Cross-setting Comparison of Risk Factors for Pressure Injuries Acquired in Post-Acute Care.

GENERAL PURPOSE: To provide information on the association between risk factors and the development of new or worsened stage 2 to 4 pressure injuries (PIs) in patients in long-term care hospitals (LTCHs), inpatient rehabilitation facilities (IRFs), and skilled nursing facilities (SNFs). TARGET AUDIENCE: This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care. LEARNING OBJECTIVES/OUTCOMES: After participating in this educational activity, the participant will:1. Compare the unadjusted PI incidence in SNF, IRF, and LTCH populations.2. Explain the extent to which the clinical risk factors of functional limitation (bed mobility), bowel incontinence, diabetes/peripheral vascular disease/peripheral arterial disease, and low body mass index are associated with new or worsened stage 2 to 4 PIs across the SNF, IRF, and LTCH populations.3. Compare the incidence of new or worsened stage 2 to 4 PI development in SNF, IRF, and LTCH populations associated with high body mass index, urinary incontinence, dual urinary and bowel incontinence, and advanced age.

Clinical Outcomes After Admission of Patients With COVID-19 to Skilled Nursing Facilities.

Importance: During the COVID-19 pandemic, stabilized COVID-19-positive patients were discharged to skilled nursing facilities (SNFs) to alleviate hospital crowding. These discharges generated controversy due to fears of seeding outbreaks, but there is little empirical evidence to inform policy. Objective: To assess the association between the admission to SNFs of COVID-19-positive patients and subsequent COVID-19 cases and death rates among residents. Design, Setting, and Participants: This cohort study analyzed survey data from the National Healthcare Safety Network of the Centers for Disease Control and Prevention. The cohort included SNFs in the US from June 2020 to March 2021. Exposed facilities (ie, with initial admission of COVID-19-positive patients) were matched to control facilities (ie, without initial admission of COVID-19-positive patients) in the same county and with similar preadmission case counts. Data were analyzed from June 2023 to February 2024. Exposure: The week of the first observable admission of COVID-19-positive patients (defined as those previously diagnosed with COVID-19 and continued to require transmission-based precautions) during the study period. Main Outcomes and Measures: Weekly counts of new cases of COVID-19, COVID-19-related deaths, and all-cause deaths per 100 residents in the week prior to the initial admission. A stacked difference-in-differences approach was used to compare outcomes for 10 weeks before and 15 weeks after the first admission. Additional analyses examined whether outcomes differed in facilities with staff or personal protective equipment (PPE) shortages. Results: A matched group of 264 exposed facilities and 518 control facilities was identified. Over the 15-week follow-up period, exposed SNFs had a cumulative increase of 6.94 (95% CI, 2.91-10.98) additional COVID-19 cases per 100 residents compared with control SNFs, a 31.3% increase compared with the sample mean (SD) of 22.2 (26.4). Exposed facilities experienced 2.31 (95% CI, 1.39-3.24) additional cumulative COVID-19-related deaths per 100 residents compared with control facilities, representing a 72.4% increase compared with the sample mean (SD) of 3.19 (5.5). Exposed facilities experiencing potential staff shortage and PPE shortage had larger increases in COVID-19 cases per 100 residents (additional 10.97 [95% CI, 2.76-19.19] cases and additional 14.81 [95% CI, 2.38-27.25] cases, respectively) compared with those without such shortages. Conclusion: This cohort study suggests that admission of COVID-19-positive patients into SNFs early in the pandemic was associated with preventable COVID-19 cases and mortality among residents, particularly in facilities with potential staff and PPE shortages. The findings speak to the importance of equipping SNFs to adhere to infection-control best practices as they continue to face COVID-19 strains and other respiratory diseases.

Experiences of chain of care and rehabilitation after stroke: a qualitative study of persons discharged to skilled nursing facilities before returning home.

OBJECTIVE: To explore how people with stroke, discharged to skilled nursing facilities before returning home, experience the chain of care and rehabilitation. DESIGN: Qualitative, semi-structured interview design. METHODS: Thirteen stroke survivors discharged from a stroke unit to a skilled nursing facility before returning to independent living participated. Semi-structured telephone interviews were conducted 2-5 months after stroke and analysed with content analysis. RESULTS: The analysis resulted in three categories, Organizational processes, critical and complex, Rehabilitation, the right support at the right time and Adaptation to the changed situation, with a total of 9 subcategories. The informants perceived low participation in planning and goalsetting and limited information. Support from the healthcare services was important to proceed with improvements although the amount of supported training varied. Factors hindering and facilitating managing everyday life were described, as well as lingering uncertainty of what the future would be like. CONCLUSION: Support and rehabilitation as well as individuals' needs varied, throughout the chain of care. To enable participation in the rehabilitation, assistance in setting goals and repeated information is warranted. Tailored care and rehabilitation throughout the chain of care should be provided, followed up at home, and coordinated for smooth transitions between organizations.

