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

Addressing infection prevention and control in Alabama through the long-term care strike team

The COVID-19 pandemic exposed the lack of infection prevention and control (IPC) infrastructure among long-term care facilities (LTCFs) in the United States; the situation in Alabama is particularly dire with LTCFs receiving some of the lowest quality ratings in the country. Alabama's LTCFs continue to be challenged by frequent staff turnover, vaccine hesitancy, and reluctance to embrace new Centers for Disease Control and Prevention (CDC) recommendations such as enhanced barrier precautions. However, the American Rescue Plan of 2021 made funds available to states through a CDC Epidemiology and Laboratory (ELC) Cooperative Agreement to promote IPC system improvement, including the creation of the Alabama Nursing Home and Long-Term Care Strike Team (LTC Strike Team). In this article, we reviewed preliminary data from Alabama for the first year of the 2-year cooperative agreement cycle (2022--2023). Data included activity tracking by Infection Preventionists (IPs) and evaluations submitted voluntarily by LTCFs upon completion of trainings and/or direct services provided by the LTC Strike Team. Results indicated a significant need for IPC training among LTCFs and a high level of satisfaction with the services provided by IPs. Despite successes, it is unclear if future funding will be available to support long-term sustainability efforts.

Dementia, nurse staffing, and health outcomes in nursing homes

OBJECTIVE

To estimate and contrast the relationships between nurse staffing and health outcomes in nursing homes with low and high dementia census, to understand the association of staffing hours with dementia care quality.

DATA SOURCES AND STUDY SETTING

A national sample of nursing homes during 2017-2019 (pre-COVID). Data included the Payroll-Based Journal, Medicare Claims, Nursing Home Care Compare, and Long-Term Care Focus.

STUDY DESIGN

Retrospective, regression analyses. We estimated separate linear models predicting six long-term facility-level outcomes. Independent variables included staffing hours per resident-day (HPRD) interacted with the facility percentage of dementia residents, controlling for other resident and facility characteristics.

DATA COLLECTION/EXTRACTION METHODS

Hospital-based nursing homes, those with fewer than 30% dementia residents, and missing data were excluded.

PRINCIPAL FINDINGS

We found that registered nurses and certified nurse assistants HPRDs were likely to exhibit positive returns in terms of outcomes throughout most of the range of HPRD for both high and low-census dementia facilities, although, high- and low-dementia facilities differed in most outcome rates at all staffing levels. Average predicted antipsychotics and activities of daily living as functions of HPRD were worse in higher dementia facilities, independent movement, and hospitalizations did not differ significantly, and Emergency Rooms and pressure sores were worse in lower dementia facilities. Average marginal effects were not statistically different [CI included zero] between the high and low dementia facilities for any outcome.

CONCLUSIONS

These findings suggest that increasing staffing will improve outcomes by similar increments in both low- and high-dementia facilities for all outcomes. However, at any given level of staffing, absolute differences in outcomes between low- and high-dementia facilities remain, suggesting that additional staffing alone will not suffice to close these gaps. Further studies are required to identify opportunities for improvement in performance for both low- and high-dementia census facilities.

Rethinking Infection Control: Nursing Home Administrator Experiences during the COVID-19 Pandemic

OBJECTIVE

To examine nursing home administrator perspectives of infection control practices in nursing homes at the height of the COVID-19 pandemic and characterize lessons learned.

DESIGN

Descriptive qualitative study.

SETTING AND PARTICIPANTS

Administrators from 40 nursing homes across 8 diverse health care markets in the United States.

METHODS

Semistructured interviews were conducted via telephone or Zoom with nursing home administrators. Interviews were repeated at 3-month intervals, for a total of 4 interviews per participant between July 2020 and December 2021 (n = 156). Qualitative analysis of interview transcripts used modified grounded theory and thematic analysis to identify overarching themes.

RESULTS

Three major themes emerged reflecting administrator experiences managing infection control practices and nursing home operations at the height of the COVID-19 pandemic. First, administrators reported that the more stringent infection control protocols implemented to manage and mitigate COVID-19 at their facilities increased awareness and understanding of the importance of infection control; second, administrators reported incorporating higher standards of infection control practices into facility-level policies, emergency preparedness plans, and staff training; and third, administrators said they and their executive leadership were reevaluating and upgrading their facilities' physical structures and operational processes for better infection control infrastructure in preparation for future pandemics or other public health crises.

CONCLUSIONS AND IMPLICATIONS

Insights from this study's findings suggest important next steps for restructuring and improving nursing home infection control protocols and practices in preparation for future pandemics and public health emergencies. Nursing homes need comprehensive, standardized infection control training and upgrading of physical structures to improve ventilation and facilitate isolation practices when needed. Furthermore, nursing home emergency preparedness plans need better integration with local, state, and federal agencies to ensure effective communication, proper resource tracking and allocation, and coordinated, rapid response during future public health crises.

