Veterans Affairs Community Living Centers Research Articles

Implementing Montessori approaches after training: A mixed methods study to examine staff understanding and movement toward action.

Background: This paper uses Normalization Process Theory (NPT) to examine staff impressions of Montessori-based program training and implementation at Veterans Affairs Community Living Centers (VA CLCs; nursing homes). Methods: We conducted a mixed-methods evaluation of Montessori Approaches to Person-Centered Care (MAP-VA) at eight VA CLCs. Trainings were conducted as either a live virtual course or a pre-recorded asynchronous class. Two NPT constructs, coherence building and cognitive participation, informed qualitative interview questions, surveys, and analyses focused on staff movement from knowledge to action during initial implementation. Data collection included staff-completed standardized post-training exams (N = 906), post-training evaluations (N = 761), and optional validated surveys on perceptions of Montessori training (N = 307). Champions (peer-leaders) from each CLC completed semi-structured qualitative interviews post-training (N = 22). Findings: The majority of staff (83%-90%) passed all courses. Staff evaluated the training highly (80%+ agreement) on learning relevant new knowledge and confidence applying new skills. On average, staff felt MAP-VA would become a normal part of their work (7.68/10 scale), and reported increased familiarity with Montessori approaches after training (p = .002). Qualitative interview data from staff trained in Montessori supported three themes concordant with the NPT dimensions of coherence building and cognitive participation. (1) Coherence regarding Montessori: staff demonstrated an understanding of the program and mentioned the benefits of Montessori compared to their previous usual routines. Cognitive participation or engagement with Montessori: (2) staff had positive feelings about Montessori principles/applications and demonstrated a willingness to try the Montessori approach, and (3) staff made sense of the new intervention through early rehearsal of Montessori principles/practices and recognized opportunities for using Montessori in future interactions. Conclusions: Montessori virtual training resulted in high levels of coherence and cognitive participation among multidisciplinary staff, evidenced by high knowledge, self-efficacy, and readiness to act. The asynchronous and synchronous trainings were accessible, relevant, and supported diverse learners.

Equity and Inclusion for LGBTQ+ Residents: Lessons Learned from the Initial Long-Term Care Equality Index (LEI)

ObjectivesMost older adults with lesbian, gay, bisexual, queer, questioning, transgender, and related identities (LGBTQ+) are concerned about receiving lower-quality care and/or being mistreated in nursing homes. Older LGBTQ+ veterans may have additional reservations about care in Department of Veterans Affairs (VA) nursing homes (Community Living Centers [CLCs]) because of experience with past discriminatory military policies (eg, bans on participating in military service, Don't Ask Don't Tell). This article describes one of the first VA CLCs to participate in the Human Rights Campaign–developed Long-Term Care Equality Index (LEI). DesignA single-site formative evaluation was completed to support quality improvement and identify opportunities for growth using the LEI. The LEI is a facility benchmarking tool to support more inclusive environments for LGBTQ+ residents and employees. The LEI offers 4 evaluation criteria: (1) Non-Discrimination and Staff Training; (2) LGBTQ+ Resident Services and Support; (3) Employee Benefits and Policies; and (4) Resident and Community Engagement. Facilities receive ratings based on the number of requirements achieved in each category. Participants and Methods: Older LGBTQ+ veterans, current CLC residents, interdisciplinary CLC providers and leadership, and national Geriatrics and Extended Care program managers collaborated to pilot the LEI and develop tools and materials to support other VA facilities' participation in the LEI. ResultsQualitative interviews with veterans and CLC residents supported inclusion of gender identity and sexual orientation in resident handbooks, discussions about person-centered care, and opportunities for additional staff training and community engagement (eg, observing Pride Month in June). Resources to support VA long-term care facilities' participation in the LEI were developed. Conclusions and ImplicationsThe LEI offers a structured approach to identifying areas for improvement in providing high-quality and equitable care in long-term care settings. Practical suggestions for CLCs and other nursing home settings considering the LEI for the first time are discussed.

