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Introduction: Older adults often have multiple comorbidities; therefore, they are at high risk for adverse events after discharge. The 4Ms framework—what matters, medications, mentation, mobility—has been used in acute and ambulatory care settings to identify risk factors for adverse events in older adults, although it has not been used in the emergency department (ED).Weaimed to determine whether 1) use of the 4Ms worksheet would help emergency clinicians understand older adult patients’ goals of care and 2) use of the worksheet was feasible in the ED.Methods: We conducted a qualitative, descriptive study among patients aged ≥60 years and emergency clinicians from January–June 2022. Patients were asked to fill out a 4Ms worksheet; following this, semi-structured interviews were conducted with patients and clinicians separately. We analysed data to create codes, which were divided into categories and sub-categories.Results: A total of 20 older patients and 19 emergency clinicians were interviewed. We identified two categories based on our aims: understanding patient goals of care (sub-categories: clinician/ patient concordance; understanding underlying goals of care; underlying goals of care discrepancy) and use of 4Ms Worksheet (sub-categories: worksheet to discussion discrepancy; challenges using worksheet; challenge completing worksheet before discharge). Rates of concordance between patient and clinician on main concern/goal of care and underlying goals of care were 82.4% and 15.4%, respectively.Conclusion: We found that most patients and emergency clinicians agreed on the main goal of care, although clinicians often failed to elicit patients’ underlying goal(s) of care. Additionally, many patients preferred to have the interviewer fill out the worksheet for them. There was often discrepancy between what was written and what was discussed with the interviewer. More research is needed to determine the best way to integrate the 4Ms framework within emergency care.

In response to rising costs associated with providing health care services to Americans over 65 years old, policymakers have called for the expansion of care coordination programs to reduce total spending while improving patient outcomes and provider efficiency. This study uses a Markov Chain model to estimate financial impacts associated with the implementation of a care coordination program across the state of Iowa. Estimates revealed an association between the implementation of the Iowa Return to Community (IRTC) and a reduction in health care service use, which yielded per capita cost savings of $7,920.24 over a 5-year span. Subgroup analysis showed that inclusion of informal care partners enhances these savings, as they contributed to reduced inpatient hospital use and deferred nursing home admissions. The continued expansion of the IRTC appears as a viable strategy to curtail aggregate health care spending while supporting older adults stay at home. [ABSTRACT FROM AUTHOR]

Unpaid/family caregivers provide support critical to older adult hospital-to-home transitions, but lack time and preparation. There is limited evidence regarding important collaboration for caregivers during the transition. The objective was to examine caregivers' process of collaborating with others, including other family members, healthcare professionals, and community, social, and professional networks, during older adult hospital-to-home transitions. This study utilized grounded theory methodology. One-on-one interviews were conducted with unpaid/family caregivers of an older adult during a hospital-to-home transition. Data were analyzed using open, axial, and selective coding. Participants (N = 16) relationship to the older adult included: partners (n = 8), friends (n = 4), children (n = 3), and siblings (n = 1). Most were female (n = 14) and living with the older adult (n = 10). A conceptual model was developed which illustrates participants' process through 3 stages: 1) identifying and learning the caregiver role, 2) collaborating with others to provide care and support to the older adult, while supporting themselves, during the hospital-to-home transition, and 3) supporting the older adult's progress in recovering independence or planning to provide long-term care and support. Participants described multiple approaches to collaborating with others: caring on own, caring in network, caring with healthcare professionals, and caring with social and professional networks. Implications include the need to recognize and promote utilization of care networks, as it may help address negative outcomes associated with caregiving. We also identified opportunities to further leverage caregivers' social/professional networks and increase focus on caregiver needs in healthcare encounters. [ABSTRACT FROM AUTHOR]

Purpose: To test a pilot home-telehealth program to enhance functional ability, physical performance, and objective physical activity in Veterans after hospital discharge. Method: A physical activity trainer and multidisciplinary team supported the progression of rehabilitation goals via a 6-month home exercise program. Pilot program feasibility, including recruitment, retention, reasons for early withdrawal, differences between those who did and did not complete the program, and completion of outcome measures are reported. Outcomes include changes in functional ability, physical performance, and physical activity (using actigraphy) from baseline to endpoint. Results: Twenty-one of 45 Veterans enrolled did not complete the 6-month program. No baseline differences were found comparing completers and non-completers. The majority of completers (n = 24) were White men with a mean age of 74 years (SD = 8 years, range = 64 to 93 years) and included those with no (n = 8), mild (n = 13), and moderate (n = 3) cognitive impairment. Although there were borderline improvements in functional ability and physical performance from baseline to endpoint, mean steps per day increased from 2,206 (SD = 1,780) to 3,888 (SD = 2,895) (p = 0.04). Conclusion: The pilot home-telehealth program is feasible and may address declines in function and activity observed during hospital-to-home transitions, including among those with cognitive impairment. [Research in Gerontological Nursing, 17(6), 271–279.] [ABSTRACT FROM AUTHOR]

