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Hua CL, Smith L, Zimmerman S, Gadkari G, Carder P, Sloane PD, Wretman CJ, Thomas KS. Admission and Discharge Practices Among Assisted Living Communities: The Role of State Regulations and Organizational Characteristics. THE GERONTOLOGIST 2024; 64:gnae076. [PMID: 38868982 PMCID: PMC11263881 DOI: 10.1093/geront/gnae076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Indexed: 06/14/2024] Open
Abstract
BACKGROUND AND OBJECTIVES A better understanding of factors associated with assisted living admission and discharge practices can help identify communities that are more likely to allow residents to age in place. This study examined how state regulations and assisted living organizational characteristics related to community admission and discharge practices for bathing, getting out of bed, and feeding. RESEARCH DESIGN AND METHODS Using data from a representative sample of 250 assisted living communities in seven states and a database of assisted living state regulations, we employed multilevel logistic regression models to examine regulatory and organizational correlates of assisted living community admission and discharge practices for 3 activities of daily living (bathing, getting out of bed, and feeding). RESULTS States' regulations were not associated with assisted living community admission and discharge practices. However, assisted living communities above the median in the number of personal care staff members per resident were 17% (95% confidence interval [CI]: 6.5%, 27.1%) more likely to admit residents who needed assistance with feeding and 25.4% (95% CI: -37.7, -13.2) less likely to discharge these residents. For-profit communities were more likely to admit residents with bathing and feeding limitations. DISCUSSION AND IMPLICATIONS Organizational characteristics (e.g., for-profit affiliation, staffing levels) may, in part, drive admission and discharge practices, especially related to different care needs. The ability to house residents with advanced care needs may be influenced more by the organizational resources available to care for these residents than by states' admission and discharge regulations.
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Affiliation(s)
- Cassandra L Hua
- Department of Public Health, University of Massachusetts Lowell, Lowell, Massachusetts, USA
| | - Lindsey Smith
- Oregon Health & Science University - Portland State University School of Public Health, Portland, Oregon, USA
| | - Sheryl Zimmerman
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- School of Social Work, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Gauri Gadkari
- Center for Gerontology & Healthcare Research, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Paula Carder
- Oregon Health & Science University - Portland State University School of Public Health, Portland, Oregon, USA
- Institute on Aging, College of Urban and Public Affairs, Portland State University, Portland, Oregon, USA
| | - Philip D Sloane
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Department of Family Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | | | - Kali S Thomas
- School of Nursing, Johns Hopkins University, Baltimore, Maryland, USA
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Dys S, Carder P. Paperwork, Paradox, and PRN: Psychotropic Medication Deficiencies in Assisted Living. J Appl Gerontol 2023; 42:2198-2206. [PMID: 37268438 DOI: 10.1177/07334648231181517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023] Open
Abstract
Individual state approaches to assisted living/residential care (AL/RC) licensing and oversight in the United States result in different practice standards and requirements, including psychotropic medication use. We examined 170 psychotropic medication deficiency citations issued to 152 Oregon AL/RC settings from 2015 to 2019. Applied thematic analysis resulted in the following themes: (1) documentation issues are primarily responsible for noncompliance, (2) unclear parameters place direct care workers in a role paradox, and (3) there is a persistent disconnect about when to seek qualified expertise before requesting psychotropic medications. AL/RC-specific mechanisms for medication prescription and administration are necessary to improve the structure and processes of care. Policymakers might consider how regulations unintentionally incentivize task-oriented versus person-centered care practices.
