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.

Interprofessional Healthcare Students' Attitudes, Skills, and Knowledge After Comprehensive Pain Assessment Training in Verbal and Nonverbal Patients.

A comprehensive pain assessment is the first step in safe, effective pain management. Few studies have explored variations of strategies and measures for multidimensional pain assessment education in both verbal and nonverbal patients. In this retrospective cohort study, interprofessional health care students enrolled in a palliative care curriculum completed a pain assessment training, which taught the PQRSTA ("palliating factors, precipitating factors, previous treatments, quality, region, radiation, severity, temporal factors and associated symptoms") mnemonic as a strategy for assessing pain in verbal patients and the Pain Assessment in Advance Dementia and Checklist of Nonverbal Pain Indicators measures for nonverbal patients. The purpose of this study was to compare the change in attitudes, self-perceived skills, and knowledge regarding pain assessment before and after the training. Attitudes and self-perceived skills were assessed in the pretraining and posttraining survey, which was analyzed using χ2 test or Fisher exact test. Students' knowledge responses were analyzed using Wilcoxon signed rank test to assess accuracy of responses compared with the expert defined score. One hundred eighty-two students were included. Results showed a statistically significant improvement in attitudes related to applicability of pain measures and self-perceived skills. Overall, data did not support an increase in knowledge using the PQRSTA mnemonic, or Pain Assessment in Advance Dementia and Checklist of Nonverbal Pain Indicators measures. Future pain trainings should consider training on only 1 nonverbal pain measure, incorporating bedside assessments, and integrating real-time feedback.

State survey of medical boards regarding abrupt loss of a prescriber of controlled substances.

OBJECTIVES: The purpose of the study was to evaluate states' experiences with abrupt changes in controlled substances (CS) prescribing, to determine whether states have action plans in place to manage such situations, and describe the components of any such plans. METHODS: A survey of executive directors of 51 medical boards was conducted to evaluate states' experiences with abrupt changes in CS prescribing, the extent of consumer complaints attributed to these events, and the types of plans in place to manage these situations. RESULTS: Forty-six executive directors of medical boards responded. Twenty boards (43.5 percent) confirmed that their state had experienced abrupt loss of CS providers and 11 (55 percent) of these executive directors indicated that the loss resulted in increased consumer complaints. The majority of executive directors (86 percent) had no action plan. Six executive directors reported some type of action plan or process consisting of regulatory action, patient-provider connection, professional education, patient education, or public notice. CONCLUSIONS: Most states do not have operational plans in place. However, a few have key strategies that may be useful in addressing potential problems following abrupt loss of a CS prescriber. State medical boards can play a significant role in the development of comprehensive preparedness plans to mitigate damage from the loss of CS prescribers in the community.

Perceived value and cost of providing emergency medication kits to home hospice patients in Maryland.

Many hospices have adopted the use of ''emergency medication kits'' (EMK) to allow for management of emergent symptoms and to prevent unscheduled patient interventions. The purpose of this study was to compare perceptions of hospice managers and clinicians regarding the value of EMK and to assess outcomes. Clinical managers and clinicians reported that EMK were valuable in preventing emergency department visits, unscheduled nursing visits, pharmacy deliveries, and increased satisfaction. A hospice using EMK reported fewer calls requiring unscheduled interventions (18% vs 33%) and resulted in cost savings (US$23.04 per call vs US$31.62 per call). Hospice managers and clinicians perceived EMK to be valuable in areas of quality, cost, and satisfaction. There appears to be an advantage to routinely providing EMK for home hospice patients.