Term Care Research Articles

A Single Nucleotide Variant in Ankyrin-2 Influencing Ventricular Tachycardia in COVID-19 Associated Myocarditis

A Single Nucleotide Variant in Ankyrin-2 Influencing Ventricular Tachycardia in COVID-19 Associated Myocarditis

Long term care facilities in England during the COVID-19 pandemic—a scoping review of guidelines, policy and recommendations

BackgroundThe disproportionate effect of COVID-19 on long term care facility (LTCF) residents has highlighted the need for clear, consistent guidance on the management of pandemics in such settings. As research exploring the experiences of LTCFs during the pandemic and the implications of mass hospital discharge, restricting staff movement, and limiting visitation from relatives are emerging, an in-depth review of policies, guidance and recommendations issued during this time could facilitate wider understanding in this area.AimsTo identify policies, guidance, and recommendations related to LTCF staff and residents, in England issued by the government during the COVID-19 pandemic, developing a timeline of key events and synthesizing the policy aims, recommendations, implementation and intended outcomes.MethodA scoping review of publicly available policy documents, guidance, and recommendations related to COVID-19 in LTCFs in England, identified using systematic searches of UK government websites. The main aims, recommendations, implementation and intended outcomes reported in included documents were extracted. Data was analysed using thematic synthesis following a three-stage approach: coding the text, grouping codes into descriptive themes, and development of analytical themes.ResultsThirty-three key policy documents were included in the review. Six areas of recommendations were identified: infection prevention and control, hospital discharge, testing and vaccination, staffing, visitation and continuing routine care. Seven areas of implementation were identified: funding, collaborative working, monitoring and data collection, reducing workload, decision making and leadership, training and technology, and communication.DiscussionLTCFs remain complex settings, and it is imperative that lessons are learned from the experiences during COVID-19 to ensure that future pandemics are managed appropriately. This review has synthesized the policies issued during this time, however, the extent to which such guidance was communicated to LTCFs, and subsequently implemented, in addition to being effective, requires further research. In particular, understanding the secondary effects of such policies and how they can be introduced within the existing challenges inherent to adult social care, need addressing.

Evaluating the Strengthening a Palliative Approach in Long Term Care

Evaluating the Strengthening a Palliative Approach in Long Term Care

Patient Priorities Care in Post Acute and Long Term Care

Patient Priorities Care in Post Acute and Long Term Care

Comparison of Full-Time Equivalent and Clinic Time Labor Input Measures in Productivity Metrics.

A lack of improvement in productivity in recent years may be the result of suboptimal measurement of productivity. Hospitals and clinics benefit from external benchmarks that allow assessment of clinical productivity. Work relative value units have long served as a common currency for this purpose. Productivity is determined by comparing work relative value units to full-time equivalents (FTEs), but FTEs do not have a universal or standardized definition, which could cause problems. We propose a new clinical labor input measure-"clinic time"-as a substitute for using the reported measure of FTEs. In this observational validation study, we used data from a cluster randomized trial to compare FTE with clinic time. We compared these two productivity measures graphically. For validation, we estimated two separate ordinary least squares (OLS) regression models. To validate and simultaneously adjust for endogeneity, we used instrumental variables (IV) regression with the proportion of days in a pay period that were federal holidays as an instrument. We used productivity data collected between 2018 and 2020 from Veterans Health Administration (VA) cardiology and orthopedics providers as part of a 2-year cluster randomized trial of medical scribes mandated by the VA Maintaining Internal Systems and Strengthening Integrated Outside Networks (MISSION) Act of 2018. Our cohort included 654 unique providers. For both productivity variables, the values for patients per clinic day were consistently higher than those for patients per day per FTE. To validate these measures, we estimated separate OLS and IV regression models, predicting wait times from the two productivity measures. The slopes from the two productivity measures were positive and small in magnitude with OLS, but negative and large in magnitude with IV regression. The magnitude of the slope for patients per clinic day was much larger than the slope for patients per day per FTE. Current metrics that rely on FTE data may suffer from self-report bias and low reporting frequency. Using clinic time as an alternative is an effective way to mitigate these biases. Measuring productivity accurately is essential because provider productivity plays an important role in facilitating clinic operations outcomes. Most importantly, tracking a more valid productivity metric is a concrete, cost-effective management tactic to improve the provision of care in the long term.

