Advance Care Planning in Dutch Nursing Homes During the First Wave of the COVID-19 Pandemic

ObjectivesTo explore how physicians in Dutch nursing homes practiced advance care planning (ACP) during the first wave of the COVID-19 pandemic, and to explore whether and how ACP changed during the first wave of the pandemic.DesignQualitative analysis of an online, mainly open-ended questionnaire on ACP among physicians working in nursing homes in the Netherlands during the first wave of the COVID-19 pandemic.Setting and ParticipantsPhysicians in Dutch nursing homes.MethodsRespondents were asked to describe a recent case in which they had a discussion on anticipatory medical care decisions and to indicate whether ACP was influenced by the COVID-19 pandemic in that specific case and in general. Answers were independently coded and a codebook was compiled in which the codes were ordered by themes that emerged from the data.ResultsA total of 129 questionnaires were filled out. Saturation was reached after analyzing 60 questionnaires. Four main themes evolved after coding the questionnaires: reasons for ACP discussion, discussing ACP, topics discussed in ACP, and decision making in ACP. COVID-19–specific changes in ACP indicated by respondents included (1) COVID-19 infection as a reason for initiating ACP, (2) a higher frequency of ACP discussions, (3) less face-to-face contact with surrogate decision makers, and (4) intensive care unit admission as an additional topic in anticipatory medical decision making.Conclusions and ImplicationsACP in Dutch nursing homes has changed because of the COVID-19 pandemic. Maintaining frequent and informal contact with surrogate decision makers fosters mutual understanding and aids the decision-making process in ACP.     

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.     

Hospital-at-Home Expands Hospital Capacity During COVID-19 Pandemic

A Coronavirus Disease 2019 (COVID-19)–specific Hospital-at-Home was implemented in a 400-bed tertiary hospital in Barcelona, Spain. Senior or immune-compromised physicians oversaw patient care. The alternative to inpatient care more than doubled beds available for hospitalization and decreased the risk of transmission among patients and health care professionals. Mild cases from either the emergency department or after hospital discharge were deemed suitable for admission to the Hospital-at-Home. More than half of all patients had pneumonia. Standardized protocols and management criteria were provided. Only 6% of cases required referral for inpatient hospitalization. These results are promising and may provide valuable insight for centers undertaking Hospital-at-Home initiatives or in the case of new COVID-19 outbreaks.     

A Novel Collaborative Care Program to Augment Nursing Home Care During and After the COVID-19 Pandemic

The 2019 novel coronavirus (COVID-19) pandemic created an immediate need to enhance current efforts to reduce transfers of nursing home (NH) residents to acute care. Long-Term Care Plus (LTC+), a collaborative care program developed and implemented during the COVID-19 pandemic, aimed to enhance care in the NH setting while also decreasing unnecessary acute care transfers. Using a hub-and-spoke model, LTC+ was implemented in 6 hospitals serving as central hubs to 54 geographically associated NHs with 9574 beds in Toronto, Canada. LTC+ provided NHs with the following: (1) virtual general internal medicine (GIM) consultations; (2) nursing navigator support; (3) rapid access to laboratory and diagnostic imaging services; and (4) educational resources. From April 2020 to June 2021, LTC+ provided 381 GIM consultations that addressed abnormal bloodwork (15%), cardiac problems (13%), and unexplained fever (11%) as the most common reasons for consultation. Sixty-five nurse navigator calls addressed requests for non-GIM specialist consultations (34%), wound care assessments (14%), and system navigation (12%). One hundred seventy-seven (46%, 95% CI 41%-52%) consults addressed care concerns sufficiently to avoid the need for acute care transfer. All 36 primary care physicians who consulted the LTC+ program reported strong satisfaction with the advice provided. Early results demonstrate the feasibility and acceptability of an integrated care model that enhances care delivery for NH residents where they reside and has the potential to positively impact the long-term care sector by ensuring equitable and timely access to care for people living in NHs. It represents an important step toward health system integration that values the expertise within the long-term care sector.     