We evaluated the Iowa Return to Community, a service demonstration designed to coordinate care and reduce preventable healthcare utilization among at-risk older persons living at home in rural communities. During 2021, 262 older persons elected to participate in the IRTC program. Individuals who participated were more likely to live in micropolitan areas (OR = 2.30, 95% CI 1.34–3.95) relative to metropolitan locations. Individuals who used recommended services were more likely to be men (OR 3.65, 95% CI 1.16–11.51) and more likely to live in rural (OR 17.48, 95% CI 1.37–223.68) and micropolitan areas (OR 3.17, 95% CI 1.00–10.05). However, prevention of health care use corresponded more with consistent and prolonged IRTC program engagement rather than volume of service use. The IRTC constitutes a population aging and rural health strategy to reduce unnecessary health care use while supporting individual preferences to remain at home. [ABSTRACT FROM AUTHOR]

Background and Objectives Little is known about how older adults engage with multiple sources of support and resources during transitions from hospital to home, a period of high vulnerability. This study aims to describe how older adults identify and collaborate with a support team, including unpaid/family caregivers, health care providers, and professional and social networks, during the transition. Research Design and Methods This study utilized grounded theory methodology. One-on-one interviews were conducted with adults aged 60 and older following their discharge from a medical/surgical inpatient unit in a large midwestern teaching hospital. Data were analyzed using open, axial, and selective coding. Results Participants (N  = 25) ranged from 60 to 82 years of age, 11 were female, and all participants were White, non-Hispanic. They described a process of identifying a support team and collaborating with that team to manage at home and progress their health, mobility, and engagement. Support teams varied, but included collaborations between the older person, unpaid/family caregiver(s), and their health care providers. Their collaboration was impacted by the participant's professional and social networks. Discussion and Implications Older adults collaborate with multiple sources of support and this collaboration is a dynamic process that varies across phases of their transition from hospital to home. Findings reveal opportunities for assessing individual's support and social networks, in addition to health and functional status, to determine needs and leverage resources during transitions in care. [ABSTRACT FROM AUTHOR]

Background and Objectives: Unpaid caregivers frequently feel underprepared and without adequate training, support, or access to services and resources to care for persons living with dementia. Health and community-based services and providers are critical to support persons living with dementia and their unpaid caregivers. The objective of this research is to understand how unpaid caregivers of persons living with dementia interact with health and community-based services and providers. Research Design and Methods: We used a qualitative descriptive approach to analyze data from one-on-one semi-structured interviews with unpaid caregivers of persons living with dementia (N = 25). We used framework analysis to organize themes and sub-themes within the systems approach to healthcare delivery. Findings: Participants described a need for additional guidance, information, and support from health and community-based services and providers. This need was described by participants at 4 levels: individual, care team, organization, and political and economic environment. Participants were active in proposing potential solutions to challenges at all 4 levels, including improving provider awareness and training in dementia, opportunities to provide resources and referrals upon dementia diagnosis, a central clearinghouse for information and resources for persons living with dementia and caregivers, and opportunities to close service gaps. Discussion and Implications: Findings of this study highlight the need for increased involvement of caregivers of persons living with dementia as community stakeholders for improving care and services. Recommendations to promote high quality care and better support unpaid caregivers by developing interventions to address multiple aspects of healthcare delivery are consistent with recent legislation and are important areas of future research. [ABSTRACT FROM AUTHOR]

The U.S. population of older adults living with dementia is projected to double by 2060. They rely on over 16 million family and unpaid caregivers to provide for their increasingly complex needs and care transitions. Caregivers frequently feel underprepared and without adequate support or access to resources. This systematic review seeks to identify the needs of family and unpaid caregivers of older adults living with dementia across various care settings in the U.S. A systematic search was conducted to identify articles pertaining to the needs of caregivers of older adults living with dementia. The data extraction tool was developed using aspects from the Care Transitions Framework and the Family Caregiver Alliance. Data were organized based on 3 domains of caregiver needs and the care setting(s) of the older adults living with dementia and their caregivers. A total of 31 articles were eligible for inclusion. The majority met the MMAT screening criteria, but more than half only met 2 or less of the 5 quality criteria. Caregivers' needs were identified in the care settings of home/community-residing, assisted living, long-term care, skilled nursing, and memory care. Most articles either did not specify a care setting or included more than 1 and did not report the findings separately. Caregivers in each care setting, except memory care, identified needs in all 3 of the following domains: (1) social support—formal and informal, (2) confidence, competence, and strengths in the caregiving role, and (3) values and preferences. [ABSTRACT FROM AUTHOR]

