Nursing homes have been described as a "ground zero" throughout the coronavirus outbreak [1-4]. While the final impact of COVID-19 (coronavirus) on short and longer-term health outcomes is still unclear as the pandemic continues to unfold [5], what is clear is that nursing home residents have suffered some of the gravest consequences of this pandemic so far [6]. Contributing to over 40% of COVID-19 deaths within the United States, 100,033 residents and workers in nursing homes have passed away from COVID-19 (as of November 24th, 2020) [7]. Worse still is the fact that the nursing home residents who have died from COVID-19 mostly died without the care or company of their family members [8-10]. These staggering numbers underscore the urgent need for healthcare researchers to understand factors that make nursing home residents more vulnerable to COVID-19, and to identify practical solutions that can address these factors in a timely fashion.
Nursing homes and nursing facilities provide long-term service and support for individuals living with chronic or disabling conditions who are unable to live at home independently [11-13]. Often living with multiple morbidities, in the United States approximately 85.1% of nursing home residents are 65 years and older, with 75.8% of these individuals experiencing hypertension, 58.9% living with Alzheimer's Disease, and 53.0% of residents living with depression [13]. Three sets of factors likely contribute to the alarming COVID-19 death rates seen in nursing homes: (1) characteristics of nursing home residents [14-18], (2) distinctive attributes of nursing home facilities [1, 6, 9, 10, 19], and (3) the micro and macro-level supports available to nursing home residents [2, 20-24]. On a micro level, research indicates that nursing home residents are more susceptible to infection and fatal outcomes from COVID-19 because they are often older adults living with medical conditions that compromise the immune systems and lowers their ability to combat the virus [13, 19, 25, 26]. Additionally, they often lack specific self-care skills, such as utilizing telemedicine tools, or they may have a physical or cognitive impairment that impedes their ability to take care of their health and wellbeing [27-31]. The macro perspective focuses on the unique characteristics of nursing home facilities, as they are typically operating on a close and shared-living environment - conditions that are ideal for the spread of the virus [10, 19, 32]. Further, nursing homes often lack adequate healthcare resources or infrastructure needed to curb the impact of COVID-19. For example, numerous studies have indicated a lack of investment in training programs for nursing home staff, in addition to high turnover rates [33, 34], that management teams are often ineffective [35, 36], and that the nursing home infrastructure is often too outdated [32, 37-39].
The third set of factors that contribute to nursing home residents' vulnerability to COVID-19 centers on social support available to these adults. Nursing home residents often have limited access to micro-level social support, including support from formal (e.g., doctors and nurses) or informal caregivers (e.g., family, friends, and acquaintances) [40], local community [41], and organizations (e.g., inexperienced or inadequately trained staff) [42]. Furthermore, nursing home residents often have limited macro-level social support. This is evidenced by harmful social norms (e.g., age-related discrimination)[43-45] and inadequate policy support that facilitates healthy aging and quality of life (e.g., insufficient regulatory oversight to ensure quality care in nursing homes) [4, 20, 46, 47]. These factors combined, could result in severe health consequences in nursing home residents, such as wide viral spread [1].
The above areas of inquiry resonate with the core principles of the bioecological model [48-51], which highlights the way individuals are influenced by a series of synergistic interactions between intrapersonal and interpersonal factors (e.g., residents, resident families), organizational characteristics (e.g., nursing homes), policy (e.g., legislative response) and the social/community (e.g., ageism) context, and how these processes can change over time (See Figure 1.) To successfully and effectively protect nursing home residents from global health crises like COVID-19, stakeholders such as policymakers, healthcare professionals, informal caregivers, and older adults themselves all need to contribute to the change-making process [2, 46, 52, 53]. While some effective changes are resource-intensive, time-consuming, and need concerted efforts from multilevel stakeholders to achieve, there are cost-effective, efficient, and accessible health solutions available to nursing home residents, such as technology-based interventions [54, 55].
Technology-based interventions can be considered as the use of technology (e.g., digital devices like tablets and wearable devices, communication platforms) to manage or support health promotion strategies that aim to produce accessible and affordable health solutions to a target audience. Compared to traditional health solutions, such as face-to-face consultations, technology-based interventions have the potential to deliver healthcare more effectively and can mitigate geographic and access-related limitations that, as studies show, can play a significant role within nursing homes [56-62]. The evidence further suggests that technology-based interventions can help free healthcare professionals from repetitive work and allow them to make more meaningful contributions in delivering healthcare solutions to the care recipients [63-65].
Telemedicine and other technology-based solutions are particularly crucial given circumstances rendered by the COVID-19 pandemic, such as the limited ability for some healthcare providers to enter residences or for residents to visit their healthcare team for primary care visits. Limiting the exposure to infection through the use of telemedicine may assist in situations where a resident is required to attend a hospital appointment and return to a residence, thus alleviating the potential risk for a virus to spread to others [66]. Further, technologies that support residents' ability to remain in contact with families and friends outside of skilled care settings may reduce the adverse effects of loneliness and social isolation that are more common among nursing home residents compared to community-dwelling older adults [17, 67].
While technology-based solutions have potential to deliver health solutions to nursing home residents [68, 69], there is limited awareness of the benefits and delivery options for state-of-art technology-based interventions specifically designed for nursing home residents. By factoring for the distinctive characteristics of nursing home residents and nursing home facilities, the main focus of this systematic review is to identify and evaluate technology-based interventions tailored explicitly for nursing home residents. Additionally, this research will present practical insights into the varying intervention approaches that can assist in the delivery of broad digital health solutions for nursing home residents amid and beyond the impact of COVID-19. Overall, our research aims are:
- To identify technology-based interventions designed for nursing home residents and describe the characteristics and effects of these interventions concerning the distinctive traits of nursing home residents and nursing facilities.
- To present practical insights into the varying intervention approaches that can assist in the delivery of broad digital health solutions for nursing home residents amid and beyond the impact of COVID-19.