Gayle Morris

Preventing hospitalizations is as much a sign of good health in older adults as it is a way to maintain it. The burden of infection control, preventing skin breakdown, pneumonia — and the myriad other reasons older adults are transferred from skilled nursing facilities to acute care hospitals — falls on the shoulders of frontline workers. 

In the middle of the COVID-19 pandemic, the brunt of that burden has fallen on long-term care facilities.

Data published in September showed that 8% of all coronavirus cases were found in long-term care facilities. However, the same facilities bore an unprecedented 40% of all deaths. The data also shows that while the percentage of deaths has remained steady in long-term care facilities, the number of cases has declined over time.

From the outset of the COVID-19 pandemic, hospital admissions fell dramatically. Data reported in Health Affairs showed non-COVID-19 admissions dropped through April 2020 but had rebounded slightly by July. However, the numbers remained well below normal for patients admitted for pneumonia, chronic obstructive pulmonary disease, urinary tract infections and acute ST-elevation myocardial infarction. The researchers believe the most plausible reason for the decline in admissions was an avoidance of hospital care in response to a fear of contagion. 

As nursing homes have expanded from purely residential settings to post-acute care facilities, the range of services they provide has also broadened substantially. During recovery, some COVID-19 patients require short-term rehabilitation, which is being sought in long-term care facilities. This has strained the resources of facilities where staff are struggling to maintain infection control procedures in the face of a novel contagion.

Mental health stressors increase hospitalization risk

Reduced healthcare costs, improved reimbursement in a value-based system and healthier patients are just three of the broad-stroke benefits of preventing unnecessary hospitalizations in older adults. 

Unfortunately, long-term care settings are a perfect storm for infectious agents as many residents are often immunocompromised, live in close quarters and congregate for eating and activities. The very activities that help maintain a resident’s mental health are those that also helped spread a contagion. While the pandemic progressed, residents in long-term care facilities became isolated as experts tried to reduce the introduction of the novel virus from outside the facility.

This in turn increased the risk of negative mental health outcomes. Older adults respond to their own stress and that experienced by staff, which can increase the risk of behavioral problems. Isolation and lack of stimulation may also lead to loneliness and depression. Each of these negative psychological outcomes has a significant impact on an individual’s immune system and the ability to fight infection.

There is evidence that chronic stress triggers a change in the hypothalamic-pituitary-adrenal axis, which in turn acts as a trigger for depression and anxiety. A rise in pro-inflammatory cytokines happens in chronically stressful situations and in depression, both of which are evident in individuals living under the stress of fear and loneliness. Researchers call this affective immunology or the point at which an individual’s emotions affect the immune response to the external environment.

This overlap between the immune system and emotional response is yet another factor that may trigger infections. The resulting discouragement and depression can lead to more sedentary behavior and lack of cooperation that may ultimately result in an infected pressure ulcer or pneumonia that requires hospitalization. 

Whether planned or unplanned, hospital admission from a skilled nursing facility interrupts care and may increase the risk of medical injury or precipitate the addition of new medications. In the end, it’s the patient who pays the greatest cost of hospitalization. Through a concerted team effort and planned communication, they may not have to face this challenge.

Gayle Morris has been writing on health and wellness for more than a decade. She spent over 20 years as a certified nurse and nurse practitioner in children’s hospitals and a rehabilitation hospital in the Midwest.