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Motivating older adults to follow up with an outpatient clinician after discharge from emergency departments (ED) is beneficial yet challenging. We aimed to answer whether psychological needs for motivation and discrete emotions observed by care transition coaches would predict this behavioral outcome.Community-dwelling older adults following ED discharge were recruited from three EDs in two U.S. states. We examined home visit notes documented by coaches (N = 725). Retrospective chart reviews of medical records tracked participants' health care utilization for 30 days.Observed knowledge-based competence predicted higher likelihood of outpatient follow-up within 30 days, while observed sadness predicted a lower likelihood of follow-up within seven days following discharge. Moreover, participants who demonstrated happiness were marginally more likely to have an in-person follow-up within seven days, and those who demonstrated knowledge-based competence were more likely to have an electronic follow-up within 30 days.Knowledge-based competence and emotions, as observed and documented in coach notes, can predict older adults' subsequent outpatient follow-up following their ED-discharge.Intervention programs might encourage coaches to check knowledge-based competence and to observe emotions in addition to delivering the content. Coaches could also customize strategies for patients with different recommended timeframes of follow-up.

Neighborhood disadvantage reflects historic and ongoing systemic injustices. Without addressing these upstream social determinants of health, hospitals may face different risk profiles for important quality metrics. Our objective was to assess differences in hospital characteristics where the proportion of patients residing in severely disadvantaged neighborhoods was high vs low. Using Medicare fee-for-service claims between January 1, 2014 and November 30, 2014 (5,807,499 hospital stays), we calculated Area Disadvantage Share (ADS), the proportion of each hospital’s discharges to severely disadvantaged neighborhoods, for 4,528 hospitals. We examined hospital characteristics by distribution of ADS and by risk-adjusted 30-day readmission. Hospitals in the highest decile cared for a higher proportion of Black patients, were more often located in rural areas, and had higher patient risk of 30-day readmission compared to all other deciles. Hospitals face unequal burdens of neighborhood disadvantage, a factor distinct from other social determinants such as rurality.

Black Americans are disproportionately affected by dementia. To expand our understanding of mechanisms of this disparity, we look to Alzheimer's disease (AD) biomarkers. In this review, we summarize current data, comparing the few studies presenting these findings. Further, we contextualize the data using two influential frameworks: the National Institute on Aging-Alzheimer's Association (NIA-AA) Research Framework and NIA's Health Disparities Research Framework. The NIA-AA Research Framework provides a biological definition of AD that can be measured in vivo. However, current cut-points for determining pathological versus non-pathological status were developed using predominantly White cohorts-a serious limitation. The NIA's Health Disparities Research Framework is used to contextualize findings from studies identifying racial differences in biomarker levels, because studying biomakers in isolation cannot explain or reduce inequities. We offer recommendations to expand study beyond initial reports of racial differences. Specifically, life course experiences associated with racialization and commonly used study enrollment practices may better account for observations than exclusively biological explanations.

We assessed fidelity of delivery and participant engagement in the implementation of a community paramedic coach-led Care Transitions Intervention (CTI) program adapted for use following emergency department (ED) visits.The adapted CTI for ED-to-home transitions was implemented at three university-affiliated hospitals in two cities from 2016 to 2019. Participants were aged ≥60 years old and discharged from the ED within 24 hours of arrival. In the current analysis, participants had to have received the CTI. Community paramedic coaches collected data on program delivery and participant characteristics at each transition contact via inventories and assessments. Participants provided commentary on the acceptability of the adapted CTI. Using a multimethod approach, the CTI implementation was assessed quantitatively for site- and coach-level differences. Qualitatively, barriers to implementation and participant satisfaction with the CTI were thematically analyzed.Of the 863 patient participants, 726 (84.1%) completed their home visits. Cancellations were usually patient-generated (94.9%). Most planned follow-up visits were successfully completed (94.6%). Content on the planning for red flags and post-discharge goal setting was discussed with high rates of fidelity overall (95% and greater), while content on outpatient follow-up was lower overall (75%). Differences in service delivery between the two sites existed for the in-person visit and the first phone follow-up, but the differences narrowed as the study progressed. Participants showed a 24.6% increase in patient activation (i.e., behavioral adoption) over the 30-day study period (Community paramedic coaches delivered the adapted CTI with high fidelity across geographically distant sites and successfully facilitated participant engagement, highlighting community paramedics as an effective resource for implementing such patient-centered interventions.

