Nursing Facility Residents Research Articles

Temperature and oxygen saturation in skilled nursing facility residents positive for SARS-CoV-2 prior to symptom onset.

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) spreads rapidly amongst residents of skilled nursing facilities (SNFs). The rapid transmission dynamics and high morbidity and mortality that occur in SNFs emphasize the need for early detection of cases. We hypothesized that residents of SNFs infected with SARS-CoV-2 would demonstrate an acute change in either temperature or oxygen saturation (SpO2 ) prior to symptom onset. The Minnesota Department of Health (MDH) conducted a retrospective analysis of both temperature and SpO2 at two separate SNFs to assess the utility of these quantitative markers to identify SARS-CoV-2 infection prior to the development of symptoms. A retrospective analysis was conducted of 165 individuals positive for SARS-CoV-2 who were residents of SNFs that experienced coronavirus disease 2019 (COVID-19) outbreaks during April-June 2020 in a metropolitan area of Minnesota. Age, sex, symptomology, temperature and SpO2 values, date of symptom onset, and date of positive SARS-CoV-2 test were analyzed. Temperature and SpO2 values for the period 14 days before and after the date of initial positive test were included. Descriptive analyses evaluated changes in temperature and SpO2 , defined as either exceeding a set threshold or demonstrating an acute change between consecutive measurements. Two (1%) residents had a temperature value ≥100°F, and 30 (18%) had at least one value ≥99°F within 14 days before symptom development. One hundred and sixteen residents (70%) had at least one SpO2 value ≤94%, while 131 (80%) had an acute decrease in SpO2 of ≥3% between consecutive values in the 14 days prior to symptom onset. Our results suggest that acute change in SpO2 might be useful in the identification of SARS-CoV-2 infection prior to the development of symptoms among residents living in SNFs. Facilities may consider adding SpO2 to daily temperature and symptom screening checklists to improve early detection of residents of SNFs infected with SARS-CoV-2.

Optimizing Health Outcomes Among Newly Dual Eligibility Beneficiaries in Managed Care: Patient‐Provider Language, Race and Technology Discordance

Research ObjectiveOver one‐third of individuals dually eligible for Medicaid and Medicare coverage (“dual eligibles”) receive care in managed care settings. Despite improvements in care processes, access and overall satisfaction, suboptimal outcomes persist. We investigated whether lack of patient portal use and/or language/race discordance were associated with potentially avoidable hospital and emergency room admissions.Study DesignLeveraging electronic health record data in a large integrated care delivery system, we applied a retrospective observational cohort design and Cox proportional hazards models to estimate the risk of potentially avoidable hospital and emergency room admissions during the first two years following dual eligibility. We examined three factors previously identified as important to patient‐provider interactions: patient engagement with providers via a patient portal, race concordance, and language concordance. Models controlled for potential patient (e.g., age, sex, race, ethnicity, comorbidity, distance to the nearest clinic, behavioral risk factors, coverage type), and health system (e.g., neighborhood deprivation index, hospital) confounders.Population StudiedWe identified 36,961 adults enrolled in Kaiser Permanente Northern California health plans who became newly eligible for dual enrollment in Medicaid and Medicaid between 2016 and 2019. We excluded individuals with any hospice services and long‐ term skilled nursing facility residents. The final model included 36,689 individuals.Principal FindingsAt time of new dual eligibility, patients were 64.7 years old on average and 59% were female. The cohort was racially and ethnically diverse: 37.4% white; 22.1% Asian; 13.5% Black or African American; 21.2% Latinx; 1.7% other; and 4.1% unknown. 4.8% had the outcome of interest within two years of new dual eligibility. Consistent with our hypothesis, individuals who did not use the patient portal were at significantly increased risk for potentially avoidable admissions [HR: 1.32; 95% CI: (1.17, 1.49)]. Race discordance was also associated with increased [HR: 1.13; 95% CI: (1.00, 1.27)]. In contrast with our hypothesis, language discordance was associated with a lower risk of avoidable hospital and ED admissions [HR: 0.72 CI: (0.61, 0.85)]. In addition, multi‐morbidity, new enrollment into the Kaiser Permanente health system, lack of exercise and living in a lower socioeconomic status neighborhood was associated with elevated risk. Younger age, enrollment in both Dual Eligible Special Needs Plans (D‐SNP) and Medicaid or in Medicare alone (versus D‐SNP only), and Asian race was associated with lower risk.ConclusionsAmong individuals newly eligible for dual coverage from Medicare and Medicaid, both race discordance and non‐use of the patient portal, was associated with increased risk of potentially avoidable hospital events. Limitations of this study include potential lack of generalizability to individuals transitioning from fee‐for‐service to managed care and reliance on indirect measures of cultural and linguistic discordance.Implications for Policy or PracticeIncreasing the use of telehealth services among dual eligibles may be critical to close the gap between potential and realized access to manage care services.Primary Funding SourceKaiser Permanente.

