Search

The purpose of the current in-depth qualitative study was to explore the experiences of older adults and family caregivers in primary care. Twenty patients and caregivers from six Comprehensive Primary Care Plus (CPC+) practices' Patient and Family Advisory Councils within a large academic health system participated in telephone interviews from December 2018 to May 2019. Participants were mostly women (60%), with an average age of 71 years and nine chronic conditions. Transcripts were coded using conventional content analysis. Two key themes emerged related to person-centered care (PCC): Engagement in Health Care and Patient–Provider Relationship . Engagement in health care was defined by participants as: being proactive, centering on patient goals in treatment discussions, adherence, and self-triaging. Approximately all participants discussed the importance of the relationship and interactions with their provider as influencing their engagement. The identified themes offer recommendations for further improvement of primary PCC. [ Journal of Gerontological Nursing, 48 (11), 7–13.]

Fluctuations in health among chronically ill adults result in frequent health care transitions. Some interventions to improve patient outcomes after hospitalization include caregiver engagement as a core component, yet there is unclear evidence of the effects of this component on outcomes.The objective of this study was to synthesize evidence regarding the attention given to caregiver engagement in randomized control trials of transitional care interventions (TCIs), estimate the overall intervention effects, and assess caregiver engagement as a moderator of intervention effects.Three databases were systematically searched for randomized control trials of TCIs targeting adults living with physical or emotional chronic diseases. For the meta-analysis, overall effects were computed using the relative risk (RR) effect size and inverse variance weighting.Fifty-four studies met criteria, representing 31,291 participants and 66 rehospitalizations effect sizes. Half (51%) the interventions lacked focus on caregiver engagement. The overall effect of TCIs on all-cause rehospitalizations was nonsignificant at 1 month (P=0.107, k=29), but significant at ≥2 months [RR=0.89; 95% confidence interval (CI): 0.82, 0.97; P=0.007, k=27]. Caregiver engagement moderated intervention effects (P=0.05), where interventions with caregiver engagement reduced rehospitalizations (RR=0.83; 95% CI: 0.75, 0.92; P=0.001), and those without, did not (RR=0.97; 95% CI: 0.87, 1.08; P=0.550). Interventions with and without caregiver engagement did not differ in the average number of components utilized, however, interventions with caregiver engagement more commonly employed baseline needs assessments (P=0.032), discharge planning (P=0.006), and service coordination (P=0.035).Future TCIs must consistently incorporate the active participation of caregivers in design, delivery, and evaluation.

GOAL: The objective of this retrospective, observational study is to assess the mediating effect of medical complexity on the relationship between social vulnerability and four acute care resource use outcomes, specifically numbers of hospitalizations, emergency department (ED) visits, observation stays, and total visits. Such information may help management better anticipate the effects of interventions targeted to the socially vulnerable in their patient population and others. METHODS: Electronic health record data from 147,496 adults served by 27 primary care practices in one large health system from 2015 to 2017 were used. Descriptive statistics were used to characterize patients and the primary care practices included in the study. Causal mediation analyses using a modified Baron and Kenny approach were performed. PRINCIPAL FINDINGS: Causal mediation analyses demonstrated that increased social vulnerability was associated with increased medical complexity (IRR=1.57), and increased number of hospitalizations (IRR=1.63), ED visits (IRR=2.14), observation stays (IRR=1.94), and total visits (IRR=2.04). Effects remained significant, though attenuated, after adjusting for medical complexity (mediator), demographics, and medications (hospitalizations IRR=1.44; ED visits IRR=2.02; observation stays IRR=1.74; and total visits IRR=1.86). Between 8% (ED visits) and 26% (hospitalizations) of variation in outcomes was explained by social vulnerability, given medical complexity. PRACTICAL APPLICATIONS: These findings reinforce the need to modify interventions for medically complex adults to address social needs and, consequently, reduce use of costly health services. Health systems seeking to reduce the use of costly care can use these results to estimate savings in the treatment of patients with high social vulnerability—both before they get chronic conditions and afterwards as they seek care.

Programs of All-Inclusive Care for the Elderly (PACE) are an effective approach to improve care quality and delay institutional admissions especially for Black and Hispanic older adults who have seen a disproportionate rise in nursing home use. Guided by Andersen's Behavioral Model of Health Services Use and employing focus groups and one-on-one interviews, we qualitatively examined factors influencing access to and use of PACE by Black and Hispanic older adults. The study sample consisted of thirty-two PACE enrollees, six marketing-team members, and four family-caregivers from three PACE sites in a northeast urban city. Informed knowledge, cultural beliefs, and attitudes toward PACE were found to affect access. Community resources, available services, and care quality facilitated enrollment/participation. Barriers identified included poor dissemination of information and inadequate emphasis on staff's sensitivity to enrollees' cultural and disability differences. Findings will help healthcare leaders capitalize on facilitators and address barriers to enhance access and use of PACE by racial and ethnic minority older adults.

The purpose of this study was to examine changes in and predictors of perceived tangible social support over a 2-year period among older adults new to LTSS. Linear mixed effects models were used to model repeated measures of tangible social support as a function of LTSS type [NH, AL, HCBS], personal, clinical, and health-related quality of life variables. AL residents reported greater initial tangible social support, but NH and HCBS residents improved more over time. Predictors of increased tangible social support over time included greater positive affect, sense of aesthetics, education, satisfaction with family relationships, and total number of close friends and family. Decreased tangible support over time was associated with greater depressive symptoms. Findings indicate the positive influence of NH and HCBS services on perception of tangible social support, and the importance of addressing depressive symptoms and assisting with the maintenance of important relationships.

