Differential Effects of an Emergency Department-to-Home Care Transitions Intervention in an Older Adult Population: A Latent Class Analysis.

BACKGROUND: Older adults frequently return to the emergency department (ED) within 30 days of a visit. High-risk patients can differentially benefit from transitional care interventions. Latent class analysis (LCA) is a model-based method used to segment the population and test intervention effects by subgroup. OBJECTIVES: We aimed to identify latent classes within an older adult population from a randomized controlled trial evaluating the effectiveness of an ED-to-home transitional care program and test whether class membership modified the intervention effect. RESEARCH DESIGN: Participants were randomized to receive the Care Transitions Intervention or usual care. Study staff collected outcomes data through medical record reviews and surveys. We performed LCA and logistic regression to evaluate the differential effects of the intervention by class membership. SUBJECTS: Participants were ED patients (age 60 y and above) discharged to a community residence. MEASURES: Indicator variables for the LCA included clinically available and patient-reported data from the initial ED visit. Our primary outcome was ED revisits within 30 days. Secondary outcomes included ED revisits within 14 days, outpatient follow-up within 7 and 30 days, and self-management behaviors. RESULTS: We interpreted 6 latent classes in this study population. Classes 1, 4, 5, and 6 showed a reduction in ED revisit rates with the intervention; classes 2 and 3 showed an increase in ED revisit rates. In class 5, we found evidence that the intervention increased outpatient follow-up within 7 and 30 days (odds ratio: 1.81, 95% CI: 1.13-2.91; odds ratio: 2.24, 95% CI: 1.25-4.03). CONCLUSIONS: Class membership modified the intervention effect. Population segmentation is an important step in evaluating a transitional care intervention.

Scalar Assessment of the Family Caregiver Activation in Transitions Tool: An Exploratory Factor Analysis.

The Family Caregiver Activation in Transitions (FCAT) tool in its current, non-scalar form is not pragmatic for clinical use as each item is scored and intended to be interpreted individually. The purpose of the current study was to create a scalar version of the FCAT to facilitate better care communications between hospital staff and family caregivers. We also assessed the scale's validity by comparing the scalar version of the measure against patient health measures. Data were collected from 463 family caregiver-patient dyads from January 2016 to July 2019. An exploratory factor analysis was performed on the 10-item FCAT, resulting in a statistically homogeneous six-item scale focused on current caregiving activation factors. The measure was then compared against patient health measures, with no significant biases found. The six-item scalar FCAT can provide hospital staff insight into the level of caregiver activation occurring in the patient's health care and help tailor care transition needs for family caregiver-patient dyads. [Journal of Gerontological Nursing, 48(12), 35-42.].

Development and validation of a pragmatic natural language processing approach to identifying falls in older adults in the emergency department.

BACKGROUND: Falls among older adults are both a common reason for presentation to the emergency department, and a major source of morbidity and mortality. It is critical to identify fall patients quickly and reliably during, and immediately after, emergency department encounters in order to deliver appropriate care and referrals. Unfortunately, falls are difficult to identify without manual chart review, a time intensive process infeasible for many applications including surveillance and quality reporting. Here we describe a pragmatic NLP approach to automating fall identification. METHODS: In this single center retrospective review, 500 emergency department provider notes from older adult patients (age 65 and older) were randomly selected for analysis. A simple, rules-based NLP algorithm for fall identification was developed and evaluated on a development set of 1084 notes, then compared with identification by consensus of trained abstractors blinded to NLP results. RESULTS: The NLP pipeline demonstrated a recall (sensitivity) of 95.8%, specificity of 97.4%, precision of 92.0%, and F1 score of 0.939 for identifying fall events within emergency physician visit notes, as compared to gold standard manual abstraction by human coders. CONCLUSIONS: Our pragmatic NLP algorithm was able to identify falls in ED notes with excellent precision and recall, comparable to that of more labor-intensive manual abstraction. This finding offers promise not just for improving research methods, but as a potential for identifying patients for targeted interventions, quality measure development and epidemiologic surveillance.

Effectiveness of a care transitions intervention for older adults discharged home from the emergency department: A randomized controlled trial.

