Benchmarking Site of Death and Hospice Use: A Case Study of Veterans Cared by Department of Veterans Affairs Home-based Primary Care.

OBJECTIVE: The objective of this study was to examine site of death and hospice use, identifying potential disparities among veterans dying in Department of Veterans Affairs (VA) Home Based Primary Care (VA-HBPC). METHODS: Administrative data (2008, 2012, and 2016) were compiled using the VA Residential-History-File which tracks health care service location, daily. Outcomes were site of death [home, nursing home (NH), hospital, inpatient hospice]; and hospice use on the day of death. We compared VA-HBPC rates to rates of 2 decedent benchmarks: VA patients and 5% Traditional Medicare non-veteran males. Potential age, race, urban/rural residence and living alone status disparities in rates among veterans dying in VA-HBPC in 2016 were examined by multinomial logistic regression. RESULTS: In 2016, 7796 veterans died in VA-HBPC of whom 62.1% died at home, 11.8% in NHs, 14.7% in hospitals and 11.4% in inpatient hospice. Hospice was provided to 60.9% of veterans dying at home and 63.9% of veterans dying in NH. Over the 2008-2012-2016 period, rates of VA-HBPC veterans who died at home and rates of home death with hospice increased and were higher than both benchmarks. Among VA-HBPC decedents, younger/older veterans were more/less likely to die at home and less/more likely to die with hospice. Race/ethnicity and urban/rural residence were unrelated to death at home but veterans living alone were less likely to die at home. CONCLUSIONS: Results reflect VA-HBPC's primary goal of supporting its veterans at home, including at the end-of-life, surpassing other population benchmarks with some potential disparities remaining.

Development of a Home Health Patient Assessment Tool for Disaster Planning.

BACKGROUND: Historically, older adults have been disproportionately affected by disasters. In particular, homebound adults are especially at risk. As one facet of bolstering community resilience, home health agencies have been tasked with improving their patients' disaster preparedness. However, home health practitioners often lack the information necessary to fulfill these requirements. Providing resources about disaster preparedness will allow these practitioners, often seen as trusted advisors, to better prepare their patients. OBJECTIVE: This study explores the utility of implementing a checklist-style assessment tool to guide Veterans Health Administration (VHA) Home-Based Primary Care (HBPC) practitioners in disaster preparedness assessments of their patients. METHODS: The HBPC Patient Assessment Tool for Disaster Planning ("Tool") was fielded by practitioners at 10 VHA HBPC programs with all patients seen over the course of a 3-week period. Descriptive statistics and bivariate analysis of the data collected via the Tool were used to understand the baseline levels of preparedness education provided by practitioners to their patients. Data from a follow-up survey and follow-up interviews with Program Managers were analyzed, the latter using content analysis methods. RESULTS: 754 surveys were returned for analysis. We examined how frequently practitioners reviewed the included preparedness items with their patients. Of those patients on oxygen, adherence ranged from 67 to 94% for practitioners covering a discussion about smoking materials/open flame, despite strong efforts to achieve high compliance on this measure as reported by several program managers. Of those items applicable to the general population, certain items were more frequently discussed than others. How to activate 911 services was most frequently reviewed (87%). Providing information about emergency shelter registration and specialty transport was the item least frequently reviewed (44%). Strengths about the Tool included its ease of use, flow, comprehensiveness, and that it fits on one page. CONCLUSION: Home-based care programs, such as the VHA HBPC program, are tasked with supporting the emergency preparedness of their patients, but often do not have the expertise to do so. This study shows that the checklist-like structure of an assessment tool can assist with this role by encouraging practitioners to cover key points with patients and their caregivers.

Missed diagnoses in African Americans with obsessive-compulsive disorder: the structured clinical interview for DSM-IV Axis I disorders (SCID-I).

