Perspectives from persons living with dementia and their caregivers on emergency department visits, care transitions, and outpatient follow-up: A qualitative study.

BACKGROUND: Persons living with dementia (PLWD) experience frequent and costly emergency department (ED) visits, with poor outcomes attributed to suboptimal care and postdischarge care transitions. Yet, patient-centered data on ED care experiences and postdischarge needs are lacking. The objective of this study was to examine the facilitators and barriers to successful ED care and care transitions after discharge, according to PLWD and their caregivers. METHODS: We conducted a qualitative study involving ED patients ages 65 and older with confirmed or suspected dementia and their caregivers. The semistructured interview protocol followed the National Quality Forum's ED Transitions of Care Framework and addressed ED care, care transitions, and outpatient follow-up care. Interviews were conducted during an ED visit at an urban, academic ED. Traditional thematic analysis was used to identify themes. RESULTS: We interviewed 11 patients and 19 caregivers. Caregivers were more forthcoming than patients about facilitators and challenges experienced. Characteristics of the patients' condition (e.g., resistance to care, forgetfulness), the availability of family resources (e.g., caregiver availability, primary care access), and system-level factors (e.g., availability of timely appointments, hospital policies tailored to persons with dementia) served as facilitators and barriers to successful care. Some resources that would ameliorate care transition barriers could be easily provided in the ED, for example, offering clear discharge instructions and care coordination services and improving patient communication regarding disposition timeline. Other interventions would require investment from other parts of the health care system (e.g., respite for caregivers, broader insurance coverage). CONCLUSIONS: ED care and care transitions for PLWD are suboptimal, and patient-level factors may exacerbate existing system-level deficiencies. Insight from patients and their caregivers may inform the development of ED interventions to design specialized care for this patient population. This qualitative study also demonstrated the feasibility of conducting ED-based studies on PLWD during their ED visit.

Optimizing voice-controlled intelligent personal assistants for use by home-bound older adults.

INTRODUCTION: Social isolation is a major public health concern, as isolated individuals are at increased risk of poor overall health, as well as at increased risk of unhealthy behaviors. During the COVID-19 pandemic, social distancing strategies have led to increased rates of loneliness and social isolation. There is a clear need for strategies to mitigate the effects of social isolation and loneliness on the mental and physical health of older adults. In this study, we sought to better understand how voice-controlled intelligent personal assistants (VIPAs) could be leveraged to reduce loneliness and social isolation among home-bound older adults. METHODS: Patients and geriatric experts were recruited to use VIPA devices (Google Home) in their homes for 4 weeks and then provide feedback. No prior training was provided. Geriatric experts were recruited via email solicitation from the Northwestern Medicine Geriatrics Clinic, and patients were solicited directly from geriatric primary care physicians. The investigators used qualitative analysis to identify codes and overarching themes. RESULTS: A total of 288 comments were received from 16 participants. Eight major themes were identified: Administrative, Companionship, Home Control, Education, Emergencies, Entertainment, Health and Well-Being, and Reminders. DISCUSSION: Results demonstrate that VIPAs can be useful across multiple domains and potentially play a role in providing physical, social, and cognitive stimulation to home-bound older adults. VIPAs have a wide range of functionality, many of which could be implemented to focus on common geriatric syndromes and may ultimately be a tool to help mitigate social isolation and the consequential loneliness.

A mastery learning approach to education about fall risk and gait assessment.

Mastery learning is a form of competency-based education in which learning time varies but outcomes are uniform. Trainees must meet a minimum passing standard (MPS) before completing a mastery learning curriculum. The objective of this study was to establish a curriculum for fall risk and gait assessment for medical students, determine an MPS for a fall risk and gait assessment clinical skills examination (CSE), and apply the MPS to a sample of medical students completing a fall risk and gait assessment CSE. Medical students completed an interactive session about fall risk and gait assessment including the Timed Up and Go (TUG) test and completed deliberate practice with 3 patients. Skills were evaluated using an 18-item skills checklist. A panel of clinical experts set the MPS at 82%. Eighty-seven medical students participated. The average score on the checklist was 14.7 of 18 (81.4%.) Although almost all performed the TUG correctly, only 61% met the MPS for the checklist. Our results suggest that a mastery learning approach may better prepare the 39% of students that did not meet MPS to complete a fall risk and gait assessment.

Development and evaluation of a simulation-based mastery learning maintenance of certification course.

