The Use of Robotic Pets with Older Adults during the COVID-19 Pandemic.

OBJECTIVES: We describe two robotic pet demonstration projects during the COVID-19 pandemic. METHODS: Key project components are stakeholders (settings), inputs (activities), and outputs (interest in programs and participant benefit). RESULTS: Stakeholders are an aging services organization in western NY (Lifespan) which served community-dwelling older adults, and a Veteran's Dementia Care Neighborhood (nursing home) that served 14 older Veterans. Project activities: both sites used commercially available robotic pets, with setting-specific deployment procedures. Outputs: 289 pets were distributed by Lifespan; nine Veterans selected pets and four engaged more actively. Community-dwelling older adults reported high satisfaction; satisfaction with the program in Veterans is evidenced by ongoing engagement via staff observation. CONCLUSIONS: Procedures used by our programs may be useful for agencies and care programs interested in implementing robotic pet programs for community-dwelling older adults and those residing in long-term care. CLINICAL IMPLICATIONS: Robotic pets were sought by individuals and care providers in community and long-term care settings to provide companionship for older adults during the COVID-19 pandemic and may be of benefit to older adults.

Benchmarking Site of Death and Hospice Use: A Case Study of Veterans Cared by Department of Veterans Affairs Home-based Primary Care.

OBJECTIVE: The objective of this study was to examine site of death and hospice use, identifying potential disparities among veterans dying in Department of Veterans Affairs (VA) Home Based Primary Care (VA-HBPC). METHODS: Administrative data (2008, 2012, and 2016) were compiled using the VA Residential-History-File which tracks health care service location, daily. Outcomes were site of death [home, nursing home (NH), hospital, inpatient hospice]; and hospice use on the day of death. We compared VA-HBPC rates to rates of 2 decedent benchmarks: VA patients and 5% Traditional Medicare non-veteran males. Potential age, race, urban/rural residence and living alone status disparities in rates among veterans dying in VA-HBPC in 2016 were examined by multinomial logistic regression. RESULTS: In 2016, 7796 veterans died in VA-HBPC of whom 62.1% died at home, 11.8% in NHs, 14.7% in hospitals and 11.4% in inpatient hospice. Hospice was provided to 60.9% of veterans dying at home and 63.9% of veterans dying in NH. Over the 2008-2012-2016 period, rates of VA-HBPC veterans who died at home and rates of home death with hospice increased and were higher than both benchmarks. Among VA-HBPC decedents, younger/older veterans were more/less likely to die at home and less/more likely to die with hospice. Race/ethnicity and urban/rural residence were unrelated to death at home but veterans living alone were less likely to die at home. CONCLUSIONS: Results reflect VA-HBPC's primary goal of supporting its veterans at home, including at the end-of-life, surpassing other population benchmarks with some potential disparities remaining.

Interdisciplinary Team Perspectives on Mental Health Care in VA Home-Based Primary Care: A Qualitative Study.

OBJECTIVES: This qualitative study describes the structure and processes of providing care to U.S. Department of Veterans Affairs (VA) Home-Based Primary Care (HBPC) enrollees with mental health care needs; explains the role of the HBPC psychologist; and describes how mental health treatment is integrated into care from the perspective of HBPC team members. DESIGN: HBPC programs were selected for in-person site visits based on initial surveys and low hospitalization rates. SETTING: Programs varied in setting, geographic locations, and primary care model. PARTICIPANTS: Eight site visits were completed. During visits, key informants including HBPC program directors, medical directors, team members, and other key staff involved with the HBPC program participated in semi-structured individual and group interviews. MEASUREMENTS: Recorded interviews, focus groups, and field observation notes. RESULTS: Qualitative thematic content analysis revealed four themes: 1) HBPC Veterans have not only complex physical needs but also co-occurring mental health needs; 2) the multi-faceted role of psychologists on HBPC teams, that includes providing care for Veterans and support for colleagues; 3) collaboration between medical and mental health providers as a means of caring for HBPC Veterans with mental health needs; and 4) gaps in providing mental health care on HBPC teams, primarily related to a lack of team psychiatrists and/or need for specialized medication management for psychiatric illness. CONCLUSIONS: Mental health providers are essential to HBPC teams. Given the significant mental health care needs of HBPC enrollees and the roles of HBPC mental health providers, HBPC teams should integrate both psychologists and consulting psychiatrists.

