Improving Interprofessional Collaboration Between Social Work and Pharmacy Through Hybrid and Virtual Learning Experiences.

The professions of pharmacy and social work are not generally assumed to directly collaborate in patient care; however, these professions are complementary. Health and wellbeing outcomes are significantly improved when care is managed by an interprofessional team that communicates and collaborates to ensure all aspects of care are effectively managed. The creation of educational opportunities for students to practice working together provides enhanced educational experiences and leads to their success as professionals. Pharmacy and social work faculty developed an interprofessional education activity specifically aimed at integrative student learning. Faculty and students based on various islands throughout the state of Hawai'i and the US territory of Guam participated in the experience. The case study encouraged interprofessional teamwork and collaboration. The case study also challenged students to share profession-specific knowledge with each other. Mean evaluation scores were compared between hybrid and fully online platforms. Evaluation scores were high and at least as good or higher in the fully online exercise compared to the hybrid exercises. Using the 20-item pre-post format, Interprofessional Collaborative Competencies Attainment Survey, results indicated statistically significant improvements in scores for all questions and domains (all P<.001). When hybrid training and fully online training were compared, there were no significant differences in pre scores, but post domain scores were significantly higher in students who experienced fully online training. This interprofessional case-based activity successfully promoted interprofessional learning and collaboration. Introducing learners to this type of collaborative practice while in school is critical for future collaboration in the workforce.

Preventive Care and Outcomes of Interprofessional Medicare Annual Wellness Visits for Older Adults.

As we anticipate a growing population of older adults, we will see an increase in chronic conditions such as dementia and falls. To meet these public health needs, we must systematically provide screening, education, preventive care, and supportive care for older patients and their caregivers in a primary care setting. This will require a workforce trained in providing for the complex medical and psychosocial needs of an older adult population in an interprofessional and collaborative fashion. By integrating geriatric screening tools into an interdisciplinary Annual Wellness Visit teaching clinic, we were able to successfully improve rates of geriatric screening for dementia, depression, falls, medication reconciliation and advance care planning. We also saw improvements in patient care and satisfaction and provided the opportunity for interprofessional collaboration and education for students in medicine, nursing, pharmacy and social work.

Taking action to advance the study of race and ethnicity: the Women's Health Initiative (WHI).

"Race" and "ethnicity" are socially constructed terms, not based on biology - in contrast to biologic ancestry and genetic admixture - and are flexible, contested, and unstable concepts, often driven by power. Although individuals may self-identify with a given race and ethnic group, as multidimensional beings exposed to differential life influencing factors that contribute to disease risk, additional social determinants of health (SDOH) should be explored to understand the relationship of race or ethnicity to health. Potential health effects of structural racism, defined as "the structures, policies, practices, and norms resulting in differential access to goods, services, and opportunities of society by "race," have been largely ignored in medical research. The Women's Health Initiative (WHI) was expected to enroll a racially and ethnically diverse cohort of older women at 40 U.S. clinical centers between 1993 and 1998; yet, key information on the racial and ethnic make-up of the WHI cohort of 161,808 women was limited until a 2020-2021 Task Force was charged by the WHI Steering Committee to better characterize the WHI cohort and develop recommendations for WHI investigators who want to include "race" and/or "ethnicity" in papers and presentations. As the lessons learned are of relevance to most cohorts, the essence of the WHI Race and Ethnicity Language and Data Interpretation Guide is presented in this paper. Recommendations from the WHI Race and Ethnicity Language and Data Interpretation Guide include: Studies should be designed to include all populations and researchers should actively, purposefully and with cultural-relevance, commit to recruiting a diverse sample; Researchers should collect robust data on race, ethnicity and SDOH variables that may intersect with participant identities, such as immigration status, country of origin, acculturation, current residence and neighborhood, religion; Authors should use appropriate terminology, based on a participant's self-identified "race" and "ethnicity", and provide clear rationale, including a conceptual framework, for including race and ethnicity in the analytic plan; Researchers should employ appropriate analytical methods, including mixed-methods, to study the relationship of these sociocultural variables to health; Authors should address how representative study participants are of the population to which results might apply, such as by age, race and ethnicity.

Evaluation of distance facilitation and technology in an interprofessional simulation exercise.

