Design and Implementation of a Skilled Nursing Facility COVID-19 Unit

Coronavirus disease 2019 (COVID-19) has challenged the health care system's capacity to care for acutely ill patients. In a collaborative partnership between a health system and a skilled nursing facility (SNF), we developed and implemented an SNF COVID-19 unit to allow expedited hospital discharge of COVID-positive older adults who are clinically improving, and to provide an alternative to hospitalization for those who require SNF care but do not require or necessarily desire aggressive disease-modifying interventions.     

Incidence and Outcomes of SARS-CoV-2 in Post-Acute Skilled Nursing Facility Care

ObjectivesTo examine the risk of contracting SARS-CoV-2 during a post-acute skilled nursing facility (SNF) stay and the associated risk of death.DesignCohort study using Minimum Data Set and electronic health record data from a large multistate long-term care provider. Primary outcomes included testing positive for SARS-CoV-2 during the post-acute SNF stay, and death among those who tested positive.Setting and ParticipantsThe sample included all new admissions to the provider's 286 SNFs between January 1 and December 31, 2020. Patients known to be infected with SARS-CoV-2 at the time of admission were excluded.MethodsSARS-CoV-2 infection and mortality rates were measured in time intervals by month of admission. A parametric survival model with SNF random effects was used to measure the association of patient demographic factors, clinical characteristics, and month of admission, with testing positive for SARS-CoV-2.ResultsThe sample included 45,094 post-acute SNF admissions. Overall, 5.7% of patients tested positive for SARS-CoV-2 within 100 days of admission, with 1.0% testing positive within 1-14 days, 1.4% within 15-30 days, and 3.4% within 31-100 days. Of all newly admitted patients, 0.8% contracted SARS-CoV-2 and died, whereas 6.7% died without known infection. Infection rates and subsequent risk of death were highest for patients admitted during the first and third US pandemic waves. Patients with greater cognitive and functional impairment had a 1.45 to 1.92 times higher risk of contracting SARS-CoV-2 than patients with less impairment.Conclusions and ImplicationsThe absolute risk of SARS-CoV-2 infection and death during a post-acute SNF admission was 0.8%. Those who did contract SARS-CoV-2 during their SNF stay had nearly double the rate of death as those who were not infected. Findings from this study provide context for people requiring post-acute care, and their support systems, in navigating decisions around SNF admission during the SARS-CoV-2 pandemic.     

Health Care Costs and Utilization Predictions by the Skilled Nursing Facility Readmission Risk Instrument

ObjectivesHealth care providers at hospitals and skilled nursing facilities (SNFs) are increasingly expected to optimize care of post-acute patients to reduce hospital readmissions and contain costs. To achieve these goals, providers need to understand their patients’ risk of hospital readmission and how this risk is associated with health care costs. A previously developed risk prediction model identifies patients’ probability of 30-day hospital readmission at the time of discharge to an SNF. With a computerized algorithm, we translated this model as the Skilled Nursing Facility Readmission Risk (SNFRR) instrument. Our objective was to evaluate the relationship between 30-day health care costs and hospital readmissions according to the level of risk calculated by this model.DesignThis retrospective cohort study used SNFRR scores to evaluate patient data.Setting and ParticipantsThe patients were discharged from Mayo Clinic Rochester hospitals to 11 area SNFs.MethodsWe compared the outcomes of all-cause 30-day standardized direct medical costs and hospital readmissions between risk quartiles based on the distribution of SNFRR scores for patients discharged to SNFs for post-acute care from April 1 through November 30, 2017.ResultsMean 30-day all-cause standardized costs were positively associated with SNFRR score quartiles and ranged from $9199 in the fourth quartile (probability of readmission, 0.27-0.66) to $2679 in the first quartile (probability of readmission, 0.07-0.13) (P ≤ .05). Patients in the fourth SNFRR score quartile had 5.68 times the odds of 30-day hospital readmission compared with those in the first quartile.Conclusions and ImplicationsThe SNFRR instrument accurately predicted standardized direct health care costs for patients on discharge to an SNF and their risk for 30-day hospital readmission. Therefore, it could be used to help categorize patients for preemptive interventions. Further studies are needed to confirm its validity in other institutions and geographic areas.     

