Hospitalizations, Emergency Department Visits, and Home Health Use Among Older Adults With Sensory Loss.

Objectives: This study examines healthcare resource use (hospitalizations, emergency department [ED] visits, and home health episodes) among adults 65 and older diagnosed with hearing, vision, or dual sensory loss (SL) seen in the primary care setting of an academic health system. Methods: Multivariable logistic regression models were used to examine the relationship between SL (identified using ICD-10 codes) and healthcare resource use for 45,000 primary care patients. Results: The sample included 5.5% (N = 2479) with hearing loss, 10.4% (N = 4697) with vision loss, and 1.0% with dual SL (N = 469). Hearing loss increased the likelihood of having an ED visit (OR = 1.22, CI: 1.07-1.39), and home health services (OR = 1.27, CI: 1.07-1.51) compared to older adults without any SL. Vision loss reduced the likelihood of having a hospitalization (OR = .81, CI: .73-.91). Discussion: Findings support research into the drivers of healthcare use among older adults with sensory loss.

Changes in Tangible Social Support Over Time Among Older Adults Receiving Long-Term Services and Supports.

The purpose of this study was to examine changes in and predictors of perceived tangible social support over a 2-year period among older adults new to LTSS. Linear mixed effects models were used to model repeated measures of tangible social support as a function of LTSS type [NH, AL, HCBS], personal, clinical, and health-related quality of life variables. AL residents reported greater initial tangible social support, but NH and HCBS residents improved more over time. Predictors of increased tangible social support over time included greater positive affect, sense of aesthetics, education, satisfaction with family relationships, and total number of close friends and family. Decreased tangible support over time was associated with greater depressive symptoms. Findings indicate the positive influence of NH and HCBS services on perception of tangible social support, and the importance of addressing depressive symptoms and assisting with the maintenance of important relationships.

Connect-Home transitional care from skilled nursing facilities to home: A stepped wedge, cluster randomized trial.

BACKGROUND: Skilled nursing facility (SNF) patients and their caregivers who transition to home experience complications and frequently return to acute care. We tested the efficacy of the Connect-Home transitional care intervention on patient and caregiver preparedness for care at home, and other patient and caregiver-reported outcomes. METHODS: We used a stepped wedge, cluster-randomized trial design to test the intervention against standard discharge planning (control). The setting was six SNFs and six home health offices in one agency. Participants were 327 dyads of patients discharged from SNF to home and their caregivers; 11.1% of dyads in the control condition and 81.2% in the intervention condition were enrolled after onset of COVID-19. Patients were 63.9% female and mean age was 76.5 years. Caregivers were 73.7% female and mean age was 59.5 years. The Connect-Home intervention includes tools, training, and technical assistance to deliver transitional care in SNFs and patients' homes. Primary outcomes measured at 7 days included patient and caregiver measures of preparedness for care at home, the Care Transitions Measure-15 (patient) and the Preparedness for Caregiving Scale (caregiver). Secondary outcomes measured at 30 and 60 days included the McGill Quality of Life Questionnaire, Life Space Assessment, Zarit Caregiver Burden Scale, Distress Thermometer, and self-reported number of patient days in the ED or hospital in 30 and 60 days following SNF discharge. RESULTS: The intervention was not associated with improvement in patient or caregiver outcomes in the planned analyses. Post-hoc analyses that distinguished between pre- and post-pandemic effects suggest the intervention may be associated with increased patient preparedness for discharge and decreased number of acute care days. CONCLUSIONS: Connect-Home transitional care did not improve outcomes in the planned statistical analysis. Post-hoc findings accounting for COVID-19 impact suggest SNF transitional care has potential to increase patient preparedness and decrease return to acute care.

The study protocol to evaluate implementation of the transitional care model in four U.S. healthcare systems during the Covid-19 pandemic.

This study protocol describes the conceptual framework, design, and methods being employed to evaluate the implementation of the Transitional Care Model (TCM) as part of a randomized controlled trial. The trial, designed to examine the health and cost outcomes of at-risk hospitalized older adults, is being conducted in the context of the COVID-19 pandemic. This parallel study is guided by the Practical, Robust, Implementation and Sustainability Model (PRISM) and uses a fixed, mixed methods convergent parallel design to identify challenges encountered by participating hospitals and post-acute and community-based providers that impact the implementation of the TCM with fidelity, strategies implemented to address those challenges and the relationships between challenges, strategies, and rates of fidelity to TCM's core components over time. Prior to the study's launch and throughout its implementation, qualitative and quantitative data related to COVID and non-COVID challenges are being collected via surveys and meetings with healthcare system staff. Strategies implemented to address challenges and fidelity to TCM's core components are also being assessed. Analyses of quantitative (established metrics to evaluate TCM's core components) and qualitative data (barriers and facilitators to implementation) are being conducted independently. These datasets are then merged and interpreted together. General linear and mixed effects modeling using all merged data and patients' socio-demographic and social determinants of health characteristics, will be used to examine relationships between key variables and fidelity rates. Implications of study findings in the context of COVID-19 and future research opportunities are suggested. Trial registration: ClinicalTrials.gov Identifier: NCT04212962.

