Incident SARS-CoV-2 Infections Among mRNA-Vaccinated and Unvaccinated Nursing Home Residents
July 29, 2021
Author: Erin Luers
IMPACT Collaboratory announces recipients of four funding mechanisms
The NIA IMPACT Collaboratory is pleased to announce the awardees of the Pilot Grants Cycle 2B, Career Development Award, and two new funding mechanisms: the Demonstration Projects Program and Health Care Systems (HCS) Scholars Program. Awardees of these funding opportunities will be supported by the IMPACT cores and teams to conduct embedded pragmatic clinical trials (ePCTs) of non-pharmacological interventions within healthcare systems to improve care for people living with Alzheimer’s Disease (AD) and AD-related dementias (ADRD) and their care partners. IMPACT prioritizes applications that promote health equity and address dementia care for people of all backgrounds. Learn more about the NIA IMPACT Collaboratory on the website. Read more about these opportunities and our newest awardees below.
The Pilot Grant Program funds several one-year pilot ePCTs that test non-pharmacological interventions embedded in health care systems to improve care for people living with AD/ADRD and their care partners. Pilot studies are conducted to generate the preliminary data necessary to design and conduct future full-scale Stage IV effectiveness ePCT (based on the NIH Stage Model) that will be funded through other grant mechanisms (National Institutes of Health or other sources).
Recipients of the Pilot Cycle 2B awards:
- Michael Lepore, PhD, LiveWell Alliance
Cognitive Stimulation Therapy for Mild to Moderate Dementia
- Medha Munshi, MD, Joslin Diabetes Center, Harvard Medical School
Deprescribing of Diabetes Treatment Regimens in Long Term Care Residents with ADRD
- Aanand Naik, MD, Baylor College of Medicine
Patient Priorities Care for Hispanics with Dementia (PPC-HD)
- Annette Totten, PhD, Oregon Health & Science University
ADVANCE-PC: Testing Critical Components for a Trial of Advance Care Planning in Primary Care for Dementia
Demonstration Projects Program
The Demonstration Projects Program is a new funding mechanism to support full-scale, Stage IV effectiveness ePCTs testing non-pharmacological interventions for people living with AD/ADRD and their care partners that are linked to the needs of a health care system. The intervention typically includes relatively simple system changes, direct patient outreach, or successfully piloted programs ready for testing at scale. The goal of the demonstration project is to generate evidence on effective care delivery practices that can be expanded and/or implemented in other systems.
Recipients of the Demonstration Projects awards:
- Xiaojuan Li, PhD and Richard Platt, MD, MSc, Harvard Medical School and Harvard Pilgrim Health Care Institute
Collaborative Care Coordination Program for Alzheimer’s Disease and Related Dementias (Co-CARE-AD)
- Michael Parchman, MD, MPH, Kaiser Permanente of Washington Health Research Institute
Can Value Champions Reduce Inappropriate Prescribing for People with Dementia?
Career Development Award Program
The Career Development Award Program prepares early-stage investigators for research careers designing and conducting ePCTs for people living with AD/ADRD and their care partners.
Recipients of the Cycle 2 Career Development Awards:
- Rupak Datta, MD, PhD, Yale School of Medicine
Antibiotic Stewardship in Homebound People Living with Dementia
- Chanee Fabius, PhD, Johns Hopkins Bloomberg School of Public Health
Engaging and Integrating Direct Care Workers in Care Delivery for Persons Living With Dementia in the Community
- Cameron Gettel, MD, Yale School of Medicine
Development and Validation of a Novel Caregiver-Reported Outcome Measure
The new Health Care Systems Embedded Research Scholars Program offers investigators an opportunity to work directly with health care systems interested in improving the care provided to people living with AD/ADRD and their care partners. The goal of the HCS Scholars Program is to embed investigators in health care systems to strengthen collaborations and learn how to successfully implement new programs that may lead to pilot studies or demonstration projects.
Recipients of the first HCS Scholar awards:
- Hillary Lum, MD, PhD, University of Colorado School of Medicine
Extraordinary Partners in Dementia: UCHealth Capacity for Pragmatic Interventions
- Quincy Samus, PhD, MS, Johns Hopkins University School of Medicine
Health Care Systems Embedded Research Program: MIND at Home at Centene Corporation
IMPACT COLLABORATORY HOSTS FIRST ANNUAL TRAINING WORKSHOP & RETREAT
IMPACT Collaboratory held its first annual Training Workshop and Retreat, “Building Skills to Conduct Embedded Pragmatic Clinical Trials for People Living with Dementia (PLWD) and their Care Partners,” on April 7-8. The training was open to early to mid-career researchers seeking to develop competence in designing and conducting ePCTs of interventions to improve care for PWLD and their care partners.