A balance focused biometric does not predict rehabilitation needs and outcomes following total knee arthroplasty.

BACKGROUND: Both length of hospital stay and discharge to a skilled nursing facility are key drivers of total knee arthroplasty (TKA)-associated spending. Identifying patients who require increased postoperative care may improve expectation setting, discharge planning, and cost reduction. Balance deficits affect patients undergoing TKA and are critical to recovery. We aimed to assess whether a device that measures preoperative balance predicts patients' rehabilitation needs and outcomes after TKA. METHODS: 40 patients indicated for primary TKA were prospectively enrolled and followed for 12 months. Demographics, KOOS-JR, and PROMIS data were collected at baseline, 3-months, and 12-months. Single-leg balance and sway velocity were assessed preoperatively with a force plate (Sparta Science, Menlo Park, CA). The primary outcome was patients' discharge facility (home versus skilled nursing facility). Secondary outcomes included length of hospital stay, KOOS-JR scores, and PROMIS scores. RESULTS: The mean preoperative sway velocity for the operative leg was 5.7 ± 2.7 cm/s, which did not differ from that of the non-operative leg (5.7 ± 2.6 cm/s, p = 1.00). Five patients (13%) were discharged to a skilled nursing facility and the mean length of hospital stay was 2.8 ± 1.5 days. Sway velocity was not associated with discharge to a skilled nursing facility (odds ratio, OR = 0.82, 95% CI = 0.27-2.11, p = 0.690) or longer length of hospital stay (b = -0.03, SE = 0.10, p = 0.738). An increased sway velocity was associated with change in PROMIS items from baseline to 3 months for global07 ("How would you rate your pain on average?" b = 1.17, SE = 0.46, p = 0.015) and pain21 ("What is your level of pain right now?" b = 0.39, SE = 0.17, p = 0.025) at 3-months. CONCLUSION: Preoperative balance deficits were associated with postoperative improvements in pain and function after TKA, but a balance focused biometric that measured single-leg sway preoperatively did not predict discharge to a skilled nursing facility or length of hospital stay after TKA making their routine measurement cost-ineffective.

Use of electronic health record data to examine administrations of pro re nata analgesics during hip fracture post-acute care.

PURPOSE: Medications prescribed to older adults in US skilled nursing facilities (SNF) and administrations of pro re nata (PRN) "as needed" medications are unobservable in Medicare insurance claims. There is an ongoing deficit in our understanding of medication use during post-acute care. Using SNF electronic health record (EHR) datasets, including medication orders and barcode medication administration records, we described patterns of PRN analgesic prescribing and administrations among SNF residents with hip fracture. METHODS: Eligible participants resided in SNFs owned by 11 chains, had a diagnosis of hip fracture between January 1, 2018 to August 2, 2021, and received at least one administration of an analgesic medication in the 100 days after the hip fracture. We described the scheduling of analgesics, the proportion of available PRN doses administered, and the proportion of days with at least one PRN analgesic administration. RESULTS: Among 24 038 residents, 57.3% had orders for PRN acetaminophen, 67.4% PRN opioids, 4.2% PRN non-steroidal anti-inflammatory drugs, and 18.6% PRN combination products. The median proportion of available PRN doses administered per drug was 3%-50% and the median proportion of days where one or more doses of an ordered PRN analgesic was administered was 25%-75%. Results differed by analgesic class and the number of administrations ordered per day. CONCLUSIONS: EHRs can be leveraged to ascertain precise analgesic exposures during SNF stays. Future pharmacoepidemiology studies should consider linking SNF EHRs to insurance claims to construct a longitudinal history of medication use and healthcare utilization prior to and during episodes of SNF care.

Healthcare utilization 9 months pre- and post- COVID-19 hospitalization among patients discharged alive.

