Search

ObjectiveAdvance care planning (ACP) is critically important for heart failure patients, yet important challenges exist. Group visits can be a helpful way to engage patients and caregivers in identifying values and preferences for future care in a resource-efficient way. We sought to evaluate the impact of group visits for ACP among older adults with heart failure and their caregivers on ACP-related outcomes.MethodsWe conducted a mixed-methods pilot study evaluating the impact of an ACP group visit for older adults with heart failure and their caregivers on ACP-related outcomes including readiness and self-efficacy. The evidence-based PREPARE for Your Care video-based intervention was used to guide the group visits. Twenty patients and 10 caregivers attended one of the five 90-min group visits led by a trained facilitator. Group visit participants completed pre-, post-, and 1-month follow-up surveys using validated 5-point ACP readiness and self-efficacy scales. Qualitative feedback obtained within 3 days of a group visit was analyzed using a directed content analysis.ResultsPatient participants had a median age of 78 years. Approximately half were female while caregiver participants were mostly female. Participants were predominantly white. Patient readiness scores improved significantly pre-to-post (+0.53; p = 0.002) but was not sustained at 1-month follow-up. Patient and caregiver self-efficacy showed some improvement pre-to-post but was also not sustained at follow-up. Interviews revealed positive impacts of group visits across the three themes: encouraging reviewing or revisiting prior ACP activities, motivating patients to take direct steps towards ACP, and serving as a "wake-up" call to action.ConclusionsDisease-focused group visits may have a short-term effect on ACP outcomes but ongoing touchpoints are likely necessary to sustain ACP over time. The results highlight a need for follow-up ACP conversations after a single group visit. Timing for follow-ups and the ideal person to follow-up ACP conversations needs to be explored.

BackgroundGroup visits have the potential to help patients identify their health care values and engage in the emotionally and cognitively challenging task of advance care planning (ACP) in a resource-efficient manner by providing a forum for social learning and social support.ObjectiveTo evaluate the feasibility and acceptability of disease-specific group visits for patients with heart failure and their caregivers.DesignFeasibility trial of a 90-minute group visit held for 10 separate groups and led by a trained facilitator using the video-based PREPARE for Your Care ACP tool.Setting/subjectsOlder adults with recent hospitalization for heart failure (n = 36; median age, 74 years) and their caregivers (n = 21).MeasurementsPre- and post-visit surveys and a postvisit telephone interview assessing perceived value and acceptability; structured nonparticipant observations to assess process and feasibility.ResultsMean scores from the postgroup visit evaluation showed that participants reported that they felt comfortable discussing ACP in a group (4.59), understood the information covered (4.70), and were able to identify and clarify their health care values (4.43). Interview and observation data demonstrated that participants were able to identify and clarify their preferences by listening and learning from a diverse range of perspectives in the group and that the disease-focused nature of the group visit created a supportive space for participants to share their experiences.ConclusionsDisease-focused ACP group visits were feasible to conduct and acceptable to participants, underscoring their value as an efficient intervention to engage patients and caregivers in the otherwise time- and resource-intensive task of ACP.

Introduction: People experiencing unsheltered homelessness (PEUH) have higher disease burden yet limited access to healthcare. COVID-19 introduced even greater risk for PEUH aged 65+ years with an underlying chronic health condition and were temporarily housed in hotels/motels for Project RoomKey (PRK). This study aimed to characterize a PRK cohort who received primary care from a street medicine program. Methods: This observational case series study included a sample of 35 PRK participants receiving primary care from a street medicine team at a single site from July to September 2020. We used the HOUSED BEDS assessment tool for taking history on PEUH. Results: Participants were 63% male, 40% Hispanic/Latino/a, 40% white, 94% English-speaking, and 73% had chronic health conditions. Assessment revealed: average Homelessness (H) of 4 years; 76% had no prior social service Outreach (O); average Utilization (U) was 4 emergency department visits in prior 6-months; 68% received Salary (S) from government income; Food access or Eat (E) was commonly purchased (29%) or donated (26%); clean water to Drink (D) for 59% of participants; 86% had access to a Bathroom (B); Encampment (E) was varied and 38% reported safety concerns; Daily routine (D) showed 76% could access a telephone, 32% received social support from family; 79% reported past or current Substance use (S). No participants contracted COVID-19 during study period. Conclusions: This study describes health and demographic characteristics of PRK participants in Southern California. Findings inform policies to continue PRK that includes onsite healthcare such as via street medicine. [ABSTRACT FROM AUTHOR]

Background: Home-based palliative care (HBPC) programs are proliferating across the U.S, yet face significant, documented challenges in promoting uptake of services and sustaining sufficient patient referrals. There is a huge need to understand effective methods for engaging physicians, patients, and caregivers in palliative care. Thus, the purpose of this study was to elicit successful practices on how to best communicate about HBPC to both healthcare providers and patients/caregivers. Method: Focus groups with nine California-based HBPC organizations were conducted between January and April 2020. Discussions lasted approximately 54 minutes, were guided by a semi-structured protocol, audio-recorded, and transcribed verbatim. Thematic analysis was used to identify themes and codes from the data. Results: Twenty-five interdisciplinary HBPC staff members participated in a focus group. Most identified as white (76%), female (76%), and working in their current position for 5 years or less (56%). Three themes were identified from the data: (1) value of relationships; (2) communication do's and don'ts; and (3) need for education. Participants discussed actionable recommendations for each theme. Discussion: Study findings highlight several successful practices for HBPC programs to communicate- and foster relationships with healthcare professionals and patients/families about palliative care, with education at the crux. Lessons learned about key words and phrases to say and to avoid are particularly valuable for budding HBPC programs. Our results suggest that HBPC providers exert enormous efforts to increase patient referrals and enrollment through strategic, continuous outreach and education to physicians, patients, and their caregivers; however, palliative care educational interventions are needed. Graphical Abstract [ABSTRACT FROM AUTHOR]