Trends in Post-Acute Care Utilization During the COVID-19 Pandemic

ObjectiveTo examine the effect of the COVID-19 pandemic on post-acute care utilization and spending.DesignWe used a large national multipayer claims data set from January 2019 through October 2020 to examine trends in posthospital discharge location and spending.Setting and participantsWe identified and included 975,179 hospital discharges who were aged ≥65 years.MethodsWe summarized postdischarge utilization and spending in each month of the study: (1) the percentage of patients discharged from the hospital to home for self-care and to the 3 common post-acute care locations: home with home health, skilled nursing facility (SNF), and inpatient rehabilitation; (2) the rate of discharge to each location per 100,000 insured members in our cohort; (3) the total amount spent per month in each post-acute care location; and (4) the percentage of spending in each post-acute care location out of the total spending across the 3 post-acute care settings.ResultsThe percentage of patients discharged from the hospital to home or to inpatient rehabilitation did not meaningfully change during the pandemic whereas the percentage discharged to SNF declined from 19% of discharges in 2019 to 14% by October 2020. Total monthly spending declined in each of the 3 post-acute care locations, with the largest relative decline in SNFs of 55%, from an average of $42 million per month in 2019 to $19 million in October 2020. Declines in total monthly spending were smaller in home health (a 41% decline) and inpatient rehabilitation (a 32% decline). As a percentage of all post-acute care spending, spending on SNFs declined from 39% to 31%, whereas the percentage of post-acute care spending on home health and inpatient rehabilitation both increased.Conclusions and ImplicationsChanges in posthospital discharge location of care represent a significant shift in post-acute care utilization, which persisted 9 months into the pandemic. These shifts could have profound implications on the future of post-acute care.     

Pandemic Care Through Collaboration: Lessons From a COVID-19 Field Hospital

During the surge of Coronavirus Disease 2019 (COVID-19) infections in March and April 2020, many skilled-nursing facilities in the Boston area closed to COVID-19 post-acute admissions because of infection control concerns and staffing shortages. Local government and health care leaders collaborated to establish a 1000-bed field hospital for patients with COVID-19, with 500 respite beds for the undomiciled and 500 post-acute care (PAC) beds within 9 days. The PAC hospital provided care for 394 patients over 7 weeks, from April 10 to June 2, 2020. In this report, we describe our implementation strategy, including organization structure, admissions criteria, and clinical services. Partnership with government, military, and local health care organizations was essential for logistical and medical support. In addition, dynamic workflows necessitated clear communication pathways, clinical operations expertise, and highly adaptable staff.     

Malnutrition Care During the COVID-19 Pandemic: Considerations for Registered Dietitian Nutritionists

Recent evidence examining adults infected with coronavirus disease 2019 (COVID-19) has indicated a significant impact of malnutrition on health outcomes. Individuals who have multiple comorbidities, are older adults, or who are malnourished, are at increased risk of being admitted to the intensive care unit and of mortality from COVID-19 infections. Therefore, nutrition care to identify and address malnutrition is critical in treating and preventing further adverse health outcomes from COVID-19 infection. This document provides guidance and practice considerations for registered dietitian nutritionists providing nutrition care for adults with suspected or confirmed COVID-19 infection in the hospital, outpatient, or home care settings. In addition, this document discusses and provides considerations for registered dietitian nutritionists working with individuals at risk of malnutrition secondary to food insecurity during the COVID-19 pandemic.     

Ensuring Racial Equity in Pregnancy Care During the COVID-19 Pandemic and Beyond

Maternal and Child Health Journal - The COVID-19 pandemic provoked sweeping changes in practice to care for pregnant and birthing people, and highlighted inequities that threaten to exacerbate...     

