Physician Availability in Long-Term Care and Resident Hospital Transfer: A Retrospective Cohort Study

ObjectivesTo investigate whether same-day physician access in long-term care homes reduces resident emergency department (ED) visits and hospitalizations.DesignRetrospective cohort study.Setting and participants161 long-term care homes in Ontario, Canada, and 20,624 residents living in those homes.MethodsWe administered a survey to Ontario long-term care homes from March to May 2017 to collect their typical wait time for a physician visit. We linked the survey to administrative databases to capture other long-term care home characteristics, resident characteristics, hospitalizations, and ED visits. We defined a cohort of residents living in survey-respondent homes between January and May 2017 and followed each resident for 6 months or until discharge or death.We estimated negative binomial regression models on counts of hospitalizations and ED visits with random intercepts for long-term care homes. We controlled for residents' sociodemographic and illness characteristics, long-term care home size, chain status, rurality, and nurse practitioner access.ResultsFifty-two homes (32%) reported same-day physician access. Among residents of homes with same-day physician access, 9% had a hospitalization and 20% had an ED visit during follow-up. In contrast, among residents in homes without same-day access, 12% were hospitalized and 22% visited an ED.The adjusted hospitalization and ED rates among residents of homes with same-day physician access were 21% lower (rate ratio = 0.79, P = .02) and 14% lower (rate ratio = 0.86, P = .07), respectively, than residents of other homes. We estimate that nearly 1 in 6 resident hospitalizations could be prevented if all long-term care homes had same-day physician access.Conclusions and implicationsResidents of long-term care homes with same-day physician access experience lower hospitalization and ED visit rates than residents in homes that wait longer for physicians, even after adjusting for important resident and home characteristics. Improved on-demand access to physicians has the potential to reduce hospital transfer rates.     

Exploring variation in rates of polypharmacy across long term care homes

ObjectiveUse of multiple, concurrent drug therapies, often referred to as polypharmacy, is a concern in the long term care (LTC) setting, where frail older adults are particularly at risk for adverse events. We quantified the scope of this practice by exploring variation in the use of nine or more drug therapies across LTC homes.DesignCross-sectional analysis of LTC home census data.SettingAll LTC homes in Ontario, Canada.ParticipantsA total of 64,394 LTC residents aged 66 years and older residing in 589 LTC homes in the fall of 2005.MeasurementsFacility-level rates of polypharmacy were compared with rates of use of Beers criteria and antipsychotic drug therapies. Multivariate logistic regression models were used to assess predictors of polypharmacy across residents and LTC homes.ResultsNine or more drug therapies were dispensed concurrently to 10,007 (15.5%) of LTC home residents. Compared with those dispensed fewer drugs, residents receiving 9 or more drug therapies were more likely to have multiple comorbidities. There was threefold variation in polypharmacy rates across homes (26.2% versus 7.9%) and facility-level rates of polypharmacy were modestly correlated with rates of use of Beers criteria drugs (r = 0.27, P < .001) and antipsychotic drug therapies (r = 0.16, P < .001). Controlling for resident factors, those living in LTC homes with high polypharmacy rates were more likely to receive 9 or more drug therapies (odds ratio 1.9, 95% confidence interval 1.7–2.0).ConclusionResidents in Ontario LTC homes commonly received nine or more concurrent drug therapies, particularly residents with multiple chronic conditions. The threefold variation in rate across homes suggests a role for this measure in guiding drug review at the facility level.     

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.     

