Social Support and Stressors among VA Medical Foster Home Caregivers.

This study aimed to identify sources of social support and stressors that facilitated or hindered caregivers in the Department of Veterans Affairs (VA) Medical Foster Home (MFH) program in performing their duties. We conducted phone interviews with 35 caregivers and found they relied on work-related, religious, and emotional social support. Caregivers' unmet needs included a lack of time to re-charge; affordable respite services; enough VA-paid relief services, adequate relief caregivers; and ability to attend church. To address these needs, VA leadership should make MFH caregivers eligible for VA Caregiver Support Programs, encourage reciprocal caregiving arrangements, and organize virtual church services.

The experience of providing hospice care concurrent with cancer treatment in the VA.

PURPOSE: Veterans with advanced cancer can receive hospice care concurrently with treatments such as radiation and chemotherapy. However, variations exist in concurrent care use across Veterans Affairs (VA) medical centers (VAMCs), and overall, concurrent care use is relatively rare. In this qualitative study, we aimed to identify, describe, and explain factors that influence the provision of concurrent cancer care (defined as chemotherapy or radiation treatments provided with hospice) for veterans with terminal cancer. METHODS: From August 2015 to April 2016, we conducted six site visits and interviewed 76 clinicians and staff at six VA sites and their contracted community hospices, including community hospices (n = 16); VA oncology (n = 25); VA palliative care (n = 17); and VA inpatient hospice and palliative care units (n = 18). RESULTS: Thematic qualitative content analysis found three themes that influenced the provision of concurrent care: (1) clinicians and staff at community hospices and at VAs viewed concurrent care as a viable care option, as it preserved hope and relationships while patient goals are clarified during transitions to hospice; and (2) the presence of dedicated liaisons facilitated care coordination and education about concurrent care; however, (3) clinicians and staff concerns about Medicare guideline compliance hindered use of concurrent care. CONCLUSIONS: While concurrent care is used by a small number of veterans with advanced cancer, VA staff valued having the option available and as a bridge to hospice. Hospice staff felt concurrent care improved care coordination with VAMCs, but use may be tempered due to concerns related to Medicare compliance.

Launching Medical Foster Home Programs: Key Components to Growing This Alternative to Nursing Home Placement.

OBJECTIVE: The objective of this research was to examine and explain elements that enhanced or thwarted program growth of the United States Veterans Health Administration Medical Foster Home program. METHODS: This qualitative study was conducted nationally through individual interviews over the phone and in-person (n = 22) with coordinators (n = 15 at slow-growth programs; n = 6 at fast-growth programs), program support assistants (PSAs) (n = 1 at slow-growth program), and home-based primary care team members (n = 3), as well as three in-person focus groups (n = 28 total participants) with home-based primary care team members. All participants (N = 53) were involved with programs in existence for at least two years. RESULTS: Facilitators and barriers that enhanced or thwarted program growth emerged around four themes: A full-time coordinator; Unmitigated home-based primary care team engagement; Pursuit and receipt of appropriate referrals; and Match between caregiver, home, and Veteran. CONCLUSIONS: To facilitate program growth, program leaders should consider themes identified and how to foster situations and shape policies that put themes into practice.

Fostering Excellence: An Examination of High-Enrollment VHA Medical Foster Home Programs.

This qualitative study aimed to assist the US Veterans Health Administration (VHA) to efficiently target recruitment into VHA Medical Foster Homes (MFHs) by understanding how high-enrollment MFH (HE-MFH) program attributes optimized MFH enrollment. We used an emergent exploratory design to study 3 HE-MFH programs across the United States. Data were collected from August 2013 through June 2014 through individual in-person and phone interviews and in-person focus group discussions with 39 MFH care providers. Three main themes emerged as essential for optimizing HE-MFH program enrollment: (1) alignment of right caregiver, right home, and right Veteran; (2) care practices that support caregiver, Veteran, and home-based primary care (HBPC); and (3) workplace practices and processes that demonstrate support of the MFH coordinator role by facility leadership and the HBPC team.

