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Background: People living with dementia (PLWD) have complex medication regimens, exposing them to increased risk of harm. Pragmatic deprescribing strategies that align with patient-care partner goals are needed., Methods: A pilot study of a pharmacist-led intervention to optimize medications with patient-care partner priorities, ran May 2021-2022 at two health systems. PLWD with ≥7 medications in primary care and a care partner were enrolled. After an introductory mailing, dyads were randomized to a pharmacist telehealth intervention immediately (intervention) or delayed by 3 months (control). Feasibility outcomes were enrollment, intervention completion, pharmacist time, and primary care provider (PCP) acceptance of recommendations. To refine pragmatic data collection protocols, we assessed the Medication Regimen Complexity Index (MRCI; primary efficacy outcome) and the Family Caregiver Medication Administration Hassles Scale (FCMAHS)., Results: 69 dyads enrolled; 27 of 34 (79%) randomized to intervention and 28 of 35 (80%) randomized to control completed the intervention. Most visits (93%) took more than 20 min and required multiple follow-up interactions (62%). PCPs responded to 82% of the pharmacists' first messages and agreed with 98% of recommendations. At 3 months, 22 (81%) patients in the intervention and 14 (50%) in the control had ≥1 medication discontinued; 21 (78%) and 12 (43%), respectively, had ≥1 new medication added. The mean number of medications decreased by 0.6 (3.4) in the intervention and 0.2 (1.7) in the control, reflecting a non-clinically meaningful 1.0 (±12.4) point reduction in the MRCI among intervention patients and a 1.2 (±12.9) point increase among control. FCMAHS scores decreased by 3.3 (±18.8) points in the intervention and 2.5 (±14.4) points in the control., Conclusion: Though complex, pharmacist-led telehealth deprescribing is feasible and may reduce medication burden in PLWD. To align with patient-care partner goals, pharmacists recommended deprescribing and prescribing. If scalable, such interventions may optimize goal-concordant care for PLWD., (© 2024 The American Geriatrics Society.)

Background and Objectives: Caregivers of persons with dementia are frequently spouses. Caregiver hospitalization causes disruption to caregiving. The goal of this research was to understand the preparedness and stress trajectory of peri-caregiver hospitalization., Research Design and Methods: Mixed methods were used. Caregivers of spouses with dementia (n = 1,000) were surveyed to determine their perceived preparedness for their own hospitalization. Journey mapping interviews (n = 18) were used to map caregivers' experiences during 5 phases: (a) their spouse with dementia (SWD)'s dementia diagnosis; (b) their SWD's dementia progression; (c) their own health event; (d) their own hospitalization; and (e) their own return home from the hospital., Results: Among the 452 (45%) eligible caregiver survey respondents, 75 (17%) had experienced hospitalization in the previous 12 months and 51 (68%) hospitalizations were unexpected. Twenty-three (31%) of hospitalized caregivers indicated they did not have prior plans in place for the care of the SWD. When asked about an unexpected hospitalization in the future, 233 (52%) felt somewhat prepared and 133 (29%) felt not at all prepared. Journey mapping revealed 3 groups of caregivers: Group 1 (n = 7) rated their stress lower during their hospitalization, Group 2 (n = 7) rated their stress highest during their hospitalization, and Group 3 (n = 4) were at a sustained high-stress level., Discussion and Implications: Many caregivers are not prepared for their own hospitalization. The stress trajectory through important phases of dementia caregiving and a caregiver's own hospitalization is not universal. Meeting the needs of caregivers' peri-hospitalization should be tailored to the individual caregiver., (© The Author(s) 2024. Published by Oxford University Press on behalf of The Gerontological Society of America.)

Background: Despite wide use of adjuvanted influenza vaccine in nursing home residents (NHR), little immunogenicity data exist for this population., Methods: We collected blood from NHR (n = 85) living in nursing homes participating in a cluster randomized clinical trial comparing MF59-adjuvanted trivalent inactivated influenza vaccine (aTIV) with nonadjuvanted vaccine (TIV) (parent trial, NCT02882100). NHR received either vaccine during the 2016-2017 influenza season. We assessed cellular and humoral immunity using flow cytometry and hemagglutinin inhibition, antineuraminidase (enzyme-linked lectin assay), and microneutralization assays., Results: Both vaccines were similarly immunogenic and induced antigen-specific antibodies and T cells, but aTIV specifically induced significantly larger 28 days after vaccination (D28) titers against A/H3N2 neuraminidase than TIV., Conclusions: NHRs respond immunologically to TIV and aTIV. From these data, the larger aTIV-induced antineuraminidase response at D28 may help explain the increased clinical protection observed in the parent clinical trial for aTIV over TIV in NHR during the A/H3N2-dominant 2016-2017 influenza season. Additionally, a decline back to prevaccination titers at 6 months after vaccination emphasizes the importance of annual vaccination against influenza., Clinical Trials Registration: NCT02882100., Competing Interests: Conflicts of interest . CSL Seqirus provided reagents, funded the study, and received a copy of the manuscript prior to publication. S. G. and D. H. C. are recipients of investigator-initiated grants to their universities from Pfizer to study pneumococcal vaccines and Sanofi Pasteur and CSL Seqirus to study influenza vaccines. S. G. does consulting for Janssen, Merck, Moderna, Novavax, Pfizer, Sanofi, CSL Seqirus, and Vaxart; has served on the speaker's bureaus for CSL Seqirus and Sanofi; and has been paid to chair data safety monitoring boards from Longevoron and SciClone. D. H. C. has done consulting work for CSL Seqirus. All other authors report no potential conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed., (© The Author(s) 2023. Published by Oxford University Press on behalf of Infectious Diseases Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Purpose: Following curative-intent therapy of lung cancer, many survivors experience dyspnea and physical inactivity. We investigated the feasibility, acceptability, safety, and potential efficacy of inspiratory muscle training (IMT) and walking promotion to disrupt a postulated "dyspnea-inactivity" spiral., Methods: Between January and December 2022, we recruited lung cancer survivors from Kaiser Permanente Colorado who completed curative-intent therapy within 1-6 months into a phase-IIb, parallel-group, pilot randomized trial (1:1 allocation). The 12-week intervention, delivered via telemedicine, consisted of exercise training (IMT + walking), education, and behavior change support. Control participants received educational materials on general exercise. We determined feasibility a priori: enrollment of ≥ 20% eligible patients, ≥ 75% retention, study measure completion, and adherence. We assessed acceptability using the Telemedicine-Satisfaction-and-Usefulness-Questionnaire and safety events that included emergency department visits or hospitalizations. Patient-centered outcome measures (PCOMs) included dyspnea (University-of-California-San-Diego-Shortness-of-Breath-Questionnaire), physical activity (activPAL™ steps/day), functional exercise capacity (mobile-based-six-minute-walk-test), and health-related quality of life (HRQL, St.-George's-Respiratory-Questionnaire). We used linear mixed-effects models to assess potential efficacy., Results: We screened 751 patients, identified 124 eligible, and consented 31 (25%) participants. Among 28 participants randomized (14/group), 22 (11/group) completed the study (79% retention). Intervention participants returned > 90% of self-reported activity logs, completed > 90% of PCOMs, and attended > 90% of tele-visits; 75% of participants performed IMT at the recommended dose. Participants had high satisfaction with tele-visits and found the intervention useful. There was no statistically significant difference in safety events between groups. Compared to control participants from baseline to follow-up, intervention participants had statistically significant and clinically meaningful improved HRQL (SGRQ total, symptom, and impact scores) (standardized effect size: -1.03 to -1.30)., Conclusions: Among lung cancer survivors following curative-intent therapy, telemedicine-based IMT + walking was feasible, acceptable, safe, and had potential to disrupt the "dyspnea-inactivity" spiral. Future efficacy/effectiveness trials are warranted and should incorporate IMT and walking promotion to improve HRQL., Trial Registration: ClinicalTrials.gov NCT05059132., (© 2023. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Objective: The objective of this program evaluation was to measure the impact of a medically tailored meals (MTM) intervention on participants' self-reported recovery and satisfaction while recovering from a recent hospitalization., Design: A qualitative design was employed using a brief survey among all participants at the end of the intervention and phone interviews with a subset of participants., Sample: Participants in this study were recently discharged from the hospital and were members of (redacted for review) who had received 2-4 weeks of MTM., Measurements: The survey assessed overall satisfaction with the meals and perceived impact on their recovery after hospitalization (81% response rate). Interview questions asked how they felt the meals may have helped while recovering (e.g., helped them financially or with their ability to remain independent)., Results: Among survey participants, 65% were extremely or very satisfied with their meals. Reasons that MTM were helpful while they were recovering included having sufficient food to eat, having healthy food to eat, the convenience of the meals, and ease of preparing the meals., Conclusions: Participants receiving MTM were generally very satisfied with the program. Including nutrition education and more flexibility in quantity and frequency of food may improve satisfaction and consumption of food., (© 2023 Wiley Periodicals LLC.)