Fisetin for COVID-19 in skilled nursing facilities: Senolytic trials in the COVID era.

The burden of senescent cells (SnCs), which do not divide but are metabolically active and resistant to death by apoptosis, is increased in older adults and those with chronic diseases. These individuals are also at the greatest risk for morbidity and mortality from SARS‐CoV‐2 infection. SARS‐CoV‐2 complications include cytokine storm and multiorgan failure mediated by the same factors as often produced by SnCs through their senescence‐associated secretory phenotype (SASP). The SASP can be amplified by infection‐related pathogen‐associated molecular profile factors. Senolytic agents, such as Fisetin, selectively eliminate SnCs and delay, prevent, or alleviate multiple disorders in aged experimental animals and animal models of human chronic diseases, including obesity, diabetes, and respiratory diseases. Senolytics are now in clinical trials for multiple conditions linked to SnCs, including frailty; obesity/diabetes; osteoporosis; and cardiovascular, kidney, and lung diseases, which are also risk factors for SARS‐CoV‐2 morbidity and mortality. A clinical trial is underway to test if senolytics decrease SARS‐CoV‐2 progression and morbidity in hospitalized older adults. We describe here a National Institutes of Health‐funded, multicenter, placebo‐controlled clinical trial of Fisetin for older adult skilled nursing facility (SNF) residents who have been, or become, SARS‐CoV‐2 rtPCR‐positive, including the rationale for targeting fundamental aging mechanisms in such patients. We consider logistic challenges of conducting trials in long‐term care settings in the SARS‐CoV‐2 era, including restricted access, consent procedures, methods for obtaining biospecimens and clinical data, staffing, investigational product administration issues, and potential solutions for these challenges. We propose developing a national network of SNFs engaged in interventional clinical trials.

Safe Transitions and Congregate Living in the Age of COVID-19: A Retrospective Cohort Study.

COVID-19 represents a grave risk to residents in skilled nursing facilities (SNFs). To determine whether establishment of an appropriate-use committee was associated with a reduction in SNF utilization. Retrospective cohort study at NorthShore University HealthSystem, a multihospital integrated health system in northern Illinois. Participants were patients hospitalized from March 19, 2019, to July 16, 2020. Creation of a multidisciplinary committee to assess appropriateness of discharge to SNF following hospitalization. Primary outcome was total discharges to SNFs. Secondary outcomes were new discharges to SNFs, readmissions, length of stay (LOS), and COVID-19 incidence following discharge. Matched populations pre and post intervention were each 4424 patients. Post intervention, there was a relative reduction in total SNF discharges of 49.7% (odds ratio [OR], 0.42; 95% CI, 0.38-0.47) and in new SNF discharges of 66.9% (OR, 0.29; 95% CI, 0.25-0.34). Differences in readmissions and LOS were not statistically significant. For patients discharged to a SNF, 2.99% (95% CI, 1.59%-4.39%) developed COVID-19 within 30 days, compared with 0.26% (95% CI, 0.29%-0.93%) of patients discharged to other settings (P < .001). Implementing a review committee to assess for appropriateness of SNF use after a hospitalization during the COVID-19 pandemic is highly effective. There was no negative impact on safety or efficiency of hospital care, and reduced SNF use likely prevented several cases of COVID-19. This model could serve as a template for other hospitals to reduce the risks of COVID-19 in SNFs and as part of a value-based care strategy.