Long Term Care Staff Perspective on Youth Volunteering

Long Term Care Staff Perspective on Youth Volunteering

Malignant Otitis Externa in an 87-year-old Long Term Care Resident

Malignant Otitis Externa in an 87-year-old Long Term Care Resident

An analysis of order utilization and overall costs secondary to an extended length of stay in hospitalized patients pending discharge to long term care facilities during the peak of Omicron

During the covid pandemic there was an influx of patients admitted to hospitals worldwide. This resulted in a presumptive overuse of resources, increased utilization costs, and decrease in hospital bed availability. This study focuses on patients admitted with a positive covid test, who required transfer to a long-term health facility after the acuity of their symptoms no longer required hospitalization but necessitated an extended length of stay due to acceptance into these facilities. Such facilities included: alternative living facility, skilled nursing facility, psychiatric institutions, or hospice. Wherein these facilities required a negative Covid PCR test or required a certain time frame to have elapsed after a positive test prior to accepting or recovering a patient. This study utilized patient records from Keralty Hospital, with admission during the 2022 peak of Omicron (January 31, 2022- February 13, 2022). Patient inclusion criteria was if they had a positive covid test on admission and experienced an extended length of stay over 2 days pending discharge to a long-term care facility. A quantitative/qualitative analysis was conducted of all orders placed subsequent to the first discharge order, and the number of additional days spent at the hospital. Correlations regarding total bed cost, and total overall, were then calculated using single tailed p values utilizing Prism 9 GraphPad software. Our research findings indicate there was a significant correlation between the number of extended hospitalization days and total bed costs but no correlation in the total overall costs or initial length of stay for each patient.

Deinstitutionalisation of foster care in Poland. Experiences of selected foster care organisers in the Zachodniopomorskie Voivodeship

Placing a child in foster care is a last resort and should take place after all possible forms of support and assistance have been exhausted. However, if a child is placed under the care and upbringing of foster care, it is necessary to create conditions as close as possible to those of a family. Since 2000, the Polish foster care system has been subject to the process of deinstitutionalisation. The organisers of foster care were obliged to take actions aimed at reducing the importance of the foster care system in the full childcare system, a smooth transition to a system where full community-level childcare is provided. The aim of the article is to present the foster care system and directions of changes in foster care in quantitative terms and to evaluate the organisation of foster care in the context of the process of its deinstitutionalisation. The conclusions were based on statistical data analysis on the foster care system, which constituted the background for discussions by organisers of foster care in selected poviats of the Zachodniopomorskie Voivodeship. The system of foster care in Poland is based on family foster care. Reducing the number of institutional foster care facilities is possible, but in the current system, it is only likely to partially eliminate them. The most significant identified challenge of the foster care system is the dropping number of foster families. Additionally, the deinstitutionalisation of foster care requires, above all, measures to increase the effectiveness of the support system and upbringing of the child and natural family in the local environment.

A Mixed Method Study to Explore How Maintenance Personnel Can Enhance Wildfire Smoke Resilience at Long-Term Care Facilities in the US Mountain West

Wildfire activity is increasing around the world, concurrent with climate change, and mitigation strategies for protecting vulnerable populations are desperately needed. Because inhaled particles are deleterious to respiratory health, particularly among older adults with co-morbidities, we engaged maintenance personnel working in long term care facilities located in the Western US. Our objective was to identify opportunities to build resilience during wildfire smoke events. We implemented a virtual workshop that addressed wildfire smoke health impacts as well as strategies to assess and maintain indoor air quality. A total of 24 maintenance personnel attended the virtual workshop and 14 participated in a quantitative survey. Workshop attendees found value in the material and there was enthusiasm for educational resources and enhancing indoor air quality. Four months later, four maintenance staff participated in a follow-up interview. Our qualitative assessment revealed the following themes: awareness and prioritization, application of knowledge, barriers, and educational resources. Access to real-time actionable air quality data was a consistent feature across these themes. Maintenance personnel could play a key role in a facility’s ability to prepare for and respond to wildfire smoke events, and this study highlights potential challenges and opportunities to involving them in resilience building strategies.

Vaccine-Preventable Disease Outbreaks among Healthcare Workers: A Scoping Review.