Despite growing recognition of the importance of community-based palliative care, optimizing the use of services continues to be a challenge. Until recently, key barriers were reimbursement and limited access. As services have become increasingly available, engagement of patients and their caregivers has emerged as a major obstacle. The Palliative Activation SystemTM (PAS) is a comprehensive, quality improvement methodology designed to promote enhanced engagement of seriously ill adults and their caregivers in optimizing the use of community-based palliative care services and accelerate clinicians’ progress in meeting patients’ and caregivers’ care goals. This paper describes the design of the PAS. Experts in patient engagement and the development and evaluation of palliative care programs advised organizational leaders in the development of this methodology. The “Patient and Family Engagement” framework proposed by Carman and colleagues (2013) guided this work. The framework informed the selection of three core concepts—care alignment, illness trajectory, and social determinants of health—as foundational to the goals of the PAS. Additionally, this framework guided the selection of measures that will be used to assess progress in achieving enhanced engagement. This background work, coupled with findings from interviews with patients and caregivers who are current recipients of palliative care services, resulted in the implementation and ongoing testing of strategies targeting clinicians and organizational leaders and designed to enhance engagement. Lessons learned from the design phase of the PAS will advance the efforts of other organizations committed to increasing patient and caregiver engagement and enhancing attainment of their goals.

Salimah H Meghani,1,2 Ryan Quinn,1 Rebecca Ashare,3,4 Kristin Levoy,1,5,6 Brooke Worster,7 Mary Naylor,1,2 Jesse Chittams,1 Martin Cheatle8 1Department of Biobehavioral Health Sciences, NewCourtland Center for Transitions and Health, School of Nursing, University of Pennsylvania, Philadelphia, PA, USA; 2Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA, USA; 3Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; 4Department of Psychology, State University of New York at Buffalo, Buffalo, NY, USA; 5Department of Community and Health Systems, School of Nursing, Indiana University, Indianapolis, IN, USA; 6Center for Aging Research, Regenstrief Institute, Indianapolis, IN, USA; 7Department of Medical Oncology, Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA, USA; 8Department of Psychiatry and Anesthesiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USACorrespondence: Salimah H MeghaniDepartment of Biobehavioral Health Sciences, NewCourtland Center for Transitions and Health, Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA, USATel +215 573-7128Email meghanis@nursing.upenn.eduIntroduction: Based on many published reports, African American patients with cancer experience higher pain severity scores and lower pain relief than White patients. This disparity results from undertreatment of pain and is compounded by low adherence to prescribed non-opioid and opioid analgesics among African American patients with cancer. While nearly one in four patients use cannabis to manage cancer-related symptoms, less is known about how cannabis use influences pain relief in this patient population.Methods: This study is based on preliminary data from an ongoing study of longitudinal outcomes of opioid therapy among African American and White patients with cancer. Linear mixed-effects models were utilized to assess the interaction of race and cannabis use on pain relief using “least pain” item scores from the Brief Pain Inventory (BPI) averaged across three time points. Models were adjusted for sociodemographic and clinical variables.Results: This analysis included 136 patients (49 African American, 87 White). Overall, 30.1% of the sample reported cannabis use for cancer pain. The mean “least pain” score on BPI was 3.3 (SD=2.42) on a scale of 0– 10. African American patients had a mean “least pain” score 1.32± 0.48 units higher (indicating lower pain relief) than White patients (p=0.006). Cannabis use did not have a significant main effect (p=0.28). However, cannabis use was a significant moderator of the relationship between race and “least pain” (p=0.03). In the absence of cannabis use, African Americans reported higher “least pain” scores compared to Whites (mean difference=1.631± 0.5, p=0.001). However, this disparity was no longer observed in African American patients reporting cannabis use (mean “least pain” difference=0.587± 0.59, p=0.32).Conclusion: These findings point to the possible role of cannabis in cancer pain management and its potential to reduce racial disparities. These findings are preliminary and further research into the role of cannabis in cancer pain outcomes is needed.Keywords: pain, cancer pain, pain relief, pain disparities, cannabis

The rate of coronavirus disease 2019 (COVID-19) vaccination uptake by US nursing home staff remains low despite the increased risks of viral transmission and related morbidity and mortality in this setting. This study describes vaccine uptake activities including a COVID-19 vaccination condition of employment (COE) policy in one community nursing home. This case study summarizes the timeline of vaccination uptake activities, staff vaccination rates over time, and stakeholder perspectives around the implementation of a COVID-19 vaccination COE. Organizational data were used to calculate vaccination rates from January 1, 2021 until May 1, 2021 among all nursing home staff. Interviews were held with the executive leadership team, human resources leadership, and nursing home staff to understand the process of implementation. During a 4-month period, nursing home leaders provided 8 written handouts about COVID-19 to all staff, hosted 5 on-site vaccination clinics in partnership with area pharmacies, conducted 2 virtual presentations for staff in addition to individual outreach and internal communications. Fewer than one-half of the staff were vaccinated prior to the decision to pursue a vaccine COE on February 9, 2021. The decision to pursue a COVID-19 vaccination COE was supported by executive leadership and nursing home staff to protect the health and safety of each other and their residents. By May 1, 2021 a total of 221 of the 246 (89.8%) nursing home staff members received a COVID-19 vaccination. The facility reached 100% compliance with the vaccination COE policy with 18 people who chose to resign and 7 people who were exempt or on a leave of absence. In combination with frequent, personalized outreach, a COVID-19 vaccination COE resulted in high staff vaccination rates and minimal staff turnover. This case study provides a detailed summary of vaccination uptake activities within an organizational context to inform efforts at other healthcare facilities.

