Do Patients Retain their Family Physicians after Long-Term Care Entry? A Retrospective Cohort Study

ObjectiveOlder adults value and benefit from the long-standing relationship they have with their family physicians. This dynamic has not been researched in a long-term care (LTC, ie, nursing home) setting. We sought to determine the proportion of LTC residents who retain their community family physician within the first 180 days of LTC, and the resident, physician, and LTC home factors that may influence retention.DesignPopulation-based retrospective cohort study.Setting and ParticipantsIndividuals from Ontario, Canada, aged 60 years or older who were newly admitted to a LTC home between April 1, 2014 and March 31, 2017.MethodsResidents were indexed upon LTC admission, and their data was linked across ICES databases. Residents were matched to their rostered family physician, and physician retention was defined as having at least 1 visit by their matched physician within 0 to 90 days and 90 to 180 days of LTC admission.ResultsOut of 50,089 LTC residents, 12.1% retained their family physicians post-LTC admission. Resident factors associated with reduced odds of retention included physical impairment [odds ratio OR (95% confidence interval, CI) = 0.59 (0.42‒0.83)], cognitive impairment [0.39 (0.33‒0.47)], and a dementia diagnosis [0.80 (0.74‒0.86)]. Physician factors associated with lower retention included a greater distance from the LTC home to the family physician's clinic [30+ kilometers 0.41 (0.35‒0.48)], having a physician who is female [0.90 (0.83‒0.98)], an international medical graduate [0.89 (0.81‒0.97)] or someone who practices in a capitation-based Family Health Organization [0.86 (0.78‒0.95)]. Factors associated with greater odds of retention were residing in a rural LTC home [2.23 (1.78‒2.79)], having a rural family physician [1.70 (1.52‒1.90)], or a family physician who has billed LTC fee codes in the past year [2.64 (2.45‒2.85)].Conclusions and ImplicationsFew LTC residents retained their family physician post-LTC admission, underscoring this healthcare transition as a breakdown point in relational continuity. Factors that influenced retention included resident health, LTC home geography, and family physician demographics and practice patterns.     

Building Long-Term Care Staff Capacity During COVID-19 Through Just-in-Time Learning: Evaluation of a Modified ECHO Model

ObjectivesThe onset of the COVID-19 pandemic significantly challenged the capacity of long-term care (LTC) homes in Canada, resulting in new, pressing priorities for leaders and health care providers (HCPs) in the care and safety of LTC residents. This study aimed to determine whether Project ECHO (Extension for Community Healthcare Outcomes) Care of the Elderly Long-Term Care (COE-LTC): COVID-19, a virtual education program, was effective at delivering just-in-time learning and best practices to support LTC teams and residents during the pandemic.DesignMixed methods evaluation.Setting and ParticipantsInterprofessional HCPs working in LTC homes or deployed to work in LTC homes primarily in Ontario, Canada, who participated in 12 weekly, 60-minute sessions.MethodsQuantitative and qualitative surveys assessing reach, satisfaction, self-efficacy, practice change, impact on resident care, and knowledge sharing.ResultsOf the 252 registrants for ECHO COE-LTC: COVID-19, 160 (63.4%) attended at least 1 weekly session. Nurses and nurse practitioners represented the largest proportion of HCPs (43.8%). Overall, both confidence and comfort level working with residents who were at risk, confirmed, or suspected of having COVID-19 increased after participating in the ECHO sessions (effect sizes ≥ 0.7, Wilcoxon signed rank P < .001). Participants also reported impact on intent to change behavior, resident care, and knowledge sharing.Conclusions and ImplicationsThe results demonstrate that ECHO COE-LTC: COVID 19 effectively delivered time-sensitive information and best practices to support LTC teams and residents. It may be a critical platform during this pandemic and in future crises to deliver just-in-time learning during periods of constantly changing information.     

