Transforming health care: A large health organizations' journey to become an age-friendly health system (AFHS) and beyond.

BACKGROUND: In 2017, the John A. Hartford Foundation partnered with the Institute for Health Care Improvement, American Hospital Association, and Catholic Health Care Organization to define the 4Ms framework to improve quality of care and health outcomes for older adults. The senior leadership of one of the largest integrated healthcare organizations (HCO) in the country recognized the relevance of these recommendations to the aging demographic of the United States. The health system provides care to over 2,000,000 unique patients annually, about 20% of whom are aged ≥65. We describe how commitment to becoming an Age-Friendly Health System (AFHS) has taken this HCO beyond the targets set by the initiative. METHODS: Steps guiding evolution of the AFHS model of care are as follows: Initiation, assessment, planning, implementation, sustainability. An AFHS leadership team including geriatrics and quality improvement expertise oversees the initiative. Plan-Do-Study-Act cycles are utilized at multiple stages to develop structures for data collection and reporting outcomes. RESULTS: Initiation and assessment stages identified key champions and existing efforts and programs that were leveraged to implement 4Ms best practices. Working committees with relevant expertise for each M selected evidence-based quality measures and designed/adapted training materials. The EHR is used to integrate quality measures and gather outcome data to inform changes in care. Dashboards capturing quality measures for each M have been implemented and pilot-tested at a community-based hospital and these processes are being adapted and disseminated to other settings. Leadership and stakeholders convene regularly to review lessons learned and next steps. CONCLUSIONS: On the health system level, partnering with quality management leaders has led to development of processes that feed into organizational level data used to track longitudinal improvements in patient outcomes. Outcome data in each of the 4M domains are presented. Learning points are shared to help others take a systems-approach to age-friendly change.

Video Intervention and Goals-of-Care Documentation in Hospitalized Older Adults: The VIDEO-PCE Randomized Clinical Trial.

Importance: Despite the benefits of goals-of-care (GOC) communication, many hospitalized individuals never communicate their goals or preferences to clinicians. Objective: To assess whether a GOC video intervention delivered by palliative care educators (PCEs) increased the rate of GOC documentation. Design, Setting, and Participants: This pragmatic, stepped-wedge cluster randomized clinical trial included patients aged 65 years or older admitted to 1 of 14 units at 2 urban hospitals in New York and Boston from July 1, 2021, to October 31, 2022. Intervention: The intervention involved PCEs (social workers and nurses trained in GOC communication) facilitating GOC conversations with patients and/or their decision-makers using a library of brief, certified video decision aids available in 29 languages. Patients in the control period received usual care. Main Outcome and Measures: The primary outcome was GOC documentation, which included any documentation of a goals conversation, limitation of life-sustaining treatment, palliative care, hospice, or time-limited trials and was obtained by natural language processing. Results: A total of 10 802 patients (mean [SD] age, 78 [8] years; 51.6% male) were admitted to 1 of 14 hospital units. Goals-of-care documentation during the intervention phase occurred among 3744 of 6023 patients (62.2%) compared with 2396 of 4779 patients (50.1%) in the usual care phase (P < .001). Proportions of documented GOC discussions for Black or African American individuals (865 of 1376 [62.9%] vs 596 of 1125 [53.0%]), Hispanic or Latino individuals (311 of 548 [56.8%] vs 218 of 451 [48.3%]), non-English speakers (586 of 1059 [55.3%] vs 405 of 863 [46.9%]), and people living with Alzheimer disease and related dementias (520 of 681 [76.4%] vs 355 of 570 [62.3%]) were greater during the intervention phase compared with the usual care phase. Conclusions and Relevance: In this stepped-wedge cluster randomized clinical trial of older adults, a GOC video intervention delivered by PCEs resulted in higher rates of GOC documentation compared with usual care, including among Black or African American individuals, Hispanic or Latino individuals, non-English speakers, and people living with Alzheimer disease and related dementias. The findings suggest that this form of patient-centered care delivery may be a beneficial decision support tool. Trial Registration: ClinicalTrials.gov Identifier: NCT04857060.

Forms or Free-Text? Measuring Advance Care Planning Activity Using Electronic Health Records.