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Affiliation(s)
- Sarah Dys
- Institute on Aging, College of Urban and Public Affairs, Portland State University, Portland, OR, USA
| | - Paula Carder
- Institute on Aging, College of Urban and Public Affairs, Portland State University, Portland, OR, USA
- School of Public Health, Oregon Health & Science University-Portland State University, Portland, OR, USA
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Hoben M, Hogan DB, Poss JW, Gruneir A, McGrail K, Griffith LE, Chamberlain SA, Estabrooks CA, Maxwell CJ. Comparing quality of care outcomes between assisted living and nursing homes before and during the COVID-19 pandemic. J Am Geriatr Soc 2023; 71:3467-3479. [PMID: 37428008 DOI: 10.1111/jgs.18499] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 05/22/2023] [Accepted: 06/25/2023] [Indexed: 07/11/2023]
Abstract
BACKGROUND While assisted living (AL) and nursing home (NHs) residents in share vulnerabilities, AL provides fewer staffing resources and services. Research has largely neglected AL, especially during the COVID-19 pandemic. Our study compared trends of practice-sensitive, risk-adjusted quality indicators between AL and NHs, and changes in these trends after the start of the pandemic. METHODS This repeated cross-sectional study used population-based resident data in Alberta, Canada. Using Resident Assessment Instrument data (01/2017-12/2021), we created quarterly cohorts, using each resident's latest assessment in each quarter. We applied validated inclusion/exclusion criteria and risk-adjustments to create nine quality indicators and their 95% confidence intervals (CIs): potentially inappropriate antipsychotic use, pain, depressive symptoms, total dependency in late-loss activities of daily living, physical restraint use, pressure ulcers, delirium, weight loss, urinary tract infections. Run charts compared quality indicators between AL and NHs over time and segmented regressions assessed whether these trends changed after the start of the pandemic. RESULTS Quarterly samples included 2015-2710 AL residents and 12,881-13,807 NH residents. Antipsychotic use (21%-26%), pain (20%-24%), and depressive symptoms (17%-25%) were most common in AL. In NHs, they were physical dependency (33%-36%), depressive symptoms (26%-32%), and antipsychotic use (17%-22%). Antipsychotic use and pain were consistently higher in AL. Depressive symptoms, physical dependency, physical restraint use, delirium, weight loss were consistently lower in AL. The most notable segmented regression findings were an increase in antipsychotic use during the pandemic in both settings (AL: change in slope = 0.6% [95% CI: 0.1%-1.0%], p = 0.0140; NHs: change in slope = 0.4% [95% CI: 0.3%-0.5%], p < 0.0001), and an increase in physical dependency in AL only (change in slope = 0.5% [95% CI: 0.1%-0.8%], p = 0.0222). CONCLUSIONS QIs differed significantly between AL and NHs before and during the pandemic. Any changes implemented to address deficiencies in either setting need to account for these differences and require monitoring to assess their impact.
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Affiliation(s)
- Matthias Hoben
- School of Health Policy and Management, Faculty of Health, York University, Toronto, Ontario, Canada
- Faculty of Nursing, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - David B Hogan
- Division of Geriatric Medicine, Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jeffrey W Poss
- School of Public Health Sciences, University of Waterloo, Waterloo, Ontario, Canada
| | - Andrea Gruneir
- Department of Family Medicine, Faculty of Medicine and Dentistry, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
- ICES, Toronto, Ontario, Canada
| | - Kim McGrail
- Centre for Health Services and Policy Research, School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lauren E Griffith
- Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Stephanie A Chamberlain
- Faculty of Nursing, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Carole A Estabrooks
- Faculty of Nursing, College of Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Colleen J Maxwell
- School of Public Health Sciences, University of Waterloo, Waterloo, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- School of Pharmacy, University of Waterloo, Waterloo, Ontario, Canada
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Manis DR, Katz P, Lane NE, Rochon PA, Sinha SK, Andel R, Heckman GA, Kirkwood D, Costa AP. Rates of Hospital-Based Care among Older Adults in the Community and Residential Care Facilities: A Repeated Cross-Sectional Study. J Am Med Dir Assoc 2023; 24:1341-1348. [PMID: 37549887 DOI: 10.1016/j.jamda.2023.06.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 06/14/2023] [Accepted: 06/16/2023] [Indexed: 08/09/2023]
Abstract
OBJECTIVE We 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. DESIGN Repeated cross-sectional study. SETTING AND PARTICIPANTS Linked, 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. METHODS We 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. RESULTS There 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 IMPLICATIONS The 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.