Allowing Family to be Family: End-of-Life Care in Veterans Affairs Medical Foster Homes.

The Medical Foster Home program is a unique long-term care program coordinated by the Veterans Health Administration. The program pairs Veterans with private, 24-hour a day community-based caregivers who often care for Veterans until the end of life. This qualitative study explored the experiences of care coordination for Medical Foster Home Veterans at the end of life with eight Veterans' family members, five Medical Foster Home caregivers, and seven Veterans Health Administration Home-Based Primary Care team members. A case study, qualitative content analysis identified these themes addressing care coordination and impact of the Medical Foster Home model on those involved: (a) Medical Foster Home program supports Veterans' families; (b) Medical Foster Home program supports the caregiver as family; (c) Veterans' needs are met socially and culturally at the end of life; and (d) the changing needs of Veterans, families, and caregivers at Veterans' end of life are addressed. Insights into how to best support Medical Foster Home caregivers caring for Veterans at the end of life were gained including the need for more and better respite options and how caregivers are compensated in the month of the Veteran's death, as well as suggestions to navigate end-of-life care coordination with multiple stakeholders involved.

Caregivers Create a Veteran-Centric Community in VHA Medical Foster Homes.

The Veteran's Health Administration's Medical Foster Home program offers a unique long-term care option for veterans who require nursing-home- or assisted-living-level care. Veterans in a medical foster home reside with community-based caregivers who provide 24-hr-a-day care and monitoring. The veterans often remain in the medical foster home until end of life. Support and oversight is provided to the caregiver from the Veteran's Health Administration's community-based medical team. This qualitative descriptive study is based on secondary analysis of interviews with 20 medical foster home caregivers from 7 programs across the United States. The study's research aims are to describe and explain (a) the type of care backgrounds and skills these caregivers possess, (b) caregivers' primary motivations to open their homes to veterans who often have complex medical and social needs, and (c) how caregivers function in their role as primary caregiver for veterans. Findings indicated that caregivers interviewed had worked in long-term care settings and/or cared for family members. A strong desire to serve veterans was a primary motivation for caregivers, rather than financial gain. The caregivers' long-term care skills aided them in building and sustaining the unique medical foster home family-like community.

Experiences of Veterans, Caregivers, and VA Home-Based Care Providers before, during, and Post-Hurricane Ian.

On 28 September 2022, Hurricane Ian pummeled parts of south Florida. Disaster and climate change research has shown that disasters exacerbate inequalities, especially amongst older and physically vulnerable people. Florida has a large population of Veterans managing multiple chronic health conditions and receiving long-term care in-home from Veterans Health Administration (VA) programs, including Home Based Primary Care and Medical Foster Home. To describe how VA staff provided high quality care during and after the hurricane, and how Veterans and caregivers accessed needed healthcare and supports post-hurricane, we conducted a site visit to Lee County, Florida area in May 2023, conducting N = 25 interviews with VA staff, Veterans, and caregivers. Findings from qualitative thematic analysis showed that while some Veterans and caregivers experienced significant challenges during and after the hurricane, including displacement and difficulty accessing oxygen, they felt highly supported by VA care teams. Staff efforts post-hurricane focused on improving care coordination in anticipation of future disasters, especially around communicating with Veterans and their caregivers, and a VA workgroup formed to implement changes. As climate change causes more severe hazard events, lessons learned from this project can better support healthcare staff, older adults, and their caregivers before and after major disasters.

Decline in Veterans' Admissions to Nursing Homes during COVID-19: Fewer Beds, More Fear, and Finding Alternative Care Settings.

