COVID-19: The Time for Collaboration Between Long-Term Services and Supports, Health Care Systems, and Public Health Is Now

Overcoming barriers to implementation: mapping implementation strategies in four hospital in home programs within the Veterans Health Administration

The Hospital at Home model, called Hospital-in-Home (HIH) in the Department of Veterans Affairs, delivers coordinated, high-value care aligned with older adult and caregiver preferences. Documenting implementation barriers and corresponding strategies to overcome them can address challenges to widespread adoption. To evaluate HIH implementation barriers and identify strategies to address them, we conducted interviews with 8 HIH staff at 4 hospitals between 2010 and 2013. We utilized qualitative directed content analysis guided by the Consolidated Framework for Implementation Research (CFIR) and mapped identified barriers to possible strategies using the CFIR-Expert Recommendations for Implementing Change (ERIC) Matching Tool. We identified 11 barriers spanning 5 CFIR domains. Three implementation strategies - identifying and preparing champions, conducting educational meetings, and capturing and sharing local knowledge - achieved high expert endorsement for each barrier. A mix of strategies targeting resources, organizational readiness and fit, and leadership engagement should be considered to support the sustainability and spread of HIH.

A regional learning health system of congregate care facilities for COVID-19 response

Introduction

The COVID-19 pandemic disproportionately affected congregate care (CC) facilities due to communal living, presence of vulnerable populations, inadequate preventive resources, and limited ability to respond to the pandemic's rapidly evolving phases. Most facilities function independently and are not organized for collaborative learning and operations.

Methods

We formed a learning health system of CC facilities in our 14-county metropolitan region, coordinated with public health and health care sectors, to address challenges driven by COVID-19. A CC steering committee (SC) was formed that represented diverse institutions and viewpoints, including skilled nursing facilities, transitional care facilities, residential facilities, prisons, and shelters. The SC met regularly and was guided by situational awareness and systems thinking. A regional CC COVID-19 dashboard was developed based on publicly available data and weekly data submitted by participating facilities. Those experiencing outbreaks or supply shortages were quickly identified. As the pandemic progressed, the role of the SC shifted to address new and forecasted needs.

Results

Over 60 facilities participated in data sharing. The SC shared new guidelines, regulations, educational material, and best practices with the participating facilities. Information about testing sites, supplies, vaccination rollout, and facilities that had the capacity to accept COVID-19 patients was regularly disseminated. The SC was able to direct resources to those facilities experiencing outbreaks or supply shortages.

Conclusions

A novel learning health system of regional CC facilities enabled preparedness, situational awareness, collaboration, and rapid dissemination of best practices across pandemic phases. Such collaborative efforts can play an important role in addressing other public and preventive health challenges.

People with Disabilities' Access to Medical Care During the COVID-19 Pandemic

Delaying and forgoing medical care intensifies the health disparities and unmet needs people with disabilities already face. While many people with disabilities were at high risk for COVID-19, less is known about their access to medical care during the pandemic. This study explored people with disabilities' access to medical care during the COVID-19 pandemic. We analyzed United States Census Bureau COVID-19 Household Pulse Survey data from the second year of the pandemic (April-July 2021) from people with (n = 38,512) and without (n = 296,260) disabilities. During the second year of the pandemic, 30.8% of people with disabilities delayed getting medical care and 28.9% forwent needed care. People with disabilities were also significantly more likely to delay and forgo medical care than people without disabilities. Attention must be drawn to the unmet needs of people with disabilities and efforts must be made to expand their access to health care.

Nurses' Experiences of Care in Portuguese Nursing Homes during the COVID-19 Pandemic: A Focus Group Study

The COVID-19 pandemic has had a considerable influence on long-term care facilities, exposing the shortcomings of nursing homes in implementing recommendations by health authorities. It also emphasizes the need for a nursing management model customized to the vulnerable status of residents, organizational demands, and occupational nursing requirements. We aimed to characterize the perspectives of nurses who have experienced COVID-19 in nursing homes regarding measures implemented to avoid or manage outbreaks in that environment. An interview was conducted with a focus group following the consolidated Criteria for Reporting Qualitative research guidelines. Data analysis was performed using WebQDA software following a thematic category orientation. Eight Portuguese nurses working in nursing homes from the country's central area participated in this study. We identified three major significant areas for long-term care respiratory outbreak management: strategic (policy, staffing, and resources); tactical (training, organization, engagement, and supervision); and operational planning (vigilance, prevention of disease spread, and family involvement). From the participants' view, the management of COVID-19 in nursing homes must be highly supportive and responsive, offering resources to control risks, supporting residents' care, and ensuring the safety and well-being of residents and staff members. Saturation was not reached; thus, further research is needed in this area.