Pharmacy Diabetes Management of a Veteran Population in a Long-Term Care Setting: A Program Evaluation.

BACKGROUND: The benefits of an outpatient pharmacy diabetes clinic has been established, with improved patient outcomes and reduced total costs of care. We describe the benefits of an inpatient clinical pharmacy diabetes service within a Department of Veterans Affairs long-term care facility. METHODS: Patients were referred to the pharmacy diabetes monitoring program between February 2016 and August 2016. During this time, clinical pharmacy specialists managed all pharmacotherapy relating to diabetes care as well as all fingerstick monitoring frequencies and laboratory monitoring to achieve a prespecified, patient-specific A1C goal. The primary endpoints were optimization of blood glucose fingerstick monitoring frequency and cessation of sliding-scale insulin. Secondary end points were achievement of A1C goal, reduction of hypoglycemic/hyperglycemic events, and reduction of total insulin injections per day. RESULTS: At the time of discharge or end of the observation period, fingerstick frequency had been reduced by a mean of 7.7 fingersticks/patient/week (35.6% total reduction, median 17.5; interquartile range [IQR] 5.5-21; P = 0.002). All eight patients initially prescribed sliding-scale insulin upon referral had their sliding scale stopped by the end of observation. Total injections per day had been reduced from baseline with a mean reduction of 0.55 injections/patient/day (16.5% total reduction; P < 0.05). A1C also showed improvement from baseline, though this was not statistically significant (median 7.75%, IQR 6.8-8.3; P = 0.1). Total hyperglycemic events were reduced from 36 prior to enrollment to 23 post-observation period, while hypoglycemic events decreased from 8 before enrollment to 4 post-observation period. CONCLUSION: Type 2 diabetes mellitus patients managed by clinical pharmacy specialists at a Veterans Affairs long-term care facility significantly decreased weekly fingerstick blood monitoring frequency, number of insulin injections per day, and ceased sliding-scale insulin use. A1C and hypoglycemic and hyperglycemic events remained stable. Our results are limited because of a small sample size.

Reducing Emergency Department Utilization Through Engagement in Telemedicine by Senior Living Communities.

BACKGROUND: High-intensity telemedicine has been shown to reduce the need for emergency department (ED) care for older adult senior living community (SLC) residents with acute illnesses. We evaluated the effect of SLC engagement in the telemedicine program on ED use rates. MATERIALS AND METHODS: We performed a secondary analysis of data from a prospective cohort study evaluating the effectiveness of high-intensity telemedicine for SLC residents. We compared the annual rate of change in ED use among subjects who resided in SLC units that were more engaged in telemedicine services with that among subjects who resided in SLC units that were less engaged in telemedicine and control subjects who lived at facilities without access to telemedicine services. RESULTS: During the study, subjects had 503 telemedicine visits, with 362 (72.0%) in the more engaged SLCs and 141 (28.0%) in the less engaged SLCs. For subjects residing in more engaged SLCs, ED use decreased at an annualized rate of 28% (rate ratio [RR] = 0.72; 95% confidence interval [CI], 0.58-0.89), whereas in the less engaged (RR = 0.962; 95% CI, 0.776-1.19) and control (RR = 0.909, 95% CI, 0.822-1.07) groups there was no significant change in ED use (p = 0.036 for group × time interaction). CONCLUSIONS: Individuals residing in more engaged SLCs experienced a greater decrease in ED use compared with subjects residing in less engaged SLCs or those without access to high-intensity telemedicine for acute illnesses. We identified potential factors associated with more engaged SLCs, but further research is needed to understand resident and staff engagement and how to increase it.

