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Objectives. Physical therapist intervention studies can be deemed ineffective when, in fact, they may not have been delivered as intended. Measurement of treatment fidelity (TF) can address this issue. The purpose of this study was to describe TF of a home-based intervention, identify factors associated with TF, and examine whether components of TF were associated with the outcome of change in 6-minute walk distance (A6MWD). Methods. This is a secondary analysis of community-dwelling hip fracture participants who completed standard therapy and were randomly assigned to the active intervention (Push). Push was 16 weeks of lower extremity strengthening, function, and endurance training. TF was defined as delivery (attendance rate, exercise duration) and receipt (progression in training load, heart rate reserve [HRR] during endurance training, and exercise position [exercise on floor]). The outcome was A6MWD. Independent variables included baseline (demographic and clinical) measures. Descriptive statistics were calculated; linear and logistic regressions were performed. Results. Eighty-nine participants were included in this analysis; 59 (66%) had attendance of 75% or greater. Participants walked for 20 minutes or more for 78% of sessions. The average training load increased by 22%; the mean HRR was 35%; and 61 (69%) participants exercised on the floor for at least 75% of sessions. Regression analyses showed that a higher body mass index and greater baseline 6MWD were related to components of TF; 4 out of 5 components of TF were significantly related to A6MWD. The strongest TF relationship showed that those who exercised on the floor improved by 62 m (95% CI = 31-93 m) more than those who did not get on the floor. Conclusions. Measures of TF should extend beyond attendance rate. This analysis demonstrates how measures of TF, including program attendance, progression in training load, endurance duration, and exercising on the floor were significantly related to improvement in 6MWD in participants post hip fracture. Impact. This careful analysis of treatment fidelity assured that the intervention was delivered and received as intended. Analysis of data from a large trial with participants after hip fracture showed that regular attendance, frequent endurance training for 20 minutes, increases in lower extremity training loads, and exercising on the floor were associated with improvements in the outcome of 6-minute-walk distance. The strongest association with improvement was exercising on the floor. Keywords: Exercise, Hip Fractures, Physical Therapists, Treatment Fidelity, Introduction Older adults demonstrate great heterogeneity in functional recovery following hip fracture. (1) Physical therapist interventions associated with hip fracture rehabilitation are complex behaviors that take time, physical effort, and [...]

Objectives: To estimate the causal impact of continuity of care (COC) on total, institutional, and noninstitutional cost among community-dwelling older veterans with dementia. Data Sources: Combined Veterans Health Administration (VHA) and Medicare data in Fiscal Years (FYs) 2014-2015. Study Design: FY 2014 COC was measured by the Blce-Boxerman Continuity of Care (BBC) index on a 0-1 scale. FY 2015 total combined VHA and Medicare cost, institutional cost of acute inpatient, emergency department [ED], long-/short-stay nursing home, and noninstitutional long-term care (LTC) cost for medical (like skilled-) and social (like unskilled-) services were assessed controlling for covariates. An instrumental variable for COC (change of residence by more than 10 miles) was used to account for unobserved health confounders. Data Collection: Community-dwelling veterans with dementia aged 66 and older, enrolled in Traditional Medicare (N = 102 073). Principal Findings: Mean BBC in FY 2014 was 0.32; mean total cost in FY 2015 was $35 425. A 0.1 higher BBC resulted in (a) $4045 lower total cost; (b) $1597 lower acute Inpatient cost, $119 lower ED cost, $4368 lower long-stay nursing home cost; (c) $402 higher noninstitutional medical LTC and $764 higher noninstitutional social LTC cost. BBC had no impact on short-stay nursing home cost. Conclusions: COC is an effective approach to reducing total health care cost by supporting noninstitutional care and reducing institutional care. KEYWORDS aging/elderly/geriatrics, dementia, health care cost, instrumental variables, primary care, VA health care system, 1 INTRODUCTION With the aging population, the number of older Americans with dementia is expected to grow rapidly. (1,2) Patients with dementia are reported to have higher health care utilization [...]

