COVID-19 Recommendations for Assisted Living: Implications for the Future

ObjectivesAssisted living (AL) emerged over 2 decades ago as a preferred residential care option for older adults who require supportive care; however, as resident acuity increased, concern has been expressed whether AL sufficiently addresses health care needs. COVID-19 amplified those concerns, and an examination of recommendations to manage COVID-19 may shed light on the future of AL. This review summarizes recommendations from 6 key organizations related to preparation for and response to COVID-19 in AL in relation to resident health and quality of life; compares recommendations for AL with those for nursing homes (NHs); and assesses implications for the future of AL.DesignNonsystematic review involving search of gray literature.Setting and ParticipantsRecommendations from key governmental bodies and professional societies regarding COVID-19 in AL, long-term care facilities (LTCFs) in general, and NHs.MeasuresWe collected, categorized, and summarized these recommendations as they pertained to quality of life and health care.ResultsMany recommendations for AL and NHs were similar, but differences provided insight into ways the pandemic was recognized and challenged AL communities in particular: recommending more flexible visitation and group activities for AL, providing screening by AL staff or an outside provider, and suggesting that AL staff access resources to facilitate advance care planning discussions. Recommendations were that AL integrate health care into offered services, including working with consulting clinicians who know both the residents and the LTC community.Conclusions and ImplicationsLong-term care providers and policy makers have recognized the need to modify current long-term care options. Because COVID-19 recommendations suggest AL communities would benefit from the services and expertise of social workers, licensed nurses, and physicians, it may accelerate the integration and closer coordination of psychosocial and medical care into AL. Future research should investigate different models of integrated, interdisciplinary health care in AL.     

Repercusiones del confinamiento por COVID-19 en pacientes crónicos de Andalucía

ObjectiveTo understand the consequences of the COVID-19 pandemic lockdown on the self-care of people living with chronic diseases and on their self-perceived health, and to identify factors that may influence the management of their disease in emergency situations.MethodA qualitative study conducted in 2020 (March and April) in Andalusia (Spain) during the COVID-19 pandemic lockdown, through virtual focus groups, using the Zoom telematics tool. Three virtual focus groups were conducted, including 34 patients from Andalusia with different chronic conditions such as arthritis, diabetes, cardiovascular disease, inflammatory bowel disease, breast cancer and fibromyalgia.ResultsPeople with chronic diseases reported effects of the lockdown in relation to their emotional experience, their coping resources, the information they received, the difficulties to manage self-care, and the contact or access to health services. They also suggested some lessons learned for the future. The need for more and better information, patient training, involving patient associations, and improving telematics access to health services are the main areas for improvement to minimize the impact of future quarantines on the self-care and the health of people with chronic diseases.ConclusionsBesides the risk of contracting COVID-19, the difficulties encountered by people with chronic diseases during the lockdown include interferences in the self-care and the health care received. Health crisis situations demand more information, training for patients and improvements in the health services accessibility for patients with chronic conditions.     

The impact of digital competence on telehealth utilization

ObjectivesTelehealth use has increased steadily since the mid-2000′s when technology shifted from voice-only systems to live video-conferencing and other technologies supported by broadband Internet. More recently, the COVID-19 pandemic has resulted in exponential growth in telehealth use. As telehealth systems become increasingly complex and gain widespread adoption, this study explores how users’ digital competences affect telehealth use.MethodsWe apply a series of multivariate logit models to a representative sample of California adults with Internet access surveyed in early 2021. We estimate the impact of self-reported digital competence–using items from the digital skills assessment scale–on a participant's likelihood of telehealth use during the COVID-19 pandemic as well as the likelihood to continue using telehealth beyond the pandemic.ResultsThe findings show that a one-unit increase in digital competence is associated with 72.8% greater odds of telehealth use (p <0.001) and 71.6% greater odds of willingness to continue using telehealth services beyond the pandemic (p<.01). We also found that greater social and economic capital generally were associated with increased odds of telehealth use.ConclusionsImproving access to telehealth will require solutions addressing both the first level (i.e., access to broadband and devices) and the second level (i.e., skills and attitudes towards the internet) of digital inequality. Policies and programs seeking to expand internet access must be coupled with investments in digital upskilling and training. Those with limited digital competence will face continued barriers in navigating telehealth systems, further exacerbating disparities in healthcare access and outcomes.Public Interest SummaryDigital competence is the ability and confidence to apply one's knowledge and skills to perform tasks through information technology, including computing devices and the internet. This study explores the relationship between digital competence and telehealth use among those with broadband internet access at home. Telehealth has become increasingly common due to its cost-effectiveness and accessibility for patients unable to visit healthcare facilities. Though the COVID-19 pandemic has contributed to a significant increase in telehealth use, it is expected that telehealth services will continue to expand after the pandemic subsides. In our analysis of California adults, a year into the pandemic, we find those with greater digital competence are more likely to have used telehealth during the pandemic. Further, among telehealth users, those with greater digital competence are more likely to continue using telehealth beyond the pandemic. Addressing disparities in healthcare access and outcomes will require improving potential users’ digital competence.     