Recent health care transitions and emergency department use by chronic long term care residents: a population-based cohort study

ObjectivesLong term care (LTC) residents commonly experience transitions between health care settings that can have important health consequences. The objective of this study was to quantify the effect of recent transitions on the risk of emergency department (ED) transfer among chronic LTC residents. Two types of transitions were considered: admission into LTC and discharge from hospital.DesignRetrospective cohort study using linked administrative data from Ontario, Canada.ParticipantsAll chronic LTC residents in Ontario older than 66 years on the date of the 2005 provincial LTC facility census.MeasurementsUsing facility census date as baseline, admission to LTC was defined as the number of days between LTC admission and baseline. Residents were categorized as one of: newly admitted (≤30 days), shorter-stay (31–90 days), or longer-stay (≥91 days). Within each group, residents were further subdivided based on having had a recent discharge from hospital. The first ED visit for each resident during the 6-month follow-up was counted, as were death and other competing risks. The cumulative incidence of ED transfer for each group was estimated and logistic regression was used to test whether differences between groups persisted after controlling for resident characteristics.ResultsOf the 64,589 residents, 3.0% were newly admitted, 4.9% were shorter-stay, and 92.1% were longer-stay. The 6-month cumulative incidences of ED transfers were 35.0% for newly admitted, 30.7% for shorter-stay, and 22.0% for longer-stay. The odds of an ED transfer were higher for newly admitted and shorter-stay residents relative to longer-stay residents, even after adjustment for resident characteristics (adjusted odds ratio, 95% confidence interval 1.9, 1.7–2.1; and 1.5, 1.4–1.7, respectively). Regardless of time since LTC admission, residents with a recent discharge from hospital had a cumulative incidence of nearly 40% and an increase in the odds of ED transfer of at least 50% compared with those who had not been in hospital.ConclusionsHealth care transitions, especially those from hospital, are associated with an increase in ED transfers among older chronic LTC residents. These findings highlight the need for a stronger focus on transitional care, especially posthospital care, for LTC residents.     

Factors Associated With Pain Assessment for Nursing Home Residents: A Systematic Review and Meta-Synthesis

ObjectivesThe burden of pain in nursing home residents is substantial; unfortunately, many times it goes undiagnosed and is inadequately treated. To improve identification of pain in this population, we aimed to review and synthesize findings from qualitative studies that report primary barriers and facilitators to pain assessment in nursing home residents.DesignThis is a Cochrane-style systematic review and narrative synthesis of qualitative evidence adhering to PRISMA guidelines. Databases were searched from inception to June 2018, supplemented by hand searching of references. We assessed the quality of included studies using the Critical Appraisal Skills Program Quality Appraisal Checklist.Setting and participantsWe included studies conducted in nursing homes. Studies focused on nursing home residents, nursing home staff, or both.MeasuresExtracted data were subject to thematic analyses and were collated and summarized into 3 groups: resident, health care provider, and health care system factors.ResultsThirty-one studies met our inclusion criteria. Resident factors had 3 subthemes: physical or cognitive impairments, attitudes and beliefs, and social/cultural/demographic characteristics. Health care provider factors had 3 subthemes: knowledge and skills, attitudes and beliefs, and social/cultural/demographic characteristics. Health care system-level factors had 3 subthemes: interpersonal factors, resources, and policy. Key barriers to pain assessment included the presence of resident cognitive impairment, health care providers' lack of knowledge, and the breakdown of communication across organizational hierarchies. Key facilitators to pain assessment included the identification of pain-related behaviors in residents, the experience and skills of health care providers, and establishing facility-level pain assessment protocols and guidelines.Conclusion and implicationsFindings from this review identify primary barriers and facilitators to pain assessment in nursing home residents, highlighting key considerations for stakeholders, including health care providers, and health care policy decision makers. These efforts have the potential to improve the identification of pain in residents, and may ultimately improve pain management and residents' quality of life.     