Outbreaks of vaccine preventable diseases (VPDs) in health care workers (HCWs) can result in morbidity and mortality and cause significant disruptions to health care services, patients and visitors as well as an added burden on the health system. This scoping review is aimed to describe the epidemiology of VPD outbreaks in HCW, caused by diseases which are prevented by the ten vaccines recommended by World Health Organization (WHO) for HCWs. In April 2022 CINAHL, MEDLINE, Global Health and EMBASE were searched for all articles reporting on VPD outbreaks in HCWs since the year 2000. Articles were included regardless of language and study type. Clinical and epidemiological characteristics of VPD outbreaks were described. Our search found 9363 articles, of which 216 met inclusion criteria. Studies describing six of the ten VPDs were found: influenza, measles, varicella, tuberculosis, pertussis and rubella. Most articles (93%) were from high- and upper middle-income countries. While most outbreaks occurred in hospitals, several influenza outbreaks were reported in long term care facilities. Based on available data, vaccination rates amongst HCWs were rarely reported. We describe several VPD outbreaks in HCWs from 2000 to April 2022. The review emphasises the need to understand the factors influencing outbreaks in HCWs and highlight importance of vaccination amongst HCWs.

Financial sustainability and automatic balance mechanisms for NDC pension systems with disability benefits

AbstractThe need for Long term care (LTC) service continues to rise due to the increasing number of elderly in the world, which stresses the healthcare systems. As most of the LTC recipients are over age 65, several authors studied retirement products combining a lifetime annuity with a long-term care benefit (typical examples are Enhanced Pension and Life Care Annuity). The development of an integrated strategy may help to address the issue of the cost of care for pensioners affected by disability. In this paper, we contribute to the debate on the introduction of LTC benefits into a notional defined contribution (NDC) pension system by using a multivariate stochastic model to represent the future evolution of transition probabilities and economic variables, which allows investigation of the financial sustainability of the system in a stochastic environment. The presence of LTC adds new risk elements, such as the uncertainty related to disability rates and mortality rates of the disabled, which may jeopardize the financial equilibrium of the integrated system. To restore the system’s equilibrium, we apply two types of automatic balance mechanisms (ABM), one based on the solvency ratio, and the other on the liquidity ratio. Both act on the indexation of pensions and the notional rate.

Maintaining Dignity and Autonomy in the Process of Aging

For decades, research has shown that ageism undermines older adults’ mental and physical health by implying they are less capable and worthy of care. The preservation of dignity and autonomy when confronted by a declining capacity for autonomous decision making due to physical or cognitive disability is difficult and can create personal and ethical dilemmas for providers and patients. It is projected that by 2050, 22.5% of the North American population will be over 65. In addition, statistics show that by 2060, 13.9 million Americans aged 65 and older are projected to be diagnosed with Alzheimer's disease and related dementias. The incidence for mild cognitive impairment (MCI) or mild neurocognitive disorder may be twice as high as dementia. The Universal Declaration of Human Rights adopted in 1948 states that all people are "free and equal in dignity and rights". However, this concept has not been implemented for all older adults especially those with cognitive impairment. Therefore, it is even more critical that mental health providers use their voice to educate people about the negative impact of ageism and advocate for older people in clinical settings.This workshop challenges conventional thinking about our aging population and moral concepts related to ageism, justice, and maintaining dignity and autonomy. This presentation will provide information on how to foster intergenerational solidarity that reduces ageism and benefits people of all ages. The presenters will discuss how autonomy plays a key role in this solidarity as it implies responsibilities as well as rights. In addition, a discussion of ethical theories which suggest that older adults are morally obligated to be productive with their talent and professions will be explained. Residents in long-term care are even more likely to be impacted by ageism as the prevailing belief in our culture is that life lived in independence is of more value than life lived in a facility. The workshop will discuss how providers who work in long term care can support residents and try to ensure their decisions and behaviors are as free from bias as possible. The presenters will use real life case scenarios to engage participants and facilitate learning about these issues.

Stuck in the Middle: Multidisciplinary Approaches to Managing Dysphagia in Older Patients with Severe and Persistent Mental Illness in Long Term Care Settings