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.     

Caring for a Relative With Dementia in Long-Term Care During COVID-19

ObjectivesThe COVID-19 pandemic created unique stressors for caregivers of persons with dementia living in long-term care (LTC) facilities. The purpose of this qualitative study was to identify the challenges associated with caring for a relative with dementia in LTC during the pandemic, as well as resources, strategies, and practices caregivers found helpful in coping with COVID-19.DesignThis study was conducted within the context of an ongoing randomized controlled trial of a psychosocial intervention to support caregivers. Open-ended survey responses (n = 125) and semistructured interviews with a subset of the sample (n = 20) collected between June 2020 and June 2021 explored caregivers' experiences during COVID-19.Setting and ParticipantsParticipants included 125 family caregivers of persons with dementia living in residential LTC.MethodsThematic analysis was used to identify themes capturing caregivers' experiences.ResultsIn addition to concerns about COVID-19 infection, participants reported key challenges such as the difficulty of maintaining contact with relatives because of visiting restrictions, lack of information about relatives' health and well-being, worries about overburdened LTC staff, impossibility of returning relatives home from the LTC facility, and fears about relatives dying alone. Participants also identified resources, strategies, and practices that they perceived as helpful, including effective infection prevention within the LTC facility, good communication with LTC staff, and creative strategies for connecting with their relatives.Conclusions and ImplicationsThis qualitative analysis informs recommendations for practice within LTC facilities, as well as supports that may help caregivers manage stressful situations in the context of COVID-19. Vaccination and testing protocols should be implemented to maximize family caregivers' opportunities for in-person contact with relatives in LTC, as alternative visiting modalities were often unsatisfactory or unfeasible. Informing caregivers regularly about individual residents' needs and status is crucial. Supports for bereaved caregivers should address complicated grief and feelings of loss.     

Evidence of Social and Structural COVID-19 Disparities by Sexual Orientation,Gender Identity,and Race/Ethnicity in an Urban Environment

The ongoing COVID-19 pandemic has had widespread social, psychological, and economic impacts. However, these impacts are not distributed equally: already marginalized populations, specifically racial/ethnic minority groups and sexual and gender minority populations, may be more likely to suffer the effects of COVID-19. The COVID-19 Resiliency Survey was conducted by the city of Chicago to assess the impact of COVID-19 on city residents in the wake of Chicago’s initial lockdown, with particular focus on the experiences of minority populations. Chi-square tests of independence were performed to compare COVID-19-related outcomes and impacts on heterosexual vs. sexual minority populations, cisgender vs. gender minority populations, and White vs. racial/ethnic minority subgroups. Marginalized populations experienced significant disparities in COVID-19 exposure, susceptibility, and treatment access, as well as in psychosocial effects of the pandemic. Notably, Black and Latinx populations reported significant difficulties accessing food and supplies (p = 0.002). Healthcare access disparities were also visible, with Black and Latinx respondents reporting significantly lower levels of access to a provider to see if COVID-19 testing would be appropriate (p = 0.013), medical services (p = 0.001), and use of telehealth for mental health services (p = 0.001). Sexual minority respondents reported significantly lower rates of using telehealth for mental health services (p = 0.011), and gender minority respondents reported significantly lower levels of primary care provider access (p = 0.016). There are evident COVID-19 disparities experienced in Chicago especially for Black, Latinx, sexual minority, and gender minority groups. A greater focus must be paid to health equity, including providing increased resources and supplies for affected groups, adapting to inequities in the built environment, and ensuring adequate access to healthcare services to ameliorate the burden of COVID-19 on these marginalized populations.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11524-020-00497-9.     

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.     

