Do end-of-life outcomes differ by assisted living memory-care designation?

BACKGROUND: Residential care/assisted living (RC/AL) is an increasingly common place of end-of-life care for persons with Alzheimer's disease and related dementia (ADRD), who have unique care needs as their health declines. Approximately 22% of RC/ALs provide specialized memory care (memory-care RC/AL). Understanding how end-of-life outcomes differ by memory care among residents with ADRD could facilitate aging/dying in place for this population. The objective of this paper is to examine if end-of-life outcomes (i.e., mortality, hospice use, and number of days receiving hospice in the last month of life) differ between residents with ADRD who moved to memory-care RC/AL, compared with residents with ADRD who moved to RC/AL without memory care (general RC/AL). METHODS: Prospective cohort of 15,152 fee-for-service Medicare beneficiaries with ADRD who moved to large RC/AL (> = 25 beds) between 2016 and 2018. We used inverse probability treatment weighting to account for observable differences between memory-care and general RC/AL residents. Two-part models estimated the difference by memory care in the number of days receiving hospice care in the last months of life among RC/AL decedents. RESULTS: The unadjusted mortality rates were 13.4% in general RC/AL and 15.8% in memory-care RC/AL with an adjusted difference of 1.3 percentage points higher mortality among memory-care RC/AL residents (p = 0.04). Hospice use was 8% and 10.6% among general and memory-care RC/AL residents, respectively, with an adjusted difference of 1.4 percentage points (p = 0.01) higher in memory care. Two-part models showed that decedents in memory-care RC/AL spent about 1.4 more days receiving hospice care in the last month of life (p = 0.02). CONCLUSION: We find a higher mortality rate and higher rate of hospice use among memory-care RC/AL residents. These findings suggest that memory care may attract residents closer to the end of life and/or promote hospice use at the end of life.

Trends and geographic differences in social work telehealth utilization.

We plotted trends in social work telehealth use among Veterans in a U.S. national social work staffing program and examined the relationship between geographic factors (rurality and neighborhood disadvantage) and telehealth use (audio and video) using linear probability models. Social work telehealth use increased among Veterans during the COVID-19 pandemic. There were no geographic differences in telephone telehealth use. Video telehealth use was less common among Veterans in isolated rural areas and among Veterans in highly disadvantaged areas. Outreach efforts can address barriers that Veterans who live in rural and disadvantaged areas may experience in using video telehealth.

Benefits and challenges in the use of RE-AIM for evaluation of a national social work staffing program in the veterans health administration.

Background: In the Department of Veterans Affairs (VA) Veterans Health Administration (VHA), social workers embedded in primary care teams address social and emotional needs that are associated with health outcomes. The mission of the National Social Work PACT Staffing Program is to improve access to social work services for rural Veterans by supporting additional social work staffing in VA medical centers serving rural areas. Methods: We obtained data from the VA corporate data warehouse on Veterans' characteristics and health care use from 2016 to 2022 for all Veterans who received primary care at a Veterans Affairs Medical Center (VAMC) or associated clinic that received funding from the program. We evaluated the program according to RE-AIM constructs as follows: Reach [total number of Veterans who engaged with PACT social work and representativeness with regard to race, rural residence, chronic conditions and health behaviors, and hospital and emergency department (ED) use in the previous 12 months]; Effectiveness (impact of the program on key health care use outcomes which include hospitalizations, emergency department visits, and palliative care); Adoption (number of VA medical centers and outpatient clinics serving rural Veterans that have participated in the program, and number and representativeness of sites eligible for program participation that have not yet received funding); Implementation (adherence to standardized note templates), and Maintenance (permanent social work positions created by the program and continued technical support). Results: In 2022, the program engaged with 30,982 Veterans, 65% of whom lived in rural areas. The program increased social work encounters, reduce hospital and emergency department use, and increase use of palliative care services among Veterans. Key elements of implementation include proactive outreach to Veterans with high-risk indicators and assessment for social risk factors using standardized, national note templates. In terms of maintenance, the program continues to provide data and technical assistance to 23 sites and has created 171 permanent social work positions. Conclusions and implications: The Social Work PACT Staffing Program demonstrates positive outcomes and program sustainment. The RE-AIM framework was a useful tool to evaluate the program, but additional adaption was needed to fit the program's needs.