Characterizing Emergency Department Use in Assisted Living

ObjectivesLittle is known about emergency department (ED) utilization among the nearly 1 million older adults residing in assisted living (AL) settings. Unlike federally regulated nursing homes, states create and enforce AL regulations with great variability, which may affect the quality of care provided. The objective of this study was to examine state variability in all-cause and injury-related ED use among residents in AL.DesignObservational retrospective cohort study.Setting and ParticipantsWe identified a cohort of 293,336 traditional Medicare beneficiaries residing in larger AL communities (25+ beds).MethodsWith Medicare enrollment and claims data, we identified ED visits and classified those because of injury. We present rates of all-cause and injury-related ED use per 100 person-years in AL, by state, adjusting for age, sex, race, dual-eligibility, and chronic conditions.ResultsRisk-adjusted state rates of all-cause ED visits ranged from 100.9 visits/100 AL person-years [95% confidence interval (CI) 92.8, 109.9] in New Mexico to 162.3 visits/100 AL person-years (95% CI 154.0, 174.7) in Rhode Island. The risk-adjusted rate of injury-related ED visits ranged from 18.7 visits/100 AL person-years (95% CI 17.2, 20.3) in New Mexico to 35.7 visits/100 AL person-years (95% CI 34.7, 36.8) in North Carolina.Conclusions and ImplicationsWe observed significant variability among states in all-cause and injury-related ED use among AL residents. There is an urgent need to better understand why this variability is occurring to prevent avoidable visits to the ED.     

Decomposing Differences in Risk-Adjusted Rates of Emergency Department Visits Between Micropolitan and Urban Nursing Homes

ObjectivesNursing homes (NHs) in micropolitan areas are reported to have different facility and market factors than urban NHs, but how these factors contribute to differences in emergency department (ED) visits remains unknown. This study examined and quantified sources of micropolitan-urban differences in NH risk-adjusted rates of any ED visit, ED without hospitalization or observation stay (outpatient ED), and potentially avoidable ED (PAED) visits of long-stay residents.DesignThe 2011-2013 national Medicare claims and NH Minimum Data Set (MDS) 3.0 were analyzed. We implemented generalized estimating equation models to examine micropolitan-urban differences in ED rates and Blinder-Oaxaca decompositions to quantify the contributions of NH and market factors.Setting and ParticipantsThe study cohort included 12,883 unique privately owned, freestanding NHs from urban and micropolitan areas.MeasuresQuarterly risk-adjusted rates of any ED visits, outpatient ED visits, and PAED visits were calculated from Medicare claims and MDS. NH and market characteristics were extracted from the Certification And Survey Provider Enhanced Reporting and Area Health Resources File.ResultsOver the study period, risk-adjusted rates averaged 10.2%, 3.4%, and 3.3% for any ED, outpatient ED, and PAED visits, respectively. Compared with urban NHs, micropolitan NHs reported similar rates of any ED, but significantly higher rates of outpatient ED and PAED (β = 0.20% and 0.27%; both P < .05). Observable differences in NH characteristics (eg, number of beds, percentage Medicare or Medicaid residents, and employment of nurse practitioners and physician assistants) explained more than 20% of the micropolitan-urban differences in rates of outpatient ED and PAED visits; market factors (mainly Medicare Advantage penetration) explained about 46% of the differences in rates of outpatient ED visits.Conclusions and ImplicationsCompared with urban NHs, micropolitan NHs tend to utilize more avoidable emergency care that can be partially explained by facility size, payer mix, use of nurse practitioners and physician assistants, and market structure.     

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.     

Post-Acute and Long-Term Care Patients Account for a Disproportionately High Number of Adverse Events in the Emergency Department

ObjectivesHigh rates of adverse events (AEs) are reported for post-acute and long-term care settings (PA/LTC: skilled nursing facilities, inpatient rehabilitation centers, long-term acute care facilities, and home health). However, emergency department (ED)-based studies in this area are lacking. We describe all-cause harm among patients from PA/LTC settings seen in the ED.DesignRetrospective observational study using the ED Trigger Tool, with dual independent nurse reviews of 5582 ED records with triggers (findings increasing the likelihood of an AE) and confirmatory physician review of putative AEs.Setting and ParticipantsWe captured data for all adult patients at an urban, academic ED over a 13-month period (92,859 visits). PA/LTC patients were identified using a computerized ED Trigger Tool and manual review (κ = 0.85).MeasuresWe characterize the AEs identified by severity and type using the ED Taxonomy of Adverse Events, and whether the AE occurred in the ED or was present on arrival. We estimate population AE rates using inverse probability weighting.ResultsCompared with non-PA/LTC patients, PA/LTC patients (4.4% of population; 8.2% of our sample) tended to be older (median age 69 vs 50 years), with comparable sex ratios (54% female overall). PA/LTC patients accounted for 21% of all AEs (26% present on arrival; 13% in ED). Rates of AEs occurring in the ED were comparable after matching on age. Present on arrival AEs from a PA/LTC setting were most commonly related to patient care (39%), medication (34%), and infections (16%).Conclusions and ImplicationsPA/LTC patients account for a small proportion of ED visits but experience a disproportionate number of AEs that are primarily present on arrival and patient-care related, and contribute to an admission rate double that for non-PA/LTC patients. Arguably, this cohort represents PA/LTC patients with the most severe AEs. Understanding these AEs may help identify high-yield targets for quality improvement.     