High-Intensity Telemedicine Decreases Emergency Department Use by Senior Living Community Residents.

BACKGROUND: The failure to provide timely acute illness care can lead to adverse consequences or emergency department (ED) use. We evaluated the effect on ED use of a high-intensity telemedicine program that provides acute illness care for senior living community (SLC) residents. MATERIALS AND METHODS: We performed a prospective cohort study over 3.5 years. Six SLCs cared for by a primary care geriatrics practice were intervention facilities, with the remaining 16 being controls. Consenting patients at intervention facilities could access telemedicine for acute illness care. Patients were provided patient-to-provider, real-time, or store-and-forward high-intensity telemedicine (i.e., technician-assisted with resources beyond simple videoconferencing) to diagnose and treat acute illnesses. The primary outcome was the rate of ED use. RESULTS: We enrolled 494 of 705 (70.1%) subjects/proxies in the intervention group; 1,058 subjects served as controls. Control and intervention subjects visited the ED 2,238 and 725 times, respectively, with 47.3% of control and 43.4% of intervention group visits resulting in discharge home. Among intervention subjects, ED use decreased at an annualized rate of 18% (rate ratio [RR]=0.82; 95% confidence interval [CI], 0.70-0.95), whereas in the control group there was no statistically significant change in ED use (RR=1.01; 95% CI, 0.95-1.07; p=0.009 for group-by-time interaction). Primary care use and mortality were not significantly different. CONCLUSIONS: High-intensity telemedicine significantly reduced ED use among SLC residents without increasing other utilization or mortality. This alternative to traditional acute illness care can enhance access to acute illness care and should be integrated into population health programs.

Identification of a neurologic scale that optimizes EMS detection of older adult traumatic brain injury patients who require transport to a trauma center.

OBJECTIVE: We sought to identify a scale or components of a scale that optimize detection of older adult traumatic brain injury (TBI) patients who require transport to a trauma center, regardless of mechanism. METHODS: We assembled a consensus panel consisting of nine experts in geriatric emergency medicine, prehospital medicine, trauma surgery, geriatric medicine, and TBI, as well as prehospital providers, to evaluate the existing scales used to identify TBI. We reviewed the relevant literature and solicited group feedback to create a list of candidate scales and criteria for evaluation. Using the nominal group technique, scales were evaluated by the expert panel through an iterative process until consensus was achieved. RESULTS: We identified 15 scales for evaluation. The panel's criteria for rating the scales included ease of administration, prehospital familiarity with scale components, feasibility of use with older adults, time to administer, and strength of evidence for their performance in the prehospital setting. After review and discussion of aggregated ratings, the panel identified the Simplified Motor Scale, GCS-Motor Component, and AVPU (alert, voice, pain, unresponsive) as the strongest scales, but determined that none meet all EMS provider and patient needs due to poor usability and lack of supportive evidence. The panel proposed that a dichotomized decision scheme that includes domains of the top-rated scales -level of alertness (alert vs. not alert) and motor function (obeys commands vs. does not obey) -may be more effective in identifying older adult TBI patients who require transport to a trauma center in the prehospital setting. CONCLUSIONS: Existing scales to identify TBI are inadequate to detect older adult TBI patients who require transport to a trauma center. A new algorithm, derived from elements of previously established scales, has the potential to guide prehospital providers in improving the triage of older adult TBI patients, but needs further evaluation prior to use.

Measuring health-related quality of life in chronic obstructive pulmonary disease: properties of the EQ-5D-5L and PROMIS-43 short form.