Front-line Nursing Home Staff Experiences During the COVID-19 Pandemic

ObjectiveThe Coronavirus disease 2019 (COVID-19) pandemic is an unprecedented challenge for nursing homes, where staff have faced rapidly evolving circumstances to care for a vulnerable resident population. Our objective was to document the experiences of these front-line health care professionals during the pandemic.DesignElectronic survey of long-term care staff. This report summarizes qualitative data from open-ended questions for the subset of respondents working in nursing homes.Setting and ParticipantsA total of 152 nursing home staff from 32 states, including direct-care staff and administrators.MethodsFrom May 11 through June 4, 2020, we used social media and professional networks to disseminate an electronic survey with closed- and open-ended questions to a convenience sample of long-term care staff. Four investigators identified themes from qualitative responses for staff working in nursing homes.ResultsRespondents described ongoing constraints on testing and continued reliance on crisis standards for extended use and reuse of personal protective equipment. Administrators discussed the burden of tracking and implementing sometimes confusing or contradictory guidance from numerous agencies. Direct-care staff expressed fears of infecting themselves and their families, and expressed sincere empathy and concern for their residents. They described experiencing burnout due to increased workloads, staffing shortages, and the emotional burden of caring for residents facing significant isolation, illness, and death. Respondents cited the presence or lack of organizational communication and teamwork as important factors influencing their ability to work under challenging circumstances. They also described the demoralizing impact of negative media coverage of nursing homes, contrasting this with the heroic public recognition given to hospital staff.Conclusions and ImplicationsNursing home staff described working under complex and stressful circumstances during the COVID-19 pandemic. These challenges have added significant burden to an already strained and vulnerable workforce and are likely to contribute to increased burnout, turnover, and staff shortages in the long term.     

Hospice in the Nursing Home: Perspectives of Front Line Nursing Home Staff

ObjectiveUse of hospice has been associated with improved outcomes for nursing home residents and attitudes of nursing home staff toward hospice influences hospice referral. The objective of this study is to describe attitudes of certified nursing assistants (CNAs), nurses, and social workers toward hospice care in nursing homes.Design, setting, and participantsWe conducted a survey of 1859 staff from 52 Indiana nursing homes.MeasurementsStudy data include responses to 6 scaled questions and 3 open-ended qualitative prompts. In addition, respondents who cared for a resident on hospice in the nursing home were asked how often hospice: (1) makes their job easier; (2) is responsive when a patient has symptoms or is actively dying; (3) makes care coordination smooth; (4) is needed; (5) taught them something; and (6) is appreciated by patients/families. Responses were dichotomized as always/often or sometimes/never.ResultsA total of 1229 surveys met criteria for inclusion. Of the respondents, 48% were CNAs, 49% were nurses, and 3% were social workers; 83% reported caring for a nursing home patient on hospice. The statement with the highest proportion of always/often rating was ‘patient/family appreciate added care’ (84%); the lowest was ‘hospice makes my job easier’ (54%). More social workers responded favorably regarding hospice responsiveness and coordination of care compared with CNAs (P = .03 and P = .05, respectively).ConclusionsA majority of staff responded favorably regarding hospice care in nursing homes. About one-third of nursing home staff rated coordination of care lower than other aspects, and many qualitative comments highlighted examples of when hospice was not responsive to patient needs, representing important opportunities for improvement.     

