The Royal Society of Canada Task Force on COVID-19 was formed in April 2020 to provide evidence-informed perspectives on major societal challenges in response to and recovery from COVID-19. The Tas...

Restoring trust: COVID-19 and the future of long-term care in Canada

Background: Although coronavirus disease 2019 (COVID-19) has impacted on a global scale, the knowledge, attitudes, and beliefs of the health care workers who provide the care at the end of life have not been evaluated. Objectives: To assess and understand palliative medicine and hospice care health care workers' knowledge, attitudes, and beliefs related to COVID-19. Design: A web-based survey was created. Primary outcomes included attitudes, beliefs, and knowledge. Secondary outcomes included comparison in between health care workers who described themselves at high risk versus not at high risk of complications related to COVID-19 infection. Setting/Subjects: In total, 1262 adult hospice workers in the United States were invited. Results: A total of 348 workers completed the survey. Of them, 321 were analyzed, 54.52% were over the age of 50 years, 84.74% were females, 41.75% were nurses, 29.6% were administrative staff, and 6.54% were physicians. Of these workers, 39.56% considered themselves at high risk to develop complications related to COVID-19 infection, 74.46% felt neutral to uncomfortable treating these patients, 77.57% believed that the recommended personal protective equipment (PPE) was adequate, 89.41% supported the risk-reduction strategies, 84.73% obtained information from health authorities, 25.55% from social media, 31.46% believed COVID-19 was likely created in a laboratory or intentionally, and 66.14% of hospice workers who considered themselves at high risk of complications felt available PPE was adequate to protect them compared with 85.05% of responders who did not consider themselves at high risk (p < 0.0001). The majority of respondents were incorrect in seven of the eight clinical scenarios. Conclusion: Improving staff knowledge and information related to COVID-19 would enhance staff safety, improve patient care, and relieve anxiety.

Health Care Workers' Knowledge, Attitudes, and Beliefs Related to COVID-19 in Palliative Medicine and Hospice Care