BACKGROUND: Emerging evidence suggests that there is an increase in healthcare utilization (HCU) in patients due to Coronavirus Disease 2019 (COVID-19). We investigated the change in HCU pre and post hospitalization among patients discharged home from COVID-19 hospitalization for up to 9 months of follow up. STUDY DESIGN AND METHODS: This retrospective study from a United States cohort used Optum® de-identified Clinformatics Data Mart; it included adults discharged home post hospitalization with primary diagnosis of COVID-19 between April 2020 and March 2021. We evaluated HCU of patients 9 months pre and post -discharge from index hospitalization. We defined HCU as emergency department (ED), inpatient, outpatient (office), rehabilitation/skilled nursing facility (SNF), telemedicine visits, and length of stay, expressed as number of visits per 10,000 person-days. RESULTS: We identified 63,161 patients discharged home after COVID-19 hospitalization. The cohort of patients was mostly white (58.8%) and women (53.7%), with mean age 72.4 (SD± 12) years. These patients were significantly more likely to have increased HCU in the 9 months post hospitalization compared to the 9 months prior. Patients had a 47%, 67%, 65%, and 51% increased risk of ED (rate ratio 1.47; 95% CI 1.45-1.49; p < .0001), rehabilitation (rate ratio 1.67; 95% CI 1.61-1.73; p < .0001), office (rate ratio1.65; 95% CI 1.64-1.65; p < .0001), and telemedicine visits (rate ratio 1.5; 95% CI 1.48-1.54; p < .0001), respectively. We also found significantly different rates of HCU for women compared to men (women have higher risk of ED, rehabilitation, and telemedicine visits but a lower risk of inpatient visits, length of stay, and office visits than men) and for patients who received care in the intensive care unit (ICU) vs those who did not (ICU patients had increased risk of ED, inpatient, office, and telemedicine visits and longer length of stay but a lower risk of rehabilitation visits). Outpatient (office) visits were the highest healthcare service utilized post discharge (64.5% increase). Finally, the risk of having an outpatient visit to any of the specialties studied significantly increased post discharge. Interestingly, the risk of requiring a visit to pulmonary medicine was the highest amongst the specialties studied (rate ratio 3.35, 95% CI 3.26-3.45, p < .0001). CONCLUSION: HCU was higher after index hospitalization compared to 9 months prior among patients discharged home post-COVID-19 hospitalization. The increases in HCU may be driven by those patients who received care in the ICU.

Bundled payments lead to quality improvements in hospitals' skilled nursing facility referral networks.

OBJECTIVES: To assess whether hospitals participating in Medicare's Bundled Payments for Care Improvement (BPCI) program for joint replacement changed their referral patterns to favor higher-quality skilled nursing facilities (SNFs). STUDY DESIGN: Retrospective observational study using 2009-2015 inpatient and outpatient claims from a 20% sample of Medicare beneficiaries undergoing joint replacement in US hospitals (N = 146,074) linked with data from Medicare's BPCI program and Nursing Home Compare. METHODS: We ran fixed effect regression models regressing BPCI participation on hospital-SNF referral patterns (number of SNF discharges, number of SNF partners, and SNF referral concentration) and SNF quality (facility inspection survey rating, patient outcome rating, staffing rating, and registered nurse staffing rating). RESULTS: We found that BPCI participation was associated with a decrease in the number of SNF referrals and no significant change in the number of SNF partners or concentration of SNF partners. BPCI participation was associated with discharge to SNFs with a higher patient outcome rating by 0.04 stars (95% CI, 0.04-0.26). BPCI participation was not associated with improvements in discharge to SNFs with a higher facility survey rating (95% CI, -0.03 to 0.11), staffing rating (95% CI, -0.07 to 0.04), or registered nurse staffing rating (95% CI, -0.09 to 0.02). CONCLUSIONS: BPCI participation was associated with lower volume of SNF referrals and small increases in the quality of SNFs to which patients were discharged, without narrowing hospital-SNF referral networks.

Interdisciplinary videoconference model for identifying potential adverse transition of care events following hospital discharge to postacute care.