Reimagining Nutrition Care and Mealtimes in Long-Term Care

Poor food and fluid intake and subsequent malnutrition and dehydration of residents are common, longstanding challenges in long-term care (LTC; eg, nursing homes, care homes, skilled nursing facilities). Institutional factors like inadequate nutrition care processes, food quality, eating assistance, and mealtime experiences, such as staff and resident interactions (ie, relationship-centered care) are partially responsible and are all modifiable. Evidence-based guidelines on nutrition and hydration for older adults, including those living with dementia, outline best practices. However, these guidelines are not sector-specific, and implementation in LTC requires consideration of feasibility in this setting, including the impact of government, LTC home characteristics, and other systems and structures that affect how care is delivered. It is increasingly acknowledged that interconnected relationships among residents, family members, and staff influence care activities and can offer opportunities for improving resident nutrition. In this special article, we reimagine LTC nutrition by reframing the evidence-based recommendations into relationship-centered care practices for nutrition care processes, food and menus, eating assistance, and mealtime experience. We then expand this evidence into actions for implementation, rating these on their feasibility and identifying the entities that are accountable. A few of the recommended activities were rated as highly feasible (6 of 27), whereas almost half were rated moderate (12/27) and the remainder low (9/27) owing to the need for additional staff and/or expert staff (including funding), or infrastructure or material (eg, food ingredients) investment. Government funding, policy, and standards are needed to improve nutrition care. LTC home leadership needs to designate roles, initiate training, and support best practices. Accountability will result from enforcement of policies through auditing of practice. Further evidence on these desirable nutrition care and mealtime actions and their benefit to residents’ nutrition and well-being is required.     

Providers’ Perspectives on High-Quality Dementia Care in Long-Term Care

ObjectivesTo understand dementia care providers’ perspectives on high-quality care for persons living with dementia (PLWD) in long-term care (LTC).DesignA qualitative study using a directed content analysis approach.Setting and ParticipantsNine national LTC dementia care providers.MethodsWe facilitated 5 listening sessions centered around dementia care philosophies, models, and practices. Two researchers first mapped qualitative data to the Holistic Approach to Transformational Change (HATCh) model for dementia care using a directed content analysis approach. They then identified themes and subthemes emerging from the data using a conventional analysis approach. They coded data iteratively and solicited input from 3 additional researchers to reach consensus where needed. Member checks were performed to ensure the trustworthiness of the data during 2 follow-up listening sessions.ResultsThe 9 participants described the importance of understanding the experiences of PLWDs in order to provide high-quality dementia care and to deliver such care with the residents and their preferences as the focus. They emphasized experiential education as essential for families and all staff, regardless of role. They noted the need to balance safety with resident choice, as well as the corresponding need for facility leadership and regulators to support such choices. The listening sessions revealed areas to foster person-centered care for PLWD, but also highlighted barriers to implementing this philosophy in LTC settings.Conclusions and ImplicationsEmergent themes included care practices that center on resident preferences and are supported by staff with the experiential education and communication skills necessary to relate to and support PLWD. These findings provide contextual information for researchers seeking to identify and test interventions that reflect LTC providers’ priorities for PLWD and emphasize the need to align research priorities with provider priorities.     

Utilization of nurse practitioners in long-term care: findings and implications of a national survey

OBJECTIVES: The objective of this study was to determine the national practice patterns of nurse practitioners (NPs) providing care in long-term care (LTC) facilities, including the number and characteristics of LTC facilities that use NPs for any portion of care to residents, NP activities, and employment arrangements between NPs, physicians, and facilities. DESIGN: Mailed survey. PARTICIPANTS: Participants included all physicians who are members of the American Medical Directors Association (AMDA). MEASUREMENT: The survey instrument was constructed to obtain information in the following six domains: (1) the number of LTC facilities that have NPs involved in providing care; (2) the number of NPs engaged in care at these facilities; (3) the types of employment/financial arrangements between NPs and LTC facilities; (4) the types of services provided by the NPs; (5) the effectiveness of the NPs as perceived by the medical directors; and (6) the perceived future demand for NPs in LTC. RESULTS: Of a total of 870 respondents (response rate 19%), 546 respondents (63%) reported the involvement of NPs in the care of residents in their facilities. In total, respondents identified 1160 NPs involved in care, with a median of two NPs per responding facility (range, 1-10). Respondents reported that NPs make sick/urgent resident visits (96%), provide preventive care to long-stay residents (88%), and perform alternating required regulatory 30/60 (88%), hospice care (80%), and wound care (78%). Significant variations in practice patterns were found between NPs employed by a LTC facility (19% of respondents) as compared with those NPs employed in other arrangements. Large majorities of medical directors stated that NPs are particularly effective in maintaining physician satisfaction (90%), resident satisfaction (87%), and family satisfaction (85%). An additional 34% of the respondents projected an increased need for NPs in nursing homes in the future. CONCLUSION: NPs involved in LTC are more likely to be involved in the care of residents in the nation's larger (>100-bed) LTC facilities. The substantial number and types of services provided by these NPs, coupled with the high resident, family, and physician satisfaction with their services, suggests the need for educational, policy, and reimbursement strategies to encourage the further involvement of NPs in the care of residents in nursing homes.     