Objectives: The perspectives of professionals involved in behavioral health (BH) services with short-stay residents in skilled nursing facilities (SNFs) are rarely captured in the literature. This study examines the real-world experiences of BH clinicians and administrators in post-acute/subacute care units in SNFs., Methods: This qualitative study used semi-structured interviews with 18 clinicians (e.g., psychologists and social workers) and five administrators (e.g., directors of social services or BH company executives) involved in BH services with short-stay SNF residents. Interviews were recorded, transcribed, and analyzed by two independent coders using conventional thematic content analysis., Results: Three themes emerged from the data: (1) BH needs are high among short-stay residents and families during post-acute care transitions; (2) BH services offer multiple unique opportunities to enhance post-acute/subacute care in SNFs; and (3) barriers to providing optimal BH care exist at multiple levels and require action from BH clinicians and stakeholders., Conclusions: Variability in clinician roles and barriers to optimized care suggest the need for future research targeting best practices and implementation strategies for BH services with short-stay SNF residents., Clinical Implications: Results identified multiple ways in which BH services may enhance resident, family, and staff outcomes, as well as the milieu in SNFs.

Background: The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has caused high inpatient mortality and morbidity throughout the world. COVID-19 convalescent plasma (CCP) has been utilized as a potential therapy for patients hospitalized with coronavirus disease 2019 (COVID-19) pneumonia. This study evaluated the outcomes of hospitalized patients with COVID-19 treated with CCP in a prospective, observational, multicenter trial., Methods: From April through August 2020, hospitalized patients with COVID-19 at 16 participating hospitals in Colorado were enrolled and treated with CCP and compared with hospitalized patients with COVID-19 who were not treated with convalescent plasma. Plasma antibody levels were determined following the trial, given that antibody tests were not approved at the initiation of the trial. CCP-treated and untreated hospitalized patients with COVID-19 were matched using propensity scores followed by analysis for length of hospitalization and inpatient mortality., Results: A total of 542 hospitalized patients with COVID-19 were enrolled at 16 hospitals across the region. A total of 468 hospitalized patients with COVID-19 were entered into propensity score matching with 188 patients matched for analysis in the CCP-treatment and control arms. Fine-Gray models revealed increased length of hospital stay in CCP-treated patients and no change in inpatient mortality compared with controls. In subgroup analysis of CCP-treated patients within 7 days of admission, there was no difference in length of hospitalization and inpatient mortality., Conclusions: These data show that treatment of hospitalized patients with COVID-19 treated with CCP did not significantly improve patient hospitalization length of stay or inpatient mortality., (© The Author(s) 2021. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.)

Purpose: This study sought to quantify physical activity and sedentary time among older adults during a skilled nursing facility (SNF) stay and after the transition home, a critical period when patients are at high risk for adverse events., Materials and Methods: We performed an observational cohort study of physical activity and sedentary behavior during the last 3-5 days before discharge from SNF and the initial 3-5 days at home using accelerometers. Participants answered questions about perceived physical activity in the SNF and at home., Results: A convenience sample of thirty-one residents from two SNFs were included. Participants spent a median 12.2% (interquartile range [IQR], 17.3%) of time upright in the SNF and 16.8% (IQR, 15.2%) of their time upright at home ( p  = 0.002) and took a median of 849 steps (IQR, 1772) in the SNF and 922 steps (IQR, 1906) at home ( p  = 0.57), per day. Participants averaged fewer sitting bouts at home ( p  = 0.03), but there was no difference in sit-to-stand transitions ( p  = 0.32) or activity scores ( p  = 0.67). Subjective perceptions of physical activity appeared to be higher than objective measurements., Conclusion: In an exploratory study, SNF residents demonstrated profoundly low levels of physical activity both during and after their SNF stay. Future studies using larger sample sizes should examine physical activity during the SNF to home transition as well as barriers and facilitators to physical activity in post-acute care environments.IMPLICATIONS FOR REHABILITATIONSNF residents in this study demonstrated low levels of physical activity and high rates of sedentary behavior that persisted after discharge home.Interventions to improve physical activity levels in the SNF are sorely needed, and those interventions should include a plan for progressing physical activity after the transition home.Objective measurement of physical activity using activity monitors may prove clinically useful for older adults following hospitalization in the SNF and home settings.

Clinical guidelines recommend clinicians in skilled nursing facilities (SNFs) monitor body weight and signs and symptoms related to heart failure (HF) and encourage a sodium restricted diet to improve HF outcomes; however, SNFs face considerable challenges in HF disease management (HF-DM). In the current study, we characterized the challenges of HF-DM with data from semi-structured, in-depth interviews with patients, caregivers, staff, and physicians from nine SNFs. Patients receiving skilled nursing care were interviewed together as a dyad with their caregiver. A data-driven, qualitative descriptive approach was used to understand the process and challenges of HF-DM. Coded text was categorized into descriptive themes. Interviews with five dyads ( n = 10 individuals), SNF nurses and certified nursing assistants ( n = 13), and physicians ( n = 2) revealed that, among the sample, HF care was not prioritized above other competing health concerns. Staff operated in the challenging SNF environment largely without protocols or educational materials to prompt HF-DM. [ Journal of Gerontological Nursing, 48 (5), 13-17.].