BACKGROUND: Improving care transitions following emergency department (ED) visits may reduce post-ED adverse events among older adults (e.g., ED revisits, decreased function). The Care Transitions Intervention (CTI) improves hospital-to-home transitions; however, its effectiveness at improving post-ED outcomes is unknown. We tested the effectiveness of the CTI with community-dwelling older adult ED patients, hypothesizing that it would reduce revisits and increase performance of self-management behaviors during the 30 days following discharge. METHODS: We conducted a randomized controlled trial among patients age ≥ 60 discharged home from one of three EDs in two states. Intervention participants received a minimally modified CTI, with a home visit 24 to 72 h postdischarge and one to three phone calls over 28 days. We collected demographic, health status, and psychosocial data at the initial ED visit. Medication adherence and knowledge of red flag symptoms were assessed via phone survey. Care use and comorbidities were abstracted from medical records. We performed multivariate regressions for intention-to-treat and per-protocol (PP) analyses. RESULTS: Participant characteristics (N = 1,756) were similar across groups: mean age 72.4 ± 8.6 years and 53% female. Of those randomized to the intervention, 84% completed the home visit. Overall, 12.4% of participants returned to the ED within 30 days. The CTI did not significantly affect odds of 30-day ED revisits (adjusted odds ratio [AOR] = 0.97, 95% confidence interval [CI] = 0.72 to 1.30) or medication adherence (AOR = 0.89, 95% CI = 0.60 to 1.32). Participants receiving the CTI (PP) had increased odds of in-person follow-up with outpatient clinicians during the week following discharge (AOR = 1.24, 95% CI = 1.01 to 1.51) and recalling at least one red flag from ED discharge instructions (AOR = 1.34 95% CI = 1.05 to 1.71). CONCLUSIONS: The CTI did not reduce 30-day ED revisits but did significantly increase key care transition behaviors (outpatient follow-up, red flag knowledge). Additional research is needed to explore if patients with different conditions benefit more from the CTI and whether decreasing ED revisits is the most appropriate outcome for all older adults.

Coaching older adults discharged home from the emergency department: The role of competence and emotion in following up with outpatient clinicians.

OBJECTIVE: Motivating older adults to follow up with an outpatient clinician after discharge from emergency departments (ED) is beneficial yet challenging. We aimed to answer whether psychological needs for motivation and discrete emotions observed by care transition coaches would predict this behavioral outcome. METHODS: Community-dwelling older adults following ED discharge were recruited from three EDs in two U.S. states. We examined home visit notes documented by coaches (N = 725). Retrospective chart reviews of medical records tracked participants' health care utilization for 30 days. RESULTS: Observed knowledge-based competence predicted higher likelihood of outpatient follow-up within 30 days, while observed sadness predicted a lower likelihood of follow-up within seven days following discharge. Moreover, participants who demonstrated happiness were marginally more likely to have an in-person follow-up within seven days, and those who demonstrated knowledge-based competence were more likely to have an electronic follow-up within 30 days. CONCLUSIONS: Knowledge-based competence and emotions, as observed and documented in coach notes, can predict older adults' subsequent outpatient follow-up following their ED-discharge. PRACTICE IMPLICATIONS: Intervention programs might encourage coaches to check knowledge-based competence and to observe emotions in addition to delivering the content. Coaches could also customize strategies for patients with different recommended timeframes of follow-up.

Care transitions intervention reduces ED revisits in cognitively impaired patients.

Introduction: About half of older adults with impaired cognition who are discharged home from the emergency department (ED) return for further care within 30 days. We tested the effect of an adapted Care Transitions Intervention (CTI) at reducing ED revisits in this vulnerable population. Methods: We conducted a pre-planned subgroup analysis of community-dwelling, cognitively impaired older (age ≥60 years) participants from a randomized controlled trial testing the effectiveness of the CTI adapted for ED-to-home transitions. The parent study recruited ED patients from three university-affiliated hospitals from 2016 to 2019. Subjects eligible for this sub-analysis had to: (1) have a primary care provider within these health systems; (2) be discharged to a community residence; (3) not receive care management or hospice services; and (4) be cognitively impaired in the ED, as determined by a score >10 on the Blessed Orientation Memory Concentration Test. The primary outcome, ED revisits within 30 days of discharge, was abstracted from medical records and evaluated using logistic regression. Results: Of our sub-sample (N = 81, 36 control, 45 treatment), 57% were female and the mean age was 78 years. Multivariate analysis, adjusted for the presence of moderate to severe depression and inadequate health literacy, found that the CTI significantly reduced the odds of a repeat ED visit within 30 days (odds ratio [OR] 0.25, 95% confidence interval [CI] 0.07 to 0.90) but not 14 days (OR 1.01, 95% CI 0.26 to 3.93). Multivariate analysis of outpatient follow-up found no significant effects. Discussion: Community-dwelling older adults with cognitive impairment receiving the CTI following ED discharge experienced fewer ED revisits within 30 days compared to usual care. Further studies must confirm and expand upon this finding, identifying features with greatest benefit to patients and caregivers.

Features of primary care practice influence emergency care-seeking behaviors by caregivers of persons with dementia: A multiple-perspective qualitative study.