BACKGROUND: The Patient Reported Outcomes Measurement Information System 43-item short form (PROMIS-43) and the five-level EQ-5D (EQ-5D-5L) are recently developed measures of health-related quality of life (HRQL) that have potentially broad application in evaluating treatments and capturing burden of respiratory-related diseases. The aims of this study were: (1) to examine their psychometric properties in patients with chronic obstructive pulmonary disease (COPD), and (2) to identify dimensions of HRQL that differ and do not differ by lung function. METHODS: We conducted a multi-center, cross-sectional study ("COPD Outcomes-based Network for Clinical Effectiveness & Research Translation" [CONCERT]). We analyzed patients who met spirometric criteria for COPD, and completed EQ-5D-5L and PROMIS questionnaires. Disease severity was graded based on the Global Initiative for Chronic Obstructive Lung Disease (GOLD) classification. Pulmonary function test, PROMIS-43, EQ-5D (index score and EQ-Visual Analog Scale [EQ-VAS]), six minute walk test (6MWT), and three dyspnea scales (mMRC, Borg, FACIT-Dyspnea) were administered. Validity and reliability of EQ-5D-5L and PROMIS-43 were examined, and differences in HRQL by GOLD grade were assessed. RESULTS: Data from 670 patients with COPD were analyzed (mean age 68.5 years; 58% male). More severe COPD was associated with more problems with mobility, self-care and usual activities (all p-values <0.01) according to EQ-5D-5L. Related domains on EQ-5D-5L, PROMIS and clinical measures were moderately (r = 0.30-0.49) to strongly (r ≥ 0.50) correlated. A statistically significant trend of decreasing HRQL with more severe lung functions was observed for EQ-5D-5L index scores, EQ-VAS scores, and PROMIS physical function and social roles. CONCLUSIONS: Results supported the validity of EQ-5D-5L and PROMIS-43 in COPD patients, and indicate that physical function and social activities decrease with level of lung function by GOLD grade, but not pain, mental health, sleep or fatigue as reported by patients.

Participation Rates in 11 National Dental Practice-Based Research Network Surveys 2014-2022.

Surveys of health professionals typically have low response rates, which have decreased in recent years. We report on the methods used, participation rates, and study time for 11 national questionnaire studies of dentists conducted from 2014-2022. Participation rates decreased (87%-25%). Concurrent with this decrease was a decrease in the intensity with which the practitioners were recruited. Participation rates were higher when postal mail invitation and paper options were used (84% vs. 58%, p < .001). Completion rates were nearly twice as high in studies that recruited in waves than those that did not (61% vs. 35%, p = .003). Study time varied from 2.6 to 28.4 weeks. Study time was longest when postal mail and completion on paper were used (26.0 vs. 11.3 weeks, p = .01). Among studies using only online methods, study time was longer when invitations were staggered than when all invitations went out in one bolus (means 12.0 and 5.2, p = .04). Study time was positively correlated with participation rates (Spearman r = .80, p = .005). General dentists participated at an average of 12% higher rates than specialists. Recruitment methodology, such as recruiting in waves or stages, should be considered when designing surveys.

Training Health Center Staff in the Provision of Culturally Responsive Care for Sexual and Gender Minority Patients: Results of a Randomized Controlled Trial.

Purpose: The study was designed to evaluate whether an educational intervention to train the health center (HC) staff to optimize care for sexual and gender minority (SGM) patients could improve documentation of sexual orientation and gender identity (SOGI) and increase preventive screenings. Methods: Twelve HCs were matched and randomized to either receive a tailored, multicomponent educational intervention or a 1-hour prerecorded webinar. Documentation of SGM status and clinical testing was measured through analysis of data that HCs report annually. Nonparametric statistics were used to assess associations between baseline HC characteristics and outcome measures. Results: The HCs were geographically, racially, and ethnically diverse. In all but one HC, <10% of the patients were identified as SGM. Intervention HCs underwent between 3 and 10 trainings, which were highly acceptable. In 2018, 9 of 12 HCs documented SO and 11 of 12 documented GI for at least 50% of their patients. Five of 6 intervention HCs increased SO documentation by 2020, compared to 3 of 6 control HCs (nonsignificant, NS). Five intervention HCs increased GI documentation, although generally by less than 10%, compared to 2 of the controls (NS). Intervention HCs tended to increase documentation of preventive services more than control HCs, but the changes were NS. Conclusions: An educational intervention designed to train the HC staff to provide culturally responsive services for SGM patients was found to be acceptable, with favorable, but nonsignificant changes. Further refinement of the intervention using a larger sample of HCs might demonstrate the effectiveness of this approach. Clinical trial registration #: NCT03554785.

