Center for Excellence in Assisted Living CEAL@UNC

Advancing the well-being of the people who live and work in assisted living through research, practice, and policy.

COVID-19

Health of the Pandemic: Dementia Paid Staff and Unpaid Caregiver Workforce in Congregate Care and Community Settings

Oct 1, 2024
Objectives The objective of this study was to assess the impact of the pandemic on the health, well-being, and access to services of paid staff and unpaid caregivers of persons living with dementia. Design Questionnaires were developed to capture the experiences of paid staff and unpaid caregivers throughout the pandemic, leveraging a pre-existing clinical trial […]

Health of the Pandemic: Dementia Paid Staff and Unpaid Caregiver Workforce in Congregate Care and Community Settings

by Lea Efird-Green

Objectives The objective of this study was to assess the impact of the pandemic on the health, well-being, and access to services of paid staff and unpaid caregivers of persons living with dementia. Design Questionnaires were developed to capture the experiences of paid staff and unpaid caregivers throughout the pandemic, leveraging a pre-existing clinical trial […]

Wastewater-Based Surveillance Reveals the Effectiveness of the First COVID-19 Vaccination Campaigns in Assisted Living Facilities

Sep 1, 2024
The COVID-19 pandemic has disproportionately affected vulnerable populations, including residents of assisted living facilities (ALFs). This study investigates the impact of non-pharmaceutical interventions (NPIs) and mass vaccination campaigns on SARS-CoV-2 transmission dynamics within four ALFs in Maricopa County, Arizona, United States from January to April 2021. Initial observations reveal a significant SARS-CoV-2 prevalence in Maricopa […]

Wastewater-Based Surveillance Reveals the Effectiveness of the First COVID-19 Vaccination Campaigns in Assisted Living Facilities

by Lea Efird-Green

The COVID-19 pandemic has disproportionately affected vulnerable populations, including residents of assisted living facilities (ALFs). This study investigates the impact of non-pharmaceutical interventions (NPIs) and mass vaccination campaigns on SARS-CoV-2 transmission dynamics within four ALFs in Maricopa County, Arizona, United States from January to April 2021. Initial observations reveal a significant SARS-CoV-2 prevalence in Maricopa […]

Associations between Specialized Dementia Care, COVID-19 and Central Nervous System Medication Use in Assisted Living: A Population-Based Repeated Cross-Sectional Study

Aug 1, 2024
Background Assisted living (AL) is an increasingly common residential setting for persons with dementia; yet concerns exist about sub-optimal care of this population in AL given its lower levels of staffing and services. Our objectives were to (i) examine associations between AL setting (dementia care vs. other), COVID-19 pandemic waves, and prevalent antipsychotic, antidepressant, anti-dementia, […]

Associations between Specialized Dementia Care, COVID-19 and Central Nervous System Medication Use in Assisted Living: A Population-Based Repeated Cross-Sectional Study

by Lea Efird-Green

Background Assisted living (AL) is an increasingly common residential setting for persons with dementia; yet concerns exist about sub-optimal care of this population in AL given its lower levels of staffing and services. Our objectives were to (i) examine associations between AL setting (dementia care vs. other), COVID-19 pandemic waves, and prevalent antipsychotic, antidepressant, anti-dementia, […]

Family Involvement among Oregon Adult Foster Home Residents, 2018-2023

Aug 1, 2024
Objectives: To track the changes that occurred in family involvement among Oregon Adult Foster Home (AFH) residents following the COVID-19 pandemic and to examine the associations between home and resident characteristics and family involvement. Design: Retrospective analysis of repeated cross-sectional data. Setting and Participants: A total of 2027 responses from AFH providers that replied to […]

Family Involvement among Oregon Adult Foster Home Residents, 2018-2023

by Lea Efird-Green

Objectives: To track the changes that occurred in family involvement among Oregon Adult Foster Home (AFH) residents following the COVID-19 pandemic and to examine the associations between home and resident characteristics and family involvement. Design: Retrospective analysis of repeated cross-sectional data. Setting and Participants: A total of 2027 responses from AFH providers that replied to […]

Comparison of Hospitalization Events among Residents of Assisted Living and Nursing Homes during COVID-19: Do Settings Respond Differently during Public Health Crises?

