US Nursing Homes Research Articles

Resident Mortality And Worker Infection Rates From COVID-19 Lower In Union Than Nonunion US Nursing Homes, 2020-21.

Since the start of the COVID-19 pandemic, nursing home residents have accounted for roughly one of every six COVID-19 deaths in the United States. Nursing homes have also been very dangerous places for workers, with more than one million nursing home workers testing positive for COVID-19 as of April 2022. Labor unions may play an important role in improving workplace safety, with potential benefits for both nursing home workers and residents. We examined whether unions for nursing home staff were associated with lower resident COVID-19 mortality rates and worker COVID-19 infection rates compared with rates in nonunion nursing homes, using proprietary data on nursing home-level union status from the Service Employees International Union for all forty-eight continental US states from June 8, 2020, through March 21, 2021. Using negative binomial regression and adjusting for potential confounders, we found that unions were associated with 10.8percent lower resident COVID-19 mortality rates, as well as 6.8percent lower worker COVID-19 infection rates. Substantive results were similar, although sometimes smaller and less precisely estimated, in sensitivity analyses.

Remote Infection Control Assessments of US Nursing Homes During the COVID-19 Pandemic, April to June 2020.

BackgroundNursing homes (NHs) provide care in a congregate setting for residents at high risk of severe outcomes from SARS-CoV-2 infection. In spring 2020, NHs were implementing new guidance to minimize SARS-CoV-2 spread among residents and staff.ObjectiveTo assess whether telephone and video-based infection control assessment and response (TeleICAR) strategies could efficiently assess NH preparedness and help resolve gaps.DesignWe incorporated Centers for Disease Control and Prevention COVID-19 guidance for NH into an assessment tool covering 6 domains: visitor restrictions; health care personnel COVID-19 training; resident education, monitoring, screening, and cohorting; personal protective equipment supply; core infection prevention and control (IPC); and communication to public health. We performed TeleICAR consultations on behalf of health departments. Adherence to each element was documented and recommendations provided to the facility.Setting and ParticipantsHealth department–referred NHs that agreed to TeleICAR consultation.MethodsWe assessed overall numbers and proportions of NH that had not implemented each infection control element (gap) and proportion of NH that reported making ≥1 change in practice following the assessment.ResultsDuring April 13 to June 12, 2020, we completed TeleICAR consultations in 629 NHs across 19 states. Overall, 524 (83%) had ≥1 implementation gap identified; the median number of gaps was 2 (interquartile range: 1-4). The domains with the greatest number of facilities with gaps were core IPC practices (428/625; 68%) and COVID-19 education, monitoring, screening, and cohorting of residents (291/620; 47%).Conclusions and ImplicationsTeleICAR was an alternative to onsite infection control assessments that enabled public health to efficiently reach NHs across the United States early in the COVID-19 pandemic. Assessments identified widespread gaps in core IPC practices that put residents and staff at risk of infection. TeleICAR is an important strategy that leverages infection control expertise and can be useful in future efforts to improve NH IPC.

Variability of Anti-Seizure Medication Concentrations in Older Adult Nursing Home Residents

Approximately 10% of nursing home (NH) residents are taking an anti-seizure medication (ASM), and 7.8% have an epilepsy/seizure indication. In one recent study, levetiracetam (LEV) and phenytoin (PHT) were the most commonly prescribed ASMs in US NH residents. There are major differences in pharmacokinetics (PK) among ASMs. PHT has complicated PK and its absorption is pH-dependent, and LEV is very water-soluble with few drug interactions. The side effect profiles also differ, with PHT being associated with ataxia and LEV with behavioral problems.

The Benefits of Culture Change in Nursing Homes-Obtaining Nationally Representative Evidence.