Patients identifying as Black and those living in rural and disadvantaged neighborhoods are at increased risk of major (above-ankle) leg amputations owing to diabetic foot ulcers. Intersectionality emphasizes that the disparities faced by multiply marginalized people (eg, rural US individuals identifying as Black) are greater than the sum of each individual disparity.To assess whether intersecting identities of Black race, ethnicity, rural residence, or living in a disadvantaged neighborhood are associated with increased risk in major leg amputation or death among Medicare beneficiaries hospitalized with diabetic foot ulcers.This retrospective cohort study used 2013-2014 data from the US National Medicare Claims Data Database on all adult Medicare patients hospitalized with a diabetic foot ulcer. Statistical analysis was conducted from August 1 to October 27, 2021.Race was categorized using Research Triangle Institute variables. Rurality was assigned using Rural-Urban Commuting Area codes. Residents of disadvantaged neighborhoods comprised those living in neighborhoods at or above the national 80th percentile Area Deprivation Index.Major leg amputation or death during hospitalization or within 30 days of hospital discharge. Logistic regression was used to explore interactions among race, ethnicity, rurality, and neighborhood disadvantage, controlling for sociodemographic characteristics, comorbidities, and ulcer severity.The cohort included 124 487 patients, with a mean (SD) age of 71.5 (13.0) years, of whom 71 286 (57.3%) were men, 13 100 (10.5%) were rural, and 21 649 (17.4%) identified as Black. Overall, 17.6% of the cohort (n = 21 919), 18.3% of rural patients (2402 of 13 100), and 21.9% of patients identifying as Black (4732 of 21 649) underwent major leg amputation or died. Among 1239 rural patients identifying as Black, this proportion was 28.0% (n = 347). This proportion exceeded the expected excess for rural patients (18.3% - 17.6% = 0.7%) plus those identifying as Black (21.9% - 17.6% = 4.3%) by more than 2-fold (28.0% - 17.6% = 10.4% vs 0.7% + 4.3% = 5.0%). The adjusted predicted probability of major leg amputation or death remained high at 24.7% (95% CI, 22.4%-26.9%), with a significant interaction between race and rurality.Rural patients identifying as Black had a more than 10% absolute increased risk of major leg amputation or death compared with the overall cohort. This study suggests that racial and rural disparities interacted, amplifying risk. Findings support using an intersectionality lens to investigate and address disparities in major leg amputation and mortality for patients with diabetic foot ulcers.

OBJECTIVE: Although individual-level social determinants of health (SDH) are known to influence 30-day readmission risk, contextual-level associations with readmission are poorly understood among children. This study explores associations between neighborhood disadvantage measured by Area Deprivation Index (ADI) and pediatric 30-day readmissions. METHODS: This retrospective cohort study included discharges of patients aged

Background: Social environments are a contributing determinant of health and disparities. This scoping review details how social environments have been operationalized in observational studies of cognitive aging and dementia. Methods: A systematic search in PubMed and Web of Science identified studies of social environment exposures and late-life cognition/dementia outcomes. Data were extracted on (1) study design; (2) population; (3) social environment(s); (4) cognitive outcome(s); (5) analytic approach; and (6) theorized causal pathways. Studies were organized using a 3-tiered social ecological model at interpersonal, community, or policy levels. Results: Of 7802 non-duplicated articles, 123 studies met inclusion criteria. Eighty-four studies were longitudinal (range 1–28 years) and 16 examined time-varying social environments. When sorted into social ecological levels, 91 studies examined the interpersonal level; 37 examined the community/neighborhood level; 3 examined policy level social environments; and 7 studies examined more than one level. Conclusions: Most studies of social environments and cognitive aging and dementia examined interpersonal factors measured at a single point in time. Few assessed time-varying social environmental factors or considered multiple social ecological levels. Future studies can help clarify opportunities for intervention by delineating if, when, and how social environments shape late-life cognitive aging and dementia outcomes.

Patient socioeconomic data is not usually included in medical records nor easily accessible to clinicians, yet socioeconomic disadvantage can be an important guide to disease management. This study evaluated the neighborhood-level Area Deprivation Index (ADI), a measure of neighborhood socioeconomic disadvantage, as a factor in diabetes mellitus prevalence. Electronic health records at an academic hospital system identified 4,770 Medicare beneficiaries. Logistic regression of diabetes diagnosis (ICD9=250.x) against ADI quintile, age, gender, and race/ethnicity found all these patient characteristics to be significantly associated. Diabetes prevalence was lowest in the least disadvantaged quintile of neighborhoods after adjusting for age, gender, and race/ethnicity. The positive non-linear association of diabetes prevalence with ADI demonstrates the power of this index to practically quantify socioeconomic disadvantage. The ADI may be suitable for clinical decision support, and for informing the policy changes which are needed to reduce socioeconomic disparities in diabetes prevalence and other health outcomes.