Objective: Skilled nursing facilities (SNFs) are common destinations after hospitalization for patients with heart failure (HF). Our objective was to determine if patients in SNFs with a primary hospital discharge diagnosis of HF benefit from an HF disease management program (HF-DMP)., Design: This is a subgroup analysis of multisite, physician and practice blocked, cluster-randomized controlled trial of HF-DMP vs usual care for patients in SNF with an HF diagnosis. The HF-DMP standardized SNF HF care using HF practice guidelines and performance measures and was delivered by an HF nurse advocate., Setting and Participants: Patients with a primary hospital discharge diagnosis of HF discharged to SNF., Methods: Composite outcome of all-cause hospitalization, emergency department visits, and mortality were evaluated at 30 and 60 days post SNF admission. Linear mixed models accounted for patient clustering at the physician level., Results: Of 671 individuals enrolled in the main study, 125 had a primary hospital discharge diagnosis of HF (50 HF-DMP; 75 usual care). Mean age was 79 ± 10 years, 53% women, and mean ejection fraction 46% ± 15%. At 60 days post SNF admission, the rate of the composite outcome was lower in the HF-DMP group (30%) compared with usual care (52%) (P = .02). The rate of the composite outcome at 30 days for the HF-DMP group was 18% vs 31% in the usual care group (P = .11)., Conclusions and Implications: Patients with a primary hospital discharge diagnosis of HF who received HF-DMP while cared for in an SNF had lower rates of the composite outcome at 60 days. Standardized HF management during SNF stays may be important for patients with a primary discharge diagnosis of HF., (Copyright © 2021 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: Patients discharged from the hospital to a skilled nursing facility (SNF) are not typically part of a heart failure disease management program (HF-DMP). The objective of this study is to determine if an HF-DMP in SNF improves outcomes for patients with HF., Design: Cluster-randomized controlled trial., Participants: The trial was conducted in 47 SNFs, and 671 patients were enrolled (329 HF-DMP; 342 to usual care)., Methods: The HF-DMP included documentation of ejection fraction, symptoms, weights, diet, medication optimization, education, and 7-day visit post SNF discharge. The composite outcome was all-cause hospitalization, emergency department visits, or mortality at 60 days. Secondary outcomes included the composite endpoint at 30 days, change in the Kansas City Cardiomyopathy Questionnaire and the Self-care of HF Index at 60 days. Rehospitalization and mortality rates were calculated as an exploratory outcome., Results: Mean age of the patients was 79 ± 10 years, 58% were women, and the mean ejection fraction was 51% ± 16%. At 30 and 60 days post SNF admission, the composite endpoint was not significant between DMP (29%) and usual care (32%) at 30 days and 60 days (43% vs 47%, respectively). The Kansas City Cardiomyopathy Questionnaire significantly improved in the HF-DMP vs usual care for the Physical Limitation (11.3 ± 2.9 vs 20.8 ± 3.6; P = .039) and Social Limitation subscales (6.0 ± 3.1 vs 17.9 ± 3.8; P = .016). Self-care of HF Index was not significant. The total number of events (composite endpoint) totaled 517 (231 in HF-DMP and 286 in usual care). Differences in the 60-day hospitalization rate [mean HF-DMP rate 0.43 (SE 0.03) vs usual care 0.54 (SE 0.05), P = .04] and mortality rate (HF-DMP 5.2% vs usual care 10.8%, P < .001) were significant., Conclusions and Implications: The composite endpoint was high for patients with HF in SNF regardless of group. Rehospitalization and mortality rates were reduced by the HF-DMP. HF-DMPs in SNFs may be beneficial to the outcomes of patients with HF. SNFs should consider structured HF-DMPs for their patients., (Copyright © 2021 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Endurance exercise can cause a decrease in serum ionized calcium (iCa) and increases in parathyroid hormone (PTH) and bone resorption, reflected by serum carboxy-terminal collagen crosslinks (CTX). We developed a calcium clamp to prevent the decrease in iCa during exercise, which attenuated increases in PTH and CTX during vigorous cycling in young men. The goal was to determine whether this occurs in older adults during brisk walking., Methods: Twelve older adults (6 men, 6 women) performed two identical 60-min treadmill walking bouts with Ca gluconate or half-normal saline infusion. Blood sampling for iCa, total calcium (tCa), phosphate (P), PTH, and CTX, occurred before, during, and for 4 h after exercise., Results: iCa decreased during exercise with the saline infusion (p = 0.04) and this provoked increases in PTH and CTX (both p < 0.01). The Ca clamp prevented the decrease in serum iCa during exercise and attenuated the PTH and CTX responses., Conclusions: Preventing the exercise-induced decrease in iCa markedly attenuated the increases in PTH and CTX. The cause of the decrease in iCa during exercise remains unclear, but the increases in PTH and CTX are likely counter-regulatory responses to defend serum iCa. This contention is supported by previous observations that the disruption of Ca homeostasis during exercise occurs regardless of training status. It will be important to establish whether this acute catabolic effect of exercise diminishes the potential chronic anabolic effects of exercise on bone., (Published by Elsevier Inc.)

Objective: Older adults in inpatient postacute care settings report high rates of depression and anxiety. Psychological interventions address these symptoms through educational, cognitive, behavioral, relaxation, and/or psychosocial approaches. The purpose of this study was to systematically evaluate the quality of existing literature on psychological interventions for depression and/or anxiety among older adults during an inpatient postacute care stay. Method: Medline, Embase, Cochrane Library, CINAHL, PsycINFO, and Google Scholar were searched for key concepts. Studies were included that (a) sampled skilled nursing facility or inpatient rehabilitation facility patients, (b) evaluated a psychological intervention, (c) measured depression and/or anxiety symptoms before and after interventions, and (d) had a mean or median age of 65+. Two raters assessed articles for inclusion and risk of bias. Results: Search strategies identified 7,506 articles for screening; nine met inclusion criteria. Included studies varied by study design, intervention type, and methodological quality. Only one study had low overall risk of bias. Four studies demonstrated preliminary treatment benefits for depression symptoms; none reported benefits for anxiety symptoms. Conclusions: Most of the included studies were limited by small sample size and high risk of bias. Thus, currently, there is insufficient evidence to support the effectiveness of psychological interventions for depression or anxiety among older adults during an inpatient postacute care stay. The authors offer a detailed discussion of methodological limitations, empirical gaps, and future directions to develop this body of literature. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Objective: Monitoring body weight and signs and symptoms related to heart failure (HF) can alert clinicians to a patient's worsening condition but the degree to which these practices are performed in skilled nursing facilities (SNFs) is unknown. This study analyzed the frequency of these monitoring practices in SNFs and explored associated factors at both the patient and SNF level., Design: An observational study of data from the usual care arm of the SNF Connect Trial, a randomized cluster trial of a HF disease management intervention. The data extracted from charts were combined with publicly available facility data. A linear regression model was estimated to evaluate the frequency of HF disease management conditional on patient and facility covariates., Setting: Data from 28 SNFs in Colorado., Participants: Patients discharged from hospital to SNFs with a primary or secondary diagnosis of HF., Measurements: Patient-level covariates included demographics, New York Heart Association class, type of HF, and Charlson comorbidity index. Facility-level covariates were from Nursing Home Compare., Results: The sample (n = 320) was majority female (66%), white (93%), with mean age 80 ± 10 years and a Charlson comorbidity index of 3.2 ± 1.5. Seventy percent had HF with preserved ejection fraction, mean ejection fraction of 50 ± 16% and 40% with a New York Heart Association class III-IV. On average, patients were weighed 40% of their days in the SNF and had documentation of at least 1 HF-related sign or symptom 70% of their days in the SNF. Patient-level factors were not associated with frequency of documenting weight and assessments of HF-related signs/symptoms. Health Inspection Star Rating was positively associated with weight monitoring (P < .05) but not associated with symptom assessment., Conclusions and Implications: Patient-level factors are not meaningfully associated with the documentation of weight tracking or sign/symptom assessment. Monitoring weight was instead associated with the Health Inspection Star Rating., (Copyright © 2020 AMDA – The Society for Post-Acute and Long-Term Care Medicine. All rights reserved.)

Objectives: Characterize key tasks and information needs for heart failure disease management (HF-DM) in the distinct care setting of skilled nursing facility (SNF) staff in partnership with community-based clinical stakeholders. Develop design recommendations contextualized to the SNF setting for informatics interventions for improved HF-DM in the SNF setting., Methods: Semi-structured interviews with fifteen participants (registered nurses, licensed practical nurses, certified nursing aides and physicians) from 8 Denver-metro SNFs. Data coded using a data-driven, inductive approach., Results: Key tasks of HF-DM: symptom assessment, communicating change in condition, using equipment, documentation of daily weights, and monitoring patients. Themes: 1) HF-DM is challenged by a culture of verbal communication; 2) staff face knowledge barriers in HF-DM that are partially attributed to unmet information needs. HF-DM information needs: identification of HF patients, HF signs and symptoms, purpose of daily weights, indicators of worsening HF, purpose of sodium restricted diet, and materials to improve patients' understanding of HF., Discussion and Conclusions: HF-DM information needs are not fully supported by current SNF information systems., (©2020 AMIA - All rights reserved.)