Effect of Receiving Dental Treatment on mortality among nursing facility residents.

To assess the association between receipt of different types of dental procedures and mortality among nursing home residents. Between June 2006 and March 2008, 535 nursing home residents received a health screening assessment and were offered comprehensive dental care. Death certificate data were obtained in September 2013 and multivariable regression models were generated to assess the effect of dental procedures delivered after the screening assessment on mortality, adjusting for demographic and health-related covariates. Residents had a mean age of 85.2years at baseline and approximately 30% were edentulous. About two-thirds received at least one dental procedure, and about 88% had died, between the screening date and the end of follow-up. Among dentate residents, after adjustment for relevant covariates, for each one-unit increase in the number of intervals during which they received at least one preventive dental procedure there was a 13% decrease in mortality (HR=0.87, 95% CI=0.78-0.98) at any given time, while for prosthetic dental procedures there was a 16% decrease in mortality (HR=0.84, 95% CI=0.72-0.97). Among edentulous residents, only prosthetic procedures were analyzed, and they were not significantly associated with mortality. Among dentate institutionalized elderly, receipt of preventive or prosthetic dental procedures was associated with decreased mortality.

Behavioral Health Services with Short-Stay Residents in Skilled Nursing Facilities: A Qualitative Study of Clinicians and Administrators

ABSTRACT Objectives The perspectives of professionals involved in behavioral health (BH) services with short-stay residents in skilled nursing facilities (SNFs) are rarely captured in the literature. This study examines the real-world experiences of BH clinicians and administrators in post-acute/subacute care units in SNFs. Methods This qualitative study used semi-structured interviews with 18 clinicians (e.g., psychologists and social workers) and five administrators (e.g., directors of social services or BH company executives) involved in BH services with short-stay SNF residents. Interviews were recorded, transcribed, and analyzed by two independent coders using conventional thematic content analysis. Results Three themes emerged from the data: (1) BH needs are high among short-stay residents and families during post-acute care transitions; (2) BH services offer multiple unique opportunities to enhance post-acute/subacute care in SNFs; and (3) barriers to providing optimal BH care exist at multiple levels and require action from BH clinicians and stakeholders. Conclusions Variability in clinician roles and barriers to optimized care suggest the need for future research targeting best practices and implementation strategies for BH services with short-stay SNF residents. Clinical Implications Results identified multiple ways in which BH services may enhance resident, family, and staff outcomes, as well as the milieu in SNFs.

Skilled Nursing Facility-to-Home Trajectories for Older Adults With Mental Illness or Dementia

ObjectivesTo examine how mental illness (MI) and Alzheimer's disease and related dementias (ADRD) were associated with whether skilled nursing facility (SNF) residents returned to and remained in the community and if receipt of home health services was associated with post-SNF home time. DesignRetrospective cohort study based on secondary data analyses. SettingNew York State Medicare beneficiaries who were admitted to an SNF in 2014. ParticipantsTotal of 46,137 older adults admitted to SNFs and 25,357 discharged from SNFs to home. MeasurementsWe used Medicare claims and assessment databases to derive our outcomes (discharge to the community and home time [i.e., days alive in the community]), determine MI/ADRD status, and obtain socio-demographic and clinical characteristics. ResultsAmong SNF admissions, 22.9% had MI, 22.6% had ADRD, and 59.0% were discharged to the community. In analyses adjusting for socio-demographic and clinical characteristics, MI and ADRD were associated with decreased odds of community discharge and less home time during 90-days of follow-up. However, when we included depressive symptoms, aggressive behaviors, and daily functioning in the analyses, these associations were attenuated. Receipt of post-SNF home health services was associated with increased home time among those with MI or ADRD. ConclusionNewly admitted SNF residents with MI or ADRD were less likely to be discharged and, if discharged, spent less time in the community. Interventions targeting depressive symptoms, aggressive behaviors, and functioning and improving linkage with home health services may help decrease differences in post-acute care trajectories between those with and without MI and ADRD.