Changes in Physical Function and Physical Therapy Use in Older Veterans Not Infected by CoVID-19 Residing in Community Living Centers during the CoVID-19 Pandemic

ObjectivesExamine physical function change and physical therapy (PT) use in short-stay and long-stay residents not infected by CoVID-19 within Veterans Affairs (VA) Community Living Centers (CLCs). DesignRetrospective cohort study using Minimum Data Set (MDS) 3.0 assessments. Settings and Participants12,606 Veterans in 133 VA CLCs between September 2019 and September 2020. MethodsDifference in physical function [MDS Activities of Daily Living Score (MDS-ADL)] and PT use (minutes in past 7 days) from admission to last assessment in a period were compared between the pre-CoVID-19 (September 2019 to February 2020) and early CoVID-19 (April 2020 to September 2020) period using mixed effects regression with multivariable adjustment. Assessments after a positive CoVID-19 test were excluded. Differences were examined in the sample and repeated after stratifying into short- and long-stay stratums. ResultsVeterans admitted during early CoVID-19 had more comorbidities, worse MDS-ADL scores, and were more often long-stay residents compared with those admitted during pre-CoVID-19. In comparison to pre-CoVID-19, Veterans in VA CLCs during early CoVID-19 experienced greater improvements in their MDS-ADL (−0.49 points, 95% CI –0.27, −0.71) and received similar minutes of therapy (2.6 minutes, 95% CI –0.8, 6.0). Stratification revealed short-stay residents had relative improvements in their function (−0.69 points, 95% CI –0.44, −0.94) and higher minutes of PT (5.1 minutes, 95% CI 0.9, 9.2) during early CoVID-19 whereas long-stay residents did not see differences in functional change (0.08 points, 95% CI –0.36, 0.51) or PT use (−0.6 minutes, 95% CI –6.1, 4.9). Conclusions and ImplicationsDuring early CoVID-19, physical function improved while the amount of PT received was maintained compared with pre-CoVID-19 for Veterans in VA CLCs. Short-stay residents experienced greater improvements in physical function and increases in PT use. These findings may be partly due to selection bias relating to Veterans admitted to CLCs during early CoVID-19.

Wandering Behavior and SARS-CoV-2 Infection in Veterans Affairs Community Living Center Residents

ObjectiveWandering behavior in nursing home (NH) residents could increase risk of infection. The objective of this study was to assess the association of wandering behavior with SARS-CoV-2 infection in Veterans Affairs (VA) Community Living Center (CLC) residents. DesignRetrospective cohort study. Setting & ParticipantsVeterans residing in 133 VA CLCs. MethodsWe included residents with SARS-CoV-2 test from March 1, 2020 to December 31, 2020 from VA electronic medical records. We identified CLC residents with wandering on Minimum Data Set 3.0 assessments and compared them with residents without wandering. The outcome was SARS-CoV-2 infection, as tested for surveillance testing, in those with and without wandering. Generalized linear model with Poisson link adjusted for relevant covariates was used. ResultsResidents (n = 9995) were included in the analytic cohort mean, (SD) age 73.4 (10.7); 388 (3.9%) women. The mean (SD) activities of daily living score in the overall cohort was 13.6 (8.25). Wandering was noted in 379 (3.8%) (n = 379) of the cohort. The exposure groups differed in prior dementia (92.6% vs 62.1%, standardized mean difference [SMD] = 0.8) and psychoses (41.4% vs 28.1%, SMD = 0.3). Overall, 12.5% (n = 1248) tested positive for SARS-CoV-2 and more residents among the wandering group were SARS-CoV-2 positive as compared with those in the group without wandering (19% [n = 72] vs 12.2% [n = 1176], SMD = 0.19). Adjusting for covariates, residents with wandering had 34% higher relative risk for SARS-CoV-2 infection (adjusted relative risk, 1.34; 95% CI, 1.04–1.69). Conclusions and ImplicationsCLC residents with wandering had a higher risk of SARS-CoV-2 infection. This may inform implementation of infection control and isolation policies as NHs attempt to balance ethical concepts of resident autonomy, proportionality, equity, and utilitarianism.

Transmission of Severe Acute Respiratory Syndrome Coronavirus 2 Among Residents and Employees in a Veterans Affairs Community Living Center: A 42-Month Prospective Cohort Study.