Four Years And More Than 200,000 Deaths Later: Lessons Learned From The COVID-19 Pandemic In US Nursing Homes

Nursing home residents and staff were disproportionately affected by the COVID-19 pandemic, drawing attention to long-standing challenges of poor infection control, understaffing, and substandard quality of care in many facilities. Evolving practices and policies during the pandemic often focused on these challenges, with little effect. Despite the emergence of best practices to mitigate transmission of the virus, even the highest-quality facilities experienced outbreaks, indicating a larger systemic problem, rather than a quality problem at the facility level. Here we present a narrative review and discussion of the evolution of policies and practices and their effectiveness, drawing on evidence from the United States that was published during 2020-23. The lessons learned from this experience point to the need for more fundamental and nuanced changes to avoid similar outcomes from a future pandemic: greater integration of long-term care into public health planning, and ultimately a shift in the physical structure of nursing homes. More incremental measures such as vaccination mandates, higher staffing, and balancing infection control with resident quality of life will avoid some adverse outcomes, but without more systemic change, nursing home residents and staff will remain at substantial risk for repetition of the poor outcomes from the COVID-19 pandemic.

Improving Nursing Home Disaster Readiness Through Implementation Science

As large-scale disasters continue to become increasingly common worldwide, nursing homes, whose residents are more vulnerable to disaster-related health and psychosocial shocks, and their staff, are carrying progressively more responsibility for health care readiness practices. Implementation science is a research discipline that seeks to improve uptake of evidence-based practices, such as health care readiness planning, and thus has potential to improve nursing home care delivery during and after disasters. We describe the limited field of existing evidence-based strategies in the peer-reviewed literature that seek to advance health care readiness in the nursing home setting and illustrate how implementation science can better support health care readiness planning for nursing homes. We rest on 3 main themes: (1) implementation science frameworks can strengthen nursing home staff engagement around health care readiness; (2) implementation science can support tailoring of emergency preparedness plans to individual nursing homes' unique needs; and (3) implementation science can advance the integration of nursing homes into local, state, and federal health care readiness planning initiatives. Finally, research is urgently needed to both generate and disseminate implementation strategies that increase uptake of evidence-based health care readiness practices in the nursing home setting.

Caregiving for Older Adults With Dementia During the Time of COVID-19: A Multi-State Exploratory Qualitative Study

This qualitative semi-structured interview study explores how 64 family caregivers for older adults with Alzheimer's Disease and related dementias across eight states experienced and executed caregiving decisions before and during the COVID-19 pandemic. First, caregivers experienced challenges communicating with loved ones and healthcare workers in all care settings. Second, caregivers displayed resilient coping strategies in adapting to pandemic restrictions, finding novel strategies to balance risks while preserving communication, oversight, and safety. Third, many caregivers modified care arrangements, with some avoiding and others embracing institutional care. Finally, caregivers reflected on the benefits and challenges of pandemic-related innovations. Certain policy changes reduced caregiver burden and could improve care access if made permanent. Telemedicine's increasing use highlights the need for reliable internet access and accommodations for individuals with cognitive deficits. Public policies must pay greater attention to challenges faced by family caregivers, whose labor is both essential and undervalued.

Assessment of Regional Nursing Home Preparedness for and Regulatory Responsiveness to Wildfire Risk in the Western US

Importance

It is uncertain whether emergency preparedness and regulatory oversight for US nursing homes are aligned with local wildfire risk.

Objective

To evaluate the likelihood that nursing homes at elevated risk of wildfire exposure meet US Centers for Medicare & Medicaid Services (CMS) emergency preparedness standards and to compare the time to reinspection by exposure status.

Design, Setting, and Participants

This cross-sectional study of nursing homes in the continental western US from January 1, 2017, through December 31, 2019, was conducted using cross-sectional and survival analyses. The prevalence of high-risk facilities within 5 km of areas at or exceeding the 85th percentile of nationalized wildfire risk across areas overseen by 4 CMS regional offices (New Mexico, Mountain West, Pacific/Southwest, and Pacific Northwest) was determined. Critical emergency preparedness deficiencies cited during CMS Life Safety Code Inspections were identified. Data analysis was performed from October 10 to December 12, 2022.

Main Outcomes and Measures

The primary outcome classified whether facilities were cited for at least 1 critical emergency preparedness deficiency during the observation window. Regionally stratified generalized estimating equations were used to evaluate associations between risk status and the presence and number of deficiencies, adjusted for nursing home characteristics. For the subset of facilities with deficiencies, differences in restricted mean survival time to reinspection were evaluated.

Results

Of the 2218 nursing homes in this study, 1219 (55.0%) were exposed to elevated wildfire risk. The Pacific/Southwest had the highest percentage of both exposed (680 of 870 [78.2%]) and unexposed (359 of 486 [73.9%]) facilities with 1 or more deficiencies. The Mountain West had the largest difference in the percentage of exposed (87 of 215 [40.5%]) vs unexposed (47 of 193 [24.4%]) facilities with 1 or more deficiencies. Exposed facilities in the Pacific Northwest had the greatest mean (SD) number of deficiencies (4.3 [5.4]). Exposure was associated with the presence of deficiencies in the Mountain West (odds ratio [OR], 2.12 [95% CI, 1.50-3.01]) and the presence (OR, 1.84 [95% CI, 1.55-2.18]) and number (rate ratio, 1.39 [95% CI, 1.06-1.83]) of deficiencies in the Pacific Northwest. Exposed Mountain West facilities with deficiencies were reinspected later, on average, than unexposed facilities (adjusted restricted mean survival time difference, 91.2 days [95% CI, 30.6-151.8 days]).

