Long-Term Care Admissions Following Hospitalization: The Role of Social Vulnerability

Referral to Geriatric Rehabilitation in the Netherlands, an Exploratory Study of Patient Characteristics

PURPOSE

Geriatric rehabilitation is intended for older adults with vulnerability, comorbidity, and acute functional impairments. To explore and evaluate referral criteria, this study followed hospital patients referred for rehabilitation in nursing homes.

DESIGN

Exploratory, retrospective cohort study.

METHODS

Participants were community living before acute hospitalization and referred for geriatric rehabilitation between January 15 and May 15, 2019. Data were collected at hospital admission, hospital discharge, and discharge from rehabilitation-oriented care. Outcome measure was the final discharge destination.

RESULTS

Out of 87 hospital patients referred for rehabilitation (mean age = 76.3 years, SD = 10.7), 73 received rehabilitation-oriented post-acute care and 60 (82.2%) returned home after rehabilitation. Premorbid functional status was regained by 45 (61.6%) participants and mobility by 40 (54.8%). Independent baseline mobility, no complications during post-acute care, fewer cognitive symptoms, and multidomain vulnerability were associated with discharge destination after rehabilitation.

CLINICAL RELEVANCE TO REHABILITATION NURSING

A multidomain assessment can make vulnerability applicable in referral decisions and induce tailored individual rehabilitation programs.

CONCLUSION

This study explored the case-mix characteristics of hospital patients following rehabilitation trajectories. No frailty measures were available; vulnerability was refined into physical, cognitive, and social components. Careful assessment of vulnerability can support personalized referral decision-making.

Changes in frailty predict social vulnerability among home care clients living in the community followed for ten years

BACKGROUND

Among community dwelling older adults, social vulnerability increases with age. Advanced age alone does not fully explain how or why older adults become more socially vulnerable; frailty may offer a better explanation.

OBJECTIVE

We aimed to understand how change in frailty relates to change in social vulnerability over time.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

We analyzed older adults aged 65 years and older from the province of Nova Scotia who accessed publicly funded home care in 2005 and 2008 followed for up to ten years.

MEASUREMENTS

We measured social vulnerability and frailty using indices. Controlling for time constant covariates, multi-level growth modelling was used to evaluate whether within-person changes in frailty were associated with within person changes in social vulnerability, after accounting for between-person differences.

RESULTS

There were 2,791 older adults in the 2005 cohort and 2,741 older adults in the 2008 cohort. Mean age, frailty index and social vulnerability index were 80.6 years (SD 7.5), 0.23 (SD 0.10), 0.22 (SD 0.07) and 80.4 (SD 7.6), 0.23 (SD 0.10), and 0.23 (SD 0.07) for each cohort respectively. After accounting for age, sex and baseline frailty, a 0.1 point increase in change of FI from baseline was associated with a 0.017 (CI 0.016 - 0.019, p < 0.001) increase in SVI in the 2005 cohort and a 0.014 (CI 0.013 - 0.016, p < 0.001) increase in SVI in the 2008 cohort.

CONCLUSIONS

Although social vulnerability tends to remain constant in the absence of increases in frailty, changes in frailty are closely associated with changes in social vulnerability. Incorporating within-person changes in health into quantitative models of late-life social vulnerability may further improve our understanding of how and why some individuals are able to stay in the community despite their vulnerabilities.

A standard procedure for constructing a multi-level social vulnerability index using CLSA and SOS data as working examples

BACKGROUND

The construct of social vulnerability attempts to understand social circumstances not merely as a descriptor, but as a predictor of adverse health events. It can be measured by aggregating social deficits in a social vulnerability index (SVI). We describe a standard procedure for constructing a multi-level SVI using two working examples.

METHODS

First, we describe a six-step approach to constructing a SVI. Then, we conducted a secondary analysis of a clinical dataset (Canadian Immunization Research Network's Serious Outcomes Surveillance Network (SOS)) and a population-based dataset (Canadian Longitudinal Study on Aging (CLSA)). In both datasets, we construct SVIs, use descriptive statistics to report distributions by age and sex, and perform a multivariable linear regression of social vulnerability on frailty.