The process of swallowing is a complex and intricate action that involves the coordinated movement of activation of 56 pairs of muscles and is performed unconsciously approximately 2000 times per day, all while protecting the airway [1]. Swallowing disorders are a frequently encountered yet inadequately understood aspect of Schizophrenia. This condition causes significant morbidity and mortality within the affected population, often due to acute respiratory distress resulting from airway obstruction or more gradual complications such as aspiration and pneumonia. [2].Elderly patients with a prior history of severe persistent mental illness encounter added elements that can exacerbate their condition. Such obstacles may encompass extensive utilization of psychotropic medications, behavioral changes, presbyphagia, central nervous system disorders, suboptimal oral hygiene, and living at long-term care facilities or institutional settings. Studies suggest a high prevalence of dysphagia in patients with Schizophrenia [3], with rates as high as 53% in those residing in care facilities [1].This symposium will focus on changes in eating and swallowing patterns among elderly patients with Schizophrenia. During the first presentation, we aim to provide a comprehensive overview of the prevalence of dysphagia, types of swallowing difficulties, pathophysiology, and complications associated with dysphagia. Specifically, we will explore changes that can be attributed to the disease itself, as well as those that may arise as a result of the use of psychotropic medications, particularly antipsychotic medications. A clinical case study presentation of a patient with Schizophrenia who developed oropharyngeal dysphagia and associated complications will be discussed in the second presentation. The case discussion will offer an opportunity to review early signs, behavioral and iatrogenic contributing factors and the importance of a multi-disciplinary team approach. During a presentation by a qualified speech pathologist, an in-depth discussion on the early indicators of dysphagia, screening techniques, as well as bedside and radiographic tests will be highlighted. Additionally, therapeutic considerations will be explored, providing valuable insights and recommendations. The final session will explore various management options, including both pharmacological and non-pharmacological approaches to treatment.The central aim of this presentation is to attain an in-depth understanding of the complexities inherent in these multifarious matters, with the ultimate goal of elevating patient care, enhancing quality of life, and attaining favorable outcomes that endure over the long term.

The Optimization of Pharmacological and Non-pharmacological Interventions in a Case of Parkinson's Psychosis

Mr. L is a 64 y.o. male with a history of Parkinson's disease s/p bilateral DBS who initially presented to the emergency room from an assisted living facility for altered mental status and increased combativeness with staff. Patient was found to be experiencing symptoms of Parkinson's Psychosis and had uncontrol behavioral disturbance. Psychiatry was consulted for recommendations for agitation and hallucinations. Mr. L was hospitalized for over a year due to the need for higher level of care, inability to obtain guardianship, and inability to obtain subsequent placement. The patient's medication regimen was optimized with use of multiple medications including clozapine, lorazepam, and trazodone. Though medications showed some efficacy, Mr. L continued to display symptoms of agitation requiring use of restraints and emergency medication. Non-pharmacological interventions were recommended and included a combination of specific approaches to help address his needs such as techniques for medication adherence and increasing environment and social stimulation to decrease agitation and confusion. After initiating and distributing behavioral plan to patient's team, he required less medication alterations, emergency treatment orders, and ultimately the quality of life for patient and treating care team members was improved. This case underlines the efficacy of medication initiation in combination with non-pharmacological interventions in the hospital setting to improve the quality of life of patients and staff providing long term care for patients. Data on behavioral intervention and standardization of behavioral intervention is limited and typically is utilized more often in outpatient settings. However, behavioral plans for complex patients with prolonged hospital stays may allow for less agitation, thus alleviating barriers to care and limiting patient discomfort while hospitalized without complicating patient care with adverse effects. Simultaneously, decreased use of restraints, emergency medications for agitation, and staff intervention can be useful for alleviating provider team and staff burnout.

Relationship between Family Income and Access to Primary Care of Senior Citizens in Kaytapos, Indang Cavite

The research investigates the relationship between family income and access to primary care among senior citizens in Kaytapos, Indang Cavite. A combined self-administered survey and an in-person interview was conducted to analyze the multifaceted factors shaping the accessibility of primary care for seniors. The study examined the socio-economic status, health conditions, and the extent of their access to primary healthcare services. The study mainly aimed to assess the relationship between family income and access to primary care of senior citizens in Kaytapos, Indang. This study further seeks to identify the respondents' socio-demographic profile and determine senior citizens' access to primary care in terms of awareness, accessibility, affordability, availability, acceptability, and accommodation. Based on the findings, it was revealed that senior citizens have good access and high awareness of primary care. The affordability and accessibility of related goods and services were also moderate. Additionally, primary care providers and healthcare institutions were deemed moderately accessible, very acceptable, and highly accommodating to senior patients. Moreover, the existing relationship between family income and senior citizens' access to primary care was statistically significant, yet there was a weak positive correlation. Hence, these findings could aid the government in policy-making planning to promote a more equitable and inclusive healthcare system. Overall, it was recommended that the government address the insufficient access to primary care by proposing free monthly check-ups, medicines, food, and allowances, especially for senior citizens in the lower income bracket.

Continuous Glucose Monitoring in Older Adults: What We Know and What We Have Yet to Learn.