The IMPACT originally expected to have about 25 participants in the virtual 1.5-day workshop and retreat, but to due to high levels of interest, the final workshop included 65 participants from 26 institutions. The curriculum provided a foundation in practical aspects of designing and conducting ePCTs in AD/ADRD through a combination of panel discussions, small group sessions, and networking opportunities with experts in the field. Workshop modules focused on healthcare systems, implementation science, and study design.
One participant described their experience: “This was a great entry into ePCTs for me. The leaders in the field are incredibly gracious sharing their time and lessons learned with the next generation of scholars.”
Our second annual Training Workshop and Retreat will be held virtually January 26-27, 2022. Applications are expected to be open mid-September 2022.
Mor contributes to publication providing evidence of COVID-19 vaccine effectiveness in a real-world nursing home setting
April 16, 2021
Vince Mor, PhD, IMPACT multiple principal investigator, contributes to publication providing evidence of COVID-19 vaccine effectiveness in a real-world setting of vulnerable nursing homes.
Abstract
Objective
To compare rates of incident SARS-CoV-2 infection and 30-day hospitalization or death among residents with confirmed infection in nursing homes with earlier versus later SARS-CoV-2 vaccine clinics.
Design
Matched pairs analysis of nursing homes that had their initial vaccine clinics between December 18, 2020, and January 2, 2021, versus between January 3, 2021, and January 18, 2021. Matched facilities had their initial vaccine clinics between 12 and 16 days apart.
Setting and Participants
Two hundred and eighty nursing homes in 21 states owned and operated by the largest long-term care provider in the United States.
Measurements
Incident SARS-CoV-2 infections per 100 at-risk residents per week; hospital transfers and/or deaths per 100 residents with confirmed SARS-CoV-2 infection per day, averaged over a week.
Results
The early vaccinated group included 136 facilities with 12,157 residents; the late vaccinated group included 144 facilities with 13,221 residents. After 1 week, early vaccinated facilities had a predicted 2.5 fewer incident SARS-CoV-2 infections per 100 at-risk residents per week (95% CI: 1.2–4.0) compared with what would have been expected based on the experience of the late vaccinated facilities. The rates remained significantly lower for several weeks. Cumulatively over 5 weeks, the predicted reduction in new infections was 5.2 cases per 100 at-risk residents (95% CI: 3.2–7.3). By 5 to 8 weeks post-vaccine clinic, early vaccinated facilities had a predicted 1.1 to 3.8 fewer hospitalizations and/or deaths per 100 infected residents per day, averaged by week than expected based on late vaccinated facilities' experience for a cumulative on average difference of 5 events per 100 infected residents per day.
Conclusions
The SARS-CoV-2 vaccines seem to have accelerated the rate of decline of incident infections, morbidity, and mortality in this large multi-state nursing home population.
Update on Two IMPACT Funded Pilot Studies
March 2021 – In Grand Rounds 15, Drs. Forester and Hwang share experiences as Pilot Cycle 1 awardees and provide updates to their funded pilot studies.
Brent P. Forester, MD, MSc on his pilot: Implementation of the Care Ecosystem training model for individuals with dementia in a high risk, integrated care management program
Ula Hwang, MD, MPH on her pilot: Pathway to Detection & Differentiation of Delirium & Dementia in the Emergency Department
Speakers
Brent P. Forester, MD, MSc
Chief, Center of Excellence in Geriatric Psychiatry, McLean Hospital Medical
Director, Behavioral Health Integration, Quality, and Patient Experience, Mass General Brigham
Ula Hwang, MD, MPH
Professor, Vice Chair for Research, Department of Emergency Medicine
Yale School of Medicine
Learning Objectives
Dr. Forester:
- To understand the rationale and design of our adaptation of the Care Ecosystem model to train nurse case managers to deliver telephone-based collaborative dementia care.
- To appreciate the successes and challenges encountered in stakeholder engagement, adaptation of the Care Ecosystem training program and implementation of the model.
- To describe updates on pilot progress to date and plans for a larger embedded pragmatic clinical trial.
Dr. Hwang:
- To describe the Pathway to Detection & Differentiation of Delirium & Dementia in the Emergency Department (PD4ED) pilot.
- To share challenges and solutions of implementation with an embedded pragmatic trial (during a pandemic and institution move).
- To provide updates on the status of the PD4ED pilot study implementation.
