Search

Background: Redesigning the healthcare system to consistently provide effective and tailored care to older adults is needed. The 4Ms (What Matters, Mobility, Medication, and Mentation) offer a framework to guide health systems' efforts to deliver Age‐Friendly care. We use an implementation science framework to characterize and assess real‐world implementation experiences with the 4Ms across varied health systems. Methods: With expert input, we selected three health systems that were early adopters of the 4Ms and engaged in different implementation support models through the Institute for Healthcare Improvement. We conducted 29 semi‐structured interviews with diverse stakeholders from each site. Stakeholders ranged from hospital leadership to frontline clinicians. Interviews covered each site's approach to and experiences with implementation, including facilitators and barriers. Interviews were recorded, transcribed, and deductively coded using the Consolidated Framework for Implementation Research. We characterized each site's implementation decisions and then inductively identified overarching themes and subthemes with supporting quotes. Results: Health systems varied in their implementation approach, including the implementation order of each of the 4Ms. We identified three overarching themes: (1) the 4Ms offered a compelling conceptual framework for advancing Age‐Friendly care, but implementation was complex and fragmented; (2) complete and sustained implementation of the 4Ms required multidisciplinary and multilevel leadership and engagement; (3) strategies that facilitate implementation success and support frontline culture change included top‐down communication and infrastructure alongside hands‐on clinical education and support. Common barriers are siloed implementation efforts across settings that impeded synergies and scaling; disengaged physicians; and difficulty implementing What Matters in a meaningful way. Conclusions: Similar to other implementation studies, we identified multifactorial domains impacting 4Ms implementation. To achieve Age‐Friendly transformation, health systems must plan for and attend to multiple phases of implementation while ensuring that the work coheres under a unified vision that spans disciplines and settings. [ABSTRACT FROM AUTHOR]

Background: Polypharmacy is common in older adults with cognitive impairment and multiple chronic conditions, increasing risks of adverse drug events, hospitalization, and death. Deprescribing, the process of reducing or stopping potentially inappropriate medications, may improve outcomes. The OPTIMIZE pragmatic trial examined whether educating and activating patients, family members and clinicians about deprescribing reduces number of chronic medications and potentially inappropriate medications. Acceptability and challenges of intervention delivery in cognitively impaired older adults are not well understood. Methods: We explored mechanisms of intervention implementation through post hoc qualitative interviews and surveys with stakeholder groups of 15 patients, 7 caregivers, and 28 clinicians. We assessed the context in which the intervention was delivered, its implementation, and mechanisms of impact. Results: Acceptance of the intervention was affected by contextual factors including cognition, prior knowledge of deprescribing, communication, and time constraints. All stakeholder groups endorsed the acceptability, importance, and delivery of the intervention. Positive mechanisms of impact included patients scheduling specific appointments to discuss deprescribing and providers being prompted to consider deprescribing. Recollection of intervention materials was inconsistent but most likely shortly after intervention delivery. Short visit times remained the largest provider barrier to deprescribing. Conclusions: Our work identifies key learnings in intervention delivery that can guide future scaling of deprescribing interventions in this population. We highlight the critical roles of timing and repetition in intervention delivery to cognitively impaired populations and the barrier posed by short consultation times. The acceptability of the intervention to patients and family members highlights the potential to incorporate deprescribing education into routine clinical practice and expand proven interventions to other vulnerable populations. [ABSTRACT FROM AUTHOR]