Telehealth Demand Trends During the COVID-19 Pandemic in the Top 50 Most Affected Countries: Infodemiological Evaluation

BackgroundThe COVID-19 pandemic has led to urgent calls for the adoption of telehealth solutions. However, public interest and demand for telehealth during the pandemic remain unknown.ObjectiveWe used an infodemiological approach to estimate the worldwide demand for telehealth services during COVID-19, focusing on the 50 most affected countries and comparing the demand for such services with the level of information and communications technology (ICT) infrastructure available.MethodsWe used Google Trends, the Baidu Index (China), and Yandex Keyword Statistics (Russia) to extract data on worldwide and individual countries’ telehealth-related internet searches from January 1 to July 7, 2020, presented as relative search volumes (RSV; range 0-100). Daily COVID-19 cases and deaths were retrieved from the World Health Organization. Individual countries’ ICT infrastructure profiles were retrieved from the World Economic Forum Report.ResultsAcross the 50 countries, the mean RSV was 18.5 (SD 23.2), and the mean ICT index was 62.1 (SD 15.0). An overall spike in worldwide telehealth-related RSVs was observed from March 11, 2020 (RSV peaked to 76.0), which then tailed off in June-July 2020 (mean RSV for the period was 25.8), but remained higher than pre-March RSVs (mean 7.29). By country, 42 (84%) manifested increased RSVs over the evaluation period, with the highest observed in Canada (RSV=100) and the United States (RSV=96). When evaluating associations between RSV and the ICT index, both the United States and Canada demonstrated high RSVs and ICT scores (≥70.3). In contrast, European countries had relatively lower RSVs (range 3.4-19.5) despite high ICT index scores (mean 70.3). Several Latin American (Brazil, Chile, Colombia) and South Asian (India, Bangladesh, Pakistan) countries demonstrated relatively higher RSVs (range 13.8-73.3) but low ICT index scores (mean 44.6), indicating that the telehealth demand outstrips the current ICT infrastructure.ConclusionsThere is generally increased interest and demand for telehealth services across the 50 countries most affected by COVID-19, highlighting the need to scale up telehealth capabilities, during and beyond the pandemic.     

Telehealth for Contraceptive Services During the COVID-19 Pandemic: Provider Perspectives

BackgroundTelehealth use rapidly increased during the COVID-19 pandemic, including for contraceptive care (e.g., counseling and method provision). This study explored providers’ experiences with contraceptive care via telehealth.MethodsWe conducted a survey with open-ended responses among contraceptive providers across the United States. The study population included physicians, nurse practitioners, health educators, and other health professionals (n = 546). Data were collected from April 10, 2020, to January 29, 2021. We conducted qualitative content analysis of the open-ended responses.ResultsProviders highlighted the benefits of telehealth, including continuing access to contraceptive services and accommodating patients who faced challenges attending in-person contraceptive visits. Providers at school-based health centers reported telehealth allowed them to reach young people while schools were closed. However, many providers noted a lack of patient awareness about the availability of telehealth services and disparities in access to technology. Providers felt there was less personal connection in virtual contraceptive counseling, noted challenges with confidentiality, and expressed concern about the inability to provide the full range of contraceptive methods through telehealth alone.ConclusionsThe pandemic significantly impacted contraceptive health care delivery. Telehealth has sustained access to contraception in important ways, but has been accompanied by various challenges, including technological access and confidentiality. As hybrid models of care evolve, it is important to assess how telehealth can play a role in providing contraceptive care while addressing its barriers.     

The Association of Service Use and Other Client Factors with the Time to Transition from Home Care to Facility-Based Care