Special Need Pooled Trust Disbursements and the Well-being of Nursing Facility Residents Receiving Medicaid Benefits

ABSTRACT Medicaid is the largest health insurer in America, comprising one-sixth of the nation’s total healthcare expenditures. Of this, 40% covers long-term care services for older adults and adults with disabilities. Yet, Medicaid does not provide access to all goods and services needed. Pooled special needs trusts (pooled trusts) are a program through which older individuals, requiring long-term care, may set aside assets and remain Medicaid eligible. Pooled trust funds purchase items such as medical devices, telecommunications and funeral services. This article explores the relationship between Medicaid, pooled trusts and their role in nursing home residents’ well-being. To understand this relationship, a descriptive study sorts the disbursements from a pooled trust into the 5 Gallup-Healthways Index well-being domains. The analysis shows that pooled trust funds purchased goods and services related to well-being. Thus, pooled trusts offer a means for states to expand the support they provide individuals in nursing facilities beyond the medical services covered by Medicaid to include goods and services associated with well-being.

Postvaccination SARS-CoV-2 infections among skilled nursing facility residents and staff members - Chicago, Illinois, December 2020-March 2021.

This article describes 22 cases of breakthrough SARS‐CoV‐2 infection among over 14,000 fully vaccinated skilled nursing facility residents and staff. The majority of such infections were asymptomatic or were associated with mild symptoms, and there was no intra‐ facility spread related to these cases. This report suggests that postvaccination breakthrough infections are rare, but also confirms that vaccines do not offer 100% protection even in nonimmunosuppressed hosts, thus underscoring the need for studies of vaccine efficacy in immunosuppressed transplant recipients.

Seroprevalence of Severe Acute Respiratory Syndrome Coronavirus 2 Among Skilled Nursing Facility Residents and Staff Members-Los Angeles County, August-September 2020.

BackgroundThe prevalence of current/past coronavirus disease 2019 (COVID-19) in skilled nursing facility (SNF) residents is unknown because of asymptomatic infection and constrained testing capacity early in the pandemic. We conducted a seroprevalence survey (SPS) to determine a more comprehensive prevalence of past COVID-19 in Los Angeles County SNF residents and staff members.MethodsWe recruited participants from 24 facilities; participants were requested to submit a nasopharyngeal (NP) swab for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) PCR testing and serum for detection of SARS-CoV-2 antibodies. All participants were cross-referenced with our surveillance database to identify persons with prior positive SARS-CoV-2 results.ResultsFrom August 18 to September 24, 2020, we enrolled 3,305 participants (1,340 residents and 1,965 staff members). Among 856 residents providing serum, 362 (42%) had current/past SARS-CoV-2 infection. Of the 346 serology positive residents, 199 (58%) did not have a documented prior positive SARS-CoV-2 PCR result. Among 1,806 staff members providing serum, 454 (25%) had current/past SARS-CoV-2 infection. Of the 447 serology positive staff members, 353 (79%) did not have a documented prior positive SARS-CoV-2 PCR result.ConclusionsPast testing practices and policies missed a substantial number of SARS-CoV-2 infections in SNF residents and staff members.

Trends in the Use of Residential Settings Among Older Adults.

As the U.S. population ages, the prevalence of disability and functional limitations, and demand for long-term services and supports (LTSS), will increase. This study identified the distribution of older adults across different residential settings, and how their health characteristics have changed over time. A cross-sectional analysis of older adults residing in traditional housing, community-based residential facilities (CBRFs), and nursing facilities using 3 data sources: the Medicare Current Beneficiary Survey (MCBS), 2008 and 2013; the Health and Retirement Study (HRS), 2008 and 2014; and the National Health and Aging Trends Study, 2011 and 2015. We calculated the age-standardized prevalence of older adults by setting, functional limitations, and comorbidities and tested for health characteristics changes relative to the baseline year (2002). The proportion of older adults in traditional housing increased over time, relative to baseline (p < .05), while the proportion of older adults in CBRFs was unchanged. The proportion of nursing facility residents declined from 2002 to 2013 in the MCBS (p < .05). The prevalence of dementia and functional limitations among traditional housing residents increased, relative to the baseline year in the HRS and MCBS (p < .05). The proportion of older adults residing in traditional housing is increasing, while the nursing facility population is decreasing. This change may not be due to better health; rather, older adults may be relying on noninstitutional LTSS.