Despite face validity and regulatory support, empirical evidence of the benefit of culture change practices in nursing homes (NHs) has been inconclusive. We used rigorous methods and large resident-level cohorts to determine whether NH increases in culture change practice adoption in the domains of environment, staff empowerment, and resident-centered care are associated with improved resident-level quality outcomes. We linked national panel 2009-2011 and 2016-2017 survey data to Minimum Data Set assessment data to test the impact of increases in each of the culture change domains on resident quality outcomes. The sample included 1584 nationally representative US NHs that responded to both surveys, and more than 188,000 long-stay residents cared for in the pre- and/or postsurvey periods. We used multivariable logistic regression with robust standard errors and a difference-in-differences methodology. Controlling for the endogeneity between increases in culture change adoption and NH characteristics that are also related to quality outcomes, we tested whether pre-post quality outcome differences (ie, improvements in outcomes) were greater for residents in NHs with culture change increases vs in those without such increases. NH performance on most quality indicators improved, but improvement was not significantly different by whether NHs increased or did not increase their culture change domain practices. This study found that increases in an NH's culture change domain practices were not significantly associated with improved resident-level quality. It describes a number of potential limitations that may have contributed to the null findings.

Development of MDS-Based Predication Model for COPD Severity in Nursing Home Residents.

Assessing chronic obstructive pulmonary disease (COPD) severity is challenging in nursing home (NH) residents due to incomplete symptom assessments and exacerbation history. The objective of this study was to predict COPD severity in NH residents using the Minimum Data Set (MDS), a clinical assessment of functional capabilities and health needs. A cohort analysis of prospectively collected longitudinal data was conducted. Residents from geographically varied Medicare-certified NHs with age ≥60 years, COPD diagnosis, and ≥6 months NH residence at enrollment were included. Residents with severe cognitive impairment were excluded. Demographic characteristics, medical history, and MDS variables were extracted from medical records. The care provider-completed COPD Assessment Test (CAT) and COPD exacerbation history were used to categorize residents by Global Initiative for Chronic Lung Disease (GOLD) A to D groups. Multivariate multinomial logit models mapped the MDS to GOLD A to D groups with stepwise selection of variables. Nursing home residents (N = 175) were 64% women and had a mean age of 77.9 years. Among residents, GOLD B was most common (A = 13.1%; B = 44.0%; C = 5.7%; D = 37.1%). Any long-acting bronchodilator (LABD) use and any dyspnea were significant predictors of GOLD A to D groups. The predicted MDS-GOLD group (A = 6.9%; B = 52.6%; C = 4.6%; D = 36.0%) showed good model fit (correctly predicted = 60.6%). Nursing home residents may underuse group-recommended LABD treatment (no LABD: B = 53.2%; C = 80.0%; D = 40.0%). The MDS, completed routinely for US NH residents, could potentially be used to estimate COPD severity. Predicted COPD severity with additional validation could provide a map to evidence-based treatment guidelines and may help to individualize treatment pathways for NH residents.

Higher Star, Better Performance in US Nursing Homes during the Covid-19 Pandemic ?

The Covid-19 pandemic has brought terrible difficulties to nursing homes, as they were locations with the highest number of confirmed Covid-19 cases and deaths in the US. The Centers for Medicare & Medicaid Services (CMS) applies the Five-Star Quality Ratings to indicate the quality of care in nursing homes based on health inspection survey, staffing, and resident outcome. Studies to date have contradictory findings regarding the relationship between nursing home reported Quality Ratings and Covid-19 cases and deaths based on US regional data. The purpose of this study is to examine whether nursing homes’ Quality Ratings were related to the total number of resident Covid-19 cases and deaths at the US National level. The study examined US nursing homes (N=13,494) linked with CMS Nursing Home Compare data and Covid-19 Nursing Home data. Using multiple linear regression analyses, results showed nursing home Quality Ratings were significantly associated with Covid-19 residents’ cases and deaths controlling for ownership type, size, occupation rate, and years of operation (p<.001; p<.001). Five-star nursing homes were less likely to have Covid-19 cases and deaths. Further, comparing lower Star Ratings nursing homes, 1-Star nursing homes showed no significant difference to 2-Star and 3-Star nursing homes when examining Covid-19 cases and deaths. Overall, the Five-Star Quality Ratings is a useful measure when investigating nursing homes’ performance during the Covid-19 pandemic. Future policymakers and administrators should also focus on nursing homes with lower star ratings when improving the quality of nursing homes, particularly with regard to resident health.