•What is the primary question addressed by this study?How do dementia prevalence and cognitive impairment severity vary according to race, ethnicity, educational attainment, and neighborhood context in a population of older adults receiving Medicaid-funded home- and community-based services in lieu of nursing home care?•What is the main finding of this study?Compared with non-Hispanic White individuals, Hispanic, but not non-Hispanic Black, individuals in the study cohort had greater severity of cognitive impairment. Dementia prevalence and cognitive impairment severity were both greater among those with less than high school education, and both were greater among those living in neighborhoods that were less socially vulnerable.•What is the meaning of the finding?Racial and ethnic group differences in dementia and cognitive impairment severity are less pronounced among older adults receiving Medicaid home- and community-based services than among other community-dwelling older adults, and older adults receiving these services may be more likely to move to lower social vulnerability neighborhoods where family members reside when they have dementia and more severe cognitive impairment.

Objective. Patients with heart failure (HF) have high rates of rehospitalization. Home health care (HHC) patients with HF are not well studied in this regard. The objectives of this study were to determine patient, HHC agency, and geographic (i.e., area variation) factors related to 30-day rehospitalization in a national population of HHC patients with HF, and to describe the extent to which rehospitalizations were potentially avoidable. Data Sources. Chronic Condition Warehouse data from the Centers for Medicare & Medicaid Services. Study Design. Retrospective cohort design. Data Extraction. The 2005 national population of HHC patients was matched with hospital and HHC claims, the Provider of Service file, and the Area Resource File. Principal Findings. The 30-day rehospitalization rate was 26 percent with 42 percent of patients having cardiac-related diagnoses for the rehospitalization. Factors with the strongest association with rehospitalization were consistent between the multilevel model and Cox proportional hazard models: number of prior hospital stays, higher HHC visit intensity category, and dyspnea severity at HHC admission. Substantial numbers of rehospitalizations were judged to be potentially avoidable. Conclusions. The persistently high rates of rehospitalization have been difficult to address. There are health care-specific actions and policy implications that are worth examining to improve rehospitalization rates. Key Words. Heart failure, epidemiology, outcomes research, home health care, Rehospitalization rates have become a focus of national interest as they are associated with high health care expenditures and questions concerning the quality of care provided during and following hospitalization. [...]

To purchase or authenticate to the full-text of this article, please visit this link: http://dx.doi.org/10.1111/j.1532-5415.2007.01630.x Byline: Richard H. Fortinsky (*), Dorothy Baker ([dagger]), Margaret Gottschalk ([double dagger]), Mary King (s.), Patricia Trella (*), Mary E. Tinetti ([dagger],[parallel]) Keywords: fall prevention; home health care; risk assessment and management; disseminating research into practice Abstract: This study determined the extent to which fall risk assessment and management practices for older patients were implemented in Medicare-certified home health agencies (HHAs) in a defined geographic area in southern New England that had participated in evidence-based fall prevention training between October 2001 and September 2004. The standardized in-service training sessions taught home health nurses and rehabilitation therapists how to conduct assessments for five evidence-based risk factors for falls in older adults-mobility impairments, balance disturbances, multiple medications, postural hypotension, and home environmental hazards-using techniques shown to be efficacious in clinical trials. Twenty-six HHAs participated in these in-service training sessions; 19 of these participated in a survey of nurses and rehabilitation therapists between October 2004 and September 2005. Self-reported assessment and management practices implemented with older patients during home healthcare visits were measured in this survey, and HHA-level measures for each fall risk factor were constructed based on proportions of clinicians reporting assessment and management practices that were recommended in the fall prevention training sessions. For all fall risk factors except postural hypotension, 80% or more of clinicians in all HHAs reported implementing recommended fall risk management practices. Greater variation was found regarding fall risk assessment practices, with fewer than 70% of clinicians in one or more HHAs reporting recommended assessment practices for all risk factors. Results suggest that evidence-based training for home healthcare clinicians can stimulate fall risk assessment and management practices during home health visits. HHA-level comparisons hold the potential to illustrate the extent of diffusion of evidence-based fall prevention practices within and between agencies. Author Affiliation: (*)Center on Aging, University of Connecticut Health Center, Farmington, ConnecticutDepartments of ([dagger])Internal Medicine, Yale University School of Medicine, New Haven, Connecticut ([parallel])Epidemiology and Public Health, Yale University School of Medicine, New Haven, Connecticut ([double dagger])Department of Rehabilitation Services, Yale-New Haven Hospital, New Haven, Connecticut (s.)Department of Medicine, Hartford Hospital, Hartford, Connecticut Article note: Address correspondence to Richard H. Fortinsky, PhD, Center on Aging, University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT 06030. E-mail: fortinsky@uchc.edu