Association of Medicaid Financing and Concentration of Assisted Living Residents Dually Eligible for Medicare and Medicaid.

This cross-sectional study examines different levels of state Medicaid financing for assisted living and the association with the number of beneficiaries with dual Medicare and Medicaid eligibility who live in assisted living facilities.

Social Work Staffing and Use of Palliative Care Among Recently Hospitalized Veterans.

Importance: Palliative care improves quality of life for patients and families but may be underused. Objective: To assess the association of an intervention to increase social work staffing in Veterans Health Administration primary care teams with use of palliative care among veterans with a recent hospitalization. Design, Setting, and Participants: This cohort study used differences-in-differences analyses of the change in palliative care use associated with implementation of the Social Work Patient Aligned Care Team (PACT) staffing program, conducted from October 1, 2016, to September 30, 2019. The study included 71 VA primary care sites serving rural veterans. Participants were adult veterans who received primary care services from a site enrolled in the program and who received inpatient hospital care. Data were analyzed from January 2020 to August 2022. Exposures: The PACT staffing program was a clinic-level intervention that provided 3-year seed funding to Veterans Health Administration medical centers to hire 1 or more additional social workers in primary care teams. Staggered timing of the intervention enabled comparison of mean outcomes across sites before and after the intervention. Main Outcomes and Measures: The primary outcome was the number of individuals per 1000 veterans who had any palliative care use in 30 days after an inpatient hospital stay. Results: The analytic sample included 43 200 veterans (mean [SD] age, 65.34 [13.95] years; 37 259 [86.25%] men) and a total of 91 675 episodes of inpatient hospital care. Among the total cohort, 8611 veterans (9.39%) were Black, 77 069 veterans (84.07%) were White, and 2679 veterans (2.92%) were another race (including American Indian or Alaskan Native, Asian, and Native Hawaiian or other Pacific Islander). A mean of 14.5 individuals per 1000 veterans (1329 individuals in all) used palliative care after a hospital stay. After the intervention, there was an increase of 15.6 (95% CI, 9.2-22.3) individuals per 1000 veterans using palliative or hospice care after a hospital stay, controlling for national time trends and veteran characteristics-a 2-fold difference relative to the mean. Conclusions and Relevance: This cohort study found significant increases in use of palliative care for recently hospitalized veterans whose primary care team had additional social work staffing. These findings suggest that social workers may increase access to and/or use of palliative care. Future work should assess the mechanism for this association and whether the increase in palliative care is associated with other health or health care outcomes.

Decline in Veterans' Admissions to Nursing Homes during COVID-19: Fewer Beds, More Fear, and Finding Alternative Care Settings.

OBJECTIVE: Examine the decline in admission to community nursing homes among Veterans that occurred following the onset of the COVID-19 pandemic. DESIGN: Multimethods study using Department of Veterans Affairs (VA) purchasing records to examine trends in total admissions and semistructured interviews with staff connected to the VA community nursing home program to contextualize observed trends. SETTING AND PARTICIPANTS: All VA-paid admissions to community nursing homes (N = 56,720 admissions) and national data on nursing home admissions from LTCFocUS. Semistructured interviews were conducted with 9 VA staff from 4 VA medical centers working in the VA community nursing home program, including social workers, nurses, and program coordinators. RESULTS: Between April and December 2020, community nursing home admissions among Veterans were 35% lower compared with the same period in 2019. Nationally, total nursing home admissions decreased by 19.6%. VA community nursing home program staff described 3 themes that contributed to this decline: (1) fewer nursing home beds available, (2) lower admissions due to fear of Veterans being exposed to COVID-19 in nursing homes, and (3) leaving nursing homes in favor of living at home with home-based care. CONCLUSIONS AND IMPLICATIONS: The decline in nursing home admissions among Veterans raises questions about how replacing nursing home care in favor of home- and community-based care affects the health outcomes and well-being of Veterans and their caregivers.

Injury-related emergency department use among assisted living residents with Alzheimer's disease and related dementias.

