Impact of POLST Adoption and of Financial Incentives on Care Receipt and on Intensity of Care Preferences in Nursing Home Patients

摘要 COVID对疗养院（NH）居民的影响不成比例-估计超过35%的死亡发生在NH居民中。为了防止COVID在脆弱的老年人中传播，美国各地的NHS已经制定了一系列干预措施，包括限制非员工进入NHS，隔离NHS内的患者，减少NHS内的团体活动，以及将患者从NHS转移到其他设施。这些措施有可能加剧阿尔茨海默病和相关痴呆症（AD/ADRD）NH患者的社会孤立，护理质量和生活质量。 有一个广泛的文献中的NHS和其他机构设置的社会支持。相比之下，在相反的极端-隔离-的研究方式相对较少，尽管事实上，在感染控制的背景下，患者隔离是常见的，特别是在NH患者中，耐药微生物的感染比在社区环境中更常见。此外，隔离的其他方面-社会隔离，情感/心理隔离和身体隔离-对患有AD/ADRD和没有AD/ADRD的患者的有效护理和安全性构成障碍。 AD/ADRD患者由于在疗养院隔离而具有异常的不良结局风险。他们更依赖于熟悉的个人和环境，有指导的活动，需要更多的帮助，当这些都不存在时，他们就有混乱和焦虑的风险。AD/ADRD患者在沟通需求方面面临更大的挑战。 为了评估大流行对NH患者护理和预后的影响，我们在本行政补充文件中建议制定和实施措施，以评估患者隔离，并将这些措施与2011年至2018年加州NH AD/ADRD患者的患者预后进行横向和纵向关联。具体而言，这一行政补充的目的是： 开发用于评估基线患者隔离的替代措施-社会，情感和身体 确定基线患者隔离是否可预测患者护理质量、护理利用率和结局 确定基线患者隔离是否与加州MDS第S节（记录POLST应答）中报告的临终护理偏好相关。 总而言之，使用现有数据构建的患者隔离结构的这些发现可以与国家MDS数据一起使用，以检查AD/ADRD患者中患者隔离的变化程度，以及它是否是COVID大流行期间患者不良结局的决定因素。

Abstract COVID has disproportionately impact nursing home (NH) residents – estimates are that more than 35% of deaths have occurred among NH residents. In order to prevent COVID spread among vulnerable elderly, NHs across the U.S. have instituted a number of interventions, including restricting access to NHs by non-employees, isolating patients within NHs, reducing group activities within NHs, and transferring patients out of NHs to other facilities. These measures have the potential to exacerbate social isolation, quality of care, and quality of life among NH patients with Alzheimer’s disease and Related Dementias (AD/ADRD). There is an extensive literature on social support within NHs and other institutional settings. In contrast, there is relatively little in the way of research in the opposite extreme – isolation – despite the fact that patient isolation in the context of infection control is common, especially among NH patients, where infections with resistant organisms are more common than in the community setting. Furthermore, other aspects of isolation – social isolation, emotional/psychological isolation, and physical isolation – present barriers to the effective care and safety of patients with AD/ADRD and without AD/ADRD in NHs. Patients with AD/ADRD are exceptionally at risk for adverse outcomes due to isolation in nursing homes. They have greater dependency on familiar individuals and settings, directed activities, require greater assistance, and are at risk for confusion and agitation when these are absent. Patients with AD/ADRD have greater challenges with communicating needs. In order to assess the national impact of the pandemic on patient care and outcomes among NH residents with and without AD/ADRD, we propose in this administrative supplement to develop and implement measures to assess patient isolation and relate these cross sectionally and longitudinally to patient outcomes among AD/ADRD patients in California NHs from 2011 to 2018. Specifically, the aims of this administrative supplement are to: Develop proxy measures for assessing baseline patient isolation – social, emotional, and physical Determine whether baseline patient isolation is predictive of patient quality of care, utilization of care, and outcomes Determine whether baseline patient isolation is related to end-of-life care preferences as reported in the California MDS Section S, where POLST responses are recorded. Taken together, these findings for a patient isolation construct using existing data can be employed with national MDS data to examine the degree to which patient isolation changed among AD/ADRD patients and whether it was a determinant of adverse patient outcomes during the COVID Pandemic.