RESULTS

Procedures for drafting a list of candidate social items, selecting deficits for inclusion, and screening deficits to meet inclusion criteria were applied to yield a 18-deficit SVI for the SOS and 74-deficit SVI for the CLSA. Deficits in each SVI were re-scored between 0 and 1, where 1 indicates the greater risk. Finally, the sum of all deficits is calculated into an index. In the SOS, SVI was associated with age only for females and was weakly associated with frailty (r = 0.26, p<0.001). In the CLSA, SVI was associated with age for both sexes and moderately associated with frailty (r = 0.41, p<0.001).

CONCLUSION

We present a standard method of constructing a SVI by incorporating factors from multiple social domains and levels in a social-ecological model. This SVI can be used to improve our understanding of social vulnerability and its impacts on the health of communities and individuals.

Podcast: Influenza-Associated Complications and the Impact of Vaccination on Public Health

Influenza is primarily considered an acute respiratory infection but can lead to a myriad of medium and long-term sequelae across every major organ system in the body. Increasing awareness, gaining broader understanding of its mechanistic pathways, identifying at-risk individuals, and determining how to better protect them could help minimize its impact. The aim of this podcast, featuring Dr Stefania Maggi, Dr Annemarijn de Boer, and Dr Melissa K. Andrew, is to outline the main influenza complications and their impact beyond acute respiratory disease, as well as highlighting vaccination as a tool at our disposal. Both physical and cognitive function can be affected as a result of influenza infection, notably in frailer individuals, which in turn may lead to a loss of independence. Observational studies have identified beneficial effects of vaccination for cardioprotection as well as preventing dementia, but more evidence is required. In conclusion, influenza can cause a wide array of complications, which vaccination may help prevent.Podcast available for this article.

Mapping a comprehensive assessment tool to a holistic definition of health for person-centred care planning in home care: a modified eDelphi study

BACKGROUND

Researchers in the Netherlands proposed the Pillars for Positive Health (PPH) as a broadly encompassing health definition to support more realistic and meaningful care planning for people living with chronic disease and other life-long health conditions. The PPH was subsequently converted to the My Positive Health (MPH) spider web visualization tool. This study sought to identify opportunities for more person-centred care planning at the point of care in home care, using the MPH tool as a framework to link comprehensive assessment and dialogue-based goal-setting.

METHODS

A modified eDelphi method was used to conduct domain mapping with a purposively sampled expert panel (n = 25). The panel consisted of researchers, health care providers, older adults and caregivers. A two-stage eDelphi process was conducted, with each stage consisting of three survey rounds. In the first stage, participants were asked to map 201 elements of the interRAI Home Care (interRAI HC) comprehensive assessment tool to the six MPH domains or "No pillar of best fit". The second stage focused on identifying opportunities to adapt or expand comprehensive assessment as it relates to the MPH domains.

RESULTS

In Stage 1, 189 of 201 elements reached consensus in domain mapping. These included: 80 elements for Bodily Functions, 32 for Daily Functioning, 32 for Mental Wellbeing, 24 for Quality of Life, 10 for Participation, and 1 for Meaningfulness. Ten elements were identified to have no pillar of best fit. The 12 elements that did not reach consensus in Stage 1 formed the basis for Stage 2, where expert panel participants proposed four new assessment elements in Meaningfulness and Participation and 11 additional descriptors across the six MPH domains. Of these, two elements and nine of the 11 descriptors reached consensus.

CONCLUSION

Findings show that elements of the interRAI HC are oriented toward the physical, functional, and mental health domains. Consequently, complementary assessment elements and/or tools may be needed to support comprehensive assessment of 'Meaningfulness' and 'Participation' in person-centred home and community care. Additional descriptors may also be needed to aid communication regarding the understanding and application of MPH domains.