Impact of Neighborhood Socioeconomic Disadvantage on Staffing Hours in US Nursing Homes

Considering the limited evidence regarding the factors that contribute to long-term consequences after hospitalization of older people, we analysed the relationship between cognitive performance and hospital-associated complications (HAC). One thousand, three hundred Individuals aged 60 and older (mean age 82.3, 53.3% female), not assigned to palliative care and admitted in medical and surgical wards from a private hospital, were followed up from admission to 30 days after discharge. HAS was evaluated using a multicomponent measure that combines 12 hospital-associated complications (delirium, functional decline, falls, pressure injuries, bronchoaspiration, non-planned ICU transfer, physical restraints, hospital stay > 30 days, death, long-term care transfer, and readmission). Cognitive performance was assessed using the "10-point cognitive screener (10-CS)", which combines temporal orientation, category fluency, and word recall evaluation.ResultsOverall, 464 (35.7%) participants had one or more HAC during their admission. Patients with HAC showed lower 10-CS scores than those with in HAC (p <0.001). Adjusting for sociodemographic data, medication, chronic diseases, delirium screening, functional performance, each 10-CS point decreased the HAC changes by 19.2% (odds ratio = 0.808; 95% CI = 0.660 – 0.990).ConclusionThese findings show that low cognitive performance was significantly associated with the risk of developing HAC during hospitalization and within 30 days after discharge. That evidence forms the critical foundation for the next steps towards validating the accuracy of these models in predicting vulnerability to HAC and developing screening tools to be used at the point of care.

Impact of Neighborhood Socioeconomic Disadvantage on Staffing Hours in US Nursing Homes

Exergames and digital health games have shown promising outcomes in older adults. Most games have had one focus (e.g., physical activity, cognitive functioning). We developed a demonstration version of a multi-focus educational exergame (i.e., healthy eating, physical activity, cognition) that builds on healthy aging theory. Community-engaged and mixed methods (e.g., surveys, focus groups) research approaches were used to examine preliminary game acceptability and usability. The game was demonstrated with 20 senior center members (95% female; 48% African American; 52% White; average age 64 years) and participants were able to play the game. The post-gameplay survey results support acceptability/usability of the game. For example, 87% of participants “agreed” or “strongly agreed” that they felt comfortable playing; the game instructions were clear; the text was readable; and gameplay was enjoyable. The majority also “agreed”/“strongly agreed” that the audio was appealing/helpful in playing the game (86%); sound quality was appropriate (78%); hand tracking was precise (57%), feedback on correct/incorrect responses was motivating (73%); they felt excited to get the correct answers (80%); they would play the game again (87%); and they would recommend it to a friend/family member (80%). When asked how often they would play it, the responses were: 33% five or more times/week; 27% three-four times/week; 20% one-two times/week; and 20% never. Observations and focus groups further clarified acceptability and identified areas for improvement (e.g., game instructions). Preliminary results support acceptability of this multi-component educational exergame with older adults and suggest the potential for future tailoring of this game.

The Importance of Redefining Geriatric Expertise in Nursing Homes to Reduce Unnecessary Hospitalizations

The lecture will be given by the 2020 recipient, Sara Czaja, PhD, FGSA of Weill Cornell Medicine. The 2020 M. Powell Lawton Award recipient is David Roth, Phd, FGSA, of Johns Hopkins University. The M. Powell Lawton Award is presented annually to an individual who has made outstanding contributions from applied research that has benefited older people and their care. The Lawton Award is generously funded by the Polisher Research Institute of the Madlyn and Leonard Abramson Center for Jewish Life.

Trends in Post-Acute Care in US Nursing Homes: 2001-2017.

To describe recent trends in post-acute care provision within nursing homes, focusing specifically on nursing homes' degree of specialization in post-acute care. Retrospective cohort study. All US nursing homes between 2001 and 2017 and all fee-for-service Medicare admissions to nursing homes for post-acute care during that time. We measured post-acute care specialization as annual Medicare admissions per bed for each nursing home and examined changes in the distribution of specialization across nursing homes over the study period. We described the characteristics of nursing homes and the patients they serve based on degree of specialization. The average number of Medicare admissions per bed increased from 1.2 in 2001 to 1.6 in 2017, a relative increase of 41%. This upward trend in the number of Medicare admissions per bed was largest among new nursing homes (those established after 2001), increasing 68% from 2001 to 2017. In contrast, nursing homes that eventually closed during the study period experienced no meaningful growth in the number of admissions per bed. Over time, the number of Medicare admissions per bed increased among highly specialized nursing homes. The number of Medicare admissions per bed grew by 66% at the 95th percentile and by 25% at the 99th percentile. Nursing homes delivering the most post-acute care were more likely to be for-profit or part of a chain, had higher staffing levels, and were less likely to admit patients who were Black, Hispanic, or dually enrolled in Medicare and Medicaid. Over the last 2decades, post-acute care has become increasingly concentrated in a subset of nursing homes, which tend to be for-profit, part of a chain, and less likely to serve racial and ethnic minorities and persons on Medicaid. Although these nursing homes may benefit financially from higher Medicare payment, it may come at the expense of equitable access and patient care.