Role of a Clinical Ethics Committee in Residential Aged Long-Term Care Settings: A Systematic Review

ObjectivesTo conduct a systematic review of literature examining the establishment and operation of clinical ethical committees (CECs) in long-term care (LTC).DesignSystematic review.Setting and ParticipantsLTC recipients/family or staff.MethodsFive databases (Ovid Medline, Ovid Cochrane Library, Ovid PsycINFO, Ovid EMBASE, and CINAHL via EbscoHost) were systematically searched from their inception to May 8, 2020. The initial search was conducted on August 22, 2017, and updated on May 8, 2020, to identify peer-reviewed studies, commentaries, or editorials. The quality of studies was assessed using the Mixed Methods Appraisal Tool.ResultsThirty-three articles were identified for inclusion, of which 13 were primary studies. Most articles were set in the United States. The purpose of establishing a CEC in LTC was typically to assist in dealing with ethical issues and improve the quality of care. The articles described the roles of CECs to include prospective case consultation, case review, policy development, and ethics education. Articles rarely reported whether the CEC was required by or enshrined in law. Membership of CECs was between 4 and 20 members and most commonly included nursing staff, physicians, and directors/administrators. The rationale behind the membership was rarely described. For case consultation, articles described that CECs were typically convened upon referral. The resident issues which a CEC could address included end-of-life care decisions, autonomy/self-determination, and medical treatment decisions. The staff issues addressed by CECs included medical treatment decisions, end-of-life care decisions, and decision-making issues. The decision-making process followed by CECs varied. The outcome of a CEC meeting was typically a recommendation, whereas the implementation of CEC recommendations and decisions were rarely reported.Conclusions and ImplicationsThis systematic review identifies how CECs operate in the LTC setting. CECs have the potential to provide valuable support in addressing complex ethical issues in LTC; however, empirical research is required to determine their efficacy in the LTC setting.     

Strategies and innovative models for delivering palliative care in nursing homes

The goals of palliative care address critical issues for individuals with complex and serious illness residing in nursing homes, including pain and symptom management, communication, preparation for death, decisions about treatment preferences, and caregiver support. Because of the uncertain prognosis associated with chronic nonmalignant diseases such as dementia, many nursing home residents are either not referred to hospice or have very short or very long hospice stays. The integration of palliative care into nursing homes offers a potential solution to the challenges relating to hospice eligibility, staffing, training, and obtaining adequate reimbursement for care that aligns with resident and surrogate's preferences and needs. However, the delivery of palliative care in nursing homes is hindered by both regulatory and staffing barriers and, as a result, is rare. In this article, we draw on interviews with nursing home executives, practitioners, and researchers to describe the barriers to nursing home palliative care. We then describe 3 existing and successful models for providing nonhospice palliative care to nursing home residents and discuss their ongoing strengths and challenges. We conclude with specific policy proposals to expedite the integration of palliative care into the nursing home setting.     