Jul 1, 2024
Background COVID-19 and resulting health system and policy decisions led to significant changes in healthcare use by nursing homes (NH) residents. It is unclear whether healthcare outcomes were similarly affected among older adults in assisted living (AL). This study compared hospitalization events in AL and NHs during COVID-19 pandemic waves 1 through 4, relative to […]

Comparison of Hospitalization Events among Residents of Assisted Living and Nursing Homes during COVID-19: Do Settings Respond Differently during Public Health Crises?

by Lea Efird-Green

Background COVID-19 and resulting health system and policy decisions led to significant changes in healthcare use by nursing homes (NH) residents. It is unclear whether healthcare outcomes were similarly affected among older adults in assisted living (AL). This study compared hospitalization events in AL and NHs during COVID-19 pandemic waves 1 through 4, relative to […]

Public Health Response to SARS-CoV-2 in Assisted Living Facilities in New York State: March 2020-December 2022

May 1, 2024
Context: Assisted living facility (ALF) residents are especially vulnerable to SARS-CoV-2 infection due to the age and comorbidities of the resident population and the social nature of these facilities. Objective: To collate all New York State Department of Health guidance and regulations to control transmission of SARS-CoV-2 infection within ALFs from March 2020 through December […]

Public Health Response to SARS-CoV-2 in Assisted Living Facilities in New York State: March 2020-December 2022

by Lea Efird-Green

Context: Assisted living facility (ALF) residents are especially vulnerable to SARS-CoV-2 infection due to the age and comorbidities of the resident population and the social nature of these facilities. Objective: To collate all New York State Department of Health guidance and regulations to control transmission of SARS-CoV-2 infection within ALFs from March 2020 through December […]

Excess Deaths in Assisted Living and Nursing Homes during the COVID-19 Pandemic in Alberta, Canada

May 1, 2024
Objectives Assisted living (AL) is a significant and growing congregate care option for vulnerable older adults designed to reduce the use of nursing homes (NHs). However, work on excess mortality in congregate care during the COVID-19 pandemic has primarily focused on NHs with only a few US studies examining AL. The objective of this study […]

Excess Deaths in Assisted Living and Nursing Homes during the COVID-19 Pandemic in Alberta, Canada

by Lea Efird-Green

Objectives Assisted living (AL) is a significant and growing congregate care option for vulnerable older adults designed to reduce the use of nursing homes (NHs). However, work on excess mortality in congregate care during the COVID-19 pandemic has primarily focused on NHs with only a few US studies examining AL. The objective of this study […]

Experiences of COVID-19 Restrictions on Physical Activity in Assisted Living

Apr 1, 2024
Physical activity is an important health behavior for older adults in assisted living, however the COVID-19 pandemic may have disrupted this behavior. This study examined the effects of the pandemic on physical activity experiences in this population. Semi-structured interviews were conducted and analyzed using thematic analysis. Participants described barriers to physical activity, transitions in their […]

Experiences of COVID-19 Restrictions on Physical Activity in Assisted Living

by Lea Efird-Green

Physical activity is an important health behavior for older adults in assisted living, however the COVID-19 pandemic may have disrupted this behavior. This study examined the effects of the pandemic on physical activity experiences in this population. Semi-structured interviews were conducted and analyzed using thematic analysis. Participants described barriers to physical activity, transitions in their […]

The Impact of Assisted Living Organizational Structure and Process Characteristics on Staff Absence During COVID-19

Apr 1, 2024
Quality of care in assisted living communities (ALCs) is important to consumers. The coronavirus disease of 2019 (COVID-19) pandemic and associated emergency policies have posed major challenges on staff recruitment and retention. This study aimed to examine the relationship between organizational characteristics of ALCs in Florida and challenges with staff absence during COVID-19 (N = 129 ALCs). […]