Association of Private Equity Investment in US Nursing Homes With the Quality and Cost of Care for Long-Stay Residents

Private equity firms have been acquiring US nursing homes; an estimated 5% of US nursing homes are owned by private equity firms. To examine the association of private equity acquisition of nursing homes with the quality and cost of care for long-stay residents. In this cohort study of 302 private equity nursing homes with 9632 residents and 9562 other for-profit homes with 249 771 residents, a novel national database of private equity nursing home acquisitions was merged with Medicare claims and Minimum Data Set assessments for the period from 2012 to 2018. Changes in outcomes for residents in private equity-acquired nursing homes were compared with changes for residents in other for-profit nursing homes. Analyses were performed from March 25 to June 23, 2021. Private equity acquisitions of 302 nursing homes between 2013 and 2017. This study used difference-in-differences analysis to examine the association of private equity acquisition of nursing homes with outcomes. Primary outcomes were quarterly measures of emergency department visits and hospitalizations for ambulatory care-sensitive (ACS) conditions and total quarterly Medicare costs. Antipsychotic use, pressure ulcers, and severe pain were examined in secondary analyses. Of the 259 403 residents in the study (170 687 women [65.8%]; 211 154 White residents [81.4%]; 204 928 residents [79.0%] dually eligible for Medicare and Medicaid; mean [SD] age, 79.3 [5.6] years), 9632 residents were in 302 private equity-acquired nursing homes and 249 771 residents were in 9562 other for-profit homes. The mean quarterly rate of ACS emergency department visits was 14.1% (336 072 of 2 383 491), and the mean quarterly rate of ACS hospitalizations was 17.3% (412 344 of 2 383 491); mean (SD) total quarterly costs were $8050.00 ($9.90). Residents of private equity nursing homes experienced relative increases in ACS emergency department visits of 11.1% (1.7 of 15.3; 1.7 percentage points; 95% CI, 0.3-3.0 percentage points; P = .02) and in ACS hospitalizations of 8.7% (1.0 of 11.5; 1.0 percentage point; 95% CI, 0.2-1.1 percentage points; P = .003) compared with residents in other for-profit homes; quarterly costs increased 3.9% (270.37 of 6972.04; $270.37; 95% CI, $41.53-$499.20; P = .02) or $1081 annually per resident. Private equity acquisition was not significantly associated with antipsychotic use (-0.2 percentage points; 95% CI, -1.7 to 1.4 percentage points; P = .83), severe pain (0.2 percentage points; 95% CI, -1.1 to 1.4 percentage points; P = .79), or pressure ulcers (0.5 percentage points; 95% CI, -0.4 to 1.3 percentage points; P = .30). This cohort study with difference-in-differences analysis found that private equity acquisition of nursing homes was associated with increases in ACS emergency department visits and hospitalizations and higher Medicare costs.

Risk Factors for COVID-19 Deaths Among Elderly Nursing Home Medicare Beneficiaries in the Prevaccine Period.