Case-finding options for COPD: results from the Burden of Obstructive Lung Disease study.

This study aimed to compare strategies for chronic obstructive pulmonary disease (COPD) case finding using data from the Burden of Obstructive Lung Disease study. Population-based samples of adults aged ≥40 yrs (n = 9,390) from 14 countries completed a questionnaire and spirometry. We compared the screening efficiency of differently staged algorithms that used questionnaire data and/or peak expiratory flow (PEF) data to identify persons at risk for COPD and, hence, needing confirmatory spirometry. Separate algorithms were fitted for moderate/severe COPD and for severe COPD. We estimated the cost of each algorithm in 1,000 people. For moderate/severe COPD, use of questionnaire data alone permitted high sensitivity (97%) but required confirmatory spirometry in 80% of participants. Use of PEF necessitated confirmatory spirometry in only 19-22% of subjects, with 83-84% sensitivity. For severe COPD, use of PEF achieved 91-93% sensitivity, requiring confirmatory spirometry in <9% of participants. Cost analysis suggested that a staged screening algorithm using only PEF initially, followed by confirmatory spirometry as needed, was the most cost-effective case-finding strategy. Our results support the use of PEF as a simple, cost-effective initial screening tool for conducting COPD case-finding in adults aged ≥40 yrs. These findings should be validated in real-world settings such as the primary care environment.

"Geriatricizing" hospitalists: identifying educational opportunities.

The objective of this study was to identify differences between geriatricians and hospitalists in caring for hospitalized older adults, so as to inform faculty development programs that have the goal of improving older patient care. Eleven hospitalists and 13 geriatricians were surveyed regarding knowledge, confidence, and practice patterns in caring for hospitalized older adults, targeting areas previously defined as central to taking care of older hospitalized patients. Overall, geriatricians had more confidence and more knowledge in caring for older hospitalized adults. The areas in which hospitalists expressed the least confidence were in caring for patients with dementia, self-care issues, and care planning. Geriatricians reported more routine medication reviews, functional and cognitive assessments, and fall evaluations. Geriatricians and hospitalists differ in their approach to older adults. Where these differences reflect lack of knowledge or experience, they set the stage for developing curricula to help narrow these gaps.

Development of telehealth principles and guidelines for older adults: A modified Delphi approach.

The COVID-19 pandemic elevated telehealth as a prevalent care delivery modality for older adults. However, guidelines and best practices for the provision of healthcare via telehealth are lacking. Principles and guidelines are needed to ensure that telehealth is safe, effective, and equitable for older adults. The Collaborative for Telehealth and Aging (C4TA) composed of providers, experts in geriatrics, telehealth, and advocacy, developed principles and guidelines for delivering telehealth to older adults. Using a modified Delphi process, C4TA members identified three principles and 18 guidelines. First, care should be person-centered; telehealth programs should be designed to meet the needs and preferences of older adults by considering their goals, family and caregivers, linguistic characteristics, and readiness and ability to use technology. Second, care should be equitable and accessible; telehealth programs should address individual and systemic barriers to care for older adults by considering issues of equity and access. Third, care should be integrated and coordinated across systems and people; telehealth should limit fragmentation, improve data sharing, increase communication across stakeholders, and address both workforce and financial sustainability. C4TA members have diverse perspectives and expertise but a shared commitment to improving older adults' lives. C4TA's recommendations highlight older adults' needs and create a roadmap for providers and health systems to take actionable steps to reach them. The next steps include developing implementation strategies, documenting current telehealth practices with older adults, and creating a community to support the dissemination, implementation, and evaluation of the recommendations.

