Search

Medicare annual wellness visits (AWV) were initiated 10 years ago. Though AWVs emphasize on disease prevention and health promotion for older adults was a huge step forward, the current "one size fits all" approach does not adequately meet the wellness needs of a diverse population of older adults. Current AWVs do not sufficiently take into consideration the medical, psychological, functional, racial, cultural and socio-economic diversity of older adults. Updated AWVs should be tailored to meet the needs and priorities of older adults receiving them. Several geriatrics approaches to care, including geriatrics Glidepaths and the 4Ms of an Age-Friendly Health System, could help develop and guide a more patient-specific geriatrics focused approach to AWVs. Medicare's IPPE is an ideal time to advise new Medicare beneficiaries regarding what they should and should not do to maximize their ability to be healthy and functionally independent into their 80s, 90s, and 100s.

The largely rural setting of Northern New England offers unique challenges to implementing improved acute care for the growing geriatric population. Northern New England is one of the United States’ most rapidly aging regions, with Vermont and New Hampshire being the second and third oldest US states respectively by median age (U.S. Census 2017). There is a need to expand innovations in geriatric emergency medicine to reach older adults in rural areas such as Northern New England. Dartmouth-Hitchcock Medical Center and the West Health are collaborating on a project leveraging telehealth to extend the reach of a GED to rural hospitals, as well as investigate the opportunities for scaling and sustaining this concept to other rural facilities across Northern New England and throughout the country. This symposium will focus on our experience implementing a hub and spoke model to achieve our goal of improving the care of older adults in rural emergency departments.

Background Acute health care interventions for residents of skilled nursing facilities (SNFs) are often unwarranted, unwanted, and/or harmful. We describe a provider-focused care model to reduce unwarranted or unwanted acute health care utilization. Objective Assess the capability of the Reducing Avoidable Facility Transfers (RAFT) model to reduce unwanted and unwarranted acute health care utilization among residents in 3 rural SNFs between January 1, 2016 and June 30, 2017. Design Prospective cohort, pre/post study. Setting Three rural SNFs in collaboration with a geriatric practice in a tertiary academic medical center. Participants Post-acute care (PAC) and long-term care (LTC) residents of 3 rural SNFs. Intervention RAFT includes the following components: (1) a small team of providers who manage longitudinal care and after hours call; (2) elicitation of advance care plans and preferences regarding acute care; (3) standardized communication process engaging the provider at the identification of an acute care event; (4) a biweekly case review of all emergency department (ED) transfers. Measures ED and hospital utilization. Results RAFT demonstrated a 35% reduction in monthly ED transfers and a 30.5% reduction in monthly hospitalizations. These reductions were greatest for LTC residents. Conclusions/Implications The RAFT approach substantially reduced unwarranted ED and hospital utilization in this study. Results support replication and evaluation in a larger, more diverse setting and population.

As Americans live longer lives, we will see an increased demand for quality healthcare for older adults. Despite the growth in the number of older adults, there will be a decrease in the supply of a primary care physician workforce to provide adequately for their care and health needs. This article reviews the literature that explores ways to address the primary care workforce shortage in a community-based geriatric healthcare setting, with special attention to elevating the role of nurses and caregivers and shifting the way we think about delivery of care and end-of-life conversations and planning. The shift is toward a more integrated and collaborative approach to care where medical and nonmedical, social services, and community providers all play a role. Several models have demonstrated promising positive benefits and outcomes to patients, families, and providers alike. The goal is to provide high quality care that addresses the unique attributes of older adults, especially those with complex conditions, and to focus more on care goals and priorities. The many barriers to scaling and spreading models of care across varied settings include payment structures, lack of education and training among all stakeholders, and, at the top of the list, leadership resistance. We address these barriers and make recommendations for a path forward where healthcare providers, policymakers, patients, families, and everyone else involved can play a role in shaping the workforce caring for older adults. J Am Geriatr Soc 67:S400-S408, 2019.