INTRODUCTION: This paper explores two objectives: (1) effectiveness of interprofessional education facilitators utilizing distance technology to facilitate and debrief an interprofessional exercise with students located on the islands Oahu and Hawai'i Island (Hilo), and (2) impact of technology on the simulation experience for facilitators and students. METHODS: Four disciplines participated in an interprofessional hospital discharge exercise for the same geriatric patient case. Two questions administered to facilitators and students after each session focused on: (1) satisfaction with the students' ability to work through the simulation, and (2) satisfaction with the use of distance technology. RESULTS: Results showed no significant differences when comparing students to facilitators for the students' ability to work through the simulation. Students gave significantly lower satisfaction scores with distance technology than faculty. There were no significant differences in scores among disciplines between either facilitators or students. Pharmacy distance students had significantly lower scores for satisfaction with the simulation exercise and for the role of distance technology compared to other students. Qualitative analyses showed trend improvements over five semesters in four technology areas; volume, noise, difficulty with clarity/understanding, and seating location/placement issues for the on-site group, but only significant improvement with clarity/understanding in the distance group. CONCLUSIONS: Interprofessional simulation exercises can be successfully facilitated from both on-site and distance site without compromising students' ability to work through the exercise. Satisfaction with distance technology was lower for distance student groups.

Evolving Palliative Care Practices among Marshall Islanders in Hawai'i: Generational Comparisons.

Little is known about Marshallese palliative care practices. We explored traditional and contemporary Marshallese palliative care practices and examined generational differences. We performed three focus groups in 2011-2012 among Marshall Islanders in Hawai'i. A native speaking interpreter assisted group facilitators. Data were analyzed using classical thematic triangulation methods to identify specific Marshallese palliative care practices, the effect of economic and social challenges in Hawai'i, and generational differences comparing young and old. Nineteen persons (10 men and 9 women, youth aged 17-27 years, and elders as defined in Marshallese culture, aged 46-79) participated. A "good death" was defined as "peaceful and pain free," occurring from natural causes. Factors associated with a "good death" included gathering of family to absolve conflicts, and proper and timely cultural practices. Factors associated with "bad deaths" included young age, active suffering, accidents, suicides, "black magic/curses," or lack of timely or proper burial. Comparing generational differences, older Marshallese had differing opinions regarding preferred place of death, burial site, cultural practice preservation, artificial prolongation of life, and cremation. Barriers included mortuary fees, cost of transporting bodies, United States (US) government policies, and wait times for death certificates. Many cultural factors contribute to "good" or "bad" deaths. Attitudes toward palliative care practices differ by generation. Having previously documented different approaches by Yapese, a generalized "one size fits all" approach to Micronesians is inappropriate. Overcoming identified barriers may facilitate practices necessary for a good death in Micronesian populations in their home nations and as they migrate to communities throughout the US.

Combining quality improvement and geriatrics training: the nursing home polypharmacy outcomes project.

To examine sustained effects of an educational intervention, the authors repeated a successful quality improvement (QI) project on medication safety and cost effectiveness. In October 2007 and August 2008, the facility leadership and geriatrics faculty identified all patients receiving nine or more medications (polypharmacy cohort) in a 170-bed teaching nursing home. They then taught Geriatric Medicine fellows (n = 12 in 2007, 11 in 2008) to (a) systematically collect medication data; (b) generate medication recommendations (stop, taper, or continue) based on expert criteria (Beers criteria) or drug-drug interaction programs; (c) discuss recommendations with patients' attending physicians; and (d) implement approved recommendations. Over the two projects, the polypharmacy cohorts demonstrated decreased potentially inappropriate medications (odds ratio [OR] = .78, 95% confidence interval [95% CI] [0.69, 0.88], p < .001), contraindicated medications (OR = .63, 95% CI [0.47, 0.85], p = .002) and medication costs (OR = .97, 95% CI [0.96, 0.99], p < .001). Findings suggest that programs planning educational QI projects for trainees may benefit from a multiyear approach to maximize clinical and educational benefits.

Standardized patient and standardized interdisciplinary team meeting: validation of a new performance-based assessment tool.