Elderly persons are prone to falling, a problem that can be prevented through proper communication of clinical assessment of risks. A study highlighting the benefits of dissemination of information relating to fall risk assessment and management is presented.

A randomized controlled trial has been carried out in 1531 community-dwelling patients over age 69 to test the hypothesis that a multiculticomponent intervention, Acute Care for Elders (ACE), will improve functional outcomes and the process of care in hospitalized older patients. It was found that ACE improved care and patient and provider satisfaction without increasing length of stay or costs.

Research demonstrates that performance of neighborhood health centers in Cleveland exceeded the standards in four of the five services provided to the older black patients. Data also indicate that office visits correlated with high performance of various preventive services.

This research compared strain among 581 family caregivers of nursing home and community dwelling older persons whose level of cognitive impairment ranged from none to severe. The study explored differences [...]

Background: Current guidelines for colorectal cancer screening do not specify the role of age or comorbidity patient selection. Reported screening practices may thus be influenced by patient, as well as physician, characteristics. Methods: A questionnaire was sent to primary care physicians in 10 states to determine recommendations for fecal occult blood testing (FOBT) and sigmoidoscopy in 4 pairs of clinical vignettes that varied by patient age (65 75 years) and comorbidity (none, mild, moderate, and terminal). Results: Among the 884 respondents (50%), most physicians recommended FOBT in all vignettes except those with a terminal illness and fewer than half recommended sigmoidoscopy in any vignette. Physician recommendations were influenced by comorbidity, but one third still recommended FOBT for terminally ill patients and less than 50% recommended sigmoidoscopy for patients with no comorbidity. Differences in recommended screening between vignettes that differed only in patient age were small. Among all subgroups of physicians, at least 30% recommended FOBT in terminally ill patients and no more than 60% recommended sigmoidoscopy in healthy patients. Conclusions: Primary care physicians were much more likely to recommend screening with FOBT than sigmoidoscopy, regardless of patient and practitioner factors. Although physician recommendations were influenced by patient comorbidity and age, they frequently recommended FOBT in clinically inappropriate settings and failed to recommend sigmoidoscopy when appropriate. Broad-based interventions to improve appropriate screening practices may be needed.