Journal of Palliative MedicineVol. 25, No. 6 Notes from the EditorFree AccessImproving Palliative and End-of-Life Care in Nursing Homes: Time to Renew Our CommitmentDavid G. Stevenson, Betty R. Ferrell, and Mary ErsekDavid G. StevensonAddress correspondence to: David G. Stevenson, PhD, SM, Department of Health Policy, Vanderbilt University School of Medicine, 2525 West End Avenue, Suite 1200, Nashville, TN 37203, USA E-mail Address: david.stevenson@vanderbilt.eduDepartment of Health Policy, Vanderbilt University School of Medicine, and Department of Veterans Affairs Medical Center, Tennessee Valley Healthcare System, Nashville, Tennessee, USA.Search for more papers by this author, Betty R. FerrellDivision of Nursing Research and Education, City of Hope, Duarte, California, USA.Search for more papers by this author, and Mary ErsekVeteran Experience Center, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA.Leonard Davis Institute, University of Pennsylvania, Philadelphia, Pennsylvania, USA.Search for more papers by this authorPublished Online:18 May 2022https://doi.org/10.1089/jpm.2022.0168AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail With the April 2022 release of its consensus report, The National Imperative to Improve Nursing Home Quality (www.nationalacademies.org/nursing-homes), an ad hoc committee of the National Academies of Sciences, Engineering, and Medicine (NASEM) outlined its vision for how our nation should deliver, finance, regulate, and measure the quality of nursing home care. Spurred by challenges that have been exacerbated by the COVID-19 pandemic, the Committee addressed barriers to quality that have existed for decades while recognizing the current practice and policy environment that shapes care. Released on the heels of President Biden's nursing home quality initiative, the timing is right for the palliative care community to renew our commitment to providing high-quality nursing home care.As readers of this journal will appreciate, and as authors of articles published in Journal of Palliative Medicine have documented, any effort to improve the quality of nursing home care must include a focus on palliative and end-of-life care.1–4 Nearly one-in-four older Medicare beneficiaries die in nursing homes, and an even larger proportion spend some time in these facilities in their last months of life.5 Many nursing home residents struggle with chronic conditions and functional limitations that carry a heavy pain and symptom burden.6 Although access to specialized hospice and palliative care services has improved in recent years, nursing home residents still experience high rates of hospitalization, potentially burdensome treatments, and undertreated symptoms at the end of life, in addition to having high levels of underdiagnosed and undertreated pain and other symptoms.7–9Recognizing that nursing home residents may receive care that is driven by regulatory, payment, and eligibility policies rather than by residents' clinical need or preferences, the NASEM Committee made recommendations in several areas to improve the quality of palliative and end-of-life care for nursing home residents. In addition to outlining reforms that could bolster quality of care generally (e.g., through increased staffing levels and a more rational approach to long-term care financing), the Committee made recommendations in three broad areas with direct relevance to palliative and end-of-life care: building internal capacity and specialized expertise at nursing homes, expanding quality measurement and reporting to encompass relevant measures, and pursuing regulatory and payment policies aligned with high-quality care.Internal Capacity Development through Staff Education and TrainingEven before the pandemic, nursing homes struggled to attract and retain sufficient staff with palliative care expertise, resulting in gaps around management and control of symptoms, including pain.10 Although education and training programs have been associated with improvements in key areas such as symptom assessment and management, end-of-life discussions, and preference-aligned care, these efforts have been limited by the absence or inadequacy of staff training requirements.For certified nursing assistants, for instance, existing training curricula tend to focus on basic tasks rather than on achieving competencies matched to the complex care needs of today's nursing home residents, including palliative and end-of-life care. Given these limitations, the Committee recommended establishing more comprehensive education and competency standards that include geriatrics-specific content such as palliative and end-of-life care. Such training could be integrated into Centers for Medicare and Medicaid Services (CMS) and state-required staff competencies, with palliative care knowledge and skills built into licensure and certification for nursing home staff, clinicians, and leadership.In recent years, the primary mechanism for delivering palliative care to nursing home residents has been through the Medicare hospice benefit, where hospice agencies external to the nursing home provide specialized services to eligible residents who choose to enroll. Observational studies have identified a range of benefits for residents receiving hospice care, including fewer hospitalizations and burdensome treatments, better pain assessment and management, and more positive bereaved family assessments of care.6 Nonetheless, relying on hospice to meet the palliative and end-of-life care needs of residents is inherently limited to those who are eligible and choose to enroll in the benefit, something that fewer than half of all nursing home decedents do currently.10 Hospice also does little for residents' palliative care needs that arise before the last six months of life.Perhaps more important, a hospice-based approach relies on an external entity to deliver these services, even though the nursing home ultimately should be responsible for the palliative and end-of-life care residents receive. To ensure their residents' palliative and end-of-life care needs are met, nursing homes must supplement engagement with hospice through strengthened internal capacity and, when this is not possible, through consultation with external palliative care experts.Quality Measurement and ReportingEfforts to improve, assure, and reimburse for the quality of palliative and end-of-life care in nursing homes depend on the availability of valid and meaningful quality measures. Although the National Quality Forum and others have developed relevant measures for use in home and hospital settings (e.g., around managing symptoms, achieving preference aligned care, and mitigating psychosocial and spiritual distress), few such measures exist for the nursing home setting, creating an important barrier to progress.11 Reflecting this gap, the NASEM Committee recommended that the Department of Health and Human Services fund the development and adoption of new quality measures that are more centrally oriented to nursing home residents' care experience, including measures related to palliative and end-of-life care, implementation of the resident's care plan, and the receipt