The interdisciplinary team (IDT) approach is critical in the care of elderly adults. Performance-based tools to assess IDT skills have not been well validated. A novel assessment tool, the standardized patient (SP) and standardized interdisciplinary team meeting (SIDTM), consisting of two stations, was developed. First, trainees evaluate a SP hospitalized after a fall. Second, trainees play the role of the physician in a standardized IDT meeting with a standardized registered nurse (SRN) and standardized medical social worker (SMSW) for discharge planning. The SP-SIDTM was administered to 52 fourth-year medical students (MS4s) and six geriatric medicine fellows (GMFs) in 2011/12. The SP, SRN, and SMSW scored trainee performance on dichotomous checklists of clinical tasks and Likert scales of communication skills, which were compared according to level of training using t-tests. Trainees rated the SP-SIDTM experience as moderately difficult, length of time about right, and believability moderate to high. Reliability was high for both cases (Cronbach α = 0.73-0.87). Interobserver correlation between SRN and SMSW checklist scores (correlation coefficient (r) = 0.82, P < .001) and total scores (r = 0.69, P < .001) were high. The overall score on the SP-SIDTM case was significantly higher for GMF (75) than for MS4 (65, P = .002). These observations support the validity of this novel assessment tool.

Correlation of a self-report and direct measure of physical activity level in the electron-beam tomography and risk assessment among Japanese and US Men in the post World War II birth cohort (ERA JUMP) study.

BACKGROUND: Physical activity (PA) is complex and a difficult behavior to assess as there is no ideal assessment tool(s) that can capture all contexts of PA. Therefore, it is important to understand how different assessment tools rank individuals. We examined the extent to which self-report and direct assessment PA tools yielded the same ranking of PA levels. METHODS: PA levels were measured by the Modifiable Activity Questionnaire (MAQ) and pedometer at baseline among 855 white (W), African-American (AA), Japanese-American (JA), and Korean (K) men (mean age 45.3 years) in 3 geographic locations in the ERA JUMP study. RESULTS: Korean men were more active than W, AA, and JA men, according to both the MAQ and pedometer (MAQ total PA [mean ± SD]: 41.6 ± 17.8, 20.9 ± 9.9, 20.0 ± 9.1, and 29.4 ± 10.3 metabolic equivalent [MET] hours/week, respectively; pedometer: 9584.4 ± 449.4, 8363.8 ± 368.6, 8930.3 ± 285.6, 8335.7 ± 368.6 steps/day, respectively). Higher levels of total PA in Korean men, as shown by MAQ, were due to higher occupational PA. Spearman correlations between PA levels reported on the MAQ and pedometer indicated positive associations ranging from rho = 0.29 to 0.42 for total activity, rho = 0.13 to 0.35 for leisure activity, and rho = 0.10 to 0.26 for occupational activity. CONCLUSIONS: The 2 assessment methods correlated and were complementary rather than interchangeable. The MAQ revealed why Korean men were more active. In some subpopulations it may be necessary to assess PA domains other than leisure and to use more than 1 assessment tool to obtain a more representative picture of PA levels.

Aging and caregiving in the Republic of Palau.

Aging has been an important population trend of the twentieth century, with most elderly people living in developing countries. Little has been published on the healthcare needs of elderly in the Pacific Islands. The Pacific Islands Geriatric Education Center, at the University of Hawaii, has a mission to promote training in geriatric education in the Pacific Islands to improve healthcare to the elderly. The aim of this project was to develop and test a family caregiver training program for Palau and was achieved in two phases: (1) assessing needs by interviewing key informants and surveying elders and (2) evaluating the caregiver training program that was designed based on findings from the assessment. The Ecological Systems Theory provided the theoretical framework for this study. The needs assessment identified training and education of family caregivers as a top priority, with the Palauan culture of family caring for seniors presently threatened by caregiver burnout. Nearly all of the long-term care in Palau is provided by families, and elders have high prevalence of geriatric syndromes. A family caregiver train-the-trainer workshop was subsequently conducted in February 2011. Forty-four trainers, including 12 from other Pacific Islands, attended the workshop. To assess changes in knowledge and confidence to teach, we compared scores on pre- and post-questionnaires using paired t tests. The train-the-trainer workshop resulted in significantly improved self-assessed competence and confidence to teach in all geriatric syndromes, including dealing with difficult behaviors, gait and transfer training, caregiver stress relief, and resources for caregivers (p < 0.0001). This successful intervention identified geriatric care needs in Palau and successfully trained family caregivers to meet these needs, and may be used as a model for similar interventions in other Pacific Islands.