Objectives: This study examines healthcare resource use (hospitalizations, emergency department [ED] visits, and home health episodes) among adults 65 and older diagnosed with hearing, vision, or dual sensory loss (SL) seen in the primary care setting of an academic health system. Methods: Multivariable logistic regression models were used to examine the relationship between SL (identified using ICD-10 codes) and healthcare resource use for 45,000 primary care patients. Results: The sample included 5.5% ( N = 2479) with hearing loss, 10.4% ( N = 4697) with vision loss, and 1.0% with dual SL ( N = 469). Hearing loss increased the likelihood of having an ED visit (OR = 1.22, CI: 1.07–1.39), and home health services (OR = 1.27, CI: 1.07–1.51) compared to older adults without any SL. Vision loss reduced the likelihood of having a hospitalization (OR = .81, CI: .73–.91). Discussion: Findings support research into the drivers of healthcare use among older adults with sensory loss.

Background Skilled nursing facility (SNF) patients are medically complex with multiple, advanced chronic conditions. They are dependent on caregivers and have experienced recent acute illnesses. Among SNF patients, the rate of mortality or acute care use is over 50% within 90 days of discharge, yet these patients and their caregivers often do not receive the quality of transitional care that prepares them to manage serious illnesses at home. Methods The study will test the efficacy of Connect-Home, a successfully piloted transitional care intervention targeting seriously ill SNF patients discharged to home and their caregivers. The study setting will be SNFs in North Carolina, USA, and, following discharge, in patients’ home. Using a stepped wedge cluster randomized trial design, six SNFs will transition at randomly assigned intervals from standard discharge planning to the Connect-Home intervention. The SNFs will contribute data for patients (N = 360) and their caregivers (N = 360), during both the standard discharge planning and Connect-Home time periods. Connect-Home is a two-step intervention: (a) SNF staff create an individualized Transition Plan of Care to manage the patient’s illness at home; and (b) a Connect-Home Activation RN visits the patient’s home to implement the written Transition Plan of Care. A key feature of the trial includes training of the SNF and Home Care Agency staff to complete the transition plan rather than using study interventionists. The primary outcomes will be patient preparedness for discharge and caregiver preparedness for caregiving role. With the proposed sample and using a two-sided test at the 5% significance level, we have 80% power to detect a 18% increase in the patient’s preparedness for discharge score. We will employ linear mixed models to compare observations between intervention and usual care periods to assess primary outcomes. Secondary outcomes include (a) patients’ quality of life, functional status, and days of acute care use and (b) caregivers’ burden and distress. Discussion Study results will determine the efficacy of an intervention using existing clinical staff to (a) improve transitional care for seriously ill SNF patients and their caregivers, (b) prevent avoidable days of acute care use in a population with persistent risks from chronic conditions, and (c) advance the science of transitional care within end-of-life and palliative care trajectories of SNF patients and their caregivers. While this study protocol was being implemented, the COVID-19 pandemic occurred and this protocol was revised to mitigate COVID-related risks of patients, their caregivers, SNF staff, and the study team. Thus, this paper includes additional material describing these modifications. Trial registration ClinicalTrials.gov NCT03810534. Registered on January 18, 2019.

Hospital readmission within 30 days of discharge (30-day readmission) is a high-priority quality measure and cost target. The purpose of this study was to explore the feasibility and efficacy of the Diabetes Transition of Hospital Care (DiaTOHC) Program on readmission risk in high-risk adults with diabetes. This was a non-blinded pilot randomized controlled trial (RCT) that compared usual care (UC) to DiaTOHC at a safety-net hospital. The primary outcome was all-cause 30-day readmission. Between 10/16/2017 and 05/30/2019, 115 patients were randomized. In the intention-to-treat (ITT) population, 14 (31.1%) of 45 DiaTOHC subjects and 15 (32.6%) of 46 UC subjects had a 30-day readmission (p=0.88) while 35.6% DiaTOHC and 39.1% UC subjects had a 30-day readmission or ED visit (p=0.72). The Intervention:UC cost ratio was 0.33 (0.13-0.79)95%CI (p7.0% (53 mmol/mol), 30-day readmission rates were 23.5% (DiaTOHC) and 31.4% (UC, p=0.46) and composite 30-day readmission or ED visit rates were 26.5% (DiaTOHC) and 40.0% (UC, p=0.23). In this subgroup, the Intervention:UC cost ratio was 0.21 (0.08-0.58)95%CI (p=0.002). The DiaTOHC Program is feasible and may decrease combined 30-day readmission/ED visit risk as well as healthcare costs among patients with higher HbA1c levels.

BACKGROUND: 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. AIMS: 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. METHODS: This study utilizes Walker and Avant’s (2019) concept analysis method, an eight-step iterative process that helps to clarify ambiguous concepts. A literature review was conducted from July 1993 through March 2019 using PubMed/MED-LINE, Scopus, CINAHL, and Embase. Inclusion criteria encompassed peer-reviewed research articles and review articles that included family caregivers of older adults with cognitive impairment. RESULTS: Eight defining attributes of this concept are 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. CONCLUSION: This paper utilizes over a quarter-century of research to build on the original analysis by Mowat and Spence Laschinger (1994) and update the concept’s definition. This analysis should provide researchers with a clearer understanding of this concept and a renewed emphasis on the importance of targeting interventions to improve self-efficacy in this vulnerable caregiving population.