Understanding routes of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission in long-term care facilities is essential for the development of effective control measures. Between March 1, 2020, and August 31, 2023, we identified coronavirus disease 2019 (COVID-19) cases among residents and employees in a Veterans Affairs community living center that conducted routine screening for asymptomatic COVID-19. Contact tracing was conducted to identify suspected transmission events, and whole genome sequencing was performed to determine the relatedness of SARS-CoV-2 samples. During the 42-month study period, 269 cases of COVID-19 were diagnosed, including 199 employees and 70 residents. A total of 48 (24.1%) employees and 30 (42.9%) residents were asymptomatic. Sequencing analysis provided support for multiple events in which employees transmitted SARS-CoV-2 to co-workers and residents. There was 1 episode of likely transmission of SARS-CoV-2 from one resident to another resident, but no documented transmissions from residents to employees. Transmission of SARS-CoV-2 in the community living center predominantly involved transmission from employees to co-workers and residents. There is a need for improved measures to prevent transmission of SARS-CoV-2 by healthcare personnel.

Fall-related Injuries and Opioid Administration Among Veterans With Dementia in US Department of Veterans Affairs Community Living Centers.

Opioid use is associated with fall-related injuries (FRI) among older adults, especially those with dementia. We examined FRI following changes in national opioid safety initiatives over 3 regulatory periods [preinitiatives baseline (period 1): October 2012 to June 2013; post-Veteran Affairs (VA) opioid safety initiative (period 2): January 2014 to November 2015; post-VA and CDC opioid prescribing guidelines (period 3): March 2017 to September 2018] among Department of VA Community Living Center (CLC) long-stay residents with dementia. VA provided and purchased care records, Medicare claims, CLC Minimum Data Set (MDS) assessments. VA bar-code medication administration data, VA outpatient prescription refill data, and Medicare Part D data were used to capture medication from inpatient, outpatient, and Medicare sources. A total of 12,229 long-stay CLC residents with dementia between October 2012 and September 2018. We applied Veteran-regulatory period level (1) generalized linear model to examine the unadjusted and adjusted trends of FRI, and (2) difference-in-difference model with propensity score weighting to examine the relationship between opioid safety initiatives and FRI in 3 regulatory periods. We applied propensity score weighting to enable the cohorts in periods 2 and 3 had similar indications for opioid administration as in period 1. FRI prevalence per month among CLC residents with Alzheimer disease and related dementias decreased from 3.1% in period 1 to 1.6% and 1.2% in periods 2 and 3, and the adjusted probability of FRI was 17% and 40% lower in periods 2 and 3 compared with period 1. The any, incident, and continued opioid administration were significantly associated with higher FRI, whereas the differences in FRI probabilities between opioid and nonopioid users had no significant changes over the 3 regulatory periods. FRI was reduced among CLC residents with Alzheimer disease and related dementias receiving care in VA CLCs over the 3 regulatory periods, but the FRI reduction was not significantly associated with opioid safety initiatives. Other interventions that potentially targeted falls are likely to have helped reduce these fall events. Future studies could examine whether opioid use reduction ultimately benefitted nursing home residents by focusing on other possible outcomes or whether such reduction only resulted in more untreated pain.

Trends in Risk-Adjusted Initiation and Reduction of Opioid Use among Veterans With Dementia in US Department of Veterans Affairs Community Living Centers.

Proper initiation and reduction of opioids is important in providing effective and safe pain relief to Veterans with dementia, including in Community Living Centers (CLCs). We examined the trends in aggregated monthly risk-adjusted opioid administration days and dosage over 3 opioid safety regulatory periods: pre-Opioid Safety Initiative period (October 1, 2012-June 30, 2013; period 1), pre-CDC Clinical Practice Guideline period (January 1, 2014-November 30, 2015, period 2) and post-Veterans Affairs Clinical Practice Guideline period (March 1, 2017-September 30, 2018; period 3). A retrospective study between October 1, 2012, and September 30,2018. 4995 long-stay CLC residents with dementia who had incident (incident cohort, n= 2609) or continued (continued opioid cohort, n= 2386) opioid administration in CLCs. CLC Minimum Data Set (MDS) assessments data and bar-code medication administration data were used. Opioid initiation was examined for incident opioid cohort and reduction was examined using continued opioid cohort. We first computed aggregated monthly risk-adjusted opioid administration days, opioid with benzodiazepine administration days and opioid dosage, and then examined risk-adjusted incident and continued opioid administration trends over the regulatory periods controlling for facility-level characteristics. Among the incident opioid cohort, compared to period 1, there were 1.9 and 2.1 fewer risk-adjusted opioid administration days per month in periods 2 and 3, respectively; 1.5 fewer risk-adjusted days per month with opioid and benzodiazepine administration in both periods 2 and 3; and 2.2 and 3.7 morphine milligrams equivalent per day (MMED) lower risk-adjusted dosage in periods 2 and 3, respectively. Among the continued opioid cohort, compared to period 1, there were 1.6 and 2.9 fewer risk-adjusted days with opioid and benzodiazepine administration days per month in periods 2 and 3, respectively, and 5.3 MMED lower risk-adjusted dosage per month in period3. CLC providers initiated and reduced opioid administration in fewer days and at lower dosage among Veterans with dementia across the regulatory periods. The result was likely due to systemic efforts from health care professionals, CLC administrators, and policy makers or VA central office, aiming to reduce opioid misuse and improve quality of care in nursing home residents with dementia. What is still unknown is whether pain was well controlled or nonpharmacologic treatments were utilized.

