Older adults who survived hospitalizations due to COVID-19 and return to their homes face substantial health challenges and an unforeseeable future. Early evidence suggests that complex and long-term physical, functional, cognitive, and emotional negative health consequences are the norm for them. However, the trajectories of health care needs of older adults with COVID-19 within the weeks and months following hospital discharge have yet to be identified.
In a writing in the Journal of Aging and policy, three researchers from the University of Pennsylvania School of Nursing (Penn Nursing) presents how the core components of the Transitional Care Model, together with early findings regarding the unique concerns of these with COVID-19, suggest a path for immediate practice and policy responses to caring for this population as they move from the hospital back to the community.
The Transitional Care Model may be an effective care management strategy proven in multiple National Institutes of Health clinical trials to reinforce health and quality of life and reduce health-care costs for diverse subgroups of hospitalized older adults to home. It encompasses comprehensive discharge planning and residential follow-up.
The Transitional Care Model is a care management strategy proven in multiple National Institutes of Health clinical trials to enhance health and quality of life and reduce health-care costs for diverse subgroups of hospitalized older adults to home. The evidence-based components of the Transitional Care model provide a framework to address the complex care needs of older adults with COVID-19 throughout episodes of acute illness (Naylor et al., 1994, 1999, 2004, 2014). These components include increasing screening, building trusting relationships, improving patient engagement, promoting collaboration across care teams, undertaking symptom management, increasing family caregiver care/education, coordinating health and social services, and improving care continuity.
To assure the delivery of timely and effective transitional care services for older adults with COVID-19, the consistent use of a standardized screening tool to identify and communicate health and social factors that increase their risk for poor outcomes is necessary. Such a tool must provide a comprehensive assessment of the needs of older adults, including information on preexisting physical, behavioral health, and cognitive conditions, functional deficits, and social vulnerabilities such as low socioeconomic status. Risks unique to COVID-19 must include key symptoms (e.g., shortness of breath) and treatments (e.g., days on ventilators). Equally important are data about family caregivers (i.e., relatives, neighbors, or friends, hereafter referred at as caregivers) whose availability (e.g., ability and willingness to provide in-home support) and capacity (e.g., health status, knowledge, and skills) certainly impacts older adults’ risks. Factors unique to this pandemic include data regarding caregivers’ development of COVID-19 symptoms and their mental health responses to the crisis. Mechanisms to assure timely communication of screening findings with acute, primary, post-acute care and community-based staff involved in older adults’ care are essential to enable these team members’ to prioritize timing of contacts with patients at higher risk for adverse outcomes and position them with interventions targeting risk mitigation.
Developing and maintaining trusting interpersonal relationships between older adults, caregivers and members of the care team are an important focus especially for the high proportion of socially disadvantaged older adults who are hospitalized with COVID-19 (Center for Disease Control, 2020), many of whom lack trust in the healthcare system (Guerrero et al., 2015). Given severe restrictions in hospital visitation policies coupled with substantially decreased in-person contact following discharge, care team members are increasingly relying on phones, texts, and video conferencing to communicate with older adults and their caregivers. While such modifications to care delivery are understandable, attention must be paid to assure that effective, culturally sensitive strategies are considered in the development of digital forms of communication. For example, engaging people who represent diverse racial and ethnic groups in the design of communication technologies will help to ensure that e-health literacy and language competency are addressed into these solutions (Barclay et al., 2014). Standards that promote the engagement of minorities in the creation of these solutions and foster the education of health professionals to deliver culturally sensitive digital care need to be advanced (Chang et al., 2004). Of critical importance is the role of a clinician who is the consistent point person in communications with older adults and their caregivers.
Collectively, the severity of older adults’ illnesses, limited in-person contact with caregivers, and overwhelmed hospital nurses and physicians have made identifying what matters to older adults and aligning plans of care with their preferences and values enormously difficult during this crisis. Indeed, these challenges highlight the importance of advance care plans that clearly describe older adults’ goals of care. Public service messages should encourage immediate conversations between older adults, family caregivers, and primary care clinicians to develop advance care plans and to make sure those plans are documented in electronic health records. Given that most hospitalized older adults with COVID-19 are individuals confronting multiple other risks, special attention should be paid to their decision-making regarding the potential use of ventilators. Since early findings reveal that as many as half of the older adults placed on ventilators did not survive (Richardson et al., 2020), some might choose palliative versus curative care. Among those hospitalized who have not communicated goals of care, every effort should be made to connect with knowledgeable caregivers and assure that discussion of treatment options takes into consideration older adults’ goals. Fostering the engagement of older adults must extend throughout the entire illness episode to assure that changes in goals associated with worsening health status are clearly communicated.