Discharge from hospitals to postacute care settings is a vulnerable time for many older adults, when they may be at increased risk for errors occurring in their care. We developed the Extension for Community Healthcare Outcomes-Care Transitions (ECHO-CT) programme in an effort to mitigate these risks through a mulitdisciplinary, educational, case-based teleconference between hospital and skilled nursing facility providers. The programme was implemented in both academic and community hospitals. Through weekly sessions, patients discharged from the hospital were discussed, clinical concerns addressed, errors in care identified and plans were made for remediation. A total of 1432 discussions occurred for 1326 patients. The aim of this study was to identify errors occurring in the postdischarge period and factors that predict an increased risk of experiencing an error. In 435 discussions, an issue was identified that required further discussion (known as a transition of care event), and the majority of these were related to medications. In 14.7% of all discussions, a medical error, defined as 'any preventable event that may cause or lead to inappropriate medical care or patient harm', was identified. We found that errors were more likely to occur for patients discharged from surgical services or the emergency department (as compared with medical services) and were less likely to occur for patients who were discharged in the morning. This study shows that a number of errors may be detected in the postdischarge period, and the ECHO-CT programme provides a mechanism for identifying and mitigating these events. Furthermore, it suggests that discharging service and time of day may be associated with risk of error in the discharge period, thereby suggesting potential areas of focus for future interventions.

Interventional analytics in skilled nursing facilities associated with reduced readmissions.

OBJECTIVE: To assess differences in longitudinal profiles for 30-day risk-adjusted readmission rates in skilled nursing facilities (SNFs) associated with Penn Medicine's Lancaster General Hospital (LGH) that implemented an interventional analytics (IA) platform vs other LGH facilities lacking IA vs other SNFs in Pennsylvania vs facilities in all other states. STUDY DESIGN: Retrospective longitudinal analysis of CMS readmissions data from 2017 through 2022, and cross-sectional analysis using CMS quality metrics data. METHODS: CMS SNF quality performance data were aggregated and compared with risk-adjusted readmissions by facility and time period. Each SNF was assigned to a cohort based on location, referral relationship with LGH, and whether it had implemented IA. Multivariable mixed effects modeling was used to compare readmissions by cohort, whereas quality measures from the fourth quarter of 2022 were compared descriptively. RESULTS: LGH profiles differed significantly from both state and national profiles, with LGH facilities leveraging IA demonstrating an even greater divergence. In the most recent 12 months ending in the fourth quarter of 2022, LGH SNFs with IA had estimated readmission rates that were 15.24, 12.30, and 13.06 percentage points lower than the LGH SNFs without IA, Pennsylvania, and national cohorts, respectively (all pairwise P < .0001). SNFs with IA also demonstrated superior CMS claims-based quality metric outcomes for the 12 months ending in the fourth quarter of 2022. CONCLUSIONS: SNFs implementing the studied IA platform demonstrated statistically and clinically significant superior risk-adjusted readmission rate profiles compared with peers nationally, statewide, and within the same SNF referral network (P < .0001). A more detailed study on the use of IA in this setting is warranted.

A Clinical Pharmacist-Led Transitions of Care Program for Veterans with Two Planned Care Transitions (Hospital to Skilled Care and Skilled Care to Home) amid the COVID-19 Pandemic.

Transitional care teams have been shown to improve patient safety. We describe a novel transitional care team with a clinical pharmacist as team leader initiated amid the COVID-19 pandemic. The program focused on Veterans with 2 planned transitions of care: hospital to skilled nursing facility (SNF) and from SNF to home. Ninety older Veterans were enrolled, and 79 medication errors and 80 appointment errors were identified. We conclude that a pharmacist-led program can improve safety in patients with 2 planned transitions of care.

A Process Evaluation of a Palliative Care Social Work Intervention for Cancer Patients in Skilled Nursing Facilities.

Background: Assessing and Listening to Individual Goals and Needs (ALIGN) is a palliative care social work intervention that aims to improve delivery of goal-concordant care for hospitalized older adults with cancer discharged to skilled nursing facilities. Objective: Explore processes through which ALIGN may improve delivery of goal-concordant care to substantiate the conceptual model grounding the intervention and to inform mechanistic hypotheses of how the intervention might be effective. Design: A process evaluation triangulating findings from patient and caregiver interviews with a matrix analysis of ALIGN social worker notes. Setting/Participants: Patients (n = 6) and caregivers (n = 13) who participated in a single-arm pilot study of ALIGN in the United States and 113 intervention notes (n = 18 patients) written by 2 ALIGN social workers. Measurement: Qualitative thematic content analysis Results: Themes included the following: (1) ALIGN helped reconcile participants' misaligned expectations of rehabilitation with the reality of the patient's progressive illness; (2) ALIGN helped participants manage uncertainty and stress about forthcoming medical decision making; (3) the longitudinal nature of ALIGN allowed for iterative value-based goals of care discussions during a time when patients were changing their focus of treatment; and (4) ALIGN activated participants to advocate for their needs. Conclusions: ALIGN offers support in prognostic understanding, communication, and decision making during a pivotal time when patient and caregivers' goals have not been met and they are reassessing priorities. A larger trial is needed to understand how these processes may improve the ability of participants to make value-based decisions and aide in delivery of goal-concordant care. Clinical Trial Registration Number: NCT04882111.