Integrating Principles of Safety Culture and Just Culture Into Nursing Homes: Lessons From the Pandemic.

Decades of concerns about the quality of care provided by nursing homes have led state and federal agencies to create layers of regulations and penalties. As such, regulatory efforts to improve nursing home care have largely focused on the identification of deficiencies and assignment of sanctions. The current regulatory strategy often places nursing home teams and government agencies at odds, hindering their ability to build a culture of safety in nursing homes that is foundational to health care quality. Imbuing safety culture into nursing homes will require nursing homes and regulatory agencies to acknowledge the high-risk nature of post-acute and long-term care settings, embrace just culture, and engage nursing home staff and stakeholders in actions that are supported by evidence-based best practices. The response to the COVID-19 pandemic prompted some of these actions, leading to changes in nursing survey and certification processes as well as deployment of strike teams to support nursing homes in crisis. These actions, coupled with investments in public health that include funds earmarked for nursing homes, could become the initial phases of an intentional renovation of the existing regulatory oversight from one that is largely punitive to one that is rooted in safety culture and proactively designed to achieve meaningful and sustained improvements in the quality of care and life for nursing home residents.

COVID-19 Vaccination in VA Home Based Primary Care: Experience of Interdisciplinary Team Members.

OBJECTIVES: Describe how Department of Veterans Affairs (VA) Home Based Primary Care (HBPC) team members discussed the COVID-19 vaccine with Veteran patients and their caregivers; describe HBPC team members' experiences providing care during the pandemic; identify facilitators and barriers to vaccinating HBPC Veterans during the COVID-19 pandemic. DESIGN: Online survey that included 3 open-ended COVID-19 vaccine-related questions. SETTING AND PARTICIPANTS: HBPC Program Directors from 145 VA Medical Centers were invited to participate and share the survey invitation with team members. The survey was open from March to May 2021. We collected N = 573 surveys from 73 sites. METHODS: We analyzed demographic data using descriptive frequencies and open-ended questions using thematic analysis. RESULTS: Respondents from all HBPC roles were included in the study: Registered Nurses, Psychologists, Advanced Registered Nurse Practitioners, Social Workers, Dieticians, Occupational Therapists, Pharmacists, Physical Therapists, HBPC Program Directors, HBPC Medical Directors, MDs, Physician Assistants, Other. Qualitative thematic analysis revealed 3 themes describing VA HBPC team members' experiences discussing and administering the COVID-19 vaccine: communication and education, advocating for prioritization of HBPC Veterans to receive the vaccine, and logistics of delivering and administering the vaccine. CONCLUSIONS AND IMPLICATIONS: Our study findings highlight the multifaceted experiences of VA HBPC team members discussing and administering initial doses of the COVID-19 vaccine to primarily homebound Veterans. Although the VA's HBPC program offers an example of a singular health care system, insights from more than 70 sites from across the United States reveal key lessons around the internal and external structures required to successfully support programs and their staff in providing these key activities. These lessons include proactively addressing the needs of homebound populations in national vaccine rollouts and developing vaccine education and training programs for HBPC team members specifically aligned to HBPC program needs. These lessons can extend to non-VA organizations who care for similar homebound populations.

Deep caries removal strategies: Findings from The National Dental Practice-Based Research Network.

