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Introduction: Older adults use the emergency department (ED) at high rates, including for illnesses that could be managed by their primary care providers (PCP). Policymakers have implemented barriers and incentives, often financial, to try to modify use patterns but with limited success. This study aims to understand the factors that influence older adults’ decision to obtain acute illness care from the ED rather than from their PCPs. Methods: We performed a qualitative study using a directed content analysis approach from February to October 2013. Fifteen community-dwelling older adults age≥65 years who presented to the ED of an academic medical center hospital for care and who were discharged home were enrolled. Semi-structured interviews were conducted initially in the ED and subsequently in patients’ homes over the following six weeks. All interviews were audio-recorded, transcribed, verified, and coded. The study team jointly analyzed the data and identified themes that emerged from the interviews. Results: The average age of study participants was 74 years (standard deviation ±7.2 years); 53% were female; 80% were white. We found five themes that influenced participants’ decisions to obtain acute illness care from the ED: limited availability of PCP-based care, variable interactions with healthcare providers and systems, limited availability of transportation for illness care, desire to avoid burdening friends and family, and previous experiences with illnesses.  Conclusion: Community-dwelling older adults integrate multiple factors when deciding to obtain care from an ED rather than their PCPs. These factors relate to personal and social considerations, practical issues, and individual perceptions based on previous experiences. If these findings are validated in confirmatory studies, policymakers wishing to modify where older adults receive care should consider person-centered interventions at the system and individual level, such as decision support, telemedicine, improved transport services, enhancing PCPs’ capabilities, and enhancing EDs’ resources to care for older patients.

Constructivist grounded theory methods were used to explore counseling engagement in clients with strong tendencies to avoid aversive emotion. Participants initially viewed counseling as a potentially adversarial and harmful relationship. An expectation and fear of judgment, as well as shame and self‐judgment, contributed to this view. Participants also reported anxiety about addressing specific issues. Their perceptions led to withholding of personal information and minimal engagement. The participants were initially susceptible to negative or fruitless counseling episodes. However, if a trusting therapeutic relationship developed, engagement increased. Trust developed if the participants perceived their counselors as non‐judgmental and genuine. Recognizing possible benefits—in addition to risks—of counseling also contributed to their decisions to engage. The participants reported that counseling helped change their perspectives. They eventually perceived and appreciated the benefits of emotional engagement. Implications for counselors are provided. [ABSTRACT FROM AUTHOR]

Purpose Although many older adults suffer from dysphagia and are required to eat texture-modified diets, little is known about the experiences and challenges faced in doing so at home. In this study, we explored the perspectives of community-dwelling older adults as they struggled to balance dysphagia symptoms and recommended diet modifications with their preferred lifestyles. Design and Methods Using an interpretive descriptive design, we conducted 37 in-home semi-structured interviews and 5 member-checking interviews, participant observations during a meal, and reviewed the medical charts of 20 participants recruited through maximum variation purposeful sampling. Meaning units and codes were identified and synthesized into 4 themes. Results Participants faced a frightening choice between eating and breathing. Hiding dysphagia symptoms from the public eye was important to preserve self-identity. Following the recommended diet created a feeling that life was “falling apart.” We also found that adhering to the diet was not an “all or none” phenomenon. Implications Given that correct adherence to the restrictive diet is rare, to effectively manage dysphagia symptoms, clinicians must appreciate the full range of impact of dysphagia and texture-modified diets on the lives of older adults. [ABSTRACT FROM AUTHOR]