Ready, set, go! The role of organizational readiness to predict adoption of a family caregiver training program using the Rogers' diffusion of innovation theory

BACKGROUND

Caregivers FIRST is an evidence-based program addressing gaps in caregivers' skills. In 2020, the Veterans Health Administration Caregiver Support Program (CSP) nationally endorsed Caregivers FIRST, offering credit in leadership performance plans to encourage all VA medical centers (VAMCs) to implement locally. This study examines the association of organizational readiness with VAMC adoption of Caregivers FIRST.

METHODS

In a cohort observational study, we surveyed CSP managers about their facilities' readiness to implement using the Organizational Readiness for Implementing Change (ORIC) instrument and compared change commitment and change efficacy domains among VAMCs "adopters" defined as delivering Caregivers FIRST within 1 year of the national announcement to those that did not ("non-adopters"). Within "adopters," we categorized time to adoption based on Rogers' diffusion of innovation theory including "innovators," "early adopters," "early majority," "late adopters," and "laggards." Organizational readiness and site characteristics (facility complexity, staffing levels, volume of applications for caregiver assistance services) were compared between "adopters," "non-adopters," and between time to adoption subcategories. Separate logistic regression models were used to assess whether ORIC and site characteristics were associated with early adoption among "adopters."

RESULTS

Fifty-one of 63 (81%) VAMCs with CSP manager survey respondents adopted Caregivers FIRST during the first year. ORIC change commitment and efficacy were similar for "adopters" and "non-adopters." However, sites that adopted earlier (innovators and early adopters) had higher ORIC change commitment and efficacy scores than the rest of the "adopters." Logistic regression results indicated that higher ORIC change commitment (odds ratio [OR] = 2.57; 95% confidence interval [CI], 1.11-5.95) and ORIC change efficacy (OR = 2.60; 95% CI, 1.12-6.03) scores were associated with increased odds that a VAMC was an early adopter (categorized as an "innovator," "early adopter", or "early majority"). Site-level characteristics were not associated with Caregivers FIRST early adoption.

CONCLUSIONS

To our knowledge, this study is the first to prospectively assess organizational readiness and the timing of subsequent program adoption. Early adoption was associated with higher ORIC change commitment and change efficacy and not site-level characteristics. These findings yield insights into the role of organizational readiness to accelerate program adoption.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03474380. Registered on March 22, 2018.

Improving Care Coordination Between Veterans Health Administration Primary Care Teams and Community Home Health Aide Providers: A Qualitative Study

Effective coordination between medical and long-term services is essential to high-quality primary care for older adults, but can be challenging. Our study assessed coordination and communication through semi-structured interviews with Veterans Health Administration (VHA) primary care clinicians (n = 9); VHA-contracted home health agencies (n = 6); and home health aides (n = 8) caring for veterans at an urban VHA medical center. Participants reported (1) establishing home health services is complex, requiring collaboration between many individuals and systems; (2) communication between medical teams and agencies is often reactive; (3) formal communication channels between medical teams and agencies are lacking; (4) aides are an important source of patient information; and (5) aides report important information, but rarely receive it. Removing structural communication barriers; incentivizing reporting channels and information sharing between aides, agencies, and primary care teams; and integrating aides into interdisciplinary teams may improve coordination of medical and long-term care.