Pathways to reduced emergency department and urgent care center use: Lessons from the comprehensive primary care initiative

ObjectiveTo determine the association between a large‐scale, multi‐payer primary care redesign—the Comprehensive Primary Care (CPC) Initiative—on outpatient emergency department (ED) and urgent care center (UCC) use and to identify the types of visits that drive the overall trends observed.Data SourcesMedicare claims data capturing characteristics and outcomes of 565 674 Medicare fee‐for‐service (FFS) beneficiaries attributed to 497 CPC practices and 1 165 284 beneficiaries attributed to 908 comparison practices.Study DesignWe used an adjusted difference‐in‐differences framework to test the association between CPC and beneficiaries’ ED and UCC use from October 2012 through December 2016. Regression models controlled for baseline practice and patient characteristics and practice‐level clustering of standard errors. Our key outcomes were all‐cause and primary care substitutable (PC substitutable) outpatient ED and UCC visits, and potentially primary care preventable (PPC preventable) ED visits, categorized by the New York University Emergency Department Algorithm. We used a propensity score‐matched comparison group of practices that were similar to CPC practices before CPC on multiple dimensions. Both groups of practices had similar growth in ED and UCC visits in the two‐year period before CPC.Principal FindingsComprehensive Primary Care practices had 2% (P = .06) lower growth in all‐cause ED visits than comparison practices. They had 3% (P = .02) lower growth in PC substitutable ED visits, driven by lower growth in weekday PC substitutable visits (4%, P = .002). There was 3% (P = .04) lower growth in PPC preventable ED visits with no weekday/nonweekday differential. As expected, our falsification test showed no difference in ED visits for injuries. UCC visits had 9% lower growth for both all‐cause (P = .08) and PC substitutable visits (P = .07).ConclusionsOur results suggest that greater access to the practice and more effective primary care both contributed to the lower growth in ED and UCC visits during the initiative.     

Hospital Proximity and Emergency Department Use among Assisted Living Residents

ObjectivesTo examine the relationship between AL communities' distance to the nearest hospital and residents’ rates of emergency department (ED) use. We hypothesize that when access to an ED is more convenient, as measured by a shorter distance, assisted living (AL)-to-ED transfers are more common, particularly for nonemergent conditions.DesignRetrospective cohort study, where the main exposure of interest was the distance between each AL and the nearest hospital.Setting and Participants2018-2019 Medicare claims were used to identify fee-for-service Medicare beneficiaries aged ≥55 years residing in AL communities.MethodsThe primary outcome of interest was ED visit rates, classified into those that resulted in an inpatient hospital admission and those that did not (ie, ED treat-and-release visits). ED treat-and-release visits were further classified, based on the NYU ED Algorithm, as (1) nonemergent; (2) emergent, primary care treatable; (3) emergent, not primary care treatable; and (4) injury-related. Linear regression models adjusting for resident characteristics and hospital referral region fixed effects were used to estimate the relationship between distance to the nearest hospital and AL resident ED use rates.ResultsAmong 540,944 resident-years from 16,514 AL communities, the median distance to the nearest hospital was 2.5 miles. After adjustment, a doubling of distance to the nearest hospital was associated with 43.5 fewer ED treat-and-release visits per 1000 resident years (95% CI −53.1, −33.7) and no significant difference in the rate of ED visits resulting in an inpatient admission. Among ED treat-and-release visits, a doubling of distance was associated with a 3.0% (95% CI −4.1, −1.9) decline in visits classified as nonemergent, and a 1.6% (95% CI −2.4%, −0.8%) decline in visits classified as emergent, not primary care treatable.Conclusions and ImplicationsDistance to the nearest hospital is an important predictor of ED use rates among AL residents, particularly for visits that are potentially avoidable. AL facilities may rely on nearby EDs to provide nonemergent primary care to residents, potentially placing residents at risk of iatrogenic events and generating wasteful Medicare spending.     