Social Vulnerability and Frailty in Hospitalized Older Adults

Background

Social vulnerability is the accumulation of disadvantageous social circumstances resulting in susceptibility to adverse health outcomes. Associated with increased mortality, cognitive decline, and disability, social vulnerability has primarily been studied in large population databases rather than frail hospitalized individuals. We examined how social vulnerability contributes to hospital outcomes and use of hospital resources for older adults presenting to the Emergency Department.

Methods

We analyzed patients 65 years of age or older admitted through the Emergency Department and consulted to internal medicine or geriatrics at a Canadian tertiary care hospital from July 2009 to September 2020. A 20-item social vulnerability index (SVI) and a 57-item frailty index (FI) were calculated, using a deficit accumulation approach. Outcomes were length of stay (LOS), extended hospital LOS designation, alternative level of care (ALC) designation, in-hospital mortality, and discharge to long-term care (LTC).

Results

In 1,146 patients (mean age 80.5±8.3, 54.0% female), mean SVI was 0.40±0.16 and FI was 0.44±0.14. The SVI scores were not associated with admission to hospital. Amongst those admitted, for every 0.1 unit increase in SVI, LOS increased by 1.15 days (p<.001) after adjusting for age, sex and FI. SVI was associated with staying over the expected LOS (aOR: 1.19, 1.05-1.34, p=.009) and ALC status (aOR 1.39, 1.12-1.74, p<.004). SVI was not associated with in-hospital mortality, but was associated with incident discharge to LTC (aOR 1.03, 1.02-1.04, p<.001).

Conclusion

Independent of frailty, being socially vulnerable was associated with increased LOS, designation as ALC, and being discharged to LTC from hospital. Consideration of social vulnerability's influence on prolonged hospitalization and long-term care needs has implications for screening and hospital resources.

Social vulnerability indices: a scoping review

BACKGROUND

Social vulnerability occurs when the disadvantage conveyed by poor social conditions determines the degree to which one's life and livelihood are at risk from a particular and identifiable event in health, nature, or society. A common way to estimate social vulnerability is through an index aggregating social factors. This scoping review broadly aimed to map the literature on social vulnerability indices. Our main objectives were to characterize social vulnerability indices, understand the composition of social vulnerability indices, and describe how these indices are utilized in the literature.

METHODS

A scoping review was conducted in six electronic databases to identify original research, published in English, French, Dutch, Spanish or Portuguese, and which addressed the development or use of a social vulnerability index (SVI). Titles, abstracts, and full texts were screened and assessed for eligibility. Data were extracted on the indices and simple descriptive statistics and counts were used to produce a narrative summary.

RESULTS

In total, 292 studies were included, of which 126 studies came from environmental, climate change or disaster planning fields of study and 156 studies were from the fields of health or medicine. The mean number of items per index was 19 (SD 10.5) and the most common source of data was from censuses. There were 122 distinct items in the composition of these indices, categorized into 29 domains. The top three domains included in the SVIs were: at risk populations (e.g., % older adults, children or dependents), education, and socioeconomic status. SVIs were used to predict outcomes in 47.9% of studies, and rate of Covid-19 infection or mortality was the most common outcome measured.

CONCLUSIONS

We provide an overview of SVIs in the literature up to December 2021, providing a novel summary of commonly used variables for social vulnerability indices. We also demonstrate that SVIs are commonly used in several fields of research, especially since 2010. Whether in the field of disaster planning, environmental science or health sciences, the SVIs are composed of similar items and domains. SVIs can be used to predict diverse outcomes, with implications for future use as tools in interdisciplinary collaborations.

Understanding Pathways into Care homes using Data (UnPiCD study): a retrospective cohort study using national linked health and social care data

BACKGROUND

Pathways into care are poorly understood but important life events for individuals and their families. UK policy is to avoid moving-in to care homes from acute hospital settings. This assumes that moves from secondary care represent a system failure. However, those moving to care homes from community and hospital settings may be fundamentally different groups, each requiring differing care approaches.