COVID-19 pandemic in long-term care: An international perspective for policy considerations

This paper identifies key factors rooted in the systemic failings of the long-term care sector amongst four high income countries during the COVID-19 pandemic. The goal is to offer practice and policy solutions to prevent future tragedies. Based on data from Australia, Canada, Spain and the United States, the findings support evidence-based recommendations at macro, meso and micro levels of practice and policy intervention. Key macro recommendations include improving funding, transparency, accountability and health system integration; and promoting not-for-profit and government-run long-term care facilities. The meso recommendation involves moving from warehouses to “green houses.” The micro recommendations emphasize mandating recommended staffing levels and skill mix; providing infection prevention and control training; establishing well-being and mental health supports for residents and staff; building evidence-based practice cultures; ensuring ongoing education for staff and nursing students; and fully integrating care partners, such as families or friends, into the healthcare team. Enacting these recommendations will improve residents' safety and quality of life; families’ peace of mind; and staff retention and work satisfaction.

Rapid evidence review: Policy actions for the integration of public health and health care in the United States

Objective

To identify policy actions that may improve the interface of public health and health care in the United States.

Methods

A rapid review of publicly-available documents informing the integration of public health and health care, and case examples reporting objective measures of success, with abstraction of policy actions, related considerations, and outcomes.

Results

Across 109 documents, there were a number of recurrent themes related to policy actions and considerations to facilitate integration during peace time and during public health emergencies. The themes could be grouped into the need for adequate and dedicated funding; mandates and shared governance for integration; joint leadership that has the authority/ability to mobilize shared assets; adequately staffed and skilled workforces in both sectors with mutual awareness of shared functions; shared health information systems with modernized data and IT capabilities for both data collection and dissemination of information; engagement with multiple stakeholders in the community to be maximally inclusive; and robust communication strategies and training across partners and with the public.

Conclusion

While the evidence does not support a hierarchy of policies on strengthening the interface of public health and health care, recurrent policy themes can inform where to focus efforts.

Resilience amongst Ontario registered practical nurses in long-term care homes during COVID-19: A grounded theory study

AIMS

This study aimed to understand how the personal and professional resilience of Registered Practical Nurses working in long-term care (LTC) homes in Ontario were impacted during the Coronavirus 2019 pandemic.

BACKGROUND

Registered Practical Nurses are primary regulated healthcare providers that have worked in Ontario LTC homes during the COVID-19 pandemic. As frontline workers, they have experienced increased stress secondary to lockdowns, changing Ministry of Health recommendations, social isolation and limited resources. LTC homes experienced almost a third of all COVID-19-related deaths in Ontario. Understanding registered practical nurses' (RPNs) resilience in this context is vital in developing the programs and supports necessary to help nurses become and stay resilient in LTC and across a range of settings.

METHODS

Purposive sampling was used to recruit 40 Registered Practical Nurses working in LTC homes across Ontario for interviews. Charmaz's Grounded theory guided in-depth one-on-one interviews and analyses completed between April to September 2021.

RESULTS

Registered Practical Nurse participants represented 15 (37.5%) private, and 25 (62.5%) public LTC homes across Ontario Local Health Integration Networks. Findings informed two distinct perspectives on resilience, one where nurses were able to maintain resilience and another where they were not. Sustaining and fraying resilience, presented as bimodal processes, was observed in four themes: 'Dynamic Role of the Nurse', 'Preserving Self', 'Banding Together' and 'Sense of Leadership Support'.

CONCLUSION

Resilience was largely drawn from themselves as individuals. Resources to support self-care and work-life balance are needed. Additionally, workplace supports to build capacity for team-based care practices, collegial support in problem-solving and opportunities for 'connecting' with LTC nursing colleagues would be beneficial. Our findings suggest a role for professional development resources in the workplace that could help rebuild this workforce and support RPNs in providing quality care for older adults living in LTC.

PATIENT OR PUBLIC CONTRIBUTION

Our research team included two members of the Registered Practical Nurses Association of Ontario, and these team members contributed to the discussion and design of the study methodology, recruitment, analysis and interpretation. Further, RPNs working in long-term care during the COVID-19 pandemic were the participants in this study and, therefore, contributed to the data. They did not contribute to data analysis or interpretation.