BACKGROUND/OBJECTIVE: Older adults frequently use the emergency department (ED) for care, but the ED-to-home transition often goes poorly, with up to 20% experiencing adverse outcomes, including return to the ED for further care. We describe a novel model of care that uses community-based paramedics to deliver a modified version of the evidence-based hospital-to-home Care Transitions Intervention (CTI) to a new context: the ED-to-home transition. DESIGN: Single blinded randomized controlled trial. SETTING: Three EDs in two cities. PARTICIPANTS: Through June 2017, 422 patients discharged home from the EDs who were consented and randomized to receive the modified CTI. INTERVENTION: We modified the hospital-to-home CTI, applying it to the ED-to-home transition and delivering services through community paramedics, thus allowing the program to benefit from the unique attributes of paramedics to deliver care. MEASUREMENTS: Through surveys of participants, medical record review, and documentation of activities by CTI coaches, we characterize the participants and program, including feasibility and acceptability. RESULTS: The median age of patient participants was 70.7 years; 241 (57.1%) subjects were female; and 385 (91.2%) were white. Coaches successfully completed 354 (83.9%) home visits and 92.7%, 90.9%, and 85.8% of planned telephone follow-up for call 1, 2, and 3, respectively. We found high levels of acceptability among participants, with most patients (76.2%) and caregivers (83.1%) reporting themselves likely or extremely likely to choose an ED featuring the CTI Program in the future. Coaches reported delivering expected services during patient contact at least 88% of the time. CONCLUSION: While finalized conclusions about program effectiveness must await the results of the randomized controlled trial, the findings reported here are promising and provide preliminary support for an ED-to-home CTI Program’s ability to improve patient outcomes. The coaches’ identity as community paramedics is particularly noteworthy, as this is a unique role for this provider type.

To examine 1-year mortality and healthcare payments of stroke patients experiencing zero, one and two or more bounce-backs within 30 days of discharge.Retrospective analysis of administrative data.Four hundred twenty-two hospitals in the southern and eastern United States.Eleven thousand seven hundred twenty-nine Medicare beneficiaries aged 65 and older surviving at least 30 days with acute ischemic stroke in 2000.One-year mortality and predicted total healthcare payments were calculated using log-normal parametric survival analysis and quantile regression, respectively. Models included sociodemographics, prior medical history, stroke severity, length of stay, and discharge site.Crude survival at 1 year for the zero, one and two or more bounce-back groups was 83%, 67%, and 55%, respectively. The one bounce-back group had 49% shorter (time ratio (TR)=0.51, 95% confidence interval (CI)=0.46-0.56) and the two or more bounce-backs group had 68% shorter (TR=0.32, 95% CI=0.27-0.38) adjusted 1-year survival time than the zero bounce-back group. For high- and low-cost patients, adjusted predicted payments were greater with each additional bounce-back experienced.Acute stroke patients experiencing bounce-backs within 30 days have strikingly poorer survival and higher healthcare payments over the subsequent year than their counterparts with no bounce-backs. Bounce-backs may serve as a simple predictor for identifying stroke patients at extremely high risk for poor outcomes.

To identify predictors of complicated transitions within 30 days after discharge from hospitalization for acute stroke.Retrospective analysis of administrative data.Four hundred twenty-two hospitals in the southern and eastern United States.Thirty-nine thousand three hundred eighty-four Medicare beneficiaries aged 65 and older discharged after acute ischemic stroke from 1998 to 2000.Complicated transition, defined as movement from less- to more-intensive care setting after hospital discharge, with hospital being most intensive and home without home health care being least intensive.Twenty percent of patients experienced at least one complicated transition; 16% of those experienced more than one complicated transition. After adjustment using logistic regression, factors predicting any complicated transition included older age, African-American race, Medicaid enrollment, prior hospitalization, gastrostomy tube, chronic disease, length of stay, and discharge site. Patients with multiple complicated transitions were more likely to be African American (odds ratio (OR)=1.38, 95% confidence interval (CI)=1.13-1.68), be male (OR=1.21, 95% CI=1.04-1.40), have a prior diagnosis of fluid and electrolyte disorder (e.g., dehydration) (OR=1.23, 95% CI=1.07-1.43), have a prior hospitalization (OR=1.18, 95% CI=1.01-1.36), and be initially discharged to a skilled-nursing facility or long-term care (OR=1.22, 95% CI=1.04-1.44) than patients with only one complicated transition. They were less likely to be initially discharged to a rehabilitation center (OR=0.71, 95% CI=0.57-0.89).Significant numbers of stroke patients experience complicated transitions soon after hospital discharge. Sociodemographic factors and initial discharge site distinguish patients with multiple complicated transitions. These factors may enable prospective identification and targeting of stroke patients at risk for "bouncing back."