OBJECTIVE: Examine the decline in admission to community nursing homes among Veterans that occurred following the onset of the COVID-19 pandemic. DESIGN: Multimethods study using Department of Veterans Affairs (VA) purchasing records to examine trends in total admissions and semistructured interviews with staff connected to the VA community nursing home program to contextualize observed trends. SETTING AND PARTICIPANTS: All VA-paid admissions to community nursing homes (N = 56,720 admissions) and national data on nursing home admissions from LTCFocUS. Semistructured interviews were conducted with 9 VA staff from 4 VA medical centers working in the VA community nursing home program, including social workers, nurses, and program coordinators. RESULTS: Between April and December 2020, community nursing home admissions among Veterans were 35% lower compared with the same period in 2019. Nationally, total nursing home admissions decreased by 19.6%. VA community nursing home program staff described 3 themes that contributed to this decline: (1) fewer nursing home beds available, (2) lower admissions due to fear of Veterans being exposed to COVID-19 in nursing homes, and (3) leaving nursing homes in favor of living at home with home-based care. CONCLUSIONS AND IMPLICATIONS: The decline in nursing home admissions among Veterans raises questions about how replacing nursing home care in favor of home- and community-based care affects the health outcomes and well-being of Veterans and their caregivers.

Lung cancer survivors' views on telerehabilitation following curative intent therapy: a formative qualitative study.

OBJECTIVES: To inform personalised home-based rehabilitation interventions, we sought to gain in-depth understanding of lung cancer survivors' (1) attitudes and perceived self-efficacy towards telemedicine; (2) knowledge of the benefits of rehabilitation and exercise training; (3) perceived facilitators and preferences for telerehabilitation; and (4) health goals following curative intent therapy. DESIGN: We conducted semi-structured interviews guided by Bandura's Social Cognitive Theory and used directed content analysis to identify salient themes. SETTING: One USA Veterans Affairs Medical Center. PARTICIPANTS: We enrolled 20 stage I-IIIA lung cancer survivors who completed curative intent therapy in the prior 1-6 months. Eighty-five percent of participants had prior experience with telemedicine, but none with telerehabilitation or rehabilitation for lung cancer. RESULTS: Participants viewed telemedicine as convenient, however impersonal and technologically challenging, with most reporting low self-efficacy in their ability to use technology. Most reported little to no knowledge of the potential benefits of specific exercise training regimens, including those directed towards reducing dyspnoea, fatigue or falls. If they were to design their own telerehabilitation programme, participants had a predominant preference for live and one-on-one interaction with a therapist, to enhance therapeutic relationship and ensure correct learning of the training techniques. Most participants had trouble stating their explicit health goals, with many having questions or concerns about their lung cancer status. Some wanted better control of symptoms and functional challenges or engage in healthful behaviours. CONCLUSIONS: Features of telerehabilitation interventions for lung cancer survivors following curative intent therapy may need to include strategies to improve self-efficacy and skills with telemedicine. Education to improve knowledge of the benefits of rehabilitation and exercise training, with alignment to patient-formulated goals, may increase uptake. Exercise training with live and one-on-one therapist interaction may enhance learning, adherence, and completion. Future work should determine how to incorporate these features into telerehabilitation.

Taking Neighborhood Health to Heart (TNH2H): building a community-based participatory data system.

BACKGROUND: Healthy People 2020 calls for increased monitoring of local health and health disparities, but successful models of designing and implementing data collection systems for this purpose are lacking. COMMUNITY CONTEXT: We describe the process, methods, and outcomes of a community-based participatory research initiative, Taking Neighborhood Health to Heart, designed to collect and disseminate comprehensive health data from 5 diverse urban neighborhoods in Denver, Colorado. METHODS: Since its beginning in 2006, this initiative has involved community members in collection of individual health surveys from 1,146 households; audits of sidewalks, buildings, and other built environment features in 412 neighborhood blocks; audits of availability, price, and quality of fresh produce in 69 local stores; and audits of conditions and amenities in 20 local parks. Community members and researchers share, interpret, and disseminate these data through a joint data review and dissemination committee. OUTCOME: Through our community-based data collection system, Taking Neighborhood Health to Heart has been able to collect, analyze, and disseminate locally relevant data on people and neighborhoods to monitor heath and health disparities. INTERPRETATION: Since 2006, the initiative has sustained its focus on community-based participatory research that targets collection and dissemination of local health data. We have used this information to identify salient health issues and advocate for neighborhood programs, policies, and environmental changes to built and social features of neighborhoods that have historically led to unequal opportunities and social disadvantage.