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Affiliation(s)
- Derek R Manis
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ, USA; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; ICES, Toronto, ON, Canada.
| | - Paul Katz
- Department of Geriatrics, College of Medicine, Florida State University, Tallahassee, FL, USA
| | - Natasha E Lane
- ICES, Toronto, ON, Canada; Department of Internal Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Paula A Rochon
- ICES, Toronto, ON, Canada; Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, ON, Canada; Women's College Research Institute, Toronto, ON, Canada; Division of Geriatric Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Samir K Sinha
- Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, ON, Canada; Division of General Internal Medicine and Geriatrics, Sinai Health and University Health Network, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada; National Institute on Ageing, Toronto Metropolitan University, Toronto, ON, Canada
| | - Ross Andel
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, AZ, USA; Department of Neurology, Charles University, Second Faculty of Medicine and Motol University Hospital, Prague, Czech Republic; International Clinical Research Center, St. Anne's University Hospital, Brno, Czech Republic
| | - George A Heckman
- School of Public Health Sciences, University of Waterloo, Waterloo, ON, Canada
| | | | - Andrew P Costa
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada; ICES, Toronto, ON, Canada; Schlegel Research Institute for Aging, Waterloo, ON, Canada; Centre for Integrated Care, St. Joseph's Health System, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada
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Zhang T, Thomas KS, Zullo AR, Coe AB, Gerlach LB, Daiello LA, Varma H, Lo D, Joshi R, Bynum JPW, Shireman TI. State Variation in Antipsychotic Use Among Assisted Living Residents With Dementia. J Am Med Dir Assoc 2023; 24:555-558.e1. [PMID: 36841263 PMCID: PMC10089770 DOI: 10.1016/j.jamda.2023.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 12/19/2022] [Accepted: 01/18/2023] [Indexed: 02/25/2023]
Abstract
OBJECTIVES More than two-thirds of assisted living (AL) residents have dementia or cognitive impairment and antipsychotics are commonly prescribed for behavioral disturbances. As AL communities are regulated by state-level policies, which vary significantly regarding the care for people with dementia, we examined how antipsychotic prescribing varied across states among AL residents with dementia. DESIGN This was an observational study using 20% sample of national Medicare data in 2017. SETTING AND PARTICIPANTS The study cohort included Medicare beneficiaries with dementia aged 65 years or older who resided in larger (≥25-bed) ALs in 2017. METHODS The study outcome was the percentage of eligible AL person-months in which antipsychotics were prescribed for each state. We used a random intercept linear regression model to shrink estimates toward the overall mean use of antipsychotics addressing unstable estimates due to small sample sizes in some states. RESULTS A total of 20,867 AL residents with dementia were included in the analysis, contributing to 194,718 person-months of observation. On average, AL residents with dementia were prescribed antipsychotics during 12.6% of their person-months. This rate varied significantly by state, with a low of 7.8% (95% CI 5.9%-10.3%) for Hawaii to a high of 20.5% (95% CI 16.4%-25.3%) for Wyoming. CONCLUSIONS AND IMPLICATIONS We observed significant state variation in the prescribing of antipsychotics among AL residents with dementia using national data. These variations may reflect differences in state regulations regarding the care for AL residents with dementia and suggest the need for further investigation to ensure high quality of care.
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Affiliation(s)
- Tingting Zhang
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA.
| | - Kali S Thomas
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA; Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA
| | - Andrew R Zullo
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA; Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Antoinette B Coe
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, MI, USA; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
| | - Lauren B Gerlach
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA; Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
| | - Lori A Daiello
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | - Hiren Varma
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA
| | - Derrick Lo
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA
| | - Richa Joshi
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA
| | - Julie P W Bynum
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA; Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Theresa I Shireman
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, RI, USA; Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI, USA
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Lei L, Samus QM, Thomas KS, Maust DT. Medication Costs and Use of Older Americans in Assisted Living Settings: a Nationally Representative Cross-Sectional Study. J Gen Intern Med 2023; 38:294-301. [PMID: 35132546 PMCID: PMC9905365 DOI: 10.1007/s11606-022-07434-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 01/21/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Assisted-living (AL) settings are an important residential care option for old and disabled Americans, but there are no national data characterizing medication use in AL. OBJECTIVE To investigate medication costs and use of older adults living in the AL settings compared to those in the community, independent living, and nursing home settings. DESIGN 2015 National Health and Aging Trends Study; nationally representative cross-sectional study. PATICIPANTS Respondents ≥ 65 years with Medicare Part D prescription drug coverage (n = 5980, representing 32.34 million older adults). MEASURES Total Part D medication costs; number of 30-day prescription fills; binary indicators for overall polypharmacy (≥ 5 and ≥ 10 concurrent medications), prescription fills of opioid and psychotropic medications including antipsychotics, benzodiazepines, gabapentinoids, antidepressants, and central nervous system-active (CNS-active) polypharmacy. RESULTS Adjusting for demographics, the annual medication costs among AL residents, at $3890, were twice as high as those of their community-dwelling counterparts ($1932; p < .01). All medication outcomes except opioids were higher for older adults in AL compared to community settings. While the adjusted number of 30-day prescription fills among AL residents was slightly lower than that of nursing home residents (89.5 vs. 106.2; p < .05), AL residents experienced equivalent rates of overall polypharmacy ≥ 10 medications (30.2% vs. 23.5%), antipsychotics (30.8% vs. 27.8%), benzodiazepines (30.7% vs. 32.6%), gabapentinoids (21.2% vs. 16.1%), and CNS-active polypharmacy (26.0% vs. 36.9%; p > .05 for all). Patterns of use across settings were consistent when limited to older adults with dementia. CONCLUSIONS Older Americans in AL experience a prescription medication burden similar to those in nursing homes. AL settings have an important opportunity to ensure their medication-related clinical services and supports match the needs of their residents.