Association of Perceived Benefit or Burden of Research Participation With Participants' Withdrawal From Cancer Clinical Trials.

Importance: Attrition in cancer clinical trials (CCTs) can lead to systematic bias, underpowered analyses, and a loss of scientific knowledge to improve treatments. Little attention has focused on retention, especially the role of perceived benefits and burdens, after participants have experienced the trial. Objectives: To examine the association between patients' perceived benefits and burdens of research participation and CCT retention. Design, Setting, and Participants: This survey study was conducted at a National Cancer Institute-designated comprehensive cancer center in the Northeast region of the US. The sample included adult patients with a cancer diagnosis participating in cancer therapeutic trials. Data were collected from September 2015 to June 2019. Analysis of study data was ongoing since November 2019 through October 2022. Exposures: Self-reported validated survey instrument with a list of 22 benefits and 23 burdens of research participation that can be rated by patients with a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). Main Outcomes and Measures: A primary outcome was actual withdrawal from the CCT, and a composite outcome was composite withdrawal that included both actual withdrawal and thoughts of withdrawing. Bivariate and multivariable logistic regressions were used. Results: Among the 334 participants in the sample, the mean (SD) age was 61.9 (11.5) years and 174 women (52.1%) were included. Top-cited benefits included both aspirational and action-oriented goals, including helping others (94.2%), contributing to society (90.3%), being treated respectfully (86.2%), and hoping for a cure (86.0%). Worry over receiving a placebo (61.3%), rearranging one's life (41.9%), and experiencing bothersome adverse effects (41.6%) were notable burdens. An increased burden score was associated with a higher probability of actual withdrawal (adjusted odds ratio [OR], 1.86; 95% CI, 1.1-3.17; P = .02) or composite withdrawal (adjusted OR, 3.44; 95% CI, 2.09-5.67; P < .001). An increased benefit score was associated with lower composite withdrawal (adjusted OR, 0.40; 95% CI, 0.24-0.66; P < .001). For participants who reported the benefits as being equal to or greater than the burdens, 13.4% withdrew. For those who perceived the benefits as being less than the burdens, 33.3% withdrew (adjusted OR, 3.38; 95% CI, 1.13-10.14; P = .03). The risk of withdrawal was even higher for the composite outcome (adjusted OR, 7.70; 95% CI, 2.76-21.48; P < .001). Conclusions and Relevance: This survey study found that patients perceived important benefits from CCT participation, and this perception was associated with trial retention, even among those who also perceived substantial burdens. A broader dialogue among stakeholders can inform an ethical and patient-centric focus on benefits throughout the course of a CCT to increase retention.

Older Adult and Family Caregiver Perspectives on Engagement in Primary Care.

The purpose of the current in-depth qualitative study was to explore the experiences of older adults and family caregivers in primary care. Twenty patients and caregivers from six Comprehensive Primary Care Plus (CPC+) practices' Patient and Family Advisory Councils within a large academic health system participated in telephone interviews from December 2018 to May 2019. Participants were mostly women (60%), with an average age of 71 years and nine chronic conditions. Transcripts were coded using conventional content analysis. Two key themes emerged related to person-centered care (PCC): Engagement in Health Care and Patient-Provider Relationship. Engagement in health care was defined by participants as: being proactive, centering on patient goals in treatment discussions, adherence, and self-triaging. Approximately all participants discussed the importance of the relationship and interactions with their provider as influencing their engagement. The identified themes offer recommendations for further improvement of primary PCC. [Journal of Gerontological Nursing, 48(11), 7-13.].

Caregiver Engagement Enhances Outcomes Among Randomized Control Trials of Transitional Care Interventions: A Systematic Review and Meta-analysis.