Context: Digital health offers innovative mechanisms to engage in palliative care, yet digital systems are typically designed for individual users, rather than integrating the patient's caregiving "social convoy" (i.e., family members, friends, neighbors, formal caregiving supports) to maximize benefit. As older adults with serious illness increasingly rely on the support of others, there is a need to foster effective integration of the social convoy in digitally supported palliative care., Objectives: Conduct a qualitative study examining patient, social convoy, and health care provider perspectives on digital health for palliative care to inform the design of future digital solutions for older adults with serious illness and their social convoy., Methods: Grounded theory approach using semi-structured interviews (N = 81) with interprofessional health care providers, older adults with serious illness, and their social convoy participants at home, clinic, or Zoom. Interviews were conducted using question guides relevant to the participant group and audio-recorded for verbatim transcription. Two coders lead the inductive analysis using open and axial coding., Results: Thematic results aligned with the human-centered design framework, which is a participatory approach to the design process that incorporates multiple user stakeholders to develop health solutions. The human-centered design process and corresponding theme included the following: 1) Empathy: Patient, Caregiver, and Provider Experience reports participants' experience with managing serious illness, caregiving, social support, and technology use. 2) Define: Reactions to Evidence-Based Care Concepts and Barriers illustrates participants' perspectives on the domains of palliative care ranging from symptom management to psychosocial-spiritual care. 3) Ideation: Desired Features reports participant recommendations for designing digital health tools for palliative care domains., Conclusion: Digital health provides an opportunity to expand the reach of geriatric palliative care interventions. This paper documents human-centered preferences of geriatric palliative care digital health to ensure technologies are relevant and meaningful to health care providers, patients, and the caregiving social convoy., (Copyright © 2020 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: Rehabilitation in skilled nursing facilities (SNFs) is under scrutiny to deliver high-quality care and superior outcomes in less time. High-intensity resistance training demonstrates functional improvements in community-dwelling and long-term care populations but has not been generalized to the SNF population. The purpose of this study was to evaluate implementation issues including safety and feasibility and to provide preliminary information on effectiveness of rehabilitation focused on high-intensity functional resistance training in an SNF., Methods: The implementation study design consisted of 2 nonrandomized independent groups (usual care and high intensity) that were staged within a single SNF. The i-STRONGER program (IntenSive Therapeutic Rehabilitation for Older Skilled NursinG HomE Residents) integrates principles of physiologic tissue overload into rehabilitation. Physical therapists administered the Short Physical Performance Battery and gait speed at evaluation and discharge. Reach, Effectiveness, Adoption, Implementation, and Maintenance was used to evaluate the implementation process. An observational checklist and documentation audits were used to assess treatment fidelity. Regression analyses evaluated the response of functional change by group., Results: No treatment-specific adverse events were reported. Treatment fidelity was high at >99%, whereas documentation varied from 21% to 50%. Patient satisfaction was greater in i-STRONGER, and patient refusals to participate in therapy sessions trended downward in i-STRONGER. Patients in i-STRONGER exhibited a 0.13 m/s greater change in gait speed than in the usual care group. Although not significant, i-STRONGER resulted in a 0.64-point greater change in the Short Physical Performance Battery than usual care, and average SNF length of stay was 3.5 days shorter for i-STRONGER patients., Conclusion: The findings from this study indicate that implementation of a high-intensity resistance training framework in SNFs is safe and feasible. Furthermore, results support a signal effectiveness of improving function and satisfaction, although the heterogeneity of the population necessitates a larger implementation study to confirm., Impact Statement: This pragmatic study demonstrates that high-intensity resistance training in medically complex older adults is safe and favorable in SNFs. This work supports the need to fundamentally change the intensity of rehabilitation provided to this population to promote greater value within post-acute care. Furthermore, this study supports the application of implementation science to rehabilitation for rapid and effective translation of evidence into practice., (© Published by Oxford University Press on behalf of American Physical Therapy Association 2020.)

Background: Many mobile health (mHealth) technologies exist for patients with heart failure (HF). However, HF mhealth lacks evidence of efficacy, caregiver involvement, and clinically useful real-time data., Objective: We aim to capture health care providers' perceived value of HF mHealth, particularly for pairing patient-caregiver-generated data with clinical intervention to inform the design of future HF mHealth., Methods: This study is a subanalysis of a larger qualitative study based on interviewing patients with HF, their caregivers, and health care providers. This analysis included interviews with health care providers (N=20), focusing on their perceived usefulness of HF mHealth tools and interventions., Results: A total of 5 themes emerged: (1) bio-psychosocial-spiritual monitoring, (2) use of sensors, (3) interoperability, (4) data sharing, and (5) usefulness of patient-reported outcomes in practice. Providers remain interested in mHealth technologies for HF patients and their caregivers. However, providers report being unconvinced of the clinical usefulness of robust real-time patient-reported outcomes., Conclusions: The use of assessments, sensors, and real-time data collection could provide value in patient care. Future research must continually explore how to maximize the utility of mHealth for HF patients, their caregivers, and health care providers., (©Jennifer Dickman Portz, Kelsey Lynett Ford, Kira Elsbernd, Christopher E Knoepke, Kelsey Flint, David B Bekelman, Rebecca S Boxer, Sheana Bull. Originally published in JMIR Cardio (http://cardio.jmir.org), 04.09.2020.)

Patient portals can play an innovative role in facilitating advanced care planning (ACP) and documenting advance directives (ADs) among older adults with multiple chronic conditions. The objective of this qualitative sub-study was to (1) understand older adults' use of an ACP patient portal section and (2) obtain user-design input on AD documentation features. Although some older adults may be reluctant, participants reported likely to use a portal for ADs with proper portal design and support.

Background: Mobile health (mHealth) is a promising tool for improving health outcomes. However, the benefits of using mHealth in palliative care are under studied. Objective: As a first step to designing meaningful palliative care-specific mobile applications, this research explored provider perspectives regarding the utility of mHealth in palliative care. Design: A qualitative phenomenological study with semistructured interviews. Setting/Subjects: Providers from multiple disciplines working in palliative care settings at an academic medical center. Results: Thematic analysis resulted in five provider recommendations regarding the utility and design of palliative care-specific mHealth, including (i) thoughtfulness to language, context, and delivery when assessing palliative care needs; (ii) include tools for prognosis and advance care planning; (iii) tailor health and quality-of-life goals; (iv) emphasize supports for family and caregivers; and (v) consider technology abilities of older adults. Conclusions: Palliative care providers are enthusiastic about the use of mHealth to improve care coordination, facilitate communication, enhance symptom monitoring, and improve patient-family support. However, providers have reservations about mobile functionality and depersonalized assessment and care. Providers stress the utility of mHealth to facilitate palliative care rather than replace important multidisciplinary services.

Prior evidence suggests that the choice of antihypertensive medication may influence functional status among older adults with hypertension, particularly in conjunction with exercise. In particular, angiotensin converting enzyme (ACE) inhibitors have shown potential to positively influence function. However, randomized, controlled trials are needed to confirm this hypothesis. This paper outlines an RCT designed to determine if choice of first-line antihypertensive medication influences functional and cardiovascular risk factor responses to exercise among older adults with hypertension. Two hundred and thirteen inactive, community-dwelling adults ≥60 years of age with hypertension and functional limitations will be recruited to engage in a 32-week intervention study. Participants will be randomized to one of three first-line antihypertensive agents: (1) the ACE inhibitor perindopril, (2) the AT1 receptor antagonist losartan, or (3) the thiazide diuretic hydrochlorothiazide (HCTZ). Six weeks after randomization, participants will begin a 20-week structured aerobic exercise intervention. Participants will perform two 45-min center-based sessions coupled with 60 min of home-based walking per week. The primary aim is to determine if perindopril improves self-paced gait speed when compared with losartan and HCTZ. The secondary aim is to determine the relative effect of perindopril on secondary outcomes such as: (a) exercise capacity, (b) body mass and composition, and (c) circulating indices of cardiovascular risk. This RCT is expected to identify differential effects of first-line antihypertensive medications when combined with physical exercise thus have potential implications for antihypertensive prescription guidelines for older adults. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT03295734., (Copyright © 2020 Harper, Baptista, Roberts, Wherry, Boxer, Hildreth, Seay, Allman, Carter, Aban, Kohrt and Buford.)