Containment of COVID-19 outbreak at a veterans affairs community living center.

Asymptomatic and pre-symptomatic staff and residents likely contribute to widespread transmission of COVID-19 in long-term care settings. Here, we describe the successful containment of a COVID-19 outbreak on one floor of a 163-bed Veterans Affairs (VA) Community Living Center (CLC). Testing using nasopharyngeal swabs with a rapid turn-around-time identified 3 of 28 (11%) residents and 2 of 41 (5%) healthcare personnel (HCP) with COVID-19. Both HCP likely worked on the floor while pre-symptomatic. When one HCP reported a cough to the secondary (employee) screening clinic, she was erroneously advised to work. Protocols to limit the risk for HCP to import COVID-19 were reinforced with Community Living Center staff as well as with personnel in secondary screening. Further, the CLC implemented an expanded screening tool that assessed residents for typical and atypical symptoms of COVID-19. No further cases of COVID-19 were detected on the CLC floor in the subsequent 6 weeks. Swift recognition and response helped contain the outbreak and prevent further COVID-19 infections among other residents and staff.

Neither Race nor Ethnicity Impact the Mortality of Residents of Veterans Affairs Community Living Center With COVID-19.

COVID-19 disproportionately affected nursing home residents and people from racial and ethnic minorities in the United States. Nursing homes in the Veterans Affairs (VA) system, termed Community Living Centers (CLCs), belong to a national managed care system. In the period prior to the availability of vaccines, we examined whether residents from racial and ethnic minorities experienced disparities in COVID-19 related mortality. Retrospective cohort study. Residents at 134 VA CLCs from April 14 to December 10,2020. We used the VA Corporate Data Warehouse to identify VA CLC residents with a positive SARS-CoV-2 polymerase chain reaction test during or 2days prior to their admission and without a prior case of COVID-19. We assessed age, self-reported race/ethnicity, frailty, chronic medical conditions, Charlson comorbidity index, the annual quarter of the infection, and all-cause 30-day mortality. We estimated odds ratios and 95% confidence intervals of all-cause 30-day mortality using a mixed-effects multivariable logistic regression model. During the study period, 1133 CLC residents had an index positive SARS-CoV-2 test. Mortality at 30days was 23% for White non-Hispanic residents, 15% for Black non-Hispanic residents, 10% for Hispanic residents, and 16% for other residents. Factors associated with increased 30-day mortality were age ≥70years, Charlson comorbidity index ≥6, and a positive SARS-CoV-2 test between April 14 and June 30, 2020. Frailty, Black race, and Hispanic ethnicity were not independently associated with an increased risk of 30-day mortality. Among a national cohort of VA CLC residents with COVID-19, neither Black race nor Hispanic ethnicity had a negative impact on survival. Further research is needed to determine factors within the VA health care system that mitigate the influence of systemic racism on COVID-19 outcomes in US nursing homes.

Dementia prevalence, a contextual factor associated with SARS-CoV-2 in veterans affairs community living centers.