Background: Older patients often have poor health status outcomes after hospitalization. Symptoms of depression are common in hospitalized older persons and may be a risk factor for these poor outcomes. Objective: To determine whether symptoms of depression predict worse health status outcomes in acutely ill, older medical patients, independent of health status and severity of illness at hospital admission. Design: Prospective cohort study. Setting: Medical service of a teaching hospital. Patients: 572 hospitalized medical patients older than 70 years of age. Measurements: 15 symptoms of depression, health status, and severity of illness were measured at admission. The main outcome was dependence in basic activities of daily living at discharge and 30 and 90 days after discharge. Other outcome measures were dependence in instrumental activities of daily living, fair or poor global health status, and poor global satisfaction with life. Results: The median number of symptoms of depression on admission was 4. Patients with 6 or more symptoms on admission (n = 196) were more likely than patients with 0 to 2 symptoms (n = 181) to be dependent in basic activities of daily living (odds ratio, 2.47 [95% Cl, 1.58 to 3.86]) after controlling for demographic characteristics and severity of illness. At each subsequent time point, patients with more symptoms of depression on admission were more likely to be dependent in basic activities of daily living. This association persisted after adjustment for dependence in basic activities of daily living, severity of illness, and demographic characteristics on admission. The odds ratios comparing patients who had 6 or more symptoms with those who had 0 to 2 symptoms were 3.23 (Cl, 1.76 to 5.95) at discharge, 3.45 (Cl, 1.81 to 6.60) 30 days after discharge, and 2.15 (Cl, 1.81 to 6.60) 30 days after discharge. At each time point, patients with 6 or more symptoms of depression were more likely to have more dependence in instrumental activities of daily living, worse global health status, and less satisfaction with life. Conclusions: Symptoms of depression identified a vulnerable group of hospitalized older persons. The health status of patients with more symptoms of depression was more likely to deteriorate and less likely to improve during and after hospitalization. This association was not attributable to health status or severity of illness on admission. The temporal sequence and magnitude of this association, its consistency over time with different measures, and its independence from the severity of the somatic illness strongly support a relation between symptoms of depression on admission and subsequent health status outcomes., Elderly hospital patients who are depressed may experience more severe health problems after discharge and have a poor quality of life. Researchers followed 572 hospitalized patients older than 70 for up to 90 days after discharge. Patients who had 6 or more symptoms of depression during their hospitalization were more than 3 times more likely to require help with activities of daily living after discharge compared to those with 2 or fewer symptoms. This was true even after adjusting for demographic characteristics and severity of the illness for which they were hospitalized.

Comparison of quality of care in 145 rural and urban nursing facilities in Maine reveal that very few differences exist between them. Only two of the twelve quality indicators of nursing facilities show significant difference. However, additional studies are needed to ascertain other aspects that may affect the quality of nursing facility in the rural and urban settings.

Impact of the Maine Medicaid waiver for the mentally retarded Introduction During the past 20 years, support for services to the developmentally disabled has expanded significantly with the availability of [...]

This cross-sectional study was conducted to examine the association between the direct and indirect effect of traumatic incident exposure at work on correctional supervisors’ experience of work-to-family conflict and depressive symptoms. The moderating role of coworker and supervisor social support was also examined. 156 correctional supervisors (i.e., lieutenants, captains, counselor supervisors) working in a Northeastern state participated in an online survey designed to assess perceptions of their work environment as well as health and family life. Structural equation modeling was used to conduct mediation and moderation analyses. Inmate assaults on inmates and staff were the most common exposures to work-related trauma among correctional supervisors. Correctional supervisors reported being more affected by traumatic incidents directed to self and/or peers (i.e., inmate assault on self/staff). The effect of traumatic incident exposure directed to inmates was associated with greater depressive symptoms for correctional supervisors [β = .31, p< .05]. The effect of traumatic incident exposure directed to self and/or peers was directly associated with greater work-to-family conflict [β = .26, p< .05]. Work-to-family conflict mediated the association between effect of traumatic incident exposure directed to self and/or peers and depressive symptoms [β = .13 (95% CI .016–.35)]. Social support moderated the association between the effect of traumatic incident exposure at work and depressive symptoms. Findings support the need for interventions addressing the adverse effect of traumatic incident exposure at work on correctional supervisors’ family life and mental health.

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A study was conducted to determine the extent to which healthcare providers address evidence-based fall risk factors in older patients after exposure to an educational intervention and to determine barriers encountered when these healthcare providers intervene with or refer older patients with identified fall-risk factors. The results pinpointed specific healthcare provider groups with scope for improvement in assessment and management of specific risk factors.

Prospective study is undertaken to determine whether hospital costs are higher in patients with lower functional status at admission, after adjustment for Medicare Diagnosis Related Group (DRG) payments. Results reveal that DRG based payments provide hospitals a financial incentive to avoid patients dependent in activities of daily living (ADLs).

