Palliative Opioids May Be a Bridge to Care for Rural Long-Term Care Facility Residents with Severe COVID-19 Symptoms.

PURPOSE: Long term care facility (LTCF) residents are at high risk for severe COVID-19 symptoms, but those in rural and resource-limited areas, such as West Virginia (WV) and the larger Appalachian region, may experience delays in obtaining higher levels of medical care due to isolated geography and limited transportation. The study examined the outcomes between residents from 1 LCTF in WV who were moved to a hospital as compared to those remaining in the facility. METHODS: This cohort study compares mortality outcomes among severely symptomatic residents desiring hospitalization and those electing to stay at the facility receiving palliative opioids with supplemental oxygen. FINDINGS: Forty residents tested positive for COVID-19 with 11 developing severe respiratory symptoms. Eight residents elected to receive care at the LTCF while 3 desired hospitalization. Mortality was assessed at 4 time points and was not statistically different between those who were hospitalized versus those who received palliative opioids at the LTCF. Although not significant, the difference in mortality between those hospitalized (66.7%) and those receiving opioids at the LTCF (12.5%) in the acute phase trended toward significance (P = .072). Overall mortality at the 6-month time point among all residents who developed severe respiratory symptoms at this LTCF was 54.5%. CONCLUSIONS: LTCF residents choosing different levels of therapeutic intervention for severe COVID-19 symptoms had no mortality difference. Palliative opioids may be an effective treatment for LTCF residents with severe COVID-19 and also a bridge to care in rural areas with limited resources until more advanced treatments can be accessed.

Improving Bisphosphonate Use and Evaluation in a Rural Family Medicine Practice.

OBJECTIVE: To evaluate the prevalence of bisphosphonate use without a drug holiday and to assess the success of an interdisciplinary approach to manage and discontinue bisphosphonate therapy. SETTING: The study was completed at one rural family medicine center. PRACTICE DESCRIPTION: The practice employs two fulltime pharmacists. Clinical pharmacists' responsibilities include chronic care management as well as collaboration with the team during interdisciplinary clinics. Clinical pharmacists frequently collaborate with other professionals on medication evaluations and quality improvement projects. PRACTICE INNOVATION: The pharmacy team and medical resident collaborated to determine appropriateness of bisphosphonate use. This was a two-phase evaluation. In the first phase, therapies were evaluated based on duration and consistency with guideline recommendations based on a retrospective chart review. In the second phase, the pharmacy and medicine team determined if therapy warranted further continuation or if a drug holiday was needed. The team reached out to providers proactively and provided patient and provider education on discontinuing therapy. MAIN OUTCOME MEASUREMENTS: Patient demographics, bisphosphonate regimen and duration of prescription, frequency of drug holidays, and success rate of therapy discontinuation. RESULTS: Bisphosphonates were prescribed for an average of 4.2 years with 56 patients prescribed therapy for >5 years. Twenty-one of the 56 patients had a history of a drug holiday, and 13 of the 35 remaining patients had therapy discontinued or a drug holiday was initiated based on the team's recommendation. Patients were more likely to be prescribed therapy for >5 years if they were older and had more provider appointments.

Frailty: Evaluation and Management.

Frailty, which is a geriatric syndrome that affects 5% to 17% of older adults, is a state of increased vulnerability across multiple health domains that leads to adverse health outcomes. Frail older adults are at increased risk of falls, disability, hospitalizations, and death. Frailty may initially be overlooked or incorrectly identified as part of the normal aging process because of the variable nature of the presentation and diagnosis. Symptoms include generalized weakness, exhaustion, slow gait, poor balance, decreased physical activity, cognitive impairment, and weight loss. There is no current recommendation for routine screening. A comprehensive geriatric assessment can identify risk factors and symptoms that suggest frailty. Several validated frailty assessment tools can evaluate a patient for frailty. Patients are diagnosed as not-frail, prefrail, or frail. Patients with a larger number of frail attributes are at higher risk of poor outcomes. The management of frail patients must be individualized and tailored to each patient's goals of care and life expectancy. Physical activity and balance exercises may be suitable for patients who are less frail. Palliative care and symptom control may be appropriate for those who are more frail.

Responding to a COVID-19 Outbreak at a Long-Term Care Facility.

This article describes an outbreak of COVID-19 in a long-term care facility (LTCF) in West Virginia that was the epicenter of the state's pandemic. Beginning with the index case, we describe the sequential order of procedures undertaken by the facility including testing, infection control, treatment, and communication with facility residents, staff, and family members. We also describe the lessons learned during the process and provide recommendations for handling an outbreak at other LTCFs.