We evaluated prevaccine pandemic period COVID-19 death risk factors among nursing home (NH) residents. In a retrospective cohort study covering Medicare fee-for-service beneficiaries aged ≥65 years residing in US NHs, we estimated adjusted hazard ratios (HRs) using multivariate Cox proportional hazards regressions. Among 608251 elderly NH residents, 57398 (9.4%) died of COVID-19-related illness 1 April to 22 December 2020; 46.9% (26893) of these deaths occurred without prior COVID-19 hospitalizations. We observed a consistently increasing age trend for COVID-19 deaths. Racial/ethnic minorities shared similarly high risk of NH COVID-19 deaths with whites. NH facility characteristics for-profit ownership and low health inspection ratings were associated with higher death risk. Resident characteristics (male [HR, 1.69], end-stage renal disease [HR, 1.42], cognitive impairment [HR, 1.34], and immunocompromised status [HR, 1.20]) were death risk factors. Other individual-level characteristics were less predictive of death than in community-dwelling population. Low NH health inspection ratings and private ownership contributed to COVID-19 death risks. Nearly half of NH COVID-19 deaths occurred without prior COVID-19 hospitalization and older residents were less likely to get hospitalized with COVID-19. No substantial differences were observed by race/ethnicity and socioeconomic status for NH COVID-19 deaths.

Staffing and Protective Equipment Access Mitigated COVID-19 Penetration and Spread in US Nursing Homes During the Third Surge.

ObjectivesDuring the last quarter of 2020—despite improved distribution of personal protective equipment (PPE) and knowledge of COVID-19 management—nursing homes experienced the greatest increases in cases and deaths since the pandemic's beginning. We sought to update COVID-19 estimates of cases, hospitalization, and mortality and to evaluate the association of potentially modifiable facility-level infection control factors on odds and magnitude of COVID-19 cases, hospitalizations, and deaths in nursing homes during the third surge of the pandemic.DesignCross-sectional analysis.Setting and ParticipantsFacility-level data from 13,156 US nursing home facilities.MethodsTwo series of multivariable logistic regression and generalized linear models to examine the association of infection control factors (personal protective equipment and staffing) on incidence and magnitude, respectively, of confirmed COVID-19 cases, hospitalizations, and deaths in nursing home residents reported in the last quarter of 2020.ResultsNursing homes experienced steep increases in COVID-19 cases, hospitalizations, and deaths during the final quarter of 2020. Four-fifths (80.51%; n = 10,592) of facilities reported at least 1 COVID-19 case, 49.44% (n = 6504) reported at least 1 hospitalization, and 49.76% (n = 6546) reported at least 1 death during this third surge. N95 mask shortages were associated with increased odds of at least 1 COVID-19 case [odds ratio (OR) 1.21, 95% confidence interval (CI) 1.05-1.40] and hospitalization (1.26, 95% CI 1.13-1.40), as well as larger numbers of hospitalizations (1.11, 95% CI 1.02-1.20). Nursing aide shortages were associated with lower odds of at least 1 COVID-19 death (1.23, 95% CI 1.12-1.34) and higher hospitalizations (1.09, 95% CI 1.01-1.17). The number of nursing hours per resident per day was largely insignificant across all outcomes. Of note, smaller (<50-bed) and midsized (50- to 150-bed) facilities had lower odds yet higher magnitude of all COVID outcomes. Bed occupancy rates >75% increased odds of experiencing a COVID-19 case (1.48, 95% CI 1.35-1.62) or death (1.25, 95% CI 1.17-1.34).Conclusions and ImplicationsAdequate staffing and PPE—along with reduced occupancy and smaller facilities—mitigate incidence and magnitude of COVID-19 cases and sequelae. Addressing shortcomings in these factors is critical to the prevention of infections and adverse health consequences of a next surge among vulnerable nursing home residents.

Life expectancy in nursing homes

ABSTRACT It is well known that life expectancy in nursing homes (NHs) is lower for older adults than those residing elsewhere. In this paper, we attempt to discover the exact extent of this loss of life expectancy, and whether it can be explained by pre-existing health state conditions, especially the seriousness of dementia. We use a parametric survival model, on a large data set spanning up to 13 years, which covers health states and types of residence for all time periods until a person dies. In the absence of health state controls, the loss of life expectancy is 47 months. Accounting for health states still leads to a 41-month loss of life. Even those with serious dementia would live longer lives if not residing in a NH. We then value the estimated loss of life years. The losses are large, equal to $1.7 million per NH resident, and $1.87 trillion for the US NH population.