A study of elderly patients admitted to two hospitals in Ohio shows that patients who self-report increased unsteadiness tend to lose daily living skills during their hospital stay.

Findings indicate that elderly patients discharged from hospitals may experience decreased functionality in activities of daily living, compared to their baseline levels. Age is also a factor in the ability to recover lost functionality

Older adults with dementia care needs often visit primary care physicians (PCPs), but PCP dementia care limitations are widely documented. This study tested the value of employing a nurse practitioner (NP) with geropsychiatric expertise to augment PCP care for newly and recently diagnosed patients and family caregivers. Twenty-one dyads received the NP intervention; 10 dyads were controls. Outcomes included patient neuropsychiatric symptom and quality of life changes, and caregiver depression, burden, and self-efficacy changes. Intervention acceptability by patients, caregivers, and PCPs was determined. No outcome differences were found; however, the NP intervention was deemed highly satisfactory by all stakeholders. Patients experienced no significant cognitive decline during the 12-month study period, helping explain why outcomes did not change. Given widespread acceptability, future tests of this PCP-enhancing intervention should include patients with more progressive cognitive decline at study entry. NPs with geropsychiatric expertise are ideal interventionists for this rapidly growing target population.[Res Gerontol Nurs. 2014; 7(3):126–137.]

CME Educational Objectives1.Understand the role of perceived personal control and accommodative strategies in adults coping with common challenges of old age.2.Describe the effect of positive affect on resilience in older adults.3.Discuss a proposed model that links conceptualizations of resilience with intervention strategies among older adults faced with chronic illness, disability, and family caregiving responsibilities.In the context of aging, resilience — the process of positive adaptation in response to threatening life circumstances, including chronic illness, disability, and providing personal and other types of care to older relatives in middle and later life — involves effective coping;In the context of aging, resilience — the process of positive adaptation in response to threatening life circumstances, including chronic illness, disability, and providing personal and other types of care to older relatives in middle and later life — involves effective coping;1the ability to ‘bounce back;’2and rapid recovery, sustainability of purpose, and personal growth3while facing adversity. Although the idea of growth through adversity is appealing and has generated considerable interest, the research methods required to capture growth have lagged behind theoretical formulations, leaving this aspect of resilience more speculative.4Resilience has been studied as an aspect of personality, and the concept of resilience has been applied to organizations, neighborhoods, and communities.

Background: Depressive symptoms are common in hospitalized older persons. However, their relation to long-term mortality is unclear because few studies have rigorously considered potential confounders of the relation between depression and mortality, such as comorbid illness, functional impairment, and cognitive impairment. Objective: To measure the association between depressive symptoms and long-term mortality in hospitalized older persons. Design: Prospective cohort study. Setting: General medical service of a teaching hospital. Patients: 573 patients 70 years of age or older. Measurements: Depressive symptoms (Geriatric Depression Scale score), severity of acute illness (Acute Physiology and Chronic Health Evaluation II score), burden of comorbid illness (Charlson comorbidity index score), physical function (a nurse assessed dependence in six activities of daily living), and cognitive function (modified Mini-Mental State Examination) were measured at hospital admission. Mortality over the 3 years after admission was determined from the National Death Index. Mortality rates among patients with six or more depressive symptoms were compared with those among patients with five or fewer symptoms. Results: The mean age of the patients was 80 years; 68% of patients were women. Patients with six or more depressive symptoms had greater comorbid illness, functional impairment, and cognitive impairment at admission than patients with fewer depressive symptoms. Three-year mortality was higher in patients with six or more depressive symptoms (56% compared with 40%; hazard ratio, 1.56 [95% CI, 1.22 to 2.00]; P [is less than] 0.001). After adjustment for age, acute illness severity, comorbid illness, functional impairment, and cognitive impairment at the time of admission, patients with six or more depressive symptoms continued to have a higher mortality rate during the 3 years after admission (hazard ratio, 1.34 [CI, 1.03 to 1.73]). Although depressive symptoms contributed less to the mortality rate than did the total burden of comorbid medical illnesses, the excess mortality rate associated with depressive symptoms was greater than that conferred by one additional comorbid medical condition. Conclusions: Depressive symptoms are associated with long-term mortality in older patients hospitalized with medical illnesses. This association is not fully explained by greater levels of comorbid illness, functional impairment, and cognitive impairment in patients with more depressive symptoms., Depressed elderly people may have a greater burden of disease and appear more likely to die than non-depressed elderly people. Researcher compared 573 patients over age 70. Depressed patients had more diseases, had less independent function, and more mental impairment that non-depressed patients. Within three years, 56% of depressed patients and 40% of non-depressed patients had died.