BACKGROUND: Injuries are a leading cause of emergency department (ED) visits among older adults, and individuals with Alzheimer's disease and related dementias (ADRD) may be at particular risk. We compared injury-related ED use among assisted living (AL) residents with and without ADRD and assessed differences in the risk of injury-related ED visits among individuals with ADRD residing in ALs with memory care designation versus general AL. METHODS: Using Medicare claims, we identified a cohort of fee-for-service beneficiaries who lived in AL in 2018 and resided in one of 20 states with site-specific information on memory care designation (n = 116,754). Outcomes included all injury-related ED visits and injury-related ED visits resulting in hospitalization in the calendar year 2018. We fit multilevel models of the association between ADRD and outcomes, adjusting for resident demographic characteristics and chronic conditions, license type characteristics, and AL characteristics, with random intercepts at the AL and license type levels. Among residents with ADRD, we examined whether memory care licensure was associated with injury-related ED visits. RESULTS: The adjusted risk of injury-related ED use during the year was 20.1% (95% CI: 19.6%, 20.6%) for residents with ADRD compared to 16.1% for residents without ADRD (95% CI: 15.7%, 16.5%; p < 0.001). The adjusted risk of injury-related ED use ending in hospitalization was 4.9% (95% CI: 4.6%, 5.1%) for AL residents with ADRD and 3.9% for residents without ADRD (95% CI: 3.8%, 4.1%; p < 0.001). There were no significant differences in injury-related ED visits between residents with ADRD in ALs with memory care designation and residents in general AL. CONCLUSIONS: Injury-related ED visits are common among AL residents with ADRD and residents in memory care, but residents in memory care AL experienced similar risks of injury as those in general AL. Further research should identify modifiable factors that can prevent injury among AL residents with ADRD.

Barriers and facilitators to interprofessional collaborative practice for community-dwelling older adults: An integrative review.

AIMS AND OBJECTIVES: The aim of this integrative review was to synthesise empirical reports of interprofessional collaborative practice (IPCP) for community-dwelling older adults and uncover barriers and facilitators related to its success as a model of care for this population. BACKGROUND: IPCP is a model of care that has demonstrated positive outcomes for community-dwelling older adults. However, a summary of barriers and facilitators to IPCP models has not been presented. METHODS: An integrative review using the method posited by Whittemore and Knafl was completed to identify barriers and facilitators to IPCP for community-dwelling older adults. The literature search was reported following PRISMA guidelines. RESULTS: Four themes emerged as barriers to IPCP: (1) A (Potential) Logistical Nightmare, (2) All About the Money, (3) If We Can't Test It, Can We Recommend It? and (4) Challenging for the Team, Challenging for the Client. Three themes emerged as facilitators to IPCP: (1) Reducing Resource Waste, (2) The "C" in IPCP and (3) What Matters Most. CONCLUSIONS: IPCP models for community-dwelling older adults must adapt to the setting of care and client needs. Interprofessional education opportunities for team members facilitate effective IPCP. Healthcare policies and funding structures need to address IPCP for community-dwelling older adults for this model to be successful and sustainable. RELEVANCE TO CLINICAL PRACTICE: Nurses participate on and lead IPCP teams caring for community-dwelling older adults and, therefore, need to be aware of barriers and facilitators to this model of care.

Community Nursing Home Program Oversight: Can the VA Meet Increased Demand for Community-Based Care?

Background: The US Department of Veterans Affairs (VA) Community Nursing Home (CNH) program provides in-person oversight monitoring the quality of care of veterans in VA-contracted community-based skilled nursing homes. The number of veterans receiving CNH care is projected to increase by 80% by 2037. Methods: Retrospective observational data describing the distance between contracted facilities and VA medical centers (VAMCs) were linked to Centers for Medicare and Medicaid monthly Nursing Home Compare and Brown University Long Term Care: Facts on Care in the US data. Qualitative interviews with CNH-based staff and VA-based CNH program oversight team members were conducted using a semistructured interview guide. Quantitative and qualitative data were analyzed independently and integrated during the interpretation of results. Results: The number of CNHs per VAMC ranged from 1 to 68 (mean, 18). One in 4 CNHs were > 70 miles from the associated VAMC; among CNHs with 2 to 5 veterans, 44% were located > 50 miles away. Four qualitative themes emerged regarding VA CNH oversight: (1) benefits of VA CNH team engagement/ visits, including quality assurance and care coordination; (2) burden of VA CNH oversight due to geographic dispersion with too few or too many veterans at each to achieve efficiency; (3) oversight burdens and limited staffing restricted ability to add CNHs; and (4) remote access and interoperability of electronic health records and balancing the number of CNH veterans with staffing could facilitate successful oversight. Conclusions: The success of the CNH program will depend on the exchange of information and matching available resources to veterans' needs. At a time when strategies to ease the burden on NHs and VA CNH coordinators are needed, the VA needs to improve to properly scale the program.