BACKGROUND: The International Caries Consensus Collaboration (ICCC) has published recommendations on carious tissue removal to treat cavitated carious lesions in a manner that preserves hard tissue and retains teeth long term. This study quantifies The National Dental Practice-Based Research Network dentists' use of selective caries removal. METHODS: This cross-sectional questionnaire study assessed reported use of selective caries removal when treating deep caries in asymptomatic and symptomatic teeth in response to clinical case scenarios. Statistical methods included the proportion of respondents concordant with ICCC guidelines at various thresholds and logistic regression to model factors associated with concordance. RESULTS: A total of 500 dentists responded. The study sample was 57% male, mean (SD) age was 50.9 (12.6) years, and 60% worked in private practice settings. Higher levels of concordance for choosing selective caries removal 50% or greater of the time were found for asymptomatic (62.4%; 95% CI, 57.6 to 67.2) than for symptomatic caries (49.3%; 95% CI, 44.4 to 54.2). These differences were significantly associated with type of practice setting. CONCLUSIONS: The National Dental Practice-Based Research Network dentists reported using selective caries removal strategies when managing deep carious lesions more often than in previous US and Japanese practice-based research network studies and from results of a systematic review and meta-analysis. Nonetheless, substantive discordance with the ICCC guidelines was seen by the authors of this study. PRACTICAL IMPLICATIONS: More dissemination and continuing education activities, as well as implementation studies, may further encourage use of selective caries removal to soft or firm dentin when indicated.

Wide Variability in Documentation of Sexual Orientation, Gender Identity, and Preventive Health Screenings in a Diverse Sample of U.S. Community Health Centers.

Purpose: This study was conducted to characterize documentation of sexual orientation and gender identity (SOGI) and provision of screening and preventive services in a diverse sample of community health centers (CHCs). Methods: Twelve CHCs provided data submitted to the Health Resources and Services Administration (HRSA) in 2018 from their Uniform Data System (UDS) reports. Prevalence of SOGI documentation, screenings, and preventive services were calculated. Sociodemographic correlates of documentation were analyzed using Fisher's exact test and Wilcoxon rank sum/Mann-Whitney U test. Results: Patient data recording sexual orientation (SO) were missing in 2%-93% of UDS reports from the 12 CHCs, and gender identity (GI) data were missing from 0% to 96% of UDS reports. CHCs were most likely to report body mass index and tobacco screening and least likely to report hepatitis A or B vaccination, independent of SO or GI. Transgender females were less likely to have mammography documented than cisgender females. Transgender males were less likely to have anal Pap tests, be vaccinated for hepatitis B, or be referred for risky alcohol use compared to cisgender males. Patients who identified as "another gender" were less likely to be referred for risky alcohol use, undergo mammography or anal Pap testing, or receive hepatitis A vaccination than cisgender people. Individuals who did not disclose their GI were less likely to be vaccinated for hepatitis A or B than cisgender people. Conclusion: SOGI status was often not documented by a diverse array of CHCs. However, when SOGI status was documented, we saw evidence of disparities in preventive interventions and referrals, particularly for transgender patients. Clinical trial registration number: NCT03554785.

Assessing Social Functioning During COVID-19 and Beyond: Tools and Considerations for Nursing Home Staff.

Social functioning is defined as how a person operates in their unique social environment (ie, engagement in activities, connectedness with others, and contributions to social roles). Healthy social functioning is important for nursing home residents as they are at increased risk for loneliness and isolation. Social functioning has long been an underacknowledged aspect of nursing home residents' health, but now, with the COVID-19 pandemic, residents' risk for decreased social functioning is increased. Several reliable and well-validated tools are available to supplement routine care planning and delivery and track and improve changes in social functioning over time. The overarching aim of this article is to provide resources and recommendations for interdisciplinary team assessment related to social functioning for nursing home residents. We describe 2 domains of social functioning measures, care-planning measures and outcome measures, and provide recommendations for how to integrate said measures into practice. Healthy social functioning is needed to maintain nursing home residents' well-being and quality of life. Measures and recommendations outlined in this article can be used by nursing home staff to understand residents' social preferences and address social functioning during COVID-19 and beyond.

Care Transitions to the Community from Veterans Affairs Nursing Homes: Experiences of Social Connection and Disconnection.