Achieving consensus on plans of care between members of the hospital, post-acute, and primary care teams is complicated under the best of circumstance, with challenges exacerbated during this pandemic. At the peak of the crisis, traditional investments made by hospital clinicians in discussing care plans with primary or post-acute providers were impossible. Clinicians’ priorities were to stabilize patients and to transfer them as quickly as possible to make room for others. Even as the number of hospitalizations has declined, effective collaboration remains difficult. Given the expected spread of this disease for months and perhaps years to come, employment/redeployment of nurses who are not involved in the care of COVID-19 patients to assume a primary role in assuring high-quality collaboration among all team members should be a priority. As of early May, over 1.4 million of America’s health-care workers, including nurses, lost their jobs (Sanger-Katz, 2020). While many of these positions will be restored, increased financial strain among hospitals may result in some longer-term unemployment. Additionally, many hospital nurses who have been serving on the front lines throughout this pandemic may benefit emotionally from role changes. On-line programs (e.g., Foundations in Transitional Care) exist to rapidly prepare nurses for these central roles. Federal programs established to mitigate the impact of COVID-19 on unemployment, especially among health-care workers, and health plans seeking to prevent breakdowns in care that result in costly hospital readmissions are likely to support this training.
Early identification and management of older adults’ physical, emotional, and cognitive symptoms are especially tricky given limited evidence about the course of this disease and, for many, its ultimate human consequences. At hospital discharge, most adults with COVID-19 are physically and emotionally depleted; some also report cognitive deficits (Khullar, 2020; The New York Times, 2020). At the same time, these patients confront a largely unpredictable future in a context, for many, characterized by social isolation and financial distress. Little wonder that early reports of anxiety and depression are common among COVID-19 survivors (Horowitz, 2020; The New York Times, 2020). Health systems have responded by substantially increasing their outreach using telehealth and other virtual tools with a primary goal of assessing physical symptom changes. Monitoring needs to be extended to include assessment and effective management of cognitive deficits and mental health concerns as a failure to address these issues will have prolonged negative health consequences (Ohrnberger et al., 2017). Engaging and training community health workers to conduct such assessments and implement early intervention for those with mild deficits, coupled with the increased use of social workers who can provide support for more severe challenges, are examples of strategies that have the potential to mitigate the impact of COVID-19 for this population.
In 2019, approximately 60,000 community health workers were providing a range of largely social support services in U.S. communities (U.S. Bureau of Labor Statistics, 2020). Evidence from other countries suggest these trained laypeople also could play a major role in identifying mental health issues such as depression or anxiety and helping those with mild issues (Stanley et al., 2014). The Center for Medicare and Medicaid Innovation should support the testing of the effects of trained community health workers in identifying and managing the mental health challenges experienced by older adults with COVID-19 and their caregivers throughout challenging health-care transitions. Additionally, future efforts aimed at reducing unemployment in socially disadvantaged communities should target the expansion of community health workers.
COVID-19 has placed a spotlight on the critical role of caregivers in assuring that the complex post-hospital care needs of older adults are addressed. Notably, preparing these “invisible caregivers” to meet expectations is occurring at a time when they are personally coping with the impact of this virus. Additionally, restrictions on visitations have prevented them from receiving teaching and instruction typically provided by hospital staff. In-person contact with home health-care teams, primary care providers, or care managers who generally provide similar guidance also is very limited. Thus, much of the preparation being provided to family caregivers is being delivered using telehealth. Caregivers confront the same set of challenges in receiving support through this mechanism as do older adults. Accessing telehealth, especially among disadvantaged populations, is hampered by limited Internet connectivity and access to technology (Yoon et al., 2020). Additionally, effective use of this mechanism in addressing the needs of culturally diverse subgroups, some of whom do not speak English, has not been demonstrated. Once again, the rapid engagement of nurses and preparing them to identify caregivers’ needs and support them during these very challenging times are essential.