Background: Social isolation is common in the last years of life, especially among individuals with cognitive impairment (CI), but it is unknown if social isolation is related to end-of-life health care use. Methods: We used nationally-representative 2006–2018 Health and Retirement Study (HRS) data linked to Medicare claims, including adults age ≥65 interviewed in the last 4 years of life (N = 2380). We used a validated social isolation scale and three social isolation subscales: (1) household contacts (marital status, household size, nearby children), (2) social network interaction (with children, family, and friends), and (3) community engagement. End-of-life health outcomes included 2+ emergency department (ED) visits in the last month of life, hospitalizations or ICU stays in the last 6 months of life, and any hospice use. CI was defined using the validated Langa-Weir methodology. We used logistic regression to test the association of each social isolation measure with each end-of-life outcome, adjusted for sociodemographic covariates, and tested for interaction terms with CI (p < 0.2). Results: The mean age of our sample of decedents was 81.2 (SD = 9.9), 53% were female, 8% Black, and 4% Hispanic. Overall, social isolation and the community engagement subscale were not associated with end-of-life health care use. Fewer household contacts were associated with lower hospice use (aOR = 0.74, p = 0.005). There were significant interaction terms between the social network interaction subscale and CI for ED use (p = 0.009) and hospitalizations (p = 0.04), and a trend for ICU stays (p = 0.15); individuals with both low social network interaction and CI had lower health care use across all three outcomes compared to other groups. Conclusions: Individuals with fewer household contacts had lower hospice use, and cognitively impaired individuals with low social network interaction had fewer end-of-life ED visits, hospitalizations, and ICU stays. Clinicians should consider mobilizing external support services to ensure access to goal-concordant care for older adults with limited end-of-life social contact when needed. [ABSTRACT FROM AUTHOR]

Background: Non‐Hispanic Black individuals may be less likely to receive a diagnosis of dementia compared to non‐Hispanic White individuals. These findings raise important questions regarding which factors may explain this observed association and any differences in the time to which disparities emerge following dementia onset. Methods: We conducted a retrospective cohort study using survey data from the 1995 to 2016 Health and Retirement Study linked with Medicare fee‐for‐service claims. Using the Hurd algorithm (a regression‐based approach), we identified dementia onset among older adult respondents (age ≥65 years) from the Telephone Interview for Cognitive Status and proxy respondents. We determined date from dementia onset to diagnosis using Medicare data up to 3 years following onset using a list of established diagnosis codes. Cox Proportional Hazards modeling was used to examine the association between an individual's reported race and likelihood of diagnosis after accounting for sociodemographic characteristics, income, education, functional status, and healthcare use. Results: We identified 3435 older adults who experienced a new onset of dementia. Among them, 30.1% received a diagnosis within 36 months of onset. In unadjusted analyses, the difference in cumulative proportion diagnosed by race continued to increase across time following onset, p‐value <0.001. 23.8% of non‐Hispanic Black versus 31.4% of non‐Hispanic White participants were diagnosed within 36 months of dementia onset, Hazard Ratio = 0.73 (95% CI: 0.61, 0.88). The association persisted after adjustment for functional status and healthcare use; however, these factors had less of an impact on the strength of the association than income and level of education. Conclusion: Lower diagnosis rates of dementia among non‐Hispanic Black individuals persists after adjustment for sociodemographic characteristics, functional status, and healthcare use. Further understanding of barriers to diagnosis that may be related to social determinants of health is needed to improve dementia‐related outcomes among non‐Hispanic Black Americans. [ABSTRACT FROM AUTHOR]

Background: Falls are common in older adults and can lead to severe injuries. The Strategies to Reduce Injuries and Develop Confidence in Elders (STRIDE) trial cluster‐randomized 86 primary care practices across 10 health systems to a multifactorial intervention to prevent fall injuries, delivered by registered nurses trained as falls care managers, or enhanced usual care. STRIDE enrolled 5451 community‐dwelling older adults age ≥70 at increased fall injury risk. Methods: We assessed fall‐related outcomes via telephone interviews of participants (or proxies) every 4 months. At baseline, 12 and 24 months, we assessed health‐related quality of life (HRQOL) using the EQ‐5D‐5L and EQ‐VAS. We used Poisson models to assess intervention effects on falls, fall‐related fractures, fall injuries leading to hospital admission, and fall injuries leading to medical attention. We used hierarchical longitudinal linear models to assess HRQOL. Results: For recurrent event models, intervention versus control incidence rate ratios were 0.97 (95% confidence interval [CI], 0.93–1.00; p = 0.048) for falls, 0.93 (95% CI, 0.80–1.08; p = 0.337) for self‐reported fractures, 0.89 (95% CI, 0.73–1.07; p = 0.205) for adjudicated fractures, 0.91 (95% CI, 0.77–1.07; p = 0.263) for falls leading to hospital admission, and 0.97 (95% CI, 0.89–1.06; p = 0.477) for falls leading to medical attention. Similar effect sizes (non‐significant) were obtained for dichotomous outcomes (e.g., participants with ≥1 events). The difference in least square mean change over time in EQ‐5D‐5L (intervention minus control) was 0.009 (95% CI, −0.002 to 0.019; p = 0.106) at 12 months and 0.005 (95% CI, −0.006 to 0.015; p = 0.384) at 24 months. Conclusions: Across a standard set of outcomes typically reported in fall prevention studies, we observed modest improvements, one of which was statistically significant. Future work should focus on patient‐, practice‐, and organization‐level operational strategies to increase the real‐world effectiveness of interventions, and improving the ability to detect small but potentially meaningful clinical effects. Clinicaltrials.gov identifier: NCT02475850. [ABSTRACT FROM AUTHOR]