OBJECTIVE: This study aimed to further knowledge of older Veterans' experiences with transitioning to the community from Veterans Affairs nursing homes (Community Living Centers or CLCs) with emphasis on social functioning. DESIGN: A qualitative study design was used in addition to administration of standardized depression and mental status screens. SETTING AND PARTICIPANTS: Veterans (n = 18) and caregivers (n = 14) were purposively sampled and recruited from 2 rural CLCs in Upstate New York. METHODS: Semistructured interviews were completed with Veterans in the CLC prior to discharge (to explore experiences during the CLC stay and expectations regarding discharge and returning home) and in the home 2-4 weeks postdischarge (to explore daily routines and perceptions of overall health, mental health, and social functioning). Caregivers participated in 1 interview, completed postdischarge. The 9-item Patient Health Questionnaire and the Brief Interview for Mental Status were administered postdischarge. RESULTS: Thematic analysis of verbatim transcriptions revealed 3 inter-related themes: (1) Veterans may experience improved social connectedness in CLCs by nature of the unique care environment (predominantly male, shared military experience); (2) Experiences of social engagement and connectedness varied after discharge and could be discordant with Veterans' expectations for recovery prior to discharge; and (3) Veterans may or may not describe themselves as "lonely" after discharge, when physically isolated. Veterans lacked moderate to severe cognitive impairment (Brief Interview for Mental Status: range = 14-15); however, they reported a wide range in depressive symptom severity postdischarge (9-item Patient Health Questionnaire: mean = 4.9, SD = 6.1, median/mode = 3, range = 0-23). CONCLUSIONS AND IMPLICATIONS: This study identified a potential for increased social isolation and disengagement after discharge from Veterans Affairs nursing homes. Nursing homes should integrate social functioning assessment for their residents, while extending care planning and transitional care to address patient-centered social functioning goals.

Factors Associated With Hospitalization by Veterans in Home-Based Primary Care.

OBJECTIVES: This study examined the extent to which program site-based and Veteran characteristics were associated with potentially avoidable hospitalizations or other hospitalization of Veterans enrolled in the Veterans Affairs (VA) Home-Based Primary Care (HBPC). DESIGN: Retrospective claims-based study. SETTING AND PARTICIPANTS: HBPC programs that responded to a national survey of HBPC programs (n = 189) in fiscal year (FY) 2016 were studied. Veterans in the analysis cohort were identified as having been enrolled in VA-HBPC in FY2016 who had not received care by VA-HBPC within 1 year prior to their first HBPC enrollment in FY2016 (N = 8497). METHODS: Multinomial logistic regression analysis with 5 outcome categories within the 6 months following the first HBPC enrollment date: (1) any potentially avoidable hospitalizations for ambulatory care-sensitive conditions (ACSC) as identified by AHRQ Prevention Quality Indicator (PQI), (2) any other hospitalizations for non-ACSC conditions, (3) died during study period, (4) discharged from HBPC, or (5) remained at home with HBPC. Average marginal effects (AME) of veteran-level and VA-HBPC-level covariates are reported for each of the outcome categories. RESULTS: More frail Veterans and Veterans 85 years old or older were more likely to have potentially preventable ACSC hospitalizations (AME = 5.4%, 1.8%, respectively). Veterans who were younger than 75 years, functionally impaired, bed-bound, or frail were more likely to have non-ACSC hospitalization (AME = 3.0%, 2.2%, 3.5%, and 9.0%, respectively). Veterans with low frailty index scores were less likely to have non-ACSC hospitalizations (AME = -17.1%). Six-month hospitalization patterns were not associated with reported HBPC site characteristics. CONCLUSIONS AND IMPLICATIONS: Within the framework of the national VA HBPC program, variations in the structural model used at HBPC sites are not significantly associated with hospitalizations. Tailoring of HBPC care, based on individual patient factors and clinical judgment rather than standard protocols, may be central to the success of HBPC in reducing ACSC hospitalizations.