State Variability in Assisted Living Residents’ End-of-Life Care Trajectories

ObjectiveA growing and increasingly vulnerable population resides in assisted living. States are responsible for regulating assisted living and vary in their requirements. Little is known about how this variability translates to differences in the dying experiences of assisted living residents. The objective of this study is to describe assisted living residents’ end-of-life care trajectories and how they vary by state.DesignObservational retrospective cohort study.Setting and ParticipantsUsing Medicare data and a methodology developed to identify beneficiaries residing in larger assisted living communities (25+ beds), we identified a cohort of 40,359 assisted living residents in the continental United States enrolled in traditional Medicare and who died in 2016.MethodsWe used Medicare data and the Residential History File to examine assisted living residents’ locations of care and services received in the last 30 days of life.ResultsNationally, 57% of our cohort died outside of an institutional setting, that is, hospital or nursing home (n = 23,165), 18,396 of whom received hospice at the time of death. Rates of hospitalization and transition to a nursing home increased during the last 30 days of life. We observed significant interstate variability in the adjusted number of days spent in assisted living in the month before death [from 13.6 days (95% confidence interval [CI] 11.8, 15.4) in North Dakota to 24.0 days (95% CI 22.7, 25.2) in Utah] and wider variation in the adjusted number of days receiving hospice in the last month of life, ranging from 2.1 days (95% CI 1.0, 3.2) in North Dakota to 13.8 days (95% CI 12.1, 15.5) in Utah.Conclusions and ImplicationsFindings suggest that assisted living residents’ dying trajectories vary significantly by state. To ensure optimal end-of-life outcomes for assisted living residents, state policy makers should consider how their regulations influence end-of-life care in assisted living, and future research should examine factors (eg, state regulations, market characteristics, provider characteristics) that may enable assisted living residents to die in place and contribute to differential access to hospice services.     

Assisted Living Communities During Hurricane Irma: The Decision to Evacuate or Shelter in Place and Resident Acuity

ObjectivesTo investigate the factors associated with whether assisted living communities (ALCs) in Florida evacuated or sheltered in place for Hurricane Irma in 2017, focusing on license type as a proxy for acuity of care.DesignCross-sectional study using data collected by the state through its emergency reporting system and a post-hurricane survey.Setting and ParticipantsAnalyses included all 3112 ALCs in the emergency reporting system. A subset of 1880 that completed the survey provided supplementary data.Methodsχ² tests were used to examine differences between ALC characteristics (license type, size, payment, profit status, rural location, geographical region, and being under an evacuation order) and whether they evacuated. Logistic regression was used to test associations between characteristics and evacuation status.ResultsOf 3112 ALCs, 560 evacuated and 2552 sheltered in place. Bivariate analysis found significant associations between evacuation status and evacuation order, license type (mental health care), payment, and region. In the adjusted analysis, medium and larger ALCs were 43% (P < .001) and 53% (P < .001) less likely to evacuate than ALCs with fewer than 25 beds. Compared with ALCs in the Southeast, nearly every region was more likely to evacuate, with the highest likelihood in the Central West (odds ratio 1.76, 95% confidence interval 1.35‒2.30). ALCs under an evacuation order were 8 times more likely to evacuate (P < .001). We found no relationship between evacuation status and having a license to provide higher care.Conclusions and ImplicationsPrior research highlighting harm associated with evacuation has led to recommendations that long-term care facilities carefully consider resident impairment in evacuation decision-making. Evidence that small ALCs are more likely to evacuate and that having a higher-care license is not associated with evacuation likelihood shows research is needed to understand how ALCs weigh resident risks in decisions to evacuate or shelter in place.     