A Structured Tool for Communication and Care Planning in the Era of the COVID-19 Pandemic

Residents in long-term care settings are particularly vulnerable to COVID-19 infections and, compared to younger adults, are at higher risk of poor outcomes and death. Given the poor prognosis of resuscitation outcomes for COVID-19 in general, the specter of COVID-19 in long-term care residents should prompt revisiting goals of care. Visitor restriction policies enacted to reduce the risk of transmission of COVID-19 to long-term care residents requires advance care planning discussions to be conducted remotely. A structured approach can help guide discussions regarding the diagnosis, expected course, and care of individuals with COVID-19 in long-term care settings. Information should be shared in a transparent and comprehensive manner to allay the increased anxiety that families may feel during this time. To achieve this, we propose an evidence-based COVID-19 Communication and Care Planning Tool that allows for an informed consent process and shared decision making between the clinician, resident, and their family.     

Recovery from Coronavirus Disease 2019 among Older Adults in Post-Acute Skilled Nursing Facilities

ObjectivesTo examine functional outcomes of post-acute care for coronavirus disease 2019 (COVID-19) in skilled nursing facilities (SNFs).DesignRetrospective cohort.Setting and ParticipantsSeventy-three community-dwelling adults ≥65 years of age admitted for post-acute care from 2 SNFs from March 15, 2020, to May 30, 2020.Measure(s)COVID-19 status was determined from chart review. Frailty was measured with a deficit accumulation frailty index (FI), categorized into nonfrail, mild frailty, and moderate-to-severe frailty. The primary outcome was community discharge. Secondary outcomes included change in functional status from SNF admission to discharge, based on modified Barthel index (mBI) and continuous functional scale scored by physical (PT) and occupational therapists (OT).ResultsAmong 73 admissions (31 COVID-19 negative, 42 COVID-19 positive), mean [standard deviation (SD)] age was 83.5 (8.8) and 42 (57.5%) were female, with mean FI of 0.31 (0.01) with no differences by COVID-19 status. The mean length of SNF stay for rehabilitation was 21.2 days (SD 11.1) for COVID-19 negative with 20 (64.5%) patients discharged to community, compared to 23.0 (SD 12.2) and 31 (73.8%) among patients who tested positive for COVID-19. Among those discharged to the community, all groups improved in mBI, PT, and OT score. Those with moderate-to-severe frailty (FI >0.35) had lower mBI scores on discharge [92.0 (6.7) not frail, 81.0 (15.4) mild frailty, 48.6 (20.4) moderate-to-severe frailty; P = .002], lower PT scores on discharge [54.2 (3.9) nonfrail, 51.5 (8.0) mild frailty, 37.1 (9.7) moderate-to-severe frailty; P = .002], and lower OT score on discharge [52.9 (3.2) nonfrail, 45.8 (9.4) mild frailty, 32.4 (7.4) moderate or worse frailty; P = .001].Conclusions and ImplicationsOlder adults admitted to a SNF for post-acute care with COVID-19 had community discharge rates and functional improvement comparable to a COVID-19 negative group. However, those who are frailer at admission tended to have lower function at discharge.     

Integration Activities Between Hospitals and Skilled Nursing Facilities: A National Survey

ObjectivesIncreasing recognition of the adverse events older adults experience in post-acute care in skilled nursing facilities (SNFs) has led to multiple efforts to improve care integration between hospitals and SNFs. We sought to measure current care integration activities between hospitals and SNFs.DesignCross-sectional survey.Setting and ParticipantsA total of 500 randomly selected Medicare-certified SNFs in the United States in 2019. The survey inquired about 12 care integration activities with the 2 highest volume referring hospitals for each SNF.MethodsWe collapsed survey responses into 5 categories of integration based on high correlations between the individual measures. These were: (1) formal integration (co-location or co-ownership); (2) informal integration (eg, formal affiliation, participation in SNF collaborative, shared pay for performance, or clinical leadership meetings between hospital and SNF); (3) shared quality/safety activities (eg, initiatives to improve medication safety or reduce hospital admission); (4) shared care coordinators; and/or (5) shared supervising clinicians. We then conducted multivariate regressions to examine associations between different care integration activities and hospital/SNF characteristics.ResultsOur overall response rate was 53.0%, including 265 SNFs that represented 487 SNF-hospital pairs. Informal integration was most common (in 53.3% of pairs), whereas shared clinicians (43.0%), care coordinators (36.5%), shared quality/safety activities (35.1%), and formal integration (7.4%) were present in a minority. Hospital-SNF pairs had lower odds of being formally integrated if the SNF was for-profit compared with not-for-profit [odds ratio (OR) 0.11, 95% confidence interval (CI) 0.03–0.42, adjusted P = .04)] and higher odds of sharing quality improvement activities in metropolitan rather than rural areas (OR 4.06, 95% CI 1.80–9.17, adjusted P = .02) and in the Midwest compared with West (OR 2.95, 95% CI 1.44–6.06, adjusted P = .049).Conclusions and ImplicationsThese findings raise important questions about what is driving variability in hospital-SNF integration activities, and which activities may be most effective for improving transitional care outcomes.     