The Health Resources and Services Administration created the Geriatric Workforce Enhancement Program (GWEP) in 2015 to address future geriatric workforce challenges and redefine the delivery of care to older adults. The John A. Hartford Foundation subsequently funded the GWEP Coordinating Center (GWEP-CC) to offer centralized, strategic support to these 44 diverse GWEP sites. This article outlines the last 3 years of GWEP work done at the national and local levels to transform geriatric care. Dissemination of the innovative Geriatric Interprofessional Team Transformation in Primary Care program, created by the Dartmouth GWEP, demonstrates how the GWEP-CC can benefit local initiatives and inform national perspectives. The GWEP-CC is a change agent in this way, scaling and distributing information and implementation support across the country. The GWEP-CC also serves as an essential repository of data, continuously determining what is working and what could be improved. This informs activity of the GWEP-CC, funders and other stakeholders, and provides the most up-to-date resources to GWEP sites and their partners. The GWEP-CC achieves its objectives through several key pillars: networking opportunities, education and training, advocacy, and evaluation. Although many advances have been made, opportunities to continue paving the way are plenty, especially with regards to mental health. This article discusses the work accomplished to date and presents some future considerations for mental health and overall healthcare transformation.

Interprofessional team care (ITC) and case management are essential to achieve the best patient-centred outcomes for complicated older adults with multiple comorbidities. Case management in geriatrics refers to a process of care coordination. Caring for complex geriatric patients with multiple chronic conditions requires the development and implementation of individualized, coordinated plans of care. Such plans of care often call for further evaluation, treatment, referrals, and patient or caregiver education, or both. Typically, this care coordination occurs in an interprofessional team of geriatric healthcare providers—which may include physicians, geriatric nurses, pharmacists, psychiatrists, therapists, and social workers. The components of good team care include effective communication, conflict resolution, understanding and respecting team member’s and responsibilities, and team governance. Formal training is necessary to achieve these skills. Providing efficient and effective team care is both challenging and critical in an environment of accountable care with a burgeoning over-85 population.

Interprofessional team care (ITC) and case management are essential to achieve the best patient-centred outcomes for complicated older adults with multiple comorbidities. Case management in geriatrics refers to a process of care coordination. Caring for complex geriatric patients with multiple chronic conditions requires the development and implementation of individualized, coordinated plans of care. Such plans of care often call for further evaluation, treatment, referrals, and patient or caregiver education, or both. Typically, this care coordination occurs in an interprofessional team of geriatric healthcare providers—which may include physicians, geriatric nurses, pharmacists, psychiatrists, therapists, and social workers. The components of good team care include effective communication, conflict resolution, understanding and respecting team member’s and responsibilities, and team governance. Formal training is necessary to achieve these skills. Providing efficient and effective team care is both challenging and critical in an environment of accountable care with a burgeoning over-85 population.

Background Frail elders in residential skilled nursing facilities (SNFs) have high rates of emergency department (ED) utilisation and hospitalizations. We sought to implement and iteratively specify an intervention to improve utilisation and cost outcomes for frail elders in rural SNFs. Objectives (1) To reduce unwanted and avoidable ED utilisation and hospitalizations; (2) to reduce related costs. Methods Adopting evidence based practices, we iteratively developed an implementation approach including the following key elements: (1) advanced directives; (2) a dedicated closed-call team of providers following SNF residents; (3) a biweekly case review of all ED referrals and hospitalizations; and (4) a standardised triage communication process. We conducted three PDSA cycles over a 6 month period and assessed clinical and cost outcomes using inferential statistics and statistical process control (SPC) methods. Results Three rural SNFs participated in the intervention from January-June 2016. Three PDSA cycles were conducted. Monthly hospital-based care utilisation for long term care (LTC) residents reduced from 10 to 3.3 episodes (p Conclusions This initial pilot was feasible, achieved significant outcomes, and is an example of the use of improvement methods to iteratively develop and optimise an implementation approach. This approach has potential to significantly impact outcomes, utilisation and cost and is worthy of continued study.