COVID-19 Deaths and the Impact of Health Disparities, Hospital Characteristics, Community, Social Distancing, and Health System Competition

The United States has one of the highest cumulative mortalities of coronavirus disease 2019 (COVID-19) and has reached 1 million deaths as of May 19th, 2022. Understanding which community and hospital factors contributed to disparities in COVID-19 mortality is important to inform public health strategies. This study aimed to explore the potential relationship between hospital service area (1) community (ie, health professional shortage areas, market competition, and uninsured percentage) and (2) hospital (ie, teaching, system, and ownership status) characteristics (2013-2018) on publicly available COVD-19 (February to October 2020) mortality data. The study included 2514 health service areas and used multilevel mixed-effects linear model to account for the multilevel data structure. The outcome measure was the number of COVID-19 deaths. This study found that public health, as opposed to acute care provision, was associated with community health and, ultimately, COVID-19 mortality. The study found that population characteristics including more uninsured greater proportion of those over 65 years, more diverse populations, and larger populations were all associated with a higher rate of death. In addition, communities with fewer hospitals were associated with a lower rate of death. When considering region in the United States, the west region showed a higher rate of death than all other regions. The association between some community characteristics and higher COVID-19 deaths demonstrated that access to health care, either for COVID-19 infection or worse health from higher disease burden, is strongly associated with COVID-19 deaths. Thus, to be better prepared for potential future pandemics, a greater emphasis on public health infrastructure is needed.

The Landscape of State Policies Supporting Family Caregivers as Aligned With the National Academy of Medicine Recommendations

Policy Points In the absence of federal policy, states adopted policies to support family caregivers, but availability and level of support varies. We describe, compare, and rank state policies to support family caregivers as aligned with National Academy of Medicine recommendations. Although the landscape of state policies supporting caregivers has improved over time, few states provide financial supports as recommended, and benefit restrictions hinder accessibility for all types of family caregivers. Implementing policies supporting family caregivers will become more critical over time, as the reliance on family caregivers as essential providers of long-term care is only expected to grow as the population ages.

CONTEXT

In the United States in 2020, approximately 26 million individuals provided unpaid care to a family member or friend. On average, 60% of caregivers were employed, and they provided 20.4 hours of care per week on top of employment. Although a handful of patchwork laws exist to aid family caregivers, systematic supports, including comprehensive training, respite, and financial support, remain limited. In the absence of federal supports, states have adopted policies to provide assistance, but they vary in availability and level of support provided. Our objectives were to describe, compare, and rank state policies to support family caregivers over time.

METHODS

We used publicly available data from the AARP Long-Term Services and Supports State Scorecard, the National Academy for State Health Policy, and Tax Credits for Workers and Families for all 50 states and the District of Columbia (2015-2019).

FINDINGS

We found that states had increased supports to family caregivers over this five-year period, although significant variability in adoption and implementation of policies persists. Approximately 20% of states had enacted policies that exceed the federal Family and Medical Leave Act requirements, and 18% offered paid family leave. However, most states had not improved spousal impoverishment protections for Medicaid beneficiaries. For example, from 2016 to 2019, 24% of states provided fewer or no protections, while 71% of states did not improve spousal impoverishment protections over time. Access to training for caregivers varied based on eligibility criteria (e.g., select populations and/or only co-residing caregivers).

CONCLUSIONS

Overall, state approaches to support family caregivers vary by eligibility and scope of services. Substantial gaps in support of caregivers, particularly economic supports, persist. Although the landscape of state policies supporting caregivers has improved over time, few states provide financial supports as recommended by the National Academy of Medicine, and benefit restrictions hinder accessibility for all family caregivers.

Long-Term Services and Supports for Older Adults: A Position Paper From the American College of Physicians

The number of Americans aged 65 years or older is expected to increase in the coming decades. Because the risk for disability increases with age, more persons will need long-term services and supports (LTSS) to help with bathing, eating, dressing, and other everyday tasks. Long-term services and supports are delivered in nursing homes, assisted living facilities, the person's home, and other settings. However, the LTSS sector faces several challenges, including keeping patients and staff safe during the COVID-19 pandemic, workforce shortages, quality problems, and fragmented coverage options. In this position paper, the American College of Physicians offers policy recommendations on LTSS coverage, financing, workforce, safety and quality, and emergency preparedness and calls on policymakers and other stakeholders to reform and improve the LTSS sector so that care is high quality, accessible, equitable, and affordable.