BackgroundAlzheimer's disease and related dementias (ADRD) impact the diagnosis and infection control of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS‐CoV‐2) in nursing homes (NH) by influencing the behavior of residents and their caregivers. Health system data show an association between ADRD and SARS‐CoV‐2. Whether this association is present in NH populations remains unknown. How increased SARS‐CoV‐2 risk among residents with ADRD impacts the greater NH population also remains unknown.MethodsThis retrospective cohort study used electronic health record data on Veterans residing in 133 Veterans Affairs Community Living Centers (CLC) and 15 spinal cord injury units from March 1, 2020 to December 13, 2020. We measured ADRD using diagnostic codes 12 months before an index SARS‐CoV‐2 test date for each resident. We used Poisson regression to determine the relative risk of SARS‐CoV‐2 for the highest quartile of facility ADRD prevalence versus the lowest, stratifying by individual ADRD status, and adjusting for covariates, with and without a random intercept to account for facility clustering.ResultsAcross the study period, 15,043 residents resided in CLCs, 1952 (13.0%) had SARS‐CoV‐2, and 8067 (53.6%) had ADRD. There was an estimated 60% increased risk of SARS‐CoV‐2 in facilities with highest dementia prevalence versus lowest (relative risk, 1.6 [95% confidence interval 0.95, 2.7]).ConclusionsCLC residents had a greater likelihood of SARS‐CoV‐2 infection in facilities with greater ADRD prevalence. Facility characteristics other than ADRD prevalence may account for this association.

Absence of racial and ethnic disparities in COVID-19 survival among residents of US Veterans’ Affairs community living centers

Background: COVID-19 has had a disproportionate effect on nursing homes residents as well as people from racial and ethnic minorities. Whether differences in mortality due to COVID-19 exists for nursing-home residents from racial and ethnic minorities is less clear, with some previous studies reporting systems-level disparities. The Department of Veterans’ Affairs (VA) has nursing homes, termed community living centers (CLCs), across the United States. We hypothesized that differences in COVID-19–related mortality among racial and ethnic minorities would be less pronounced among residents of CLCs. Methods: Using data from the VA Corporate Data Warehouse, we conducted a retrospective cohort study from April 14, 2020 (implementation of population-based testing) to December 10, 2020 (availability of a COVID-19 vaccine). Inclusion criteria were residents with a positive SARS-CoV-2 test while residing in or <48 hours before admission to a CLC. Positive tests <180 days after a prior positive test were excluded. We assessed the cohort for demographics, including self-reported race or ethnicity, clinical characteristics, and survival probability including all-cause 30-day mortality. A multivariable logistic regression model was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for all-cause 30-day mortality that included race, ethnicity, age, and Charlson comorbidity index (CCI). Results: Among 14,759 CLC residents, 651 (4.4%) had a positive SARS-COV-2 test. Their mean age was 75.7 ± 11.3 years, and self-reported race or ethnicity was 68% White (445 of 651), 23% Black (152 of 651), and 4% Hispanic/Latinx (27 of 651). The mean CCI was lower among White residents than Black residents (4.15 ± 2.6 vs 4.61 ± 3.1, respectively). All-cause 30-day mortality for CLC residents following positive SARS-COV-2 test was 25% for White patients, 14% for Black patients, and 15% for Hispanic/Latinx patients (Fig. 1). Age (in years), but neither race or ethnicity nor CCI, was independently associated with all-cause 30-day mortality (OR, 1.07; 95% CI, 1.05–1.09) in CLC residents with COVID-19. Conclusions: Among VA CLC residents with a positive COVID-19 test, minority CLC residents did not have worse outcomes than white residents, suggesting that users of the VA healthcare system may enjoy abrogation of some aspects of health disparities.Funding: NoneDisclosures: None

Quality Improvement Efforts in VA Community Living Centers Increased Following Public Reporting of Performance

In 2018, the US Department of Veterans Affairs (VA) began publicly reporting performance ratings for its 134 Community Living Centers (CLCs; nursing homes) based on health inspections, staffing, and clinical quality measures. CLCs operate within a large, integrated healthcare system with unique financial and market incentives. Although public reporting has led to quality improvements in non-VA nursing homes, we do not know whether CLCs respond to public reporting differently than private sector nursing homes. To address this knowledge gap, we used a comparative case study approach involving 3 purposively selected CLCs with varied (low, medium, high) performance ratings. We conducted semi-structured interviews with personnel (n=12) responsible for quality measurement and improvement. Interviews focused on opinions of public reporting, actions taken to improve performance ratings, and motivations for change. Participants indicated public reporting improved transparency and provided an “outside perspective” on their performance. Strategies to improve performance ratings involved 1) data/information, 2) individual roles, and 3) teamwork/communication. All 3 CLCs made changes in these areas, yet respondents in the higher performing CLCs described implementing more strategies immediately after learning their ratings. Respondents in all 3 CLCs described being motivated to deliver good care and achieve public ratings that reflected the care they provided. This meant addressing internal weaknesses that contributed to lower scores for 2 CLCs. Our findings suggest public reporting may improve internal data collection, reporting, and quality improvement efforts in CLCs. They highlight the potential positive impact of public reporting in prompting quality improvement in nursing homes.

