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.

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.

Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED): a protocol for an implementation study in the Veterans Health Administration.

BACKGROUND: Empirical evidence supports the use of structured goals of care conversations and documentation of life-sustaining treatment (LST) preferences in durable, accessible, and actionable orders to improve the care for people living with serious illness. As the largest integrated healthcare system in the USA, the Veterans Health Administration (VA) provides an excellent environment to test implementation strategies that promote this evidence-based practice. The Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED) program seeks to improve care outcomes for seriously ill Veterans by supporting efforts to conduct goals of care conversations, systematically document LST preferences, and ensure timely and accurate communication about preferences across VA and non-VA settings. METHODS: PERSIVED encompasses two separate but related implementation projects that support the same evidence-based practice. Project 1 will enroll 12 VA Home Based Primary Care (HBPC) programs and Project 2 will enroll six VA Community Nursing Home (CNH) programs. Both projects begin with a pre-implementation phase during which data from diverse stakeholders are gathered to identify barriers and facilitators to adoption of the LST evidence-based practice. This baseline assessment is used to tailor quality improvement activities using audit with feedback and implementation facilitation during the implementation phase. Site champions serve as the lynchpin between the PERSIVED project team and site personnel. PERSIVED teams support site champions through monthly coaching sessions. At the end of implementation, baseline site process maps are updated to reflect new steps and procedures to ensure timely conversations and documentation of treatment preferences. During the sustainability phase, intense engagement with champions ends, at which point champions work independently to maintain and improve processes and outcomes. Ongoing process evaluation, guided by the RE-AIM framework, is used to monitor Reach, Adoption, Implementation, and Maintenance outcomes. Effectiveness will be assessed using several endorsed clinical metrics for seriously ill populations. DISCUSSION: The PERSIVED program aims to prevent potentially burdensome LSTs by consistently eliciting and documenting values, goals, and treatment preferences of seriously ill Veterans. Working with clinical operational partners, we will apply our findings to HBPC and CNH programs throughout the national VA healthcare system during a future scale-out period.

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.

Veterans Health Administration Staff Perceptions of Overseeing Care in Community Nursing Homes During COVID-19.

INTRODUCTION: The Veterans Health Administration (VA) contracts with non-VA owned and operated community nursing homes (CNHs) to provide Veterans nursing home care. This study explored VA staffs' experiences coordinating care with CNH staff during the COVID-19 pandemic. METHODS: Qualitative study interviewing VA staff overseeing and coordinating care for CNH Veterans. Interviews were recorded, transcribed, and analyzed using inductive and deductive thematic analysis. RESULTS: Three themes influenced care coordination. (1) Pre-established working relationships strengthened trust in CNH staff and remote access to CNH electronic medical records (EMRs). (2) Remote oversight proved challenging as virtual visits did not fully capture Veterans' needs and Veterans experienced challenges due to cognitive status, hearing impairment, and discomfort with technology. (3) Partnerships strengthened as VA staff provided CNHs personal protective equipment, COVID-19 testing, infection control education, and emotional support. DISCUSSION: Despite pre-existing relationships and improved partnerships, most VA staff felt uncertain about the quality of oversight provided through remote monitoring and preferred in-person interactions. However, they found benefit in remote access to CNH EMRs and shared optimism with expanding virtual care. CONCLUSIONS: Fostering strong partnerships between VAs and CNHs improve care coordination during crises like the COVID-19 pandemic and for daily care.

Sharing Space to Age in Community: A Mixed-Methods Study of Homeshare Organizations.

As adults age, they often require more assistance with personal care needs and other daily living activities. Along with requiring more assistance, access to affordable housing options is also a concern. Homesharing has emerged as a potential means of addressing these housing challenges for older adults. In this study, we surveyed 23 homeshare organizations and interviewed 16 survey respondents to understand characteristics of homeshare organizations, populations served, and the homeshare model. Findings suggest that homeshare organizations use a high-touch matching approach and that they experience challenges to sustainability. Individuals who enter a match are a small subset of those who apply due to organizational eligibility criteria and characteristics of applicants that impact their suitability for homesharing. While homesharing is a niche housing option that is not appropriate for many people, future research should explore whether homesharing fills gaps in housing options for older adults and the outcomes of homesharing.

Applying the Tailored Implementation in Chronic Diseases framework to inform implementation of the Preferences Elicited and Respected for Seriously Ill Veterans through enhanced decision-making program in the United States Veterans Health Administration.