The Impact of Assisted Living Organizational Structure and Process Characteristics on Staff Absence During COVID-19

by Lea Efird-Green

Quality of care in assisted living communities (ALCs) is important to consumers. The coronavirus disease of 2019 (COVID-19) pandemic and associated emergency policies have posed major challenges on staff recruitment and retention. This study aimed to examine the relationship between organizational characteristics of ALCs in Florida and challenges with staff absence during COVID-19 (N = 129 ALCs). […]

Assisted Living Residents with Dementia: Disparities in Mental Health Services Pre and During COVID-19

Apr 1, 2024
Background Little is known about mental health among Medicare beneficiaries with Alzheimer’s disease or related dementias (ADRD) who reside in assisted living (AL) communities. The COVID-19 pandemic may have curtailed ambulatory care access for these residents, but telehealth may have expanded it. We examined in-person and telehealth use of ambulatory mental health visits among AL […]

Assisted Living Residents with Dementia: Disparities in Mental Health Services Pre and During COVID-19

by Lea Efird-Green

Background Little is known about mental health among Medicare beneficiaries with Alzheimer’s disease or related dementias (ADRD) who reside in assisted living (AL) communities. The COVID-19 pandemic may have curtailed ambulatory care access for these residents, but telehealth may have expanded it. We examined in-person and telehealth use of ambulatory mental health visits among AL […]

Psychotropic, Anticonvulsant, and Opioid Use in Assisted Living Residents Before and During the COVID-19 Pandemic

Oct 1, 2023
WHAT THIS MEANS FOR YOU: Administrative data from 256 assisted living communities in Alberta during the COVID-19 pandemic found that during waves 2 to 4, antipsychotic use increased, (significantly more for dementia care residents), and that anticonvulsant use increased for assisted living (but not dementia care) residents. Additionally, there was an increase in antidepressant use and a decrease in benzodiazepine use for both assisted living and dementia care residents. The persistence of a pandemic-associated increase in these medications raises concerns about well-established health and wellbeing impacts for residents.

Psychotropic, Anticonvulsant, and Opioid Use in Assisted Living Residents Before and During the COVID-19 Pandemic

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Administrative data from 256 assisted living communities in Alberta during the COVID-19 pandemic found that during waves 2 to 4, antipsychotic use increased, (significantly more for dementia care residents), and that anticonvulsant use increased for assisted living (but not dementia care) residents. Additionally, there was an increase in antidepressant use and a decrease in benzodiazepine use for both assisted living and dementia care residents. The persistence of a pandemic-associated increase in these medications raises concerns about well-established health and wellbeing impacts for residents.

Effect of Quarantine on Body Weight Among Residents of Assisted Living Facilities During the COVID-19 Pandemic

Sep 1, 2023
WHAT THIS MEANS FOR YOU: During the COVID-19 pandemic, 40% of 53 assisted living residents who had been in room quarantine experienced significant weight loss; men had a greater risk of significant weight loss than women. If quarantine is used for future epidemics, weight should be monitored and reported to avoid negative health outcomes associated with rapid weight loss.

Effect of Quarantine on Body Weight Among Residents of Assisted Living Facilities During the COVID-19 Pandemic

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: During the COVID-19 pandemic, 40% of 53 assisted living residents who had been in room quarantine experienced significant weight loss; men had a greater risk of significant weight loss than women. If quarantine is used for future epidemics, weight should be monitored and reported to avoid negative health outcomes associated with rapid weight loss.

Barriers to Infection Prevention and Control in Long-term Care/Assisted Living Settings in British Columbia During the COVID-19 Pandemic: A Cross-Sectional Survey

Aug 1, 2023
WHAT THIS MEANS FOR YOU: A study of over 1,300 health care workers and infection prevention and control (IPAC) professionals in British Columbia found that healthcare workers in long-term care/assisted living experienced more barriers following IPAC recommendations compared to those in acute care. Barriers included that IPAC was lower priority compared to other tasks; not their responsibility; that there were limited personal protective equipment, hand hygiene, and cleaning/disinfection products; deficits in IPAC leadership and support; limited IPAC education and training; and limited patient care knowledge for managing COVID-19 infections.

