Catalyzing dementia care through the learning health system and consumer health information technology.

To advance care for persons with Alzheimer's disease and related dementias (ADRD), real-world health system effectiveness research must actively engage those affected to understand what works, for whom, in what setting, and for how long-an agenda central to learning health system (LHS) principles. This perspective discusses how emerging payment models, quality improvement initiatives, and population health strategies present opportunities to embed best practice principles of ADRD care within the LHS. We discuss how stakeholder engagement in an ADRD LHS when embedding, adapting, and refining prototypes can ensure that products are viable when implemented. Finally, we highlight the promise of consumer-oriented health information technologies in supporting persons living with ADRD and their care partners and delivering embedded ADRD interventions at scale. We aim to stimulate progress toward sustainable infrastructure paired with person- and family-facing innovations that catalyze broader transformation of ADRD care.

Factors Associated With Loss of Usual Source of Care Among Older Adults.

PURPOSE: Access to a usual source of care (USC) is associated with better preventive health and chronic disease treatment. Although most older adults have a USC, loss of USC, and factors associated with loss of USC, have not previously been examined. METHODS: We followed 7,609 participants of the National Health and Aging Trends Study annually for up to 6 years (2011-2016). Discrete time-to-event techniques and pooled logistic regression were used to identify demographic, clinical, and social factors associated with loss of USC. RESULTS: Ninety-five percent of older adults reported having a USC in 2011, of whom 5% subsequently did not. Odds of losing a USC were higher among older adults with unmet transportation needs (adjusted odds ratio [aOR] 1.67), who moved to a new residence (aOR 2.08), and who reported depressive symptoms (aOR 1.40). Odds of losing a USC were lower for those who had ≥4 chronic conditions (vs 0-1; aOR 0.42) and with supplemental (aOR 0.52) or Medicaid (aOR 0.67) insurance coverage. CONCLUSIONS: We identified factors associated with older adults' loss of a USC. Potentially modifiable factors, such as access to transportation and supplemental insurance, deserve further investigation to potentially assist older adults with continuous access to care.

First-Year Internal Medicine Residents' Reflections on Nonmedical Home Visits to High-Risk Patients.

PROBLEM: Patients who are high utilizers of care often experience health-related challenges that are not readily visible in an office setting but paramount for residents to learn. A nonmedical home visit performed at the beginning of residency training may help residents better understand social underpinnings related to their patient's health and place subsequent care within the context of the patient's life. INTERVENTION: First-year internal medicine residents completed a nonmedical home visit to an at-risk patient prior to seeing the patient in the office for his or her first medical visit. CONTEXT: We performed a thematic analysis of internal medicine interns' (n = 16) written narratives on their experience of getting to know a complex patient in his or her home prior to seeing the patient for a medical visit. Narratives were written by the residents immediately following the visit and then again at the end of the intern year, to assess for lasting impact of the intervention. Residents were from an urban academic residency program in Baltimore, Maryland, USA. OUTCOME: We identified four themes from the submitted narratives. Residents discussed the visit's impact on future practice, the effect of the community and support system on health, the impact on the depth of the relationship, and the visit as a source of professional fulfillment. Whereas the four themes were present at both time points, the narratives completed immediately following the visit focused more on the themes of impact of future practice and the effect of the community and support system on health. The influence of the home visit on the depth of the relationship was a more prevalent theme in the end-of-the-year narratives. LESSONS LEARNED: Although there is evidence to support the utility of learners completing medical home visits, this exploratory study shows that a nonmedical home visit can be rewarding and formative for early resident physicians. Future studies could examine the patient's perspective on the experience and whether a nonmedical home visit is a valuable tool in other patient populations.

The effect of dementia on patterns of healthcare use in older adults with diabetes.