The objective of this study was gather pilot data from informal caregivers regarding the potential for a training program to assist current or past caregivers in reentering the job market, and thus offering a pathway to economic resilience. In an effort that could foster a sustainable and competent caregiving market to help meet the needs of an aging America, whether training informal caregivers might help them transition into a paid caregiving or other health service role was explored. Caregivers (N = 55) of a chronically or terminally ill family member or friend in a suburban county near Chicago were interviewed. The interview guide addressed household economic effect of illness, emotional burden, and training program interest. Fifty-six percent of caregivers were interested in training to work outside the home, caring for people in other households, 84% indicated a desire to learn more about health care, and 68% reported a desire to explore job possibilities in health care. Eighty-two percent were experienced in working with an individual aged 50 and older. Informal caregivers' interest in a training program to bolster their qualifications for a role in the healthcare workforce, including the option of a formal caregiver position, supports the demand for such a program. Considering the need for healthcare workers to serve the growing elderly population and the desire of informal caregivers to find gainful employment, these informal caregivers could provide the impetus to invest in informal caregiver training. [ABSTRACT FROM AUTHOR]

Objective: Advance care planning (ACP) is critically important for heart failure patients, yet important challenges exist. Group visits can be a helpful way to engage patients and caregivers in identifying values and preferences for future care in a resource‐efficient way. We sought to evaluate the impact of group visits for ACP among older adults with heart failure and their caregivers on ACP‐related outcomes. Methods: We conducted a mixed‐methods pilot study evaluating the impact of an ACP group visit for older adults with heart failure and their caregivers on ACP‐related outcomes including readiness and self‐efficacy. The evidence‐based PREPARE for Your Care video‐based intervention was used to guide the group visits. Twenty patients and 10 caregivers attended one of the five 90‐min group visits led by a trained facilitator. Group visit participants completed pre‐, post‐, and 1‐month follow‐up surveys using validated 5‐point ACP readiness and self‐efficacy scales. Qualitative feedback obtained within 3 days of a group visit was analyzed using a directed content analysis. Results: Patient participants had a median age of 78 years. Approximately half were female while caregiver participants were mostly female. Participants were predominantly white. Patient readiness scores improved significantly pre‐to‐post (+0.53; p = 0.002) but was not sustained at 1‐month follow‐up. Patient and caregiver self‐efficacy showed some improvement pre‐to‐post but was also not sustained at follow‐up. Interviews revealed positive impacts of group visits across the three themes: encouraging reviewing or revisiting prior ACP activities, motivating patients to take direct steps towards ACP, and serving as a "wake‐up" call to action. Conclusions: Disease‐focused group visits may have a short‐term effect on ACP outcomes but ongoing touchpoints are likely necessary to sustain ACP over time. The results highlight a need for follow‐up ACP conversations after a single group visit. Timing for follow‐ups and the ideal person to follow‐up ACP conversations needs to be explored. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Healthcare organizations are expanding community‐based serious illness care programs to deliver care for homebound patients. Programs typically focus on home‐based primary care or home‐based palliative care, yet this population may require both services. We developed and evaluated a primary and palliative care program serving seriously ill older adults, called the Reaching Out to Enhance the Health of Adults in Their Communities and Homes (REACH) program. Our objective was to determine the impact of the REACH program on healthcare utilization and the patient care experience. DESIGN: Case study using medical record review and telephone interviews. SETTING: Home‐based serious illness care program in central North Carolina. PARTICIPANTS: Patients enrolled in the REACH program from August 2014 to March 2016 (n = 159). INTERVENTION: Home‐based primary and palliative care delivered by an interdisciplinary team for seriously ill older adults. MEASUREMENTS: Structured medical record review including demographics, health and functional status, and acute hospitalization and emergency department (ED) visits in the 12 months preceding and following initiation of the REACH program. A convenience sample of participants completed telephone interviews that measured the quality‐of‐care experience and quality of communication. RESULTS: REACH patients had a 43% reduction in hospital visits and a 25% reduction in ED visits. Participants in telephone interviews reported a high‐quality care experience and very good quality of communication with REACH providers. CONCLUSION: A care model that integrates home‐based primary care and palliative care has the potential to reduce health service utilization and enhance the care experience for older patients with serious illness. J Am Geriatr Soc 67:825–830, 2019. [ABSTRACT FROM AUTHOR]