Introduction: Exercise can cause a decrease in serum ionized calcium (iCa) concentration, which stimulates parathyroid hormone (PTH) secretion and activates bone resorption. We postulated that dermal Ca loss during cycling exercise is the major determinant of the serum iCa, PTH, and bone resorption (C-terminal telopeptide of type 1 collagen [CTX]) responses., Methods: To investigate this, women (n = 13) and men (n = 12) age 18 to 45 yr performed the same exercise bout under cool (18°C) and warm (26°C) conditions. Exercise was 60 min of cycling at ~75% of peak aerobic power. Sweat samples were obtained during exercise using a skin patch method, and blood samples were obtained before and during exercise and during 60 min of recovery., Results: Sweat volume and estimated sweat Ca loss were 50% higher for the warm condition than the cool condition. Despite this, there were no differences between thermal conditions in the changes (mean, 95% confidence interval [95% CI]) in iCa (cool, -0.07 mg·dL; 95% CI, -0.16 to 0.03); warm, -0.07 mg·dL; 95% CI, -0.20 to 0.05), PTH (cool, 34.4 pg·mL; 95% CI, 23.6-45.2; warm: 35.8 pg·mL; 95% CI, 22.4-49.1), or CTX (cool, 0.11 ng·mL; 95% CI, 0.08-0.13; warm, 0.15 ng·mL; 95% CI, 0.11-0.18). Adjusting for exercise-related shifts in plasma volume revealed a marked decline in vascular iCa content in the first 15 min of exercise (cool, -0.85 mg·dL; 95% CI, -1.01 to -0.68; warm, -0.85 mg·dL; 95% CI, -1.05 to -0.66), before substantial sweat Ca loss had occurred., Conclusions: This indicates that dermal Ca loss was not the primary trigger for the increases in PTH and CTX during exercise. Further research is necessary to understand the causes and consequences of the disruption in Ca homeostasis during exercise and specifically the extravascular shift in iCa.

Background: The accuracy of data is vital to identifying hospitalization outcomes for clinical trials. Patient attrition and recall bias affects the validity of patient-reported outcomes, and the growing prevalence of Medicare Advantage (MA) could mean Fee-for-Service (FFS) claims are less reliable for ascertaining hospital utilization. Statewide health information exchanges (HIEs) may be a more complete data source but have not been frequently used for research., Design: Secondary analysis comparing identification of readmissions using 3 different acquisition approaches., Setting: Randomized controlled trial of heart failure (HF) disease management in 37 skilled nursing facilities (SNFs)., Participants: Patients with HF discharged from the hospital to SNF., Measures: Readmissions up to 60 days post-SNF admission collected by patient self-report, recorded by nursing home (NH) staff during the SNF stay, or recorded in the state HIE., Results: Among 657 participants (mean age 79 ± 10 years, 49% with FFS), 295 unique readmissions within 60 days of SNF admission were identified. These readmissions occurred among 221 patients. Twenty percent of all readmissions were found using only patient self-report, 28% were only recorded by NH staff during the SNF stay, and 52% were identified only using the HIE. The readmission rate (first readmission only) based only on patient self-report and direct observation was 18% rather than 34% with the addition of the enhanced HIE method., Conclusions and Implications: More than one-quarter (34%) of HF patients were rehospitalized within 60 days post SNF admission. Use of a statewide HIE resulted in identifying an additional 153 admissions, 52% of all the readmissions seen in this study. Without use of an HIE, nearly half of readmissions would have been missed as a result of incomplete patient self-report or loss to follow-up. Thus, HIEs serve as an important resource for researchers to ensure accurate outcomes data., (Copyright © 2019 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Endurance exercise can cause a decrease in serum ionized calcium (iCa) and increases in parathyroid hormone (PTH) and c-terminal telopeptide of type I collagen (CTX), which may be due to Ca loss in sweat., Purpose: This study aimed to determine whether exercise in a warm environment exaggerates the decrease in iCa and increases in PTH and CTX compared with a cool environment in older adults., Methods: Twelve women and men 61-78 yr old performed two identical 60-min treadmill bouts at ~75% of maximal heart rate under warm and cool conditions. Serum iCa, PTH, and CTX were measured every 15 min starting 15 min before and continuing for 60 min after exercise. Sweat Ca loss was estimated from sweat volume and sweat Ca concentration., Results: Sweat volume was low and variable; there were no differences in sweat volume or Ca concentration between conditions. iCa decreased after 15 min of exercise, and the change was similar in both conditions. Increases in PTH (warm: 16.4, 95% confidence interval [CI] = 6.2, 26.5 pg·mL; cool: 17.3, 95% CI = 8.1, 26.4 pg·mL) and CTX (warm: 0.08, 95% CI = 0.05, 0.11 ng·mL; cool: 0.08, 95% CI = 0.01, 0.16 ng·mL) from before to immediately after exercise were statistically significant and similar between conditions. Adjusting for plasma volume shifts did not change the results., Conclusion: The increases in PTH and CTX, despite the low sweat volume, suggest that dermal Ca loss is not a major factor in the decrease in iCa and increases in PTH and CTX observed during exercise in older adults.

Despite multiple initiatives in post-acute and long-term nursing home care settings (NHs) to improve the quality of care while reducing health care costs, research in NHs can prove challenging. Extensive regulation for both research and NHs is designed to protect a highly vulnerable population but can be a deterrent to conducting research. This article outlines regulatory challenges faced by NHs and researchers, such as protecting resident privacy as well as health information and obtaining informed consent. The article provides lessons learned to help form mutually beneficial partnerships between researchers and NHs to conduct studies that grow and advance NH research initiatives and clinical care., (Copyright © 2019 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: Conduct a needs assessment among post-acute and long-term care (PA-LTC) stakeholder groups to identify (1) research topics of highest priority and (2) perspectives on research, including concerns/barriers to conducting research in the PA-LTC setting., Design: Mixed methods multistakeholder engagement process. Needs assessment conducted with tailored strategies per stakeholder group: interview, survey, and focus group., Setting and Participants: Four stakeholder groups-medical directors/providers (n = 89), administrative leadership (n = 5), frontline staff (n = 17), and family members of residents and residents themselves (n = 11)-were recruited from the Colorado PA-LTC community through an academic-community partnership between the University of Colorado and Colorado Medical Directors Association., Main Outcome(s): Stakeholder perspectives on research and high priority PA-LTC research topics., Results: Research priorities common across stakeholder groups included polypharmacy (overuse of medication generally and overuse of antibiotics specifically), care transitions, mental health (including dementia, Alzheimer's disease, behaviors), chronic pain, urinary tract infection, and quality of life issues. Providers specifically prioritized heart failure, Parkinson's, and other chronic illnesses. Administrators and directors of nurses emphasized hospitalizations. Staff prioritized medication/therapy compliance. Families/residents prioritized neurologic disease. Concerns included staff burden, consenting process, privacy, and family involvement., Conclusions/implications: PA-LTC patients have a lot to offer as participants and decision makers in research, frontline staff are enthusiastic about participation, family members want to be involved, and providers value research findings in their practice but need a more supportive environment to produce and participate in research., (Copyright © 2019 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Although family technical support seems intuitive, there is very little research exploring this topic., Objective: The objective of this study was to conduct a subanalysis of data collected from a large-scale qualitative project regarding older adults' experiences in using health information technology. Specifically, the subanalysis explored older adults' experiences with technology support from family members to inform strategies for promoting older adults' engagement with new health technologies. Although the primary analysis of the original study was theoretically driven, this paper reports results from an inductive, open-coding analysis., Methods: This is a subanalysis of a major code identified unexpectedly from a qualitative study investigating older adults' use experience of a widespread health technology, the patient portal. A total of 24 older patients (≥65 years) with multiple chronic conditions (Charlson Comorbidity Index >2) participated in focus groups conducted at the patients' primary clinic. While conducting the primary theoretically driven analysis, coders utilized an open-coding approach to ensure important ideas not reflected in the theoretical code book were captured. Open coding resulted in 1 code: family support. This subanalysis further categorized family support by who provided tech support, how tech support was offered, and the opinions of older participants about receiving family tech support., Results: The participants were not specifically asked about family support, yet themes around family assistance and encouragement for technology emerged from every focus group. Participants repeatedly mentioned that they called their grandchildren and adult children if they needed help with technology. Participants also reported that family members experienced difficulty when teaching technology use. Family members struggled to explain simple technology tasks and were frustrated by the slow teaching process., Conclusions: The results suggest that older adults ask their family members, particularly grandchildren, to support them in the use of new technologies. However, family may experience difficulties in providing this support. Older adults will be increasingly expected to use health technologies, and family members may help with tech support. Providers and health systems should consider potential family support and engagement strategies to foster adoption and use among older patients., (©Jennifer Dickman Portz, Christine Fruhauf, Sheana Bull, Rebecca S Boxer, David B Bekelman, Alejandra Casillas, Kathy Gleason, Elizabeth A Bayliss. Originally published in JMIR Aging (http://aging.jmir.org), 06.06.2019.)