Advance care planning (ACP) discussions seek to guide future serious illness care. These discussions may be recorded in the electronic health record by documentation in clinical notes, structured forms and directives, and physician orders. Yet, most studies of ACP prevalence have only examined structured electronic health record elements and ignored data existing in notes. We sought to investigate the relative comprehensiveness and accuracy of ACP documentation from structured and unstructured electronic health record data sources. We evaluated structured and unstructured ACP documentation present in the electronic health records of 435 patients with cancer drawn from three separate healthcare systems. We extracted structured ACP documentation by manually annotating written documents and forms scanned into the electronic health record. We coded unstructured ACP documentation using a rule-based natural language processing software that identified ACP keywords within clinical notes and was subsequently reviewed for accuracy. The unstructured approach identified more instances of ACP documentation (238, 54.7% of patients) than the structured ACP approach (187, 42.9% of patients). Additionally, 16.6% of all patients with structured ACP documentation only had documents that were judged as misclassified, incomplete, blank, unavailable, or a duplicate of a previously entered erroneous document. ACP documents scanned into electronic health records represent a limited view of ACP activity. Research and measures of clinical practice with ACP should incorporate information from unstructured data.

Structural Barriers to Well-grounded Advance Care Planning for the Seriously Ill: a Qualitative Study of Clinicians' and Administrators' Experiences During a Pragmatic Trial.

BACKGROUND: Advance Care Planning (ACP) comprises an iterative communication process aimed at understanding patients' goals, values, and preferences in the context of considering and preparing for future medical treatments and decision making in serious illness. The COVID pandemic heightened patients' and clinicians' awareness of the need for ACP. OBJECTIVE: Our goal was to explore the experiences of clinicians and administrators in the context of an intervention to improve ACP during the COVID pandemic. DESIGN: Qualitative interview study. PARTICIPANTS: Clinicians and administrators across five sites that participated in the ACP-COVID trial. APPROACH: We conducted semi-structured, qualitative interviews examining the context and approach to ACP. Interviews were analyzed using template analysis to systematically organize the data and facilitate review across the categories and participants. Templates were developed with iterative input and line-by-line review by the analytic team, to reach consensus. Findings were then organized into emergent themes. KEY RESULTS: Across 20 interviews (4 administrators, 16 clinicians) we identified three themes related to how participants thought about ACP: (1) clinicians have varying views of what constitutes ACP; (2) the health system critically shapes ACP culture and norms; and (3) the centrality of clinicians' affective experience and own needs related to ACP. Varying approaches to ACP include a forms-focused approach; a discussion-based approach; and a parental approach. System features that shape ACP norms are (1) the primacy of clinician productivity measures; (2) the role of the EHR; and (3) the culture of quality improvement. CONCLUSIONS: Despite high organizational commitment to ACP, we found that the health system channeled clinicians' ACP efforts narrowly on completion of forms, in tension with the ideal of well-grounded ACP. This resulted in a state of moral distress that risks undermining confidence in the process of ACP and may increase risk of harm for patients, family/caregivers, and providers. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04660422.

The psychosocial health, experiences and needs of older adults and care partners during the first surge of the COVID-19 pandemic: a mixed-methods study.

BACKGROUND: Minimal research has leveraged qualitative data methods to gain a better understanding of the experiences and needs of older adults (OAs) and care partners of OAs with and without Alzheimer's Disease (AD) and AD-related dementias (AD/ADRD) during the first surge of the COVID-19 pandemic. In this study, we: 1) quantitatively evaluated the psychosocial health of community-dwelling OAs; 2) quantitatively evaluated the perceived stress of care partners for OAs; 3) qualitatively characterized the experiences and needs of community-dwelling OAs and their care partners; and 4) explored differences in the experiences of care partners of OAs with and without AD/ADRD during the first surge of the COVID-19 pandemic in the New York metropolitan area. METHODS: In this mixed-methods study, telephone interviews were conducted with 26 OAs and 29 care partners (16 of whom cared for OAs with AD/ADRD) from April to July 2020. Quantitative data included: demographics; clinical characteristics (Katz Index of independence in activities of daily living (Katz ADL) and the Lawton-Brody instrumental activities of daily living scale (Lawton-Brody)); and psychosocial health: stress was assessed via the Perceived Stress Scale (PSS), social isolation via the Lubben Social Network Scale (LSNS), loneliness via the DeJong Loneliness Scale (DeJong), and depression and anxiety via the Patient Health Questionnaire-Anxiety and Depression (PHQ). Qualitative questions focused on uncovering the experiences and needs of OAs and their care partners. RESULTS: OAs (N = 26) were mostly female (57.7%), and White (76.9%), average age of 81.42 years. While OAs were independent (M = 5.60, Katz ADL) and highly functional (M = 6.92, Lawton-Brody), and expressed low levels of loneliness, stress, depression and anxiety (M = 1.95 on DeJong; M = 12.67 on PSS; M = 1.05 on PHQ depression; and M = 1.09 on PHQ anxiety), open-ended questions elicited themes of fear and worry. Care partners (N = 29) were mostly female (75.9%), White (72.4%), and married (72.4%), and reported moderate stress (M = 16.52 on the PSS), as well as a psychological impact of the pandemic. CONCLUSIONS: Early in the pandemic, OAs reported minimal stress and loneliness; this may have been related to their reports of frequent interaction with family, even if only virtually. By contrast, care partners were moderately stressed and worried, potentially more than usual due to the additional challenges they face when trying to meet their loved ones' needs during a pandemic.

