Trauma re-engagement and PTSD in older medically ill veterans: implications for trauma-informed care.

OBJECTIVES: We characterize rates and correlates of PTSD and of trauma re-engagement without PTSD in medically ill older Veterans, as well as supportive strategies, with the goal of advancing trauma-informed care. METHODS: We interviewed medically ill older Veterans (N = 88, M age 75.13, SD = 6.14) with primary care screening measures for PTSD and trauma re-engagement, and open-ended questions to assess supportive strategies. RESULTS: One-fifth (20.5%) presented with probable PTSD, associated with greater trauma exposures (r=.57, p<.001), whereas two-fifths (43.2%) reported re-engagement with military memories without PTSD, associated with having a spouse/partner (t = 2.27, p=.028). Of those who experienced trauma, half reported thinking more about the trauma recently and becoming more emotional on certain days. In response to the question 'What gives you strength as you think about the future with your illness' Veterans described support of family, healthcare, worldview, personal control, acceptance, and health behaviors. CONCLUSION: Memories of trauma are common with medical illness. Age-friendly trauma-informed care could consider factors that patients describe as sources of strength with illness.

Front-Line innovation: Rapid implementation of a nurse-driven protocol for care of outpatients with COVID-19.

AIMS AND OBJECTIVES: Our objective was to rapidly adapt and scale a registered nurse-driven Coordinated Transitional Care (C-TraC) programme to provide intensive home monitoring and optimise care for outpatient Veterans with COVID-19 in a large urban Unites States healthcare system. BACKGROUND: Our diffuse primary care network had no existing model of care by which to provide coordinated result tracking and monitoring of outpatients with COVID-19. DESIGN: Quality improvement implementation project. METHODS: We used the Replicating Effective Programs model to guide implementation, iterative Plan-Do-Study-Act cycles and SQUIRE reporting guidelines. Two transitional care registered nurses, and a geriatrician medical director developed a protocol that included detailed initial assessment, overnight delivery of monitoring equipment and phone-based follow-up tailored to risk level and symptom severity. We tripled programme capacity in time for the surge of cases by training Primary Care registered nurses. RESULTS: Between 23 March and 15 May 2020, 120 Veterans with COVID-19 were enrolled for outpatient monitoring; over one-third were aged 65 years or older, and 70% had medical conditions associated with poor COVID-19 outcomes. All Veterans received an initial call within a few hours of the laboratory reporting positive results. The mean length of follow-up was 8.1 days, with an average of 4.2 nurse and 1.3 physician or advanced practice clinician contacts per patient. The majority (85%) were managed entirely in the outpatient setting. After the surge, the model was disseminated to individual primary care teams through educational sessions. CONCLUSION: A model based on experienced registered nurses can provide comprehensive, effective and sustainable outpatient monitoring to high-risk populations with COVID-19.

Frailty, Implantable Cardioverter Defibrillators, and Mortality: a Systematic Review.

BACKGROUND: Evidence for the benefit of implantable cardioverter defibrillators (ICD) in preventing sudden cardiac death (SCD) in older adults is mixed; age alone may not predict benefit. Frailty may help identify patients in whom an ICD does not improve overall mortality risk. METHODS: Structured search of PubMed, Embase, Web of Science, and Cochrane Central Register of Controlled Trials on 1/31/2019, without language restriction, with terms for ICD, frailty, and mortality. Frailty was defined broadly using any validated single component (e.g., walking speed, weight loss) or multi-component tool (e.g., cumulative deficit index). Each study was assessed for quality and risk of bias. RESULTS: We identified and screened 2649 titles, reviewed 280 abstracts, and extracted 71 articles. Nine articles, including two RCTs, one prospective cohort, and six retrospective cohort studies met all criteria. The most common reason for exclusion was a lack of frailty definition. Frailty definitions were heterogeneous, including cumulative deficit models, low weight, and walking speed. Follow-up time for mortality differed: from days to > 6 years. All studies indicated that mortality was higher amongst individuals identified as frail, regardless of definition. In one RCT, slow walkers did not benefit from ICD therapy after 3 years. A cohort of 83,792 Medicare beneficiaries in an ICD registry reported higher 1-year mortality following ICD in those with frailty or dementia. Four studies reported an association between being underweight and increased mortality following ICD placement. CONCLUSION: Existing literature suggests that individuals with frailty may not benefit from ICD placement for primary prevention of SCD.