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Affiliation(s)
- Lianlian Lei
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA.
| | - Quincy M Samus
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Kali S Thomas
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, USA
- Center of Innovation in Long-Term Services and Supports, Providence VA Medical Center, Providence, RI, USA
| | - Donovan T Maust
- Department of Psychiatry, University of Michigan, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
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Coe AB, Zhang T, Zullo AR, Gerlach LB, Thomas KS, Daiello LA, Varma H, Lo D, Joshi R, Shireman TI, Bynum JP. Psychotropic medication prescribing in assisted living and nursing home residents with dementia after the National Partnership. J Am Geriatr Soc 2022; 70:3513-3525. [PMID: 35984088 PMCID: PMC9771901 DOI: 10.1111/jgs.18004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 06/30/2022] [Accepted: 07/27/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND The Centers for Medicare & Medicaid Services implemented the National Partnership to Improve Dementia Care in Nursing Homes (the Partnership) to decrease antipsychotic use and improve care for nursing home (NH) residents with dementia. We determined whether the extent of antipsychotic and other psychotropic medication prescribing in AL residents with dementia mirrored that of long-stay NH (LSNH) residents after the Partnership. METHODS Using a 20% sample of fee-for-service Medicare beneficiaries with Part D, we conducted a retrospective cohort study including AL and LSNH residents with dementia. The monthly prevalence of psychotropic medication prescribing (antipsychotics, antidepressants, anxiolytics/sedative-hypnotics, anticonvulsants/mood stabilizers, benzodiazepines, and antidementia medications) was examined. We used an interrupted time-series analysis to compare medication prescribing before (July 1, 2010-March 31, 2012) and after (April 1, 2012-December 31, 2017) the Partnership in both settings. RESULTS We identified 107,931 beneficiaries with ≥1 month as an AL resident and 323,766 beneficiaries with ≥1 month as a LSNH resident with dementia, including 1,923,867 person-months and 4,984,405 person-months, respectively. Antipsychotic prescribing declined over the study period in both settings. After the launch of the Partnership, the rate of decline in antipsychotic prescribing slowed in AL residents with dementia (slope change = 0.03 [95% CLs: 0.02, 0.04]) while the rate of decline in antipsychotic prescribing increased in LSNH residents with dementia (slope change = -0.12 [95% CLs: -0.16, -0.08]). Antidepressants were the most prevalent medication prescribed, anticonvulsant/mood stabilizer prescribing increased, and anxiolytic/sedative-hypnotic and antidementia medication prescribing declined. CONCLUSIONS The federal Partnership to reduce antipsychotic prescribing in NH residents did not appear to affect antipsychotic prescribing in AL residents with dementia. Given the increase in the prescribing of mood stabilizers/anticonvulsants that occurred after the launch of the Partnership, monitoring may be warranted for all psychotropic medications in AL and NH settings.