Clinical Comorbidities and Transitions Between Care Settings Among Residents of Assisted Living Facilities: A Repeated Cross-Sectional Study

ObjectiveWe investigate the changes in the sociodemographic characteristics, clinical comorbidities, and transitions between care settings among residents of assisted living facilities.DesignRepeated cross-sectional study.Setting and ParticipantsLinked, individual-level health system administrative data on residents of assisted living facilities in Ontario, Canada, from January 1, 2013, to December 31, 2019.MethodsCounts and proportions were calculated to describe the sociodemographic characteristics and clinical comorbidities. Relative changes and trend tests were calculated to quantify the longitudinal changes in the characteristics of residents of assisted living facilities between 2013 and 2019. A Sankey plot was graphed to display transitions between different care settings (ie, hospital admission, nursing home admission, died, or remained in the assisted living facility) each year from 2013 to 2019.ResultsThere was a 34% relative increase in the resident population size of assisted living facilities (56,975₂₀₁₉ vs 42,600₂₀₁₃). These older adults had a mean age of 87 years, and women accounted for nearly two-thirds of the population across all years. The 5 clinical comorbidities that had the highest relative increases were renal disease (24.3%), other mental health conditions (16.8%), cardiac arrhythmias (9.6%), diabetes (8.5%), and cancer (6.9%). Nearly 20% of the original cohort from 2013 remained in an assisted living facility at the end of 2019, and approximately 10% of that cohort transitioned to a nursing home in any year from 2013 to 2019.Conclusions and ImplicationsResidents of assisted living facilities are an important older adult population that has progressively increased in clinical complexity within less than a decade. Clinicians and policy makers should advocate for the implementation of on-site medical care that is aligned with the needs of these older adults.     

Rates of Hospital-Based Care among Older Adults in the Community and Residential Care Facilities: A Repeated Cross-Sectional Study

ObjectiveWe examine annual rates of emergency department (ED) visits, hospital admissions, and alternate levels of care (ALC) days (ie, the number of days that an older adult remained in hospital when they could not be safely discharged to an appropriate setting in their community) among older adults.DesignRepeated cross-sectional study.Setting and ParticipantsLinked, individual-level health system administrative data on community-dwelling persons, home care recipients, residents of assisted living facilities, and residents of nursing homes aged 65 years and older in Ontario, Canada, from January 1, 2013, to December 31, 2019.MethodsWe calculated rates of ED visits, hospital admissions, and ALC days per 1000 individuals per older adult population per year. We used a generalized linear model with a gaussian distribution, log link, and year fixed effects to obtain rate ratios.ResultsThere were 1,655,656 older adults in the community, 237,574 home care recipients, 42,600 older adults in assisted living facilities, and 94,055 older adults in nursing homes in 2013; there were 2,129,690 older adults in the community, 281,028 home care recipients, 56,975 older adults in assisted living facilities, and 95,925 older adults in nursing homes in 2019. Residents of assisted living facilities had the highest rates of ED visits (1260.69₂₀₁₉ vs 1174.91₂₀₁₃), hospital admissions (482.63₂₀₁₉ vs 480.19₂₀₁₃), and ALC days (1905.57₂₀₁₉ vs 1443.03₂₀₁₃) per 1000 individuals. Residents of assisted living facilities also had significantly higher rates of ED visits [rate ratio (RR) 3.30, 95% CI 3.20, 3.41), hospital admissions (RR 6.24, 95% CI 6.01, 6.47), and ALC days (RR 25.68, 95% CI 23.27, 28.35) relative to community-dwelling older adults.Conclusions and ImplicationsThe disproportionate use of ED visits, hospital admissions, and ALC days among residents of assisted living facilities may be attributed to the characteristics of the population and fragmented licensing and regulation of the sector, including variable models of care. The implementation of interdisciplinary, after-hours, team-based approaches to home and primary care in assisted living facilities may reduce the potentially avoidable use of ED visits, hospital admissions, and ALC days among this population and optimize resource allocation in health care systems.     

Variation in influenza vaccine assessment,receipt, and refusal by the concentration of Medicare Advantage enrollees in U.S. nursing homes