Barriers to Infection Prevention and Control in Long-term Care/Assisted Living Settings in British Columbia During the COVID-19 Pandemic: A Cross-Sectional Survey

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: A study of over 1,300 health care workers and infection prevention and control (IPAC) professionals in British Columbia found that healthcare workers in long-term care/assisted living experienced more barriers following IPAC recommendations compared to those in acute care. Barriers included that IPAC was lower priority compared to other tasks; not their responsibility; that there were limited personal protective equipment, hand hygiene, and cleaning/disinfection products; deficits in IPAC leadership and support; limited IPAC education and training; and limited patient care knowledge for managing COVID-19 infections.

Comparing Quality of Care Outcomes Between Assisted Living and Nursing Homes Before and During the COVID-19 Pandemic

Jul 1, 2023
WHAT THIS MEANS FOR YOU: This study used Resident Assessment Instrument data from 2017-2021 in Alberta to examine quality indicator differences between assisted living and nursing home residents (over 2,000 assisted living and about 13,000 nursing home residents per quarter). Antipsychotic use and pain rates were consistently higher in assisted living, while depressive symptoms, dependency, restraint use, delirium, and weight loss were consistently higher in nursing homes. During the COVID-19 pandemic, antipsychotic use increased in both settings, and total dependency increased in assisted living.

Comparing Quality of Care Outcomes Between Assisted Living and Nursing Homes Before and During the COVID-19 Pandemic

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study used Resident Assessment Instrument data from 2017-2021 in Alberta to examine quality indicator differences between assisted living and nursing home residents (over 2,000 assisted living and about 13,000 nursing home residents per quarter). Antipsychotic use and pain rates were consistently higher in assisted living, while depressive symptoms, dependency, restraint use, delirium, and weight loss were consistently higher in nursing homes. During the COVID-19 pandemic, antipsychotic use increased in both settings, and total dependency increased in assisted living.

Primary Care Telemedicine Use among Assisted Living Residents with Dementia during COVID-19: Race and Dual Enrollment Status

May 1, 2023
WHAT THIS MEANS FOR YOU: This study used Medicare and CDC datasets to examine telemedicine primary care among 62,000 AL residents with dementia during the first year of the COVID-19 pandemic (2020). During the first three quarters of the pandemic, racially minoritized groups (Black, Hispanic) and Medicare-Medicaid dual eligibles were able to successfully use telemedicine at high rates. Gaps in primary care access between these groups and others (white, non-Medicaid eligible) were reduced due to telemedicine. This could inform CMS decisions about Medicare coverage for telemedicine primary care.

Primary Care Telemedicine Use among Assisted Living Residents with Dementia during COVID-19: Race and Dual Enrollment Status

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: This study used Medicare and CDC datasets to examine telemedicine primary care among 62,000 AL residents with dementia during the first year of the COVID-19 pandemic (2020). During the first three quarters of the pandemic, racially minoritized groups (Black, Hispanic) and Medicare-Medicaid dual eligibles were able to successfully use telemedicine at high rates. Gaps in primary care access between these groups and others (white, non-Medicaid eligible) were reduced due to telemedicine. This could inform CMS decisions about Medicare coverage for telemedicine primary care.

Caregiver Involvement and Concerns with Care of Residents of Assisted Living Before and During the COVID-19 Pandemic

Apr 1, 2023
WHAT THIS MEANS FOR YOU: A survey about AL family caregiver experiences in Western Canada was conducted before and during waves one (Mar to Jun 2020) and two (Oct 2020 to Feb 2021) of the COVID-19 pandemic. A total of 386 family caregivers representing 110 AL communities participated. In-person visits and caregiver involvement decreased significantly during wave one of the pandemic due to visitor restrictions. Caregivers’ concerns about their relatives significantly increased during both waves, especially when they did not feel well-informed or involved in their relative’s care.