Autonomy Support of Nursing Home Residents With Dementia in Staff-Resident Interactions: Observations of Care

ObjectivesPeople with dementia living in nursing homes benefit from a social environment that fully supports their autonomy. Yet, it is unknown to what extent this is supported in daily practice. This study aimed to explore to which extent autonomy is supported within staff–resident interactions.DesignAn exploratory, cross-sectional study.Setting and ParticipantsIn total, interactions between 57 nursing home residents with dementia and staff from 9 different psychogeriatric wards in the Netherlands were observed.MethodsStructured observations were carried out to assess the support of resident autonomy within staff–resident interactions. Observations were performed during morning care and consisted of 4 main categories: getting up, physical care, physical appearance, and breakfast. For each morning care activity, the observers consecutively scored who initiated the care activity, how staff facilitated autonomy, how residents responded to staff, and how staff reacted to residents’ responses. Each resident was observed during 3 different mornings. In addition, qualitative field notes were taken to include environment and ambience.ResultsIn total, 1770 care interactions were observed. Results show that autonomy seemed to be supported by staff in 60% of the interactions. However, missed opportunities to engage residents in choice were frequently observed. These mainly seem to occur during interactions in which staff members took over tasks and seemed insensitive to residents’ needs and wishes. Differences between staff approach, working procedures, and physical environment were observed across nursing home locations.Conclusions and ImplicationsThe findings of this study indicate that staff members support resident autonomy in more than one-half of the cases during care interactions. Nonetheless, improvements are needed to support resident autonomy. Staff should be encouraged to share and increase knowledge in dementia care to better address residents’ individual needs. Especially for residents with severe dementia, it seems important that staff develop skills to support their autonomy.     

The Influence of Hospice Use on Nursing Home and Hospital Use in Assisted Living Among Dual-Eligible Enrollees

ObjectiveThis study examined the impact of hospice enrollment on the probabilities of hospital and nursing home admissions among a sample of frail dual-eligible assisted living (AL) residents.DesignThe study used a retrospective cohort design. We estimated bivariate probit models with 2 binary outcome variables: any hospital admissions and any nursing home admissions after assisted living enrollment.SettingA total of 328 licensed AL communities accepting Medicaid waivers in Florida.ParticipantsWe identified all newly admitted dual-eligible AL residents in Florida between January and June of 2003 who had complete state assessment data (n = 658) and followed them for 6 to 12 months.MeasurementsUsing the Andersen behavioral model, predisposing (age, gender, race), enabling (marital status, available caregiver, hospice use), and need (ADL/IADL, comorbidity conditions, and incontinence) characteristics were included as predictors of 2 binary outcomes (hospital and nursing home admission). Demographics, functional status, and caregiver availability were obtained from the state client assessment database. Data on diagnosis and hospital, nursing home, and hospice use were obtained from Medicare and Medicaid claims. Death dates were obtained from the state vital statistics death certificate data.ResultsThe mean age of the study sample was 81.5 years. Three-fourths were female and 63% were White. The average resident had a combined ADL/IADL dependency score of 11.49. Fifty-eight percent of the sample had dementia. During the average 8.9-month follow-up period, 6.8% were enrolled in hospice and 10.2% died. Approximately 33% of the sample had been admitted into a hospital and 20% had been admitted into a nursing home. Bivariate probit models simultaneously predicting the likelihood of hospital and nursing home admissions showed that hospice enrollment was associated with lower likelihood of hospital (OR = 0.24, P < .01) and nursing home admissions (OR = 0.56, P < .05). Significant predictors of hospital admissions included higher Charlson Comorbidity Index score and incontinence. Predictors of nursing home admissions included higher Charlson Comorbidity Index score, the absence of available informal caregiver, and incontinence.ConclusionsHospice enrollment was associated with a lower likelihood of hospital and nursing home admissions, and, thus, may have allowed AL residents in need of palliative care to remain in the AL community. AL providers should support and facilitate hospice care among older frail dual-eligible AL residents. More research is needed to examine the impact of hospice care on resident quality of life and total health care expenditures among AL residents.     