BackgroundMore older adults enrolled in Medicare Advantage (MA) are entering nursing homes (NHs), and MA concentration could affect vaccination rates through shifts in resident characteristics and/or payer-related influences on preventive services use. We investigated whether rates of influenza vaccination and refusal differ across NHs with varying concentrations of MA-enrolled residents.MethodsWe analyzed 2014–2015 Medicare enrollment data and Minimum Data Set clinical assessments linked to NH-level characteristics, star ratings, and county-level MA penetration rates. The independent variable was the percentage of residents enrolled in MA at admission and categorized into three equally-sized groups. We examined three NH-level outcomes including the percentages of residents assessed and appropriately considered for influenza vaccination, received influenza vaccination, and refused influenza vaccination.ResultsThere were 936,513 long-stay residents in 12,384 NHs. Categories for the prevalence of MA enrollment in NHs were low (0% to 3.3%; n = 4131 NHs), moderate (3.4% to 18.6%; n = 4127 NHs) and high (>18.6%; n = 4126 NHs). Overall, 81.3% of long-stay residents received influenza vaccination and 14.3% refused the vaccine when offered. Adjusting for covariates, influenza vaccination rates among long-stay residents were higher in NHs with moderate (1.70 percentage points [pp], 95% confidence limits [CL]: 1.15 pp, 2.24 pp), or high (3.05 pp, 95% CL: 2.45 pp, 3.66 pp) MA versus the lowest prevalence of MA. Influenza vaccine refusal was lower in NHs with moderate (-3.10 pp, 95% CL: ?3.53 pp, ?2.68 pp), or high (-4.63 pp, 95% CL: ?5.11 pp, ?4.15 pp) MA compared with NHs with the lowest prevalence of MA.ConclusionA higher concentration of long-stay NH residents enrolled in MA was associated with greater influenza vaccine receipt and lower vaccine refusal. As MA becomes a larger share of the Medicare program, and more MA beneficiaries enter NHs, decisionmakers need to consider how managed care can be leveraged to improve the delivery of preventive services like influenza vaccinations in NH settings.     

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.     

End-of-Life Care Transitions in Assisted Living: Associations With State Staffing and Training Regulations

ObjectiveWe examined the frequency and categories of end-of-life care transitions among assisted living community decedents and their associations with state staffing and training regulations.DesignCohort study.Setting and ParticipantsMedicare beneficiaries who resided in assisted living facilities and had validated death dates in 2018–2019 (N = 113,662).MethodsWe used Medicare claims and assessment data for a cohort of assisted living decedents. Generalized linear models were used to examine the associations between state staffing and training requirements and end-of-life care transitions. The frequency of end-of-life care transitions was the outcome of interest. State staffing and training regulations were the key covariates. We controlled for individual, assisted living, and area-level characteristics.ResultsEnd-of-life care transitions were observed among 34.89% of our study sample in the last 30 days before death, and among 17.25% in the last 7 days. Higher frequency of care transitions in the last 7 days of life was associated with higher regulatory specificity of licensed [incidence risk ratio (IRR) = 1.08; P = .002] and direct care worker staffing (IRR = 1.22; P < .0001). Greater regulatory specificity of direct care worker training (IRR = 0.75; P < .0001) was associated with fewer transitions. Similar associations were found for direct care worker staffing (IRR = 1.15; P < .0001) and training (IRR = 0.79; P < .001) and transitions within 30 days of death.Conclusions and ImplicationsThere were significant variations in the number of care transitions across states. The frequency of end-of-life care transitions among assisted living decedents during the last 7 or 30 days of life was associated with state regulatory specificity for staffing and staff training. State governments and assisted living administrators may wish to set more explicit guidelines for assisted living staffing and training to help improve end-of-life quality of care.     

Cancer Pain in Relation to Metropolitan Area Segregation and Nursing Home Racial and Ethnic Composition

ObjectivesTo estimate pain reporting among residents with cancer in relation to metropolitan area segregation and NH racial and ethnic composition.DesignCross-sectional study.Setting and Participants383,757 newly admitted black (B), Hispanic (H), or white (W) residents with cancer in 12,096 US NHs (2011-2013).MethodsUsing the Minimum Data Set 3.0, pain in past 5 days was determined by self-report or use of pain management. The Theil entropy index, a measure of metropolitan area segregation, was categorized [high (up to 0.20), very high (0.20-0.30), or extreme (0.30-0.53)].ResultsPain prevalence decreased across segregation level (black: high = 77%, very high = 75%, extreme = 72%; Hispanic: high = 79%, very high = 77%, extreme = 70%; white: high = 80%, very high = 77%, extreme = 74%). In extremely segregated areas, all residents were less likely to have recorded pain [adjusted prevalence ratios: blacks, 4.6% less likely, 95% confidence interval (CI) 3.1%-6.1%; Hispanics, 6.9% less likely, 95% CI 4.2%-9.6%; whites, 7.4% less likely, 95% CI 6.5%-8.2%] than in the least segregated areas. At all segregation levels, pain was recorded more frequently for residents (black or white) in predominantly white (>80%) NHs than in mostly black (>50%) NHs or residents (Hispanic or white) in predominantly white NHs than mostly Hispanic (>50%) NHs.Conclusions and ImplicationsWe observed decreased pain recording in metropolitan areas with greater racial and ethnic segregation. This may occur through the inequitable distribution of resources between NHs, resident-provider empathy, provider implicit bias, resident trust, and other factors.     