BACKGROUND: Fluctuations in health among chronically ill adults result in frequent health care transitions. Some interventions to improve patient outcomes after hospitalization include caregiver engagement as a core component, yet there is unclear evidence of the effects of this component on outcomes. OBJECTIVE: The objective of this study was to synthesize evidence regarding the attention given to caregiver engagement in randomized control trials of transitional care interventions (TCIs), estimate the overall intervention effects, and assess caregiver engagement as a moderator of intervention effects. METHODS: Three databases were systematically searched for randomized control trials of TCIs targeting adults living with physical or emotional chronic diseases. For the meta-analysis, overall effects were computed using the relative risk (RR) effect size and inverse variance weighting. RESULTS: Fifty-four studies met criteria, representing 31,291 participants and 66 rehospitalizations effect sizes. Half (51%) the interventions lacked focus on caregiver engagement. The overall effect of TCIs on all-cause rehospitalizations was nonsignificant at 1 month (P=0.107, k=29), but significant at ≥2 months [RR=0.89; 95% confidence interval (CI): 0.82, 0.97; P=0.007, k=27]. Caregiver engagement moderated intervention effects (P=0.05), where interventions with caregiver engagement reduced rehospitalizations (RR=0.83; 95% CI: 0.75, 0.92; P=0.001), and those without, did not (RR=0.97; 95% CI: 0.87, 1.08; P=0.550). Interventions with and without caregiver engagement did not differ in the average number of components utilized, however, interventions with caregiver engagement more commonly employed baseline needs assessments (P=0.032), discharge planning (P=0.006), and service coordination (P=0.035). DISCUSSION: Future TCIs must consistently incorporate the active participation of caregivers in design, delivery, and evaluation.

Medical Complexity Mediates Healthcare Resource Use in the Socially Vulnerable.

GOAL: The objective of this retrospective, observational study was to assess the mediating effect of medical complexity on the relationship between social vulnerability and four acute care resource use outcomes-number of hospitalizations, emergency department (ED) visits, observation stays, and total visits. Such information may help healthcare managers better anticipate the effects of interventions targeted to the socially vulnerable in their patient population. METHODS: Electronic health records of 147,496 adults served by 27 primary care practices in one large health system from 2015 to 2017 were used. Descriptive statistics were applied to characterize patients and the primary care practices included in the study. Causal mediation analyses using a modified Baron and Kenny approach were performed. PRINCIPAL FINDINGS: Causal mediation analyses demonstrated that increased social vulnerability was associated with increased medical complexity (incidence rate ratio [IRR] = 1.57) and increased numbers of hospitalizations (IRR = 1.63), ED visits (IRR = 2.14), observation stays (IRR = 1.94), and total visits (IRR = 2.04). Effects remained significant, though attenuated, after adjusting for medical complexity (mediator), demographics, and medications (hospitalizations IRR = 1.44, ED visits IRR = 2.02, observation stays IRR = 1.74, total visits IRR = 1.86). Social vulnerability, given medical complexity, explained between 8% (ED visits) and 26% (hospitalizations) of the variation in outcomes. PRACTICAL APPLICATIONS: These findings reinforce the need to modify interventions for medically complex adults to address their social needs and, consequently, reduce costly health services. Health systems seeking to reduce costly care can use these results to estimate savings in the treatment of patients with high social vulnerability-before they get chronic conditions and later as they seek care.

Predictors of change over time in satisfaction with outdoor activities ratings among long-term care services and supports recipients.

OBJECTIVES: To identify predictors of change in older adults' satisfaction with outdoor activities ratings over the first two years of enrollment in long-term services and supports (LTSS). METHODS: Self-rated satisfaction with outdoor activities (not at all satisfied to extremely satisfied) was the primary outcome of this secondary data analysis. Mixed-effects linear regression modeling with a backward elimination process was used for analyses. RESULTS: In the final model (N = 453) older LTSS recipients at baseline had lower ratings of satisfaction with outdoor activities over time, whereas younger recipients had higher ratings over time. Those who moved into a residential facility at baseline had an increase in outdoor activity satisfaction ratings over time compared to older adults who received home and community-based services that had a decrease. DISCUSSION: LTSS clinicians can use these findings to support older adults with decision-making around enrollment into LTSS, address preferences, and develop person-centered care interventions for outdoor activity.

The Diabetes Transition of Hospital Care (DiaTOHC) Pilot Study: A Randomized Controlled Trial of an Intervention Designed to Reduce Readmission Risk of Adults with Diabetes.