BACKGROUND: Research on the utility of structured interviews in assessing OCD is scarce, and even more so, in its use for OCD in African Americans. The purpose of this study was to examine the utility of the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) in detecting OCD in African Americans when used by well-trained, culturally competent clinicians. METHODS: Seventy-four African American adults with OCD were assessed with the SCID-I and additional measures of OCD. RESULTS: Results revealed the poor diagnostic utility of the SCID OCD section (SCID-OCD), with 66.2% (N = 49) correctly identified and 33.8% (N = 25) incorrectly diagnosed. Participants receiving the correct diagnosis were more likely to endorse compulsive behaviors, specifically ordering compulsions, and experience greater symptom severity. CONCLUSION: The lack of sensitivity for identification of OCD is discussed as the SCID-OCD seems to often miss a true diagnosis of OCD in African Americans.

Congenital syphilis: trends in mortality and morbidity in the United States, 1999 through 2013.

BACKGROUND: Congenital syphilis (CS) results when an infected pregnant mother transmits syphilis to her unborn child prior to or at delivery. The severity of infection can range from a delivery at term without signs of infection to stillbirth or death after delivery. OBJECTIVE: We sought to describe CS morbidity and mortality during 1999 through 2013. STUDY DESIGN: National CS case data reported to Centers for Disease Control and Prevention during 1999 through 2013 were analyzed. Cases were classified as dead (stillbirths and deaths up to 12 months after delivery), morbid (cases with strong [physical, radiographic, and/or nonserologic laboratory] evidence of CS), and nonmorbid (cases with a normal physical examination reported, without strong evidence of infection). Annual rates of these cases were calculated. Cases were compared using selected maternal and infant criteria. RESULTS: During 1999 through 2013, 6383 cases of CS were reported: 6.5% dead, 33.6% morbid, 53.9% nonmorbid, and 5.9% unknown morbidity; 81.8% of dead cases were stillbirths. Rates of dead, morbid, and nonmorbid cases all decreased over this time period, but the overall proportions that were dead or morbid cases did not significantly change. The overall case fatality ratio during 1999 through 2013 was 6.5%. Among cases of CS, maternal race/ethnicity was not associated with increased morbidity or death, although most cases (83%) occurred among black or Hispanic mothers. No or inadequate treatment for maternal syphilis, <10 prenatal visits, and maternal nontreponemal titer ≥1:8 increased the likelihood of a dead case; risk of a dead case increased with maternal nontreponemal titer (χ(2) for trend P < .001). Infants with CS born alive at <28 weeks' gestation (relative risk, 107.4; P < .001) or born weighing <1500 g (relative risk, 43.9; P < .001) were at greatly increased risk of death. CONCLUSION: CS remains an important preventable cause of perinatal morbidity and mortality, with comparable case fatality ratios during 1999 through 2013 (6.5%) and 1992 through 1998 (6.4%). Detection and treatment of syphilis early during pregnancy remain crucial to reducing CS morbidity and mortality.

Candida albicans Kinesin Kar3 Depends on a Cik1-Like Regulatory Partner Protein for Its Roles in Mating, Cell Morphogenesis, and Bipolar Spindle Formation.

Candida albicans is a major fungal pathogen whose virulence is associated with its ability to transition from a budding yeast form to invasive hyphal filaments. The kinesin-14 family member CaKar3 is required for transition between these morphological states, as well as for mitotic progression and karyogamy. While kinesin-14 proteins are ubiquitous, CaKar3 homologs in hemiascomycete fungi are unique because they form heterodimers with noncatalytic kinesin-like proteins. Thus, CaKar3-based motors may represent a novel antifungal drug target. We have identified and examined the roles of a kinesin-like regulator of CaKar3. We show that orf19.306 (dubbed CaCIK1) encodes a protein that forms a heterodimer with CaKar3, localizes CaKar3 to spindle pole bodies, and can bind microtubules and influence CaKar3 mechanochemistry despite lacking an ATPase activity of its own. Similar to CaKar3 depletion, loss of CaCik1 results in cell cycle arrest, filamentation defects, and an inability to undergo karyogamy. Furthermore, an examination of the spindle structure in cells lacking either of these proteins shows that a large proportion have a monopolar spindle or two dissociated half-spindles, a phenotype unique to the C. albicans kinesin-14 homolog. These findings provide new insights into mitotic spindle structure and kinesin motor function in C. albicans and identify a potentially vulnerable target for antifungal drug development.

Kar3Vik1 mechanochemistry is inhibited by mutation or deletion of the C terminus of the Vik1 subunit.