Beyond Compliance: A More Integrated Public Health Approach To Outbreaks In Nursing Homes And Other Disasters

Nursing home residents are vulnerable to disproportionate harm during disasters and health emergencies, as evidenced by the recent impact of COVID-19 and extreme weather events. Evaluation of these disasters shows that the nursing homes in question were often in compliance with relevant regulations around emergency planning. However, advance planning for disasters cannot anticipate every contingency, leading to the need for flexibility and quick adaptation on the part of nursing home leaders. In addition, disasters often involve larger, regional problems and situations that individual providers cannot solve. We suggest that policy makers need to prioritize development and expectations around leadership skills in nursing home management and better integrate the long-term care sector into local, state, and federal public health planning for future pandemics and other disasters.

Remote Infection Control Assessments of U.S. Nursing Homes During the COVID-19 Pandemic, April to June 2020

Background

Nursing homes (NHs) provide care in a congregate setting for residents at high risk of severe outcomes from SARS-CoV-2 infection. In spring 2020, NHs were implementing new guidance to minimize SARS-CoV-2 spread among residents and staff.

Objective

To assess whether telephone and video-based infection control assessment and response (TeleICAR) strategies could efficiently assess NH preparedness and help resolve gaps.

Design

We incorporated Centers for Disease Control and Prevention COVID-19 guidance for NH into an assessment tool covering 6 domains: visitor restrictions; health care personnel COVID-19 training; resident education, monitoring, screening, and cohorting; personal protective equipment supply; core infection prevention and control (IPC); and communication to public health. We performed TeleICAR consultations on behalf of health departments. Adherence to each element was documented and recommendations provided to the facility.

Setting and Participants

Health department–referred NHs that agreed to TeleICAR consultation.

Methods

We assessed overall numbers and proportions of NH that had not implemented each infection control element (gap) and proportion of NH that reported making ≥1 change in practice following the assessment.

Results

During April 13 to June 12, 2020, we completed TeleICAR consultations in 629 NHs across 19 states. Overall, 524 (83%) had ≥1 implementation gap identified; the median number of gaps was 2 (interquartile range: 1-4). The domains with the greatest number of facilities with gaps were core IPC practices (428/625; 68%) and COVID-19 education, monitoring, screening, and cohorting of residents (291/620; 47%).

Conclusions and Implications

TeleICAR was an alternative to onsite infection control assessments that enabled public health to efficiently reach NHs across the United States early in the COVID-19 pandemic. Assessments identified widespread gaps in core IPC practices that put residents and staff at risk of infection. TeleICAR is an important strategy that leverages infection control expertise and can be useful in future efforts to improve NH IPC.

Implications of the ongoing coronavirus disease 2019 pandemic for primary care

The coronavirus disease 2019 pandemic has caused widespread global disruption. In this article, the authors put forward lessons from the pandemic for primary care. Among these are primary healthcare requires substantial investment; big data should be carefully regulated and used to strengthen primary care; primary care physicians can support media to provide impartial, objective information; protecting the health of vulnerable populations is important; and infectious diseases are still relevant today. Travel and tourism significantly impact health and primary care. Pandemics may be more common in the future due to climate change, increased human population and habitat loss, among other reasons. We should apply the lessons learned from the current pandemic to better prepare for future pandemics.

Supporting the Behavioral Health of Older Adults: Evaluating a Multi-Site, Multi-Actor, Multi-Agency Initiative

Policymakers often overlook people living with physical disabilities and older adults' behavioral health (BH) needs. Older adults experience alarmingly high rates of mental illness and substance use disorders, which often intersect with neurocognitive challenges. Emerging evidence suggests the SARS-COV-2 pandemic has exacerbated these disparities. BH needs amongst older adults and people living with physical disabilities have major implications for policy and service delivery. While a multitude of local interventions to support BH exist, few state-level programs focus on this population. In 2015, Oregon established the Behavioral Health Initiative for Older Adults and People with Physical Disabilities (referred to as the Initiative) with this specific purpose. A multi-year evaluation of this Initiative suggests several important improvements have occurred. Yet, barriers remain that hinder optimal service provision and enable siloed aging and BH services between agencies. The findings indicate ways the Initiative can leverage initial successes to further support this population.