An innovative rehabilitation program for the veterans affairs post-acute skilled nursing setting: Preliminary results.

BACKGROUND: Skilled nursing rehabilitative care plays a critical role in older adults' functional recovery impacting post-discharge outcomes. Variations across post-acute rehabilitative care services and patient outcomes indicate a need to improve rehabilitative care in this setting. We adapted a successful outpatient care program (Live Long Walk Strong-LLWS) to address this need in post-acute care settings within the Veterans Health Administration. LLWS differs from standard PT care by treating impairments linked to functional decline that are not traditionally targeted by standard care, providing formalized coaching to optimize behavior change, and providing post-discharge case management to optimize long-term outcomes. The purpose was to adapt, refine and implement the LLWS program for the Community Living Center (CLC), determine its acceptability and feasibility, and evaluate its preliminary effectiveness among older adults. METHODS: The design of the program was adapted from the original outpatient LLWS program to the CLC setting through quality improvement methods and the Replicating Effective Programs (REP) framework. Primary outcomes included measures of feasibility and acceptability of >80% enrollment and completion of sessions as well as preliminary effectiveness using performance-based and patient-reported measures of function including the Short Physical Performance Battery (SPPB), AM-PAC, a Global Rating of Change questionnaire, and a satisfaction survey. RESULTS: After 18 months, 51 Veterans had enrolled in the LLWS program, with 94.1% maintaining enrollment. We observed >80% completion of the inpatient and home follow-up sessions. Most patients were highly satisfied with care. Improvements in the SPPB (2.3 (SD 2.2) points), gait speed (0.17 (0.14) m/s) and the AM-PAC (6.5 (SD 5.7)) surpassed clinically meaningful thresholds. CONCLUSIONS: This novel care program is feasible and acceptable to Veterans, demonstrating preliminary effectiveness with improving functional outcomes. Future research is needed to further examine the program's impact on other important outcomes relative to standard modes of care.

Coordinated-Transitional Care (C-TraC) for Veterans from Subacute Rehabilitation to Home.

OBJECTIVES: To adapt a successful acute care transitional model to meet the needs of veterans transitioning from post-acute care to home. DESIGN: Quality improvement intervention. SETTING AND PARTICIPANTS: Veterans discharged from a subacute care unit in the VA Boston Healthcare System's skilled nursing facility. METHODS: We used the Replicating Effective Programs framework and Plan-Do-Study-Act cycles to adapt the Coordinated-Transitional Care (C-TraC) program to the context of transitions from a VA subacute care unit to home. The major adaptation of this registered nurse-driven, telephone-based intervention was combining the roles of discharge coordinator and transitional care case manager. We report the details of the implementation, its feasibility, and results of process measures, and describe its preliminary impact. RESULTS: Between October 2021 and April 2022, all 35 veterans who met eligibility criteria in the VA Boston Community Living Center (CLC) participated; none were lost to follow-up. The nurse case manager delivered core components of the calls with high fidelity-review of red flags, detailed medication reconciliation, follow-up with primary care physician, and discharge services were discussed and documented in 97.9%, 95.9%, 86.8%, and 95.9%, respectively. CLC C-TraC interventions included care coordination, patient and caregiver education, connecting patients to resources, and addressing medication discrepancies. Nine medication discrepancies were discovered in 8 patients (22.9%; average of 1.1 discrepancies per patient). Compared with a historical cohort of 84 veterans, more CLC C-TraC patients received a post-discharge call within 7 days (82.9% vs 61.9%; P = .03). There was no difference between rates of attendance to appointments and acute care admissions post-discharge. CONCLUSIONS AND IMPLICATIONS: We successfully adapted the C-TraC transitional care protocol to the VA subacute care setting. CLC C-TraC resulted in increased post-discharge follow-up and intensive case management. Evaluation of a larger cohort to determine its impact on clinical outcomes such as readmissions is warranted.

Nurse-led supportive Coordinated Transitional Care (CTraC) program improves care for veterans with serious illness.