Excess Mortality Among Assisted Living Residents With Dementia During the COVID-19 Pandemic.

OBJECTIVE: To evaluate whether assisted living (AL) residents with Alzheimer's disease and related dementias (ADRD) experienced a greater rate of excess all-cause mortality during the first several months of the COVID-19 pandemic compared to residents without ADRD, and to compare excess all-cause mortality rates in memory care vs general AL among residents with ADRD. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: Two cohorts of AL residents enrolled in Medicare Fee-For-Service who resided in 9-digit ZIP codes corresponding to US AL communities of ≥25 beds during calendar year 2019 or 2020. METHOD: By linking Medicare claims and Vital Statistics data, we examined the weekly excess all-cause mortality rate, comparing the rate from March 12, 2020, to December 31, 2020, to the rate from January 1, 2019, to March 11, 2020. We adjusted for demographics, chronic conditions, AL community size, and county fixed effects. RESULTS: Of the 286,350 residents in 2019 and the 273,601 in 2020 identified in these cohorts, approximately 31% had a diagnosis of ADRD. Among all AL residents, the excess weekly mortality rate in 2020 was 49.1 per 100,000 overall during the pandemic. Compared to residents without ADRD, residents with ADRD experienced 33.4 more excess deaths per 100,000 during the pandemic. Among residents with ADRD, those who resided in memory care communities did not experience a statistically significant different mortality rate than residents who lived in general AL. CONCLUSIONS AND IMPLICATIONS: AL residents with ADRD were more vulnerable to mortality during COVID-19 than residents without ADRD, a finding similar to those reported in other settings such as nursing homes. Additionally, the study provides important new information that residents with ADRD in memory care communities may not have been at differential risk of COVID-19 mortality when compared to residents with ADRD in general AL, despite prior research suggesting they have more advanced dementia.

Purchasing High-Quality Community Nursing Home Care: A Will to Work With VHA Diminished by Contracting Burdens.

OBJECTIVES: The Veterans Health Administration (VHA) purchases community nursing home care; however, the administrative burden may lead nursing homes to avoid contracting with the VHA. This study aimed to describe how the VHA's purchasing policies impede or facilitate contracting with nursing homes. DESIGN: Semistructured interviews of key stakeholders in the VHA's community nursing home contracting process. SETTING AND PARTICIPANTS: We interviewed 15 VHA and 21 nursing home staff at 6 VHA medical centers and 17 nursing homes. VHA medical centers were selected from sites with the greatest magnitude of difference in quality rankings between VHA contracted and noncontracted nursing homes in the same market area. METHODS: Qualitative content analysis of interviews. RESULTS: Five themes emerged: (1) VHA purchases nursing home care to fill gaps in geographic, specialty, and quality care needs; (2) business opportunities and the mission to care for Veterans motivate nursing homes to work with the VHA; (3) the VHA's reputation for unreliable or insufficient payment and inability of nursing homes to comply with federal wage standards serve as barriers to establishing contracts; (4) complexity of establishing a contract, ambiguity about new policies, and inadequate VHA staffing for the nursing home inspection team hinder the VHA's ability to establish contracts with nursing homes; and (5) nursing homes that have established corporate processes, nursing home administrators with prior experience working with the VHA, and relationships between VHA and nursing home staff serve as facilitators to establishing new nursing home contracts. CONCLUSIONS AND IMPLICATIONS: Nursing homes will work with the VHA, but the process of executing VHA contracts is burdensome. Streamlining and standardizing the purchasing processes and ensuring timely payment may expand the number of nursing homes willing to contract with the VHA, thereby increasing choices for Veterans and becoming a model for other long-term care networks.

Memory care reduces nursing home admissions among assisted-living residents with dementia.