The purpose of this investigation is to examine differences in rest-activity patterns and sleep characteristics in older adults with heart failure (HF) and healthy older adults. The sample included older adults with HF (n = 20) and a reference group of healthy older adults (n = 20). Traditional cosinor analysis was used to assess three parameters of rest–activity from wrist actigraphy data: amplitude (range of activity), mesor (mean activity), and acrophase (time of peak activity). Traditional sleep characteristics were also determined from actigraphy data: total sleep time (TST), sleep latency (SL), sleep efficiency (SE), and wake after sleep onset (WASO). The HF group demonstrated significantly lower mesor and amplitude than the reference group (p < .01). The HF group had significantly greater TST (p < .01), but the groups had similar SE, SL, and WASO. Despite similar sleep characteristics to healthy older adults, overall rest–activity patterns were significantly dampened in those with HF. [ABSTRACT FROM AUTHOR]

Background and Objectives The literature on transitions after hospitalization is based on a medicalized model focusing primarily on medication management and readmission, but little is known about the process older adults engage in to maintain their normal life posthealth event or how older adults define what the transition is. This grounded theory study aimed to describe how older adults understand and define a transition process, what actions they take based on their understanding, and what consequences they experience as they transition. Research Design and Methods Adults aged 65 and older discharged from a large Midwestern teaching hospital (N = 14) were interviewed using in-depth one-on-one interviews. Data were analyzed using open, axial, and selective coding. Results All participants described the process of transition as moving from a state of normal function to loss, and then working back to a normal state. A conceptual model was developed to illustrate the complexity of movement related to how older adults understand and manage the transition. All participants described starting out being normal until they experienced a major health event (acute or chronic illness). Losing normal involved experiencing a lower level of function both inside and outside the home. Working back to normal was accomplished by two different pathways: those "working to regain" focused on getting back to the level they were at prior to the major health event, whereas those "working to maintain" often involved redefining a new normal. The consequences of the two pathways were quite different, with those working to maintain describing several negative consequences. Discussion and Implications This study provides a detailed understanding of how older adults transition and the complexity of that transition. Findings provide a foundation for broadening our understanding of function beyond typical activities of daily living and reveal a more complex transition process that can span months to years. [ABSTRACT FROM AUTHOR]

Purpose of the Study: Falls are common events for hospitalized older adults, resulting in negative outcomes both for patients and hospitals. The Center for Medicare and Medicaid (CMS) has placed pressure on hospital administrators by identifying falls as a "never event", resulting in a zero falls goal for many hospitals. Staff nurses are responsible for providing direct care to patients and for meeting the hospital no falls goal. Little is known about the impact of "zero falls" on nurses, patients and the organization. Design and Methods: A qualitative study, using Grounded Dimensional Analysis (GDA) was conducted to explore nurses' experiences with fall prevention in hospital settings and the impact of those experiences on how nurses provide care to fall risk patients. Twenty-seven registered nurses and certified nursing assistants participated in in-depth interviews. Open, axial and selective coding was used to analyze data. A conceptual model which illustrates the impact of intense messaging from nursing administration to prevent patient falls on nurses, actions nurses take to address the message and the consequences to nurses, older adult patients and to the organization was developed. Results: Intense messaging from hospital administration to achieve zero falls resulted in nurses developing a fear of falls, protecting self and unit, and restricting fall risk patients as a way to stop messages and meet the hospital goal. Implications: Results of this study identify unintended consequences of fall prevention message on nurses and older adult patients. Further research is needed understand how nurse care for fall risk patients. [ABSTRACT FROM AUTHOR]

Within the last decade, system and policy-level changes have driven substantial shifts in heart failure (HF) care from hospital to home, requiring greater support from informal care partners. What has not been examined is the state of the care partner science by person and system-level domains using qualitative studies to understand impact across multiple person and system levels.(1) Identify by person and system levels and domain what is known about informal care partners and (2) Identify gaps in the caregiving science and suggest ways to move forward.This secondary analysis of a large HF systematic review is guided by the National Institute on Minority Health and Health Disparities and MIRACLE frameworks and uses meta-synthesis techniques with critical realist approaches to synthesize and interpret the themes across papers.Using data from 46 papers and 1695 care partners, we identified patterns occurring across 6 domains (biological, behavioral, affective, physical/built environment, sociocultural environment, and healthcare system) and on 4 levels (individual, interpersonal, community, and societal). Existing research predominantly addressed affective and behavioral domains, followed by health system and sociocultural domains. Few studies focused on biological and physical/built environment domains, leaving large gaps in what is known about caregiving at the cellular (biological) and societal (community and societal) levels.HF caregiving continues to be studied at a very rudimentary level. This synthesis also reveals critical gaps in what is known about caregiving within the physical/built environment domain and at the community and societal levels. [ABSTRACT FROM AUTHOR]