[Did entry into nursing home during the health crisis favor the emergence of traumatic symptoms in the elderly?: Entry into nursing home and Covid]. / L'entrée en Ehpad, durant la crise sanitaire, a-t-elle favorisé l'émergence de symptômes traumatiques chez le sujet âgé ?

Our aim is to explore the possible emergence of traumatic symptoms and the identity-related repercussions of the restrictions on elderly, who entered into nursing homes during the Covid-19 health crisis in France. Twenty-five subjects institutionalised before the health crisis and twenty-six subjects institutionalised during the periods of lockdown into nursing homes completed scales assessing anxiety-depressive symptomatology, traumatic symptoms and identity. Anxiety and depression symptoms were similar between the groups. The institutionalised group showed a significantly higher prevalence of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria D and E on the Post traumatic Stress Disorder Checklist version DSM-5 (PCL-5) during lockdown. Entry into an institution during the health crisis would have favored the emergence of traumatic symptoms in the participants. Consideration of the ethical issues raised by this study could make it possible to offer more individualised support to elderly during their transition to a new home.

[Care of patients in nursing homes, what stumbling blocks and stepping for general practitioners? A qualitative study]. / Prise en charge des patients en Ehpad, quels freins et leviers pour le médecin généraliste ? Une étude qualitative.

Due to increased dependency and health needs, the follow-up of the patients in nursing home (NH) by general practitioners (GP) is difficult, in a context of an aging population and declining medical density. This study sought to describe facilitating or limiting factors faced by GP in Drôme, Isère and Savoy in their NH patients' follow-up and to collect suggestions for improvement. A qualitative study, with phenomenological analysis, was identified factors linked to patients (complexity, specific needs, Doctor-patient relationship affected, ethical considerations), to physicians (to conjugate his office activity with visits and emergencies) and to NH (cooperation with information sharing amongst professional microcosm, their representations by GP). The Covid pandemic revived questions about the meaning of care but revealed adaptive work reveals the challenges GP face at NH, as well as prospects for improvment.

Preferences for Postacute Care at Home vs Facilities.

Importance: Two in 5 US hospital stays result in rehabilitative postacute care, typically through skilled nursing facilities (SNFs) or home health agencies (HHAs). However, a lack of clear guidelines and understanding of patient and caregiver preferences make it challenging to promote high-value patient-centered care. Objective: To assess preferences and willingness to pay for facility-based vs home-based postacute care among patients and caregivers, considering demographic variations. Design, Setting, and Participants: In September 2022, a nationally representative survey was conducted with participants 45 years or older. Using a discrete choice experiment, participants acting as patients or caregivers chose between facility-based and home-based postacute care that best met their preferences, needs, and family conditions. Survey weights were applied to generate nationally representative estimates. Main Outcomes and Measures: Preferences and willingness to pay for various attributes of postacute care settings were assessed, examining variation based on demographic factors, socioeconomic status, job security, and previous care experiences. Results: A total of 2077 adults were invited to participate in the survey; 1555 (74.9%) completed the survey. In the weighted sample, 52.9% of participants were women, 6.5% were Asian or Pacific Islander, 1.7% were American Indian or Alaska Native, 11.2% were Black or African American, 78.4% were White; the mean (SD) age was 62.6 (9.6) years; and there was a survey completion rate of 74.9%. Patients and caregivers showed a substantial willingness to pay for home-based and high-quality care. Patients and caregivers were willing to pay an additional $58.08 per day (95% CI, 45.32-70.83) and $45.54 per day (95% CI, 31.09-59.99) for HHA care compared with a shared SNF room, respectively. However, increased demands on caregiver time within an HHA scenario and socioeconomic challenges, such as insecure employment, shifted caregivers' preferences toward facility-based care. There was a strong aversion to below average quality. To avoid below average SNF care, patients and caregivers were willing to pay $75.21 per day (95% CI, 61.68-88.75) and $79.10 per day (95% CI, 63.29-94.91) compared with average-quality care, respectively. Additionally, prior awareness and experience with postacute care was associated with willingness to pay for home-based care. No differences in preferences among patients and caregivers based on race, educational background, urban or rural residence, general health status, or housing type were observed. Conclusions and Relevance: The findings of this survey study underscore a prevailing preference for home-based postacute care, aligning with current policy trends. However, attention is warranted for disadvantaged groups who are potentially overlooked during the shift toward home-based care, particularly those facing caregiver constraints and socioeconomic hardships. Ensuring equitable support and improved quality measure tools are crucial for promoting patient-centric postacute care, with emphasis on addressing the needs of marginalized groups.