Evaluation of a nursing home medical director's curriculum for geriatric medicine fellows.

OBJECTIVES: To describe the evaluation of a nursing home medical directorship curriculum for geriatric medicine fellows. DESIGN: Six first-year geriatric medicine fellows from the University of Hawaii program participated in this educational intervention. INTERVENTION: A medical directorship curriculum based on the American Medical Directors Association's description of the roles and responsibilities of the medical director. Seven 1-hour sessions covering core topics were delivered in case-based format, with the opportunity to practice application. MEASUREMENTS: The curriculum's impact on learner's knowledge, attitudes, skills, and abilities was evaluated using pretests and posttests. The curriculum was evaluated using a structured individual feedback interview after the completion of this curriculum. Pre-post mean scores for attitudes and skills/ability items were compared using paired t tests. A summary of comments from fellows' interviews was tabulated. RESULTS: Fellows showed a significant improvement in knowledge scores after the intervention (63.33% correct before the intervention and 76.67% correct after the intervention, mean change = 13.33%, P = .03). The mean overall scores for attitudes and skills/ability items increased from 4.72 to 5.33 (change = 0.61, P = .11), and 2.67 to 3.83 (change = 1.17, P = .009), respectively. Comments from the interviews were positive and fell into 3 categories. First, fellows felt that they achieved a good knowledge base. Second, they gained a better understanding of the roles and responsibilities. Last, all participants felt the curriculum was very practical and helped them feel more prepared to become medical directors. CONCLUSIONS: An innovative curriculum for nursing home medical direction provided for first-year geriatric medicine fellows had a significantly positive impact on their knowledge, ability, and skills. The curriculum was effective in helping fellows better understand and apply what they learned regarding the roles and responsibilities in medical direction.

Reducing cost by reducing polypharmacy: the polypharmacy outcomes project.

OBJECTIVE: To examine the effect of intervention by geriatric medicine fellows and a geriatrician on medication cost among long term care residents with polypharmacy. DESIGN: Interventional study. SETTING: A single hospital-affiliated long term care facility. PARTICIPANTS: Long term care residents with polypharmacy, defined as being on 9 or more medications. INTERVENTION: Medication lists of all nursing home residents were reviewed in October 2007 by geriatric medicine fellows and a faculty geriatrician using the 2003 Beers Criteria and the Epocrates online drug-drug interaction program. Recommendations for each resident were prepared and discussed directly with their primary physicians, who made the final decisions regarding medication discontinuation or taper. MEASUREMENTS: Mean monthly costs (derived from current retail prices) for overall as well as scheduled and pro re nata (PRN) medications were compared before and after the intervention. Estimated reduction in nursing administration time and cost were calculated based on published literature on medication administration time and nursing labor costs. RESULTS: Seventy-four (46.3%) of 160 residents were on 9 or more medications. Four residents died or were discharged before the intervention, leaving a final sample of 70 residents for the intervention. After the intervention, mean monthly medication costs per resident significantly decreased; overall medications, from $874.27 to $843.56 (P < .0001); scheduled medications, from $814.05 to $801.14 (P= .007); PRN medications, from $60.22 to $42.43 (P < .0001). Gastrointestinal medications demonstrated the highest cost savings of all medication categories (eg, promethazine and proton pump inhibitors), followed by central nervous system-active medications (including benzodiazepines and fluoxetine), then analgesics and diabetes medications. CONCLUSION: This polypharmacy reduction intervention by physicians used readily available tools, demonstrated a significant decrease in medication-related costs, and provided training in the core competencies of practice-based learning and improvement and systems-based practice to geriatric medicine fellows in long term care.

Factors associated with place of death for elderly Japanese-American men: the Honolulu Heart Program and Honolulu-Asia Aging Study.

