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Abstract Date Presented 03/22/24 This study explored potential associations between COVID-19–related symptoms and rehabilitation intensities. COVID-19 patients with delirium may be less able to tolerate high rehabilitation amounts. Moderate rehabilitation amounts are recommended. Primary Author and Speaker: Benjamin Ezra Canter Additional Authors and Speakers: Anne Escher Contributing Authors: Lauren Raschen, Joann Reinhardt, Himali Weerahandi, Wingyun Mak, Orah Burack, Kenneth Boockvar

Homebound older adults are medically complex and often have difficulty accessing outpatient medical care. Home-based primary care (HBPC) may improve care and outcomes for this population but data from randomized trials of HBPC in the United States are limited. We conducted a randomized controlled trial of HBPC versus office-based primary care for adults ages ≥65 years who reported ≥1 hospitalization in the prior 12 months and met the Medicare definition of homebound. HBPC was provided by teams consisting of a physician, nurse practitioner, nurse, and social worker. Data were collected at baseline, 6- and 12-months. Outcomes were quality of life, symptoms, satisfaction with care, hospitalizations, and emergency department (ED) visits. Recruitment was terminated early because more deaths were observed for intervention patients. The study enrolled 229 patients, 65.4% of planned recruitment. The mean age was 82 (9.0) years and 72.3% had dementia. Of those assigned to HBPC, 34.2% never received it. Intervention patients had greater satisfaction with care than controls (2.26, 95% CI 1.46-3.06, p < 0.0001; effect size 0.74) and lower hospitalization rates (-17.9%, 95% CI -31.0% to -1.0%; p=0.001; number needed to treat 6, 95% CI 3-100). There were no significant differences in quality of life (1.25, 95% CI -0.39-2.89, p=0.13), symptom burden (-1.92, 95% CI -5.22-1.37, p=0.25) or ED visits (1.2%, 95% CI -10.5%-12.4%; p=0.87). There were 24 (21.1%) deaths among intervention patients and 12 (10.7%) among controls (p < 0.0001). HBPC was associated with greater satisfaction with care and lower hospitalization rates but also more deaths compared to office-based primary care. Additional research is needed to understand the nature of the higher death rate for HBPC patients, as well as to determine the effects of HBPC on quality of life and symptom burden given the trial's early termination.

This qualitative study aimed to provide an in-depth understanding of the challenges experienced by certified nursing assistants and administrators during the unprecedented COVID-19 crisis. We conducted 6 administrator interviews and 10 remote focus groups with day and evening CNAs at 5 nursing homes (N = 56) in downstate New York. Content analysis was conducted, and emerging themes were identified across sites and roles. Results showed numerous challenges for both CNAs and administrators including many that were personal. These personal challenges included feeling helpless, anxious, or fearful; experience of COVID illness; and balancing high concurrent demands of work and family. There were also many operational challenges such as a lack of COVID testing capacity, information, and consistent guidance and support, staffing and equipment. Understanding these challenges can facilitate goals to promote future safety, skill refinement, and enhanced resilience in the workforce.

There is growing concern of mental health issues among South Asian immigrant populations, although limited disaggregated data on determinants of these issues exists. The aim of this study was to examine factors associated with mental health outcomes among South Asian older adult immigrants living in New York City (NYC). Data were sourced from a needs assessment among self-identified South Asians aged 60+ conducted by an NYC-based frontline agency and nonprofit organization. Variables assessed included the 9-item Patient Health Questionnaire, degree of difficulty experienced due to depression, loneliness, emotional distress, as well as sociodemographic, living situation, acculturation, general health, and financial related indicators. Among the 682 responses, 9.4% of participants displayed symptoms of mild or moderate depression (16% of Caribbean-origin, 10% of Pakistani, 9% of Bangladeshi, and 8% of Indian participants). About a third of participants (29.9%) reported feeling lonely sometimes and 39.1% experienced any type of emotional distress. When compared to those with excellent or very good self-rated health, having fair, poor, or terrible self-rated health was associated with a greater adjusted odds ratio (AOR) of having mild or moderate depression (AOR: 8.42, 95% confidence interval [CI]: 22.09) and experiencing emotional distress (AOR: 3.03, 95% CI: 1.88-4.94). Those experiencing emotional distress were more likely to be younger (AOR: 0.97, 95% CI: 0.95-1.00) and live alone (AOR: 2.06, 95% CI: 1.21-3.53). Findings support the need for tailored mental health interventions targeting concerns, such as poor self-rated health, among South Asian older adult immigrants, as well as specific subpopulations such as Indo-Caribbeans who may be experiencing a disproportionate burden.