How Social Determinants of Health of Individuals Living or Working in U.S. Department of Veterans Affairs Home-Based Long-Term Care Programs in Puerto Rico Influenced Recovery after Hurricane Maria.

In September 2017, Hurricane Maria devastated Puerto Rico, causing extensive infrastructure damage and a significant number of deaths. In the months and years since, recovery from Maria has been slow, hampered by delayed delivery of fiscal aid, corruption, economic hardships, and Puerto Rico's colonial status. Simultaneously, Puerto Rico's population is rapidly aging and hundreds of thousands of mostly younger Puerto Ricans are migrating out of Puerto Rico for more opportunities. Many Puerto Ricans who are older or disabled and need long-term care receive this care in home-based environments, as Puerto Rico has minimal institutionalized long-term care infrastructure and limited funding to expand it. The Department of Veterans Affairs (VA) offers several home-based long-term care options for Veterans in Puerto Rico. In this qualitative case study, veterans, VA staff, veterans' caregivers, caregivers' family members, and veterans' family members receiving or involved with providing this care were interviewed regarding their experiences during and after Hurricane Maria. Specifically, this study highlights how social determinants of health of those residing in or involved with VA home-based long-term care programs influenced recovery from Hurricane Maria, and how findings can inform disaster recovery and provision of home-based long-term care going forward.

Applying the Tailored Implementation in Chronic Diseases framework to inform implementation of the Preferences Elicited and Respected for Seriously Ill Veterans through enhanced decision-making program in the United States Veterans Health Administration.

In 2017, the National Center for Ethics in Health Care for the United States Department of Veterans Affairs (VA) commenced national roll-out of the Life-Sustaining Treatment Decisions Initiative. This national VA initiative aimed to promote personalized, proactive, patient-driven care for seriously ill Veterans by documenting Veterans' goals and preferences for life-sustaining treatments in a durable electronic health record note template known as the life-sustaining treatment template. The Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED) quality improvement program was created to address the high variation in life-sustaining treatment template completion in VA Home Based Primary Care (HBPC) and Community Nursing Home programs. This manuscript describes the program that focuses on improving life sustaining treatment template completion rates amongst HBPC programs. To increase life-sustaining treatment template completion for Veterans receiving care from HBPC programs, the PERSIVED team applies two implementation strategies: audit with feedback and implementation facilitation. The PERSIVED team conducts semi-structured interviews, needs assessments, and process mapping with HBPC programs in order to identify barriers and facilitators to life-sustaining treatment template completion to inform tailored facilitation. Our interview data is analyzed using the Tailored Implementation in Chronic Diseases (TICD) framework, which identifies 57 determinants that might influence practice or implementation of interventions. To quickly synthesize and use baseline data to inform the tailored implementation plan, we adapted a rapid analysis process for our purposes. This paper describes a six-step process for conducting and analyzing baseline interviews through applying the TICD that can be applied and adapted by implementation scientists to rapidly inform tailoring of implementation facilitation.

Caring for Homebound Veterans during COVID-19 in the U.S. Department of Veterans Affairs Medical Foster Home Program.

The onset of the COVID-19 pandemic made older, homebound adults with multiple chronic conditions increasingly vulnerable to contracting the virus. The United States (US) Department of Veterans Affairs (VA) Medical Foster Home (MFH) program cares for such medically complex veterans residing in the private homes of non-VA caregivers rather than institutional care settings like nursing homes. In this qualitative descriptive study, we assessed adaptations to delivering safe and effective health care during the early stages of the pandemic for veterans living in rural MFHs. From December 2020 to February 2021, we interviewed 37 VA MFH care providers by phone at 16 rural MFH programs across the US, including caregivers, program coordinators, and VA health care providers. Using both inductive and deductive approaches to thematic analysis, we identified themes reflecting adaptations to caring for rural MFH veterans, including care providers rapidly increased communication and education to MFH caregivers while prioritizing veteran safety. Telehealth visits also increased, MFH veterans were prioritized for in-home COVID-19 vaccinations, and strategies were applied to mitigate the social isolation of veterans and caregivers. The study findings illustrate the importance of clear, regular communication and intentional care coordination to ensure high-quality care for vulnerable, homebound populations during crises like the COVID-19 pandemic.