Trends in COVID‐19 Cases, Related Deaths, and Staffing Shortage in Nursing Homes By Rural and Urban Status

Research ObjectiveInitial efforts to understand the impact of COVID‐19 on nursing home (NHs) staffing levels indicated considerable increases in staffing shortages occurred during the first few months of the COVID‐19 pandemic. In response, this study built upon initial staffing reports by examining the long‐term consequence of the pandemic on staffing shortages in US NHs by rural/urban status using the most recently compiled NH COVID‐19 data (May 2020–February 2021). The specific aim of this study was to examine trends in COVID‐19 cases, related deaths, and staffing shortages in NHs by rural and urban status and over time.Study DesignThis cross‐sectional time‐series study compiled four data sources, including: the NH COVID‐19 files and provider information files from Centers for Medicare and Medicaid Services, the Area Health Resource Files from Health Resources and Services Administration, and the New York Times county‐level COVID‐19 data. We plotted the proportion of NHs with at least one COVID‐19 case, one related death, and four types of staff shortages (aides, licensed nurses, medical providers, and other staff) by rural/urban status from 5/25/20 to 2/28/21 to visualize the weekly trends over time. Then, weekly data were combined into four periods with 10 weeks of the aggregated data in each period. Our main analyses estimated the likelihood of having at least one case of COVID‐19 infection, related death, or at least one week of staffing shortage in rural NHs compared to urban NHs over four time periods using generalized linear mixed models with state‐fixed effects.Population StudiedWe identified a total 59,515 aggregated cases combined from all four periods, involving 15,139 unique NHs that submitted at least one‐week report during the study period.Principal FindingsFindings suggest that staffing shortage trends varied by both time and location. Rural areas experienced an increasing proportion of NHs with staffing shortages until mid‐November, 2020, and then a gradual decrease afterwards, corresponding with trends in COVID‐19 cases. Conversely, the proportion of NHs reporting staffing shortages in urban areas was relatively stable over time. The interaction effect between period and rural/urban status in adjusted models revealed a significantly higher likelihood of having at least one COVID‐19 case, related death, and shortages in aides, licensed nurses, and other staff in rural NHs in later periods than in the earlier one, compared to changes in urban NHs over time. The proportion of NHs with medical provider shortage was about 10% which was lower than other types of staff shortages and unchanged during the study period in both rural and urban NHs.ConclusionsOur findings suggest that direct care provider staffing shortages in rural NHs were greatly accelerated over time with a surge in COVID‐19 cases.Implications for Policy or PracticeThe COVID‐19 pandemic may have significantly strained rural NHs that are already burdened with healthcare human resource infrastructural deficits. Findings highlight the needs to develop effective strategies that maximize rural NH workforce crisis resilience, including enhanced recruitment and retention incentives, and targeted resource allocation to prepare for short‐ and long‐term consequences of natural disasters such as COVID‐19 pandemic.

Adverse Events Following One Dose of mRNA COVID-19 Vaccination Among US Nursing Home Residents With and Without a Previous SARS-CoV-2 Infection

ObjectivesTo compare rates of adverse events following Coronavirus Disease 2019 (COVID-19) vaccination among nursing home residents with and without previous severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. DesignProspective cohort. Setting and ParticipantsA total of 20,918 nursing home residents who received the first dose of messenger RNA COVID-19 vaccine from December 18, 2020, through February 14, 2021, in 284 facilities within Genesis Healthcare, a large nursing home provider spanning 24 US states. MethodsWe screened the electronic health record for adverse events, classified by the Brighton Collaboration, occurring within 15 days of a resident’s first COVID-19 vaccine dose. All events were confirmed by physician chart review. To obtain risk ratios, multilevel logistic regression model that accounted for clustering (variability) across nursing homes was implemented. To balance the probability of prior SARS-CoV-2 infection (previous positive test or diagnosis by the International Classification of Diseases, 10th Revision, Clinical Modification) more than 20 days before vaccination, we used inverse probability weighting. To adjust for multiplicity of adverse events tested, we used a false discovery rate procedure. ResultsStatistically significant differences existed between those without (n = 13,163) and with previous SARS-CoV-2 infection [symptomatic (n = 5617) and asymptomatic (n = 2138)] for all baseline characteristics assessed. Only 1 adverse event was reported among those with previous SARS-CoV-2 infection (asymptomatic), venous thromboembolism [46.8 per 100,000 residents 95% confidence interval (CI) 8.3–264.5], which was not significantly different from the rate reported for those without previous infection (30.4 per 100,000 95% CI 11.8–78.1). Several other adverse events were observed for those with no previous infection, but were not statistically significantly higher than those reported with previous infection after adjustments for multiple comparisons. Conclusions and ImplicationsAlthough reactogenicity increases with preexisting immunity, we did not find that vaccination among those with previous SARS-CoV-2 infection resulted in higher rates of adverse events than those without previous infection. This study stresses the importance of monitoring novel vaccines for adverse events in this vulnerable population.