Caregiver Involvement and Concerns with Care of Residents of Assisted Living Before and During the COVID-19 Pandemic

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: A survey about AL family caregiver experiences in Western Canada was conducted before and during waves one (Mar to Jun 2020) and two (Oct 2020 to Feb 2021) of the COVID-19 pandemic. A total of 386 family caregivers representing 110 AL communities participated. In-person visits and caregiver involvement decreased significantly during wave one of the pandemic due to visitor restrictions. Caregivers’ concerns about their relatives significantly increased during both waves, especially when they did not feel well-informed or involved in their relative’s care.

Preparedness and Response of Assisted Living Facilities Toward COVID-19 Infection Control in Houston, Texas, USA

Feb 1, 2023
WHAT THIS MEANS FOR YOU: The Houston Health Department conducted onsite assessments at AL communities to assess infection prevention and control practices. Larger AL communities better implemented CDC guidelines and were more proactive in their COVID-19 response activities. For example, many medium and small communities lacked access to COVID-19 PCR testing and had lower resident vaccination rates.

Preparedness and Response of Assisted Living Facilities Toward COVID-19 Infection Control in Houston, Texas, USA

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: The Houston Health Department conducted onsite assessments at AL communities to assess infection prevention and control practices. Larger AL communities better implemented CDC guidelines and were more proactive in their COVID-19 response activities. For example, many medium and small communities lacked access to COVID-19 PCR testing and had lower resident vaccination rates.

Digital Immunization Tracking in Long-Term Care and Assisted Living Facilities

Feb 1, 2023
WHAT THIS MEANS FOR YOU: Vaccines are a part of the solution to infectious disease outbreaks like COVID-19, but not everyone is getting them, especially older adults. In a Canadian study, pneumonia vaccine uptake was improved by providing assisted living and long-term care communities with vaccine coverage data and providing automatic reminders for subsequent doses. Therefore, a cloud-based digital vaccination record is one solution to promote the uptake of adult vaccines for older adults, as well as tracking immunization records and sharing them with policymaking organizations. This can improve communication and inform policymakers to reduce the risk of infection in AL communities.

Digital Immunization Tracking in Long-Term Care and Assisted Living Facilities

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Vaccines are a part of the solution to infectious disease outbreaks like COVID-19, but not everyone is getting them, especially older adults. In a Canadian study, pneumonia vaccine uptake was improved by providing assisted living and long-term care communities with vaccine coverage data and providing automatic reminders for subsequent doses. Therefore, a cloud-based digital vaccination record is one solution to promote the uptake of adult vaccines for older adults, as well as tracking immunization records and sharing them with policymaking organizations. This can improve communication and inform policymakers to reduce the risk of infection in AL communities.

Coping Behaviors and Health Status during the COVID-19 Pandemic among Caregivers of Assisted Living Residents in Western Canada

Dec 1, 2022
WHAT THIS MEANS FOR YOU: Surveys from 673 assisted living direct caregivers revealed that coping behaviors such as alcohol and smoking/cannabis use, and psychotropic drug use increased during the first two waves of the COVID-19 pandemic and were more common among caregivers who had anxiety or depression symptoms before the pandemic. These caregivers are thus particularly vulnerable to negative coping behaviors during stressful events and may require additional support.

Coping Behaviors and Health Status during the COVID-19 Pandemic among Caregivers of Assisted Living Residents in Western Canada

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Surveys from 673 assisted living direct caregivers revealed that coping behaviors such as alcohol and smoking/cannabis use, and psychotropic drug use increased during the first two waves of the COVID-19 pandemic and were more common among caregivers who had anxiety or depression symptoms before the pandemic. These caregivers are thus particularly vulnerable to negative coping behaviors during stressful events and may require additional support.