Force production by kinesins has been linked to structural rearrangements of the N and C termini of their motor domain upon nucleotide binding. In recent crystal structures, the Kar3-associated protein Vik1 shows unexpected homology to these conformational states even though it lacks a nucleotide-binding site. This conservation infers a degree of commonality in the function of the N- and C-terminal regions during the mechanochemical cycle of all kinesins and kinesin-related proteins. We tested this inference by examining the functional effects on Kar3Vik1 of mutating or deleting residues in Vik1 that are involved in stabilizing the C terminus against the core and N terminus of the Vik1 motor homology domain (MHD). Point mutations at two moderately conserved residues near the Vik1 C terminus impaired microtubule gliding and microtubule-stimulated ATP turnover by Kar3Vik1. Deletion of the seven C-terminal residues inhibited Kar3Vik1 motility much more drastically. Interestingly, none of the point mutants seemed to perturb the ability of Kar3Vik1 to bind microtubules, whereas the C-terminal truncation mutant did. Molecular dynamics simulations of these C-terminal mutants showed distinct root mean square fluctuations in the N-terminal region of the Vik1 MHD that connects it to Kar3. Here, the degree of motion in the N-terminal portion of Vik1 highly correlated with that in the C terminus. These observations suggest that the N and C termini of the Vik1 MHD form a discrete folding motif that is part of a communication pathway to the nucleotide-binding site of Kar3.

Neck rotation and neck mimic docking in the noncatalytic Kar3-associated protein Vik1.

BACKGROUND: Kar3Vik1 is a heterodimeric kinesin with one catalytic subunit (Kar3) and one noncatalytic subunit (Vik1). RESULTS: Vik1 experiences conformational changes in regions analogous to the force-producing elements in catalytic kinesins. CONCLUSION: A molecular mechanism by which Kar3 could trigger Vik1's release from microtubules was revealed. SIGNIFICANCE: These findings will serve as the prototype for understanding the motile mechanism of kinesin-14 motors in general. It is widely accepted that movement of kinesin motor proteins is accomplished by coupling ATP binding, hydrolysis, and product release to conformational changes in the microtubule-binding and force-generating elements of their motor domain. Therefore, understanding how the Saccharomyces cerevisiae proteins Cik1 and Vik1 are able to function as direct participants in movement of Kar3Cik1 and Kar3Vik1 kinesin complexes presents an interesting challenge given that their motor homology domain (MHD) cannot bind ATP. Our crystal structures of the Vik1 ortholog from Candida glabrata may provide insight into this mechanism by showing that its neck and neck mimic-like element can adopt several different conformations reminiscent of those observed in catalytic kinesins. We found that when the neck is α-helical and interacting with the MHD core, the C terminus of CgVik1 docks onto the central ß-sheet similarly to the ATP-bound form of Ncd. Alternatively, when neck-core interactions are broken, the C terminus is disordered. Mutations designed to impair neck rotation, or some of the neck-MHD interactions, decreased microtubule gliding velocity and steady state ATPase rate of CgKar3Vik1 complexes significantly. These results strongly suggest that neck rotation and neck mimic docking in Vik1 and Cik1 may be a structural mechanism for communication with Kar3.

Do women with persistently negative nontreponemal test results transmit syphilis during pregnancy?

BACKGROUND: Syphilis screening algorithms have been reversed to take advantage of new automated treponemal tests. Screening that begins with a treponemal test identifies persons with positive treponemal and negative nontreponemal test results who were missed when screening began with a nontreponemal test. The significance of these results is uncertain. We wondered if mothers with persistently negative nontreponemal test results could transmit syphilis to their newborns. METHODS: We reviewed congenital syphilis cases reported to the Centers for Disease Control and Prevention to identify all instances where (1) the mother had persistently negative nontreponemal test results (best evidence would be multiple negative nontreponemal test results with at least one >30 days after birth) and (2) the child had evidence of infection (best evidence a confirmed case, older child, stillbirth, or "probable" by the criteria of Kaufman et al.). RESULTS: A total of 23,863 patients with congenital syphilis had birthdates between 1991 and 2009. Of 106 mothers initially classified as having only negative nontreponemal test results reported, 20 were misclassified; the remaining 86 mothers had no infants with confirmed syphilis and no syphilitic stillbirths. The 23,757 other mothers had 284 (1.2%) infants with confirmed syphilis and 1271 (5.4%) syphilitic stillbirths. Twelve of the 86 mothers had negative nontreponemal test results more than 30 days after delivery; none of their children had convincing evidence of infection. One mother had a negative nontreponemal test result 27 days after delivery of a child with "positive x-rays" and elevated cerebrospinal fluid cell count or protein, but details were unavailable. Fifty-nine children were diagnosed at age 1 year or older; nontreponemal test results were available for 13 of the mothers, and all were positive. CONCLUSIONS: We found no convincing evidence of syphilis transmission from mothers with persistently negative nontreponemal test results. Only 1 case suggested that transmission may have occurred, and records were incomplete.