Financial and Work-flow Benefits of Reducing Avoidable Hospitalizations of Nursing Home Residents

Objectives1) Explain the financial benefit of potential revenue recapture (PRR) for non-billable days due to hospitalizations of nursing home (NH) residents using a six-year longitudinal analysis of 11 of 16 NHs participating in the Missouri Quality Initiative (MOQI); and 2) Discuss the work-flow benefits of early detection of changes in health status using qualitative data from all MOQI homes.DesignA CMS funded demonstration project with full-time advanced practice registered nurses (APRN) and operations support team focused on reducing avoidable hospitalizations for long stay NH residents (2012–2020).Setting and ParticipantsSetting was a sample of 11 of 16 US NHs participating in the CMS project. The NHs ranged in size between 121 and 321 beds located in urban and rural areas in one midwestern geographic region.MethodsFinancial and occupancy data were analyzed using descriptive methods. Data are readily available from most NH financial systems and include information about short and long stay residents to calculate non-billable days due to hospitalizations. Average hospital transfer rates per 1000 resident days were used. Qualitative data collected in MOQI informed the work-flow benefits analysis.ResultsThere was over $2.6 million in actual revenue recapture due to hospitalization of long stay residents in the 11 participating NHs during five years, 2015–2019, with 2014 as baseline; savings to payers was more than $31 million during those same years. The PRR for both short and long stay residents combined totaled $32.5 million for six years (2014–2019); for each NH this ranged from $590,000 to over $5 million. On average, an additional $500,000 of revenue each year per 200 beds could have been recaptured by further reducing hospitalizations. Workflow improved for nurses and nursing assistants using INTERACT and focusing on early detection of health changes.ConclusionsReducing avoidable hospitalizations reduces costs to payers and increases revenue by substantially recapturing revenue lost each day of hospitalization.ImplicationsFocusing nursing staff on early illness recognition and management of condition changes within NHs has benefits for residents as the stress of hospital transfer and resulting functional decline is avoided. Nurses and nursing assistants benefit from workflow improvements by focusing on early illness detection, managing most condition changes within NHs. NHs benefit financially from increased revenue by reducing empty bed days.

Most US Nursing Homes Had Multiple, Sustained COVID-19 Outbreaks, GAO Reports.

The majority of US nursing homes experienced 2 or more outbreaks of COVID-19 from May 2020 through January 2021, and many such outbreaks had weeks of sustained transmission, according to a report from the federal government’s Government Accountability Office (GAO).

Antimicrobial Use in a Cohort of US Nursing Homes, 2017

Controlling antimicrobial resistance in health care is a public health priority, although data describing antimicrobial use in US nursing homes are limited. To measure the prevalence of antimicrobial use and describe antimicrobial classes and common indications among nursing home residents. Cross-sectional, 1-day point-prevalence surveys of antimicrobial use performed between April 2017 and October 2017, last survey date October 31, 2017, and including 15 276 residents present on the survey date in 161 randomly selected nursing homes from selected counties of 10 Emerging Infections Program (EIP) states. EIP staff reviewed nursing home records to collect data on characteristics of residents and antimicrobials administered at the time of the survey. Nursing home characteristics were obtained from nursing home staff and the Nursing Home Compare website. Residence in one of the participating nursing homes at the time of the survey. Prevalence of antimicrobial use per 100 residents, defined as the number of residents receiving antimicrobial drugs at the time of the survey divided by the total number of surveyed residents. Multivariable logistic regression modeling of antimicrobial use and percentages of drugs within various classifications. Among 15 276 nursing home residents included in the study (mean [SD] age, 77.6 [13.7] years; 9475 [62%] women), complete prevalence data were available for 96.8%. The overall antimicrobial use prevalence was 8.2 per 100 residents (95% CI, 7.8-8.8). Antimicrobial use was more prevalent in residents admitted to the nursing home within 30 days before the survey date (18.8 per 100 residents; 95% CI, 17.4-20.3), with central venous catheters (62.8 per 100 residents; 95% CI, 56.9-68.3) or with indwelling urinary catheters (19.1 per 100 residents; 95% CI, 16.4-22.0). Antimicrobials were most often used to treat active infections (77% [95% CI, 74.8%-79.2%]) and primarily for urinary tract infections (28.1% [95% CI, 15.5%-30.7%]). While 18.2% (95% CI, 16.1%-20.1%) were for medical prophylaxis, most often use was for the urinary tract (40.8% [95% CI, 34.8%-47.1%]). Fluoroquinolones were the most common antimicrobial class (12.9% [95% CI, 11.3%-14.8%]), and 33.1% (95% CI, 30.7%-35.6%) of antimicrobials used were broad-spectrum antibiotics. In this cross-sectional survey of a cohort of US nursing homes in 2017, prevalence of antimicrobial use was 8.2 per 100 residents. This study provides information on the patterns of antimicrobial use among these nursing home residents.