Conclusions and Relevance

In this cross-sectional study, regional heterogeneity in nursing home emergency preparedness for and regulatory responsiveness to local wildfire risk was observed. These findings suggest that there may be opportunities to improve the responsiveness of nursing homes to and regulatory oversight of surrounding wildfire risk.

Evaluating California nursing homes' emergency preparedness for wildfire exposure

BACKGROUND

The relationship between the risk of exposure to environmental hazards and the emergency preparedness of nursing homes is not well-understood. This study evaluates the association between wildfire exposure risk and nursing home emergency preparedness.

METHODS

From a sample of Centers for Medicare & Medicaid Services (CMS) certified nursing homes in California, we determined the prevalence of "exposed" facilities that were located within 5 km of a wildfire risk area, as informed by a field-tested model. Among the 1182 nursing homes, we identified emergency preparedness deficiencies from January 2017 to December 2019. We estimated associations between exposure and emergency preparedness deficiencies using unadjusted and adjusted generalized estimating equations with logistic and negative binomial distributions.

RESULTS

A greater percentage of the 495 exposed facilities had at least one emergency preparedness deficiency than the 687 unexposed facilities (83.9% vs 76.9%). The mean (3.6 vs 3.2) and median (3 vs 2) numbers of emergency preparedness deficiencies were also greater for exposed facilities. In both the unadjusted and adjusted analyses, exposure to wildfire risk was significantly associated with the likelihood of at least one emergency preparedness deficiency (adjusted odds ratio 1.52, p-value 0.007). There was a positive but not statistically significant association between exposure and the number of emergency preparedness deficiencies assigned to a nursing home (adjusted rate ratio 1.12, p-value 0.062). These results were consistent in analyses that used more stringent distance- and severity-thresholds to define exposure status.

CONCLUSION

California nursing homes at heightened risk of exposure to wildfires have poorer emergency preparedness than unexposed facilities. These findings suggest that nursing home management and staff may be unaware of important environmental risks to which their facilities are exposed. Improved integration of nursing homes into community disaster planning may better align facility preparedness with surrounding wildfire risk.

Protecting nursing home residents in disasters: The urgent need for a new approach amid mounting climate warnings

This editorial comments on the articles by Festa et al. and Hua et al. in this issue.

Association of Nursing Home Exposure to Hurricane-Related Inundation With Emergency Preparedness

Importance

Whether US nursing homes are well prepared for exposure to hurricane-related inundation is uncertain.

Objectives

To estimate the prevalence of nursing homes exposed to hurricane-related inundation and evaluate whether exposed facilities are more likely to meet Centers for Medicare & Medicaid Services (CMS) emergency preparedness standards.

Design, Setting, and Participants

This cross-sectional study included CMS-certified nursing homes in Coastal Atlantic and Gulf Coast states from January 1, 2017, to December 31, 2019. The prevalence of facilities exposed to at least 2 feet of hurricane-related inundation used models from the National Hurricane Center across coastal areas overseen by 5 CMS regional offices: New England, New York metropolitan area, Mid-Atlantic region, Southeast and Eastern Gulf Coast, and Western Gulf Coast. Critical emergency preparedness deficiencies cited during CMS life safety code inspections were identified.

Main Outcomes and Measures

The analysis used generalized estimating equations with binomial and negative binomial distributions to evaluate associations between exposure status and the presence and number of critical emergency preparedness deficiencies. Regionally stratified associations (odds ratios [ORs]) and rate ratios [RRs]) with 95% CIs, adjusted for state-level fixed effects and nursing home characteristics, were reported.

Results

Of 5914 nursing homes, 617 (10.4%) were at risk of inundation exposure, and 1763 (29.8%) had a critical emergency preparedness deficiency. Exposed facilities were less likely to be rural, were larger, and had similar CMS health inspection, quality, and staffing ratings compared with unexposed facilities. Exposure was positively associated with the presence and number of emergency preparedness deficiencies for the nursing homes within the Mid-Atlantic region (adjusted OR, 1.91 [95% CI, 1.15-3.20]; adjusted RR, 2.51 [95% CI, 1.41-4.47]). Conversely, exposure was negatively associated with the number of emergency preparedness deficiencies among facilities within the Western Gulf Coast (aRR, 0.55 [95% CI, 0.36-0.86]). The associations for the number of emergency preparedness deficiencies remained after correction for multiple comparisons.

Conclusions and Relevance

The findings of this cross-sectional study suggest that the association between exposure to hurricane-related inundation and nursing home emergency preparedness differs considerably across the Coastal Atlantic and Gulf regulatory regions. These findings further suggest that there may be opportunities to reduce regional heterogeneity and improve the alignment of nursing home emergency preparedness with surrounding environmental risks.