PURPOSE: Although health-related quality of life in older people is generally assessed by measuring specific domains of health status, such as activities of daily living or pain, the association between health-status measures and patients' perceptions of their quality of life is not clear. Indeed, it is controversial whether these health-status measures should be considered measures of quality of life at all. Our objective was to determine the association between health-status measures and older patients' perceptions of their global quality of life. SUBJECTS AND METHODS: We performed a cross-sectional study of 493 cognitively intact patients 80 years of age and older, interviewed 2 months after a hospitalization. We measured patients' self-assessed global quality of life and four domains of health status: physical capacity, limitations in performing activities of daily living, psychological distress, and pain. RESULTS: Each of the four scales was significantly correlated with patients' global perceptions of their quality of life (P [is less than] 0.001). The ability of the health-status scales to discriminate between patients with differing global quality of life was generally good, especially for the physical capacity (c statistic = 0.72) and psychological distress scales (c statistic = 0.70). However, for a substantial minority of patients, scores on the health-status scales did not accurately reflect their global quality of life. For example, global quality of life was described as fair or poor by 15% of patients with the highest (best tertile) physical capacity scores, 25% of patients who were independent in all activities of daily living, 21% of patients with the least psychological distress (best tertile), and by 30% with no pain symptoms. Similarly, global quality of life was described as good or better by 43% of patients with the worst physical capacity (worst tertile), 49% of patients who were dependent in at least two activities of daily living, 47% of patients with the most psychological distress (worst), and 51% of patients with severe pain. CONCLUSION: On average, health status is a reasonable indicator of global quality of life for groups of older patients with recent illness. However, disagreement between patients' reported health status and their perceptions of their global quality of life was common. Therefore, assumptions about the overall quality of life of individual patients should not be based on measures of their health status alone. Am J Med. 1999;106: 435-440. [C] 1999 by Excerpta Medica, Inc.

Physicians increasingly are expected to link patients affected by dementia and their families with community support services; yet, little is known about physicians' referral patterns or their familiarity with such [...]

Background and Purpose.An abundance of evidence suggests that interventions targeting fall risk factors are effective; however, it remains unknown whether, or to what extent, this body of evidence has affected the clinical practice of physical therapy providers. The purposes of this study were: (1) to describe knowledge of, and attitudes toward, fall risk factors and fall reduction strategies; (2) to assess self-reported use of fall reduction strategies with patients; and (3) to identify factors associated with increased use of fall reduction strategies with patients among physical therapy providers exposed to a behavioral change strategy. Subjects and Methods.A cross-sectional survey of physical therapy providers from hospital-based and freestanding outpatient physical therapy facilities throughout north-central Connecticut was conducted between October 2002 and April 2003. The participants were 94 physical therapy providers who had been exposed to the Connecticut Collaboration for Fall Prevention (CCFP) behavioral change effort. The CCFP program uses multicomponent professional behavioral change strategies to embed fall risk factor assessment and management, based on evidence from randomized controlled trials, into the clinical care of older patients. A telephone questionnaire—focusing on fall risk factor knowledge and attitudes and self-reported fall risk factor assessment and management practices before and after exposure to the CCFP efforts—was administered to consenting physical therapy providers. Results.Environmental hazards and gait and balance deficits were named as fall risk factors by 86 (91%) and 73 (78%) participants, respectively. All of the targeted risk factors were mentioned by at least 30% of the participants. Sixty-four participants (68%) reported increased fall reduction practice behaviors. The area of multiple medications was noted most frequently, with 77 participants (82%) noting new practices related to medication use. Only knowledge of fall risk factors and pre-CCFP behaviors were associated with increased fall reduction practices. Discussion and Conclusion.Physical therapy providers reported an increase in practice behaviors in response to the multicomponent behavioral change strategy. Knowledge of fall risk factors was associated with increased fall reduction practice behaviors, most likely due to the focused nature of the education strategy.