Background: Hospital at home (HaH) is a model of care that provides acute‐level services in the home. HaH has been shown to improve quality and patient satisfaction, and reduce iatrogenesis and costs. Uptake of HaH in the United States has been limited, and little research exists on how to implement it successfully. Objectives: This study examined facilitators and barriers to implementation of an HaH program. Design: A HaH program that included a 30‐day transitional care bundle following the acute stay was implemented through a Centers for Medicare & Medicaid Services Innovations Award. Informants completed a priming table describing initial implementation components, their barriers, and facilitators. These were followed up with semistructured focus groups and individual interviews that were transcribed and independently coded using thematic analysis by two independent investigators. Setting: Large urban academic health system. Participants: Clinical and administrative personnel from Mount Sinai, the Visiting Nurse Service of New York, and executive leaders at partner organizations (laboratory, pharmacy, radiology, and transportation). Results: To facilitate successful development and implementation of a high‐quality HaH program, a number of barriers needed to be overcome through significant teamwork and communication internally with policymakers and external partners. Areas of paramount importance include facilitating work‐arounds to regulatory barriers and health system policies; altering an electronic health record that was not designed for HaH; developing the necessary payment and billing mechanisms; and building effective and collaborative partnerships and communication with outside vendors. Conclusion: Development of HaH programs in the United States are feasible but require strategic planning and development of strong, tightly coordinated partnerships. J Am Geriatr Soc 67:588–595, 2019. [ABSTRACT FROM AUTHOR]

Objectives To examine racial differences in the use of rehabilitation services and functional improvement during receipt of services. Design Secondary analysis of the 2016 National Health and Aging Trends Study ( NHATS). Setting Standardized in-person home interviews. Participants Community-dwelling Medicare enrollees (N = 6,309), 1,276 of whom reported receiving rehabilitation services in the previous 12 months. Measurements Self-reported use of rehabilitation services, setting (inpatient, outpatient, home based), reason for use, and perceptions of change in functioning after receiving services. Results Controlling for sex, dual eligibility for Medicaid, age, number of chronic conditions, functional mobility at the prior round, income, and geographic region, the odds of receiving rehabilitation services in any setting was 1.38 times as great in whites as in blacks (95% confidence interval = 1.09-1.75). Of those receiving therapy, whites were more likely to receive home-based and inpatient rehabilitation services, but there were no racial differences in improvement in function. Conclusion Strategies are needed to identify possible barriers to use of rehabilitation services for vulnerable groups of aging individuals who need rehabilitation services, particularly older blacks. [ABSTRACT FROM AUTHOR]

Objectives To determine the association between homebound status and mortality. Design Cross-sectional. Setting Annual, in-person interviews. Participants A nationally representative sample of community-dwelling, Medicare beneficiaries aged 65 and older enrolled in the National Health and Aging Trends Study between 2011 and 2013 (N = 6,400). Measurements Two-year mortality and prevalence of homebound status in the year before death are described using three categories of homebound status: homebound (never or rarely left home in the last month), semihomebound (left home with assistance, needed help or had difficulty), and nonhomebound (left home without help or difficulty). Results In unadjusted analyses, 2-year mortality was 40.3% in homebound participants, 21.3% in those who were semihomebound and 5.8% in those who were nonhomebound. Homebound status was associated with greater 2-year mortality, adjusted for sociodemographic characteristics, comorbidities, and functional status (hazard ratio = 2.08; 95% confidence interval = 1.63-2.65, P < .001). Half of older community-dwelling Medicare beneficiaries were homebound in the year before death. Conclusion Homebound status is associated with greater risk of death independent of functional impairment and comorbidities. To improve outcomes for homebound older adults and the many older adults who will become homebound in the last year of life, providers and policymakers need to extend healthcare services from hospitals and clinics to the homes of vulnerable individuals. [ABSTRACT FROM AUTHOR]

