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The purpose of this concept analysis is to address fundamental gaps in the understanding of self-efficacy in family caregivers of older adults with cognitive impairment, including updating the 26-year-old concept analysis with a contemporary definition. With the first of the baby boomers set to turn 75 in 2021, the growing number of Americans with Alzheimer’s disease is predicted to more than double over the next 30 years, while the pool of potential family caregivers is likely to diminish by half. Research demonstrates that increased self-efficacy can help family caregivers of older adults with Alzheimer’s and other types of cognitive impairment experience lower burden and depressive symptom severity. This study utilized Walker and Avant’s method of concept analysis, an eight-step iterative process that helps to clarify the meaning of ambiguous concepts. A literature review was conducted from July 1993 through March 2019 using PubMed/MEDLINE, Scopus, CINAHL, and Embase. Eight defining attributes of this concept were identified. The revised definition of self-efficacy in this population is “a family caregiver’s confidence in their ability to: manage behaviors and other caregiving stresses, control upsetting thoughts, acquire medical information, manage medical issues, obtain self-care, access community supports, assist with activities of daily living and other care, and maintain a good relationship with a relative, friend, or neighbor of an older adult with cognitive impairment.” Practice implications include tailoring interventions to improve family caregiver self-efficacy. Policy implications include fostering evidence-based health strategies through payment and delivery incentives that further support caregiver self-efficacy.

The Transitional Care Model (TCM) has been rigorously tested in multiple clinical trials but the adoption of this EBI has been one system at a time. The purpose of the first study was to describe key themes important to the decision to adopt the evidence-based interventions (EBIs) and, more specifically, the Transitional Care Model (TCM). A National Advisory Committee (NAC) with representation from providers, payers (public and private) and purchasers were interviewed and transcripts were analyzed using conventional content analyses. Key factors influencing decision making included: 1) the view that “my population” is different; 2) the central role of incentives (specifically payment); 3) beliefs about the value of evidence; and 4) the influence of peers. Factors influencing decision making to adopt EBIs such as the TCM are multidimensional. Understanding the perspectives of decision makers (i.e., providers, payers, and purchasers) is essential to promote adoption of EBIs such as the TCM.

To evaluate the potential of a TCM policy flight simulator to engage individual health systems in making informed decisions regarding the adoption of TCM and increase their confidence in the decision to adopt. The TCM policy flight simulator was developed using TCM data and multiple publically available datasets and guided by the qualitative study findings. The TCM simulator was well received by all decision makers. Findings from the presentation of the TCM simulator support the value of additional tailoring to fit each organization’s unique circumstances. Such tailoring would further increase decision makers’ confidence regarding adoption of the TCM. Key lessons learned will be presented. The use of simulation provides a systematic tool to explore the implications and suitability of adopting the TCM for a particular organization prior to actually implementing it.

To address a gap in the transitional care (TC) literature, Project ACHIEVE established a multi-stakeholder workgroup to recommend essential components for the TC care of vulnerable older adults. Guided by a review of published evidence, the workgroup identified and defined a preliminary set of TC components. Next, each TC component was compared with real-world patients’ and caregivers’ experiences. Ultimately, eight TC components were identified: patient engagement, caregiver engagement, complexity and medication management, patient education, caregiver education, patients’ and caregivers’ well-being, care continuity, and accountability. This session will define each component, describe the rationale for inclusion and describe how collectively, the eight components provide a framework for improving and evaluating high value TC.

For the foreseeable future, chronic illness will be the major health challenge confronting the U.S. The Transitional Care Model (TCM) is a proven care management approach that contributes to a more person-centered, effective and efficient response to this challenge. Despite TCM’s proven value, uptake of the TCM continues to be achieved slowly. One promising strategy to accelerate uptake of the TCM is the use of a “policy flight simulator”. Policy flight simulators fuse aspects of multiple scientific disciplines with visualization to provide decision makers with a comprehensive understanding of the consequences of interventions for each major stakeholder. This symposium is designed to: describe the factors most important to key decision makers in healthcare, to examine the potential usefulness of the TCM policy flight simulator as a tool in making decisions to implement the TCM, and to explore what happens when the TCM policy flight simulator is applied using data for 3000+ U.S. hospitals. Paper one includes background of both the TCM as well as qualitative findings from individual and group discussions held with a National Advisory Committee (NAC)—comprised of decision makers representing providers, payers and purchasers. Paper two presents the use of the qualitative findings combine with data from multiple TCM studies and publicly available sources to develop a TCM policy flight simulator. Finally, paper three provides application of the TCM Policy flight simulator to available public data to determine the financial attractiveness of adopting the TCM.