Access to Psychiatrist Services for Older Adults in Long-Term Care: A Population-Based Study

ObjectivesAlthough mental health disorders are common among older adults in long-term care (LTC), little is known about access to psychiatric services in LTC. We described the need for psychiatric services in LTC settings and identified variables associated with receipt of psychiatric services.DesignPopulation-based retrospective cohort study.Setting and participantsAll adults aged 66 years and older who resided in LTC homes in Ontario, Canada, between 2015 and 2016. Individuals were included in the study at the time of LTC admission or first annual reassessment.MeasuresWe determined the percentage of LTC residents who received any psychiatric service within 90 days. We then compared the characteristics of individuals who did and did not receive any psychiatric service to determine variables associated with receipt of psychiatric services. Multivariate logistic regression was used to determine independent variables associated with receipt of psychiatric services.ResultsA total of 67,165 unique participants were included in the study sample, 27,650 (41.2%) of whom had identified psychiatric need. Overall, 3175 (4.7%) individuals received any psychiatric service within 90 days following cohort entry. After adjustment for potential confounders, receipt of psychiatric services was positively associated with younger age, male gender, history of major mental disorders, previous receipt of psychiatric services, indicators of psychiatric need, residence in larger LTC homes, and health region of residence.Conclusions/ImplicationsReceiving psychiatric services in Ontario LTC homes is limited when compared to the high need for services. Several factors other than patient need symptoms are associated with receipt of services, which suggests inequities in access to care. Improving the distribution of psychiatric services may help address these inequities, and additional psychiatric resources are also likely required to meet these needs. Our results directly apply to a Canadian context and have implications for other comparable countries, including the United States.     

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.     

Social Connection in Long-Term Care Homes: A Scoping Review of Published Research on the Mental Health Impacts and Potential Strategies During COVID-19

ObjectivesGood social connection is associated with better health and wellbeing. However, social connection has distinct considerations for people living in long-term care (LTC) homes. The objective of this scoping review was to summarize research literature linking social connection to mental health outcomes, specifically among LTC residents, as well as research to identify strategies to help build and maintain social connection in this population during COVID-19.DesignScoping review.Settings and ParticipantsResidents of LTC homes, care homes, and nursing homes.MethodsWe searched MEDLINE(R) ALL (Ovid), CINAHL (EBSCO), PsycINFO (Ovid), Scopus, Sociological Abstracts (ProQuest), Embase and Embase Classic (Ovid), Emcare Nursing (Ovid), and AgeLine (EBSCO) for research that quantified an aspect of social connection among LTC residents; we limited searches to English-language articles published from database inception to search date (July 2019). For the current analysis, we included studies that reported (1) the association between social connection and a mental health outcome, (2) the association between a modifiable risk factor and social connection, or (3) intervention studies with social connection as an outcome. From studies in (2) and (3), we identified strategies that could be implemented and adapted by LTC residents, families and staff during COVID-19 and included the articles that informed these strategies.ResultsWe included 133 studies in our review. We found 61 studies that tested the association between social connection and a mental health outcome. We highlighted 12 strategies, informed by 72 observational and intervention studies, that might help LTC residents, families, and staff build and maintain social connection for LTC residents.Conclusions and ImplicationsPublished research conducted among LTC residents has linked good social connection to better mental health outcomes. Observational and intervention studies provide some evidence on approaches to address social connection in this population. Although further research is needed, it does not obviate the need to act given the sudden and severe impact of COVID-19 on social connection in LTC residents.     