BACKGROUND/OBJECTIVES: To develop and evaluate a post-acute care simulation-based mastery learning (SBML) continuing medical education (CME)/maintenance of certification (MOC) procedure course. DESIGN: Pretest-posttest study of the SBML intervention. SETTING: A 2-day post-acute care procedures course. PARTICIPANTS: Sixteen practicing clinicians (5 physicians,11 advanced practice providers). Participants engaged in a skills pretest on knee aspiration/injection, gastrostomy tube removal/replacement, tracheostomy tube exchange, and basic suturing using a checklist created for each procedure. Participants received a didactic on each procedure followed by deliberate practice with feedback. Using the same checklists, participants completed a skills posttest and were required to meet a minimum passing standard (MPS) to obtain CME/MOC credit. MEASUREMENTS: The MPS for each skills checklist was determined by a multidisciplinary panel of 11 experts. Participants completed surveys on procedure self-confidence and a course evaluation. RESULTS: There was statistically significant improvement between pre- and posttests for all four procedures (p < .001). All participants were able to meet or exceed the MPS for each skill during the 2-day course. Participants' self-confidence regarding each procedure improved significantly (p < .001). CONCLUSION: An SBML training course granting CME/MOC credit for post-acute care providers significantly improves performance of knee aspiration/injection, gastrostomy tube removal/replacement, tracheostomy tube exchange, and basic suturing.

We've got what the NHS ultimately intended for us: Experiences of community engagement in rural primary care services change.

Policy promotes service user engagement in health services design and delivery. Various tools exist to support the engagement of citizens within health services design. We consider community engagement within the context of primary care delivery in remote and rural areas of Scotland. We present findings from three years of qualitative work with community members and healthcare professionals within five different remote and rural areas, undergoing primary care service changes. 364 interviews were carried out with community members and healthcare professionals on their experiences of, and feelings towards, the services changes. A key theme to emerge from our thematic analysis of the qualitative data is experiences of community engagement. In this paper we present our analysis of this theme. We identify different types of community engagement discourse within community and healthcare professional interviews. We illustrate these themes and, through consideration of five case study areas, demonstrate how these discourses can co-exist within the same service change process. The paper presents our sub-themes on community engagement relating to discourses of inclusion and exclusion; the role of the General Practitioner (GP); conceptualisations of the organisational role of the NHS; discourses of fear and, finally, community members understandings of what it means to be active "agents of change" (or not) within health services redesign. We argue that context is as important as method when it comes to facilitating a positive community engagement experience for citizens. Our findings have relevance to the emerging social science literature on citizen experience of public sector community engagement activities.

Ruptured Visceral Artery Aneurysms: A Deadly Cause of Epigastric Pain.

Visceral artery aneurysms (VAA) are rare, life-threatening disease processes that often affect the celiac, superior mesenteric, or inferior mesenteric arteries and their respective branches. The splenic, hepatic, superior mesenteric, and tripod celiac arteries are most commonly affected and have high rupture and mortality rates. This case describes splenic and celiac artery aneurysms in a patient that led to hemorrhagic shock and multisystem organ failure despite timely diagnosis and ligation. A brief review of the literature further elucidates the key risk factors in identifying patients with VAAs and their treatment course.

Stressors Facing Home-Based Primary Care Providers.

The numbers of homebound patients in the United States are increasing. Home-based primary care (HBPC) is an effective model of interdisciplinary care that has been shown to have high patient satisfaction rates and excellent clinical outcomes. However, there are few clinicians that practice HBPC and clinicians that do face additional stressors. This study sought to better understand the stressors that HBPC providers face in caring for homebound patients. This was a cross-sectional qualitative survey and analysis of HBPC providers. Responses were categorized into four themes: The patient in the home setting, caregiver support, logistics, and administrative concerns. This research is the first to analyze the stressors that providers of HBPC face in serving the needs of complex homebound patients. Awareness and attention to these issues will be important for the future sustainability of home-based primary care.

Evaluation of a Community-Based Program That Integrates Joyful Movement Into Fall Prevention for Older Adults.

Background: Despite the development of evidence-based fall-prevention programs, there remains a need for programming that will engage older adults in real-world settings. Objective: This study aimed to evaluate a community-based group program that integrates joyful movement into fall prevention. The curriculum emphasizes a positive experience of movement, cultivating a healthy body image, and retraining of biomechanics. Design: Program evaluation was conducted using a one-group pre-post test study design. Key outcomes were functional balance and confidence. Qualitative feedback was gathered at the final class sessions. Results: Two hundred fifteen older adults enrolled at four sites over the period from 2010 to 2014. Among 86 participants who provided feedback, most credited the program for an increased sense of optimism and/or confidence (70%), and better walking ability (50%). Among 102 participants who completed both initial and final assessments, there was evidence of significant improvements on the Functional Reach Test (d = .60, p < .001) and Modified Falls Efficacy Scale (d = .17, p < .001). Conclusion: A joyful movement curriculum is acceptable to older participants, and they show improvements in functional balance and confidence. Future research should examine whether the positive changes encouraged by joyful movement lead to lasting reductions in fall risk and additional health benefits.

Medical students' reflections of a posthospital discharge patient visit.

