POLYPHARMACY IN ASSISTED LIVING: WHERE ARE WE NOW AND EFFECTIVE APPROACHES TO IMPROVE MEDICATION MANAGEMENT

Abstract There are many definitions for polypharmacy used within clinical practice and research and many factors contributing to this problem. Definitions vary from being based on the number of medications the older adult is taking to a more qualitative evaluation of the appropriateness of medication based on the benefit of the drug for a specific problem. For research purposes the definition is more commonly conceptualized as being equivalent to taking five or more medicines. Polypharmacy is noted to be presented in about 40% of older adults living in the community. Limited research has focused specifically on polypharmacy in assisted living settings. In addition to concerns about polypharmacy in assisted living there has also been a focus on the use of psychotropic medication and opioids in these settings as prevalence ranges from 53% to 68%. Although there are not regulations related to decreasing polypharmacy via deprescribing or to decrease use of psychotropics or opioids in assisted living, there are currently major initiatives in geriatrics to focus on these areas. This symposium will provide current data on medication use and polypharmacy among a large sample of 781 assisted living residents from 85 communities across three states and address the impact of a Function Focused Care approach on decreasing polypharmacy and use of psychotropics and opioids. Lastly data will be provided on the value of Deprescribing Networks to help decrease polypharmacy within these settings. The findings from this symposium will provide recommendations for future research as well as guidance for clinical practice.

Direct care workers (DCWs) have low wages and some states have tried to improve their wages through policies such as Medicaid wage pass-throughs and wage floors specific to DCWs. The purpose of this study was to examine the wages of DCWs in comparison to those of other entry level workers and assess the effect of state wage policies on changes in DCW wages. We analyzed state-level hourly wages using Bureau of Labor Statistics (BLS) data for two categories of DCWs separately-(1) home health and personal care aides and (2) nursing assistants and compared these to wages for other entry-level workers. Results show that many states that implemented policies to improve the wages of DCWs reduced the gap between these workers' wages and the wages of other entry-level workers, but the gap was still substantial in many states. Additional efforts will be needed to increase DCW wages. The COVID-19 pandemic affected home care workers in several important ways. The purpose of this study was to detail the challenges faced and the state and federal policy responses implemented to address those challenges. We conducted scans of federal and state policies enacted during the pandemic, home care agency practices described in media reports and the literature, and interviews with 25 stakeholders. Some challenges encountered were entirely new and resulted directly from the pandemic, such as limited access to personal protective equipment due to workers not being recognized as "essential." In other cases, the pandemic worsened long-standing challenges, such as recruitment and retention. State policy responses included Medicaid rate increases, hazard pay, and changes to staff training requirements. Federal policy responses included disaster relief funding as well as allowing non-physician practitioners to order services. Stakeholders suggested additional policy changes will be needed to address ongoing challenges experienced by this workforce. Nursing facilities (NFs) used a variety of strategies to mitigate worsening nursing staff shortages during the COVID-19 pandemic. We conducted analysis of payroll based journal PBJ data and interviewed 9 experts to understand COVID's impact on NF staffing, especially changes in contract staffing. In 2020, NFs increased their use of contract staff hours per resident day (HPRD) by 24%. Use of contract staff during the first year of the pandemic (comparing 2020 to 2019) varied by some facility characteristics (e.g., profit status). NF providers, and industry and academic experts confirmed facilities used multiple strategies beyond using contract staffing, such as temporary nurse aides, hazard pay and flexible schedules to maintain staffing throughout the pandemic. Competition for nursing staff from other healthcare settings and nonhealthcare industries has grown throughout the pandemic, continuing to threaten the stability of the NF workforce.

Chair: Barbara Resnick
There are many definitions for polypharmacy used within clinical practice and research and many factors contributing to this problem. Definitions vary from being based on the number of medications the older adult is taking to a more qualitative evaluation of the appropriateness of medication Innovation in Aging, 2022, Vol. 6, No. S1 based on the benefit of the drug for a specific problem. For research purposes the definition is more commonly conceptualized as being equivalent to taking five or more medicines. Polypharmacy is noted to be presented in about 40% of older adults living in the community. Limited research has focused specifically on polypharmacy in assisted living settings. In addition to concerns about polypharmacy in assisted living there has also been a focus on the use of psychotropic medication and opioids in these settings as prevalence ranges from 53% to 68%. Although there are not regulations related to decreasing polypharmacy via deprescribing or to decrease use of psychotropics or opioids in assisted living, there are currently major initiatives in geriatrics to focus on these areas. This symposium will provide current data on medication use and polypharmacy among a large sample of 781 assisted living residents from 85 communities across three states and address the impact of a Function Focused Care approach on decreasing polypharmacy and use of psychotropics and opioids. Lastly data will be provided on the value of Deprescribing Networks to help decrease polypharmacy within these settings. The findings from this symposium will provide recommendations for future research as well as guidance for clinical practice.