Infection Prevention and Control Standards in Assisted Living Facilities: Are Residents' Needs Being Met?

BackgroundAssisted living facilities (ALFs) provide housing and care to persons unable to live independently, and who often have increasing medical needs. Disease outbreaks illustrate challenges of maintaining adequate resident protections in these facilities.ObjectivesDescribe current state laws on assisted living admissions criteria, medical oversight, medication administration, vaccination requirements, and standards for infection control training.MethodsWe abstracted laws and regulations governing assisted living facilities for the 50 states using a structured abstraction tool. Selected characteristics were compared according to the time period in which the regulation took effect. Selected state health departments were queried regarding outbreaks identified in assisted living facilities.ResultsOf the 50 states, 84% specify health-based admissions criteria to assisted living facilities; 60% require licensed health care professionals to oversee medical care; 88% specifically allow subcontracting with outside entities to provide routine medical services onsite; 64% address medication administration by assisted living facility staff; 54% specify requirements for some form of initial infection control training for all staff; 50% require reporting of disease outbreaks to the health department; 18% specify requirements to offer or require vaccines to staff; 30% specify requirements to offer or require vaccines to residents. Twelve states identified approximately 1600 outbreaks from 2010 to 2013, with influenza or norovirus infections predominating.ConclusionsThere is wide variation in how assisted living facilities are regulated in the United States. States may wish to consider regulatory changes that ensure safe health care delivery, and minimize risks of infections, outbreaks of disease, and other forms of harm among assisted living residents.     

Health System Success in Delivering Bamlanivimab Within Post-acute and Long-Term Care Facilities

ObjectivesPost-acute and long-term care (PALTC) residents are disproportionately affected by coronavirus 2019 (COVID-19). We describe a health system approach that incorporated PALTC stakeholders to treat residents effectively and efficiently with monoclonal antibodies during the pandemic.DesignRetrospective observational.Setting and ParticipantsIntegrated health system headquartered in Sioux Falls, South Dakota, with urban hub and surrounding rural communities. Patients of the health system include PALTC and assisted living (AL) residents of facilities.MethodsMonoclonal Data Registry captured time to infusion after a positive COVID-19 test, residency (independent or PALTC), and site of infusion (PALTC, hospital outpatient, infusion center). AL residents are included in PALTC data. Registry limited to patients living in SD. Communication and operational resources were tailored to support PALTC infusions. The monoclonal antibody therapy administered to PALTC residents during the first 6 weeks after emergency use authorization (EUA) of monoclonal antibodies was bamlanivimab. The EUA for bamlanivimab was revoked due to lack of effectiveness against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants on April 16, 2021.ResultsThe results are analyzed for the 6 weeks after bamlanivimab EUA. In PALTC, there was a median of 3 days between positive test and infusion. The total number of monoclonal antibody infusions captured in the registry during this time was 87 PALTC on-site infusions.Conclusion and ImplicationsA collaborative approach between health system executives and PALTC experts quickly enabled access to potentially life-saving therapy to a vulnerable population. PALTC settings should be routinely included in health system investment and planning to improve the capacity of the system to achieve optimal outcomes, prevent unnecessary mortality, and preserve health care resources.     