Study protocol for Video Images about Decisions to Improve Ethical Outcomes with Palliative Care Educators (VIDEO-PCE): a pragmatic stepped wedge cluster randomised trial of older patients admitted to the hospital

INTRODUCTION: Despite the known benefit to patients and families, discussions about goals, values and preferences for medical care in advancing serious illness often do not occur. Many system and clinician factors, such as patient and clinician reticence and shortage of specialty palliative care teams, contribute to this lack of communication. To address this gap, we designed an intervention to promote goals-of-care conversations and palliative care referrals in the hospital setting by using trained palliative care educators and video decision aids. This paper presents the rationale, design and methods for a trial aimed at addressing barriers to goals-of-care conversations for hospitalised adults aged 65 and older and those with Alzheimer's disease and related Dementias, regardless of age. METHODS AND ANALYSIS: The Video Image about Decisions to Improve Ethical Outcomes with Palliative Care Educators is a pragmatic stepped wedge, cluster randomised controlled trial, which aims to improve and extend goals-of-care conversations in the hospital setting with palliative care educators trained in serious illness communication and video decision aids. The primary outcome is the proportion of patients with goals-of-care documentation in the electronic health record. We estimate that over 9000 patients will be included. ETHICS AND DISSEMINATION: The Institutional Review Board (IRB) at Boston Medical Center will serve as the single IRB of record for all regulatory and ethical aspects of this trial. BMC Protocol Number: H-41482. Findings will be presented at national meetings and in publications. This trial is registered at ClinicalTrials.gov. TRIAL REGISTRATION NUMBER: NCT04857060; ClinicalTrials.gov.

Early DNR in Older Adults Hospitalized with SARS-CoV-2 Infection During Initial Pandemic Surge.

The role of early Do Not Resuscitate (DNR) in hospitalized older adults (OAs) with SARS-CoV-2 infection is unknown. The objective of the study was to identify characteristics and outcomes associated with early DNR in hospitalized OAs with SARS-CoV-2. We conducted a retrospective chart review of older adults (65+) hospitalized with COVID-19 in New York, USA, between March 1, 2020, and April 20, 2020. Patient characteristics and hospital outcomes were collected. Early DNR (within 24 hours of admission) was compared to non-early DNR (late DNR, after 24 hours of admission, or no DNR). Outcomes included hospital morbidity and mortality. Of 4961 patients, early DNR prevalence was 5.7% (n = 283). Compared to non-early DNR, the early DNR group was older (85.0 vs 76.8, P < .001), women (51.2% vs 43.6%, P = .012), with higher comorbidity index (3.88 vs 3.36, P < .001), facility-based (49.1% vs 19.1%, P < .001), with dementia (13.3% vs 4.6%, P < .001), and severely ill on presentation (57.9% vs 32.3%, P < .001). In multivariable analyses, the early DNR group had higher mortality risk (OR: 2.94, 95% CI: 2.10-4.11), less hospital delirium (OR: 0.55, 95% CI: 0.40-.77), lower use of invasive mechanical ventilation (IMV, OR: 0.37, 95% CI: .21-.67), and shorter length of stay (LOS, 4.8 vs 10.3 days, P < .001), compared to non-early DNR. Regarding early vs late DNR, while there was no difference in mortality (OR: 1.12, 95% CI: 0.85-1.62), the early DNR group experienced less delirium (OR: 0.55, 95% CI: .40-.75), IMV (OR: 0.53, 95% CI: 0.29-.96), and shorter LOS (4.82 vs 10.63 days, OR: 0.35, 95% CI: 0.30-.41). In conclusion, early DNR prevalence in hospitalized OAs with COVID-19 was low, and compared to non-early DNR is associated with higher mortality but lower morbidity.