THE IMPACT OF FFC-AC-EIT ON DECREASING USE OF PSYCHOTROPIC MEDICATIONS AND OPIOIDS IN ASSISTED LIVING Barbara Resnick, University of Maryland, Baltimore, Maryland, United States
The secondary aim of the study testing the impact of Function Focused Care for Assisted Living Using the Evidence Integration Triangle (FFC-AL-EIT) was to decrease psychotropic medications and opioids among assisted living residents. Function Focused Care is a philosophy of care in which direct care workers are taught how to evaluate older adults' underlying function and physical activity and optimize their participation in all activities. This randomized controlled trial included 85 communities and 781 residents across three states. A total of 501 out of 794 participants (63%) received at least one psychotropic medication or opioid. Except for opioid use at four months, there was no significant difference in the intervention groups with regard to medication use at any time point. The findings suggest that encouraging participation in physical activity during all care interactions does not result in an increase in the need for and prescribing of psychotropic medications or opioids.

POLYPHARMACY IN ASSISTED LIVING Elizabeth Galik, University of Maryland, Baltimore, Baltimore, Maryland, United States
The purpose of this study was to describe polypharmacy in assisted living settings, evaluate the factors that influence polypharmacy and the impact of polypharmacy on clinical outcomes. Baseline data from the study entitled, Dissemination and Implementation of Function Focused Care for Assisted Living Using the Evidence Integration Triangle (FFC-AL-EIT) was used. Total number of drugs taken daily among the 781 participants was 5.16 (SD=2.40) and over half (N=484, 62%) were exposed to polypharmacy. None of the predicted variables (age, gender, race, setting, diagnoses, and cognition) were associated with polypharmacy (Wald = .207, p=.65). Similarly, controlling for age, gender, race, setting, diagnoses, cognition, function, and physical activity, polypharmacy was not associated with falls, emergency room visits or hospitalizations. Factors not included in the data contributing to the high rate of polypharmacy in assisted living settings will be discussed and recommendations for further research and practice implications reviewed.

DEPRESCRIBING IN ASSISTED LIVING
Barbara Zarowitz 1 , and Nicole Brandt 2 , 1. University of Maryland School of Pharmacy,Las Vegas,Nevada,United States,2. University of Maryland,Baltimore,Baltimore,Maryland,United States Deprescribing is defined as the thoughtful process of "tapering, stopping, discontinuing, or withdrawing drugs, with the goal of managing polypharmacy and improving outcomes." There are multiple clinical issues that deprescribing can address such as: antibiotic resistance caused by inappropriate and excessive use, the ongoing opioid epidemic, as well as over treatment particularly at the end of life. Networks have been established to address deprescribing across settings including assisted living nationally and internationally. Fourteen key informants from these networks were interviewed including different disciplines. From the interviews, six major themes across two domains were identified. The two domains included regional resources and knowledge gaps and the six themes included: (a) network structure, (b) public perception, (c) policy implications, (d) implementation, (e) challenges, and (f) recommendations. Overall, the importance of collaboration among interprofessional team members will be critical to the success of deprescribing as this clinical issue moves ahead.

CONTENDING WITH UNCERTAINTY: IMPLEMENTING THE CMS ACUTE HOSPITAL CARE AT HOME WAIVER PROGRAM IN THE UNITED STATES
Ksenia Gorbenko 1 , Emily Franzosa 1 , Abigail Baim-Lance 1 , Gabrielle Schiller 2 , Heather Wurtz 1 , Sybil Masse 1 , David Levine 3 , and Albert Siu 1 , 1. Icahn School of Medicine at Mount Sinai,New York,New York,United States,2. CUNY School of Public Health,Astoria,New York,United States,3. Mass General Brigham,Boston,Massachusetts,United States As Congress considers renewing the Acute Hospital Care At Home (AHCaH) waiver, which provides a full hospital payment for Hospital at Home (HaH) care, evaluating uncertainty around the future of HaH payment is critical. Our qualitative study explored HaH leaders' experiences with implementing HaH (N=18, clinical/medical directors, operational and program managers) from 14 new and pre-existing programs across the U.S. We conducted semi-structured interviews with HaH programs diverse by size, urbanicity, and geography. We analyzed transcripts using a thematic approach. Participants across settings and regions wanted greater clarity about the waiver's future. Lack of clarity affected