ObjectivesPeople are living longer with complex health needs and wish to remain in their homes as their care needs change. We examined which client factors (sociodemographic, health service use, health, and function) influenced older persons’ (≥65 years) time to transition from home living to assisted living (AL) or long-term care (LTC) facilities.DesignRetrospective cohort study.Setting and ParticipantsLong-term services and supports in Alberta, Canada. Long-stay home care clients (≥65 years) who received a Resident Assessment Instrument–Home Care (RAI-HC) assessment between 2014 and 2018.MeasuresWe assessed time from initial receipt of long-term home care to AL and LTC facility transitions, using Cox proportional hazard regressions, and a provincial continuing care data repository (Alberta Continuing Care Information System). We adjusted for client sociodemographic, health, function, and health service use variables. The outcome was time from initial long-term home care receipt to transition to facility living.ResultsWe included 33,432 home care clients. Clients who were visited by care aides once in the last 7 days transitioned to AL later than those with no care aide visits [hazard ratio (HR) 0.976, 95% confidence interval (CI) 0.852, 0.964]. Clients receiving physical therapy services once or more a week transitioned to LTC later than those who did not receive these services (HR 0.767, CI 0.672, 0.875). Institutionalizations happened sooner if the client's caregiver was unable to continue (AL: HR 1.335, CI 1.306, 1.365; LTC: HR 1.339, CI 1.245, 1.441) and if clients socialized less (AL: HR 1.149, CI 1.079, 1.223; LTC: HR 1.087, CI 1.018, 1.61).Conclusions and ImplicationsThe diverse role of care aides needs to be explored to determine which specific services help to delay AL transitions. Physical therapy exercises that require minimal supervision should be integrated early into care plans to delay LTC transitions. Social/recreational programs to improve older adults’ socialization and informal caregiver support could delay transitions.     

Telehealth transition in a comprehensive care unit for eating disorders: Challenges and long-term benefits

The 2019 novel coronavirus disease (COVID-19) pandemic has forced many eating disorder medical stabilization units to consider adjustments that uphold both the quality of care delivered to patients while also observing social distancing public health directives for patients and staff. To date, inpatient facilities for eating disorders (both medical stabilization units and higher level of care facilities) have not needed to consider how to translate services to electronic platforms, given that most of these programs have in-person staff. We outline our transition to telehealth broadly, emphasizing some unexpected benefits of using telehealth services that we plan on integrating into our work-flow post COVID-19. These may be useful for other higher level of care eating disorder programs, including medical stabilization units, residential, partial hospitalization, and intensive outpatient programs. We also highlight aspects of transition that have been more challenging for this particular patient population, warranting the need for in-person services.     

Excess Mortality Among Assisted Living Residents With Dementia During the COVID-19 Pandemic

ObjectiveTo evaluate whether assisted living (AL) residents with Alzheimer’s disease and related dementias (ADRD) experienced a greater rate of excess all-cause mortality during the first several months of the COVID-19 pandemic compared to residents without ADRD, and to compare excess all-cause mortality rates in memory care vs general AL among residents with ADRD.DesignRetrospective cohort study.Setting and ParticipantsTwo cohorts of AL residents enrolled in Medicare Fee-For-Service who resided in 9-digit ZIP codes corresponding to US AL communities of ≥25 beds during calendar year 2019 or 2020.MethodBy linking Medicare claims and Vital Statistics data, we examined the weekly excess all-cause mortality rate, comparing the rate from March 12, 2020, to December 31, 2020, to the rate from January 1, 2019, to March 11, 2020. We adjusted for demographics, chronic conditions, AL community size, and county fixed effects.ResultsOf the 286,350 residents in 2019 and the 273,601 in 2020 identified in these cohorts, approximately 31% had a diagnosis of ADRD. Among all AL residents, the excess weekly mortality rate in 2020 was 49.1 per 100,000 overall during the pandemic. Compared to residents without ADRD, residents with ADRD experienced 33.4 more excess deaths per 100,000 during the pandemic. Among residents with ADRD, those who resided in memory care communities did not experience a statistically significant different mortality rate than residents who lived in general AL.Conclusions and ImplicationsAL residents with ADRD were more vulnerable to mortality during COVID-19 than residents without ADRD, a finding similar to those reported in other settings such as nursing homes. Additionally, the study provides important new information that residents with ADRD in memory care communities may not have been at differential risk of COVID-19 mortality when compared to residents with ADRD in general AL, despite prior research suggesting they have more advanced dementia.     

COVID-19 Collaborative Model for an Academic Hospital and Long-Term Care Facilities

The COVID-19 pandemic is devastating post-acute and long-term care (PA/LTC). As geriatricians practicing in PA/LTC and a regional academic medical center, we created this program for collaboration between academic medical centers and regional PA/LTC facilities. The mission of the Geriatric Engagement and Resource Integration in Post-Acute and Long-Term Care Facilities (GERI-PaL) program is to support optimal care of residents in PA/LTC facilities during the COVID-19 pandemic. There are 5 main components of our program: (1) Project ECHO; (2) nursing liaisons; (3) infection advisory consultation; (4) telemedicine consultation; and (5) resident social contact remote connections. Implementation of this program has had positive response from our local PA/LTC facilities. A key component of our program is our interprofessional team, which includes physicians and nursing, emergency response, and public health experts. With diverse professional backgrounds, our team members have created a new model for academic medical centers to collaborate with local PA/LTC facilities.     