Clinical Characterization of Nursing Facility Residents With Chronic Obstructive Pulmonary Disease.

To describe clinical characteristics, medication use, and low peak inspiratory flow rate (PIFR) (< 60 L/min) prevalence in nursing facility residents with chronic obstructive pulmonary disease (COPD). Residents 60 years of age and older with a COPD diagnosis and≥ 6 months' nursing facility residence, were enrolled between December 2017 and February 2019 from 26 geographically varied United States nursing facilities. Data, extracted from residents' charts, included demographic/clinical characteristics, COPD-related medications, exacerbations and hospitalizations within the past 6 months, and functional status from the most recent Minimum Data Set. At enrollment, residents completed the modified Medical Research Council (mMRC) Dyspnea Scale and COPD Assessment Test (CAT™). Spirometry and PIFR were also assessed. Residents' (N = 179) mean age was 78.0 ± 10.6 years, 63.7% were female, and 57.0% had low PIFR. Most prevalent comorbidities were hypertension (79.9%), depression (49.2%), and heart failure (41.9%). The average forced expiratory volume in 1 second (FEV11) % predicted was 45.9% ± 20.9%. On the CAT, 78.2% scored≥ 10 and on the mMRC Dyspnea Scale, 74.1% scored≥ 2, indicating most residents had high COPD symptom burden. Only 49.2% were receiving a scheduled long-acting bronchodilator (LABD). Among those with low PIFR prescribed a LABD, > 80% used dry powder inhalers for medication delivery. This study highlights underutilization of scheduled LABD therapy in nursing facility residents with COPD. Low PIFR was prevalent in residents while the majority used suboptimal medication delivery devices. The findings highlight opportunities for improving management and outcomes for nursing facility residents with COPD.

Postvaccination SARS-CoV-2 Infections Among Skilled Nursing Facility Residents and Staff Members — Chicago, Illinois, December 2020–March 2021

Early studies suggest that COVID-19 vaccines protect against severe illness (1); however, postvaccination SARS-CoV-2 infections (i.e., breakthrough infections) can occur because COVID-19 vaccines do not offer 100% protection (2,3). Data evaluating the occurrence of breakthrough infections and impact of vaccination in decreasing transmission in congregate settings are limited. Skilled nursing facility (SNF) residents and staff members have been disproportionately affected by SARS-CoV-2, the virus that causes COVID-19 (4,5), and were prioritized for COVID-19 vaccination (6,7). Starting December 28, 2020, all 78 Chicago-based SNFs began COVID-19 vaccination clinics over several weeks through the federal Pharmacy Partnership for Long-Term Care Program (PPP).† In February 2021, through routine screening, the Chicago Department of Public Health (CDPH) identified a SARS-CoV-2 infection in a SNF resident >14 days after receipt of the second dose of a two-dose COVID-19 vaccination series. SARS-CoV-2 cases, vaccination status, and possible vaccine breakthrough infections were identified by matching facility reports with state case and vaccination registries. Among 627 persons with SARS-CoV-2 infection across 75 SNFs since vaccination clinics began, 22 SARS-CoV-2 infections were identified among 12 residents and 10 staff members across 15 facilities ≥14 days after receiving their second vaccine dose (i.e., breakthrough infections in fully vaccinated persons). Nearly two thirds (14 of 22; 64%) of persons with breakthrough infections were asymptomatic; two residents were hospitalized because of COVID-19, and one died. No facility-associated secondary transmission occurred. Although few SARS-CoV-2 infections in fully vaccinated persons were observed, these cases demonstrate the need for SNFs to follow recommended routine infection prevention and control practices and promote high vaccination coverage among SNF residents and staff members.

Documentation Sharing Deficiencies of Posthospitalized Skilled Nursing Facility Residents: A Retrospective Review.