In 2017, the National Center for Ethics in Health Care for the United States Department of Veterans Affairs (VA) commenced national roll-out of the Life-Sustaining Treatment Decisions Initiative. This national VA initiative aimed to promote personalized, proactive, patient-driven care for seriously ill Veterans by documenting Veterans' goals and preferences for life-sustaining treatments in a durable electronic health record note template known as the life-sustaining treatment template. The Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED) quality improvement program was created to address the high variation in life-sustaining treatment template completion in VA Home Based Primary Care (HBPC) and Community Nursing Home programs. This manuscript describes the program that focuses on improving life sustaining treatment template completion rates amongst HBPC programs. To increase life-sustaining treatment template completion for Veterans receiving care from HBPC programs, the PERSIVED team applies two implementation strategies: audit with feedback and implementation facilitation. The PERSIVED team conducts semi-structured interviews, needs assessments, and process mapping with HBPC programs in order to identify barriers and facilitators to life-sustaining treatment template completion to inform tailored facilitation. Our interview data is analyzed using the Tailored Implementation in Chronic Diseases (TICD) framework, which identifies 57 determinants that might influence practice or implementation of interventions. To quickly synthesize and use baseline data to inform the tailored implementation plan, we adapted a rapid analysis process for our purposes. This paper describes a six-step process for conducting and analyzing baseline interviews through applying the TICD that can be applied and adapted by implementation scientists to rapidly inform tailoring of implementation facilitation.

Social Support and Stressors among VA Medical Foster Home Caregivers.

This study aimed to identify sources of social support and stressors that facilitated or hindered caregivers in the Department of Veterans Affairs (VA) Medical Foster Home (MFH) program in performing their duties. We conducted phone interviews with 35 caregivers and found they relied on work-related, religious, and emotional social support. Caregivers' unmet needs included a lack of time to re-charge; affordable respite services; enough VA-paid relief services, adequate relief caregivers; and ability to attend church. To address these needs, VA leadership should make MFH caregivers eligible for VA Caregiver Support Programs, encourage reciprocal caregiving arrangements, and organize virtual church services.

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.

Staff Experiences with a Team-based Approach to Sleep Medicine Referrals: A Qualitative Evaluation.

Rationale: Sleep disorders are highly prevalent, and the volume of referrals sent to sleep specialists frequently exceeds their capacity. To manage this demand, we will need to consider sustainable strategies to expand the reach of our sleep medicine workforce. The Referral Coordination Initiative (RCI) takes a team-based approach to streamlining care for new specialty care referrals by 1) incorporating registered nurses into initial decision-making, 2) integrating administrative staff for coordination, and 3) sharing resources across facilities. Although prior work shows that the RCI can improve access to sleep care, we have a limited understanding around staff experiences and perspectives with this approach. Objectives: To assess staff experiences with a team-based approach to sleep medicine referrals. Methods: From June 2019 to September 2020, we conducted semistructured interviews with staff members who interacted with the RCI in sleep medicine. We recruited a variety of staff, including RCI team members (nurses and medical support assistants), sleep specialists, and referring providers. Two analysts used content analysis to identify themes. Results: We conducted 48 interviews among 35 unique staff members and identified six themes: 1) efficiency, in which staff described the impacts of the RCI program regarding efficient use of staff time and resources; 2) patient access and experience, in which staff noted improvements to patients' ability to receive care; 3) staff well-being and satisfaction, in which specialists and RCI staff described how the RCI mitigated the adverse impact of triage volume on staff well-being; 4) sharing specialty knowledge, in which nurses and specialists discussed the challenges of sharing specialty knowledge and training nurses to triage; 5) nurse autonomy, in which staff discussed nurses' ability to make triage decisions in the RCI system and highlighted the crucial role that decision support tools play in supporting that autonomy; and 6) coordination and communication, in which staff noted the importance, challenges, and facilitators of coordination and communication across facilities and at the interface of primary and specialty care. Conclusions: Staff endorsed positive and negative experiences around the RCI system, identifying opportunities to further streamline the referral process in support of access, patient experience, and staff well-being.

Who Receives Care in VA Medical Foster Homes?

OBJECTIVE: The Veterans Health Administration (VHA) Medical Foster Home (MFH) program was created to give veterans a community-based alternative to institutional long-term care (LTC). This study describes demographic, clinical, and functional characteristics of veterans in MFHs. METHODS: Findings from in-home assessments of veterans in MFHs tied to 4 VHA medical centers for ≥ 90 days between April 2014 and December 2015 were collected. Trained nurses completed Minimum Data Set (MDS) 3.0 assessments for 92 veterans in MFHs. The assessment included demographic characteristics, cognition, behaviors, depression, pain, functional status, mobility, and morbidity. RESULTS: MFH veterans were primarily male (85%), aged > 65 years (83%), cognitively impaired (55%), and had a diagnosis of depression (52%). Overall, 22% had caregiverreported aggressive behaviors and 45% self-reported pain. More than half used a wheelchair (56%). Of the 11 activities of daily living (ADLs) assessed, MFH residents were most likely to require assistance with bathing and least likely to require assistance with bed mobility and eating, although more than half required eating assistance. CONCLUSIONS: Veterans residing in MFHs have a wide range of care needs, including some veterans with high needs for help with ADLs and others who are completely independent in performing ADLs. These results provide insights about which veterans are staying in MFH care. Future studies should explore how VHA care providers refer veterans to LTC settings.

Patient experiences with telehealth in sleep medicine: a qualitative evaluation.