COVID-19 Vaccination in VA Home Based Primary Care: Experience of Interdisciplinary Team Members.

OBJECTIVES: Describe how Department of Veterans Affairs (VA) Home Based Primary Care (HBPC) team members discussed the COVID-19 vaccine with Veteran patients and their caregivers; describe HBPC team members' experiences providing care during the pandemic; identify facilitators and barriers to vaccinating HBPC Veterans during the COVID-19 pandemic. DESIGN: Online survey that included 3 open-ended COVID-19 vaccine-related questions. SETTING AND PARTICIPANTS: HBPC Program Directors from 145 VA Medical Centers were invited to participate and share the survey invitation with team members. The survey was open from March to May 2021. We collected N = 573 surveys from 73 sites. METHODS: We analyzed demographic data using descriptive frequencies and open-ended questions using thematic analysis. RESULTS: Respondents from all HBPC roles were included in the study: Registered Nurses, Psychologists, Advanced Registered Nurse Practitioners, Social Workers, Dieticians, Occupational Therapists, Pharmacists, Physical Therapists, HBPC Program Directors, HBPC Medical Directors, MDs, Physician Assistants, Other. Qualitative thematic analysis revealed 3 themes describing VA HBPC team members' experiences discussing and administering the COVID-19 vaccine: communication and education, advocating for prioritization of HBPC Veterans to receive the vaccine, and logistics of delivering and administering the vaccine. CONCLUSIONS AND IMPLICATIONS: Our study findings highlight the multifaceted experiences of VA HBPC team members discussing and administering initial doses of the COVID-19 vaccine to primarily homebound Veterans. Although the VA's HBPC program offers an example of a singular health care system, insights from more than 70 sites from across the United States reveal key lessons around the internal and external structures required to successfully support programs and their staff in providing these key activities. These lessons include proactively addressing the needs of homebound populations in national vaccine rollouts and developing vaccine education and training programs for HBPC team members specifically aligned to HBPC program needs. These lessons can extend to non-VA organizations who care for similar homebound populations.

Veterans Health Administration Staff Perceptions of Overseeing Care in Community Nursing Homes During COVID-19.

INTRODUCTION: The Veterans Health Administration (VA) contracts with non-VA owned and operated community nursing homes (CNHs) to provide Veterans nursing home care. This study explored VA staffs' experiences coordinating care with CNH staff during the COVID-19 pandemic. METHODS: Qualitative study interviewing VA staff overseeing and coordinating care for CNH Veterans. Interviews were recorded, transcribed, and analyzed using inductive and deductive thematic analysis. RESULTS: Three themes influenced care coordination. (1) Pre-established working relationships strengthened trust in CNH staff and remote access to CNH electronic medical records (EMRs). (2) Remote oversight proved challenging as virtual visits did not fully capture Veterans' needs and Veterans experienced challenges due to cognitive status, hearing impairment, and discomfort with technology. (3) Partnerships strengthened as VA staff provided CNHs personal protective equipment, COVID-19 testing, infection control education, and emotional support. DISCUSSION: Despite pre-existing relationships and improved partnerships, most VA staff felt uncertain about the quality of oversight provided through remote monitoring and preferred in-person interactions. However, they found benefit in remote access to CNH EMRs and shared optimism with expanding virtual care. CONCLUSIONS: Fostering strong partnerships between VAs and CNHs improve care coordination during crises like the COVID-19 pandemic and for daily care.

Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED): a protocol for an implementation study in the Veterans Health Administration.