What matters to psychology trainees when making decisions about internship and postdoctoral training sites: Differences between racial/ethnic minority and White VA trainees.

It is projected that by 2045, racial/ethnic minorities in the U.S. will become the majority. Unfortunately, the numbers of racial/ethnic minority psychologists have not kept up with population trends. This discrepancy poses challenges for many psychology training sites, including the Department of Veterans Affairs (VA). There is a lack of data on what factors are important for psychology applicants, including racial/ethnic minority trainees when they are considering internship and postdoctoral training sites. This quality improvement project surveyed 237 VA psychology trainees (59% psychology interns, 32.5% psychology postdoctoral fellows, 69.6% White, 9.3% multiracial, 6.8% Asian American or Pacific Islander, 5.1% Black/African American, 4.2% Latinx American, 0.8% Native American, 0.8% Middle Eastern) to study what factors are important when considering training sites. Results indicated that overall, racial/ethnic minority and White trainees endorsed similar primary factors when considering training programs. Site related factors (e.g., perceived workload, training opportunities) and future work related factors (e.g., ease of licensure, obtaining a first job) were top considerations regardless of race/ethnicity. The groups diverged in secondary factors with racial/ethnic minorities desiring infusion of diversity in training more than White applicants and White applicants considering quality of life factors such as extracurricular opportunities and convenience of daily living more important than racial/ethnic minority applicants. Qualitative data indicated applicants perceived VA training sites to be more welcoming and offer more opportunities for learning about diversity than non-VA sites. Recommendations for recruiting psychology trainees in general, and then specifically for racial/ethnic minority applicants are discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Crystal structure of the Kar3-like kinesin motor domain from the filamentous fungus Ashbya gossypii.

Kar3 kinesins are microtubule (MT) minus-end-directed motors with pleiotropic functions in mitotic spindle formation and nuclear movement in budding and fission yeasts. A Kar3-like kinesin is also expressed by the filamentous fungus Ashbya gossypi, which exhibits different nuclear movement challenges from its yeast relatives. Presented here is a 2.35 Å crystal structure and enzymatic analysis of the AgKar3 motor domain (AgKar3MD). Compared to the previously published Saccharomyces cerevisiae Kar3MD structure (ScKar3MD), AgKar3MD displays differences in the conformation of some of its nucleotide-binding motifs and peripheral elements. Unlike ScKar3MD, the salt bridge between Switch I and Switch II in AgKar3MD is broken. Most of the Switch I, and the adjoining region of helix α3, are also disordered instead of bending into the active site cleft as is observed in ScKar3MD. These aspects of AgKar3MD are highly reminiscent of the ScKar3 R598A mutant that disrupts the Switch I-Switch II salt bridge and impairs MT-stimulated ATPase activity of the motor. Subtle differences in the disposition of secondary structure elements in the small lobe (ß1a, ß1b, and ß1c) at the edge of the MD are also apparent even though it contains approximately the same number of residues as ScKar3. These differences may reflect the unique enzymatic properties we measured for this motor, which include a lower MT-stimulated ATPase rate relative to ScKar3, or they could relate to its interactions with different regulatory companion proteins than its budding yeast counterpart.

Trichomonas vaginalis antimicrobial drug resistance in 6 US cities, STD Surveillance Network, 2009-2010.