Transitions of care is an important part of patient safety that is not often taught in medical schools. As part of a curriculum for patient safety and transitions of care, third-year medical students followed patients they cared for during their inpatient rotations on a posthospital discharge visit. Students answered reflection questions on these visits, which were reviewed at a group debriefing session. The written reflections and oral debriefings were analyzed qualitatively to identify what medical students were able to learn from a posthospital discharge visit. Of the students who visited patients, 265 participated in the debriefing sessions, and their responses were grouped into 7 domains and 33 themes. Students commented most often on the importance of family and caregivers who provided support for the patient after hospitalization. They identified problems specific to the discharge process and factors that helped or hindered transitions, noted new experiences visiting postacute care facilities, and also developed solutions to improve transitions. Postdischarge visits combined with brief reflection writing and debriefing allowed students to better understand difficulties that can be faced in care transitions.

A patient safety and transitions of care curriculum for third-year medical students.

The elderly are the most vulnerable to adverse events during and after hospitalization. This study sought to evaluate the effectiveness of a curriculum on patient safety and transitions of care for medical students during an Internal Medicine-Geriatrics Clerkship on students' knowledge, skills, and attitudes. The curriculum included didactics on patient safety, health literacy, discharge planning and transitions of care, and postdischarge visits to patients. Analysis of pre- and postassessments showed afterwards students were significantly more comfortable assessing a patient's health literacy and confident performing a medication reconciliation, providing education regarding medications, and identifying barriers during transitions. More students were able to identify the most common source of adverse events after discharge (86% vs. 62% before), risk factors for low health literacy (28% vs. 14%), and ways to assess a patient's health literacy (14% vs. 2%). It was feasible to implement a postdischarge visit assignment in an urban tertiary care setting and only required on average of approximately an one and one half hours for students to complete.

Geriatric assistive devices.

Disability and mobility problems increase with age. Assistive devices such as canes, crutches, and walkers can be used to increase a patient's base of support, improve balance, and increase activity and independence, but they are not without significant musculoskeletal and metabolic demands. Most patients with assistive devices have never been instructed on the proper use and often have devices that are inappropriate, damaged, or are of the incorrect height. Selection of a suitable device depends on the patient's strength, endurance, balance, cognitive function, and environmental demands. Canes can help redistribute weight from a lower extremity that is weak or painful, improve stability by increasing the base of support, and provide tactile information about the ground to improve balance. Crutches are useful for patients who need to use their arms for weight bearing and propulsion and not just for balance. Walkers improve stability in those with lower extremity weakness or poor balance and facilitate improved mobility by increasing the patient's base of support and supporting the patient's weight. Walkers require greater attentional demands than canes and make using stairs difficult. The top of a cane or walker should be the same height as the wrist crease when the patient is standing upright with arms relaxed at his or her sides. A cane should be held contralateral to a weak or painful lower extremity and advanced simultaneously with the contralateral leg. Clinicians should routinely evaluate their patients' assistive devices to ensure proper height, fit, and maintenance, and also counsel patients on correct use of the device.

Falls in older adults.

Falls are prevalent among older adults and can lead to injury, hospitalization, and increased healthcare costs. Environmental hazards, medications, vision problems, and impairments in strength, gait, or balance can increase fall risk. A multifactorial fall-risk assessment including a fall history, physical exam, gait and balance evaluation, and environmental assessment is recommended for all older adults who present with a fall or problem with gait or balance. Multiple-component exercise programs, tai chi, vitamin D supplementation, withdrawal of psychotropic medications, and early cataract surgery have all been shown to reduce fall rates. Multifactorial interventions that include medication review, vision correction, management of orthostasis, environmental modification, and balance, strength, and gait training can also be beneficial in preventing falls.

Predictors of serious injury among hospitalized patients evaluated for falls.

BACKGROUND: Inpatient falls are common and result in significant patient morbidity. OBJECTIVE: To identify predictors of serious injury being found on imaging studies of inpatients evaluated after a fall. DESIGN: Retrospective study. SETTING: : An 1171-bed urban academic medical center. PATIENTS: All inpatients who fell on thirteen medical and surgical units from January 1 to December 31, 2006. MEASUREMENTS: Patient characteristics, circumstances surrounding falls, fall-related injuries, and length of stay were collected through review of incident reports and computerized medical records. Primary outcome of fall-related injury was determined by evidence of injury on imaging studies within two weeks of the fall. Univariate and multivariate logistic regression were used to calculate adjusted odds ratios (ORs) for injury after an inpatient fall. RESULTS: A total of 513 patients had 636 falls during the study time period. Fall incidence rate was 1.97 falls per 1,000 patient days. 95 patients (19%) fell multiple times (range, 2-6 events); 74% of the falls occurred in patients who were previously assessed as being "at risk" by the nursing staff. Multivariate analysis, adjusting for age and sex, found evidence of trauma after a fall (OR = 24.6, P < 0.001) and ambulatory status (OR = 7.3, P < 0.01) to be independent predictors of injury being found on imaging studies. CONCLUSIONS: Inpatient falls are common despite high-risk patients being identified. After adjusting for age and sex, evidence of trauma and ambulatory status were independent predictors of an injury being found on imaging studies after an inpatient fall.