OBJECTIVES Compare patient characteristics by hospital discharge disposition (home without services, home with home healthcare (HHC) services, or post-acute care (PAC) facilities). Examine timing and rates of 30-day healthcare utilization (rehospitalization, emergency department (ED) visit, or observation (OBS) visit) and patient characteristics associated with rehospitalization by discharge location. DESIGN Retrospective analysis of hospital administrative and clinical data. SETTING AND PARTICIPANTS A total of 3,294 older adult inpatients discharged home with or without HHC services or to a PAC facility. MEASUREMENTS Patient-level sociodemographic and clinical characteristics. Number of and time to occurrences of rehospitalization or ED/OBS visit within 30 days of hospital discharge. RESULTS Most rehospitalizations and ED/OBS visits occurred within 14 days from hospital discharge. Patients who returned within 24 hours came mostly from inpatient rehabilitation facilities (IRFs). More intense levels of PAC services were linked with higher rehospitalization risk. However, specific predictors differed by discharge location. Being unemployed, being single, and having more comorbidities were most associated with rehospitalization in those who went home with or without services, whereas patients rehospitalized from IRFs were younger, with less chronic illness burden, but greater and recent functional decline. Those discharged with HHC services had more return ED/OBS visits. CONCLUSIONS Although sicker patients were referred for more intense levels of PAC services, patients with greater chronic illness burden were still most often rehospitalized. In addition to unique patient differences, rehospitalizations from IRF within 24 hours suggest systems factors are contributory. Most return acute healthcare utilization occurred within 14 days; therefore, interventions should focus on smoothing transitions to all discharge locations. Because predictors of rehospitalization risk differed by discharge disposition, future research is necessary to study approaches aimed at matching patients' care needs with the most suitable PAC services at the right time. J Am Geriatr Soc 68:2279-2287, 2020.

Older adults receiving long-term services and supports (LTSS) experience barriers to outdoor activities and satisfaction ratings with such experiences are not well understood. Our study used cross-sectional data ( n = 329) to (a) examine whether those new to LTSS were satisfied with their outdoor activities and (b) describe the characteristics and factors associated with satisfaction levels. Self-report of satisfaction with outdoor activities was the outcome variable. Multivariable linear regression modeling of the outcome was conducted. Fifty-nine percent were satisfied with their outdoor activities. More depressive symptoms ( p < .001) and higher cognitive functioning ( p = .011) were associated with lower ratings. Higher self-rated physical health ( p = .009) and more independence with activities of daily living ( p = .022) were associated with greater satisfaction. Findings suggest an unmet need among four in 10 new recipients of LTSS (41%) related to their outdoor activities. LTSS interdisciplinary teams can use these findings to inform their assessments, develop person-centered care plans, and address barriers.

Objective The goal of this study was to explore whether features of recorded and transcribed audio communication data extracted by machine learning algorithms can be used to train a classifier for anxiety. Materials and Methods We used a secondary data set generated by a clinical trial examining problem-solving therapy for hospice caregivers consisting of 140 transcripts of multiple, sequential conversations between an interviewer and a family caregiver along with standardized assessments of anxiety prior to each session; 98 of these transcripts (70%) served as the training set, holding the remaining 30% of the data for evaluation. Results A classifier for anxiety was developed relying on language-based features. An 86% precision, 78% recall, 81% accuracy, and 84% specificity were achieved with the use of the trained classifiers. High anxiety inflections were found among recently bereaved caregivers and were usually connected to issues related to transitioning out of the caregiving role. This analysis highlighted the impact of lowering anxiety by increasing reciprocity between interviewers and caregivers. Conclusion Verbal communication can provide a platform for machine learning tools to highlight and predict behavioral health indicators and trends.

Background Our health care system is facing unprecedented and complex challenges in caring for older adults and their families. A paradigm shift is needed that recognizes new roles and competencies for nurses to play a leadership role in the design and implementation of high value care models. Purpose The purpose of this paper is to introduce a series of recommendations for leveraging nurses to generate innovative tools and solutions for the delivery of value-based care for older adults living with complex health and social needs and their families. Methods These recommendations were generated by a Think-Tank of national experts based on review of current evidence and focus groups with older adults. Finding The generated recommendations focus on positioning nurses to assume leadership roles in implementing evidence-based care models, preparing nurses to serve as health innovators and catalysts of system transformation, and fostering system-level infrastructure that leverages the contributions of nurses for current and emerging roles. Discussion Nurses as innovators can address the challenges in providing high quality care for older adults with complex needs and their families. System-level infrastructure, including resources for training and implementation of well-established programs, is necessary to leverage the contributions of nurses and facilitate innovative approaches to care.

OBJECTIVES: To identify predictors of change in older adults’ satisfaction with outdoor activities ratings over the first two years of enrollment in long-term services and supports (LTSS). METHODS: Self-rated satisfaction with outdoor activities (not at all satisfied to extremely satisfied) was the primary outcome of this secondary data analysis. Mixed-effects linear regression modeling with a backward elimination process was used for analyses. RESULTS: In the final model (N = 453) older LTSS recipients at baseline had lower ratings of satisfaction with outdoor activities over time, whereas younger recipients had higher ratings over time. Those who moved into a residential facility at baseline had an increase in outdoor activity satisfaction ratings over time compared to older adults who received home and community-based services that had a decrease. DISCUSSION: LTSS clinicians can use these findings to support older adults with decision-making around enrollment into LTSS, address preferences, and develop person-centered care interventions for outdoor activity.