STUDY OBJECTIVES: The field of sleep medicine has been an avid adopter of telehealth, particularly during the COVID-19 pandemic. The goal of this study was to assess patients' experiences receiving sleep care by telehealth. METHODS: From June 2019 to May 2020, the authors recruited a sample of patients for semi-structured interviews, including patients who had 1 of 3 types of telehealth encounters in sleep medicine: in-clinic video, home-based video, and telephone. Two analysts coded transcripts using content analysis and identified themes that cut across patients and categories. RESULTS: The authors conducted interviews with 35 patients and identified 5 themes. (1) Improved access to care: Patients appreciated telehealth as providing access to sleep care in a timely and convenient manner. (2) Security and privacy: Patients described how home-based telehealth afforded them greater feelings of safety and security due to avoidance of anxiety-provoking triggers (eg, crowds). Patients also noted a potential loss of privacy with telehealth. (3) Personalization of care: Patients described experiences with telehealth care that either improved or hindered their ability to communicate their needs. (4) Patient empowerment: Patients described how telehealth empowered them to manage their sleep disorders. (5) Unmet needs: Patients recognized specific areas where telehealth did not meet their needs, including the need for tangible services (eg, mask fitting). CONCLUSIONS: Patients expressed both positive and negative experiences, highlighting areas where telehealth can be further adapted. As telehealth in sleep medicine continues to evolve, the authors encourage providers to consider these aspects of the patient experience. CITATION: Donovan LM, Mog AC, Blanchard KN, et al. Patient experiences with telehealth in sleep medicine: a qualitative evaluation. J Clin Sleep Med. 2021;17(8):1645-1651.

Using the theory of planned behavior to understand intentions to perform bystander CPR among college students.

OBJECTIVE: The purpose of this study was to determine the extent to which the Theory of Planned Behavior (TPB) accounts for variability in intention to perform cardiopulmonary resuscitation (CPR) and to explore which constructs in the TPB most strongly predict intention to perform CPR among college students. Participants: Undergraduate college students (N = 588, 51% women) recruited between September and November 2016. Methods: A cross-sectional survey design. Results: Attitude was the strongest predictor of intention to perform CPR (ß = 0.381, p < .001), followed by subjective norm (ß = 0.303, p < .001), and perceived behavioral control (ß = 0.167, p < .001). The TPB accounted for 51% of the variance in intention to perform CPR (F[3, 536] = 186, p < .001). Conclusion: Attitude and subjective norm are the strongest predictors of intention to perform CPR among college students. Resuscitation trainings that highlight positive outcomes and social norms associated with performing CPR may help bystanders form intentions to perform CPR in an emergency.

Addressing Gaps in Cardiopulmonary Resuscitation Education: Training Middle School Students in Hands-Only Cardiopulmonary Resuscitation.

BACKGROUND: Training middle school students to perform hands-only cardiopulmonary resuscitation (HOCPR) is a potential method to increase overall rates of bystander cardiopulmonary resuscitation (CPR). We aimed to examine the feasibility of teaching this population CPR using teacher-implemented education sessions guided by American Heart Association (AHA) training kits and resources. METHODS: We conducted a national HOCPR training campaign in middle schools during the 2014-2015 school year. Participating schools utilized AHA CPR training kits to train seventh and eighth grade students. We assessed pretest/posttest knowledge and comfort in performing HOCPR. RESULTS: We recruited 1131 schools and trained approximately 334,610 students in HOCPR. The average pretest score on knowledge questions was 50% and the average posttest score was 84%. Most students (76%) felt comfortable performing HOCPR after the education session. Overall, 98% of teachers said they would continue to implement CPR training in the future. CONCLUSIONS: Large-scale, teacher-implemented CPR education sessions in the middle school setting are a successful approach to increase middle school student's knowledge and comfort in performing HOCPR and to increase overall bystander CPR rates.

Clinical outcomes after continuous-flow left ventricular assist device: a systematic review.

BACKGROUND: Conveying the complex trade-offs of continuous-flow left ventricular assist devices is challenging and made more difficult by absence of an evidence summary for the full range of possible outcomes. We aimed to summarize the current evidence on outcomes of continuous-flow left ventricular assist devices. METHODS AND RESULTS: PubMed and Cochrane Library were searched from January 2007 to December 2013, supplemented with manual review. Three reviewers independently assessed each study for saliency on patient-centered outcomes. Data were summarized in tabular form. Overall study characteristics encouraged inclusion of all indications (destination therapy and bridge to transplant) and prevented meta-analysis. The electronic search identified 465 abstracts, of which 50 met inclusion criteria; manual review added 2 articles in press. The articles included 10 industry-funded trials and registries, 10 multicenter reports, and the remainder single-center observational experiences. Estimated actuarial survival after continuous-flow left ventricular assist devices ranged from 56% to 87% at 1 year, 43% to 84% at 2 years, and 47% at 4 years. Improvements in functional class and quality of life were reported, but missing data complicated interpretation. Adverse events were experienced by the majority of patients, but estimates for bleeding, stroke, infection, right heart failure, arrhythmias, and rehospitalizations varied greatly. CONCLUSIONS: The totality of data for continuous-flow left ventricular assist devices show consistent improvements in survival and quality of life counterbalanced by a range of common complications. Although this summary should provide a practical resource for healthcare provider-led discussions with patients, it highlights the critical need for high-quality patient-centered data collected with standard definitions.