Nitroimidazoles (metronidazole and tinidazole) are the only recommended drugs for treating Trichomonas vaginalis infection, and previous samples that assessed resistance of such isolates have been limited in geographic scope. We assessed the prevalence of in vitro aerobic metronidazole and tinidazole resistance among T. vaginalis isolates from multiple geographic sites in the United States. Swab specimens were obtained from women who underwent routine pelvic examinations at sexually transmitted disease clinics in 6 US cities. Cultured T. vaginalis isolates were tested for nitroimidazole resistance (aerobic minimum lethal concentration [MLC] >50 µg/mL). Of 538 T. vaginalis isolates, 23 (4.3%) exhibited low-level in vitro metronidazole resistance (minimum lethal concentrations 50-100 µg/mL). No isolates exhibited moderate- to high-level metronidazole resistance or tinidazole resistance. Results highlight the possibility that reliance on a single class of antimicrobial drugs for treating T. vaginalis infections may heighten vulnerability to emergence of resistance. Thus, novel treatment options are needed.

Family reports of end-of-life care among veterans in home-based primary care: The role of hospice.

BACKGROUND: The Department of Veterans Affairs (VA)'s home-based primary care (HBPC) program provides coordinated, interdisciplinary care to seriously ill and disabled veterans, but few evaluations have considered end-of-life (EOL) care in this population. The aim of this study was to describe veterans' use of community-based hospice services while enrolled in HBPC and their associations with bereaved families' perceptions of care. METHODS: This study was a retrospective analysis of electronic medical record and bereaved family survey (BFS) data for veterans who died while enrolled in VA's HBPC program between October 2013 and September 2019. Seven regional VA networks called Veteran Integrated Service Networks participated in BFS data collection. The final sample included 3967 veterans who were receiving HBPC services at the time of death and whose next-of-kin completed a BFS. The primary outcome was the BFS global rating of care received in the last 30 days of life. Adjusted proportions for all BFS outcomes were examined and compared between those who received community-based hospice services and those who did not. RESULTS: Overall, 52.6% of BFS respondents reported that the care received by HBPC-enrolled veterans in the last 30 days of life was excellent using the BFS global rating. Among families of HBPC-enrolled veterans who received community-based hospice services, the BFS global rating was roughly eight percentage points higher than those who did not (55.7 vs. 47.0%, p < 0.001). On 12 of the 14 secondary BFS outcomes, veterans who received hospice scored higher than those who did not. CONCLUSIONS: Receipt of hospice services while enrolled in HBPC was associated with higher ratings of EOL care by bereaved family members. Integration of community hospice partners for qualifying veterans who are enrolled in the HBPC program represents a potential opportunity to improve the overall experience of EOL care for veterans and their families.

Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED): a protocol for an implementation study in the Veterans Health Administration.

BACKGROUND: Empirical evidence supports the use of structured goals of care conversations and documentation of life-sustaining treatment (LST) preferences in durable, accessible, and actionable orders to improve the care for people living with serious illness. As the largest integrated healthcare system in the USA, the Veterans Health Administration (VA) provides an excellent environment to test implementation strategies that promote this evidence-based practice. The Preferences Elicited and Respected for Seriously Ill Veterans through Enhanced Decision-Making (PERSIVED) program seeks to improve care outcomes for seriously ill Veterans by supporting efforts to conduct goals of care conversations, systematically document LST preferences, and ensure timely and accurate communication about preferences across VA and non-VA settings. METHODS: PERSIVED encompasses two separate but related implementation projects that support the same evidence-based practice. Project 1 will enroll 12 VA Home Based Primary Care (HBPC) programs and Project 2 will enroll six VA Community Nursing Home (CNH) programs. Both projects begin with a pre-implementation phase during which data from diverse stakeholders are gathered to identify barriers and facilitators to adoption of the LST evidence-based practice. This baseline assessment is used to tailor quality improvement activities using audit with feedback and implementation facilitation during the implementation phase. Site champions serve as the lynchpin between the PERSIVED project team and site personnel. PERSIVED teams support site champions through monthly coaching sessions. At the end of implementation, baseline site process maps are updated to reflect new steps and procedures to ensure timely conversations and documentation of treatment preferences. During the sustainability phase, intense engagement with champions ends, at which point champions work independently to maintain and improve processes and outcomes. Ongoing process evaluation, guided by the RE-AIM framework, is used to monitor Reach, Adoption, Implementation, and Maintenance outcomes. Effectiveness will be assessed using several endorsed clinical metrics for seriously ill populations. DISCUSSION: The PERSIVED program aims to prevent potentially burdensome LSTs by consistently eliciting and documenting values, goals, and treatment preferences of seriously ill Veterans. Working with clinical operational partners, we will apply our findings to HBPC and CNH programs throughout the national VA healthcare system during a future scale-out period.