Transitions in care are events that occur as individuals transfer between settings and providers of healthcare. The movement from a hospital to home-based care is a common example of a care transition. Due to common breakdowns between health and social care systems, continuing risks for acute health events, and the lack of support to manage complex treatments at home, between 15-20% of hospitalized adults are rehospitalized within thirty days of returning home. This high rate of hospital readmissions points up the need for transitional care services to address challenges in continuing care at home

ImportanceAttrition in cancer clinical trials (CCTs) can lead to systematic bias, underpowered analyses, and a loss of scientific knowledge to improve treatments. Little attention has focused on retention, especially the role of perceived benefits and burdens, after participants have experienced the trial.ObjectivesTo examine the association between patients’ perceived benefits and burdens of research participation and CCT retention.Design, Setting, and ParticipantsThis survey study was conducted at a National Cancer Institute–designated comprehensive cancer center in the Northeast region of the US. The sample included adult patients with a cancer diagnosis participating in cancer therapeutic trials. Data were collected from September 2015 to June 2019. Analysis of study data was ongoing since November 2019 through October 2022.ExposuresSelf-reported validated survey instrument with a list of 22 benefits and 23 burdens of research participation that can be rated by patients with a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree).Main Outcomes and MeasuresA primary outcome was actual withdrawal from the CCT, and a composite outcome was composite withdrawal that included both actual withdrawal and thoughts of withdrawing. Bivariate and multivariable logistic regressions were used.ResultsAmong the 334 participants in the sample, the mean (SD) age was 61.9 (11.5) years and 174 women (52.1%) were included. Top-cited benefits included both aspirational and action-oriented goals, including helping others (94.2%), contributing to society (90.3%), being treated respectfully (86.2%), and hoping for a cure (86.0%). Worry over receiving a placebo (61.3%), rearranging one’s life (41.9%), and experiencing bothersome adverse effects (41.6%) were notable burdens. An increased burden score was associated with a higher probability of actual withdrawal (adjusted odds ratio [OR], 1.86; 95% CI, 1.1-3.17; P = .02) or composite withdrawal (adjusted OR, 3.44; 95% CI, 2.09-5.67; P P P = .03). The risk of withdrawal was even higher for the composite outcome (adjusted OR, 7.70; 95% CI, 2.76-21.48; P Conclusions and RelevanceThis survey study found that patients perceived important benefits from CCT participation, and this perception was associated with trial retention, even among those who also perceived substantial burdens. A broader dialogue among stakeholders can inform an ethical and patient-centric focus on benefits throughout the course of a CCT to increase retention.

BACKGROUND: Speech and language cues are considered significant data sources that can reveal insights into one’s behavior and well-being. The goal of this study is to evaluate how different machine learning (ML) classifiers trained both on the spoken word and acoustic features during live conversations between family caregivers and a therapist, correlate to anxiety and quality of life (QoL) as assessed by validated instruments. METHODS: The dataset comprised of 124 audio-recorded and professionally transcribed discussions between family caregivers of hospice patients and a therapist, of challenges they faced in their caregiving role, and standardized assessments of self-reported QoL and anxiety. We custom-built and trained an Automated Speech Recognition (ASR) system on older adult voices and created a logistic regression-based classifier that incorporated audio-based features. The classification process automated the QoL scoring and display of the score in real time, replacing hand-coding for self-reported assessments with a machine learning identified classifier. FINDINGS: Of the 124 audio files and their transcripts, 87 of these transcripts (70%) were selected to serve as the training set, holding the remaining 30% of the data for evaluation. For anxiety, the results of adding the dimension of sound and an automated speech-to-text transcription outperformed the prior classifier trained only on human-rendered transcriptions. Specifically, precision improved from 86% to 92%, accuracy from 81% to 89%, and recall from 78% to 88%. INTERPRETATION: Classifiers can be developed through ML techniques which can indicate improvements in QoL measures with a reasonable degree of accuracy. Examining the content, sound of the voice and context of the conversation provides insights into additional factors affecting anxiety and QoL that could be addressed in tailored therapy and the design of conversational agents serving as therapy chatbots.

EXECUTIVE SUMMARY In this study, the authors used simulation to explore factors that might influence hospitals' decisions to adopt evidence-based interventions. Specifically, they developed a simulation model to examine the extent to which hospitals would benefit economically from the transitional care model (TCM). The TCM is designed to transition high-risk older adults from hospitals back to communities using interventions focused on preventing readmissions.The authors used qualitative methods to identify and validate simulation facets. Four simulation experiments explored the economic impact of the TCM on more than 3,000 U.S. hospitals: (1) magnitude of readmission penalty, (2) application to specific diagnosis-related groups, (3) level of cost sharing between payer and provider, and (4) capitated versus fee-for-service payments. The simulator projected hospital-specific economic effects. The authors used Monte Carlo methods for the simulations, which were parameterized with public data sets from the Centers for Medicare & Medicaid Services (CMS) and TCM data from randomized controlled trials and comparative effectiveness studies.Under current conditions, the simulation indicated that only 10 of more than 3,000 Medicare-certified hospitals would benefit financially from the TCM. If current readmission penalties were doubled, the number of hospitals projected to benefit would increase to 300. Targeting selected diagnosis cohorts would also increase the number of hospitals to 300. If payers reimbursed providers for 100% of the TCM costs, 2,000 hospitals would benefit financially. Under a capitated payment model, 1,500 hospitals would benefit from the TCM.Current CMS penalties-or reasonable increases-have little economic effect on the TCM. In the current environment, two strategies are likely to facilitate adoption: (1) persuading payers to reimburse TCM costs and (2) focusing on hospitals with higher bed occupancies and higher revenue patients.

Objective: To determine predictors of health care transitions (i.e., acute care service use, transfers from lower to higher intensity services) among older adults new to long-term services and supports [LTSS]. Method: 470 new LTSS recipients followed for 24 months. Multivariable Poisson regression modeling within a generalized estimating equation framework. Results: Being male, having multiple chronic conditions, lower self-reported physical health ratings and lower quality of life ratings at baseline were associated with increased risk of health care transitions. Older adults in assisted living communities and nursing homes experienced decreases in health care transitions over time, while LTSS recipients at home had no change in risk. LTSS recipients who had orders to receive therapy, compared with those who did not, had a lower relative risk of transitions over time. Discussion: Predictors of future health care transitions support the need for LTSS providers to anticipate and monitor this risk for LTSS recipients.