Documentation Sharing Deficiencies of Posthospitalized Skilled Nursing Facility Residents: A Retrospective Review.

Results of a hospitalization policy of asymptomatic and pre-symptomatic COVID-19-positive long-term care facility residents in the province of Salzburg\u2014a report from the AGMT COVID-19 Registry

COVID-19-associated case fatality rates up to 48% were reported among nursing facility residents. During the first wave of the COVID-19 pandemic, routine SARS-CoV-2 testing in long-term care facilities in the Province of Salzburg and centralized hospitalization in the COVID-19 unit of the Paracelsus Medical University Salzburg (Austria) irrespective of symptoms was implemented. Baseline characteristics and the course of COVID-19 disease were assessed among hospitalized long-term care facility residents within the COVID-19 Registry of the Austrian Group Medical Tumor Therapy (AGMT; NCT04351529). Between the 24th of March and the 20th of April 2020, 50 COVID-19-positive residents were hospitalized. The median age was 84.5 years (range: 79–88) and the median number of comorbidities and baseline medication classes was 6 (IQR: 4–7) and 5 (IQR: 3–6), respectively. At admission, 31 residents (62%) were symptomatic, nine residents (18%) pre-symptomatic whereas ten residents (20%) remained asymptomatic. The 30-day mortality rate from hospitalization was 32% and significantly higher in symptomatic residents at admission when compared to asymptomatic residents including pre-symptomatic residents (48% [95% CI: 27–63%] versus 5% [95% CI: 0–15%], p=0.006). The Early Warning Score (EWS) at admission was associated with 30-day mortality: high risk: 100%, intermediate risk: 50% (95% CI: 0–78%), and low risk: 21% (95% CI: 7-32%) (p<0.001). In light of comparably low mortality rates between asymptomatic and pre-symptomatic hospitalized COVID-19-positive residents, we suggest the supply of comparable intensity and quality of monitoring and care in long-term care facilities as an alternative to immediate hospitalization upon a positive COVID-19 test in asymptomatic residents.

Factors associated with concordance between POLST orders and current treatment preferences.

POLST is widely used to document the treatment preferences of nursing facility residents as orders, but it is unknown how well previously completed POLST orders reflect current preferences (concordance) and what factors are associated with concordance. To describe POLST preference concordance and identify factors associated with concordance. Chart reviews to document existing POLST orders and interviews to elicit current treatment preferences. POLST-using nursing facilities (n= 29) in Indiana. Nursing facility residents (n= 123) and surrogates of residents without decisional capacity (n= 152). Concordance was determined by comparing existing POLST orders for resuscitation, medical interventions, and artificial nutrition with current treatment preferences. Comfort-focused POLSTs contained orders for do not resuscitate, comfort measures, and no artificial nutrition. Overall, 55.7% (123/221) of residents and 44.7% (152/340) of surrogates participated (total n= 275). POLST concordance was 44%, but concordance was higher for comfort-focused POLSTs (68%) than for non-comfort-focused POLSTs (27%) (p< 0.001). In the unadjusted analysis, increasing resident age (OR 1.04, 95% CI 1.01-1.07, p< 0.01), better cognitive functioning (OR 1.07, 95% CI 1.02-1.13, p< 0.01), surrogate as the decision-maker (OR 2.87, OR 1.73-4.75, p< 0.001), and comfort-focused POLSTs (OR 6.01, 95% CI 3.29-11.00, p< 0.01) were associated with concordance. In the adjusted multivariable model, only having an existing comfort-focused POLST was associated with higher odds of POLST concordance (OR 5.28, 95% CI 2.59-10.73, p < 0.01). Less than half of all POLST forms were concordant with current preferences, but POLST was over five times as likely to be concordant when orders reflected preferences for comfort-focused care. Findings suggest a clear need to improve the quality of POLST use in nursing facilities and focus its use among residents with stable, comfort-focused preferences.

Claims-Based Frailty and Outcomes: Applying an Aging Measure to Older Adults with Parkinson's Disease.