BACKGROUND: For persons with diabetes, incidence of dementia has been associated with increased hospitalization; however, little is known about healthcare use preceding and following incident dementia. We describe healthcare utilization in the 3 years pre- and post-incident dementia among older adults with diabetes. METHODS: We used the National Health and Aging Trends Study (NHATS) linked to Medicare fee-for-service claims from 2011 to 2018. We included community-dwelling adults ≥65 years who had diabetes without dementia. We matched older adults with dementia (identified with validated NHATS algorithm) at the year of incident dementia to controls using coarsened exact matching. We examined annual outpatient visits, emergency department (ED) visits, hospitalization, and post-acute skilled nursing facility (SNF) use 3 years preceding and 3 years following dementia onset. RESULTS: We included 195 older adults with diabetes with incident dementia and 1107 controls. Groups had a similar age (81.6 vs 81.7 years) and were 56.4% female. Persons with dementia were more likely to be of minority racial and ethnic groups (26.7% vs 21.3% Black, non-Hispanic, 15.3% vs 6.7% other race or Hispanic). We observed a larger decrease in outpatient visits among persons with dementia, primarily due to decreasing specialty visits (mean outpatient visits: 3 years pre-dementia/matching 6.8 (SD 2.6) dementia vs 6.4 (SD 2.6) controls, p < 0.01 to 3 years post-dementia/matching 4.6 (SD 2.3) dementia vs 5.5 (SD 2.7) controls, p < 0.01). Hospitalization, ED visits, and post-acute SNF use were higher for persons with dementia and rose in both groups (e.g., ED visits 3 years pre-dementia/matching 3.9 (SD 5.4) dementia vs 2.2 (SD 4.8) controls, p < 0.001; 3 years post-dementia/matching 4.5 (SD 4.7) dementia vs 3.5 (SD 6.1) controls, p = 0.04). CONCLUSIONS: Older adults with diabetes with incident dementia have higher rates of acute and post-acute care use, but decreasing outpatient use over time, primarily due to a decrease in specialty visits.

Care partners and consumer health information technology: A framework to guide systems-level initiatives in support of digital health equity.

Introduction: Consumer-oriented health information technologies (CHIT) such as the patient portal have a growing role in care delivery redesign initiatives such as the Learning Health System. Care partners commonly navigate CHIT demands alongside persons with complex health and social needs, but their role is not well specified. Methods: We assemble evidence and concepts from the literature describing interpersonal communication, relational coordination theory, and systems-thinking to develop an integrative framework describing the care partner's role in applied CHIT innovations. Our framework describes pathways through which systematic engagement of the care partner affects longitudinal work processes and multi-level outcomes relevant to Learning Health Systems. Results: Our framework is grounded in relational coordination, an emerging theory for understanding the dynamics of coordinating work that emphasizes role-based relationships and communication, and the Systems Engineering Initiative for Patient Safety (SEIPS) model. Cross-cutting work systems geared toward explicit and purposeful support of the care partner role through CHIT may advance work processes by promoting frequent, timely, accurate, problem-solving communication, reinforced by shared goals, shared knowledge, and mutual respect between patients, care partners, and care team. We further contend that systematic engagement of the care partner in longitudinal work processes exerts beneficial effects on care delivery experiences and efficiencies at both individual and organizational levels. We discuss the utility of our framework through the lens of an illustrative case study involving patient portal-mediated pre-visit agenda setting. Conclusions: Our framework can be used to guide applied embedded CHIT interventions that support the care partner role and bring value to Learning Health Systems through advancing digital health equity, improving user experiences, and driving efficiencies through improved coordination within complex work systems.

Effects of screening for geriatric conditions and advance care planning at the Medicare Annual Wellness Visit.