Recommendations for Welcoming Back Nursing Home Visitors During the COVID-19 Pandemic: Results of a Delphi Panel

ObjectivesNursing homes became epicenters of COVID-19 in the spring of 2020. Due to the substantial case fatality rates within congregate settings, federal agencies recommended restrictions to family visits. Six months into the COVID-19 pandemic, these largely remain in place. The objective of this study was to generate consensus guidance statements focusing on essential family caregivers and visitors.DesignA modified 2-step Delphi process was used to generate consensus statements.Setting and ParticipantsThe Delphi panel consisted of 21 US and Canadian post-acute and long-term care experts in clinical medicine, administration, and patient care advocacy.MethodsState and federal reopening statements were collected in June 2020 and the panel voted on these using a 3-point Likert scale with consensus defined as ≥80% of panel members voting “Agree.” The consensus statements then informed development of the visitor guidance statements.ResultsThe Delphi process yielded 77 consensus statements. Regarding visitor guidance, the panel made 5 strong recommendations: (1) maintain strong infection prevention and control precautions, (2) facilitate indoor and outdoor visits, (3) allow limited physical contact with appropriate precautions, (4) assess individual residents' care preferences and level of risk tolerance, and (5) dedicate an essential caregiver and extend the definition of compassionate care visits to include care that promotes psychosocial well-being of residents.Conclusions and ImplicationsThe COVID-19 pandemic has seen substantial regulatory changes without strong consideration of the impact on residents. In the absence of timely and rigorous research, the involvement of clinicians and patient care advocates is important to help create the balance between individual resident preferences and the health of the collective. The results of this evidence-based Delphi process will help guide policy decisions as well as inform future research.     

Defining Skilled Nursing Facility Residents’ Dining Style Preferences

The desire of skilled nursing facilities to increase quality of service to meet changes in residents’ expectations, improve marketability, and adhere to regulations warrant a new look at culture change and homelike dining as defined by residents in skilled nursing facilities (SNF). The objectives of this study were to determine residents’ home dining practices, to define residents’ desired dining style practices in the SNF, and to determine the relationship between home dining practices and dining preferences in SNF. One hundred and four residents in three SNF in the central Texas area who met the cognition criteria and consumed facility-provided food were engaged in a standardized interview using the Resident Dining Style Preferences Survey. Data were analyzed to determine the degree to which home practices determine SNF dining preferences. Our findings showed that the majority of the participants want hot, home cooked meals served in the dining room. They want to be seated at the table with friends and neighbors and served on every day plates in a quiet atmosphere, with food served restaurant or table service style. Length of stay and generational group were not significant predictors of dining style preferences. Study limitations included small sample size and lack of ethnic diversity. Our study results show that removing dining time restrictions may be the most valuable adaptation for a SNF looking to initiate culture change.     

Risk of Readmission After Discharge From Skilled Nursing Facilities Following Heart Failure Hospitalization: A Retrospective Cohort Study

Objective

Discharge to skilled nursing facilities (SNFs) is common in patients with heart failure (HF). It is unknown whether the transition from SNF to home is risky for these patients. Our objective was to study outcomes for the 30 days after discharge from SNF to home among Medicare patients hospitalized with HF who had subsequent SNF stays of 30 days or less.

Project ReEngineered Discharge (RED) Lowers Hospital Readmissions of Patients Discharged From a Skilled Nursing Facility

Context

Patients admitted to skilled nursing facilities (SNFs) have a high risk for rehospitalization.

Objective

The goal of this project was to implement Project RED in an SNF to increase patient preparedness for care transitions and lower rehospitalization rates in the 30 days after discharge from the SNF facility.