Frailty is a geriatric syndrome with negative health impacts not captured by comorbidity and disability alone. The prevalence of frailty in Parkinson's disease (PD) has been described, but data on frailty-associated outcomes are limited. To describe the level of frailty and investigate the association between frailty and outcomes in a Medicare sample of persons diagnosed with PD. We used the claims-based frailty index to assess frailty in a cohort of Medicare beneficiaries with PD in 2013. Frailty was categorized as non-frail/pre-frail, mildly frail, moderately frail, and severely frail. Adjusted logistic regression models examined the relationship between frailty and mortality, hospitalization, emergency department visits, and fall-related injuries through 2014. Of 62,786 beneficiaries with PD in 2013, 55.3% were frail. Frail individuals were more likely to be female, older, Black, metropolitan dwelling, without neurologist care, nursing facility residents, or multimorbid. The average daily levodopa equivalent dose initially increased, then decreased from the pre-frail to the severely frail groups. Compared to non-frail/pre-frail persons, severely frail persons had higher adjusted odds of 1-year mortality (AOR 2.74, 95% CI 1.98, 3.78), hospitalization (AOR 2.34, 95% CI 1.74, 3.14), emergency department visits (AOR 2.97, 95% CI 2.14, 4.13), and fall-related injury (AOR 1.43, 95% CI 0.90, 2.26). Frailty is common and differentially distributed among older adults with PD. Frailty in PD is associated with adverse health outcomes and death. Observational study analyses may benefit from adjustment for frailty; claims-based frailty surveillance may identify vulnerable PD patients in health system, registry, or administrative data. © 2021 International Parkinson and Movement Disorder Society.

Hand-Feeding Nursing Facility Residents with Dementia Competency Training Modules

<h3>Introduction</h3> Problem: In nursing homes around 70% of residents have some form of dementia and are at risk of malnourishment (Zimmerman et al., 2014). In this long-term care (LTC) unit, residents have varying degrees of cognitive impairment (CI) affecting their functional capabilities, including their capacity to feed themselves. The director of nursing (DON) identified that residents are vulnerable to decreased food and fluid intake, and this problem may reflect the limited feeding skills of direct care workers (DCWs). More than half of the staff in this LTC unit report that it is a challenge to assist a resident with dementia during mealtimes when they exhibit difficult feeding behaviors. The majority of staff report that one of the greatest challenges when assisting a resident with mealtimes is resistance to eating demonstrated by residents turning their head away or not opening their mouths. Only one staff member on this unit reports having additional training on feeding assistance, and only one staff member uses assistive hand-feeding techniques when assisting a resident with CI during mealtimes. Evidence supports staff training as in intervention, however no specific training has been implemented to improve DCW's feeding assistance. Purpose: The purpose of this quality improvement (QI) project is to implement and evaluate the evidence-based <i>Hand-Feeding Nursing Facility Residents with Dementia</i> training within a LTC setting, to ameliorate DCWs feeding assistance skills, enhance the mealtime experience, and improve residents' health outcomes. <h3>Methods</h3> The QI project was developed by project leaders with the help of content expert and creator of the evidence-based training program titled <i>Hand-Feeding Nursing Facility Residents with Dementia</i>. The project included nine DCWs that were chosen to participate by the DON and worked during a shift that required the provision of assisting residents with a meal. The participants completed a pre-training survey and baseline interview with project leaders to assess knowledge and use of assistive handfeeding techniques. The participants were provided online access to the training modules on topics of assessment of residents' functional and cognitive abilities, determining the most appropriate handfeeding technique, mealtime challenges associated with residents with CI, and strategies to manage feeding behaviors to promote meal intake. A train-the-trainer strategy was utilized, and the project champion was trained on the competency modules and how to perform the post-training skill checks. Participants completed the online competency modules, and the project champion completed the post-training skills checks. After the competency training modules were completed, participants completed the post-training survey and final interview with project leaders to report their utilization of learned assistive handfeeding skills and techniques, and improvement in residents' meal intake and feeding behaviors. <h3>Results</h3> Preliminary Results: Preliminary findings suggest that completion of the <i>Hand-Feeding Nursing Facility Residents with Dementia</i> competency training modules, improves DCW's utilization of assistive hand-feeding skills and techniques to better assist residents with dementia during mealtimes. <h3>Conclusions</h3> Preliminary Conclusions: The <i>Hand-Feeding Nursing Facility Residents with Dementia</i> competency training course enhanced DCWs' mealtime interactions with residents with dementia, and residents' nutritional status will be improved as a result of project implementation. <h3>Funding</h3> No funding was available.