1. Describe the street medicine model of care, how it differentiates from other models, and where it sits on the continuum of care. 2. Identify the unique challenges faced by people experiencing unsheltered homelessness as they age and manage serious illness while living outside. This study elicited the street medicine clinician and patient perspective on aging and managing serious illness while experiencing unsheltered homelessness. Results highlight constraints placed on clinicians and patients by the rigid healthcare system and incompatibility with the unique circumstances of unhoused people and the street medicine model of care. Older adults experiencing homelessness constitute the fastest-growing segment of the homeless population in the US. Research has found older homeless adults to have more chronic conditions, greater odds of physical disability, and experience accelerated aging. Little is known about the role of street medicine in providing care and support to aged and aging unsheltered homeless patients. To elicit the perspective of clinicians and unsheltered homeless patients on aging and managing serious illness. Individual interviews with street medicine clinicians and patients receiving street medicine. Interviews were guided by a semi-structured research protocol developed by the team, audio recorded, and transcribed verbatim. Transcripts and field notes were analyzed by two independent coders following a thematic analysis approach. Eight clinicians from street medicine and eight patients were interviewed. On average, clinicians were 41 years old and identified as white (50%) females (50%) with varying experience in street medicine (1-16 years). Clinicians were multidisciplinary. Patients identified as male (63%), having 3+ chronic health conditions (100%), and aged on average 56 years. Thematic analysis of clinician interviews revealed four major themes: characteristics of older homeless adults, challenges, end-of-life conversations, and recommendations for improved support of older homeless adults. Overriding themes from the patient interviews were related to aging, illness, and the street medicine model of care. Clinician and patient perspectives on aging and serious illness while living outside offer insight into significant challenges faced when balancing the restrictive healthcare system with the needs of their patients/self. Results highlight constraints placed on clinicians and patients by the rigid healthcare system and incompatibility with the unique circumstances of unhoused people and the street medicine model of care. Findings from this study suggest actionable strategies that hold implications for policy and practice to better meet the needs of unsheltered homeless older adults. Scientific Research [ABSTRACT FROM AUTHOR]

The objective of this article is to test the effectiveness of a multifaceted exercise and nutritional education intervention for chronically ill, community-dwelling older adults. A pre/post cohort design was implemented with measures of physical activity, fitness, depression, and anthropometry collected via 4-month in-person interview and telephone follow-up. The study was conducted at two community-based senior centers in the Los Angeles area and participants (n=62) were older adults aged 60 or older, with multiple chronic conditions, with one or more emergency department visits or hospital admissions in the previous 6 months, and at nutritionally moderate to high risk. The intervention was a fitness program providing nutritional counseling, low-impact exercise, and weight management. Results revealed significant improvements for hours of weekly exercise (Z = −4.3, p < .001), daily walking distance (Z = −5.7, p < .001), performance on fitness tests, depression (Z = 3.9, p < .001), and body measurements were observed. Findings speak to the healthy benefits of exercise and good nutrition as possible alternatives or adjuncts to pharmacotherapy for weight loss and depression. [ABSTRACT FROM AUTHOR]

Objectives: To identify factors associated with physician referrals to end-of-life (EOL) care., Study Design: Cross-sectional, web-based survey., Methods: Participants were managed care physicians (n = 545) from the Southern California region of a national nonprofit health maintenance organization who treated a patient in their office within 6 months of the patient's death from a chronic condition. Measures included self-reports of referrals to EOL services, comfort level discussing EOL with patients, personal/family experience with hospice, and demographic characteristics., Results: Participants were most commonly US born (69.1%), married (83.8%), and male (66.0%) with a mean age of 47 years (SD = 8.9 years). About half were Caucasian (51.7%). Logistic regression revealed that family/internal medicine physicians were nearly 9 times more likely to make EOL referrals (95% confidence interval [CI] 3.879-19.434), and physicians comfortable discussing EOL care were nearly 7 times more likely to refer (95% CI 3.465-12.750). Younger age was significantly associated with EOL referrals; with every 1-year decrease in age, physicians were 5% more likely to refer (95% CI 0.911-0.985). Family/internal medicine physicians (95% CI 1.259-2.899) and those comfortable discussing EOL care (95% CI 2.964-9.685) were also more likely to make frequent (4 or more) referrals, Conclusions: This study highlights factors associated with EOL referrals that may be enhanced at the organizational level through training and educating physicians. Results suggest that organizations should work toward improving physician ease and comfort with EOL conversations. This study serves as an important step toward understanding and reducing physician-level barriers to EOL referrals.