Testing the Implementation of Function-focused Care in Assisted Living Settings

ObjectivesThe purpose of this study was to evaluate the Function-Focused Care for Assisted Living Using the Evidence Integration Triangle (FFC-AL-EIT) intervention.DesignFFC-AL-EIT was a randomized controlled pragmatic trial including 85 sites and 794 residents.InterventionFFC-AL-EIT was implemented by a Research Nurse Facilitator working with a facility champion and stakeholder team for 12 months to increase function and physical activity among residents. FFC-AL-EIT included (Step I) Environment and Policy Assessments; (Step II) Education; (Step III) Establishing Resident Function-Focused Care Service Plans; and (Step IV) Mentoring and Motivating.Setting and ParticipantsThe age of participants was 89.48 years [standard deviation (SD) = 7.43], and the majority were female (n = 561; 71%) and white (n = 771; 97%).MethodsResident measures, obtained at baseline, 4, and 12 months, included function, physical activity, and performance of function-focused care. Setting outcomes, obtained at baseline and 12 months, included environment and policy assessments and service plans.ResultsReach was based on 85 of 90 sites that volunteered (94%) participating. Effectiveness was based on less decline in function (P < .001), more function-focused care (P = .012) and better environment (P = .032) and policy (P = .003) support for function-focused care in treatment sites. Adoption was supported with 10.00 (SD = 2.00) monthly meetings held, 77% of settings engaged in study activities as or more than expected, and direct care workers providing function-focused care (63% to 68% at 4 months and 90% at 12 months). The intervention was implemented as intended, and education was received based on a mean knowledge test score of 88% correct. Evidence of maintenance from 12 to 18 months was noted in treatment site environments (P = .35) and policies continuing to support function-focused care (P = .28)].Conclusions and ImplicationsThe Evidence Integration Triangle is an effective implementation approach for assisted living. Future work should continue to consider innovative approaches for measuring RE-AIM outcomes.     

Feasibility of Routine Quality of Life Measurement for People Living With Dementia in Long-Term Care

ObjectivesMaximizing quality of life (QoL) is the ultimate goal of long-term dementia care. However, routine QoL measurement is rare in nursing home (NH) and assisted living (AL) facilities. Routine QoL measurement might lead to improvements in resident QoL. Our objective was to assess the feasibility of using DEMQOL-CH, completed by long-term care staff in video calls with researchers, to assess health-related quality of life (HrQoL) of NH and AL residents with dementia or other cognitive impairment.DesignCross-sectional study.Setting and ParticipantsWe included a convenience sample of 5 NHs and 5 AL facilities in the Canadian province of Alberta. Forty-two care staff who had worked in the facility for ≥3 months completed DEMQOL-CH assessments of 183 residents who had lived in the facility for 3 months or more and were aged ≥65 years. Sixteen residents were assessed independently by 2 care staff to assess inter-rater reliability.MethodsWe assessed HrQoL in people with dementia or other cognitive impairment using DEMQOL-CH, and assessed time to complete, inter-rater reliability, internal consistency reliability, and care staff ratings of feasibility of completing the DEMQOL-CH.ResultsAverage time to complete DEMQOL-CH was <5 minutes. Staff characteristics were not associated with time to complete or DEMQOL-CH scores. Inter-rater reliability [0.735, 95% confidence interval (CI): 0.712-0.780] and internal consistency reliability (0.834, 95% CI: 0.779-0.864) were high. The DEMQOL-CH score varied across residents (mean = 84.8, standard deviation = 11.20, 95% CI: 83.2-86.4). Care aides and managers rated use of the DEMQOL-CH as highly feasible, acceptable, and valuable.Conclusions and ImplicationsThis study provides a proof of concept that DEMQOL-CH can be used to assess HrQoL in NH and AL residents and provides initial indications of feasibility and resources required. DEMQOL-CH may be used to support actions to improve the QoL of residents.     

Factors Associated With COVID-19 Hospitalizations and Deaths in French Nursing Homes