of care that is aligned with one's goals and preferences.Once these quality measures are developed and shown to distinguish between higher- and lower-performing nursing homes reliably, they could ideally be incorporated into public reporting efforts such as Care Compare and even included as a separate domain of the 5-star rating system. Beyond offering consumers and families guidance about which facilities provide high-quality palliative and end-of-life care, the measures could help incentivize and guide quality improvement and quality assurance efforts. The incorporation of such measures could push facilities beyond their current orientation around maintenance and improvement of functioning, which are important but not all-encompassing goals.Payment Reform That Incentivizes High-Quality Palliative and End-of-Life CareA key facet of the NASEM Committee's work on nursing home quality centered on how financing and payment incentives can shape the resulting structures and delivery of care. These dynamics are no different for individuals with palliative and end-of-life care needs, as payment and coverage policies for the Medicare skilled nursing facility (SNF) and hospice benefits intermingle (and sometimes conflict) with Medicaid and other coverage of nursing home stays.12 For Medicare beneficiaries being discharged from a hospital after an SNF-qualifying stay, for instance, nursing homes and families alike have financial incentives to begin an SNF stay, even if hospice and palliative care would be more appropriate than rehabilitative care. These dynamics reflect a lack of universal long-term care coverage, disparate payment rates between Medicare and Medicaid, and a fragmentation between acute and long-term care.The Committee considered approaches to payment that could address current fragmentation of residents' postacute, end-of-life, and long-term care needs, recommending the study of alternative payment models to make providers more accountable for residents' total costs of care. For long-stay residents at the end of life, the Committee recommended that demonstration projects use global capitated budgets that include Medicare postacute and hospice care in addition to Medicaid long-term care services.Such an approach could address the current financial misalignment between Medicare and Medicaid and support improved care coordination. The Committee's recommendation differs from previous value-based payment efforts (including Medicare Advantage) that have largely carved out hospice care.13,14 Importantly, demonstration design and payments should be tied to broad-based quality metrics, including staffing metrics, resident experience of care, and end-of-life care to ensure that the models maintain—and hopefully improve—quality of care.Concluding ThoughtsTo achieve any vision of high-quality nursing home care, we must include strategies to improve palliative and end-of-life care for all persons receiving both postacute and long-term care in nursing homes. For too long, these areas have been afterthoughts in our broader discussions of quality, despite their central importance. The National Imperative to Improve Nursing Home Quality recognizes this need and includes recommendations to build staff expertise, develop salient quality measures, and better align our approaches to payment. Making progress in the years to come will require our commitment both as a field and as a nation. The Palliative Care community is well prepared to respond to the recommendations of this NASEM report and lead efforts to improve the quality of palliative care in nursing homes.DisclaimerThe contents of this article do not represent the views of the Department of Veterans Affairs or the U.S. government.AcknowledgmentAll authors were members of the ad hoc Committee on the Quality of Care in Nursing Homes—National Academies of Sciences, Engineering, and Medicine (NASEM).Funding InformationD.G.S.'s time was supported in part by the Veterans Affairs Tennessee Valley Health care System. B.R.F and M.E. have no funding to report.Author Disclosure StatementNo competing financial interests exist.References1. Anhang Price R, Tolpadi A, Schlang D, et al.: Characteristics of hospices providing high-quality care. J Palliat Med 2020;23:1639–1643. Link, Google Scholar2. Dingfield LE, Brooks MK, O'Keefe D, et al.: Palliative care pandemic support for long-term care. J Palliat Med 2020;23:890–891. Link, Google Scholar3. Lima JC, Miller SC: Palliative care consults in U.S. nursing homes: Not just for the dying. J Palliat Med 2018;21:188–193. Link, Google Scholar4. Miller SC, Lima JC, Thompson SA: End-of-life care in nursing homes with greater versus less palliative care knowledge and practice. J Palliat Med 2015;18:527–534. Link, Google Scholar5. Teno JM, Gozalo P, Trivedi AN, et al.: Site of death, place of care, and health care transitions among US Medicare Beneficiaries, 2000–2015. JAMA 2018;320:264–271. Crossref, Medline, Google Scholar6. Stevenson D, Bramson J: Hospice care in the nursing home setting: A review of the literature. J Pain Symptom Manage 2009;38:440–451. Crossref, Medline, Google Scholar7. Hoben M, Chamberlain SA, Knopp-Sihota JA, et al.: Impact of symptoms and care practices on nursing home residents at the end of life: A rating by front-line care providers. J Am Med Dir Assoc 2016;17:155–161. Crossref, Medline, Google Scholar8. Esteban-Burgos AA, Lozano-Terrón MJ, Puente-Fernandez D, et al.: A new approach to the identification of palliative care needs and advanced chronic patients among nursing home residents. Int J Environ Res Public Health 2021;18:3171. Crossref, Medline, Google Scholar9. Stephens CE, Hunt LJ, Bui N, et al.: Palliative care eligibility, symptom burden, and quality-of-life ratings in nursing home residents. JAMA Intern Med 2018;178:141–142. Crossref, Medline, Google Scholar10. Ersek M, Unroe KT, Carpenter JG, et al.: High-quality nursing home and palliative care-one and the same. J Am Med Dir Assoc 2022;23:247–252. Crossref, Medline, Google Scholar11. Temkin-Greener H, Ladwig S, Caprio T, et al.: Developing palliative care practice guidelines and standards for nursing home–based palliative care teams: A Delphi Study. J Am Med Dir Assoc 2015;16:86.e1–86.e7. Crossref, Medline, Google Scholar12. Aragon K, Covinsky K, Miao Y, et al.: Use of the Medicare posthospitalization skilled nursing benefit in the last 6 months of life. Arch Intern Med 2012;172:1573–1579. Crossref, Medline, Google Scholar13. Stevenson DG: Growing pains for the Medicare hospice benefit. N Engl J Med 2012;367:1683–1685. Crossref, Medline, Google Scholar14. Stevenson DG, Huskamp HA: Integrating care at the end of life: Should Medicare Advantage include hospice? JAMA 2014;311:1493–1494. Crossref, Medline, Google ScholarFiguresReferencesRelatedDetails Volume 25Issue 6Jun 2022 InformationCopyright 2022, Mary Ann Liebert, Inc., publishersTo cite this article:David G. Stevenson, Betty R. Ferrell, and Mary Ersek.Improving Palliative and End-of-Life Care in Nursing Homes: Time to Renew Our Commitment.Journal of Palliative Medicine.Jun 2022.846-848.http://doi.org/10.1089/jpm.2022.0168Published in Volume: 25 Issue 6: May 18, 2022PDF download 