Psychotropic Medication Use Is Associated With Greater 1-Year Incidence of Dementia After COVID-19 Hospitalization.

Background: COVID-19 has been associated with an increased risk of incident dementia (post-COVID dementia). Establishing additional risk markers may help identify at-risk individuals and guide clinical decision-making. Methods: We investigated pre-COVID psychotropic medication use (exposure) and 1-year incidence of dementia (outcome) in 1,755 patients (≥65 years) hospitalized with COVID-19. Logistic regression models were used to examine the association, adjusting for demographic and clinical variables. For further confirmation, we applied the Least Absolute Shrinkage and Selection Operator (LASSO) regression and a machine learning (Random Forest) algorithm. Results: One-year incidence rate of post-COVID dementia was 12.7% (N = 223). Pre-COVID psychotropic medications (OR = 2.7, 95% CI: 1.8-4.0, P < 0.001) and delirium (OR = 3.0, 95% CI: 1.9-4.6, P < 0.001) were significantly associated with greater 1-year incidence of post-COVID dementia. The association between psychotropic medications and incident dementia remained robust when the analysis was restricted to the 423 patients with at least one documented neurological or psychiatric diagnosis at the time of COVID-19 admission (OR = 3.09, 95% CI: 1.5-6.6, P = 0.002). Across different drug classes, antipsychotics (OR = 2.8, 95% CI: 1.7-4.4, P < 0.001) and mood stabilizers/anticonvulsants (OR = 2.4, 95% CI: 1.39-4.02, P = 0.001) displayed the greatest association with post-COVID dementia. The association of psychotropic medication with dementia was further confirmed with Random Forest and LASSO analysis. Conclusion: Confirming prior studies we observed a high dementia incidence in older patients after COVID-19 hospitalization. Pre-COVID psychotropic medications were associated with higher risk of incident dementia. Psychotropic medications may be risk markers that signify neuropsychiatric symptoms during prodromal dementia, and not mutually exclusive, contribute to post-COVID dementia.

Association of an Advance Care Planning Video and Communication Intervention With Documentation of Advance Care Planning Among Older Adults: A Nonrandomized Controlled Trial.

Importance: COVID-19 has disproportionately killed older adults and racial and ethnic minority individuals, raising questions about the relevance of advance care planning (ACP) in this population. Video decision aids and communication skills training offer scalable delivery models. Objective: To assess whether ACP video decision aids and a clinician communication intervention improved the rate of ACP documentation during an evolving pandemic, with a focus on African American and Hispanic patients. Design, Setting, and Participants: The Advance Care Planning: Communicating With Outpatients for Vital Informed Decisions trial was a pre-post, open-cohort nonrandomized controlled trial that compared ACP documentation across the baseline pre-COVID-19 period (September 15, 2019, to March 14, 2020), the COVID-19 wave 1 period (March 15, 2020, to September 14, 2020), and an intervention period (December 15, 2020, to June 14, 2021) at a New York metropolitan area ambulatory network of 22 clinics. All patients 65 years or older who had at least 1 clinic or telehealth visit during any of the 3 study periods were included. Main Outcomes and Measures: The primary outcome was ACP documentation. Results: A total of 14 107 patients (mean [SD] age, 81.0 [8.4] years; 8856 [62.8%] female; and 2248 [15.9%] African American or Hispanic) interacted with clinicians during the pre-COVID-19 period; 12 806 (mean [SD] age, 81.2 [8.5] years; 8047 [62.8%] female; and 1992 [15.6%] African American or Hispanic), during wave 1; and 15 106 (mean [SD] 80.9 [8.3] years; 9543 [63.2%] female; and 2535 [16.8%] African American or Hispanic), during the intervention period. Clinicians documented ACP in 3587 patients (23.8%) during the intervention period compared with 2525 (17.9%) during the pre-COVID-19 period (rate difference [RD], 5.8%; 95% CI, 0.9%-7.9%; P = .01) and 1598 (12.5%) during wave 1 (RD, 11.3%; 95% CI, 6.3%-12.1%; P < .001). Advance care planning was documented in 447 African American patients (30.0%) during the intervention period compared with 233 (18.1%) during the pre-COVID-19 period (RD, 11.9%; 95% CI, 4.1%-15.9%; P < .001) and 130 (11.0%) during wave 1 (RD, 19.1%; 95% CI, 11.7%-21.2%; P < .001). Advance care planning was documented for 222 Hispanic patients (21.2%) during the intervention period compared with 127 (13.2%) during the pre-COVID-19 period (RD, 8.0%; 95% CI, 2.1%-10.9%; P = .004) and 82 (10.2%) during wave 1 (RD, 11.1%; 95% CI, 5.5%-14.5%; P < .001). Conclusions and Relevance: This intervention, implemented during the evolving COVID-19 pandemic, was associated with higher rates of ACP documentation, especially for African American and Hispanic patients. Trial Registration: ClinicalTrials.gov Identifier: NCT04660422.

