[Liaison geriatrics with nursing homes in COVID time. A new coordination model arrived to stay]

Atención Primaria y personas mayores en las residencias: propuestas de mejora tras la experiencia durante la pandemia

Con este artículo hemos querido acercarnos a la visión que desde la Atención Primaria (AP) tenemos sobre lo que ha supuesto la pandemia de la COVID-19 en la población mayor y particularmente en las personas ancianas que viven en residencias. La situación previa de los centros residenciales ha influido durante la pandemia en un elevado número de fallecimientos, aislamiento social y problemas de salud derivados. Las personas de estos centros son generalmente más vulnerables, frágiles, dependientes y longevas, pero estos condicionantes no justifican el nivel de contagios y mortalidad por sí mismos. En los momentos de mayor dureza de la crisis sanitaria, se activaron una serie de respuestas sociales y sanitarias variadas y diversas en cada comunidad autónoma. Algunas de estas tuvieron carácter urgente y terminaron por originar diferentes estrategias y/o nuevos modelos de atención y gestión de las residencias. En algunos casos, estos cambios se siguen manteniendo. El objetivo de este artículo es analizar algunas de las principales medidas que se llevaron a cabo, los cambios que se implementaron, los puntos en común, el consenso en la toma de decisiones, la evidencia sobre la que se basaron, los aspectos éticos y legales que inspiraron estas estrategias y los resultados en salud obtenidos. Atendiendo a lo comentado, el grupo hace una serie de propuestas de mejora de cara al futuro.

[Situation and activity of the liaison geriatrics units with nursing homes in the Community of Madrid]

INTRODUCTION

In June 2020, after the first wave of the COVID-19 pandemic, Hospital-Based Liaison Geriatrics units and Primary Care nursing care units were created in the Community of Madrid to improve health care for residents in a coordinated manner.

OBJECTIVE

To analyze the situation and the activity of the Hospital-Based Liaison Geriatrics units.

MATERIAL AND METHODS

A cross-sectional study was conducted using an electronic survey prepared and sent to the liaison geriatricians in March 2022, including the following sections: available resources, areas of health care, reasons for consultation, care interventions, research and teaching activity, profiles of residents attended and coordination with other health professionals at that time. A descriptive analysis of the data was performed.

RESULTS

100% of the existing Liaison Geriatrics units responded, describing essential differences in human resources, hours of care and volume of patients attended. Regarding the care activity of these units, they highlighted the telematic consultation, and the face-to-face assessment during hospitalization and in the emergency department. The main reasons for assessment were decision-making, acute pathology and geriatric syndromes; and the in-hospital drug management or orthoprosthetic aids among the interventions.

CONCLUSIONS

Despite the heterogeneity in the resources of the different Liaison Geriatric units, there is a similarity in their care activity and the use of telemedicine. It is common to request an assessment for decision-making, acute pathology or geriatric syndromes and interventions for managing in-hospital drugs and tests, orthoprosthetic aids and coordination with other specialists. Liaison Geriatrics units must continue leading quality health care coordinated with nursing homes, as well as continuity of care for residents.

Do mobile hospital teams in residential aged care facilities increase health care efficiency: an evaluation of French residential care policy

CONTEXT

Patients in residential aged care facilities (RACF) are frequently admitted to hospital since the RACF often lack adequate medical resources. Different economic agents, whose missions and funding may conflict, provide care for RACF residents: residential facility, primary care physicians, and hospital. In this article, I estimate the economic impact of employing a mobile hospital team (MHT) in RACF, which modifies the relationship between these three agents by providing care directly in RACF.

METHOD

A national, patient level database on RACF from 2014 to 2017 is used to calculate RACF outcome indicators. I analyse the difference between RACFs, that use MHT for the first time during the period (treatment group), and those that did not use MHT at all in the same period using a difference in difference (DID) model.

RESULTS

The MHT had a significant impact on health care quality in treated RACFs and reduced the number of patients transferred to hospital and the number of emergency department visits, and increased palliative care utilisation at the end-of-life, without increasing total hospital expenditure.

CONCLUSION

MHT appear improve care quality in RACFs by filling the gap in care needs including better end of life care, without increasing health expenditure. Given the high number of hospital transfers especially towards the end of life, securing the right level and mix of social and medical resources in RACFs is essential. Transferring some competencies of MHT teams to residential facilities may improve the quality of life of residents while improving allocative efficiency of public resources.

An unprecedented and large-scale support mission to assist residential care facilities during the COVID-19 pandemic

Background

In March 2020, COVID-19 cases occurred in residential care facilities. To assist these facilities, the regional health agency of the Meurthe-et-Moselle administrative district ordered a support mission.

Methods

Infection prevention and control mobile teams were formed under the coordination of the infection prevention and control department (IPCD) of a university hospital. Teams went to residential care facilities for the elderly, to facilities for people with disabilities (FPD) and independent living communities (ILC). They visited the facilities and met with the management and the ward staff to assess the situation and to identify any potential support needs.

Results

Over two non-consecutive weeks, 104 residential care facilities were visited (9025 residents). If urgent needs were identified, the IPCD was directly informed by the teams to initiate an extensive assistance operation. Thereby, additional staff and equipment were provided for every facility in need. Although most of them had implemented good management to face the pandemic, four emergency field support operations took place in facilities with uncontrolled outbreaks.

Conclusions

This is the first reported support action for residential care facilities during the pandemic in France. As no major outbreaks were noticed later, this mission was deemed a success and met the residential care facilities' needs for support. Many facilities have expressed the need to cooperate with infection prevention and control specialists in the future, both during outbreaks, also in routine daily practice. This report highlights the need to maintain support for residential care facilities and to implement a permanent collaboration between hospitals and residential care facilities.