Impact of fever thresholds in detection of COVID-19 in Department of Veterans Affairs Community Living Center residents.

BackgroundAmong nursing home residents, for whom age and frailty can blunt febrile responses to illness, the temperature used to define fever can influence the clinical recognition of COVID‐19 symptoms. To assess the potential for differences in the definition of fever to characterize nursing home residents with COVID‐19 infections as symptomatic, pre‐symptomatic, or asymptomatic, we conducted a retrospective study on a national cohort of Department of Veterans Affairs (VA) Community Living Center (CLC) residents tested for SARS‐CoV‐2.MethodsResidents with positive SARS‐CoV‐2 tests were classified as asymptomatic if they did not experience any symptoms, and as symptomatic or pre‐symptomatic if the experienced a fever (>100.4°F) before or following a positive SARS‐CoV‐2 test, respectively. All‐cause 30‐day mortality was assessed as was the influence of a lower temperature threshold (>99.0°F) on classification of residents with positive SARS‐CoV‐2 tests.ResultsFrom March 2020 through November 2020, VA CLCs tested 11,908 residents for SARS‐CoV‐2 using RT‐PCR, with a positivity of rate of 13% (1557). Among residents with positive tests and using >100.4°F, 321 (21%) were symptomatic, 425 (27%) were pre‐symptomatic, and 811 (52%) were asymptomatic. All‐cause 30‐day mortality among residents with symptomatic and pre‐symptomatic COVID‐19 infections was 24% and 26%, respectively, while those with an asymptomatic infection had mortality rates similar to residents with negative SAR‐CoV‐2 tests (10% and 5%, respectively). Using >99.0°F would have increased the number of residents categorized as symptomatic at the time of testing from 321 to 773.ConclusionsAll‐cause 30‐day mortality was similar among VA CLC residents with symptomatic or pre‐symptomatic COVID‐19 infection, and lower than rates reported in non‐VA nursing homes. A lower temperature threshold would increase the number of residents recognized as having symptomatic infection, potentially leading to earlier detection and more rapid implementation of therapeutic interventions and infection prevention and control measures.

De-implementing and sustaining an intervention to eliminate nursing home resident bed and chair alarms: interviews on leadership and staff perspectives

BackgroundImproving nursing home quality of care relies partly on reducing or stopping ineffective or harmful practices, a process known as de-implementation. We know little about de-implementation in this setting. Relatively recent policy changes reclassified resident position-change (bed and chair) alarms, which monitor resident movement, as restraints. This created an optimal environment in which to study impressions of an alarm de-implementation and sustainment intervention.MethodsThis cross-sectional interview study focused on understanding participants’ experience of a quality improvement program in the Department of Veterans Affairs Community Living Centers (nursing homes). The program’s goal was to improve resident outcomes and staff communication and teamwork through, among other foci, eliminating resident position-change alarms. The Community Living Centers were located in geographically dispersed areas of the continental United States. Interview participants were leadership and staff members from seven Community Living Centers. We conducted in-depth, semi-structured qualitative interviews using a convenience sample and used a thematic analytic approach.ResultsWe conducted seventeen interviews. We identified five main themes: Initiating De-implementation (compelling participants with evidence, engaging local leadership, and site-level education and training), Changing Expectations (educating staff and family members), Using Contrasting Approaches (gradual or abrupt elimination of alarms), Witnessing Positive Effects of De-implementation (reduction in resident falls, improved resident sleep, reduction in distressing behaviors, and increased resident engagement), and Staying the Course (sustainment of the initiative).ConclusionsFindings highlight how participants overcame barriers and successfully eliminated resident position-change alarms and sustained the de-implementation through using convincing evidence for the initiative, local leadership involvement and support, and staff and family member education and engagement. These findings and the resulting three-phase process to support nursing homes' de-implementation efforts expand the de-implementation science knowledge base and provide a promising framework for other nursing home-based de-implementation initiatives.