The Effect of Advance Care Planning Intervention on Hospitalization Among Nursing Home Residents: A Systematic Review and Meta-Analysis

ObjectiveTo evaluate the effect of advance care planning (ACP) interventions on the hospitalization of nursing home residents.DesignSystematic review and meta-analysis.Setting and ParticipantsNursing homes and nursing home residents.MethodsA literature search was systematically conducted in 6 electronic databases (Embase, Ovid MEDLINE, Cochrane Library, CINAHL, AgeLine, and the Psychology & Behavioral Sciences Collection), in addition to hand searches and reference list checking; the articles retrieved were those published from 1990 to November 2021. The eligible studies were randomized controlled trials, controlled trials, and pre-post intervention studies describing original data on the effect of ACP on hospitalization of nursing home residents; these studies had to be written in English. Two independent reviewers appraised the quality of the studies and extracted the relevant data using the Joanna Briggs Institute abstraction form and critical appraisal tools. A study protocol was registered in PROSPERO (CRD42022301648).ResultsThe initial search yielded 744 studies. Nine studies involving a total of 57,180 residents were included in the review. The findings showed that the ACP reduced the likelihood of hospitalization [relative risk (RR) 0.54, 95% CI 0.47-0.63; I² = 0%)], it had no effect on emergency department (ED) visits (RR 0.60, 95% CI 0.31-1.42; I² = 99), hospice enrollment (RR 0.98, 95% CI 0.88-1.10; I² = 0%), mortality (RR 0.83, 95% CI 0.68-1.00; I² = 4%), and satisfaction with care (standardized mean difference: ?0.04, 95% CI ?0.14 to ?0.06; I² = 0%).Conclusion and ImplicationsACP reduced hospitalizations but did not affect the secondary outcomes, namely, ED visits, hospice enrollment, mortality, and satisfaction with care. These findings suggest that policy makers should support the implementation of ACP programs in nursing homes. More robust studies are needed to determine the effects of ACP on ED visits, hospice enrollment, mortality, and satisfaction with care.     

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.     

Reducing Avoidable Facility Transfers (RAFT): Outcomes of a Team Model to Minimize Unwarranted Emergency Care at Skilled Nursing Facilities

BackgroundAcute health care interventions for residents of skilled nursing facilities (SNFs) are often unwarranted, unwanted, and/or harmful. We describe a provider-focused care model to reduce unwarranted or unwanted acute health care utilization.ObjectiveAssess the capability of the Reducing Avoidable Facility Transfers (RAFT) model to reduce unwanted and unwarranted acute health care utilization among residents in 3 rural SNFs between January 1, 2016 and June 30, 2017.DesignProspective cohort, pre/post study.SettingThree rural SNFs in collaboration with a geriatric practice in a tertiary academic medical center.ParticipantsPost-acute care (PAC) and long-term care (LTC) residents of 3 rural SNFs.InterventionRAFT includes the following components: (1) a small team of providers who manage longitudinal care and after hours call; (2) elicitation of advance care plans and preferences regarding acute care; (3) standardized communication process engaging the provider at the identification of an acute care event; (4) a biweekly case review of all emergency department (ED) transfers.MeasuresED and hospital utilization.ResultsRAFT demonstrated a 35% reduction in monthly ED transfers and a 30.5% reduction in monthly hospitalizations. These reductions were greatest for LTC residents.Conclusions/ImplicationsThe RAFT approach substantially reduced unwarranted ED and hospital utilization in this study. Results support replication and evaluation in a larger, more diverse setting and population.     

Associations Between Daily Nurse Staffing Levels and Daily Hospitalizations and ED Visits in Nursing Homes

ObjectivesAlthough many prior studies have shown that high average levels of nurse staffing in nursing homes are associated with fewer hospitalizations, some studies have not, suggesting that the average nursing level may mask a more complex relationship. This study examines this issue by investigating the associations of daily staffing patterns and daily hospitalizations and emergency department (ED) visits.DesignRetrospective analyses of national Payroll Based Journal (PBJ) staffing data merged with the Minimum Data Set.Setting and ParticipantsA total of 15,718 nursing homes nationally reporting PBJ data during 2017–2019, their staff, and residents.MethodsWe estimated facility-day-level models as conditional facility fixed-effect Poisson regressions with robust standard errors. The dependent variables were daily numbers of hospitalization and ED visits and the independent variables of interest were the number of registered nurse (RN), licensed practical nurse (LPN), and certified nurse assistant (CNA) hours on the same and prior days.ResultsThe daily number of hospital transfers averaged 0.28 (SD 0.21). Daily total direct-care staffing hours averaged 288.7 (SD 188.2), with RNs accounting for 35.0, LPNs for 68.7, and CNAs for 185.0. Higher staffing was associated with more hospitalizations on the concurrent day. Higher staffing on the day prior was associated with fewer hospitalizations. The effect size was larger for RNs and LPNs (same day = ～2%; prior day = approximately ?0.7% to ?0.9%) than for CNAs (same day <1%; prior day < ?0.5%). ED visits not leading to hospitalizations, and analyses for subsamples exhibited similar findings.Conclusions and ImplicationsOur findings suggest that staff can address developing problems and prevent admissions the next day and identify emergent problems and hospitalize the same day. They also underscore the complex array of nursing home factors involved in hospitalization and ED visits, including the influence of daily staffing variation, suggesting the need for further research to better understand the associations between staffing and appropriate resident transfers to the hospital or the ED, and the potential implications for quality metrics in these domains.     