Background: Patient portals offer modern digital tools for older adults with multiple chronic conditions (MCC) to engage in their health management. However, there are barriers to portal adoption among older adults. Understanding portal user interface and user experience (UI and UX) preferences of older adults with MCC may improve the accessibility, acceptability, and adoption of patient portals., Objective: The aim of this study was to use the Technology Acceptance Model (TAM) as a framework for qualitatively describing the UI and UX, intent to use, and use behaviors among older patients with MCC., Methods: We carried out a qualitative descriptive study of Kaiser Permanente Colorado's established patient portal, My Health Manager. Older patients (N=24; mean 78.41 (SD 5.4) years) with MCC participated in focus groups. Stratified random sampling was used to maximize age and experience with the portal among participants. The semistructured focus groups used a combination of discussion and think-aloud strategies. A total of 2 coders led the theoretically driven analysis based on the TAM to determine themes related to use behavior, portal usefulness and ease of use, and intent to use., Results: Portal users commonly used email, pharmacy, and lab results sections of the portal. Although, generally, the portal was seen to be easy to use, simple, and quick, challenges related to log-ins, UI design (color and font), and specific features were identified. Such challenges inhibited participants' intent to use the portal entirely or specific features. Participants indicated that the portal improved patient-provider communication, saved time and money, and provided relevant health information. Participants intended to use features that were beneficial to their health management and easy to use., Conclusions: Older adults are interested in using patient portals and are already taking advantage of the features available to them. We have the opportunity to better engage older adults in portal use but need to pay close attention to key considerations promoting usefulness and ease of use., (©Jennifer Dickman Portz, Elizabeth A Bayliss, Sheana Bull, Rebecca S Boxer, David B Bekelman, Kathy Gleason, Sara Czaja. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 08.04.2019.)

Objectives: To evaluate the quality of communication between hospitals and home health care (HHC) clinicians and patient preparedness to receive HHC in a statewide sample of HHC nurses and staff., Design: A web-based 48-question cross-sectional survey of HHC nurses and staff in Colorado to describe the quality of communication after hospital discharge and patient preparedness to receive HHC from the perspective of HHC nurses and staff. Questions were on a Likert scale, with optional free-text questions., Setting and Participants: Between January and June 2017, we sent a web-based survey to individuals from the 56 HHC agencies in the Home Care Association of Colorado that indicated willingness to participate., Results: We received responses from 50 of 122 individuals (41% individual response rate) representing 14 of 56 HHC agencies (25% agency response rate). Half of the respondents were HHC nurses, the remainder were managers, administrators, or quality assurance clinicians. Among respondents, 60% (n = 30) reported receiving insufficient information to guide patient management in HHC and 44% (n = 22) reported encountering problems related to inadequate patient information. Additional tests recommended by hospital clinicians was the communication domain most frequently identified as insufficient (58%). More than half of respondents (52%) indicated that patient preparation to receive HHC was inadequate, with patient expectations frequently including extended-hours caregiving, housekeeping, and transportation, which are beyond the scope of HHC. Respondents with electronic health record (EHR) access for referring providers were less likely to encounter problems related to a lack of information (27% vs 57% without EHR access, P = .04). Respondents with EHR access were also more likely to have sufficient information about medications and contact isolation., Conclusions/implications: Communication between hospitals and HHC is suboptimal, and patients are often not prepared to receive HHC. Providing EHR access for HHC clinicians is a promising solution to improve the quality of communication., (Copyright © 2019 AMDA – The Society for Post-Acute and Long-Term Care Medicine. All rights reserved.)

Background: Patients discharged from the hospital with skilled home healthcare (HHC) services have multiple comorbidities, high readmission rates, and multiple care needs. In prior work, HHC nurses described that patients often express expectations for services beyond the scope of skilled HHC., Objective: The objective of this study is to evaluate and compare expectations for HHC from the patient, caregiver, and HHC perspectives after hospital discharge., Design/participants: This was a descriptive qualitative case study including HHC patients, caregivers, and clinicians. Patients were discharged from an academic medical center between July 2017 and February 2018., Results: The sample (N = 27) included 11 HHC patients, eight caregivers, and eight HHC clinicians (five nurses and three physical therapists). Patient mean age was 66 years and the majority were female, white, and had Medicare. We observed main themes of clear and unclear expectations for HHC after discharge. Clear expectations occur when the patient and/or caregiver have expectations for HHC aligned with the services received. Unclear expectations occur when the patient and/or caregiver expectations are uncertain or misaligned with the services received. Patients and caregivers with clear expectations for HHC frequently described prior experiences with skilled HHC or work experience within the healthcare field. In most cases with unclear expectations, the patient and caregiver did not have prior experience with HHC., Conclusions: To improve HHC transitions, we recommend actively engaging both patients and caregivers in the hospital and HHC settings to provide education about HHC services, and assess and address additional care needs., (© 2019 Society of Hospital Medicine.)

There is growing recognition that acute hospitalization contributes to marked functional decline in older adult populations. Nearly 20% of all hospitalized older adults in the United States are discharged to skilled nursing facilities (SNFs) to address these functional deficits. However, current approaches to care in SNFs may not adequately restore function, which may contribute to low community discharge rates and high hospital readmission rates. Barriers to rehabilitation innovation in SNFs include management, staff, patient, and researcher-level factors. This clinical commentary builds upon clinical innovation strategies in other health care settings by describing barriers in the context of the SNF environment. Fostering collaboration between academic clinical researchers and SNFs may be the answer to advancing rehabilitation practices and care delivery, thereby improving outcomes in this vulnerable population.

