL communities. MEASURES: The number of injury-related and other medical visits per 1,000 person-days within 30 and 90 days of September 1 in 2016 and 2017. We adjusted for age, race, sex, and chronic conditions using linear regression with AL fixed effects. We compared the top 10 primary diagnoses resulting in an ED visit between 2016 and 2017. RESULTS: Adjusted rates of injury-related visits were 12.5% higher at 30 days but did not differ at 90 days. Other medical visits were 12% higher at 30 days in 2017 than in 2016 and 7.7% higher at 90 days. Heart failure was a leading cause of ED visits within 90 days of September 1 in 2017, unlike in 2016. CONCLUSIONS AND IMPLICATIONS: Increased attention should be paid to AL communities in disaster preparedness and response efforts given the increased likelihood of ED visits following a hurricane.

Association of Power Outage With Mortality and Hospitalizations Among Florida Nursing Home Residents After Hurricane Irma.

Importance: Exposure to hurricanes is associated with increased mortality and morbidity in nursing home (NH) residents, but the factors contributing to these outcomes are less understood. One hypothesized pathway could be power outages from hurricanes that expose NH residents to excess ambient heat. Objective: To determine the association of power loss from Hurricane Irma with hospitalization and mortality in NH residents in Florida. Design Setting and Participants: This retrospective cohort study of NH residents residing in Florida when Hurricane Irma landed on September 10, 2017, assessed mortality at 7 and 30 days after the storm and hospitalization at 30 days after the storm. The analysis was conducted from May 2, 2021, to June 28, 2021. All NH residents residing in Florida at landfall were eligible (N = 67 273). We excluded those younger than 65 years, missing power status information, or who were evacuated (13 178 [19.6%]). Exposure: We used state-administered surveys to determine NH power outage status. Exposed residents experienced a power outage poststorm, whereas unexposed residents did not experience a power outage poststorm. Main Outcomes and Measures: We used Medicare claims to assess mortality and hospitalization after Hurricane Irma landfall using generalized linear models with robust standard errors. Results: In the aftermath of Hurricane Irma, 27 892 residents (18 510 women [66.4%]; 3906 [14.0%] Black, 1651 [5.9%] Hispanic, and 21 756 [78.0%] White individuals) in 299 NHs were exposed to power loss and 26 203 residents (17 620 women [67.2%]; 4175 [15.9%] Black, 1030 [3.9%] Hispanic, and 20 477 [78.1%] White individuals) in 292 NHs were unexposed. Nursing homes that lost power were similar in size, quality star rating, and type of ownership compared with NHs that did not lose power. Power loss was associated with an increased adjusted odds of mortality among all residents within 7 days (odds ratio [OR],1.25; 95% CI,1.05-1.48) and 30 days (OR, 1.12; 95% CI,1.02-1.23) poststorm and hospitalization within 30 days, although only among residents aged 65 to 74 years (OR, 1.16; 95% CI, 1.03-1.33). Conclusions and Relevance: In this cohort study, power loss was associated with higher odds of mortality in all affected NH residents and hospitalization in some residents. The benefits and costs of policies that require NHs to have emergency alternate power sources should be assessed.

Effect of Hurricane Irma on daily direct-care nurse staffing in nursing homes.

OBJECTIVES: To examine the effect of Hurricane Irma on staff-related financial expenditures and daily direct-care nurse staffing levels. DESIGN: Retrospective cohort study. SETTING: September 3-24, 2017 in the state of Florida, United States. Hurricane Irma made landfall on September 10, 2017. PARTICIPANTS: Six hundred and fifty-three nursing homes (NHs), 81 evacuated facilities, and 572 facilities that sheltered-in-place. MEASUREMENTS: This study used data from Payroll-Based Journaling (PBJ), Certification and Survey Provider Enhanced Reports (CASPER), and Florida's health providers' emergency reporting system. PBJ provided estimates of daily direct-care nurse staffing levels for registered nurses, licensed practical nurses, and certified nursing assistants. CASPER reported facility-level characteristics such as profit status, chain membership, and special care unit availability. Florida's emergency reporting system identified evacuation status during Hurricane Irma. Linear mixed-effects models were used to estimate the unique contribution of evacuation status on daily staffing increases over time from September 3 to 10. RESULTS: Among all facilities, we found significant increases in staffing for licensed practical nurses (p = 0.02) and certified nursing assistants (p < 0.001), but not for registered nurses (p = 0.10) before Hurricane Irma made landfall. From 1 week before landfall to 2 weeks after landfall (September 3-24), an additional estimated $2.41 million was spent on direct-care nurse staffing. In comparison to facilities that sheltered-in-place, evacuated facilities increased staffing levels of all nurse types (all p < 0.001). At landfall, evacuated facilities spent an estimated $93.74 on nurse staffing per resident whereas facilities that sheltered-in-place spent $76.10 on nurse staffing per resident. CONCLUSION: NHs face unprecedented challenges during hurricanes, including maintaining adequate direct-care nurse staffing levels to meet the needs of their residents. NHs that evacuated residents had an increase in direct-care nurse staffing that was greater than that seen in NHs that sheltered-in-place.