Health Trajectories of Skilled Nursing Facility Patients With Alzheimer's Disease and Related Dementias: Evidence for Practicing Nurses.

PURPOSE: Older adults with Alzheimer's disease and related dementias (ADRD) are at high risk for acute medical problems and their health trajectories frequently include hospital admission and care in a skilled nursing facility (SNF). Their health trajectories after SNF discharge are poorly understood. Therefore, in the current study, we sought to describe health trajectories and factors associated with hospital read-missions for older adults with ADRD during the 30 days following SNF discharge. METHOD: We conducted a secondary analysis of data from a clinical trial of transitional care of older adults with transitions from SNF to home and assisted living. A multiple case study design was used in the analysis of the health trajectories of 49 SNF patients with ADRD, 51% discharged from SNF to their own home, 34% discharged to a family member's home, and 15% transferred to assisted living. RESULTS: Within 30 days of discharge, 20% of patients with ADRD experienced new or recurrent acute needs and hospital readmission. CONCLUSION: Our findings suggest the need for nursing interventions to support patients with ADRD during care transitions, such as focusing care on the patient-caregiver dyad, providing transitional care, referring patients for palliative care consultation, and conducting nurse-led research to improve care transitions of these patients and their caregivers. [Journal of Gerontological Nursing, 50(4), 34-41.].

Barriers and facilitators to care for agitation and/or aggression among persons living with dementia in long-term care.

BACKGROUND: Agitation and/or aggression affect up to 60% of persons living with dementia in long-term care (LTC). It can be treated via non-pharmacological and pharmacological interventions, but the former are underused in clinical practice. In the literature, there is currently a lack of understanding of the challenges to caring for agitation and/or aggression among persons living with dementia in LTC. This study assesses what barriers and facilitators across the spectrum of care exist for agitation and/or aggression among people with dementia in LTC across stakeholder groups. METHODS: This was a qualitative study that used semi-structured interviews among persons involved in the care and/or planning of care for people with dementia in LTC. Participants were recruited via purposive and snowball sampling, with the assistance of four owner-operator models. Interviews were guided by the Theoretical Domains Framework and transcribed and analyzed using Framework Analysis. RESULTS: Eighteen interviews were conducted across 5 stakeholder groups. Key identified barriers were a lack of agitation and/or aggression diagnostic measures, limited training for managing agitation and/or aggression in LTC, an overuse of physical and chemical restraints, and an underuse of non-pharmacological interventions. Facilitators included using an interdisciplinary team to deliver care and having competent and trained healthcare providers to administer non-pharmacological interventions. CONCLUSIONS: This study advances care for persons living with dementia in LTC by drawing attention to unique and systemic barriers present across local and national Canadian LTC facilities. Findings will support future implementation research endeavours to eliminate these identified barriers across the spectrum of care, thus improving care outcomes among people with dementia in LTC.

Post-acute care transitions during COVID-19: Racial, ethnic, and socioeconomic differences in older adults with Alzheimer's disease and related dementia.

