SHARING Choices: Lessons Learned from a Primary-Care Focused Advance Care Planning Intervention.

BACKGROUND: Few advance care planning (ACP) interventions have been scaled in primary care. PROBLEM: Best practices for delivering ACP at scale in primary care do not exist and prior efforts have excluded older adults with Alzheimer's Disease and Related Dementias (ADRD). INTERVENTION: SHARING Choices (NCT#04819191) is a multicomponent cluster-randomized pragmatic trial conducted at 55 primary care practices from two care delivery systems in the Mid-Atlantic region of the U.S. We describe the process of implementing SHARING Choices within 19 practices randomized to the intervention, summarize fidelity to planned implementation, and discuss lessons learned. OUTCOMES: Embedding SHARING Choices involved engagement with organizational and clinic-level partners. Of 23,220 candidate patients, 17,931 outreach attempts by phone (77.9%) and the patient portal (22.1%) were made by ACP facilitators and 1215 conversations occurred. Most conversations (94.8%) were less than 45 minutes duration. Just 13.1% of ACP conversations included family. Patients with ADRD comprised a small proportion of patients who engaged in ACP. Implementation adaptations included transitioning to remote modalities, aligning ACP outreach with the Medicare Annual Wellness Visit, accommodating primary care practice flexibility. LESSONS LEARNED: Study findings reinforce the value of adaptable study design; co-designing workflow adaptations with practice staff; adapting implementation processes to fit the unique needs of two health systems; and modifying efforts to meet health system goals and priorities.

Place of Death for Persons With and Without Cognitive Impairment in the United States.

BACKGROUND/OBJECTIVES: There is increasing recognition that place of death is an important component of quality of end-of-life care (EOLC) and quality of death. This study examined where older persons with and without cognitive impairment die in the United States, what factors contribute to place of death, and whether place of death influences satisfaction with EOLC. DESIGN: Cross-sectional secondary data analysis. SETTING: In-person interviews with community-dwelling proxy respondents. PARTICIPANTS: Data were collected from 1,500 proxies for deceased participants in the National Health and Aging Trends Study (NHATS), a nationally-representative sample of community-dwelling Medicare beneficiaries aged 65 and older. MEASUREMENTS: Study variables were obtained from the NHATS "last month of life" interview data. Survey weights were applied to all analyses. RESULTS: Persons with cognitive impairment (CI) most often died at home, while cognitively healthy persons (CHP) were equally likely to die at home or in a hospital. Persons with CI who utilized the Medicare Hospice Benefit were 14.5 times more likely to die at home than in a hospital, and 3.4 times more likely to die at home than a nursing home. CHP who use this benefit were over six times more likely to die at home than in a hospital, and more than twice as likely to die at home than a nursing home. Place of death for CHP was also associated with age and race. Proxies of persons with CI who died at home rated EOLC as more favorable, while proxies of CHP rated in-home and hospital care equally. CONCLUSION: Findings add to the scant literature identifying factors associated with place of death for older adults with and without CI and results suggest that place of death is a quality of care indicator for these populations. These findings may inform EOLC planning and policy-making and facilitate greater well-being at end-of-life.

Integrating Culturally Competent Advance Care Planning for Korean Immigrants: An Integrative Review.

AIMS: This review aims to explore the extant literature on the current utilization of ACP in Kisin order to obtain a comprehensive understanding of their health disparities and to determineevidence-based best practices to integrate culturally-competent ACP for EOL care of KIs. DESIGN: A systematic integrative review of the literature Data Sources:  Four electronic databases including PubMed, the Cumulative Index of Nursing and Allied Health Literature, the Cochrane Library, and Embase. METHOD: The detailed search strategy for databases implicated a combination of MeSHkeywords and associated terms, which can be found in Table A.Results: Three themes emerged in relation to fundamental components in the integration of culturally-competent ACP for EOL of KIs: (1) cultural characteristics of KIs; (2) disparities in ethnic-oriented ACP and EOL care resources in KIs; and (3) KIs' perspectives on ACP. CONCLUSION: The findings of this review indicate that culturally-competent ACP resources for KIsare presently quite insufficient. It is determined that much future research is needed on howculturally-competent ACP can best augment the quality of EOL care for KIs, and on howspecific interventions can effectively implement ACP in community settings. Impact: Such ongoing research dedicated to the development of feasible culturally competent practice guidelines is anticipated to markedly reduce health disparities and promote ACP in KIs. The recommendations in this review may support Korean primary HCPs, Korean health care center administrators, Korean health maintenance organizations (HMOs), Korean advance care nurse practitioners in hospice and palliative care, and nurse researchers in their work.

Student perceptions of cultural competence content in the curriculum.

The 31-item Blueprint for Integration of Cultural Competence in the Curriculum (BICCC) was used as an organizing framework and an evaluative tool to survey student perceptions of inclusion of cultural-specific content in undergraduate and graduate courses. Quantitative and qualitative data were used to complete this survey, which provided definitive information about the strengths and deficiencies of the curriculum initiative. Findings show that faculty made considerable progress with the curriculum integrative efforts. With responses of sometimes to quite often on the BICCC survey, 90% of the master's, 87% of senior, and 25% of first-semester freshmen participants reported a sufficient level of teaching in response to the survey items on aspects of culture and health. For all cohorts, the survey showed that content related to critique of health disparities research and theoretical formulation about culture, health, and nursing were not sufficiently addressed. Open-ended comments showed that freshmen reported a solid foundation of culturally related courses in arts and humanities courses; seniors disclosed a high level of knowledge about aspects of culture competence; and master's participants had high levels of self-awareness about values, cultural beliefs, and challenges of cross-cultural communication. The BICCC provided substantial information for faculty to address areas of omission, deficiency, and redundancy in the cultural competence education.

Cognitive function assessment in individuals at risk for Alzheimer's disease.

PURPOSE: To describe brief assessments of functional performance and cognition to detect Alzheimer's disease (AD) and depression in older adults for the primary care provider. DATA SOURCES: Review of the literature. CONCLUSIONS: It is important for the clinician to interview both the patient and a knowledgeable informant to assess changes in the patients' functioning in daily life tasks and to administer brief screening tests to detect cognitive impairment and depression in older adults. Several suggested instruments for use in the primary care setting are included. IMPLICATIONS FOR PRACTICE: Standardized assessments of functional performance and brief cognitive tests identify individuals with clinically meaningful cognitive impairment and provide baseline measurement against which to compare future assessments.