Introduction of the BNT162b2 vaccine during a COVID-19 nursing home outbreak

BackgroundCoronavirus disease 2019 (COVID-19) outbreaks often occur in nursing homes and prompt frequent surveillance testing for SARS-CoV-2. A single dose of the BNT162b2 vaccine reduces viral load and transmission. In this study, we describe the real-world efficacy of BNT162b2 single-dose vaccination during a COVID-19 outbreak at a Veterans Affairs Community Living Center (CLC). MethodsFrom 12/2/20 to 5/14/21, twice weekly antigen testing was used to detect COVID-19 among 146 residents at the CLC. Residents without a prior history of COVID-19 who agreed to immunization were vaccinated with the BNT162b2 vaccine on 12/16/20 and 1/6/21. Single-dose vaccine efficacy was determined for days 1-21 and days 14-21 after the first vaccine dose. ResultsThe outbreak occurred from 12/2/20 to 1/7/21 with an attack rate of 30.8% (45/146); 46.7% (21/45) of the cases were due to asymptomatic COVID-19. One unit accounted for 77.8% (35/45) of the cases. In the vaccine analysis, 116 residents were a median age of 74.5 years and 93.1% (108/116) had ≥ 1 comorbid condition. Between the first and second dose, 15.5% (15/97) of vaccinated residents, and 21.2% (4/19) of unvaccinated residents developed COVID-19 (P = .81). One week after the second dose, no cases of COVID-19 occurred. ConclusionsAlbeit limited by the small numbers, a single dose of the BNT162b2 vaccine was not efficacious at preventing COVID-19 during this nursing home outbreak.

Proportion of SARS-CoV-2 positive tests and vaccination in Veterans Affairs Community Living Centers.

Background/ObjectivesCOVID‐19 has caused significant morbidity and mortality in nursing homes. Vaccination against SARS‐COV‐2 holds promise for reduction in COVID‐19. This operational analysis describes the proportion of SARS‐COV‐2 positive tests before, during, and after vaccination.DesignRetrospective longitudinal cohort analysis from October 1, 2020 until February 14, 2021.SettingA total of 130 Department of Veterans Affairs (VA) Community Living Centers (CLC), analogous to nursing homes.InterventionVaccination for SARS‐CoV‐2.MeasurementsThe primary measure is the proportion of SARS‐CoV‐2 positive tests among CLC residents. In a pooled analysis of weekly testing and vaccine data, the proportion of positive tests was compared for the unvaccinated, first dose, and second dose. For each CLC, we identified the week in which 50% of CLC residents were vaccinated (index week). The analysis aligned the index week for CLCs and examined the proportion of SARS‐CoV‐2 positive tests at the CLC level before and after. As a reference, we plotted the proportion of positive tests in nursing homes in the same county as the CLC using publicly reported data.ResultsWithin the pooled VA CLCs, the first SARS‐CoV‐2 vaccine dose was delivered to 50% of CLC residents within 1 week of availability and second dose within 5 weeks. Relative to the index week, the risk ratio of SARS‐CoV‐2 positive tests in the vaccinated relative to unvaccinated was significantly lower in Week 4 (relative risk 0.37, 95% confidence interval 0.20–0.68). Throughout the study period, the proportion of SARS‐CoV‐2 positive tests in community nursing homes was higher compared to VA CLC and also declined after vaccine availability.ConclusionThe proportion of SARS‐CoV‐2 positive tests significantly declined in VA CLCs 4 weeks after vaccine delivery and continued to decline in vaccinated and unvaccinated residents. The results describe the importance of SARS‐CoV‐2 surveillance and vaccination in VA nursing home residents.

Impact of Pharmacy-Directed Medication Management for Patients Experiencing Falls in a Veterans Affairs Community Living Center.

