key: cord-1038747-xgao2qgi
authors: Shi, Sandra; Lo, On-Yee; Newmeyer, Natalie; Bakaev, Innokentiy; Kim, Dae Hyun
title: Recovery from COVID-19 among older adults in post-acute skilled nursing facilities Post-acute COVID-19 functional recovery
date: 2021-04-12
journal: J Am Med Dir Assoc
DOI: 10.1016/j.jamda.2021.04.003
sha: efc7cd2e8933349b7e2efb87eb430697b423e5c9
doc_id: 1038747
cord_uid: xgao2qgi

Objectives To examine functional outcomes of post-acute care for COVID-19 in skilled nursing facilities (SNFs). Design Retrospective cohort Setting and Participants: 73 community-dwelling adults ≥65 years admitted for post-acute care from two SNFs from March 15th, 2020, to May 30th, 2020. Measure (s): COVID-19 status was determined from chart review. Frailty was measured with a deficit accumulation frailty index, categorized into non-frail, mild frailty, and moderate-to-severe frailty. The primary outcome was community discharge. Secondary outcomes included change in functional status from SNF admission to discharge, based on modified Barthel index (mBI) and continuous functional scale scored by physical (PT) and occupational therapists (OT). Results Among 73 admissions (31 COVID-19 negative, 42 COVID-19 positive), mean (SD) age was 83.5 (8.8) and 42 (57.5%) were female, with mean frailty index of 0.31 (0.01) with no differences by COVID-19 status. The mean length of SNF stay for rehabilitation was 21.2 days (SD 11.1) for COVID-19 negative with 20 (64.5%) patients discharged to community, compared to 23.0 (SD 12.2) and 31 (73.8%) among COVID-19 positive patients. Among those discharged to the community, all groups improved in mBI, PT, and OT score. Those with moderate-to-severe frailty (FI >0.35) had lower mBI scores on discharge (92.0 [6.7] not frail, 81.0 [15.4] mild frailty, 48.6 [20.4] moderate-to-severe frailty; p=0.002), lower PT scores on discharge (54.2 [3.9] non-frail, 51.5 [8.0] mild frailty, 37.1 [9.7] moderate-to-severe frailty; p=0.002), and lower OT score on discharge (52.9 [3.2] non-frail, 45.8 [9.4] mild frailty, 32.4 [7.4] moderate or worse frailty; p=0.001). Conclusions and Implications Older adults admitted to a SNF for post-acute care with COVID-19 had community discharge rates and functional improvement comparable to a COVID-19 negative group. However, those who are frailer at admission tended to have lower function at discharge.

Older adults account for almost half of hospitalizations due to Coronavirus Disease 2019 29 . 1 Providing post-acute rehabilitation for frail older adults recovering from COVID-30 19 remains a significant challenge as nursing facilities, 2 one of the most common settings for 31 post-acute care, have become overwhelmed by the COVID-19 pandemic. 3 As the post-acute 32 period is an essential window of opportunity for recovery, having timely information to guide 33 care decisions is critical to tailoring care. Older adults with frailty are at exceptionally high risk 34 for complications including delirium and hospital-acquired disability. 4-6

We conducted a retrospective cohort study of older adults admitted after hospitalization 36 in 2 SNFs. The purpose of the study was to compare 1) functional recovery between older adults 37 presenting with and without COVID-19 and 2) post-acute recovery by baseline frailty in older 38 adults presenting with COVID-19. We hypothesized that older adults would have good 39 functional recovery after COVID-19, and that older adults with more frailty at baseline would 40 have slower recovery during the post-acute care, compared to those with less frailty.

This study was conducted in two long-term care facilities in [REDACTED] . Both facilities had 44 designated COVID-19 units that were separated from the rest of the facility and continued to 45 accept patients for skilled nursing care after post-acute hospitalizations during this timeframe.