BACKGROUND: Persons with dementia use emergency department services at rates greater than other older adults. Despite risks associated with emergency department use, persons with dementia and their caregivers often seek emergency services to address needs and symptoms that could be managed within primary care settings. As emergency departments (EDs) are typically sub-optimal environments for addressing dementia-related health issues, facilitating effective primary care provision is critical to reduce the need for, or decision to seek, emergency services. The aim of this study is to explore how features of primary care practice influence care-seeking decisions by community-dwelling persons with dementia and familial caregivers. METHODS: Semi-structured qualitative interviews were conducted with 27 key dementia-care stakeholders (10 primary care/geriatrics providers, 5 caregivers, 4 emergency medicine physicians, 5 aging service providers, and 3 community paramedics) from multiple health systems. Transcripts from audio recordings were analyzed using a thematic analysis framework to iteratively code and develop emergent themes. Features of primary care were also synthesized into lists of tangible factors leading to emergency care-seeking and those that help prevent (or decrease the need for) ED use. FINDINGS: Stakeholders identified eight categories of features of primary care encompassing the clinical environment and provision of care. These collapsed into four major themes: (1) clinic and organizational features-including clinic structure and care team staffing; (2) emphasizing proactive approaches to anticipate needs and avoid acute problems-including establishing goals of care, preparing for the future, developing provider-patient/provider-caregiver relationships, and providing caregiver support, education, and resources to help prevent emergencies; (3) health care provider skills and knowledge of dementia-including training and diagnostic capabilities; and (4) engaging appropriate community services/resources to address evolving needs. CONCLUSIONS: Features of primary care practice influence decisions to seek emergency department care at the system, organizational/clinic, medical, and interpersonal levels, particularly regarding proactive and reactive approaches to addressing dementia-related needs. Interventions for improving primary care for persons with dementia and their caregivers should consider incorporating features that facilitate proactive family-centered dementia care across the four identified themes, and minimize those leading to caregiver decisions to utilize emergency services.

Predictors of Older Adult Adherence With Emergency Department Discharge Instructions.

OBJECTIVE: Older adults discharged from the emergency department (ED) are at high risk for adverse outcomes. Adherence to ED discharge instructions is necessary to reduce those risks. The objective of this study is to determine the individual-level factors associated with adherence with ED discharge instructions among older adult ED outpatients. METHODS: We performed a secondary analysis of data from the control group of a randomized controlled trial testing a care transitions intervention among older adults (age ≥ 60 years) discharged home from the ED in two states. Taking data from patient surveys and chart reviews, we used multivariable logistic regression to identify patient characteristics associated with adherence to printed discharge instructions. Outcomes were patient-reported medication adherence, provider follow-up visit adherence, and knowledge of "red flags" (signs of worsening health requiring further medical attention). RESULTS: A total 824 patients were potentially eligible, and 699 had data in at least one pillar. A total of 35% adhered to medication instructions, 76% adhered to follow-up instructions, and 35% recalled at least one red flag. In the multivariate analysis, no factors were significantly associated with failure to adhere to medications. Participants with poor health status (adjusted odds ratio [AOR] = 0.55, 95% confidence interval [CI] = 0.31 to 0.98) were less likely to adhere to follow-up instructions. Participants who were older (AORs trended downward as age category increased) or depressed (AOR = 0.39, 95% CI = 0.17 to 0.85) or had one or more functional limitations (AOR = 0.62, 95% CI = 0.41 to 0.94) were less likely to recall red flags. CONCLUSION: Older adults discharged home from the ED have mixed rates of adherence to discharge instructions. Although it is thought that some subgroups may be higher risk than others, given the opportunity to improve ED-to-home transitions, EDs and health systems should consider providing additional care transition support to all older adults discharged home from the ED.

A Family-Centered Rounds Checklist, Family Engagement, and Patient Safety: A Randomized Trial.

BACKGROUND AND OBJECTIVES: Family-centered rounds (FCRs) have become standard of care, despite the limited evaluation of FCRs' benefits or interventions to support high-quality FCR delivery. This work examines the impact of the FCR checklist intervention, a checklist and associated provider training, on performance of FCR elements, family engagement, and patient safety. METHODS: This cluster randomized trial involved 298 families. Two hospital services were randomized to use the checklist; 2 others delivered usual care. We evaluated the performance of 8 FCR checklist elements and family engagement from 673 pre- and postintervention FCR videos and assessed the safety climate with the Children's Hospital Safety Climate Questionnaire. Random effects regression models were used to assess intervention impact. RESULTS: The intervention significantly increased the number of FCR checklist elements performed (ß = 1.2, P < .001). Intervention rounds were significantly more likely to include asking the family (odds ratio [OR] = 2.43, P < .05) or health care team (OR = 4.28, P = .002) for questions and reading back orders (OR = 12.43, P < .001). Intervention families' engagement and reports of safety climate were no different from usual care. However, performance of specific checklist elements was associated with changes in these outcomes. For example, order read-back was associated with significantly more family engagement. Asking families for questions was associated with significantly better ratings of staff's communication openness and safety of handoffs and transitions. CONCLUSIONS: The performance of FCR checklist elements was enhanced by checklist implementation and associated with changes in family engagement and more positive perceptions of safety climate. Implementing the checklist improves delivery of FCRs, impacting quality and safety of care.