Place of death is an indicator of health service utilization at the end of life and differs according to cause of death. Asian Americans may have a higher percentage of hospital deaths than Caucasian Americans, yet reasons for this finding are unclear. This study examined distribution of place of death and the associations between place and cause of death in elderly Japanese-American men in a longitudinal cohort: the Honolulu Heart Program and Honolulu-Asia Aging Study. Data collected between 1991 and 1999 on 1,352 men aged 73 to 99 at death were analyzed for associations between cause-of-death characteristics and hospital, home, or nursing home location of death. Fifty-nine percent of men died in hospitals, 23% died at home, and 18% died in nursing homes. Of the dementia-related deaths, 43% occurred in hospitals (vs 16% in a national study), 37% occurred in nursing homes (vs 67% in a national study), and 20% occurred at home. Of the stroke deaths, 53% occurred in hospitals, 40% were in nursing homes, and 7% occurred at home. Of the cancer deaths, 53% occurred in hospitals, 34% occurred at home, and 13% were in nursing homes. Traditional family obligation to care for elderly people at home and inability to access care for dementia may account for the greater rate of hospital death and lower rate of nursing home deaths in this cohort. Attitudes of elderly Japanese Americans and their families regarding place of care at the end of life, particularly in the setting of dementia, merit future study.

Linkage and association analyses of type 2 diabetes/impaired glucose metabolism and adiponectin serum levels in Japanese Americans from Hawaii.

Type 2 diabetes is a common disorder associated with obesity. Lower plasma levels of adiponectin were associated with type 2 diabetes. Candidate regions on chromosomes 1 ( approximately 70 cM) and 14 ( approximately 30 cM) were evaluated for replication of suggestive linkage results for type 2 diabetes/impaired glucose homeostasis in an independent sample of Japanese Americans. Replication of independent linkage evidence for serum levels of adiponectin on chromosome 14 was also evaluated. We investigated 529 subjects from 175 sibships who were originally part of the Honolulu Heart Program. Analyses included nonparametric linkage and association using SAGE (Statistical Analysis for Genetic Epidemiology) and FBAT (family-based test of association) programs and Monte Carlo simulation of Fisher's exact test in SAS. For type 2 diabetes/impaired glucose metabolism, nominal linkage evidence (P < 0.02) followed-up by genotypic association (P = 0.016) was found with marker D14S297 at 31.8 cM; linkage analyses using only diabetes phenotype were also nominally significant at this marker (P < 0.02). Nominal evidence for genotypic association to adiponectin serum level phenotype (P = 0.04) was found with the marker D14S1032 at 23.2 cM. The present study was limited by relatively small sample size. Nevertheless, these results corroborate earlier studies, suggesting that further research is warranted in the candidate region approximately 30 cM on chromosome 14.

Disability and depression: investigating a complex relation using physical performance measures.

OBJECTIVE: The objective of this study was to examine the relation of physical performance measures with depressive symptoms in older men. METHOD: A cross-sectional, multivariate comparison of several measures of upper- and lower-extremity performance and their relation with depressive symptoms was performed in 2,856 older Japanese American men, aged 71-93 years, who participated in the fourth examination of the Honolulu Heart Program. Depressive symptoms were measured using an 11-item version of Center for Epidemiologic Studies Depression (CES-D) Scale. A score of at least 9 (from a maximum score of 33) is considered clinically significant. Timed functional performance tests, including walking and repeated chair stands, were used to assess lower-extremity performance; handgrip strength was used as an indicator of upper-extremity performance. RESULTS: Two hundred eighty-three participants (9.9%) had a score of 9 or greater on the 11-question CES-D Scale and were considered to be at high risk for depression. Time to walk 10 feet and time to complete five chair stands were significantly longer in those with depressive symptoms, whereas handgrip strength was significantly lower. Only the association of gait speed (time to walk 10 feet) and depressive symptoms remained significant when all physical performance measures were simultaneously included in a multivariate analysis. CONCLUSION: These results demonstrate physical performance measures, particularly gait speed, may be important potential correlates of depression in community-dwelling older men.

Midlife risk factors and healthy survival in men.