BACKGROUND: The Medicare Annual Wellness Visit (AWV) requires screening for geriatrics conditions and can include advance care planning (ACP). We examined (1) the prevalence of positive screens for falls, cognitive impairment, and activities of daily living (ADL) impairment, (2) referrals/orders generated potentially in response, and (3) the increase in ACP among those with two AWVs. METHODS: In this retrospective analysis, we used electronic medical record data from a Mid-Atlantic group ambulatory practice. We included adults age > 65 who had ≥1 AWV (n = 16,176) in years 2014-2017. Analyses on high-risk prescribing were limited to those (n = 13,537) with ≥3 months of follow up and ACP to those (n = 9097) with two AWVs. We used responses from the AWV health risk questionnaire to identify screening status for falls, cognitive and ADL impairment and whether an older adult had an ACP. For each screen we identified orders/referrals placed potentially in response (e.g., physical therapy for falls). High-risk medications were based on the 2019 Beers Criteria. RESULTS: Positive screening rates were 38% for falls, 23% for cognition, and 32% for ADL impairment. The adjusted odds of having an order placed potentially in response to the screening were 1.8 (95% CI 1.6-2.0) for falls, 1.4 (1.3-1.7) for cognition, 2.8 (2.4-3.3) for ADL impairment. The adjusted odds of a high-risk prescription in the 3 months after a positive screen were 2.1 (95% CI 1.8-2.5) for falls and 1.9 (95% CI 1.6-2.4) for cognition. Of those with two AWVs, 48% had an ACP at the first AWV. Among the remaining 52% with no ACP at the first AWV, the predicted probability of having an ACP at the second AWV was 0.22 (95% CI 0.18-0.25). CONCLUSION: Our results may indicate positive effects of screening for geriatric conditions at the AWV, and highlight opportunities to improve geriatrics care related to prescribing and ACP.

Factors associated with potentially inappropriate medication use in community-dwelling older adults in the United States: a systematic review.

OBJECTIVES: Potentially inappropriate medication (PIM) use in older adults is a prevalent problem associated with poor health outcomes. Understanding drivers of PIM use is essential for targeting interventions. This study systematically reviews the literature about the patient, clinician and environmental/system factors associated with PIM use in community-dwelling older adults in the United States. METHODS: PRISMA guidelines were followed when completing this review. PubMed and EMBASE were queried from January 2006 to September 2017. Our search was limited to English-language studies conducted in the United States that assessed factors associated with PIM use in adults ≥65 years who were community-dwelling. Two independent reviewers screened titles and abstracts. Reviewers abstracted data sequentially and assessed risk of bias independently. KEY FINDINGS: Twenty-two studies were included. Nineteen examined patient factors associated with PIM use. The most common statistically significant factors associated with PIM use were taking more medications, female sex, and higher outpatient and emergency department utilization. Only three studies examined clinician factors, and few were statistically significant. Fifteen studies examined system-level factors such as geographic region and health insurance. The most common statistically significant association was the south and west geographic region relative to the northeast United States. CONCLUSIONS: Amongst older adults, women and persons on more medications are at higher risk of PIM use. There is evidence that increased healthcare use is also associated with PIM use. Future studies are needed exploring clinician factors, such as specialty, and their association with PIM prescribing.

Determinants of Potentially Inappropriate Medication Use in Long-Term and Acute Care Settings: A Systematic Review.

BACKGROUND: Potentially inappropriate medications (PIMs) are widely used in institutionalized older adults, yet the key determinants that drive their use are incompletely characterized. METHODS: We systematically searched published literature within MEDLINE and Embase from January 1998 to March 2017. We searched for studies conducted in the United States that described determinants of PIM use in adults ≥60 years of age in a nursing home or residential care facility, in the emergency department (ED), or in the hospital. Paired reviewers independently screened abstracts and full-text articles, assessed quality, and extracted data. RESULTS: Among 30 included articles, 12 examined PIM use in the nursing home or residential care settings, 4 in the ED, 12 in acute care hospitals, and 2 across settings. The Beers criteria were most frequently used to identify PIM use, which ranged from 3.6% to 92.0%. Across all settings, the most common determinants of PIM use were medication burden and geographic region. In the nursing home, the most common additional determinants were younger age, and diagnoses of depression or diabetes. In both the ED and hospital, patients receiving care in the West, Midwest, and South, relative to the Northeast, were at greater risk of receiving a PIM. Very few studies examined clinician determinants of PIM use; geriatricians used fewer PIMs in the hospital than other clinicians. CONCLUSIONS: Among older adults, those who are on many medications are at increased risk for PIM use across multiple settings. We propose that careful testing of interventions that target modifiable determinants are indicated to assess their impact on PIM use.