The purpose of this study was to examine the predictors of excessive daytime sleepiness (EDS) over the first two years of long-term services and supports (LTSS) for 470 older adults in assisted living communities (ALCs), nursing homes (NHs), or their homes. Mixed effects linear regression modeling using a backward elimination process was used to build a final multivariable model. In the final model, being female (p

Long-term services and supports (LTSS), delivered by home and community-based services [HCBS], assisted living facilities [ALF] and nursing homes [NH]), are provided to nearly six million frail older adults in the US. Physical and cognitive decline are common among LTSS recipients. However, predictors of health care transitions (i.e., to hospitals, emergency departments, skilled nursing facilities or rehabilitation centers) among this population are poorly understood. The purpose of this study was to examine predictors of health care transitions among a cohort of 470 new LTSS recipients using data collected quarterly over two years. Using multivariable Poisson regression modeling within a generalized estimating equation framework, the mean number of care transitions over the two year period was 3.1 (median=2). New NH and ALF recipients experienced fewer transitions over time, while the transitions’ profile for new HCBS recipients remained stable over time (p

This session will describe findings from the study’s qualitative phase designed to explore expert practitioners’ perceptions of the rationale for adapting the TCM. Study investigators developed a questionnaire, interviewed 26 purposefully-selected TCM practitioners from the Phase I survey, conducted thematic analysis and described the characteristics and value of common contextual and content adaptations. Contextual adaptations were common. The TCM was commonly delivered by registered nurses and in a variety of settings (e.g., hospitals, integrated health systems, home care, etc.). Content adaptations also were common. Most often, visits were provided for higher-risk patients during hospital to home transitions but separate staff provided hospital and home services. Respondents offered diverse goals for adapting the TCM including: expanding the reach of services, engaging patients, and collaborating with multiple clinicians. All respondents anticipated future TC program growth. Findings suggest the need to rigorously evaluate the effects of adaptations on health and cost outcomes.

The Patient-Centered Medical Home (PCMH) and the Transitional Care Model (TCM) are among the few care management approaches that have targeted chronically ill adults and demonstrated improvements in multiple dimensions of patients’ health, while decreasing costs. With the guidance a multi-stakeholder advisory group including nationally recognized experts and in collaboration with partnering primary care clinicians, a PCMH+TCM intervention was designed and pilot tested. 54 patients were enrolled in the PCMH+TCM group and 25 patients enrolled in the PCMH only group. Data on patient outcomes and resource use were collected at enrollment, 1-, 3-, 6- and 12-months. Propensity score weighted mixed effects and Cox proportional hazard models were used to compare the PMCH+TCM vs. PCMH only groups on outcomes. The PCMH+TCM group demonstrated improvements in emotional health (decreased depression) and quality of life over time when compared to the PCMH only group. For a subset of patients with hospitalizations in the 30 days prior to enrollment (N=36), the PCMH+TCM group (n=15) had a longer time to first rehospitalization than the PCMH only group (n=21). 25% of the PCMH+TCM group were rehospitalized by day 228 vs. day 27 for the PCMH only group. The hazard of being rehospitalized in the PCMH+TCM group was 40% lower than the PCMH only group. While the effect size was strong, small sample sizes influence the power to detect statistically significant differences. Findings from this pilot suggest that this co-management care model can improve patient reported outcomes and reduce costly resource use among at-risk, community-dwelling older adults.

Decisions about who should be referred for post-acute care (PAC) are made by individual clinicians or teams for 14 million older adults per year, without national standards or guidelines. Using teams of multi-disciplinary experts we built a decision support (DS) tool that assists clinicians with these important decisions. The DS is based on two algorithms calculated from the characteristics of the patient during the hospital stay and provides a suggestion of refer or not, and which site of care is recommended. We will describe the development and testing of live DS in two hospitals. When the tool said to refer and patients did not get referred, readmission risk and ED use were 40% and 43% higher respectively, than those who did get referred. Use of DS can assure that high risk patients are identified and referred for PAC.