Implementation of a Geriatrics-Focused Orthopaedic and Hospitalist Fracture Program Decreases Perioperative Complications and Improves Resource Utilization.

OBJECTIVE: To evaluate whether the implementation of a geriatrics-focused orthopaedic and hospitalist comanagement program can improve perioperative outcomes and decrease resource utilization. DESIGN: A retrospective chart review study was conducted before and after the implementation of a geriatrics-focused orthopaedic and hospitalist comanagement program, based on the American Geriatrics Society (AGS) AGS CoCare:Ortho. SETTING: A large urban, academic tertiary center, located in the greater New York metropolitan area. PARTICIPANTS: Patients 65 years and older hospitalized for operative hip fracture. Those with pathologic or periprosthetic fractures and chronic substance use were excluded. MAIN OUTCOME MEASUREMENTS: Outcome measures included time to operating room (TtOR), length of stay, daily and total morphine milligram equivalents, use of preoperative transthoracic echocardiogram and blood transfusions, perioperative complications (eg, urinary tract infections), and 6-month mortality. RESULTS: Our study included 290 patients hospitalized with hip fracture, before (N = 128) and after (N = 162) implementation. When compared with the preimplementation group, the postimplementation comanagement group had a lower TtOR (36.2 vs. 30.0 hours, P = 0.026) and hospital length of stay, decreased use of indwelling bladder catheters preoperatively and postoperatively (68.0% vs. 46.9%, P < 0.001, and 83.6 vs. 58.0%, P < 0.001, respectively), reduced daily opiate use (16.0 vs. 11.1 morphine milligram equivalents, P = 0.011), and decreased 30-day complications (32.8% vs. 16.7%, P = 0.002). There was no difference in 6-month mortality between the 2 groups. CONCLUSIONS: The implementation of an AGS CoCare:Ortho-based comanagement program led to decreased perioperative complications and resource utilization. Comanagement programs are essential to improving and standardizing hip fracture care for older adults. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Coping Through COVID-19: A Mixed Method Approach to Understand How Palliative Care Teams Managed the COVID-19 Pandemic.

OBJECTIVE: While previous work documented a substantial increase in patient mortality consultations and workload for palliative teams, little is known about how these team members managed their mental and physical health during the COVID-19 pandemic. We investigated how job resources (coworker and supervisor support) and personal resources (coping strategies) reduced perceptions of burnout and increased perceptions of well-being. METHOD: An anonymous electronic survey was sent to all members (N = 64) of the palliative medical team among 14 hospitals of a New York State health system. Data were collected between September 2020 to October 2020. Measures included validated scales for burnout (Oldenburg Burnout Inventory), coping strategies (Cybernetic Coping Scale), subjective well-being (BBC Subjective Well-being scale), and coworker/supervisor support (7 items from Yang et al). RESULTS: Results indicated devaluation coping tactics were used to reduce perceptions of burnout and to increase perceptions of physical health. Higher burnout was identified when using avoidance coping techniques. Furthermore, coworkers and supervisor(s) support significantly reduced disengagement when compared to coworker support alone. CONCLUSION: COVID-19 exacerbated burnout experienced by palliative care teams, yet the use of coping behaviors (devaluation/avoidance) and external resources (coworker and supervisor support) utilized by these teams were found to have positive effects. Further research should investigate these antagonizing factors to help preventing and addressing burn out during times of crises and in the everyday of palliative care teams.