Improving Palliative and End-of-Life Care in Nursing Homes: Time to Renew Our Commitment

Resumo Introdução O controle da disseminação do coronavírus em Instituições de Longa Permanência para Idosos (ILPI) é considerado um desafio, uma vez que os idosos fazem parte do grupo de risco e apresentam prognóstico bastante desfavorável e também alta letalidade. Objetivo Conduzir uma rapid review para mapear e sintetizar a literatura sobre medidas de enfrentamento de Coronavirus Disease-2019 (COVID-19) em ILPI. Método Foi realizada uma Rapid review, e as buscas foram conduzidas nas bases de dados eletrônicas Biblioteca Cochrane, Web of Science, Scopus, Scielo, Medline/Pubmed e Google Scholar. Foram incluídas publicações a partir de 2019, nos idiomas português, inglês ou espanhol. A seleção das publicações ocorreu em duas etapas: leitura dos títulos/resumos; e leitura na íntegra de todas as publicações selecionadas. As recomendações para enfrentamento da COVID-19 em Instituições de Longa Permanência para Idosos foram extraídas e agrupadas de acordo com o conteúdo. Resultados Foram selecionadas 59 publicações que descreviam recomendações referentes aos temas: controle da disseminação do vírus; formação / educação continuada dos trabalhadores responsáveis pelo cuidado ao idoso; bem como o cuidado no contexto da pandemia: residentes, trabalhadores e familiares, e planejamento e gerenciamento de ações para o enfrentamento. Conclusão As recomendações para o enfrentamento da COVID-19 demandam comportamentos para evitar a disseminação do vírus, adaptações nas dinâmicas de cuidado e de convivência nas instituições, planejamento de ações específicas e suporte familiar, institucional e do Estado para assegurar a proteção da saúde física e psicossocial dos idosos e trabalhadores.

https://www.scielo.br/j/cadsc/a/xq6rDhzVKdtDRKzpdD5b7HD/?lang=pt&format=pdf

Michelle K. Brooks

Papers

Palliative Care Pandemic Support for Long-Term Care.