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Affiliation(s)
- Antoinette B. Coe
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor, Michigan, USA., Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Tingting Zhang
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Andrew R. Zullo
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA., Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA., Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA., Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA
| | - Lauren B. Gerlach
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA., Department of Psychiatry, University of Michigan, Ann Arbor, Michigan, USA
| | - Kali S. Thomas
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA., Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA., Center of Innovation in Long-Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA
| | - Lori A. Daiello
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA., Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Hiren Varma
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Derrick Lo
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Richa Joshi
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Theresa I. Shireman
- Center for Gerontology and Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Julie P.W. Bynum
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA., Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
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Wretman CJ, Zimmerman S, Sloane PD, Preisser JS. Staff Attitudes Related to Antipsychotic Prescribing in Assisted Living. J Am Med Dir Assoc 2022; 23:1503-1504. [PMID: 35605682 PMCID: PMC10575547 DOI: 10.1016/j.jamda.2022.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 04/24/2022] [Indexed: 11/23/2022]
Affiliation(s)
- Christopher J Wretman
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; School of Social Work, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sheryl Zimmerman
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; School of Social Work, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Philip D Sloane
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - John S Preisser
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Zimmerman S, Sloane PD, Wretman CJ, Cao K, Silbersack J, Carder P, Thomas KS, Allen J, Butrum K, Chicotel T, Giorgio P, Hernandez M, Kales H, Katz P, Klinger JH, Kunze M, Laxton C, McNealley V, Meeks S, O'Neil K, Pace D, Resnick B, Schwartz L, Seitz D, Smetanka L, Van Haitsma K. Recommendations for Medical and Mental Health Care in Assisted Living Based on an Expert Delphi Consensus Panel: A Consensus Statement. JAMA Netw Open 2022; 5:e2233872. [PMID: 36173637 DOI: 10.1001/jamanetworkopen.2022.33872] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
IMPORTANCE Assisted living (AL) is the largest provider of residential long-term care in the US, and the morbidity of AL residents has been rising. However, AL is not a health care setting, and concern has been growing about residents' medical and mental health needs. No guidance exists to inform this care. OBJECTIVE To identify consensus recommendations for medical and mental health care in AL and determine whether they are pragmatic. EVIDENCE REVIEW A Delphi consensus statement study was conducted in 2021; as a separate effort, the extent to which the recommendations are reflected in practice was examined in data obtained from 2016 to 2021 (prepandemic). In the separate effort, data were from a 7-state study (Arkansas, Louisiana, New Jersey, New York, Oklahoma, Pennsylvania, Texas). The 19 Delphi panelists constituted nationally recognized experts in medical, nursing, and mental health needs of and care for older adults; dementia care; and AL and long-term care management, advocacy, regulation, and education. One invitee was unavailable and nominated an alternate. The primary outcome was identification of recommended practices based on consensus ratings of importance. Panelists rated 183 items regarding importance to care quality and feasibility. FINDINGS Consensus identified 43 recommendations in the areas of staff and staff training, nursing and related services, resident assessment and care planning, policies and practices, and medical and mental health clinicians and care. To determine the pragmatism of the recommendations, their prevalence was examined in the 7-state study and found that most were in practice. The items reflected the tenets of AL, the role of AL in providing dementia care, the need for pragmatism due to the diversity of AL, and workforce needs. CONCLUSIONS AND RELEVANCE In this consensus statement, 43 recommendations important to medical and mental health care in AL were delineated that are highly pragmatic as a guide for practice and policy.
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Affiliation(s)
- Sheryl Zimmerman
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill
- School of Social Work, University of North Carolina at Chapel Hill, Chapel Hill
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill
| | - Philip D Sloane
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill
- Department of Family Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill
| | | | - Kevin Cao
- School of Medicine, University of Illinois Chicago, Chicago
| | - Johanna Silbersack
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill
| | | | | | - Josh Allen
- Allen Flores Consulting Group, Searcy, Arkansas
| | | | - Tony Chicotel
- California Advocates for Nursing Home Reform, Berkeley
| | | | | | - Helen Kales
- Department of Psychiatry, University of Michigan, Ann Arbor
| | - Paul Katz
- Department of Geriatrics, College of Medicine, Florida State University, Tallahassee
| | | | - Margo Kunze
- American Assisted Living Nurses Association, Belmar, New Jersey
| | | | | | - Suzanne Meeks
- Department of Psychological & Brain Sciences, University of Louisville, Louisville, Kentucky
| | | | | | | | - Lindsay Schwartz
- Workforce & Quality Innovations, LLC, Bear Creek, North Carolina
| | - Dallas Seitz
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Lori Smetanka
- National Consumer Voice for Quality Long-Term Care, Washington, DC
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10
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Excess Mortality Among Assisted Living Residents With Dementia During the COVID-19 Pandemic. J Am Med Dir Assoc 2022; 23:1743-1749.e6. [PMID: 36065095 PMCID: PMC9359515 DOI: 10.1016/j.jamda.2022.07.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 07/25/2022] [Accepted: 07/26/2022] [Indexed: 11/22/2022]
Abstract
Objective To 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. Design Retrospective cohort study. Setting and Participants Two 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. Method By 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. Results Of 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 Implications AL 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.