BACKGROUND: Empirical evidence supports the use of structured goals of care conversations and documentation of life-sustaining treatment (LST) preferences in durable, accessible, and actionable orders to improve the care for people living with serious illness. As the largest integrated healthcare system in the USA, the Veterans Health Administration (VA) provides an excellent environment to test implementation strategies that promote this evidence-based practice. The Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED) program seeks to improve care outcomes for seriously ill Veterans by supporting efforts to conduct goals of care conversations, systematically document LST preferences, and ensure timely and accurate communication about preferences across VA and non-VA settings. METHODS: PERSIVED encompasses two separate but related implementation projects that support the same evidence-based practice. Project 1 will enroll 12 VA Home Based Primary Care (HBPC) programs and Project 2 will enroll six VA Community Nursing Home (CNH) programs. Both projects begin with a pre-implementation phase during which data from diverse stakeholders are gathered to identify barriers and facilitators to adoption of the LST evidence-based practice. This baseline assessment is used to tailor quality improvement activities using audit with feedback and implementation facilitation during the implementation phase. Site champions serve as the lynchpin between the PERSIVED project team and site personnel. PERSIVED teams support site champions through monthly coaching sessions. At the end of implementation, baseline site process maps are updated to reflect new steps and procedures to ensure timely conversations and documentation of treatment preferences. During the sustainability phase, intense engagement with champions ends, at which point champions work independently to maintain and improve processes and outcomes. Ongoing process evaluation, guided by the RE-AIM framework, is used to monitor Reach, Adoption, Implementation, and Maintenance outcomes. Effectiveness will be assessed using several endorsed clinical metrics for seriously ill populations. DISCUSSION: The PERSIVED program aims to prevent potentially burdensome LSTs by consistently eliciting and documenting values, goals, and treatment preferences of seriously ill Veterans. Working with clinical operational partners, we will apply our findings to HBPC and CNH programs throughout the national VA healthcare system during a future scale-out period.

Purchasing High-Quality Community Nursing Home Care: A Will to Work With VHA Diminished by Contracting Burdens.

OBJECTIVES: The Veterans Health Administration (VHA) purchases community nursing home care; however, the administrative burden may lead nursing homes to avoid contracting with the VHA. This study aimed to describe how the VHA's purchasing policies impede or facilitate contracting with nursing homes. DESIGN: Semistructured interviews of key stakeholders in the VHA's community nursing home contracting process. SETTING AND PARTICIPANTS: We interviewed 15 VHA and 21 nursing home staff at 6 VHA medical centers and 17 nursing homes. VHA medical centers were selected from sites with the greatest magnitude of difference in quality rankings between VHA contracted and noncontracted nursing homes in the same market area. METHODS: Qualitative content analysis of interviews. RESULTS: Five themes emerged: (1) VHA purchases nursing home care to fill gaps in geographic, specialty, and quality care needs; (2) business opportunities and the mission to care for Veterans motivate nursing homes to work with the VHA; (3) the VHA's reputation for unreliable or insufficient payment and inability of nursing homes to comply with federal wage standards serve as barriers to establishing contracts; (4) complexity of establishing a contract, ambiguity about new policies, and inadequate VHA staffing for the nursing home inspection team hinder the VHA's ability to establish contracts with nursing homes; and (5) nursing homes that have established corporate processes, nursing home administrators with prior experience working with the VHA, and relationships between VHA and nursing home staff serve as facilitators to establishing new nursing home contracts. CONCLUSIONS AND IMPLICATIONS: Nursing homes will work with the VHA, but the process of executing VHA contracts is burdensome. Streamlining and standardizing the purchasing processes and ensuring timely payment may expand the number of nursing homes willing to contract with the VHA, thereby increasing choices for Veterans and becoming a model for other long-term care networks.

Evaluating implementation strategies to support documentation of veterans' care preferences.