Patients with chronic illness are associated with high health-care utilization and this is exacerbated in the end of life, when health-care utilization and costs are highest. Complex Care Management (CCM) is a model of care developed to reduce health-care utilization, while improving patient outcomes. We aimed to examine the relationship between health-care utilization patterns and patient characteristics over time in a sample of older adults enrolled in CCM over the last 2 years of life. Generalized estimating equation models were used. The sample (n = 126) was 52% female with an average age of 85 years. Health-care utilization rose sharply in the last 3 months of life with at least one hospitalization for 67% of participants and an emergency department visit for 23% of participants. In the last 6 months of life, there was an average of 2.17 care transitions per participant. The odds of hospitalization increased by 27% with each time interval ( P < .001). Participants demonstrated 11% greater odds of having a hospitalization for each additional comorbidity ( P = .05). A primary diagnosis of heart failure or coronary artery disease was associated with 21% greater odds of hospitalization over time compared to other primary diagnoses ( P = .017). Females had 70% greater odds of an emergency department visit compared to males ( P = .046). For each additional year of life, the odds of an emergency department visit increased by about 7% ( P < .001). Findings suggest the need for further interventions targeting chronically ill older adults nearing end of life within CCM models.

Background Research suggests that growth in Black and Hispanic (minority) older adults' nursing home (NH) use may be the result of disparities in access to community-based and alternative long-term services and supports (LTSS). Objective We aimed to determine whether minority groups receiving care in NHs versus the community had fewer differences in their functional needs compared with the differences in nonminority older adults, suggesting a disparity. Methods We identified respondents aged 65 years or above with a diagnosis of Alzheimer disease or dementia in the 2016 Health and Retirement Study who reported requiring LTSS help. We performed unadjusted analyses to assess the difference in functional need between community and NH care. Functional need was operationalized using a functional limitations score and 6 individual activities of daily living. We compared the LTSS setting for minority older adults to White older adults using difference-in-differences. Results There were 186 minority older adults (community=75%, NH=25%) and 357 White older adults (community=50%, NH=50%). Between settings, minority older adults did not differ in education or marital status, but were younger and had greater income in the NH versus the community. The functional limitations score was higher in NHs than in the community for both groups. Functional needs for all 6 activities of daily living for the minority group were greater in NHs compared with the community. Conclusion Functional need for minority older adults differed by setting while demographics varied in unexpected ways. Factors such as familial and financial support are important to consider when implementing programs to keep older adults out of NHs.

Objectives:Daytime sleepiness is associated with multiple negative outcomes in older adults receiving long-term services and supports (LTSS) including reduced cognitive performance, need for greater assistance with activities of daily living and decreased social engagement. The purpose of this study was to identify predictors of change in subjective daytime sleepiness among older adults during their first 2 years of receiving LTSS.Design and Setting:Secondary analysis of data from a prospective longitudinal study of older adults who received LTSS in their homes, assisted living communities or nursing homes interviewed at baseline and every 3 months for 24 months.Participants:470 older adults (60 years and older) newly enrolled in LTSS (mean = 81, SD = 8.7; range 60–98; 71% women).Measurements:Subjective daytime sleepiness was assessed every 3 months through 2 years using the Epworth Sleepiness Scale. Multiple validated measures were used to capture health-related quality of life characteristics of enrollees and their environment, including symptom status (Symptom Bother Scale), cognition (Mini Mental Status Exam), physical function (Basic Activities of Daily Living), physical and mental general health, quality of life (Dementia Quality of Life, D-QoL), depressive symptoms (Geriatric Depression Scale) and social support (Medical Outcomes Survey-Social Support).Results:Longitudinal mixed effects modeling was used to examine the relationship between independent variables and continuous measure of daytime sleepiness. Increased feelings of belonging, subscale of the D-QoL (effect size = −0.006, 95% CI: −0.013 to −0.0001,p= 0.045) and higher number of depressive symptoms (effect size = −0.002, 95% CI: −0.004 to −0.001,p= 0.001) at baseline were associated with slower rates of increase in daytime sleepiness over time.Conclusions:Comprehensive baseline and longitudinal screening for changes in daytime sleepiness along with depression and perceived quality of life should be used to inform interventions aimed at reducing daytime sleepiness among older adults receiving LTSS.

As of May 2020, nursing home residents account for a staggering one-third of the more than 80,000 deaths due to COVID-19 in the U.S. This pandemic has resulted in unprecedented threats to achieving and sustaining care quality even in the best nursing homes, requiring active engagement of nursing home leaders in developing solutions responsive to the unprecedented threats to quality standards of care delivery during the pandemic. This perspective offers a framework, designed with the input of nursing home leaders, to facilitate internal and external decision-making and collective action to address these threats. Policy options focus on assuring a shared understanding among nursing home leaders and government agencies of changes in the operational status of nursing homes throughout the crisis, improving access to additional essential resources needed to mitigate the crisis' impact, and promoting shared accountability for consistently achieving accepted standards in core quality domains.