From 1999 to 2003, the home health industry in the United States moved from an environment with extremely diverse data collection protocols and little or no dissemination of quality‐related information, to an environment in which uniformly collected clinical data are transformed into information and then into publicly available reports using federally mandated quality indicators. This speed to action has raised many questions about the adequacy of home healthcare data and their use as quality‐monitoring tools. This article summarizes current evidence about the scientific and clinical adequacy of data currently used to measure home healthcare quality and discusses roles of a variety of policy stakeholders in implementing and refining data, information, and quality indicators that are now the cornerstones of federal home healthcare quality policy. The scientific adequacy of Outcome and Assessment Information Set data is acceptable but bears routine monitoring and review; efforts should be made to develop home healthcare quality indicators sensitive to nursing interventions and published clinical practice guidelines for specific medical conditions; and policy stakeholders should collaborate to maximize the utility of home healthcare quality reports now disseminated to consumers, providers, and insurers.

The Outcome and Assessment Information Set (OASIS) is the universal clinical assessment tool for adult nonmaternity patients receiving skilled care at home from Medicare-certified home health agencies in the United States. Anticipating increased use of OASIS data for research purposes, this article explored the usefulness of Rasch modeling to address disability measurement challenges presented by the unique response category structure of the seven activities of daily living (ADL) and eight instrumental ADL (IADL) items in the OASIS.

Little is known about the role of psychological factors in the functional recovery process of hip fracture patients. This study employed a prospective cohort design to test the hypothesis that hospitalized hip fracture patients with greater reported self-efficacy for conducting rehabilitation therapy would have a greater likelihood of recovering to a pre-fracture level of locomotion function six months after the fracture. This hypothesis was tested controlling for pre-fracture level of function and depressive symptoms reported during hospitalization for surgical repair. An original measure of rehabilitation therapy self-efficacy was evaluated prior to hypothesis testing. Study patients were recruited from two hospitals, interviewed during hospitalization and followed up six months later. Patients included in hypothesis test analyses (n  24) were mostly women (82) with a mean age of 79 years. Results showed that patients with higher self-efficacy scores had a greater likelihood of locomotion recovery, controlling for pre-fracture locomotion function level (adjusted odds ratio (AOR)  1.21; 95 confidence interval (CI)  1.00–1.45;P  0.05). This positive association between rehabilitation therapy self-efficacy and likelihood of locomotion recovery persisted after adding depressive symptoms (the Center for Epidemiological Studies-depression (CES-D) score) to this logistic regression model (AOR for self-efficacy  1.18; 95 CI  0.99–1.42;P  0.07). It is concluded that rehabilitation therapy self-efficacy is a potentially important psychological factor in helping hip fracture patients recover locomotion functioning.

The Alzheimer's Service Coordination Program (ASCP) was developed based on the rationale that family caregivers of people with dementia could benefit in measurable ways from a care partnership arrangement linking primary care physicians with a community organization that specializes in dementia education and support. In metropolitan Cleveland, Ohio, USA, 29 physicians referred 62 family caregivers to a Service Coordinator (SC), who provided individualized consultation to family caregivers and capable patients with dementia regarding all non-medical aspects of dementia care and available resources in the community. Over a six-month intervention period, 44 caregivers with complete follow-up data reported statistically significant increases in self-efficacy for managing dementia symptoms, and self-efficacy for using community support services. Caregivers and participating physicians reported satisfaction with the ASCP. Despite relatively small numbers of participants, the service coordination and individualized consultation model featured in the ASCP has been adapted for two larger randomized trials in the USA.