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11
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Yakubi H, Gac B, Apollonio DE. Marketing Opioids to Veterans and Older Adults: A Content Analysis of Internal Industry Documents Released from State of Oklahoma v. Purdue Pharma LP, et al. JOURNAL OF HEALTH POLITICS, POLICY AND LAW 2022; 47:453-472. [PMID: 35044464 DOI: 10.1215/03616878-9716712] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
CONTEXT From 1999 to 2018 the opioid epidemic claimed more than 500,000 lives in the United States. Military veterans and older adults were particularly affected; veterans' deaths attributed to opioid use increased by 65% from 2010 to 2016, while opioid prescriptions for older adults increased ninefold between 1995 and 2010. METHODS We reviewed internal pharmaceutical industry documents released in legal discovery to determine how companies targeted these groups to increase prescribing and sales. This review included an analysis of corporate goals and plans identified through internal emails, sales pitches, and presentations. FINDINGS These policy and advertising campaigns focused on (a) lobbying policy makers, (b) undertaking unbranded campaigns promoting opioid use, and (c) promoting opioid use in research and the popular media. Opioid manufacturers claimed that opioids could resolve preexisting concerns identified among military veterans and older adults and that the use of opioids would improve quality of life. These campaigns were positioned as public health initiatives and efforts to increase disease awareness. CONCLUSIONS The findings suggest a need for regulatory reform and transparency related to lobbying, advocacy group relationships with industry, and pharmaceutical advertising.
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Affiliation(s)
| | - Brian Gac
- University of California San Francisco
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12
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Zimmerman S, Sloane PD, Hickey JS, Wretman CJ, Gizlice SP, Thomas KS, Carder P, Preisser JS. Dementia and COVID-19 Infection Control in Assisted Living in Seven States. J Am Geriatr Soc 2022; 70:2653-2658. [PMID: 35666527 PMCID: PMC9347951 DOI: 10.1111/jgs.17923] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 05/16/2022] [Accepted: 05/25/2022] [Indexed: 11/30/2022]
Abstract
Background Assisted living (AL) is the largest residential long‐term care provider in the United States, including for persons with Alzheimer's disease and related dementias. Despite recognizing the challenge of infection control for persons with dementia, this study of 119 AL communities is the first to describe dementia‐relevant COVID‐19 infection control across different types of AL communities, and to discuss implications for the future. Methods From a parent study sampling frame of 244 AL communities across seven states, 119 administrators provided data about COVID‐19 infection control practices and resident behaviors. Data were collected from July 2020 through September 2021. Communities were differentiated based on the presence of beds/units dedicated for persons living with dementia, as being either dementia‐specific, mixed, or integrated. Data obtained from administrators related to feasibility of implementing seven infection control practices, and the extent to which residents themselves practiced infection prevention. Analyses compared practices across the three community types. Results Less than half of administrators found it feasible to close indoor common areas, all community types reported a challenge organizing group activities for safe distancing, and more than half of residents with dementia did not wear a face covering or maintain physical distance from other residents when indicated. Dementia‐specific AL communities were generally the most challenged with infection control during COVID‐19. Conclusion All AL community types experienced infection control challenges, more so in dementia‐specific communities (which generally provide care to persons with more advanced dementia and have fewer private beds). Results indicate a need to bolster infection prevention capacity when caring for this especially vulnerable population, and have implications for care in nursing homes as well.
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Affiliation(s)
- Sheryl Zimmerman
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC.,School of Social Work, University of North Carolina at Chapel Hill, Chapel Hill, NC.,Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Philip D Sloane
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC.,Department of Family Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Johanna Silbersack Hickey
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Christopher J Wretman
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC.,School of Social Work, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Selen P Gizlice
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | | | | | - John S Preisser
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
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