Patient Factors and Hospital Outcomes Associated With Atypical Presentation in Hospitalized Older Adults With COVID-19 During the First Surge of the Pandemic.

BACKGROUND: Literature indicates an atypical presentation of COVID-19 among older adults (OAs). Our purpose is to identify the frequency of atypical presentation and compare demographic and clinical factors, and short-term outcomes, between typical versus atypical presentations in OAs hospitalized with COVID-19 during the first surge of the pandemic. METHODS: Data from the inpatient electronic health record were extracted for patients aged 65 and older, admitted to our health systems' hospitals with COVID-19 between March 1 and April 20, 2020. Presentation as reported by the OA or his/her representative is documented by the admitting professional and includes both symptoms and signs. Natural language processing was used to code the presence/absence of each symptom or sign. Typical presentation was defined as words indicating fever, cough, or shortness of breath; atypical presentation was defined as words indicating functional decline or altered mental status. RESULTS: Of 4 961 unique OAs, atypical presentation characterized by functional decline or altered mental status was present in 24.9% and 11.3%, respectively. Atypical presentation was associated with older age, female gender, Black race, non-Hispanic ethnicity, higher comorbidity index, and the presence of dementia and diabetes mellitus. Those who presented typically were 1.39 times more likely than those who presented atypically to receive intensive care unit-level care. Hospital outcomes of mortality, length of stay, and 30-day readmission were similar between OAs with typical versus atypical presentations. CONCLUSION: Although atypical presentation in OAs is not associated with the same need for acute intervention as respiratory distress, it must not be dismissed.

Leveraging Interdisciplinary Teams for Pre-Visit Planning to Improve Pneumococcal Immunization Rates Among Internal Medicine Subspecialty Practices.

BACKGROUND: Despite the ready availability of pneumococcal vaccines and recommendation of vaccination by Center for Disease Control and Prevention (CDC), the immunization rates among adults less than 65 years of age with chronic and immunocompromised conditions remain low. METHODS: This interventional (cohort) study aimed to improve the pneumococcal vaccination rate for patients with an increased risk of pneumococcal disease by utilizing a three-pronged approach. This included: (1) clinician education webinar, (2) pre-visit counseling performed by registered nurses, targeted toward patients with upcoming appointments, to address vaccination status, and (3) modified pre-visit interdisciplinary team huddle with clinicians and registered nurses to review which patients are amenable to vaccination at the time of visit and those who may benefit from re-engagement and further motivational interviewing. After the completion of the 10-week intervention, study organizers reviewed the percent of patients with completed pneumococcal vaccinations. RESULTS: In this 10-week rapid cycle initiative, a total of 482 patients were eligible for vaccination. During the intervention phase, 370 patients were contacted and of these 38% of patients were amenable to receiving a vaccine during the pre-visit counseling, 5% were previously vaccinated, 18% were not amenable, and 38% were unreachable prior to visit. This initiative resulted in a 43% increase in the vaccination rate in this cohort. CONCLUSIONS: The significant increase in vaccination rate supports the utilization of a framework in the multidisciplinary approach to pre-visit planning in non-primary care specialties and other vaccination efforts, especially emerging diseases such as COVID-19. Future directions of study include the efficacy of telemedicine counseling with a same-day appointment for vaccination, co-location of registered nurses within the practice sites, as well as the use of other ancillary staff (such as medical office assistants) to engage patients in pre-visit planning.

Geriatrics-focused indicators predict mortality more than age in older adults hospitalized with COVID-19.