Long-term care survey reveals challenges. Facilities grapple with five broad issues, including changes in leadership and AIDS

The Catholic Health Association's 1992 survey of Catholic long-term care (LTC) facilities identified five broad issues LTC facilities face in the 1990s: leadership, system affiliation, community programs, resident issues, and care of persons with AIDS. The transition to lay leadership presents new challenges to the relationship between LTC facilities and their sponsors. Despite the dominance of religious sponsors, an increasing number of laypersons are serving as healthcare administrators both in long-term and acute care. Thirty percent of respondents reported being affiliated with a multi-institutional system. This percentage has changed little in the past few years, although the number of facilities that are system members continues to increase at the fastest rate of any type of LTC facility. Only 27 percent of survey respondents said they provide educational or informational programs for persons in their communities. Thirty-nine percent of system-affiliated LTC facilities reported offering such programs. One encouraging finding shows that 80 percent of facilities have written policies for living wills, 64 percent for designated proxy, and 86 percent for durable power of attorney for healthcare. LTC providers are struggling to determine their role in caring for persons with HIV and AIDS. Only 3.6 percent of respondents care for residents with AIDS. A major problem LTC administrators face is a fear of potential infection of staff or residents.     

Adherence to “No Transfer to Hospital” Advance Directives Among Nursing Home Residents

ObjectivesMany older adults in long-term care (LTC) experience acute health crises but are at high risk of transfer distress and in-hospital morbidity and mortality. Residents often complete advance directives (ADs) regarding future care wishes, including directives for hospital transfers. This study aims to estimate the prevalence of, and adherence to, “no transfer to hospital” ADs in LTC, and to explore the circumstances leading to transfers against previously expressed directives.DesignWe conducted a mixed methods study in 10 nursing homes in Nova Scotia, Canada. A total of 748 resident charts and Emergency Health Services (EHS) database notes were reviewed from 3 time periods spanning implementation of a new primary care model, Care by Design (CBD).MeasuresADs were divided into those requesting transfer to hospital vs on-site management only, which were then analyzed in relation to actual hospital transfers. Reasons for EHS calls, management, and qualitative data were derived from the EHS database. Resident variables were obtained from LTC charts. Measures were compared between time periods.ResultsADs were complete in 92.4% of charts. Paramedics were called for 80.5% of residents, and 73.6% were transferred to hospital, 51.3% of whom had explicit ADs to the contrary. The majority of those were transferred for fall-related injuries, followed by medical illness. Unclear care plans, symptom control, and perceived need for investigations and procedures all influenced transfer decisions.Conclusions/ImplicationsThe use of “no transfer to hospital” directives did not appear to impact the number of residents being transferred to acute care. Half of those transferred to hospital had explicit ADs to the contrary, largely driven by fall-related injury. The high incidence of injury-related transfers highlights an important gap in advance care planning. Clarifying transfer preferences for injury management in advance directives may lead to better end-of-life experiences for residents and improve effective resource utilization.     

Telemedicine and Telehealth in Nursing Homes: An Integrative Review

ObjectivesTelemedicine and telehealth are increasingly used in nursing homes (NHs). Their use was accelerated further by the COVID-19 pandemic, but their impact on patients and outcomes has not been adequately investigated. These technologies offer promising avenues to detect clinical deterioration early, increasing clinician's ability to treat patients in place. A review of literature was executed to further explore the modalities' ability to maximize access to specialty care, modernize care models, and improve patient outcomes.DesignWhittemore and Knafl's integrative review methodology was used to analyze quantitative and qualitative studies.Setting and ParticipantsPrimary research conducted in NH settings or focused on NH residents was included. Participants included clinicians, NH residents, subacute patients, and families.MethodsPubMed, Web of Science, CINAHL, Embase, PsycNET, and JSTOR were searched, yielding 16 studies exploring telemedicine and telehealth in NH settings between 2014 and 2020.ResultsMeasurable impacts such as reduced emergency and hospital admissions, financial savings, reduced physical restraints, and improved vital signs were found along with process improvements, such as expedient access to specialists. Clinician, resident, and family perspectives were also discovered to be roundly positive. Studies showed wide methodologic heterogeneity and low generalizability owing to small sample sizes and incomplete study designs.Conclusions and ImplicationsPreliminary evidence was found to support geriatrician, psychiatric, and palliative care consults through telemedicine. Financial and clinical incentives such as Medicare savings and reduced admissions to hospitals were also supported. NHs are met with increased challenges as a result of the COVID-19 pandemic, which telemedicine and telehealth may help to mitigate. Additional research is needed to explore resident and family opinions of telemedicine and telehealth use in nursing homes, as well as remote monitoring costs and workflow changes incurred with its use.     