Unplanned hospital readmission is a high-priority quality measure and target for cost reduction. Patients with diabetes are at higher risk of readmission than patients without diabetes. We previously presented results of a pilot randomized controlled trial (RCT) of an intervention designed to reduce readmission risk (the Diabetes Transition of Hospital Care [DiaTOHC] program) with outcomes assessed 30 days after hospital discharge. Here we present secondary outcomes assessed 90 days after discharge. Patients predicted to be high risk (>=27%) for readmission based on a validated readmission risk tool (DERRITM) were randomized 1:1 to the intervention (INT) or usual care (UC). The intervention consisted of inpatient diabetes education, coordination of care, post-discharge support by a nurse practitioner, adjustment of diabetes therapy, and weekly phone calls for 30 days after discharge. There were 45 INT and 46 UC patients randomized and analyzed by intention-to-treat. Twenty-one INT and 23 UC patients had a readmission (46.7% vs. 50%) while 25 INT and 27 UC patients had a readmission or Emergency Department (ED) visit (55.6% vs. 58.7%). The ratio of the mean estimated cost of readmissions, ED visits, and the intervention in the INT group was 0.51 (0.25-1.02)95%CL the cost of readmissions and ED visits in the UC group. Among the 69 patients with an admission A1C >7%, 14 INT and 17 UC patients had a readmission (41.2% vs. 48.6%), and 18 INT and 21 UC patients had a readmission or ED visit (52.9% vs. 60.0%), yielding relative risk reductions of 15.2% and 11.8%. The INT:UC group ratio of the mean estimated cost was 0.50 (0.22-1.12)95%CL. No differences were statistically significant in this pilot study. The DiaTOHC intervention may modestly reduce readmission risk and cut costs by half within 90 days after discharge among patients with an admission A1C >7%. This merits further investigation in a larger RCT. Disclosure D.J. Rubin: None. S. Watts: None. A. Deak: None. C. Vaz: None. S. Tanner: None. D. Recco: None. M. Tivon: None. F.R. Dillard: None. E. Brzana: None. K.E. Joyce: None. A. Karunakaran: None. A. Iwamaye: None. E. Miller: None. C. Mathai: None. N. Kondamuri: None. B.S. Albury: None. S. Allen: None. M.D. Naylor: None. S. Golden: None. J. Wu: None. Funding National Institute of Diabetes and Digestive and Kidney Diseases (K23DK102963)

Older adults with COVID-19 who survive hospitalizations and return to their homes confront substantial health challenges and an unpredictable future. While understanding of the unique needs of COVID-19 survivors is developing, components of the evidence-based Transitional Care Model provide a framework for taking a more immediate, holistic response to caring for these individuals as they moved back into the community. These components include: increasing screening, building trusting relationships, improving patient engagement, promoting collaboration across care teams, undertaking symptom management, increasing family caregiver care/education, coordinating health and social services, and improving care continuity. Evidence generated from rigorous testing of these components reveal the need for federal and state policy solutions to support the following: employment/redeployment of nurses, social workers, and community health workers; training and reimbursement of family caregivers; widespread access to research-based transitional care tools; and coordinated local efforts to address structural barriers to effective transitions. Immediate action on these policy options is necessary to more effectively address the complex issues facing these older adults and their family caregivers who are counting on our care system for essential support.

The demand to expand the nurse scientist pipeline over the past decade has generated numerous pedagogical innovations in nursing doctoral education. A PhD nursing education summit was held at the University of Pennsylvania in October 2019 to discuss pedagogical innovations. The main pedagogical innovations discussed by Summit attendees included: 1) the expansion of both 3-year PhD programs and BSN to PhD programs; 2) changes in learning opportunities and curricula content; and 3) the role of postdoctoral fellowships. This overview examines the numerous opportunities and challenges generated by these innovations. Opportunities include producing scholars with research careers that are potentially longer than historically seen in the nursing profession, as well as the emergence of unique educational and mentoring opportunities both during and after doctoral studies. Challenges involve the impact condensed program timelines have had on both the content and delivery of curricula, as well as the research expertise and skillsets of nursing PhD program graduates. There is a need to conduct a national coordinated evaluation of PhD program using shared metrics in order to better evaluate the effect of these pedagogical innovations on the development of nurse scientists, and ultimately, the discipline.

Background and Objectives 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. During the transition to LTSS, older adults are at risk of increased depressive symptoms. In addition, older adults may identify unmet needs despite having access to new LTSS resources. The goal of this study was to examine the factors associated with increased depressive symptoms among a pool of older adults, with a focus on change in reported needs after starting LTSS. Research Design and Methods This cross-sectional analysis of a cohort study included 352 older adults new to LTSS (R01AG025524). The outcome of depressive symptoms was measured using the Geriatric Depression Scale—Short Form. Reported needs included supportive equipment, devices, transportation, and social activities. Bivariate and linear regression modeling using change in needs 3 months later were performed. Results Depressive symptoms were present among 40% of the LTSS recipients at enrollment and 3 months. At baseline, 29% of LTSS recipients reported a need for supportive equipment, 30% for transportation, and 23% for social activities. After 3 months, an average of 12% of LTSS recipients’ needs were met, 13% of LTSS recipients’ needs persisted, and 11% of LTSS recipients reported new needs. Depressive symptoms 3 months later were higher for those who reported persistent unmet needs compared with those who reported no needs at all, controlling for functional status and LTSS type. Discussion and Implications The transition to LTSS is a vulnerable time for older adults. Assessing the need for equipment, transportation, and social activities during this period may identify opportunities to improve the lives and emotional status of this population.