Heart failure (HF) affects 20% of nursing home (NH) residents, causing high morbidity and mortality. The optimal approach to HF management in NHs remains elusive. We conducted a scoping review of published guidelines and HF management interventions in NHs. A search for English publications since 1990 was conducted using PubMed, EMBASE, CINAHL, and Scopus, for scientific statements, guidelines, recommendations, or intervention studies that addressed at least 1 principle of HF management. Of 2545 records retrieved, 19 articles were retained after screening, and 2 additional articles identified through reference list manual searches. Six articles represented 5 guidelines and 15 described interventions. All guidelines endorsed the applicability of general HF guidelines to NH residents, tailored to comorbidities, frailty, and advance care preferences. Four addressed quality assurance but not feasibility and sustainability. Methodological quality of the interventions was poor, although results suggest that guideline-based HF management in NHs can improve nursing staff knowledge and job satisfaction, prescribing, and reduce acute care utilization. Clinically-based education for staff, and access to specialist mentorship are important. NH physician involvement was limited, and resident/family education potentially ineffective. Concerns about feasibility, sustainability, and quality assurance were identified in most interventions, and advance care planning was rarely addressed. HF guidelines for NH support the applicability of general HF guidelines to the care of NH residents, and published interventions suggest that guideline-based HF management in NHs is effective. Future work should support greater physician and resident engagement, advance care planning, and provide robust guidelines on developing feasible and sustainable interventions., (Copyright © 2018 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Exercise can cause a decrease in serum ionized calcium (iCa) and increases in parathyroid hormone (PTH) and bone resorption. We used a novel intravenous iCa clamp technique to determine whether preventing a decline in serum iCa during exercise prevents increases in PTH and carboxy-terminal collagen crosslinks (CTX). Eleven cycling-trained men (aged 18 to 45 years) underwent two identical 60-min cycling bouts with infusion of Ca gluconate or saline. Blood sampling for iCa, total calcium (tCa), PTH, CTX, and procollagen type 1 amino-terminal propeptide (P1NP) occurred before, during, and for 4 hours after exercise; results are presented as unadjusted and adjusted for plasma volume shifts (denoted with subscript ADJ). iCa decreased during exercise with saline infusion (p = 0.01 at 60 min) and this was prevented by Ca infusion (interaction, p < 0.007); there were abrupt decreases in Ca content (iCa ADJ and tCa ADJ ) in the first 15 min of exercise under both conditions. PTH and CTX were increased at the end of exercise (both p < 0.01) on the saline day, and markedly attenuated (-65% and -71%; both p < 0.001) by Ca. CTX remained elevated for 4 hours after exercise on the saline day (p < 0.001), despite the return of PTH to baseline by 1 hour after exercise. P1NP increased in response to exercise (p < 0.001), with no difference between conditions, but the increase in P1NP ADJ was not significant. Results for PTH ADJ and CTX ADJ were similar to unadjusted results. These findings demonstrate that bone resorption is stimulated early in exercise to defend serum iCa. Vascular Ca content decreased early in exercise, but neither the reason why this occurred, nor the fate of Ca, are known. The results suggest that the exercise-induced increase in PTH had an acute catabolic effect on bone. Future research should determine whether the increase in PTH generates an anabolic response that occurs more than 4 hours after exercise. © 2018 American Society for Bone and Mineral Research., (© 2018 American Society for Bone and Mineral Research.)

Background: In 2012, nearly one-third of adults 65 years or older with Medicare discharged to home after hospitalization were referred for home health care (HHC) services. Care coordination between the hospital and HHC is frequently inadequate and may contribute to medication errors and readmissions. Insights from HHC nurses could inform improvements to care coordination., Objective: To describe HHC nurse perspectives about challenges and solutions to coordinating care for recently discharged patients., Design/participants: We conducted a descriptive qualitative study with six focus groups of HHC nurses and staff (n = 56) recruited from six agencies in Colorado. Focus groups were recorded, transcribed, and analyzed using a mixed deductive/inductive approach to theme analysis with a team-based iterative method., Key Results: HHC nurses described challenges and solutions within domains of Accountability, Communication, Assessing Needs & Goals, and Medication Management. One additional domain of Safety, for both patients and HHC nurses, emerged from the analysis. Within each domain, solutions for improving care coordination included the following: 1) Accountability-hospital physicians willing to manage HHC orders until primary care follow-up, potential legislation allowing physician assistants and nurse practitioners to write HHC orders; 2) Communication-enhanced access to hospital records and direct telephone lines for HHC; 3) Assessing Needs & Goals-liaisons from HHC agencies meeting with patients in hospital; 4) Medication Management-HHC coordinating directly with clinician or pharmacist to resolve discrepancies; and 5) Safety-HHC nurses contributing non-reimbursable services for patients, and ensuring that cognitive and behavioral health information is shared with HHC., Conclusions: In an era of shared accountability for patient outcomes across settings, solutions for improving care coordination with HHC are needed. Efforts to improve care coordination with HHC should focus on clearly defining accountability for orders, enhanced communication, improved alignment of expectations for HHC between clinicians and patients, a focus on reducing medication discrepancies, and prioritizing safety for both patients and HHC nurses.

Background: Individuals with heart failure (HF) who are hospitalized and admitted to skilled nursing facilities (SNFs) are at high risk for rehospitalization and death. The care preferences of this high-risk population have not been studied., Objectives: To describe care preferences of patients with HF admitted to SNFs for rehabilitation based on Medical Orders for Scope of Treatment (MOST) documentation, and evaluate goal-concordant care based on MOST documentation, emergency department (ED) visits, and hospitalization., Design, Setting, and Participants: Retrospective study of patients with HF in 35 SNFs enrolled in a randomized controlled trial of HF-disease management versus usual care between July 2014 and May 2016., Measurements: Validity of MOST forms, care preference documentation, and ED visits/hospitalizations within 60 days of SNF admission., Results: Of 370 patients (mean age 78.6 years, 58% women, 25% systolic HF), 278 (75%) had a MOST form in the SNF chart, of which 96 forms (35%) were invalid. The most common reason for an invalid MOST form was missing date accompanying patient or provider signature. Of 182 valid MOST forms, 47% of patients chose no cardiopulmonary resuscitation ("No CPR"), 58% selected "Full Treatment," 17% chose "Selective Treatment," and 23% chose "Comfort-Focused Treatment." Patients who were older [odds ratio (OR) = 1.50, 95% confidence interval (CI) = 1.25, 1.81] and female (OR = 2.33, 95% CI = 1.18, 4.59) had higher odds of choosing "No CPR." Sixty-six of 182 patients (36%) with valid MOST forms had an ED/hospital visit within 60 days of SNF admission; only 3 patients received medical care that was potentially discordant: all 3 chose "Comfort-Focused Treatment" and were hospitalized for more than symptom management., Conclusion: Seventy-five percent of patients with HF admitted to SNFs had care preferences documented using the MOST form, and 95% received goal-concordant care based on care preferences documented during the SNF admission. Clinicaltrials.gov # NCT01822912., (Copyright © 2017 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Background/aims: Conducting clinical trials in skilled nursing facilities is particularly challenging. This manuscript describes facility and patient recruitment challenges and solutions for clinical research in skilled nursing facilities., Methods: Lessons learned from the SNF Connect Trial, a randomized trial of a heart failure disease management versus usual care for patients with heart failure receiving post-acute care in skilled nursing facilities, are discussed. Description of the trial design and barriers to facility and patient recruitment along with regulatory issues are presented., Results: The recruitment of Denver-metro skilled nursing facilities was facilitated by key stakeholders of the skilled nursing facilities community. However, there were still a number of barriers to facility recruitment including leadership turnover, varying policies regarding research, fear of litigation and of an increased workload. Engagement of facilities was facilitated by their strong interest in reducing hospital readmissions, marketing potential to hospitals, and heart failure management education for their staff. Recruitment of patients proved difficult and there were few facilitators. Identified patient recruitment challenges included patients being unaware of their heart failure diagnosis, patients overwhelmed with their illness and care, and frequently there was no available proxy for cognitively impaired patients. Flexibility in changing the recruitment approach and targeting skilled nursing facilities with higher rates of admissions helped to overcome some barriers., Conclusion: Recruitment of skilled nursing facilities and patients in skilled nursing facilities for clinical trials is challenging. Strategies to attract both facilities and patients are warranted. These include aligning study goals with facility incentives and flexible recruitment protocols to work with patients in "transition crisis."

Objective: To assess patient- and hospital-level factors associated with home health care (HHC) referrals following nonelective U.S. patient hospitalizations in 2012., Data Source: The 2012 National Inpatient Sample (NIS)., Study Design: Retrospective, cross-sectional multivariable logistic regression modeling to assess patient- and hospital-level variables in patient discharges with versus without HHC referrals., Data Collection: Analysis included 1,109,905 discharges in patients ≥65 years with Medicare., Principal Findings: About 29.2 percent of discharges were referred to HHC, which were more likely with older age, female sex, urban location, low income, longer length of stay, higher severity of illness scores, diagnoses of heart failure or sepsis, and hospital location in New England (referent: Pacific)., Conclusions: As health policy changes influence postacute HHC, defining specific diagnoses and regional patterns associated with HHC is a first step to optimize postacute HHC services., (© Health Research and Educational Trust.)