OBJECTIVE

To characterise individuals who move-in to a care home from hospital and compare with those moving-in from the community.

DESIGN AND SETTING

A retrospective cohort study using cross-sectoral data linkage of care home data.

METHODS

We included adults moving-in to care homes between 1/4/13 and 31/3/16, recorded in the Scottish Care Home Census. Care home data were linked to general and psychiatric hospital admissions, community prescribing and mortality records to ascertain comorbidities, significant diagnoses, hospital resource use, polypharmacy and frailty. Multivariate logistic regression identified predictors of moving-in from hospital compared to from community.

RESULTS

We included 23,892 individuals moving-in to a care home, 13,564 (56.8%) from hospital and 10,328 (43.2%) from the community. High frailty risk adjusted Odds Ratio (aOR) 5.11 (95% Confidence Interval (CI): 4.60-5.68), hospital discharge with diagnosis of fracture aOR 3.91 (95%CI: 3.41-4.47) or stroke aOR 8.42 (95%CI: 6.90-10.29) were associated with moving-in from hospital. Discharge from in-patient psychiatry was also a highly significant predictor aOR 19.12 (95%CI: 16.26-22.48).

CONCLUSIONS

Individuals moving-in to care homes directly from hospital are clinically distinct from those from the community. Linkage of cross-sectoral data can allow exploration of pathways into care at scale.

The Association between Social Vulnerability and Frailty in Community Dwelling Older People: A Systematic Review

The aim of this systematic literature review was to determine whether social vulnerability is associated with frailty in older people. Databases were searched for literature from January 2001 to March 2022. Hand searches of reference lists of the selected articles were also used to identify other relevant studies. Studies that met the inclusion criteria were selected. Two independent reviewers assessed the methodological quality using an established tool. Eleven eligible studies from Canada, Europe, USA, Tanzania, Mexico, and China were selected. The level of social vulnerability measured by the Social Vulnerability Index (SVI) from a meta-analysis was 0.300 (95% CI: 0.242, 0.358), with the highest SVI in Tanzania (0.49), while the lowest level of SVI was reported in China (0.15). The highest frailty level of 0.32 was observed in both Tanzania and Europe, with the lowest frailty reported in a USA study from Hawaii (0.15). In all studies, social vulnerability was a significant predictor of mortality for both sexes at subsequent data collection points. The association between SVI and frailty was high in Tanzania (r = 0.81), with other studies reporting stronger correlations for females compared to males, but at small to moderate levels. In one study, an increase of 1SD in SVI was linked to a 20% increase in frailty score at a subsequent evaluation. Additional study is warranted to determine a potential causality between social vulnerability and frailty.

Depression within the First Year of Relocation to Residential Care/Assisted Living: Where You Come From Matters

Depression is common within the first year of relocation to residential care/assisted living (RC/AL). Yet, few studies investigate the relationship between depression and relocation factors that might help identify at-risk residents, such as previous location. This study analyzed cross-sectional resident data (n = 2651) from the National Survey of Residential Care Facilities to test: (1) group differences between residents relocating from acute/post-acute facilities (e.g., hospital, rehabilitation facility) and community-based residences, and (2) the relationship between previous location and depression within the first year of relocation. The 921 (35%) residents relocating directly from acute/post-acute facilities were more likely to have depression (p < .001) and poorer outcomes on select health and psychosocial variables. After controlling for covariates, relocating directly from an acute/post-acute facility significantly related to depression (OR = 1.22). Findings highlight opportunities to improve routine screening and transitional care for this subpopulation of RC/AL residents at heightened risk for depression.

Thoracic surgery with geriatric assessment and collaboration can prepare frail older adults for lung cancer surgery

BACKGROUND AND OBJECTIVES

We assessed frailty, measured by a comprehensive geriatric assessment-based frailty index (FI-CGA), and its association with postoperative outcomes among older thoracic surgical patients.