VA home-based primary care interdisciplinary team structure varies with Veterans' needs, aligns with PACE regulation.

BACKGROUND: Interdisciplinary team (IDT) care is central to home-based primary care (HBPC) of frail elders. Traditionally, all HBPC disciplines managed a patient (Full IDT), a costly approach to maintain. The recent PACE (Program of All-inclusive Care for the Elderly) regulation provides for a flexible approach of annual assessments from a core team with involvement of additional disciplines dependent upon patient needs (Core+). Current Department of Veterans Affairs (VA) HBPC guidance specifies Full IDTs care for medically complex and functionally impaired Veterans similar to PACE participants. We evaluated whether VA HBPC has adopted the flexible structure of the PACE regulation, aligned to Veteran needs. DESIGN: Cross-sectional analysis. SETTING: All 139 VA HBPC programs administered across 379 sites. PARTICIPANTS: About 55,173 Veterans enrolled in HBPC during fiscal year 2018. MEASUREMENTS: Patients' HBPC physician, nurse, psychologist/psychiatrist, social worker, therapist, dietitian, and pharmacist visits were grouped into interdisciplinary team types. Patient frailty was classified using VA HNHR v2 (High-Need High-Risk version 2, a measure of high, medium, and low risk of long-term institutionalization). Medical complexity was measured by clusters of impairment in the JEN frailty index (JFI). JFI clusters were validated by VA's Nosos measure to project cost and Care Assessment Need (CAN) measure of hospitalization and mortality risk. RESULTS: HBPC provided Full IDT care to 21%, Core+ care to 54%, and Home Health+ (HHA+) care (skilled home health services plus additional disciplines, without primary care) to 16% of Veterans. Team type was associated with medical complexity (X2 2863.5 [66 df], p < 0.0001). High-risk Veterans (72% of sample) were more likely to receive Full IDT care (X2 62.9, 1 df), p < 0.0001), while low-risk Veterans (28%) were more likely to receive HHA+ care (X2 314.8, 1 df, p < 0.0001). CONCLUSION: There is a strong association between HBPC team patterns and patient frailty, indicating tailoring of care to match Veteran needs.

Longitudinal investigation of wandering behavior in Department of Veterans Affairs nursing home care units.

OBJECTIVES: To explore the extent of and factors associated with male residents who change wandering status post nursing home admission. DESIGN: Longitudinal design with secondary data analyses. Admissions over a 4-year period were examined using repeat assessments with the Minimum Data Set (MDS) to formulate a model understanding the development of wandering behavior. SETTING: One hundred thirty-four Veterans Administration (VA) nursing homes throughout the United States. PARTICIPANTS: Included 6673 residents admitted to VA nursing homes between October 2000 and October 2004. MEASUREMENTS: MDS variables (cognitive impairment, mood, behavior problems, activities of daily living and wandering) included ratings recorded at residents' admission to the nursing home and a minimum of two other time points at quarterly intervals. RESULTS: The majority (86%) of the sample were classified as non-wanderers at admission and most of these (94%) remained non-wanderers until discharge or the end of the study. Fifty-one per cent of the wanderers changed status to non-wanderers with 6% of these residents fluctuating in status more than two times. Admission variables associated with an increased risk of changing status from non-wandering to wandering included older age, greater cognitive impairment, more socially inappropriate behavior, resisting care, easier distractibility, and needing less help with personal hygiene. Requiring assistance with locomotion and having three or more medical comorbidities were associated with a decreased chance of changing from non-wandering to wandering status. CONCLUSION: A resident's change from non-wandering to wandering status may reflect an undetected medical event that affects cognition, but spares mobility.