Safety, Effectiveness, and Immunogenicity 6 Months After BNT162B2 mRNA Vaccine in Frail Nursing Home Residents

BACKGROUND

Elderly people who reside in long-term care facilities form a frail and vulnerable population, with multiple pathologies and high percentages of cognitive and functional disability.

OBJECTIVES

The aims of this study were to assess the safety of vaccination against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in frail nursing home residents and to evaluate its effectiveness 6 months after full vaccination.

DESIGN

This was an ambispective observational study.

SETTING

Residents of a long-term care facility in Madrid, Spain.

PARTICIPANTS

One hundred and thirty-seven nursing home residents (81.8% female, mean age 87.77 ± 8.31 years) with high comorbidity (61.3% Charlson Index ≥ 3) and frailty (75% Clinical Frail Scale ≥ 7) who received the BNT162B2 mRNA vaccine.

MEASUREMENTS

Safety data were collected to evaluate the type of adverse drug reactions and their duration, severity, and causality. Immunogenicity was tested 6 months after the primary vaccination and effectiveness was evaluated by the incidence of SARS-CoV-2 infection, the number of hospital admissions, and mortality due to coronavirus disease 2019 (COVID-19).

RESULTS

Safety: Of the residents, 21.9% had some adverse reaction and 5.8% had a severe or more serious adverse reaction. The most frequent adverse reactions were fatigue (13.1%), pyrexia (12.4%), and headache (7.3%). No association was observed between frailty (including a need for palliative care) and clinical, functional or cognitive status of the participants and the occurrence of adverse events. Immunogenicity and Effectiveness: After 6 months of vaccination, only one case of SARS-CoV-2 infection was confirmed in the vaccinated residents. Most of the nursing home residents presented positive serology (95.2%). Loss of immunogenicity was associated with older age (95.12 ± 3.97 vs. 87.24 ± 8.25 years; p = 0.03) and no previous COVID-19 infection (16.6% vs. 70%; p < 0.001). Binary logistic regression models did not reveal this association.

CONCLUSION

The BNT162B2 vaccine is well tolerated and effective in nursing home residents, independently of their clinical, functional, cognitive, or frailty characteristics. For the most part, immunogenicity has been maintained over time, regardless of comorbidity, functional status or frailty.

Proactive Geriatric Comanagement of Nursing Home Patients by a New Hospital-Based Liaison Geriatric Unit: A New Model for the Future

During the SARS-CoV-2 pandemic, hospital-based liaison geriatric units (LGUs) were created in Spanish hospitals with the aim to improve health care coordination between nursing homes (NHs) and hospitals. Our university hospital created a comprehensive, proactive LGU serving 31 public and private NHs of different sizes and characteristics to offer support to more than 2500 residents. In the first 3 months of 2021, this LGU performed 1252 assessments (81% as outpatients, 12% at the emergency department, and 7% during hospitalization), avoiding an estimated 49 hospital transfers and 29 hospitalizations. Other activities included giving NHs support and advice during COVID-19 outbreaks, comanagement of selected residents with other hospital-based specialists (implementing telemedicine), and implementation of a protocol that allowed using drugs only approved for hospital use in selected NHs. This model of LGU has been shown to be feasible, to improve residents' health care, and avoid hospital referrals. Long-term care needs to be re-imagined, and hospital geriatric departments need to prove that they are able to offer expertise to support NH health care professionals.

Characteristics, hospital referrals and 60-day mortality of older patients living in nursing homes with COVID-19 assessed by a liaison geriatric team during the first wave: a research article

BACKGROUND

The infection by SARS-CoV-2 (COVID-19) has been especially serious in older patients. The aim of this study is to describe baseline and clinical characteristics, hospital referrals, 60-day mortality, factors associated with hospital referrals and mortality in older patients living in nursing homes (NH) with suspected COVID-19.

METHODS

A retrospective observational study was performed during March and April 2020 of institutionalized patients assessed by a liaison geriatric hospital-based team. Were collected all older patients living in 31 nursing homes of a public hospital catchment area assessed by a liaison geriatric team due to the suspicion of COVID-19 during the first wave, when the hospital system was collapsed. Sociodemographic variables, comprehensive geriatric assessment, clinical characteristics, treatment received including care setting, and 60-days mortality were recorded from electronic medical records. A logistic regression analysis was performed to analyze the factors associated with mortality.

RESULTS

419 patients were included in the study (median age 89 years old, 71.6 % women, 63.7 % with moderate-severe dependence, and 43.8 % with advanced dementia). 31.1 % were referred to the emergency department in the first assessment, with a higher rate of hospital referral in those with better functional and mental status. COVID-19 atypical symptoms like functional decline, delirium, or eating disorders were frequent. 36.9% had died in the 60 days following the first call. According to multivariate logistic regression age (p 0.010), Barthel index <60 (p 0.002), presence of tachypnea (p 0.021), fever (p 0.006) and the use of ceftriaxone (p 0.004) were associated with mortality. No mortality differences were found between those referred to the hospital or cared at the nursing home.

CONCLUSIONS AND IMPLICATIONS

31% of the nursing home patients assessed by a liaison geriatric hospital-based team for COVID-19 were referred to the hospital, being more frequently referred those with a better functional and cognitive situation. The 60-days mortality rate due to COVID-19 was 36.8% and was associated with older age, functional dependence, the presence of tachypnea and fever, and the use of ceftriaxone. Geriatric comprehensive assessment and coordination between NH and the hospital geriatric department teams were crucial.