COVID-19 pandemic and Rohingya refugees in Bangladesh: What are the major concerns?

ABSTRACT

The COVID-19 pandemic is now a global crisis and the Rohingya refugees in Bangladesh are in the most vulnerable situation. Lack of access to services that are considered critical and life-saving such as food, drinkable water, and shelter, together with limited access to health services are turning an already serious crisis into a major human disaster. Meanwhile, there are concerns that Rohingya refugees are already in too poor health to ward off the COVID-19. Access to the abovementioned facilities and trustworthy information about COVID-19 are amongst their dire needs to combat this pandemic. The humanitarian organisations in collaboration with the Government of Bangladesh should urgently scale up their efforts to provide proper isolation centres, protective equipment, and trained health care representatives to avoid a potential catastrophe. Finally, immediate education intervention is desperately needed to protect the Rohingya refugees from this deadly COVID-19 pandemic.     

Telehealth During the COVID-19 Pandemic: A Cross-Sectional Survey of Registered Dietitian Nutritionists

During the current coronavirus disease 2019 (COVID-19) pandemic, health care practices have shifted to minimize virus transmission, with unprecedented expansion of telehealth. This study describes self-reported changes in registered dietitian nutritionist (RDN) practice related to delivery of nutrition care via telehealth shortly after the onset of the COVID-19 pandemic in the United States. This cross-sectional, anonymous online survey was administered from mid-April to mid-May 2020 to RDNs in the United States providing face-to-face nutrition care prior to the COVID-19 pandemic. This survey included 54 questions about practitioner demographics and experience and current practices providing nutrition care via telehealth, including billing procedures, and was completed by 2016 RDNs with a median (interquartile range) of 15 (6-27) years of experience in dietetics practice. Although 37% of respondents reported that they provided nutrition care via telehealth prior to the COVID-19 pandemic, this proportion was 78% at the time of the survey. Respondents reported spending a median (interquartile range) of 30 (20-45) minutes in direct contact with the individual/group per telehealth session. The most frequently reported barriers to delivering nutrition care via telehealth were lack of client interest (29%) and Internet access (26%) and inability to conduct or evaluate typical nutrition assessment or monitoring/evaluation activities (28%). Frequently reported benefits included promoting compliance with social distancing (66%) and scheduling flexibility (50%). About half of RDNs or their employers sometimes or always bill for telehealth services, and of those, 61% are sometimes or always reimbursed. Based on RDN needs, the Academy of Nutrition and Dietetics continues to advocate and provide resources for providing effective telehealth and receiving reimbursement via appropriate coding and billing. Moving forward, it will be important for RDNs to participate fully in health care delivered by telehealth and telehealth research both during and after the COVID-19 public health emergency.     

Findings from an online survey on the mental health effects of COVID-19 on Canadians with disabilities and chronic health conditions

BackgroundAlthough the COVID-19 pandemic has led to worsening mental health outcomes throughout the Canadian population, its effects have been more acute among already marginalized groups, including people with disabilities and chronic health conditions. This paper examines how heightened fears of contracting the virus, financial impacts, and social isolation contribute to declining mental health among this already vulnerable group.Objective/hypothesisThis paper investigates how increases in anxiety, stress, and despair are associated with concerns about getting infected, COVID-19-induced financial hardship, and increased social isolation as a result of adhering to protective measures among people with disabilities and chronic health conditions.MethodsThis study uses original national quota-based online survey data (n = 1027) collected in June 2020 from people with disabilities and chronic health conditions. Three logistic regression models investigate the relationship between COVID-19’s effects on finances, concerns about contracting the virus, changes in loneliness and belonging, and measures taken to combat the spread of COVID-19 and reports of increased anxiety, stress, and despair, net of covariates.ResultsModels show that increased anxiety, stress, and despair were associated with negative financial effects of COVID-19, greater concerns about contracting COVID-19, increased loneliness, and decreased feelings of belonging. Net of other covariates, increased measures taken to combat COVID-19 was not significantly associated with mental health outcomes.ConclusionsFindings address how the global health crisis is contributing to declining mental health status through heightened concerns over contracting the virus, increases in economic insecurity, and growing social isolation, speaking to how health pandemics exacerbate health inequalities.