ObjectivesTo describe the clinical characteristics and management of residents in French nursing homes with suspected or confirmed coronavirus disease 2019 (COVID-19) and to determine the risk factors for COVID-19–related hospitalization and death in this population.DesignA retrospective multicenter cohort study.Setting and ParticipantsFour hundred eighty nursing home residents with suspected or confirmed COVID-19 between March 1 and May 20, 2020, were enrolled and followed until June 2, 2020, in 15 nursing homes in Marseille’s greater metropolitan area.MethodsDemographic, clinical, laboratory, treatment type, and clinical outcome data were collected from patients’ medical records. Multivariable analysis was used to determine factors associated with COVID-19–related hospitalization and death. For the former, the competing risk analysis—based on Fine and Gray’s model—took death into account.ResultsA total of 480 residents were included. Median age was 88 years (IQR 80-93), and 330 residents were women. A total of 371 residents were symptomatic (77.3%), the most common symptoms being asthenia (47.9%), fever or hypothermia (48.1%), and dyspnea (35.6%). One hundred twenty-three patients (25.6%) were hospitalized and 96 (20%) died. Male gender [specific hazard ratio (sHR) 1.63, 95% confidence interval (CI) 1.12-2.35], diabetes (sHR 1.69, 95% CI 1.15-2.50), an altered level of consciousness (sHR 2.36, 95% CI 1.40-3.98), and dyspnea (sHR 1.69, 95% CI 1.09-2.62) were all associated with a greater risk of COVID-19–related hospitalization. Male gender [odds ratio (OR) 6.63, 95% CI 1.04-42.39], thermal dysregulation (OR 2.64, 95% CI 1.60-4.38), falls (2.21 95% CI 1.02-4.75), and being aged >85 years (OR 2.36, 95% CI 1.32-4.24) were all associated with increased COVID-19–related mortality risk, whereas polymedication (OR 0.46, 95% CI 0.27-0.77) and preventive anticoagulation (OR 0.46, 95% CI 0.27-0.79) were protective prognostic factors.Conclusions and ImplicationsMale gender, being aged >85 years old, diabetes, dyspnea, thermal dysregulation, an altered level of consciousness, and falls must all be considered when identifying and protecting nursing home residents who are at greatest risk of COVID-19–related hospitalization and death.     

Association Between Dementia Care Programs in Assisted Living Facilities and Transitions to Nursing Homes in Ontario,Canada: A Population-Based Cohort Study

ObjectiveWe investigate whether older adults who were newly diagnosed with dementia (severity unspecified) and resided in an assisted living facility that offered a dementia care program had a lower rate of transition to a nursing home, compared to those who resided in an assisted living facility without such a program.DesignPopulation-based retrospective cohort study.Setting and ParticipantsLinked, person-level health system administrative data on older adults who were newly diagnosed with dementia and resided in an assisted living facility in Ontario, Canada, from 2014 to 2019 (n = 977).MethodsAccess to a dementia care program in an assisted living facility (n = 57) was examined. Multivariable Cox proportional hazards regression with robust standard errors clustered on the assisted living facility was used to model the time to transition to a nursing home from the new dementia diagnosis.ResultsThere were 11.8 transitions to a nursing home per 100 person-years among older adults who resided in an assisted living facility with a dementia care program, compared with 20.5 transitions to a nursing home per 100 person-years among older adults who resided in an assisted living facility without a dementia care program. After adjustment for relevant characteristics at baseline, older adults who resided in an assisted living facility with a dementia care program had a 40% lower rate of transition to a nursing home (hazard ratio 0.60, 95% confidence interval 0.44, 0.81), compared with those in an assisted living facility without such a program at any point during the follow-up period.Conclusions and ImplicationsThe rate of transition to a nursing home was significantly lower among older adults who resided in an assisted living facility that offered a dementia care program. These findings support the expansion of dementia care programs in assisted living facilities.     

Education to Reduce Potentially Harmful Medication Use Among Residents of Assisted Living Facilities: A Randomized Controlled Trial

ObjectivesThe objectives of this study were (1) to investigate the effect of nurse training on the use of potentially harmful medications; and (2) to explore the effect of nurse training on residents' health-related quality of life (HRQoL), health service utilization, and mortality.DesignA randomized controlled trial.Setting and participantsIn total, 227 residents in 20 wards of assisted living facilities in Helsinki were recruited. The 20 wards were randomized into those in which (1) staff received two 4-hour training sessions on appropriate medication treatment (intervention group), and (2) staff received no additional training and continued to provide routine care (control group).InterventionTwo 4-hour interactive training sessions for nursing staff based on constructive learning theory to recognize potentially harmful medications and corresponding adverse drug events.MeasurementsUse of potentially harmful medications, HRQoL assessed using the 15 dimensional instrument of health-related quality of life, health service utilization, and mortality assessed at baseline, and 6 and 12 months.ResultsDuring the 12-month follow-up, the mean number of potentially harmful medications decreased in the intervention wards [−0.43, 95% confidence interval (CI) −0.71 to −0.15] but remained constant in the control wards (+0.11, 95% CI −0.09 to +0.31) (P = .004, adjusted for age, sex, and comorbidities). HRQoL declined more slowly in the intervention wards (−0.038 (95% CI −0.054 to −0.022) than in the control wards (−0.072 (95% CI −0.089 to −0.055) (P = .005, adjusted for age, sex, and comorbidities). Residents of the intervention wards had significantly less hospital days (1.4 days/person/year, 95% CI 1.2–1.6) than in the control wards (2.3 days/person/year; 95% CI 2.1–2.7) (relative risk 0.60, 95% CI 0.49–0.75, P < .001, adjusted for age, sex, and comorbidities).ConclusionsActivating learning methods directed at nurses in charge of comprehensive care can reduce the use of harmful medications, maintain HRQoL, and reduce hospitalization in residents of assisted living facilities.     