Characterizing Emergency Department Use in Assisted Living.

OBJECTIVES: Little is known about emergency department (ED) utilization among the nearly 1 million older adults residing in assisted living (AL) settings. Unlike federally regulated nursing homes, states create and enforce AL regulations with great variability, which may affect the quality of care provided. The objective of this study was to examine state variability in all-cause and injury-related ED use among residents in AL. DESIGN: Observational retrospective cohort study. SETTING AND PARTICIPANTS: We identified a cohort of 293,336 traditional Medicare beneficiaries residing in larger AL communities (25+ beds). METHODS: With Medicare enrollment and claims data, we identified ED visits and classified those because of injury. We present rates of all-cause and injury-related ED use per 100 person-years in AL, by state, adjusting for age, sex, race, dual-eligibility, and chronic conditions. RESULTS: Risk-adjusted state rates of all-cause ED visits ranged from 100.9 visits/100 AL person-years [95% confidence interval (CI) 92.8, 109.9] in New Mexico to 162.3 visits/100 AL person-years (95% CI 154.0, 174.7) in Rhode Island. The risk-adjusted rate of injury-related ED visits ranged from 18.7 visits/100 AL person-years (95% CI 17.2, 20.3) in New Mexico to 35.7 visits/100 AL person-years (95% CI 34.7, 36.8) in North Carolina. CONCLUSIONS AND IMPLICATIONS: We observed significant variability among states in all-cause and injury-related ED use among AL residents. There is an urgent need to better understand why this variability is occurring to prevent avoidable visits to the ED.

Assisted Living Communities During Hurricane Irma: The Decision to Evacuate or Shelter in Place and Resident Acuity.

OBJECTIVES: To investigate the factors associated with whether assisted living communities (ALCs) in Florida evacuated or sheltered in place for Hurricane Irma in 2017, focusing on license type as a proxy for acuity of care. DESIGN: Cross-sectional study using data collected by the state through its emergency reporting system and a post-hurricane survey. SETTING AND PARTICIPANTS: Analyses included all 3112 ALCs in the emergency reporting system. A subset of 1880 that completed the survey provided supplementary data. METHODS: χ2 tests were used to examine differences between ALC characteristics (license type, size, payment, profit status, rural location, geographical region, and being under an evacuation order) and whether they evacuated. Logistic regression was used to test associations between characteristics and evacuation status. RESULTS: Of 3112 ALCs, 560 evacuated and 2552 sheltered in place. Bivariate analysis found significant associations between evacuation status and evacuation order, license type (mental health care), payment, and region. In the adjusted analysis, medium and larger ALCs were 43% (P < .001) and 53% (P < .001) less likely to evacuate than ALCs with fewer than 25 beds. Compared with ALCs in the Southeast, nearly every region was more likely to evacuate, with the highest likelihood in the Central West (odds ratio 1.76, 95% confidence interval 1.35‒2.30). ALCs under an evacuation order were 8 times more likely to evacuate (P < .001). We found no relationship between evacuation status and having a license to provide higher care. CONCLUSIONS AND IMPLICATIONS: Prior research highlighting harm associated with evacuation has led to recommendations that long-term care facilities carefully consider resident impairment in evacuation decision-making. Evidence that small ALCs are more likely to evacuate and that having a higher-care license is not associated with evacuation likelihood shows research is needed to understand how ALCs weigh resident risks in decisions to evacuate or shelter in place.