BACKGROUND: Age has been implicated as the main risk factor for COVID-19-related mortality. Our objective was to utilize administrative data to build an explanatory model accounting for geriatrics-focused indicators to predict mortality in hospitalized older adults with COVID-19. METHODS: Retrospective cohort study of adults age 65 and older (N = 4783) hospitalized with COVID-19 in the greater New York metropolitan area between 3/1/20-4/20/20. Data included patient demographics and clinical presentation. Stepwise logistic regression with Akaike Information Criterion minimization was used. RESULTS: The average age was 77.4 (SD = 8.4), 55.9% were male, 20.3% were African American, and 15.0% were Hispanic. In multivariable analysis, male sex (adjusted odds ration (adjOR) = 1.06, 95% CI:1.03-1.09); Asian race (adjOR = 1.08, CI:1.03-1.13); history of chronic kidney disease (adjOR = 1.05, CI:1.01-1.09) and interstitial lung disease (adjOR = 1.35, CI:1.28-1.42); low or normal body mass index (adjOR:1.03, CI:1.00-1.07); higher comorbidity index (adjOR = 1.01, CI:1.01-1.02); admission from a facility (adjOR = 1.14, CI:1.09-1.20); and mechanical ventilation (adjOR = 1.52, CI:1.43-1.62) were associated with mortality. While age was not an independent predictor of mortality, increasing age (centered at 65) interacted with hypertension (adjOR = 1.02, CI:0.98-1.07, reducing by a factor of 0.96 every 10 years); early Do-Not-Resuscitate (DNR, life-sustaining treatment preferences) (adjOR = 1.38, CI:1.22-1.57, reducing by a factor of 0.92 every 10 years); and severe illness on admission (at 65, adjOR = 1.47, CI:1.40-1.54, reducing by a factor of 0.96 every 10 years). CONCLUSION: Our findings highlight that residence prior to admission, early DNR, and acute illness severity are important predictors of mortality in hospitalized older adults with COVID-19. Readily available administrative geriatrics-focused indicators that go beyond age can be utilized when considering prognosis.

Impact of a community health conversation upon advance care planning attitudes and preparation intentions.

Background: Advance care planning conversations and preparations do not occur as frequently as they should. Framing advance care planning as a health behavior and an opportunity for community engagement can help improve community-dwellers' intentions to have discussions and preparations regarding facing serious illness, death and dying.Methods: A multi-setting confidential pre/post paper survey assessing advance care planning discussions and preparation intentions was given to community-dwelling citizens residing in the New York metropolitan area. Survey items were adapted from a previous end of life survey to include questions on chronic illnesses, important conversations, comfort levels and concerns about end of life. The intervention was a 1-hour presentation on advance care planning (importance, laws, effective communication and audience questions)Results: Our study found significant interest in discussing advanced care planning across age groups. There were significant changes for participant intentions regarding: having conversations with loved ones, a health care proxy or similar document and none; as well as differences in participant intentions for discussions with caregiver, family, friends, primary physician and no-one.Conclusion: Educating individuals on the importance of advance care planning may be effective in changing community dwellers' intentions to start the conversation and put advanced care planning measures in place.Abbreviations: ACP: Advance Care Planning; CHAT: Conversations Health and Treatments; EoL: End of Life; HCP: Health Care Proxy; MOLST: Medical Orders for Life-Sustaining Treatments; PCP: Primary Care Physician.

Implementation of Hip Fracture Co-Management Program (AGS CoCare: Ortho®) in a Large Health System.

OBJECTIVES: Acute hip fracture is common and leads to significant morbidity and mortality. Co-management programs, such as American Geriatric Society (AGS) CoCare: Ortho®, that optimize perioperative care of older adults, have demonstrated improved outcomes. Yet there is substantial variation in hip fracture care nationally. Our objective was to describe the implementation of AGS CoCare: Ortho® across a large integrated health system. DESIGN: Program implementation of four phases. SETTING: Large integrated health system. PARTICIPANTS: One tertiary and three community hospitals. MEASUREMENTS: The first two phases were communication and system-level planning. The communication phase consisted of getting health system leadership buy-in, creating an interdisciplinary steering committee, and building a business model. The planning phase consisted of choosing process and outcome measures, ensuring accurate and timely data collection, and creating standardized order sets and physician documentation. RESULTS: The second two phases were hospital-level planning and implementation. The planning phase consisted of identifying sites and developing the co-management structure. The implementation phase consisted of identifying and engaging frontline staff, rolling out the program, optimizing workflow, and educating providers. CONCLUSION: The program was implemented at four diverse sites. Major lessons learned included the need for an engaged steering committee to oversee the program; the importance of standardizing order sets and documentation; the utilization of hospitalists as co-managers; the benefit of developing and actively using a data dashboard; the challenge of ensuring wide uptake of education modules; and the need to take proactive steps to improve multidisciplinary communication. J Am Geriatr Soc 68:1706-1713, 2020.

Knowledge, Attitudes, and Interactions with Chaplains and Nursing Staff Outcomes: A Survey Study.