Emergency Department Use Among Assisted Living Residents After Hurricane Irma

ObjectivesNursing home residents are especially vulnerable to adverse outcomes after a hurricane. Prior research suggests that emergency department (ED) visits increase among community-residing older adults after natural disasters. However, little is known about the impact of hurricanes on the large population of older adults residing in assisted living (AL) settings, particularly the influence of storms on the rates and causes of ED visits. We examined whether rates of ED use for injuries and other medical reasons increased after Hurricane Irma in 2017 among AL residents in Florida.DesignRetrospective cohort study.Setting and ParticipantsSamples of 30,358 Medicare fee-for-service beneficiaries in 2016 and 28,922 beneficiaries in 2017 who resided in Florida AL communities.MeasuresThe number of injury-related and other medical visits per 1,000 person-days within 30 and 90 days of September 1 in 2016 and 2017. We adjusted for age, race, sex, and chronic conditions using linear regression with AL fixed effects. We compared the top 10 primary diagnoses resulting in an ED visit between 2016 and 2017.ResultsAdjusted rates of injury-related visits were 12.5% higher at 30 days but did not differ at 90 days. Other medical visits were 12% higher at 30 days in 2017 than in 2016 and 7.7% higher at 90 days. Heart failure was a leading cause of ED visits within 90 days of September 1 in 2017, unlike in 2016.Conclusions and ImplicationsIncreased attention should be paid to AL communities in disaster preparedness and response efforts given the increased likelihood of ED visits following a hurricane.     

Reducing the Risk of Hospitalization for Nursing Home Residents: Effects and Facility Variation From OPTIMISTIC

ObjectivesThe Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) project led to significant decreases in potentially avoidable hospitalizations of long-stay nursing facility residents in external evaluation. The purpose of this study was to quantify hospitalization risk from the start of the project and describe the heterogeneity of the enrolled facilities in order to better understand the context for successful implementation.DesignPre-post analysis design of a prospective intervention within a single group.Setting and ParticipantsA total of 4320 residents in the 19 facilities were included from admission until time to the first hospitalization.MeasuresData were extracted from Minimum Data Set assessments and linked with facility-level covariates from the LTCFocus.org data set. Kaplan-Meier and Cox proportional hazards regression were used to assess risk of hospitalization during the preintervention period (2011-2012), a “ramp-up” period (2013-2014), and an intervention period (2015-2016).ResultsThe cohort consisted of 4230 long-stay nursing facility residents. Compared with the preintervention period, residents during the intervention period had an increased probability of having no hospitalizations within 1 year, increasing from 0.51 to 0.57, which was statistically significant (P < .001). In adjusted Cox models, the risk of hospitalization was lower in the ramp-up period compared to the pre-period [hazard ratio (HR) 0.85, 95% confidence interval (CI) 0.75-0.95] and decreased further during the intervention period (HR 0.74, 95% CI 0.65-0.84).Conclusions and ImplicationsAs part of a large multisite demonstration project, OPTIMISTIC has successfully reduced hospitalizations. However, this study highlights the magnitude and extent to which results differ across facilities. Implementing the OPTIMISTIC program was associated with a 16% risk reduction after the first 18 months and continued to a final risk reduction of 26% after 5½ years. Although this model of care reduces hospitalizations overall, facility variation should be expected.