The Metrics Matter: Improving Comparisons of COVID-19 Outbreaks in Nursing Homes

ObjectivesIn the United States, nursing facility residents comprise fewer than 1% of the population but more than 40% of deaths due to Coronavirus Disease 2019 (COVID-19). Mitigating the enormous risk of COVID-19 to nursing home residents requires adequate data. The widely used Centers for Medicare & Medicaid Services (CMS) COVID-19 Nursing Home Dataset contains 2 derived statistics: Total Resident Confirmed COVID-19 Cases per 1000 Residents and Total Resident COVID-19 Deaths per 1000 Residents. These metrics provide a misleading picture, as facilities report cumulative counts of cases and deaths over different time periods but use a point-in-time measure as proxy for number of residents (number of occupied beds in a week), resulting in inflated statistics. We propose an alternative statistic to better illustrate the burden of COVID-19 cases and deaths across nursing facilities. DesignRetrospective cohort study. Setting and ParticipantsUsing the CMS Nursing Home Compare and COVID-19 Nursing Home Datasets, we examined facilities with star ratings and COVID-19 data passing quality assurance checks for each reporting period from May 31 to August 16, 2020 (n = 11,115). MethodsWe derived an alternative measure of the number of COVID-19 cases per 1000 residents using the net change in weekly census. For each measure, we compared predicted number of cases/deaths by overall star rating using negative binomial regression with constant dispersion, controlling for county-level cases per capita and nursing home characteristics. ResultsThe average number of cases per 1000 estimated residents using our method is lower compared with the metric using occupied beds as proxy for number of residents (44.8 compared with 66.6). We find similar results when examining number of COVID-19 deaths per 1000 residents. Conclusions and ImplicationsFuture research should estimate the number of residents served in nursing facilities when comparing COVID-19 cases/deaths in nursing facilities. Identifying appropriate metrics for facility-level comparisons is critical to protecting nursing home residents as the pandemic continues.

A mobile unit overcomes the challenges to monoclonal antibody infusion for COVID-19 in skilled care facilities.

BackgroundResidents of nursing homes and long‐term care facilities are at increased risk for severe coronavirus disease‐19 (COVID‐19) but may not be able to access monoclonal antibody therapies offered at outpatient infusion centers due to frailty and logistical issues. We describe a mobile monoclonal antibody infusion program for patients with COVID‐19 in skilled nursing facilities and provide descriptive data on its outcomes.DesignRetrospective cohort study.SettingCollaboration between Mayo Clinic and skilled nursing facilities in Southeast Minnesota was developed to administer anti‐spike monoclonal antibodies under the FDA Emergency Use Authorization.ParticipantsSeventy five residents of skilled nursing facilities at high risk of COVID‐19 complications.ExposureEmergency use treatment with bamlanivimab and casirivimab–imdevimab.MeasurementsHospitalization and medically attended visits.ResultsThe mobile infusion unit, staffed by Mayo Clinic Infusion Therapy registered nurses and supported by the skilled nursing facility staff, infused anti‐spike monoclonal antibodies to 45 of 75 patients (average age, 77.8 years) in December 2020. The infusions occurred at an average of 4.3 days after COVID‐19 diagnosis. Fourteen days after infusion, there were no deaths, two emergency department visits, and three hospitalizations, for a combined event rate of 11.1%. There was one reported adverse event.ConclusionThe implementation of a mobile infusion unit embedded in a collaborative process resulted in rapid infusion of monoclonal antibodies to high‐risk COVID‐19 patients in skilled nursing facilities, who would otherwise be unable to access the novel therapies. The therapies were well tolerated and appear beneficial. Further study is warranted to explore the scalability and efficacy of this program.