To assess the growing use of continuous glucose monitoring (CGM) systems by older adults and explore additional areas integration that could benefit adults with frailty. The use of CGM devices has expanded rapidly in the last decade. This has been supported by substantial data showing significant benefit in glycemic metrics: hemoglobin A1c improvements, less hypoglycemia, and improved quality of life. However, sub-populations, such as older persons, exist where available data are limited. Furthermore, frail older adults represent a heterogeneous population with their own unique challenges to the management of diabetes. This group has some of the poorest outcomes related to the sequela of diabetes. For example, hypoglycemia resulting in significant morbidity and mortality is more frequent in older person with diabetes than in younger persons with diabetes. We present a concise literature review on CGM use in the older adult as well as expand upon glycemic and nonglycemic benefits of CGM for patients, caregivers, and providers. Retrospective analysis of inpatient glycemic data of 16,935 older adults with Type 2 diabetes mellitus at Atrium Health Wake Forest Baptist indicated those with fraility managed with insulin or sulfonylurea had the highest rates of delirium (4.8%), hypoglycemia (3.5%), cardiovascular complications (20.2%) and ED visits/hospitalizatoins (49%). In addition, we address special consideration of specific situations including inpatient, palliative and long term care settings. This review article summarizes the available data for CGM use in older adults, discusses the benefits and obstacles with CGM use in this population, and identifies areas of future research needed for improved delivery of care to older persons with diabetes.

Frailty and nutrition.

As the ageing population grows and forms a significant category of over 65s in many societies, along with it comes the risk of developing physical and psychological degenerative changes. This presents many challenges for health and social care services in not only identifying those at risk but also managing that risk to try to preserve health and independence for as long as possible. Screening for frailty has supported services to identify those that may be at risk of hospitalisation, requiring long term care or support services at home in older age. Frailty can be exacerbated by the risk of nutritional deficiencies and more severe malnutrition. Therefore, screening for frailty should also include a nutritional assessment, which can be supported by a recognition of the need for nutritional support along with other holistic frailty management.

Effectiveness of shared medical appointments delivered in primary care for improving health outcomes in patients with long-term conditions: a systematic review of randomised controlled trials

ObjectivesTo examine the effectiveness of shared medical appointments (SMAs) compared with one-to-one appointments in primary care for improving health outcomes and reducing demand on healthcare services by people with one...

Resource Utilization following Anterior Versus Posterior Cervical Decompression and Fusion for Acute Central Cord Syndrome.

Retrospective cohort study. The purpose of this study is to compare the impact of anterior cervical decompression and fusion (ACDF) versus posterior cervical decompression and fusion (PCDF) for the treatment of acute traumatic central cord syndrome (CCS) on hospital episodes of care in terms of (1) cost, (2) length of hospital stay, and (3) discharge destination. Acute traumatic CCS is the most common form of spinal cord injury in the United States. CCS is commonly treated with surgical decompression and fusion. Hospital resource utilization based on surgical approach remains unclear. Patients undergoing ACDF and PCDF for acute traumatic CCS were identified using the 2019 Medicare Provider Analysis and Review Limited Data Set and Centers for Medicare and Medicaid Services 2019 Impact File. Multivariate models for hospital cost of care, length of stay, and discharge destination were performed, controlling for confounders. Subanalysis of accommodation and revenue center cost drivers was performed. There were 1474 cases that met inclusion criteria: 673 ACDF (45.7%) and 801 PCDF (54.3%). ACDF was independently associated with a decreased cost of $9802 (P<0.001) and a 59.2% decreased risk of discharge to nonhome destinations (adjusted odds ratio: 0.408, P<0.001). The difference in length of stay was not statistically significant. On subanalysis of cost drivers, ACDF was associated with decreased charges ($55,736, P<0.001) compared with PCDF, the largest drivers being the intensive care unit ($15,873, 28% of total charges, P<0.001) and medical/surgical supply charges ($19,651, 35% of total charges, P<0.001). For treatment of acute traumatic CCS, ACDF was associated with almost $10,000 less expensive cost of care and a 60% decreased risk of discharge to nonhome destination compared with PCDF. The largest cost drivers appear to be ICU and medical/surgical-related. These findings may inform value-based decisions regarding the treatment of acute traumatic CCS. However, injury and patient clinical factors should always be prioritized in surgical decision-making, and increased granularity in reimbursement policies is needed to prevent financial disincentives in the treatment of patients with CCS better addressed with posterior approach-surgery.