Comprehensive Geriatric Hospital at Home: Adaptation to Referral and Case-Mix Changes During the COVID-19 Pandemic

ObjectivesTo describe the evolution of a Hospital at Home (HAH) based on comprehensive geriatric assessment (CGA), including its adaptability to changing case-mixes and pathways during the COVID-19 pandemic.DesignObservational study of consecutive admissions to a combined step-up (admissions from home) and step-down (hospital discharge) HAH during 3 periods: prepandemic (2018?February 2020) vs pandemic (March?December 2020, and January?December 2021).Setting and ParticipantsParticipants were all consecutive patients admitted to a CGA-based HAH, located in Barcelona, Spain. Referrals followed acute events or exacerbation of chronic conditions, by either primary care (step-up) or after post-acute discharge (step-down).MethodsHAH intervention based on CGA and incorporated geriatric rehabilitation. Patient case-mix, functional evolution (Barthel index), and mortality were compared across periods and between pathways.ResultsHAH capacity expanded 3 fold from 15 to 45 virtual beds and altogether managed 688 consecutive patients [mean age (SD) = 82.5 (9.6) years; 59% women]. Pandemic case-mix was slightly older (mean age = 83.5 vs 82 years, P = .012) than prepandemic, with greater mobility impairment. Across periods, step-up increased (26.1%, 40.9%, 48.2%, P < .01) because of medical events, skin ulcers, and post-acute stroke, whereas step-down decreased; multivariable models showed no differences in functional improvement or mortality. When comparing pathways, step-up featured older patients with higher comorbidity, worse functional status, and lower absolute functional gain than step-down (5.6 vs 13 points of Barthel index, P < .01), remaining statistically significant after adjusting for covariates (P = .003); no differences in mortality were observed.Conclusions and ImplicationsA multipurpose, step-down and step-up CGA HAH expanded its activity and adapted to changing case-mixes and pathways throughout COVID-19 pandemic waves. Although further quantitative and qualitative studies are needed to assess the impact of this model, our results suggest that harnessing the adaptability of HAH may help advance a paradigm shift toward more person-centered, cost-effective models of clinical care aimed at older adults.     

Pandemic Birthing: Childbirth Satisfaction,Perceived Health Care Bias,and Postpartum Health During the COVID-19 Pandemic

Maternal and Child Health Journal - To examine the impact of the COVID-19 pandemic on birth satisfaction and perceived health care discrimination during childbirth, and in turn, the influence of...     

Burnout and Associated Factors Among Health Care Workers in Singapore During the COVID-19 Pandemic

ObjectivesThe strain on health care systems due to the COVID-19 pandemic has led to increased psychological distress among health care workers (HCWs). As this global crisis continues with little signs of abatement, we examine burnout and associated factors among HCWs.DesignCross-sectional survey study.Setting and ParticipantsDoctors, nurses, allied health professionals, administrative, and support staff in 4 public hospitals and 1 primary care service in Singapore 3 months after COVID-19 was declared a global pandemic.MethodsStudy questionnaire captured demographic and workplace environment information and comprised 3 validated instruments, namely the Oldenburg Burnout Inventory (OLBI), Safety Attitudes Questionnaire (SAQ), and Hospital Anxiety and Depression Scale (HADS). Multivariate mixed model regression analyses were used to evaluate independent associations of mean OLBI-Disengagement and -Exhaustion scores. Further subgroup analysis was performed among redeployed HCWs.ResultsAmong 11,286 invited HCWs, 3075 valid responses were received, giving an overall response rate of 27.2%. Mean OLBI scores were 2.38 and 2.50 for Disengagement and Exhaustion, respectively. Burnout thresholds in Disengagement and Exhaustion were met by 79.7% and 75.3% of respondents, respectively. On multivariate regression analysis, Chinese or Malay ethnicity, HADS anxiety or depression scores ≥8, shifts lasting ≥8 hours, and being redeployed were significantly associated with higher OLBI mean scores, whereas high SAQ scores were significantly associated with lower scores. Among redeployed HCWs, those redeployed to high-risk areas in a different facility (offsite) had lower burnout scores than those redeployed within their own work facility (onsite). A higher proportion of HCWs redeployed offsite assessed their training to be good or better compared with those redeployed onsite.Conclusions and ImplicationsEvery level of the health care workforce is susceptible to high levels of burnout during this pandemic. Modifiable workplace factors include adequate training, avoiding prolonged shifts ≥8 hours, and promoting safe working environments. Mitigating strategies should target every level of the health care workforce, including frontline and nonfrontline staff. Addressing and ameliorating burnout among HCWs should be a key priority for the sustainment of efforts to care for patients in the face of a prolonged pandemic.