Design

Intervention study with historical control; phone survey 30 days after discharge from the SNF for data collection.

Setting

The study was conducted in an SNF admitting patients from acute care hospitals in Boston, MA.

Patients or Other Participants

A consecutive sample of patients in the SNF before (n = 524) and after initiation (n = 100) of the intervention. Participants had an average age of 80 (SD = 10), 67% were female, and 84% were non-Hispanic white. Phone surveys were completed with 88% of participants in each group.

Intervention(s)

We adapted Project RED for use in an SNF. This includes a comprehensive approach to transitions of care that includes creating and teaching a personalized care plan to patients and their families. Software facilitating these activities was integrated into the electronic medical record of the SNF; intervention activities were delivered by existing staff.

Main Outcome Measure(s)

The main outcome was hospital readmission within 30 days of discharge from the SNF. Secondary outcomes included attendance to a medical appointment within 30 days of discharge from the SNF and preparedness for care transitions as measured by a 6-item survey.

Results

The rate of hospitalization 30 days after discharge from the SNF for participants prior to the intervention was 18.9% and for participants during the intervention was 10.2 %, P < .05. This remained significant adjusting for multiple potential confounders (P = .045). More patients in the intervention group had attended an outpatient appointment within 30 days of discharge (70.5% versus 52.0%, P < .003). In addition, intervention participants reported a higher level of preparedness for care transitions.

Conclusions

Patients in the intervention had a lower rate of returning to the hospital within 30 days of discharge from the SNF, were more likely to attend medical appointments, and were better prepared for their care transition.     

Solving the COVID-19 Crisis in Post-Acute and Long-Term Care

Our nation's nursing home industry has been in need of overhaul for decades—a situation made all the more evident by COVID-19. AMDA–The Society for Post-Acute and Long-Term Care Medicine is dedicated to quality in post-acute and long-term care process and outcomes. This special article presents 5 keys to solving the COVID-19 crisis in post-acute and long-term care, related to policy, collaboration, individualization, leadership, and reorganization. Taking action during this crisis may prevent sinking back into the complacency and habits of our pre-COVID-19 lives.     

Long-Term Care,Residential Facilities,and COVID-19: An Overview of Federal and State Policy Responses

The COVID-19 pandemic has disproportionately affected residents and staff at long-term care (LTC) and other residential facilities in the United States. The high morbidity and mortality at these facilities has been attributed to a combination of a particularly vulnerable population and a lack of resources to mitigate the risk. During the first wave of the pandemic, the federal and state governments received urgent calls for help from LTC and residential care facilities; between March and early June of 2020, policymakers responded with dozens of regulatory and policy changes. In this article, we provide an overview of these responses by first summarizing federal regulatory changes and then reviewing state-level executive orders. The policy and regulatory changes implemented at the federal and state levels can be categorized into the following 4 classes: (1) preventing virus transmission, which includes policies relating to visitation restrictions, personal protective equipment guidance, and testing requirements; (2) expanding facilities' capacities, which includes both the expansion of physical space for isolation purposes and the expansion of workforce to combat COVID-19; (3) relaxing administrative requirements, which includes measures enacted to shift the attention of caretakers and administrators from administrative requirements to residents' care; and (4) reporting COVID-19 data, which includes the reporting of cases and deaths to residents, families, and administrative bodies (such as state health departments). These policies represent a snapshot of the initial efforts to mitigate damage inflicted by the pandemic. Looking ahead, empirical evaluation of the consequences of these policies—including potential unintended effects—is urgently needed. The recent availability of publicly reported COVID-19 LTC data can be used to inform the development of evidence-based regulations, though there are concerns of reporting inaccuracies. Importantly, these data should also be used to systematically identify hot spots and help direct resources to struggling facilities.     