Transitioning across medical settings (e.g. from hospital to post-acute (PA) or PA to homecare (HC)) is a difficult time with numerous challenges, as critical information passes across sites, new systems are quickly established, and caretakers change. Older cardiac heart failure (CHF) patients, often with comorbidities and having fewer social supports, are especially vulnerable to rehospitalizations at that time. This study examines the impact of a Social Work Transitions (SWT) intervention, designed to ease older cardiac patients’ transition from a PA to HC setting, on rehospitalization rates. The SWT model for CHF patients was developed in a large healthcare system with a continuum of services for older adults including PA and HC. Once a patient enters PA from the hospital a transitions social worker (SW) remains the patient’s primary support and contact through PA discharge and the transition to HC. In HC, that same SW ensures needed services occur, conducts home visits, and provides additional follow-up via phone calls. Study 1: compared HC rehospitalization rates of CHF patients receiving SWT (N=28) with those not receiving SWT (N=26). This natural control group arose during the initial program months, as SW turnover occurred and some CHF patients were not accompanied by a transitions SW. SWT patients had half the rehospitalizations (25%) as controls (54%). Study 2 tracked 30 day rehospitalizations rates for the first 17 study months (N=257). Program rehospitalization rates (16.7%) were below the CMS benchmark (21%). These findings support using the SWT program to prevent unnecessary rehospitalizations in CHF patient.

To describe patterns of antihypertensive medication treatment in hypertensive nursing home (NH) residents with and without dementia and determine the association between antihypertensive treatment and outcomes important to individuals with dementia. Observational cohort study. All US NHs. Long-term NH residents treated for hypertension in the second quarter of 2013, with and without moderate or severe cognitive impairment, as defined by the NH Minimum Data Set (MDS) Cognitive Function Scale. The primary exposure was intensity of antihypertensive treatment, as defined as number of first-line antihypertensive medications in Medicare Part D dispensing data. The outcome measures were hospitalization, hospitalization for cardiovascular diseases using Medicare Hierarchical Condition Categories, decline in physical function using the MDS Activities of Daily Living (ADLs) scale, and death during a 180-day follow-up period. Of 255 670 NH residents treated for hypertension, 117 732 (46.0%) had moderate or severe cognitive impairment. At baseline, 54.4%, 34.3%, and 11.4% received one, two, and three or more antihypertensive medications, respectively. Moderate or severe cognitive impairment (odds ratio [OR] = 0.80 vs no or mild impairment; P < .0001), worse physical function (OR = 0.64 worst vs best tertile; P < .0001), and hospice or less than a 6-month life expectancy (OR = 0.80; P < .0001) were associated with receipt of fewer antihypertensive medications. Increased intensity of antihypertensive treatment was associated with small increases in hospitalization (difference per additional medication = 0.24%; 95% confidence interval = 0.03%-0.45%) and cardiovascular hospitalization (difference per additional medication = 0.30%; 95% confidence interval = 0.21%-0.39%) and a small decrease in ADL decline (difference per additional medication = -0.46%; 95% confidence interval = -0.67% to -0.25%). There was no significant difference in mortality (difference per additional medication = -0.05%; 95% confidence interval = -0.23% to 0.13%). Long-term NH residents with hypertension do not experience significant benefits from more intensive antihypertensive treatment. Antihypertensive medications are reasonable targets for deintensification in residents in whom this is consistent with goals of care. J Am Geriatr Soc 67:2058-2064, 2019.

Empirical evidence for the positive effects of culture change components such as elder choice, consistent staffing, and organizational redesign is growing. We conducted a retrospective comparison of residents living in Small House communities with a matched sample of those living in traditional, legacy communities in the same nursing home. Most residents had moderate to severe cognitive loss. We found no significant changes on quality of life / care indicators from admission to six months. However, findings showed that at six months, a significantly greater proportion of Small House compared to Legacy residents fell into a lower care intensity group indicating better elder functioning and fewer care resources needed. Further, when comparing activities of daily living, we found that Small House compared to Legacy residents were more likely to have improved mobility within their environment. Findings provide some evidence that the Small House model can potentially improve function.

To examine the relationship between antihypertensive drug deintensification and recurrent falls in long-term care. Department of Veterans Affairs (VA) inpatient, outpatient, and purchased care data, Minimum Data Set assessments from VA nursing homes (NHs), and Medicare claims from fiscal years 2010 - 2015. We identified NH residents with evidence of overaggressive antihypertensive treatment, defined as systolic blood pressure (SBP) 80-120 and an index fall. Recurrent fall, hospitalization, and mortality within 30days were compared between veterans whose antihypertensive medications were deintensified versus those whose antihypertensive medications were not using propensity score methods (PSM). Among 2,212 NH residents with possibly overaggressive antihypertensive treatment, 11 percent experienced antihypertensive drug deintensification. Lower blood pressure, >1 antihypertensive drug, no congestive heart failure, fracture from index fall, and older age were associated with higher likelihood of deintensification. Antihypertensive deintensification was associated with statistically significant (p-value<.01) lower risk of recurrent fall among residents with SBP 80-100 (marginal effect = -11.4 percent; PSM = -13.6 percent) and higher risk of death among residents with SBP 101-120 (marginal effect = 2.1 percent, p-value = .07; with PSM = 4.3 percent, p-value = .04). Results provide some needed evidence and guidelines for deintensifying antihypertensive medication among frail older residents; since hypertension is prevalent among 54 percent of NH residents, the potential impact of new evidence is great.

Abstract This is the first of a two-part paper. The first paper will explore the forensic social worker in the role of expert examiner and witness for immigration lawyers and the immigration court. The second paper will explore the many issues that need to be examined during the biopsychosocial interview to ensure a complete assessment. This paper will consider the four types of cases referred to immigration experts in forensic social work: Spousal abuse cases, criminal immigration cases, hardship cases, and asylum cases.