These units were geographically cohorted with full multidisciplinary rehabilitation support for post-acute care during this period of time, including physical therapy, occupational therapy, and 48 standard nursing/staff ratios. All care including rehabilitation as delivered in individual patient rooms. We included patient admissions from March 15 th , 2020, to May 30 th , 2020, when these facilities stopped accepting new patients to the designated COVID-19 units. Patients were 51 excluded if they 1) were not discharged from a hospital inpatient admission; 2) age <65; or 3) 52 lived in a nursing home or long-term care before acute hospital admission. 53 We reviewed electronic health records for COVID-19 status on admission.

Demographics, comorbidities, and hospital admission details, including length of stay and illness 55 severity, were obtained from admission notes. Discharge dates and destination were obtained 56 from discharge summaries. We extracted details of functional baseline (activities of daily living

[ADLs] and instrumental activities of daily living [IADLs] ) and therapy progress from physical 58 therapy (PT) and occupational therapy (OT) notes, including modified Barthel index (range 0-59 100, higher scores indicate better function), 7 admission, and discharge function status (described 60 in detail below). Study data were collected and managed using REDCap electronic data capture right, sit to lying, lying to sit, sit to stand, chair to bed, walking 10 feet, walking 50 feet, walking 68 150 feet), and OT (eating, oral hygiene, toileting, bathing, upper body dressing, lower body 69 dressing, footwear, picking up objects off the floor). Each task was scored based on a continuous 70 scale (1-7; dependent to independent), scored by physical and occupational therapists on 71 admission and discharge. Thus, the range for PT score and OT score is 8 (complete dependence in all 8 tasks) to 56 (complete independence in all 8 tasks), with higher scores indicating better function. 74 We described the characteristics of the population using means and standard deviations 75 (SD), and proportions. We used Fisher's exact test to compare community discharge rates 76 between frailty groups and Kruskal Wallis test to compare length of stay. We also calculated 77 the mean change in the modified Barthel index, 7 PT functional scale, and OT functional scale 78 from SNF admission to discharge among those discharged to the community, compared the mean 79 changes by baseline frailty category using analysis of variance or Kruskal Wallis test as 80 appropriate based on whether or not the outcome measures were normally distributed. Tukey's 81 posthoc testing was used to confirm where the differences occurred between frailty groups after a 82 statistically significant main effect. All analyses were done in Stata v16.0.

Out of 98 admissions screened, 73 patients were included (Supplemental Table 1 ) mean (SD) age 86 was 83.5 (8.8) and 42 (57.5%) were female, with mean frailty index of 0.31 (0.01). The most 87 common reason for exclusion was that the patient was not presenting post-hospitalization (n=15).

A total of 42 (57.5%) were COVID-19 positive. change was also significantly different among the frailty groups for the OT score (p=0.04) but 120 not for the BI (p=0.59) and PT (p=0.49) scores. In Tukey's post hoc testing the significant 121 differences were between the non-frail and moderate-to-severe frailty groups. OT score, which is commensurate or even superior to those who were COVID-19 negative 152 during this period of time. Of note, this finding may reflect a greater severity of illness among 153 older adults who were admitted for post-acute care during the pandemic yet were COVID-19 154 negative.

Although previous literature has consistently demonstrated that frailty is a risk factor for 156 poor outcomes in patients with 12, 13 ours is among the first to examine post-acute

The authors have no conflicts of interest to disclose. We like to acknowledge the incredible 186 efforts of the interdisciplinary teams who worked tirelessly during the pandemic to provide 187 rehabilitation for older adults. J o u r n a l P r e -p r o o f Abbreviations: mBI, modified Barthel Index; OT Occupational, Therapy; PT, Physical Therapy 253 † n=31 for Barthel Index data, due to missing; Abbreviations: LOS -length of stay; OT -254 Occupational Therapy; PT -Physical Therapy; SD -Standard Deviation

Nursing Home Care in Crisis in the Wake of COVID-19

Physical Function and Frailty for Predicting Adverse 199

Outcomes in Older Primary Care Patients

Change in disability after hospitalization 202 or restricted activity in older persons

Hospitalization, restricted activity, and the 205 development of disability among older persons