BACKGROUND: Differences in the post-acute care (PAC) destinations among racial, ethnic, and socioeconomic groups have been documented before the COVID-19 pandemic. Yet, the pandemic's impact on these differences remains unknown. We examined the impact of the COVID-19 pandemic on PAC destinations and its variation by individual race, ethnicity, and socioeconomic status among community-dwelling older adults with Alzheimer's disease and related dementia (ADRD). METHODS: We linked 2019-2021 national data (Medicare claims, Minimum Data Set, Master Beneficiary Summary File) and several publicly available datasets, including Provider of Services File, Area Deprivation Index, Area Health Resource File, and COVID-19 infection data. PAC discharge destinations included skilled nursing facilities (SNFs), home health agencies (HHA), and homes without services. Key variables of interest included individual race, ethnicity, and Medicare-Medicaid dual status. The analytic cohort included 830,656 community-dwelling Medicare fee-for-service beneficiaries with ADRD who were hospitalized between 2019 and 2021. Regression models with hospital random effects and state-fixed effects were estimated, stratified by the time periods, and adjusted for the individual, hospital, and county-level covariates. RESULTS: SNF discharges decreased while home and HHA discharges increased during the pandemic. The trend was more prominent among racial and ethnic minoritized groups and even more so among dual-eligible beneficiaries. For instance, the reduction in the probabilities of SNF admissions between the pre-pandemic period and the 2nd year of COVID was 4.6 (White non-duals), 18.5 (White duals), 8.7 (Black non-duals), and 20.1 (Black duals) percentage-point, respectively. We also found that non-duals were more likely to replace SNF with HHA services, while duals were more likely to be discharged home without HHA. CONCLUSIONS: The COVID-19 pandemic significantly impacted PAC destinations for individuals with ADRD, especially among socioeconomically disadvantaged and racial and ethnic minoritized populations. Future research is needed to understand if and how these transitions may have affected health outcomes.

Characterizing changes to older adults' care transition patterns from hospital to home care in the initial year of COVID-19.

BACKGROUND: Skilled home healthcare (HH) provided in-person care to older adults during the COVID-19 pandemic, yet little is known about the pandemic's impact on HH care transition patterns. We investigated pandemic impact on (1) HH service volume; (2) population characteristics; and (3) care transition patterns for older adults receiving HH services after hospital or skilled nursing facility (SNF) discharge. METHODS: Retrospective, cohort, comparative study of recently hospitalized older adults (≥ 65 years) receiving HH services after hospital or SNF discharge at two large HH agencies in Baltimore and New York City (NYC) 1-year pre- and 1-year post-pandemic onset. We used the Outcome and Assessment Information Set (OASIS) and service use records to examine HH utilization, patient characteristics, visit timeliness, medication issues, and 30-day emergency department (ED) visit and rehospitalization. RESULTS: Across sites, admissions to HH declined by 23% in the pandemic's first year. Compared to the year prior, older adults receiving HH services during the first year of the pandemic were more likely to be younger, have worse mental, respiratory, and functional status in some areas, and be assessed by HH providers as having higher risk of rehospitalization. Thirty-day rehospitalization rates were lower during the first year of the pandemic. COVID-positive HH patients had lower odds of 30-day ED visit or rehospitalization. At the NYC site, extended duration between discharge and first HH visit was associated with reduced 30-day ED visit or rehospitalization. CONCLUSIONS: HH patient characteristics and utilization were distinct in Baltimore versus NYC in the initial year of the COVID-19 pandemic. Study findings suggest some older adults who needed HH may not have received it, since the decrease in HH services occurred as SNF use decreased nationally. Findings demonstrate the importance of understanding HH agency responsiveness during public health emergencies to ensure older adults' access to care.

Occupational Injuries in the US Nursing Homes.

BACKGROUND: Workplace injuries adversely affect worker well-being and may worsen staffing shortages and turnover in nursing homes. A better understanding of the trends in injuries in nursing homes including organizational factors associated with injuries can help improve our efforts in addressing worker injuries. OBJECTIVE: To summarize the trends in injuries and organizational correlates of injuries in US nursing homes. RESEARCH DESIGN: We combine national injury tracking data from the Occupational Safety and Health Administration (2016-2019) with nursing home characteristics from Nursing Home Compare. Our outcomes include the proportion of nursing homes reporting any injuries, the mean number of injuries, and the mean number of injuries or illnesses with days away from work, or job transfer or restriction, or both (DART). We descriptively summarize trends in injuries over time. We also estimate the association between nursing home characteristics and injuries using multivariable regressions. RESULTS: We find that approximately 93% of nursing homes reported at least 1 occupational injury in any given year. Injuries had a substantial impact on productivity with 4.1 DART injuries per 100 full-time employees in 2019. Higher bed size, occupancy, RN staffing, and chain ownership are associated with increased DART rates whereas higher overall nursing home star ratings and for-profit status are associated with decreased DART rates. CONCLUSIONS: A high proportion of nursing homes report occupational injuries that can affect staff well-being, productivity, and quality of care. Injury prevention policies should target the types of injuries occurring in nursing homes and OSHA should monitor nursing homes reporting high and repeated injuries.