OBJECTIVE: To analyze medication interventions prior to and following implementation of the Pharmacy Medication Related Falls Risk Assessment consult service in an older adult population. DESIGN: Retrospective chart review. SETTING: This study involved patients admitted to the Cincinnati Veterans Affairs Medical Center's (VAMC) Community Living Center (CLC), an institutional practice setting. PATIENTS, PARTICIPANTS: Any patient who experienced a fall while admitted to the CLC during fiscal years 2013 or 2018 was considered for inclusion. Patients were excluded if falls were not evaluated by a provider, the patient expired within 10 days after falling, or falls in fiscal year 2018 that did not have a pharmacy consult placed. Fifty falls from each fiscal year were selected. MAIN OUTCOME MEASURES: The primary endpoint encompassed the number of pharmacy medication interventions made within 10 days postfall, with a secondary endpoint evaluating subsequent falls within 30 days of initial event. RESULTS: Following consult implementation, a larger number of pharmacist recommendations (40 vs. 123) and subsequent interventions (accepted recommendations) within ten days postfall (12 vs. 49) were completed. There were 14 subsequent falls within 30 days of the initial event for both fiscal years. A larger percentage of falls and patients experiencing falls from each fiscal year did not receive previous medication interventions. CONCLUSION: Consult implementation increased the number of pharmacist recommendations and subsequent interventions for patients within ten days postfall, reducing the risk of adverse effects, drug-drug interactions, subsequent falls, and polypharmacy.

A Multidisciplinary Process to Improve Quality Indicators in a Veterans Affairs Community Living Center

Quality Indicators (QIs) are an important part of Long-Term Care Quality improvement initiatives and 1 of 3 domains of the overall star rating developed by Centers for Medicare/Medicaid (CMS). At the Corporal Michael J Cresencz Veterans Affairs Community Living Center (CLC), a 120-bed Long-Term Care institution in Philadelphia, PA, we were scored a 1-star facility on CMS standardized quality indicators. The administrative and clinical teams felt we were better than this and undertook an initiative to study and hopefully improve the indicators.

Improving End-of-Life Care using the Life Sustaining Treatment Decision Initiative in a Veterans Affairs Community Living Center

In 2018, the Department of Veterans Affairs (VA) implemented the Life Sustaining Treatment Decisions Initiative (LSTDI), a national, multi-pronged program to support clinicians in conducting Goals of Care Conversations (GoCC) with seriously ill Veterans and documenting them using a standardized note and orders template. Addressing GoCC is a crucial part of comprehensive care in LTC facilities and thus Veterans residing in VA nursing homes (Community Living Centers, CLCs) are appropriate recipients of this initiative. However, due to the challenges of addressing the many complex medical and psychosocial needs of veterans in CLCs, even the minimum task of completing the LSTDI note can be challenging.

QUALITY IMPROVEMENT IN LTC: EFFECTIVENESS OF MONTESSORI-BASED ACTIVITY PROGRAMMING IN VA COMMUNITY LIVING CENTER

Montessori-based Activity Programming (MAP) was adapted for Veterans Affairs (VA) Community Living Centers (CLCs) and aims to increase independence and meaningful engagement in residents with cognitive impairment. The Montessori model prioritizes offering choice, knowing and harnessing a resident’s abilities, and enabling them to carry out purposeful roles and activities. Any perceived deficit in cognitive functioning is “circumvented” by preparing the environment to support maximum independence. The implementation of MAP-VA in VA Western NY CLC involved 3 lodges, 52 staff, 16 champions, and 65 CLC residents. Standardized implementation measures demonstrated improvements over six months in five domains assessing development of a resident-directed community. Hypothesized outcomes included improved national percentile quality improvement (QI) rankings related to psychological symptoms and medications (e.g., depressive symptoms and use of antipsychotic/antianxiety medications) and physical functioning (e.g., less falls and ability to move independently). Scores six months prior to the implementation of MAP-VA (April, 2018 to September, 2018) were compared with scores during six months of implementation post training (November, 2018 to March, 2019). Compared to pre-intervention QI measures related to psychological symptoms, a clinically meaningful trajectory of symptom decrease was observed with rankings during implementation (e.g., depressive symptoms, amount of antipsychotic medications). Likewise, compared to pre-intervention QI rankings regarding physical functioning, post-training rankings showed a trajectory of improvement (e.g., help with ADLs, ability to move independently). Implementation of the MAP-VA intervention demonstrates preliminary evidence for improvement in QI measures related to psychological symptoms and physical functioning. Implications for QI efforts in VA CLCs will be presented.