INTRODUCTION: We compare nursing-home and hospital admissions among residents with Alzheimer's disease and related dementias (ADRD) in memory-care assisted living to those in general assisted living. METHODS: Retrospective study of Medicare beneficiaries with ADRD in large (>25 bed) assisted-living communities. We compared admission to a hospital, to a nursing home, and long-term (>90 day) admission to a nursing home between the two groups, using risk differences and survival analysis. RESULTS: Residents in memory-care assisted living had a lower adjusted risk of hospitalization (risk difference = -1.8 percentage points [P = .014], hazard ratio = 0.93 [0.87-1.00]), a lower risk of nursing-home admission (risk difference = -2.2 percentage points [P < .001], hazard ratio = 0.87 [-.79-0.95]), and a lower risk of a long-term nursing home admission (risk difference = -1.1 percentage points [P < .001], hazard ratio = 0.71 [0.57-0.88]). DISCUSSION: Memory care is associated with reduced rates of nursing-home placement, particularly long-term stays, compared to general assisted living.

Adaptation of a social risk screening and referral initiative across clinical populations, settings, and contexts in the Department of Veterans Affairs Health System.

Identifying and addressing social risks and social needs in healthcare settings is an important step towards achieving health equity. Assessing Circumstances and Offering Resources for Needs (ACORN) is a Department of Veterans Affairs (VA) social risk screening and referral model that aims to systematically identify and address social needs. Since initial piloting in 2018, our team has collaborated with clinical and operations partners to implement ACORN across multiple VA clinical settings while adapting and tailoring the initiative to meet the needs of different populations, specialties, and individuals administering screening. Given ACORN's complexity as a growing initiative with multiple partners and frequent real-time modifications within a large national healthcare system, we recognized a need to systematically document the rationale and process of adaptations over time. We looked to three implementation frameworks-RE-AIM, the Adaptome, and FRAME-to describe the rationale for adaptations, the nature of and context within which adaptations were made, and the details of each adaptation. In this manuscript, we uniquely interweave these three frameworks to document adaptations to ACORN across diverse VA clinical settings, with a focus on how adaptations support the promotion of heath equity in the Veteran population.

Association of statewide stay-at-home orders with utilization of case management and supportive services for veterans experiencing housing insecurity.

The US Department of Housing and Urban Development-Department of Veterans Affairs (VA) Supportive Housing (HUD-VASH) program provides Veterans with a subsidy for rent and case management. In response to the Coronavirus 2019 pandemic, many states enacted stay-at-home orders that may have limited access to case managers. Therefore, we examined the association between statewide stay-at-home orders and utilization of HUD-VASH case management. We linked data on whether a state implemented a statewide stay-at-home order between March 1, 2020 and April 30, 2020 with VA medical records. Analysis time was centered on the date of a state's stay-at-home order (exposed states). For Veterans in states without a stay-at home-order (unexposed states), we used the average date exposed states implemented an order (March 27, 2020). We used a difference-in-difference design and adjusted linear regression models to compare total, in-person, telephone, and video case management encounters per Veteran in the 60 days after a stay-at-home order relative to the prior year. There was no significant difference in utilization of case management between Veterans who lived in states that did and did not issue a stay-at-home order. Across all states and in the 60 days after the index date relative to the prior year, Veterans had more total, telephone and video, and fewer in-person encounters. Statewide stay-at-home orders did not differentially affect utilization of case management. Virtual case management in HUD-VASH can increase program reach; however, the effect of virtual case management on outcomes such as quality of life and Veteran satisfaction is unknown.

Antipsychotic initiation and new diagnoses excluded from quality-measure reporting among Veterans in community nursing homes contracted by the Veterans Health Administration in the United States.

OBJECTIVES: To assess whether prevailing antipsychotic use rates in community nursing homes (CNH) influence new initiation of antipsychotics and diagnosis with antipsychotic indications among Veterans. METHODS: We used linked 2013-2016 Veterans Administration (VA) data, Medicare claims, Nursing Home Compare, and Minimum Data Set (MDS) assessments. The exposure was the proportion (in quintiles) of all CNH residents prescribed antipsychotics in the quarter preceding a Veteran's admission date. Using adjusted logistic regression, we analyzed two outcomes measured using MDS: antipsychotic initiation, and new diagnosis of an antipsychotic quality-measure exclusionary condition (i.e., schizophrenia, Tourette's syndrome, or Huntington's disease). RESULTS: Among 8201 Veterans without an indication for antipsychotics at baseline, 21.1% initiated antipsychotics and 3.5% were newly diagnosed with any exclusionary diagnosis after CNH admission. Schizophrenia accounted for almost all (96.8%) the new diagnoses. Antipsychotic initiation increased with higher CNH antipsychotic use rates: OR = 2.55, 95% CI: 2.08--3.12, quintile 5 versus 1. CNHs with the highest prevalent use of antipsychotics were associated with increased odds of Veterans acquiring an exclusionary diagnosis (OR = 2.09, 95% CI: 1.32-3.32, quintile 5 vs. 1). CONCLUSIONS: Incident antipsychotic use is common among Veterans admitted to CNHs. CNH antipsychotic prescribing practices are associated with Veterans being newly diagnosed with antipsychotic prescription indications, primarily schizophrenia.