Risk Factors Associated With SARS-CoV-2 Infections, Hospitalization, and Mortality Among US Nursing Home Residents

Nursing home residents account for approximately 40% of deaths from SARS-CoV-2. To identify risk factors for SARS-CoV-2 incidence, hospitalization, and mortality among nursing home residents in the US. This retrospective longitudinal cohort study was conducted in long-stay residents aged 65 years or older with fee-for-service Medicare residing in 15 038 US nursing homes from April 1, 2020, to September 30, 2020. Data were analyzed from November 22, 2020, to February 10, 2021. The main outcome was risk of diagnosis with SARS-CoV-2 (per International Statistical Classification of Diseases, Tenth Revision, Clinical Modification [ICD-10-CM] codes) by September 30 and hospitalization or death within 30 days after diagnosis. Three-level (resident, facility, and county) logistic regression models and competing risk models conditioned on nursing home facility were used to determine association of patient characteristics with outcomes. Among 482 323 long-stay residents included, the mean (SD) age was 82.7 (9.2) years, with 326 861 (67.8%) women, and 383 838 residents (79.6%) identifying as White. Among 137 119 residents (28.4%) diagnosed with SARS-CoV-2 during follow up, 29 204 residents (21.3%) were hospitalized, and 26 384 residents (19.2%) died within 30 days. Nursing homes explained 37.2% of the variation in risk of infection, while county explained 23.4%. Risk of infection increased with increasing body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) (eg, BMI>45 vs BMI 18.5-25: adjusted hazard ratio [aHR], 1.19; 95% CI, 1.15-1.24) but varied little by other resident characteristics. Risk of hospitalization after SARS-CoV-2 increased with increasing BMI (eg, BMI>45 vs BMI 18.5-25: aHR, 1.40; 95% CI, 1.28-1.52); male sex (aHR, 1.32; 95% CI, 1.29-1.35); Black (aHR, 1.28; 95% CI, 1.24-1.32), Hispanic (aHR, 1.20; 95% CI, 1.15-1.26), or Asian (aHR, 1.46; 95% CI, 1.36-1.57) race/ethnicity; impaired functional status (eg, severely impaired vs not impaired: aHR, 1.15; 95% CI, 1.10-1.22); and increasing comorbidities, such as renal disease (aHR, 1.21; 95% CI, 1.18-1.24) and diabetes (aHR, 1.16; 95% CI, 1.13-1.18). Risk of mortality increased with age (eg, age >90 years vs 65-70 years: aHR, 2.55; 95% CI, 2.44-2.67), impaired cognition (eg, severely impaired vs not impaired: aHR, 1.79; 95% CI, 1.71-1.86), and functional impairment (eg, severely impaired vs not impaired: aHR, 1.94; 1.83-2.05). These findings suggest that among long-stay nursing home residents, risk of SARS-CoV-2 infection was associated with county and facility of residence, while risk of hospitalization and death after SARS-CoV-2 infection was associated with facility and individual resident characteristics. For many resident characteristics, there were substantial differences in risk of hospitalization vs mortality. This may represent resident preferences, triaging decisions, or inadequate recognition of risk of death.