Nursing Home Design and COVID-19: Implications for Guidelines and Regulation

ObjectivesNursing homes (NHs) are important health care and residential environments for the growing number of frail older adults. The COVID-19 pandemic highlighted the vulnerability of NHs as they became COVID-19 hotspots. This study examines the associations of NH design with COVID-19 cases, deaths, and transmissibility and provides relevant design recommendations.DesignA cross-sectional, nationwide study was conducted after combining multiple national data sets about NHs.Setting and ParticipantsA total of 7785 NHs were included in the study, which represent 50.8% of all Medicare and/or Medicaid NH providers in the United States.MethodsZero-inflated negative binomial models were used to predict the total number of COVID-19 resident cases and deaths, separately. The basic reproduction number (R₀) was calculated for each NH to reflect the transmissibility of COVID-19 among residents within the facility, and a linear regression model was estimated to predict log(R₀ – 1). Predictors of these models included community factors and NHs’ resident characteristics, management and rating factors, and physical environmental features.ResultsIncreased percentage of private rooms, larger living area per bed, and presence of a ventilator-dependent unit are significantly associated with reductions in COVID-19 cases, deaths, and transmissibility among residents. After setting the number of actual residents as the exposure variable and controlling for staff cases and other variables, increased number of certified beds in the NH is associated with reduced resident cases and deaths. It also correlates with reduced transmissibility among residents when other risk factors, including staff cases, are controlled.Conclusions and ImplicationsArchitectural design attributes have significant impacts on COVID-19 transmissions in NHs. Considering the vulnerability of NH residents in congregated living environments, NHs will continue to be high-risk settings for infection outbreaks. To improve safety and resilience of NHs against future health disasters, facility guidelines and regulations should consider the need to increase private rooms and living areas.     

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

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

Disease Management in Skilled Nursing Facilities Improves Outcomes for Patients With a Primary Diagnosis of Heart Failure

ObjectiveSkilled nursing facilities (SNFs) are common destinations after hospitalization for patients with heart failure (HF). Our objective was to determine if patients in SNFs with a primary hospital discharge diagnosis of HF benefit from an HF disease management program (HF-DMP).DesignThis is a subgroup analysis of multisite, physician and practice blocked, cluster-randomized controlled trial of HF-DMP vs usual care for patients in SNF with an HF diagnosis. The HF-DMP standardized SNF HF care using HF practice guidelines and performance measures and was delivered by an HF nurse advocate.Setting and ParticipantsPatients with a primary hospital discharge diagnosis of HF discharged to SNF.MethodsComposite outcome of all-cause hospitalization, emergency department visits, and mortality were evaluated at 30 and 60 days post SNF admission. Linear mixed models accounted for patient clustering at the physician level.ResultsOf 671 individuals enrolled in the main study, 125 had a primary hospital discharge diagnosis of HF (50 HF-DMP; 75 usual care). Mean age was 79 ± 10 years, 53% women, and mean ejection fraction 46% ± 15%. At 60 days post SNF admission, the rate of the composite outcome was lower in the HF-DMP group (30%) compared with usual care (52%) (P = .02). The rate of the composite outcome at 30 days for the HF-DMP group was 18% vs 31% in the usual care group (P = .11).Conclusions and ImplicationsPatients with a primary hospital discharge diagnosis of HF who received HF-DMP while cared for in an SNF had lower rates of the composite outcome at 60 days. Standardized HF management during SNF stays may be important for patients with a primary discharge diagnosis of HF.     

Transitions From Skilled Nursing Facility to Home: The Relationship of Early Outpatient Care to Hospital Readmission

Background

Many adults are discharged to skilled nursing facilities (SNFs) prior to returning home from the hospital. Patient characteristics and factors that can help to prevent postdischarge adverse outcomes are poorly understood.

How a Barcelona Post-Acute Facility became a Referral Center for Comprehensive Management of Subacute Patients With COVID-19

The COVID-19 pandemic's greatest impact is among older adults. Management of the situation requires a systemic response, and post-acute care (PAC) can provide an adequate mix of active treatment, management of associated geriatric syndromes and palliative care, both in the acute phase, and in post–COVID-19 recovery. In the region of Catalonia, Spain, selected PAC centers have become sites to treat older patients with COVID-19. Referrals come from the emergency department or COVID-19 wards of the acute reference hospitals, nursing homes, or private homes. We critically review the actions taken by Parc Sanitari Pere Virgili, a PAC facility in Barcelona, to manage the pandemic, including its administration, health care, communication, psychological support, and ethical frameworks. We believe that the strategies we used and the lessons we learned can be useful for other sites and countries where similar adaptation of existing facilities may be implemented.     

Implementation of a Person-Centered Medical Care Model in a Skilled Nursing Facility: A Pilot Evaluation

Objectives

The objective of this study was to evaluate the feasibility and impact of implementing a person-centered medical care model for post-acute care residents within a skilled nursing facility (SNF).