We conducted a cross-sectional survey of nursing staff (n = 51) in an academic hospital finding a significant inverse relationship between the frequency of chaplaincy interaction and perceived stress (r = - 0.27, p = 0.05). We also found a significant positive relationship between rated importance of having a chaplain at the hospital and secondary trauma (r = 0.30, p = 0.03). There was a significant positive relationship between religiosity and rated importance for having a chaplain (r = 0.30, p = 0.03) and rated helpfulness of chaplains (r = 0.32, p = 0.02). Similarly, there was a significant positive relationship between spirituality and average length of conversations with a chaplain, rated importance for having a chaplain, and helpfulness of chaplains (r = 0.32, p = 0.03; r = 0.44, p = 0.001; and r = 0.52, p = 0.0001, respectively). Interaction with chaplains is associated with decreased employee perceived stress for nursing staff who provide care for severely ill patients.

The development and piloting of a goals of care conversation education program for an advanced illness population.

Ten thousand Americans turn 65 daily. With age, individuals are confronted by complex medical modalities which can be difficult to understand and potentially burdensome. Historically, clinicians lacked the education, skill, and comfort level to identify the need for and address the patient's goals of care (GoC). Inter-professional content experts convened to develop a comprehensive program to educate and increase the comfort level of clinicians when having GoC conversations. The goal was to provide structured guidance to increase the practitioners' level of confidence in engaging patients/families in these conversations. A multimodal educational methodology using simulation was chosen as a learning strategy permitting clinicians to practice GoC conversations while receiving immediate feedback. A five hour inter-professional educational program called Goals of Care Conversation Education Program® (GoCCEP™) was developed and piloted. The GoCCEPTM's evaluations demonstrate success giving clinicians necessary tools and a safe practice environment increasing knowledge and confidence to have substantive GoC conversations.

Views on the use of the term 'elder orphans': A qualitative study.

Older adults living alone in the community with no immediate family network or support are referred in the literature as 'elder orphans'. The grey literature has a growing emphasis on the importance of supporting this vulnerable group, particularly with health and social care. However, there is a dearth of empirical research on 'elder orphans', and definitions remained semantically complicated and unknown to the public, healthcare professionals and those being referred as elder orphans. This research explored the views of older adults on the use of the terminology 'elder orphans', and the implications of using the terminology in health and social care systems. A descriptive qualitative approach through face-to-face interviews of 11 older adults was undertaken in Auckland, New Zealand in October 2018. Narratives were analysed using thematic analysis. Two themes were identified from the analysis of interview data. The first theme was 'realistic and practical term', which emphasised the participants' impression of the term 'elder orphan' resonating to themselves with great relevance to their current and future situations. The second theme is 'visibility and vulnerability', which highlighted participants' both positive and ambivalent views on the use of the terminology in healthcare settings. The participants viewed this terminology as beneficial to alerting care services, and in promoting awareness among healthcare providers. Older adults from the study, who are living alone without immediate family networks and support self-identified themselves as 'elder orphans' through a gradual realisation of their current and anticipated social situations. The use of the term within healthcare was considered and preferred by the participants to be used contextually, and targeted towards appropriate health and social care services within and outside hospital-care settings.

Developing and Piloting a Tool to Identify Food Insecurity in Older Adults.

OBJECTIVE: The literature shows that food insecurity (FI) can negatively affect the trajectory of many chronic illnesses. FI can be acutely severe for older adults, but screening for FI is not regularly performed in the hospital setting. Our goal was to develop a tool to screen for FI upon hospital discharge to identify patients who may require community food resources. This is the first attempt to build such a tool for implementation in our health system. METHODS: In two university hospitals and one community hospital, patients 65 years old and older were admitted to the Internal Medicine service who would approach discharge within 2 days. We screened patients meeting our criteria using an FI tool (FIT), which addressed patterns associated with FI. All of the patients screened were offered a list of community resources. RESULTS: Of the patients recruited, 69 met the study criteria. The majority of patients screened displayed some FI, with 56% having ≥3 food insecurities. Statistically significant relationships were established for individual FIT questions with age, admission albumin level, body mass index, length of stay, and median household income based on ZIP code. CONCLUSIONS: Use of the FIT can help identify vulnerable patients and connect them to food resources. The FIT was easy to use, well tolerated, and time-efficient, leaving it poised for use in the busy environment of inpatient services.