Hurricanes Harvey, Irma, and Maria: Exploring the Role of Home-Based Care Programs.

OBJECTIVE: The aim of this study is to determine the response of home-based primary care programs to the fall 2017 Atlantic hurricane season. METHODS: This study examines the experiences of 9 Veterans Health Administration (VHA) Home-Based Primary Care (HBPC) programs in their responses to Hurricanes Harvey, Irma, and Maria. Thirty-four phone interviews with HBPC leadership and staff were conducted from April to July 2018. RESULTS: The total census of impacted HBPC programs was 3118. No program reported loss of life due to these hurricanes. Early preparedness was key to an effective program response. Response included prompt tracking of the patients. In the most affected areas, respondents noted limited resources to support basic patient needs. CONCLUSIONS: Medically complex patients served by programs such as the VHA's HBPC program represent a subset of the population, yet they have an outsized impact on health care resources that could be exacerbated by inadequate disaster preparedness. HBPC programs serve a unique role in supporting the "older old." They are tasked with supporting disaster preparedness activities of patients. Understanding what is involved in actualizing their requirements shows communities how to effectively engage with these programs.

Provider Delivery of Emergency Preparedness Education in Home-Based Primary Care.

ABSTRACTIntroductionHome health agencies have been tasked to improve their patients' disaster preparedness. Few studies have evaluated the robustness of tools to support preparedness in home health. Through evaluation of the Home-Based Primary Care (HBPC) Patient Assessment Tool, we conducted a survey to identify strengths and challenges in supporting the preparedness of patients served by home health programs such as the Veterans Health Administration's HBPC program. METHODS: Practitioners from 10 HBPC programs fielded the Patient Assessment Tool with all patients during a 3-week period. Logistic regression and bivariate analyses were used to identify patient characteristics associated with the delivery of preparedness education. RESULTS: A total of 754 Patient Assessment Tools were returned. The educational item most likely to be covered was how to activate 911 services (87%). The item least likely to be discussed was information on emergency shelter registration and emergency specialty transportation (44%). When compared to the low risk group, HBPC patients in the high/medium risk group were more likely to receive preparedness education materials for 6 of the 9 educational preparedness items (P values less than 0.05).DiscussionPractitioners are relaying preparedness education to their most vulnerable patients, suggesting that home health agencies can provide disaster preparedness in the home. Nonetheless, there is room for improvement. (Disaster Med Public Health Preparedness. 2019;13:547-554).

Wanderers with cognitive impairment in Department of Veterans Affairs nursing home care units.

OBJECTIVES: To explore the extent of and factors associated with male nursing home residents who wander. DESIGN: Cross-sectional design with secondary data analyses. SETTING: One hundred thirty-four nursing home facilities operated by the Department of Veterans Affairs. PARTICIPANTS: Fifteen thousand ninety-two nursing home residents with moderate or severe cognitive impairment admitted over a 4-year period. MEASUREMENTS: Selected variables from the Minimum Data Set included ratings recorded at residents' admission to the nursing home (cognitive impairment, mood, behavior problems, activities of daily living, and wandering). RESULTS: In this sample of residents with moderate or severe cognitive impairment, the proportion of wanderers was found to be 21%. Wanderers were more likely to exhibit severe (vs moderate) cognitive impairment, socially inappropriate behavior, resistance to care, use of antipsychotic medication, independence in locomotion or ambulation, and dependence in activities of daily living related to basic hygiene. A sizable proportion of wanderers were found to be wheelchair users (25%) or were wanderers with dual dementia and psychiatric diagnoses (23%), characteristics that are not well documented in the literature. CONCLUSION: These results support previous clinical understanding of wanderers to be those who are more likely to exhibit more-severe cognitive impairment. Based on a statistical model with variables generated from prior research findings, classification as a wanderer was found to be associated with other disruptive activity such as socially inappropriate behavior and resisting care. Two understudied populations of wanderers were documented: wheelchair wanderers and those with comorbid dementia and psychiatric diagnoses. Future longitudinal studies should examine predictors of wandering behavior, and further research should explore the understudied subpopulations of wheelchair and dual-diagnosis wanderers who emerged in this study.