BACKGROUND: The Coordinated Transitional Care (CTraC) program is a telephone-based, nurse-driven program shown to decrease readmissions. The aim of this project was to implement and evaluate an adapted version of CTraC, Supportive CTraC, to improve the quality of transitional and end-of-life care for veterans with serious illness. METHODS: We used the Replicating Effective Programs framework to guide adaptation and implementation. An RN nurse case manager (NCM) with experience in geriatrics and palliative care worked closely with inpatient and outpatient care teams to coordinate care. Eligible patients had a life-limiting diagnosis with substantial functional impairment and were not enrolled in hospice. The NCM identified veterans at VA Boston Healthcare System during an acute admission and delivered a protocolized intervention to define care needs and preferences, align care with patient values, optimize discharge plans, and provide ongoing, intensive phone-based case management. To evaluate efficacy, we matched each Supportive CTraC enrollee 1:1 to a contemporary comparison subject by age, risk of death or hospitalization, and discharge diagnosis. We used Kaplan-Meier plots and Cox-Proportional Hazards models to evaluate outcomes. Outcomes included palliative and hospice care use, acute care use, Massachusetts Medical Orders for Life Sustaining Treatment documentation, and survival. RESULTS: The NCM enrolled 104 veterans with high protocol fidelity. Over 1.5 years of follow-up, Supportive CTraC enrollees were 61% more likely to enroll in hospice than the comparison group (n = 57 vs. 39; HR = 1.61; 95% CI = 1.07-2.43). While overall acute care use was similar between groups, Supportive CTraC patients had fewer ICU admissions (n = 36 vs. 53; p = 0.005), were more likely to die in hospice (53 vs. 34; p = 0.008), and twice as likely to die at home with hospice (32.0 vs. 15.5; p = 0.02). There was no difference in survival between groups. CONCLUSIONS: A nurse-driven transitional care program for veterans with serious illness is feasible and effective at improving end-of-life outcomes.

Defining Undertreatment and Overtreatment in Older Adults With Cancer: A Scoping Literature Review.

PURPOSE: The terms undertreatment and overtreatment are often used to describe inappropriate management of older adults with cancer. We conducted a comprehensive scoping review of the literature to clarify the meanings behind the use of the terms. METHODS: We searched PubMed (National Center for Biotechnology Information), Embase (Elsevier), and CINAHL (EBSCO) for titles and abstracts that included the terms undertreatment or overtreatment with regard to older adults with cancer. We included all types of articles, cancer types, and treatments. Definitions of undertreatment and overtreatment were extracted, and categories underlying these definitions were derived through qualitative analysis. Within a random subset of articles, C.D. and K.P.L. independently performed this analysis to determine final categories and then independently assigned these categories to assess inter-rater reliability. RESULTS: Articles using the terms undertreatment (n = 236), overtreatment (n = 71), or both (n = 51) met criteria for inclusion in our review (n = 256). Only 14 articles (5.5%) explicitly provided formal definitions; for the remaining, we inferred the implicit definitions from the terms' surrounding context. There was substantial agreement (κ = 0.81) between C.D. and K.P.L. in independently assigning categories of definitions within a random subset of 50 articles. Undertreatment most commonly implied less than recommended therapy (148; 62.7%) or less than recommended therapy associated with worse outcomes (88; 37.3%). Overtreatment most commonly implied intensive treatment of an older adult in whom the harms of treatment outweigh the benefits (38; 53.5%) or intensive treatment of a cancer not expected to affect an older adult in his/her remaining lifetime (33; 46.5%). CONCLUSION: Undertreatment and overtreatment of older adults with cancer are imprecisely defined concepts. We propose new, more rigorous definitions that account for both oncologic factors and geriatric domains.

An application to support COVID-19 occupational health and patient tracking at a Veterans Affairs medical center.

OBJECTIVE: Reducing risk of coronavirus disease 2019 (COVID-19) infection among healthcare personnel requires a robust occupational health response involving multiple disciplines. We describe a flexible informatics solution to enable such coordination, and we make it available as open-source software. MATERIALS AND METHODS: We developed a stand-alone application that integrates data from several sources, including electronic health record data and data captured outside the electronic health record. RESULTS: The application facilitates workflows from different hospital departments, including Occupational Health and Infection Control, and has been used extensively. As of June 2020, 4629 employees and 7768 patients and have been added for tracking by the application, and the application has been accessed over 46 000 times. DISCUSSION: Data captured by the application provides both a historical and real-time view into the operational impact of COVID-19 within the hospital, enabling aggregate and patient-level reporting to support identification of new cases, contact tracing, outbreak investigations, and employee workforce management. CONCLUSIONS: We have developed an open-source application that facilitates communication and workflow across multiple disciplines to manage hospital employees impacted by the COVID-19 pandemic.