OBJECTIVE: To identify age‐related differences in the treatment of patients with acute myocardial infarction.

Concerns about the increasing cost of hospital care have directed policy attention to inappropriate hospital use and, in particular, to hospital patients awaiting long-term care (LTC) placement. In 1982, pursuant to changes in federal Medicare and Medicaid law, Maine implemented changes in Medicaid reimbursement policy for subacute patients designed to reduce hospital backups and corresponding Medicaid expenditures for unnecessary hospital care. This article evaluates the impact of this change in Medicaid hospital payment policy on the volume of subacute patient days and the length of subacute stays (LOS) in Maine. Although declines in Medicaid expenditures, total subacute days, and LOS of patients awaiting LTC placement were observed in the 1st year of the policy, study findings do not show a statistically significant impact of the policy on the length of patients' subacute stays. Patient diagnosis of mental and nervous system disorders and nursing home occupancy rates in the hospital service area were both Significant predictors of subacute LOS. Study findings indicate that efforts to reduce hospital backups must address specific barriers to timely LTC placement, including shortages of institutional and noninstitutional LTC services, and the lack of financial incentives for LTC providers to accept heavier care patients.

OBJECTIVE:To compare the hospital costs of caring for medical patients on a special unit designed to help older people maintain or achieve independence in self‐care activities with the costs of usual care.

This study explored the use of functional assessment as a means for understanding individuals' needs for long-term care in the home setting. A primary focus of the study was to test the usefulness of a modified Barthel Index as the functional assessment instrument that measured personal care need. Data were derived from 89 chronically ill andor disabled people who were receiving home health care from the Visiting Nurse Association of metropolitan Providence, Rhode Island (VNA). In addition to personal care need, the study explored psychological, socioeconomic and demographic characteristics of these individuals, as well as the specific services delivered by the VNA. Results indicate that the modified Barthel Index may be used to obtain detailed information regarding ability to perform activities of daily living in the home. The data also suggest that psychological functioning must be carefully assessed when personal care need is found to exist, particularly in elderly persons. The findings of the study indicate that individual need for long-term care might be measured by functional assessment in order to most effectively direct services into the home.

This study examined how a sample of family practitioners, general internists, and osteopathic physicians practicing in the state of Maine (N=353) diagnose symptoms of cognitive dysfunction. Physicians' reported diagnostic approaches were compared to American and Canadian expert panel recommendations, and were associated with their sociodemographic and office practice characteristics. Sample members responded to a self-administered questionnaire, which was completed in response to a clinical vignette describing a patient with either mild symptoms or more progressive symptoms of cognitive dysfunction. Results showed that 59 percent of respondents would perform a formal cognitive status test and 32 percent would perform a depression screening test; both types of tests are recommended by American and Canadian expert panels. Adjusting for other factors, female physicians were twice as likely as males to perform a depression screening test (OR=2.04; 95 percent C1=1.13-3.67). Most respondents (87 percent) would order at least three of four recommended laboratory tests, and 59 percent would order a computerized tomography (CT) scan, even though expert guidelines are ambiguous about the value of CT scans in diagnostic workups. Diagnostic approaches were not significantly affected by plans to refer patients to other physicians for additional testing. Practicing physicians should be encouraged to perform recommended nueropsychological and mental status tests when patients present with symptoms of cognitive dysfunction.

This study interprets results of a needs assessment completed by active and former caregivers of relatives with Alzheimers disease (AD). Self-administered questionnaires yielded data about information and service needs at the time of diagnosis and at the time of the survey. Implications point to the need for high-quality educational material throughout the caregiving career, improved training for health professionals about AD, and an important role for former caregivers as resources to disseminate knowledge about AD to still-active caregivers and others in their own communities.