OBJECTIVE The authors describe characteristics, treatment, and acute service use associated with agitation and depression in dementia. METHODS Authors used retrospective chart review of symptoms, physician-level prescribing, and acute service use over 3 months for 2,487 physically frail older residents, including 1,836 with dementia, (mean age: 79.8 years) in 109 long-term care facilities, describing differences between uncomplicated dementia and three mutually exclusive subgroups of complicated dementia, including dementia with agitation-only, dementia with depression-only, and dementia with mixed agitation and depression. RESULTS Compared with the other subgroups, frail elderly patients with dementia complicated by mixed agitation and depression have the highest rate of hospitalization, the greatest number of medical diagnoses, and the greatest medical severity, and they receive the greatest number of psychiatric medications. Depression in dementia (either alone or mixed with agitation) was associated with greater prevalence of pain. CONCLUSIONS Dementia complicated by mixed agitation and depression accounts for over one-third of complicated dementia and is associated with multiple psychiatric and medical needs, intensive pharmacological treatment, and use of high-cost services. Research should target this complex, high-risk group to develop appropriate diagnostic criteria and effective treatment interventions.

Geriatric nurse practitioners (GNPs) often serve as clinical preceptors for nurse practitioner students. The Nursing Interest Group of the John A. Hartford Foundation's Geriatric Interdisciplinary Team Training Program recognized a need for a condensed guide that clarifies the role of a GNP preceptor. This guide uses information from the literature to clarify the role of the preceptor, offer suggestions for clinical teaching, provide guidance to determine expectations for student performance, and delineate the progression of a nurse practitioner student. This article reviews the contents of the guide and offers suggestions for its use in clinical practice. (Geriatr Nurs 2002;23:94-98)

Postburn deformities are common in the small finger. A boutonniere-like deformity may develop when no injury has been noted in the central slip of the extensor tendon. Attention to the anatomic differences of the fifth digit and principles of graft contraction make this deformity preventable. In the long-standing burn hyperextension deformity of the metacarpophalangeal joint, recurrence of the deformity may occur after reconstruction. Evaluation of extrinsic extensor tightness may indicate an alteration in the soft tissue-to-skeleton relationship. Composite tissue expansion of the tendon and overlying skin graft provides an alternative reconstruction method.

Geriatric interdisciplinary team training has long been a goal in health education with little progress. In 1997, the John A. Hartford Foundation funded eight programs nationally to create Geriatric Interdisciplinary Team Training (GITT) programs. Faculty trained 1,341 health professions students. The results of the evaluation, including presentation of new measures developed to assess interdisciplinary knowledge, are presented, and the implications of the program as a model of interdisciplinary education are discussed. Evaluation data from 537 student trainees are presented. At posttest, GITT trainees demonstrated improvement on all measures of attitudinal change, no change on the geriatric care planning measure, and a change in some of the questions on the test of team dynamics that varied by discipline. Changes were greatest for all the attitudinal measures with the self-reported Team Skills Scale indicating the most significant change—a change that is significant across medicine, nursing, and social work trainees.

Geriatric interdisciplinary team training (GITT) is an initiative funded by the John A. Hartford Foundation since 1995. Building from the substantial knowledge gained from the Veteran's Administration project in interdisciplinary team training and lessons from the Pew Foundation initiative, GITT was reconceived by the Foundation to address the need for teams in the care of older adults in the new era of managed care and health care cost containment. This training program has served to help us understand attitudes toward teams, how teams function, and how teams should be trained in the changing health care environment, where length of stay is dramatically different from the earlier team training projects. This introductory paper provides an overview of GITT, and the companion papers give detail of the GITT curricula, measures and lessons learned.

As part of the Geriatric Interdisciplinary Team Training (GITT) Program funded by the John A. Hartford Foundation, the authors of this article worked to create an instrument, the Trainee Test of Team Dynamics, to assess health care trainees' understanding of team dynamics. The Trainee Test of Team Dynamics is a five-question written test designed to capture GITT trainees' knowledge of team process and skills in addressing conflict that is administered after watching a five-minute videotape of a simulated interdisciplinary health care team meeting. The test was created to measure health professions students' abilities to recognize effective geriatric health care teams, to respond to effective and ineffective team behaviors, and to determine whether or not the team meeting achieved its purpose: to meet the patient's needs for an interdisciplinary care plan. Scripts and test items developed and tested by practitioners in social work, medicine, public health, nursing and others assured a product that compensated for differences in educational level and occupation, yet captured accurate and appropriate responses. The results reported here include an analysis of 740 trainees' baseline responses from the multi-site educational programs to determine the construct validity of the new measure.