CONTEXT: Healthy survival has no clear phenotypic definition, and little is known about its attributes, particularly in men. OBJECTIVE: To test whether midlife biological, lifestyle, and sociodemographic risk factors are associated with overall survival and exceptional survival (free of a set of major diseases and impairments). DESIGN, SETTING, AND PARTICIPANTS: Prospective cohort study within the Honolulu Heart Program/Honolulu Asia Aging Study. A total of 5820 Japanese American middle-aged men (mean age, 54 [range, 45-68] years) free of morbidity and functional impairments were followed for up to 40 years (1965-2005) to assess overall and exceptional survival. Exceptional survival was defined as survival to a specified age (75, 80, 85, or 90 years) without incidence of 6 major chronic diseases and without physical and cognitive impairment. MAIN OUTCOME MEASURE: Overall survival and exceptional survival. RESULTS: Of 5820 original participants, 2451 participants (42%) survived to age 85 years and 655 participants (11%) met the criteria for exceptional survival to age 85 years. High grip strength and avoidance of overweight, hyperglycemia, hypertension, smoking, and excessive alcohol consumption were associated with both overall and exceptional survival. In addition, high education and avoidance of hypertriglyceridemia were associated with exceptional survival, and lack of a marital partner was associated with mortality before age 85 years. Risk factor models based on cumulative risk factors (survival risk score) suggest that the probability of survival to oldest age is as high as 69% with no risk factors and as low as 22% with 6 or more risk factors. The probability of exceptional survival to age 85 years was 55% with no risk factors but decreased to 9% with 6 or more risk factors. CONCLUSION: These data suggest that avoidance of certain risk factors in midlife is associated with the probability of a long and healthy life among men.

Knowledge and attitudes about geriatrics of medical students, internal medicine residents, and geriatric medicine fellows.

OBJECTIVES: To evaluate the attitudes and knowledge of medical students (MS1-3), internal medicine residents (postgraduate years 1 to 3 (PGY1-3)), and geriatric medicine fellows about elderly patients before implementation of a new geriatrics curriculum. DESIGN: Cross-sectional study. SETTING: An academic medical center. PARTICIPANTS: Two hundred eleven people participated: 54 MS1, 52 MS2, 50 MS3, 20 PGY1, 12 PGY2, 12 PGY3, and 11 geriatric medicine fellows. MEASUREMENTS: Each participant completed a questionnaire, including a 16-item geriatrics attitude scale, and a 23-item knowledge test (both revised versions of the University of California at Los Angeles (UCLA) Geriatrics Survey). Pearson correlation coefficients and t tests were used for statistical analyses. RESULTS: Both surveys demonstrated high internal consistency (alpha=0.70 and 0.71, respectively). Knowledge test scores increased with advancing level of training. MS1 and MS2 scored significantly lower and fellows scored significantly higher than others. PGY3 scored significantly higher than PGY1 on the knowledge test. All groups demonstrated positive attitudes toward geriatric patients (score>3.5). MS1 and fellows had significantly more favorable attitudes scores than more advanced students and residents. CONCLUSION: The results suggest that the UCLA Attitudes Scale and Knowledge Test can be used reliably to assess attitudes and knowledge level across all levels of medical education and training. The information from this study will be used to implement a more structured and comprehensive geriatrics curriculum across all trainee levels to improve attitudes and knowledge in the care of the geriatric patient.

Using standardized patients to assess the geriatrics medicine skills of medical students, internal medicine residents, and geriatrics medicine fellows.

PURPOSE: Medical schools and residency programs are placing additional emphasis on including clinical geriatrics competencies within their curricula. An eight-station, Geriatric Medicine Standardized Patient Examination (GSPX) was studied as a method to assess bedside geriatrics clinical skills over the continuum of medical education from medical school through residency and fellowship training. METHOD: The GSPX was administered to 39 medical students, 49 internal medicine residents, and 11 geriatrics medicine fellows in 2001-02. Reliability of standardized patient (SP) checklists and rating scales used to assess examinees' performance was measured by Cronbach's alpha. Validity was measured by surveying the examinees' assessment of fairness, individual case length, difficulty, and believability, and by faculty standard setting for each level of trainee. RESULTS: Reliability was high (alpha =.89). All levels of examinees found the SPs to be believable, station lengths to be adequate, and rated the GSPX as a fair assessment. Students rated the cases as more difficult. Previous experience with similar real patients increased significantly with level of training (Pearson's r =.48, p <.0001). Faculty set passing scores that increased from students to residents to fellows. However, GSPX scores decreased with level of training (r = -.25, p =.01). CONCLUSION: The GSPX is a reliable measure of geriatrics medicine skills with adequate face validity for examinees at all levels. However, GSPX scores did not increase with level of training, suggesting that a single form of the examination cannot be used across the continuum of training. Potential modifications to the GSPX that might provide more discrimination between levels of training are currently being explored.