Joan Carpenter, PhD, CRNP
University of Maryland School of Nursing
Implementation of a Telehealth Palliative Care Model for Persons with Dementia
Health Care Systems
University of Maryland School of Nursing
Dr. Carpenter is an assistant professor at the University of Maryland School of Nursing and a health scientist at the Corporal Michael J. Crescenz VA Medical Center. Dr. Carpenter is a geriatric nurse practitioner, an advanced certified hospice and palliative care nurse, and fellow in palliative care nursing. She is an expert in geriatric palliative care, specializing in post-acute and long-term care settings. Her research interests focus on the implementation and evaluation of non-pharmacologic palliative care interventions to improve quality of life, reduce symptom burden, and enhance decision making for people with serious illness and their care partners in post-acute and long-term care. She has extensive experience collaborating with interdisciplinary health professionals in community skilled nursing facilities and Veterans Affairs community living centers to implement evidence-based practices and complex interventions to support high-quality palliative care. Her position as an educator, researcher, and leader supports national efforts to enhance serious illness care for older adults.
RATIONALE: People living with dementia (PLWD) receiving post-acute care in nursing homes (NHs) often receive treatments focused on intense rehabilitation and/or aggressive, disease-focused therapies. This has profound implications for quality of life and end-of-life experiences of PLWD. Palliative care consultation offers an evidence-based alternative for PLWD; it increases advance care planning, improves patient and care partner satisfaction, and reduces costs and acute care use.
OBJECTIVE: This pilot study will assess the implementation outcomes and fidelity of a Nurse Practitioner (NP)-delivered telehealth Palliative Care Consultation in Post-Acute Care (PCC-PAC) intervention. The evidence-based PCC-PAC is a multi-component non-pharmacologic, NP-delivered intervention designed to meet the needs of PLWD receiving post-acute care in NHs.
SETTING: One nursing home located in the northeast United States.
POPULATION: PLWD and their care partners newly admitted to NHs for post-acute care following a recent hospitalization.
DESIGN: Single arm pilot study for an embedded pragmatic clinical trial (ePCT)
OUTCOMES: The acceptability, appropriateness, and NP and NH fidelity to the telehealth delivered PCC-PAC.
IMPACT: Embedding complex interventions in NHs is challenging and requires addressing barriers to adopting new practices as well as effective implementation. Findings from this study will immediately inform refinements of the telehealth PCC-PAC and prepare the team for testing the PCC-PAC in a large-scale effectiveness/implementation cluster, randomized ePCT.
Richard Fortinsky, PhD
University of Connecticut Health Center
Pilot Pragmatic Clinical Trial to Embed Tele-Savvy into Health Care Systems
Health Care Systems
University of Connecticut Health Center
Emory University
Dr. Fortinsky is a professor at the University of Connecticut School of Medicine, where he is a core faculty member at the UConn Center on Aging and holds the Health Net, Inc. endowed chair in geriatrics and gerontology. For more than 30 years, Dr. Fortinsky has collaborated with colleagues from a wide range of scientific disciplines, and with numerous healthcare system and community-based organization partners, to design and carry out studies intended to improve healthcare and optimize health-related outcomes for community-dwelling older adults living with Alzheimer’s disease and AD-related dementia and their families. Presently, he serves as principal investigator for studies funded by the National Institute on Aging (NIA) and the Patient-Centered Outcomes Research Institute designed to test in-home, team-based interventions targeting older adults with cognitive vulnerability due to dementia, depression, and/or a history of delirium.
RATIONALE: Efficacious interventions offering meaningful benefits to family and other informal caregivers of older adults with Alzheimer’s disease and related dementias (ADRD) would be attractive to office-based practitioners if a pragmatic linkage could be made between interventions and these types of health care settings.
OBJECTIVE: We aim to embed a pragmatic caregiver identification and invitation strategy into the daily workflow of two outpatient clinics, enabling caregivers to complete the efficacious online psychoeducational Tele-Savvy program. We also aim to evaluate Tele-Savvy effectiveness, assess implementation of the caregiver identification and invitation strategy, and determine viability of routinely collecting and storing caregiver outcomes data into the clinics’ electronic health record systems.
SETTING: Geriatric and dementia care outpatient clinics in two health care systems.
POPULATION: 100 family and other informal caregivers of older adults living at home with ADRD who are patients in the two outpatient care settings.
DESIGN: At each clinical site, caregivers will be recruited in three sequential cohorts. Within each cohort, caregivers will be randomly assigned to join a Tele-Savvy program or to access an online self-guided program about caregiving during crisis. We also will carry out an implementation evaluation to determine clinical staff acceptability and willingness to adopt Tele-Savvy as a routinely-offered caregiver psychoeducational program.
OUTCOMES: Primary outcome is self-reported caregiver mastery. Secondary outcomes are self-reported caregiver reactions to memory and behavior problems, and self-reported perceived stress. All of these outcomes were used in the Tele-Savvy intervention efficacy trial.
IMPACT: If this pilot study successfully achieves its objectives, we will be poised to design a large embedded pragmatic trial engaging sites from the large pool of geriatric and dementia care clinics nationwide. Our longterm goal is to routinely offer Tele-Savvy to caregivers, and to routinely store caregiver outcome data, in health care systems that provide outpatient care to people living with ADRD and their families.