Rising to the Occasion: A National Nursing Home Study Documenting Attempts to Address Social Isolation During the COVID-19 Pandemic

ObjectivesCOVID-19–related policies introduced extraordinary social disruption in nursing homes. In response, nursing facilities implemented strategies to alleviate their residents’ loneliness. This study sought to describe interventions nursing homes used, document the perceived effectiveness of efforts, and determine barriers to implementing strategies to mitigate social isolation and loneliness.DesignNational survey of nursing homes sampled in strata defined by facility size (beds: 30-99, 100+) and quality ratings (1, 2-4, 5).Settings and ParticipantsUS Nursing Home Directors of Nursing/Administrators (n = 1676).MethodsThe survey was conducted between February and May 2022 (response rate: 30%; n = 504, weighted n = 14,506). Weighted analyses provided nationally representative results.ResultsOne-third were extremely concerned about their home's ability to meet residents' medical and social needs during COVID-19 before vaccines were available and 13% after vaccines. Nearly all reported trying to mitigate residents' social isolation during the pandemic. Efforts tried, and perceived as most useful, included using technology (tablets, phones, emails), assigning staff as a family contact, and more staff time with residents. Most frequently cited barriers to implementation were related to staffing issues.Conclusions and ImplicationsDespite multiple challenges, nearly all nursing homes tried to implement many different approaches to address residents’ social needs, with some (eg, having an assigned family contact, use of tablets and phones) perceived as more useful than others. Staffing issues presented barriers for addressing the social needs of nursing home residents. Many strategies for addressing social isolation placed more demands on a workforce already stretched to the limit. While concerns about resident social isolation reduced after vaccine availability, administrators remained extremely concerned about staff burnout and mental health.     

Guidance to (Re)integrate Caregivers as Essential Care Partners Into the LTC Setting: A Rapid Review

ObjectivesThis rapid review aimed to identify the strategies used to (re)integrate essential caregivers (ECs) into the LTC setting, particularly pertaining to principles of equity, diversity, and inclusion. In addition, this rapid review aimed to identify the strategies used during prior infectious disease threats, when similar blanket visitor restrictions were implemented in LTC homes. The review was part of a larger effort to support LTC homes in Ontario.DesignA rapid review was conducted in accordance with principles from the Canadian National Collaborating Centre for Methods and Tools.Setting and ParticipantsECs, residents, staff, and policy decision makers in long-term care home settings.MethodsFive electronic databases were searched for academic and gray literature using predefined search terms. Selected documents met inclusion criteria if they included policy guidance or an intervention to (re)integrate ECs into LTC homes at the local, national, and/or international level.ResultsIn total, 15 documents met the inclusion and exclusion criteria. All documents retrieved focused on the context of COVID-19. Documents were either policy guidance (n = 13) or primary research studies (n = 2). Documents differed in these notable ways: Definition of EC; the degree to which an EC is recognized for her or his role in the care of the resident; the degree to which ECs are (re)integrated into the LTC setting is prioritized; response to community spread of COVID-19; visitation during an outbreak or if a resident is symptomatic; the reliance on equity, diversity, and inclusion principles; and lastly, monitoring and improving the process.Conclusions and ImplicationsUsing an equity, diversity, and inclusion lens, we posit promising practices for (re)integration. It is clear from the rapid review that more research is needed to understand the efficacy of policies and guidelines to (re)integrate ECs into the LTC setting. Until such evidence is available, expert opinion will drive best care practices.