Evaluating the Effect of COVID-19 Pandemic Lockdown on Long-Term Care Residents’ Mental Health: A Data-Driven Approach in New Brunswick

Long-term care (LTC) residents, isolated because of the COVID-19 pandemic, are at increased risk for negative mental health outcomes. The purpose of our article is to demonstrate how the interRAI LTC facility (LTCF) assessment can inform clinical care and evaluate the effect of strategies to mitigate worsening mental health outcomes during the COVID-19 pandemic. We present a supporting analysis of the effects of lockdown in homes without COVID-19 outbreaks on depression, delirium, and behavior problems in a network of 7 LTC homes in New Brunswick, Canada, where mitigative strategies were deployed to minimize poor mental health outcomes (eg, virtual visits and increased student volunteers). This network meets regularly to review performance on risk-adjusted quality of care indicators from the interRAI LTCF and share learning through a community of practice model. We included 4209 assessments from 765 LTC residents between January 2017 to June 2020 and modeled the change within and between residents for depression, delirium, and behavioral problems over time with longitudinal generalized estimating equations. Though the number of residents who had in-person visits with family decreased from 73.2% before to 17.9% during lockdown (chi square, P < .001), the number of residents experiencing delirium (4.5%-3.5%, P = .51) and behavioral problems (35.5%-30.2%, P = .19) did not change. The proportion of residents with indications of depression decreased from 19.9% before to 11.5% during lockdown (P < .002). The final multivariate models indicate that the effect of lockdown was not statistically significant on depression, delirium, or behavioral problems. Our analyses demonstrate that poor mental health outcomes associated with lockdown can be mitigated with thoughtful intervention and ongoing evaluation with clinical information systems. Policy makers can use outputs to guide resource deployment, and researchers can examine the data to identify better management strategies for when pandemic strikes again.     

High-Intensity Telemedicine Reduces Emergency Department Use by Older Adults With Dementia in Senior Living Communities

ObjectivesIndividuals with dementia have high rates of emergency department (ED) use for acute illnesses. We evaluated the effect of a high-intensity telemedicine program that delivers care for acute illnesses on ED use rates for individuals with dementia who reside in senior living communities (SLCs; independent and assisted living).DesignWe performed a secondary analysis of data for patients with dementia from a prospective cohort study over 3.5 years that evaluated the effectiveness of high-intensity telemedicine for acute illnesses among SLC residents.Setting and participantsWe studied patients cared for by a primary care geriatrics practice at 22 SLCs in a northeastern city. Six SLCs were selected as intervention facilities and had access to patient-to-provider high-intensity telemedicine services to diagnose and treat illnesses. Patients at the remaining 15 SLCs served as controls. Participants were considered to have dementia if they had a diagnosis of dementia on their medical record problem list, were receiving medications for the indication of dementia, or had cognitive testing consistent with dementia.MeasuresWe compared the rate of ED use among participants with dementia and access to high-intensity telemedicine services to control participants with dementia but without access to services.ResultsIntervention group participants had 201 telemedicine visits. In participants with dementia, it is estimated that 1 year of access to telemedicine services is associated with a 24% decrease in ED visits (rate ratio 0.76, 95% confidence interval 0.61, 0.96).Conclusions/ImplicationsTelemedicine in SLCs can effectively decrease ED use by individuals with dementia, but further research is needed to confirm this secondary analysis and to understand how to best implement and optimize telemedicine for patients with dementia suffering from acute illnesses.