State Medicaid Financing and Access to Large Assisted Living Settings for Medicare-Medicaid Dual-Eligibles.

Assisted living has become more widely used by dual-eligible Medicare beneficiaries as states try to rebalance their long-term services and supports away from institutional (nursing home) care. In an analysis of 2014 Medicare data for 506,193 adults who live in large (25+ beds) assisted living communities, we found wide variability among states in the share of assisted living residents who were dual-eligible, ranging from 6% in New Hampshire to over 40% in New York. This variation is strongly correlated with the Medicaid support for assisted living care: In states with a Medicaid state plan option covering services in assisted living or both a state plan and waiver, the percent of assisted living residents with dual-eligibility was more than 10 percentage points higher than in states with neither a state plan nor waiver. Findings provide a basis for understanding the role of Medicaid financing in access to assisted living for duals.

The Relationship Between States' Staffing Regulations And Hospitalizations Of Assisted Living Residents.

Assisted living provides housing and long-term care services to more than 811,000 older adults in the United States daily and is regulated by the states. This article describes changes in the specificity of state regulations governing the staffing in assisted living settings (that is, requirements for sufficient staffing or staffing ratios or levels) between 2007 and 2018 and the association between these changes and rates of hospitalization among a national sample of assisted living residents, including a subgroup with dementia. We found that increased regulatory specificity for direct care workers (for example, a change from requiring "sufficient" direct care worker staffing to requiring a specific staffing ratio or level) was associated with a 4 percent reduction in the monthly risk for hospitalization among residents in our sample and a 6 percent reduction among the subgroup with dementia. However, an increase in regulatory specificity for licensed practical nurses was associated with a 2.5 percent increase in the monthly risk for hospitalization and a 5 percent increase among the subgroup with dementia. Given that no federal requirements exist for the number of staff members or composition of staff in assisted living, these findings can inform states' policy decisions about staffing requirements for assisted living settings.

Association of Home-Based Primary Care Enrollment with Social Determinants of Health for Older Veterans.

BACKGROUND: Home-based Primary Care (HBPC) provides comprehensive primary care to Veterans who may be at risk of adverse health outcomes due to their social determinants of health. Area Deprivation Index (ADI) can be used as a surrogate measure of a Veteran's social needs. OBJECTIVE: To estimate the effect of neighborhood disadvantage, as measured by ADI, on HBPC enrollment for a sample of Veterans. METHODS: We estimated a linear multivariate model in which the exposure was ADI and the outcome was enrollment in HBPC. Controls included clinical and demographic characteristics. RESULTS: In a final sample of 12,005,453 observations (total Veteran months) on 353,485 individual Veterans, 18.4% lived in high-deprivation neighborhoods (ADI greater than 80). Mean monthly probability of new HBPC enrollment was 0.0061. Controlling for clinical characteristics, housing instability, and distance from the medical center, Veterans residing in high-deprivation neighborhoods were 1.4% to 14.8% less likely to enroll in HBPC, though the association was not statistically significant. CONCLUSIONS: More research is needed to determine the relationship between Veterans' social needs and HBPC enrollment.

Social work and telehealth: How Patient Aligned Care Team (PACT) social workers in the Veterans Health Administration responded to COVID-19.

In March 2020, the Veterans Health Administration (VA) responded to pandemic shutdowns with a rapid pivot toward providing services via telehealth. Using data on Veterans who received interventions from social workers between 2019 and 2020 at sites that participated in a national program to increase social work staffing in primary care, we examined changes in frequency and modality of social work encounters that occurred with the onset of the COVID-19 pandemic. We found that primary care social workers maintained a consistent level of engagement, with increases in telephone and video telehealth encounters as in-person visits decreased. Through front-line perspectives, we discuss the practical innovations and policies that enabled those changes in care from VA primary care social workers.

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.