Coordinating health and social services for older adults with COVID-19 has been challenged by failures to universally adopt commonsense solutions. For example, the Caregiver Advise, Record, Enable (CARE) Act, is a model state legislation designed, in part, to make sure the names of family caregivers who will assume primary responsibility for hospitalized older adults’ care following the transition to home are documented in their medical records. At times of crisis, immediate access to this basic information is central to effective transitions. As of 2019, 40 states and territories have enacted CARE Acts (Reinhard et al., 2019).
Another challenge to effective coordination has been the lack of consistent guidance to health-care facilities throughout this crisis. Early in the pandemic, for example, federal and state agencies strongly recommended that skilled nursing facilities (SNFs) refuse to accept COVID-19 patients (Center for Clinical Standards and Quality/Quality Safety & Oversight Group, 2020). By late April, some states reversed course and ordered SNFs to accept such patients (Schoch, 2020). Since then, some SNFs have decided to specialize in the care of COVID-19 residents. Others have instituted protocols that require clustering of infected residents in one area, assigning consistent staff to those residents for at least 14 days, and routinely testing all staff and residents to mitigate the spread of this deadly disease. Despite the availability of these protocols, SNFs in some regions still refuse to accept COVID-19 patients. Consequently, this group of patients require high-intensity, post-acute care in their homes (Werner & Van Houtven, 2020). This solution generally entails 24/7 telehealth support supplemented by in-home visits by nurses for services such as symptom management and intravenous infusions and therapists for post-acute rehabilitation. Faced with unsatisfactory alternatives for especially complex patients, clinicians continue to confront difficult transitional care decisions. Strong collaboration among leaders of local health-care organizations and policymakers is needed to remove this decision-making burden from clinicians and provide them with consistent and unified responses to challenges such as this.
The longer-term burden of coordinating care rests with their caregivers. In addition to monitoring older adults, making sure they receive their medications and other treatments and communicating with multiple care team members, caregivers also are attempting to access food and other supplies while being asked to stay at home. For some, the financial burden associated with addressing older adults’ needs, especially those caregivers affected by unemployment, only adds to their stress. Once again, engaging and training community health workers to collaborate with social workers to support these caregivers is essential to positive health outcomes for both older adults and their caregivers.
Given massive disruptions in the delivery of person-centered care following the rapid spread of COVID-19, the critical need for a single clinician to whom older adults and caregivers can confidently turn throughout vulnerable transitions cannot be overstated. The information overload accompanying this disease, for example, requires a trusted broker to assist these populations in accessing reliable and continually evolving knowledge regarding symptoms and treatments. Once again, rapid employment/redeployment of nurses to fill this role represents an immediate opportunity to address huge gaps in the area of care continuity.
Informed by this evidence-based framework, immediate implementation of targeted federal and state policy solutions would position a health and community-based care systems to respond more effectively to the enormous challenges encountered by older adults with COVID-19 throughout transitions from hospital to home. The following are among the key options federal and state policymakers should pursue:
Support for rapid employment/redeployment and training of nurses, social workers, and community health workers to assume the transitional care roles described above.
Investment in training and reimbursement of family caregivers to support them in assuming transitional care responsibilities.
Universal adoption and implementation of the CARE Act.
Investment in the design and implementation of public service messages (e.g., related to advance care planning), tools (e.g., standardized screening, effective communication using virtual technology), and strategies (e.g., addressing access to telehealth), all focused on improving care transitions.
Support for local coordination to identify and address structural barriers to care transitions.
Increased understanding of the unique challenges facing older adults hospitalized with COVID-19 who transition to home is required. In the meantime, components of the evidence-based Transitional Care Model provide a framework for undertaking more immediate holistic responses to meeting the needs of this population. To more effectively address the complex issues confronting this population and support their family caregivers, immediate action on targeted policy solutions is needed.
Little is known about the needs of older adults with COVID-19 after hospital discharge.
Components of a transitional care model offer a framework for immediate response.
Policies targeting training and support of key workforce members are a priority.
Coordinated local efforts are needed to address barriers to care transitions.
“Informed by this evidence-based framework, immediate implementation of targeted federal and state policy solutions would place health and community-based care systems to reply more effectively to the big challenges encountered by older adults with COVID-19 throughout transitions from hospital to home,” wrote the three authors: Mary D. Naylor, PhD, RN, FAAN, the Marian S. Ware Professor in Gerontology and therefore the Director of the New Courtland Center for Transitions and Health; Karen B. Hirschman, PhD, MSW, research associate professor; and Kathleen McCauley, PhD, RN, FAAN, FAHA, Professor Emerita of Cardiovascular Nursing.
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