METHODS

Patients aged ≥65 years evaluated in the geriatric-thoracic clinic between June 2016 through May 2020 who underwent lung surgery were included. Frailty was defined as FI-CGA > 0.2, and "occult frailty", a level not often recognized by surgical teams, as 0.2 < FI-CGA < 0.4. A qualitative analysis of geriatric interventions was performed.

RESULTS

Seventy-three patients were included, of which 45 (62%) were nonfrail and 28 (38%) were frail. "Occult frailty" was present in 23/28 (82%). Sixty-one (84%) had lung malignancy. Geriatric interventions included delirium management, geriatric-specific pain and bowel regimens, and frailty optimization. More sublobar resections versus lobectomies (61% vs. 25%) were performed among frail patients. Frailty was not significantly associated with overall complications (odds ratio [OR]: 2.4; 95% confidence interval [CI]: 0.88-6.44; p = 0.087), major complications (OR: 2.33; 95% CI: 0.48-12.69; p = 0.293), discharge disposition (OR: 2.8; 95% CI: 0.71-11.95; p = 0.141), or longer hospital stay (1.3 more days; p = 0.18).

CONCLUSION

Frailty and "occult frailty" are prevalent in patients undergoing lung surgery. However, with integrated geriatric management, these patients can safely undergo surgery.

Do Interventions Reducing Social Vulnerability Improve Health in Community Dwelling Older Adults? A Systematic Review

Background

Social vulnerability occurs when individuals have been relatively disadvantaged by the social determinants of health. Complex interventions that reduce social vulnerability have the potential to improve health in older adults but robust evidence is lacking.

Objective

To identify, appraise and synthesize evidence on the effectiveness of complex interventions targeting reduction in social vulnerability for improving health related outcomes (mortality, function, cognition, subjective health and healthcare use) in older adults living in the community.

Methods

A mixed methods systematic review was conducted. Five databases and targeted grey literature were searched for primary studies of all study types according to predetermined criteria. Data were extracted from each distinct intervention and quality was assessed using the Mixed Methods Appraisal Tool. Effectiveness data were synthesized using vote counting by direction of effect, combining p values and Albatross plots.

Results

Across 38 included studies, there were 34 distinct interventions categorized as strengthening social supports and communities, helping older adults and their caregivers navigate health and social services, enhancing neighbourhood and built environments, promoting education and providing economic stability. There was evidence to support positive influences on function, cognition, subjective health, and reduced hospital utilization. The evidence was mixed for non-hospital healthcare utilization and insufficient to determine effect on mortality.

Conclusion

Despite high heterogeneity and varying quality of studies, attention to reducing an older adult's social vulnerability assists in improving older adults' health.

The relative impact of socioeconomic position and frailty varies by population setting

Introduction

Frailty and socioeconomic position (SEP) are well-established determinants of health. However, we know less about the contributions of frailty and SEP in older adults, especially in acute settings. We set out to answer how frailty and SEP might influence health outcomes in older people, comparing a population sample and patients managed by a speciality acute frailty service.

Methods

We used the Delirium and Population Health Informatics Cohort, a population sample of 1510 individuals aged ≥70 years from the London Borough of Camden and 1750 acute frailty patients. SEP was determined using the Index of Multiple Deprivation. Linear and Cox proportional hazard regression models were conducted to assess SEP on frailty, readmission, and mortality outcomes.

Results

In the population sample, SEP was significantly associated with frailty and mortality with successive increases in rate of death for each IMD quintile (HR = 1.28, 95% CI 1.11 to 1.49, P < 0.005). Increasing SEP, age, and admission status among hospitalized individuals were associated with greater frailty. For individuals seen by the speciality frailty service, SEP was not associated with frailty, mortality, or readmission.

Discussion

When older people experience acute illness severe enough to require secondary care, particularly specialist services, this overcomes any prior advantages conferred by a higher SEP.