Heart disease is the leading cause of death in the United States. Heart failure disease management can improve health outcomes for elderly community dwelling patients with heart failure. This paper describes DCDS, a real-time data capture and personalized decision support system for a Randomized Controlled Trial Investigating the Effect of a Heart Failure Disease Management Program (HF-DMP) in Skilled Nursing Facilities (SNF). SNF is a study funded by the NIH National Heart, Lung, and Blood Institute (NHLBI). The HF-DMP involves proactive weekly monitoring, evaluation, and management, following National HF Guidelines. DCDS collects a wide variety of data including 7 elements considered standard of care for patients with heart failure: documentation of left ventricular function, tracking of weight and symptoms, medication titration, discharge instructions, 7 day follow up appointment post SNF discharge and patient education. We present the design and implementation of DCDS and describe our preliminary testing results.

Introduction: Information exchange is critical to high-quality care transitions from hospitals to post-acute care (PAC) facilities. We conducted a survey to evaluate the completeness and timeliness of information transfer and communication between a tertiary-care academic hospital and its related PAC facilities., Methods: This was a cross-sectional Web-based 36-question survey of 110 PAC clinicians and staff representing 31 PAC facilities conducted between October and December 2013., Results: We received responses from 71 of 110 individuals representing 29 of 31 facilities (65% and 94% response rates). We collapsed 4-point Likert responses into dichotomous variables to reflect completeness (sufficient vs insufficient) and timeliness (timely vs not timely) for information transfer and communication. Among respondents, 32% reported insufficient information about discharge medical conditions and management plan, and 83% reported at least occasionally encountering problems directly related to inadequate information from the hospital. Hospital clinician contact information was the most common insufficient domain. With respect to timeliness, 86% of respondents desired receipt of a discharge summary on or before the day of discharge, but only 58% reported receiving the summary within this time frame. Through free-text responses, several participants expressed the need for paper prescriptions for controlled pain medications to be sent with patients at the time of transfer., Discussion: Staff and clinicians at PAC facilities perceive substantial deficits in content and timeliness of information exchange between the hospital and facilities. Such deficits are particularly relevant in the context of the increasing prevalence of bundled payments for care across settings as well as forthcoming readmissions penalties for PAC facilities. Targets identified for quality improvement include structuring discharge summary information to include information identified as deficient by respondents, completion of discharge summaries before discharge to PAC facilities, and provision of hard-copy opioid prescriptions at discharge., (Copyright © 2016 AMDA – The Society for Post-Acute and Long-Term Care Medicine. Published by Elsevier Inc. All rights reserved.)

Skilled nursing facilities (SNFs) have emerged as an integral component of care for older adults with heart failure (HF). Despite their prominent role, poor clinical outcomes for the medically complex patients with HF managed in SNFs are common. Barriers to providing quality care include poor transitional care during hospital-to-SNF and SNF-to-community discharges, lack of HF training among SNF staff, and a lack of a standardized care process among SNF facilities. Although no evidence-based practice standards have been established, various measures and tools designed to improve HF management in SNFs are being investigated. In this review, we discuss the challenges of HF care in SNFs as well as potential targets and recommendations that can help improve care with respect to transitions, HF management within SNFs, and modifiable factors within facilities. Policy considerations that might help catalyze improvements in SNF-based HF management are also discussed., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: We report on a skilled nursing facility (SNF) that added designated heart failure (HF) beds and created a patient registry to track the number and reasons for rehospitalization., Background: Targeting the reduction of rehospitalizations from SNFs is an important goal and patients with HF are particularly vulnerable for rehospitalizations as HF disease management programs in SNFs are rare., Methods: A case study of a local quality improvement initiative., Results: The data from the registry revealed, that compared to patients without HF, patients with HF were more often rehospitalized for cardiopulmonary symptoms and less often for infection. In addition, patients with HF were most often rehospitalized during the first 7 days of their SNF stay and if they had a primary hospital discharge diagnosis of HF., Conclusion: We highlight the benefits of a patient registry to guide future quality improvement initiatives to reduce patient rehospitalization rates., (Copyright © 2016 Elsevier Inc. All rights reserved.)

DNA alkylating agents like nitrogen mustard (NM) are easily absorbed through the skin and exposure to such agents manifest not only in direct cellular death but also in triggering inflammation. We show that toxicity resulting from topical mustard exposure is mediated in part by initiating exaggerated host innate immune responses. Using an experimental model of skin exposure to NM we observe activation of inflammatory dermal macrophages that exacerbate local tissue damage in an inducible nitric oxide synthase (iNOS)-dependent manner. Subsequently these activated dermal macrophages reappear in the bone marrow to aid in disruption of hematopoiesis and contribute ultimately to mortality in an experimental mouse model of topical NM exposure. Intervention with a single dose of 25-hydroxyvitamin D3 (25(OH)D) is capable of suppressing macrophage-mediated iNOS production resulting in mitigation of local skin destruction, enhanced tissue repair, protection from marrow depletion, and rescue from severe precipitous wasting. These protective effects are recapitulated experimentally using pharmacological inhibitors of iNOS or by compounds that locally deplete skin macrophages. Taken together, these data highlight a critical unappreciated role of the host innate immune system in exacerbating injury following exposure to NM and support the translation of 25(OH)D in the therapeutic use against these chemical agents.

Importance: Low levels of vitamin D are associated with elevated blood pressure (BP) and future cardiovascular events. Whether vitamin D supplementation reduces BP and which patient characteristics predict a response remain unclear., Objective: To systematically review whether supplementation with vitamin D or its analogues reduce BP., Data Sources: We searched MEDLINE, CINAHL, EMBASE, Cochrane Central Register of Controlled Trials, and http://www.ClinicalTrials.com augmented by a hand search of references from the included articles and previous reviews. Google was searched for gray literature (ie, material not published in recognized scientific journals). No language restrictions were applied. The search period spanned January 1, 1966, through March 31, 2014., Study Selection: We included randomized placebo-controlled clinical trials that used vitamin D supplementation for a minimum of 4 weeks for any indication and reported BP data. Studies were included if they used active or inactive forms of vitamin D or vitamin D analogues. Cointerventions were permitted if identical in all treatment arms., Data Extraction and Synthesis: We extracted data on baseline demographics, 25-hydroxyvitamin D levels, systolic and diastolic BP (SBP and DBP), and change in BP from baseline to the final follow-up. Individual patient data on age, sex, medication use, diabetes mellitus, baseline and follow-up BP, and 25-hydroxyvitamin D levels were requested from the authors of the included studies. For trial-level data, between-group differences in BP change were combined in a random-effects model. For individual patient data, between-group differences in BP at the final follow up, adjusted for baseline BP, were calculated before combining in a random-effects model., Main Outcomes and Measures: Difference in SBP and DBP measured in an office setting., Results: We included 46 trials (4541 participants) in the trial-level meta-analysis. Individual patient data were obtained for 27 trials (3092 participants). At the trial level, no effect of vitamin D supplementation was seen on SBP (effect size, 0.0 [95% CI, -0.8 to 0.8] mm Hg; P=.97; I2=21%) or DBP (effect size, -0.1 [95% CI, -0.6 to 0.5] mm Hg; P=.84; I2=20%). Similar results were found analyzing individual patient data for SBP (effect size, -0.5 [95% CI, -1.3 to 0.4] mm Hg; P=.27; I2=0%) and DBP (effect size, 0.2 [95% CI, -0.3 to 0.7] mm Hg; P=.38; I2=0%). Subgroup analysis did not reveal any baseline factor predictive of a better response to therapy., Conclusions and Relevance: Vitamin D supplementation is ineffective as an agent for lowering BP and thus should not be used as an antihypertensive agent.