BACKGROUND AND OBJECTIVES: To identify determinants of self-reported physical functioning (PF) among older adults new to long-term services and supports (LTSS). RESEARCH DESIGN AND METHOD: Using the International Classification of Function, Disability, and Health (ICF) framework, we conducted a secondary analysis of self-reported data on symptoms, basic/instrumental activities of daily living, quality of life, assistive devices, physical therapy needs, prior healthcare utilization, health status, and demographics from 470 older adults new to LTSS (Home/Community-Based n = 156; Assisted Living n = 156; Nursing Home n = 158). Multiple linear regression was used to identify associations between ICF constructs and self-reported PF (SF-12 Physical Composite Summary score [SF12PCS], lower scores indicate worse PF). RESULTS: LTSS recipients were mostly female (71%) and over age 80 (Mean: 80.9 years, SD: 8.7). LTSS recipients’ mean SF12PCS score was 37.3 (SD 11.0), indicating overall low self-reported PF. LTSS recipients living in their homes (b = −3.35, p = .003) or assisted living facilities (b = −2.93, p = .012) had significantly lower mean scores compared to recipients in nursing homes. Higher SF12PCS scores were associated with fewer activities of daily living deficits (p < .001), and better quality of life (p < .001). Lower scores were associated with more symptoms (p < .001), poorer nutrition (p = .013), ambulation aid use (p < .001), and physical therapy (p < .026). DISCUSSION AND IMPLICATIONS: Diverse health, activity, and environmental factors may facilitate early identification of new LTSS recipients most in need of interventions to optimize self-reported PF. Several health conditions may be targets for such interventions. Additional research is needed to evaluate and compare PF trajectories among older adults receiving LTSS in diverse settings.

Long term services and supports (LTSS) are vital for older adults with physical and cognitive disabilities. LTSS can be provided in settings such as nursing homes, assisted living, or via community-based services. The aim of this study is to describe the perceived needs for older adults new to LTSS, examine whether those needs are met in the first three months of LTSS, and determine the relationship with quality of life (QoL). This secondary analysis included data from 470 older adults new to LTSS (average age: 81, 71% female, 51% white, 35% black, 20% Hispanic.) The main outcome of QoL was measured using a single item (“How would you rate your overall quality of life at the present time?”). Perceived needs included supportive equipment devices, transportation, physical therapy, and social activities. Analyses at baseline and three months included t-tests, ANOVAs and simple regression modeling. LTSS recipient reported needs at baseline were: 29% supportive equipment, 31% transportation, 20% physical therapy, and 25% social activities. Those who reported needs at baseline had a lower QoL than those who reported no needs (for all). At three months reported needs decreased by an average of 6% (range: 3%-10%). QoL ratings were associated with changes in physical therapy and social activities needs at three months. The implications of these results related to LTSS recipients’ QoL in the first three months of services, with emphasis on physical therapy and social activities needs, is an opportunity to be more person-centered in delivery of care.

Close to 50% of adults over age 65 years have three or more chronic illnesses and over 20% live with more than five chronic conditions (G. Anderson & Horvath, 2002). Comorbidity is associated with numerous adverse effects including poor quality of life, polypharmacy and increased adverse drug events, increased use of health care resources, increased mortality, and caregiver (CG) burden (Boyd et al., 2007; Gijsen et al., 2001; McGlynn et al., 2003). The posthospitalization period is an extremely vulnerable time for these individuals. Cognitive impairment (defined in this study as a diagnosis of dementia or delirium or as deficits in orientation, recall, or executive function) is one of the most common comorbidities seen in an older adult population, and its presence compounds the management as well as the complications associated with multiple illnesses, including a greater risk for morbidity, preventable rehospitalizations, and decreased survival (Feil, Marmon, & Unuizer, 2003; Zuccala et al., 2003). Research has also demonstrated that chronic cognitive impairment typically worsens during hospitalization for a variety of reasons, that delirium is also highly prevalent in hospitalized elderly individuals, and that preexisting cognitive impairment can increase hospitalized patients’ level of vulnerability to adverse events as well as CG burden and CG stress posthospitalization (Bell, Araki, & Neumann, 2001; Inouye, 2006). To address the issues surrounding an increasingly elderly population and test strategies for reducing the adverse effects of hospitalization for cognitively impaired older adults, we conducted a study of an advanced practice nurse (APN)-led Transitional Care Model (TCM; M. Naylor et al., 1994; M. D. Naylor et al., 1999, 2004) intervention. The TCM has been tested with cognitively intact older adults in previous research (M. Naylor et al., 1994; M. D. Naylor et al., 1999, 2004); in this article, we report the findings of an exploratory, qualitative descriptive content analysis focused on the barriers and facilitators associated with implementing this model in a population of cognitively impaired older adults and their family CGs.