Cost and Effectiveness of Long-Term Care Following Integrated Discharge Planning: A Prospective Cohort Study

Little is known about the effects of seamless hospital discharge planning on long-term care (LTC) costs and effectiveness. This study evaluates the cost and effectiveness of the recently implemented policy from hospital to LTC between patients discharged under seamless transition and standard transition. A total of 49 elderly patients in the standard transition cohort and 119 in the seamless transition cohort were recruited from November 2016 to February 2018. Data collected from medical records included the Multimorbidity Frailty Index, Activities of Daily Living Scale, and Malnutrition Universal Screening Tool during hospitalization. Multiple linear regression and Cox regression models were used to explore risk factors for medical resource utilization and medical outcomes. After adjustment for effective predictors, the seamless cohort had lower direct medical costs, a shorter length of stay, a higher survival rate, and a lower unplanned readmission rate compared to the standard cohort. However, only mean total direct medical costs during hospitalization and 6 months after discharge were significantly (p < 0.001) lower in the seamless cohort (USD 6192) compared to the standard cohort (USD 8361). Additionally, the annual per-patient economic burden in the seamless cohort approximated USD 2.9–3.3 billion. Analysis of the economic burden of disability in the elderly population in Taiwan indicates that seamless transition planning can save approximately USD 3 billion in annual healthcare costs. Implementing this policy would achieve continuous improvement in LTC quality and reduce the financial burden of healthcare on the Taiwanese government.

"Eyes in the Home": Addressing Social Complexity in Veterans Affairs Home-Based Primary Care

BACKGROUND

Home-Based Primary Care (HBPC) has demonstrated success in decreasing risk of hospitalization and improving patient satisfaction through patient targeting and integrating long-term services and supports. Less is known about how HBPC teams approach social factors.

OBJECTIVE

Describe HBPC providers' knowledge of social complexity among HBPC patients and how this knowledge impacts care delivery.

DESIGN, SETTING, AND PARTICIPANTS

Between 2018 and 2019, we conducted in-person semi-structured interviews with 14 HBPC providers representing nursing, medicine, physical therapy, pharmacy, and psychology, at an urban Veterans Affairs (VA) medical center. We also conducted field observations of 6 HBPC team meetings and 2 home visits.

APPROACH

We employed an exploratory, content-driven approach to qualitative data analysis.

RESULTS

Four thematic categories were identified: (1) HBPC patients are socially isolated and have multiple layers of medical and social complexity that compromise their ability to use clinic-based care; (2) providers having "eyes in the home" yields essential information not accessible in outpatient clinics; (3) HBPC fills gaps in instrumental support, many of which are not medical; and (4) addressing social complexity requires a flexible care design that HBPC provides.

CONCLUSION AND RELEVANCE

HBPC providers emphasized the importance of having "eyes in the home" to observe and address the care needs of homebound Veterans who are older, socially isolated, and have functional limitations. Patient selection criteria and discharge recommendations for a resource-intensive program like VA HBPC should include considerations for the compounding effects of medical and social complexity. Additionally, staffing that provides resources for these effects should be integrated into HBPC programming.

Influenza vaccination and the evolution of evidence-based recommendations for older adults: A Canadian perspective

Older adults are at high risk from influenza and its complications, and are therefore an important population for prevention efforts. In Canada, public health efforts targeting influenza are multi-pronged and include vaccination programs as well as surveillance which informs the national surveillance reporting platform FluWatch run by the Public Health Agency of Canada. Recommendations regarding use of vaccines are made nationally by the National Advisory Committee on Immunization (NACI) and by the Comité sur l'immunisation du Québec in Quebec, while vaccination programs are planned and delivered at the provincial/territorial level as opposed to as a harmonized national immunization program. NACI performs rigorous targeted literature reviews to inform their statements, and recommendations also vary by whether they apply on Individual (pertaining to decisions for individual patients) vs. Programmatic (informing policy decisions for implementation of publicly funded vaccination programs) levels. This unique context results in inter-provincial variation in vaccine schedules and funded vaccine products. In this paper, the importance of influenza vaccination for older adults is discussed; to provide insights from the Canadian context, the evolution of NACI evidence reviews and recommendations on influenza vaccination is presented.