Excess Mortality Among Assisted Living Residents with Dementia during the COVID-19 Pandemic

Oct 1, 2022
WHAT THIS MEANS FOR YOU: Data from over 560,000 Medicare recipients revealed that residents with dementia experienced 33.4 more excess deaths per 100,000 compared to those without dementia during the COVID-19 pandemic. Residents in memory care communities did not have significantly different mortality rates compared to those in general assisted living settings.

Excess Mortality Among Assisted Living Residents with Dementia during the COVID-19 Pandemic

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Data from over 560,000 Medicare recipients revealed that residents with dementia experienced 33.4 more excess deaths per 100,000 compared to those without dementia during the COVID-19 pandemic. Residents in memory care communities did not have significantly different mortality rates compared to those in general assisted living settings.

Caregivers’ Concerns about Assisted Living Residents’ Mental Health during the COVID-19 Pandemic: A Cross-Sectional Survey Study

Sep 1, 2022
WHAT THIS MEANS FOR YOU: Surveys with 673 caregivers from Western Canada found that concerns about residents' depressed mood, loneliness, and anxiety doubled three months after the COVID-19 pandemic started, compared with three months before the pandemic. Factors that may alleviate concerns in the future include improving residents' access to counseling services and better informing caregivers about resident care.

Caregivers’ Concerns about Assisted Living Residents’ Mental Health during the COVID-19 Pandemic: A Cross-Sectional Survey Study

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Surveys with 673 caregivers from Western Canada found that concerns about residents’ depressed mood, loneliness, and anxiety doubled three months after the COVID-19 pandemic started, compared with three months before the pandemic. Factors that may alleviate concerns in the future include improving residents’ access to counseling services and better informing caregivers about resident care.

Prevalence and Correlates of Anxiety and Depression in Caregivers to Assisted Living Residents during COVID-19: A Cross-Sectional Study

Aug 1, 2022
WHAT THIS MEANS FOR YOU: A study of 673 family and friend caregivers of residents in AL from two Canadian provinces from Oct 2020 – Mar 2021 found that 29% had clinically significant anxiety and 39% had clinically significant depression. Caregivers who faced personal stressors such as health issues, reduced income, and lack of social support, along with concerns about residents due to COVID-19, were more likely to experience anxiety and depression. Healthcare providers and assisted living staff should be aware of caregivers' mental health challenges during public health crises and provide appropriate screening and support.

Prevalence and Correlates of Anxiety and Depression in Caregivers to Assisted Living Residents during COVID-19: A Cross-Sectional Study

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: A study of 673 family and friend caregivers of residents in AL from two Canadian provinces from Oct 2020 – Mar 2021 found that 29% had clinically significant anxiety and 39% had clinically significant depression. Caregivers who faced personal stressors such as health issues, reduced income, and lack of social support, along with concerns about residents due to COVID-19, were more likely to experience anxiety and depression. Healthcare providers and assisted living staff should be aware of caregivers’ mental health challenges during public health crises and provide appropriate screening and support.

Coronavirus Disease 2019 (COVID-19) in Assisted Living Communities: Neighborhood Deprivation and State Social Distancing Policies Matter

Aug 1, 2022
WHAT THIS MEANS FOR YOU: Using confirmed COVID-19 cases from 5 states, assisted living communities with a higher population of Medicare/Medicaid dual-eligible minority residents were more likely to have COVID-19 cases, as were those located in more socioeconomically deprived neighborhoods. Communities in states with stricter social distancing policies had significantly lower numbers of cases.

Coronavirus Disease 2019 (COVID-19) in Assisted Living Communities: Neighborhood Deprivation and State Social Distancing Policies Matter

by Lea Efird-Green

WHAT THIS MEANS FOR YOU: Using confirmed COVID-19 cases from 5 states, assisted living communities with a higher population of Medicare/Medicaid dual-eligible minority residents were more likely to have COVID-19 cases, as were those located in more socioeconomically deprived neighborhoods. Communities in states with stricter social distancing policies had significantly lower numbers of cases.