Objectives This study examined potential barriers to mental healthcare use of older adults from diverse ethnic and racial backgrounds. Design Data were obtained from the 2007, 2009, 2011-12, and 2013-14 California Health Interview Survey ( CHIS), a population-based survey representative of California's noninstitutionalized population. Participants The total sample consisted of 75,324 non-Hispanic white ( NHW), 6,600 black, 7,695 Asian and Pacific Islander ( API), and 4,319 Hispanic adults aged 55 and older. Results Results from logistic regression analyses that controlled for multiple demographic and health status characteristics revealed ethnic and racial differences in reasons for not seeking treatment and for terminating treatment. Specifically, API and Hispanic adults had greater odds than NHWs of endorsing feeling uncomfortable talking to a professional as a reason for not seeking treatment. Hispanic respondents had lower odds of endorsing concerns about someone finding out than APIs, and APIs and blacks had significantly greater odds of endorsing this concern as a reason for not seeking treatment than NHWs. When asked about reasons for no longer receiving treatment, all respondents, irrespective of race or ethnicity, endorsed that they no longer needed treatment as the most frequent reason for terminating treatment, although specific ethnic and racial differences emerged with respect to perceptions of not getting better, lack of time or transportation, and lack of insurance coverage as reasons for no longer seeking treatment. Conclusion Understanding how barriers to mental health treatment differ for older adults from diverse ethnic and racial backgrounds is an important step toward designing interventions to overcome these obstacles and improve mental health outcomes. [ABSTRACT FROM AUTHOR]

Objectives To determine whether there are racial and ethnicity group differences in Resources for Enhancing Alzheimer's Caregiver Health ( REACH II) intervention delivery. Design Randomized controlled trial. Setting Community-based intervention delivered at five sites across the United States. Participants Family caregivers of persons with dementia who were randomized to the active intervention condition (N = 323). Intervention Nine in-home sessions (90 minutes each) and three telephone sessions (30 minutes each) were intended to be delivered and designed to reduce caregiver burden and depression, improve caregiver self-care and social support, and help caregivers manage behavior problems in persons with dementia. Measurements Interventionists recorded the type of intervention (home or telephone), start and stop times, and whether specific intervention content modules (e.g., stress management, social support) were administered in each session. Results Overall, REACH II intervention delivery was high, with more than 80% of randomized caregivers completing at least five in-home sessions and receiving eight or more hours of intervention contact, but black caregivers completed fewer in-home sessions (mean 6.98) than Hispanics (mean 7.84) or whites (mean 8.25) and received less total intervention contact time (mean 683 minutes) than Hispanics (mean 842 minutes) or whites (mean 798 minutes). No significant differences in exposure to content according to race or ethnicity were found after controlling for demographic covariates. Conclusion Blacks in REACH II received significantly less intervention contact. Similar multicomponent interventions should examine whether there are systematic differences in intervention delivery across specific demographic subgroups and explore implications for treatment outcomes. [ABSTRACT FROM AUTHOR]

Improving healthcare safety, quality, and coordination, as well as quality of life, are important aims of caring for older adults with multiple chronic conditions and/or functional limitations. Person-centered care is an approach to meeting these aims, but there are no standardized, agreed-upon parameters for delivering such care. The SCAN Foundation charged a team from the American Geriatrics Society ( AGS) in collaboration with a research and clinical team from the Keck School of Medicine of the University of Southern California to provide the evidence base to support a definition of person-centered care and its essential elements. An interprofessional panel of experts in person-centered care principles and practices that the AGS convened developed this statement. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented which addresses the strategies that primary care clinicians use to discuss when to stop cancer screening procedures for older adults with limited life expectancy, and it mentions medical decisionmaking and concerns about quality of life and cancer screening risks.