Frail older patients-unlike younger persons in the health care system or even well elders-require complex care. Most frail older patients have multiple chronic illnesses. Optimum care cannot be achieved by following the paradigm of ongoing traditional health care, which emphasizes disease and cure. Because no one health care professional can possibly have all of the specialized skills required to implement such a model of health care delivery, interdisciplinary team care has evolved. This paper describes the roles of the participating team members in the context of interdisciplinary care for frail older adults. In addition, the challenges that occur when Geriatric Interdisciplinary (ID) Teams involved in providing care to frail older patients are identified and discussed.

The Geriatric Interdisciplinary Team Training (GITT) program, an educational intervention funded by The John A. Hartford Foundation of New York City, has trained more than 1800 health care professions students and clinicians throughout the United States. Evaluating the effectiveness of this training intervention has proven to be quite a challenge. Core measures were collected pre- and post-GITT training to evaluate student development as a result of GITT. This paper focuses on one of these core measures, the Test of Geriatric Interdisciplinary Care Planning (TGICP). This instrument, developed for the GITT program, is one mechanism created to test trainees' ability to develop an interdisciplinary plan of care. Using a case study methodology, this two-part instrument provides an innovative approach to quantifying and correlating responses from an interdisciplinary cohort of students. This paper will describe the development of the TGICP, including the creation and validation of the case studies, the framework for the questionnaire, and the coding and scoring mechanism created to evaluate trainee responses.

The authors describe characteristics, treatment, and acute service use associated with agitation and depression in dementia.Authors used retrospective chart review of symptoms, physician-level prescribing, and acute service use over 3 months for 2,487 physically frail older residents, including 1,836 with dementia, (mean age: 79.8 years) in 109 long-term care facilities, describing differences between uncomplicated dementia and three mutually exclusive subgroups of complicated dementia, including dementia with agitation-only, dementia with depression-only, and dementia with mixed agitation and depression.Compared with the other subgroups, frail elderly patients with dementia complicated by mixed agitation and depression have the highest rate of hospitalization, the greatest number of medical diagnoses, and the greatest medical severity, and they receive the greatest number of psychiatric medications. Depression in dementia (either alone or mixed with agitation) was associated with greater prevalence of pain.Dementia complicated by mixed agitation and depression accounts for over one-third of complicated dementia and is associated with multiple psychiatric and medical needs, intensive pharmacological treatment, and use of high-cost services. Research should target this complex, high-risk group to develop appropriate diagnostic criteria and effective treatment interventions.

WHY: Studies on pain in older adults (persons 65 years of age and older) have demonstrated that 25%45% of community dwelling older people have chronic pain. 45-85% of nursing home residents also report pain that is often left untreated. Although there is minimal research that strictly focuses on pain in older adults, studies with younger participants have elucidated associations between pain and depression. Increased pain has further resulted in decreased socialization, impaired ambulation and increased healthcare utilization and costs. Older adults are reluctant to report pain: therefore, nurses need to be proactive in screening for and assessing pain.

" t's time to start preparing for this year's flu season. The Centers for . Disease Control (CDC) say they are expecting two strains of type A Taiwan and Shanghai--and one strain of B--Yamagati. Both type A and type B virus produce a similar syndrome of fever, coryza, sore throat, myalgias, and nonproductive cough. Even a moderate epidemic may lead to more than 170,000 hospitalizations at a cost of $600 million dollars and 20,000 influenza-associated deaths in a single year(l). The CDC estimate 55,000 to 65,000 people died in last year's flu epidemic. Of these deaths, 90 percent were of people 65 and older or those with chronic health problems. Amantadine is one of the few drugs that" can help once an outbreak of flu occurs. It is specific to the type A virus, but plays a dual role during an influenza A epidemic: It can prevent the flu syndrome in uninfected people, and it can lower, morbidity in patients already infected with the virus. To be effective, amantadine should be started within 24 to 48 hours of the first sign of flu and continued until 24 to 48 hours after the last sign disappears.