Limited information exists on the perceived health of older adults new to receiving long-term services and supports (LTSS) compared with the year prior, posing challenges to the anticipation of health care need and optimization of wellness efforts for this growing population. In response, we sought to identify differences in perceived worsened physical health across three LTSS types (nursing home, assisted living, and home and community-based services) along with health-related quality of life (HRQoL) characteristics associated with older adults’ ratings of perceived worsened physical health at the start of receiving LTSS. Enrolled LTSS recipients completed a single interview assessing their HRQoL. Bivariate and multivariable logistic regression analyses were performed to determine associations in LTSS types and HRQoL characteristics with perceived worsened physical health among older adults (≥60 years old) since 1 year prior to study enrollment. Among the 467 LTSS recipients, perceived physical health was rated as worse than the previous year by 36%. Bivariate analyses revealed no differences in perceived worsened physical health across LTSS types. In adjusted analyses, religiousness/spirituality and better mental and general health perception had a decreased odds of being associated with perceived worsened physical health ( P < .05). Participants with major changes in their health in the past 6 months were more likely to report perceived worsened physical health ( P < .001). Findings provide information that may be used to target efforts to enhance perceived physical health and improve quality of life among LTSS enrollees.

In the U.S., older adults hospitalized with acute episodes of chronic conditions often are rehospitalized within 30 days of discharge. Numerous studies reveal that poor management of the complex needs of this population remains the norm. METHODS: This prospective, intent-to-treat, randomized controlled trial (RCT) will assess the effects of replicating the rigorously studied Transitional Care Model (TCM) in four U.S. healthcare systems. The TCM is an advanced practice registered nurse led, team-based, care management intervention that supports older adults throughout vulnerable care episodes that span hospital to home. This RCT will compare health and economic outcomes demonstrated by at-risk older adults hospitalized with heart failure, chronic obstructive pulmonary disease or pneumonia randomized to receive usual discharge planning (control group, N = 800) to those observed by a similar group of older adults randomized to receive the TCM protocol (N = 800). The primary outcome is number of rehospitalizations at 12 months post-discharge, with secondary resource use outcomes measured at multiple intervals. Patient experience with care, health and quality of life outcomes will be assessed at 90 days post-discharge. DISCUSSION: Based on health and economic benefits demonstrated in multiple NIH funded RCTs, the study team hypothesizes that the intervention group, both within and across participating health systems, will have decreased acute care resource use and costs at 12 months and better ratings of the care experience and health and quality of life through 90 days post-discharge compared to the control group. The impact of COVID-19 on implementation of this study also is discussed.

Despite a growing body of evidence that adaptations of evidence-based interventions (EBI) are ubiquitous, few studies have examined the nature and rationale for modifications to the components of these interventions. The primary aim of this study was to describe and classify common local adaptations of the Transitional Care Model (TCM), an EBI comprised of 10 components that has been proven in multiple clinical trials to improve the care and outcomes of chronically ill older adults transitioning from hospitals to home. Guided by Stirman's System of Classifying Adaptations, 582 transitional care clinicians in health systems and community-based organizations throughout the U.S. completed a survey between September 2014 and January 2015; interviews were then conducted with a subset of survey respondents (N = 24) between April and December 2015. A total of 342 survey respondents (59%) reported implementation of the TCM in distinct organizations. Of this group, 96% reported a mean of 4.4 adaptations to the 10 TCM components (40%, one to three; 43%, four to six; and 17%, seven to nine). Nine of ten respondents (94%) reported contextual adaptations while content adaptations were less frequently reported (58%). The top three reported adaptations all related to context (i.e., delivering services from hospital to home, relying on advance practice nurses, and fostering care continuity); interviews clarified a diverse set of reasons for such modifications. Findings reinforce the need for investment in adaptation science and suggest hypotheses to guide rigorous examination of the association between adaptations of TCM components and desired outcomes.

Aim: The goal of this study was to compare postacute care costs of three care management interventions. Materials & methods: A total of 202 hospitalized older adults with cognitive impairment received either Augmented Standard Care, Resource Nurse Care or the Transitional Care Model. The Lin method was used to estimate costs at 30 and 180 days postindex hospital discharge. Results: The Transitional Care Model had significantly lower costs than the Augmented Standard Care group at both 30 (p Conclusion: These findings suggest that the Transitional Care Model can reduce both the amount of other postacute care and the total cost of care compared with alternative services for cognitively impaired older adults. Clinicaltrials.gov : NCT00294307.

Aims and objectives To explore how older patients with multiple chronic conditions and their family caregivers perceive their engagement and overall care experience throughout the preoperative phase of elective orthopaedic hip or knee joint replacement. Background Patient engagement is a critical component of care necessary for improving patient outcomes. Little is known about how older adults with multiple chronic conditions and their family caregivers engage in preoperative care transitions and the subsequent impact of this experience on postoperative health outcomes. Design Prospective qualitative descriptive design was used. Methods Semi-structured telephone interviews with a convenience sample of older adults coping with multiple chronic conditions and their family caregivers. Interviews were conducted prior to surgery and, again 21 days postsurgery, were audio-recorded and transcribed for qualitative content analysis. The Quality Health Outcomes Model was used to categorise study findings. Results Eleven patients and five family caregivers participated. Guided by the Quality Health Outcomes Model, four major themes were identified. (i) Older adults perceive that joint replacement is about quality of life. (ii) Standardised interventions often fail to address the unique needs of complex older adults. (iii) Family caregivers perceive they are the primary care coordinators. (iv) Postoperative outcomes and resource utilisation vary widely in complex older adults. Conclusion Findings suggest that current preoperative care interventions are often not designed to effectively engage complex older patients and their family caregivers. Coordinated patient-centred preoperative care that reflects the needs and goals of complex older patients and their family caregivers may positively influence perioperative care transitions and outcomes beyond this episode of care. Relevance to clinical practice The current research documents the need for more in-depth knowledge about the relationship between older adults' and their family caregivers' engagement preoperatively and postoperative outcomes and resource utilisation.