OBJECTIVE: To evaluate the effectiveness of feedback reports and feedback reports + external facilitation on completion of life-sustaining treatment (LST) note the template and durable medical orders. This quality improvement program supported the national roll-out of the Veterans Health Administration (VA) LST Decisions Initiative (LSTDI), which aims to ensure that seriously-ill veterans have care goals and LST decisions elicited and documented. DATA SOURCES: Primary data from national databases for VA nursing homes (called Community Living Centers [CLCs]) from 2018 to 2020. STUDY DESIGN: In one project, we distributed monthly feedback reports summarizing LST template completion rates to 12 sites as the sole implementation strategy. In the second involving five sites, we distributed similar feedback reports and provided robust external facilitation, which included coaching, education, and learning collaboratives. For each project, principal component analyses matched intervention to comparison sites, and interrupted time series/segmented regression analyses evaluated the differences in LSTDI template completion rates between intervention and comparison sites. DATA COLLECTION METHODS: Data were extracted from national databases in addition to interviews and surveys in a mixed-methods process evaluation. PRINCIPAL FINDINGS: LSTDI template completion rose from 0% to about 80% throughout the study period in both projects' intervention and comparison CLCs. There were small but statistically significant differences for feedback reports alone (comparison sites performed better, coefficient estimate 3.48, standard error 0.99 for the difference between groups in change in trend) and feedback reports + external facilitation (intervention sites performed better, coefficient estimate -2.38, standard error 0.72). CONCLUSIONS: Feedback reports + external facilitation was associated with a small but statistically significant improvement in outcomes compared with comparison sites. The large increases in completion rates are likely due to the well-planned national roll-out of the LSTDI. This finding suggests that when dissemination and support for widespread implementation are present and system-mandated, significant enhancements in the adoption of evidence-based practices may require more intensive support.

Older adults with multi-morbidity: medication management processes and design implications for personal health applications.

BACKGROUND: Older adults often have multiple chronic problems requiring them to manage complex medication regimens overseen by various clinicians. Personal health applications (PHAs) show promise assisting in medication self-management, but adoption of new computer technologies by this population is challenging. Optimizing the utility of PHAs requires a thorough understanding of older adults' needs, preferences, and practices. OBJECTIVE: The objective of our study was to understand the medication self-management issues faced by older adults and caregivers that can be addressed by an electronic PHA. METHODS: We conducted a qualitative analysis of a series of individual and group semistructured interviews with participants who were identified through purposive sampling. RESULTS: We interviewed 32 adult patients and 2 adult family caregivers. We identified 5 core themes regarding medication self-management challenges: seeking reliable medication information, maintaining autonomy in medication treatment decisions, worrying about taking too many medications, reconciling information discrepancies between allopathic and alternative medical therapies, and tracking and coordinating health information between multiple providers. CONCLUSIONS: This study provides insights into the latent concerns and challenges faced by older adults and caregivers in managing medications. The results suggest that PHAs should have the following features to accommodate the management strategies and information preferences of this population: (1) provide links to authoritative and reliable information on side effects, drug interactions, and other medication-related concerns in a way that is clear, concise, and easy to navigate, (2) facilitate communication between patients and doctors and pharmacists through electronic messaging and health information exchange, and (3) provide patients the ability to selectively disclose medication information to different clinicians.

Two complementary personal medication management applications developed on a common platform: case report.

BACKGROUND: Adverse drug events are a major safety issue in ambulatory care. Improving medication self-management could reduce these adverse events. Researchers have developed medication applications for tethered personal health records (PHRs), but little has been reported about medication applications for interoperable PHRs. OBJECTIVE: Our objective was to develop two complementary personal health applications on a common PHR platform: one to assist children with complex health needs (MyMediHealth), and one to assist older adults in care transitions (Colorado Care Tablet). METHODS: The applications were developed using a user-centered design approach. The two applications shared a common PHR platform based on a service-oriented architecture. MyMediHealth employed Web and mobile phone user interfaces. Colorado Care Tablet employed a Web interface customized for a tablet PC. RESULTS: We created complementary medication management applications tailored to the needs of distinctly different user groups using common components. Challenges were addressed in multiple areas, including how to encode medication identities, how to incorporate knowledge bases for medication images and consumer health information, how to include supplementary dosing information, how to simplify user interfaces for older adults, and how to support mobile devices for children. CONCLUSIONS: These prototypes demonstrate the utility of abstracting PHR data and services (the PHR platform) from applications that can be tailored to meet the needs of diverse patients. Based on the challenges we faced, we provide recommendations on the structure of publicly available knowledge resources and the use of mobile messaging systems for PHR applications.