Hospital readmission within 30 days of discharge (30-day readmission) is a high-priority quality measure and cost target. The purpose of this study was to explore the feasibility and efficacy of the Diabetes Transition of Hospital Care (DiaTOHC) Program on readmission risk in high-risk adults with diabetes. This was a non-blinded pilot randomized controlled trial (RCT) that compared usual care (UC) to DiaTOHC at a safety-net hospital. The primary outcome was all-cause 30-day readmission. Between 16 October 2017 and 30 May 2019, 93 patients were randomized. In the intention-to-treat (ITT) population, 14 (31.1%) of 45 DiaTOHC subjects and 15 (32.6%) of 46 UC subjects had a 30-day readmission, while 35.6% DiaTOHC and 39.1% UC subjects had a 30-day readmission or ED visit. The Intervention−UC cost ratio was 0.33 (0.13−0.79) 95%CI. At least 93% of subjects were satisfied with key intervention components. Among the 69 subjects with baseline HbA1c >7.0% (53 mmol/mol), 30-day readmission rates were 23.5% (DiaTOHC) and 31.4% (UC) and composite 30-day readmission/ED visit rates were 26.5% (DiaTOHC) and 40.0% (UC). In this subgroup, the Intervention−UC cost ratio was 0.21 (0.08−0.58) 95%CI. The DiaTOHC Program may be feasible and may decrease combined 30-day readmission/ED visit risk as well as healthcare costs among patients with HbA1c levels >7.0% (53 mmol/mol).

Minority Older Adults' Access to and Use of Programs of All-Inclusive Care for the Elderly.

Programs of All-Inclusive Care for the Elderly (PACE) are an effective approach to improve care quality and delay institutional admissions especially for Black and Hispanic older adults who have seen a disproportionate rise in nursing home use. Guided by Andersen's Behavioral Model of Health Services Use and employing focus groups and one-on-one interviews, we qualitatively examined factors influencing access to and use of PACE by Black and Hispanic older adults. The study sample consisted of thirty-two PACE enrollees, six marketing-team members, and four family-caregivers from three PACE sites in a northeast urban city. Informed knowledge, cultural beliefs, and attitudes toward PACE were found to affect access. Community resources, available services, and care quality facilitated enrollment/participation. Barriers identified included poor dissemination of information and inadequate emphasis on staff's sensitivity to enrollees' cultural and disability differences. Findings will help healthcare leaders capitalize on facilitators and address barriers to enhance access and use of PACE by racial and ethnic minority older adults.

Examining spoken words and acoustic features of therapy sessions to understand family caregivers' anxiety and quality of life.

BACKGROUND: Speech and language cues are considered significant data sources that can reveal insights into one's behavior and well-being. The goal of this study is to evaluate how different machine learning (ML) classifiers trained both on the spoken word and acoustic features during live conversations between family caregivers and a therapist, correlate to anxiety and quality of life (QoL) as assessed by validated instruments. METHODS: The dataset comprised of 124 audio-recorded and professionally transcribed discussions between family caregivers of hospice patients and a therapist, of challenges they faced in their caregiving role, and standardized assessments of self-reported QoL and anxiety. We custom-built and trained an Automated Speech Recognition (ASR) system on older adult voices and created a logistic regression-based classifier that incorporated audio-based features. The classification process automated the QoL scoring and display of the score in real time, replacing hand-coding for self-reported assessments with a machine learning identified classifier. FINDINGS: Of the 124 audio files and their transcripts, 87 of these transcripts (70%) were selected to serve as the training set, holding the remaining 30% of the data for evaluation. For anxiety, the results of adding the dimension of sound and an automated speech-to-text transcription outperformed the prior classifier trained only on human-rendered transcriptions. Specifically, precision improved from 86% to 92%, accuracy from 81% to 89%, and recall from 78% to 88%. INTERPRETATION: Classifiers can be developed through ML techniques which can indicate improvements in QoL measures with a reasonable degree of accuracy. Examining the content, sound of the voice and context of the conversation provides insights into additional factors affecting anxiety and QoL that could be addressed in tailored therapy and the design of conversational agents serving as therapy chatbots.

Older Adults' Goals and Expectations When Using Long-Term Services and Supports.

OBJECTIVE: Despite recent research focused on aging well, little is known regarding the goals and expectations from long-term services and supports (LTSS) use among older adults. METHODS: To address this knowledge gap, interviewer-guided surveys with older adults newly receiving LTSS in home and community-based, assisted living, and nursing home settings in Philadelphia, New Jersey, and New York were conducted. RESULTS: Twelve subthemes regarding the goals and expectations of 464 older adults receiving LTSS and in the context of Aging Well emerged from our analysis: maintaining function, optimizing health and circumstances, maintaining the status quo, transitioning back to the previous state, achieving independence, preserving cognitive function and capacity for psychosocial and emotional health, achieving purpose, increasing quality of life, receiving social support, increasing engagement, relieving burden, and feeling a sense of security/safety. DISCUSSION: This in-depth analysis of qualitative data provides context for LTSS use among older adults.

MIRROR-TCM: Multisite Replication of a Randomized Controlled Trial - Transitional Care Model.

In the U.S., older adults hospitalized with acute episodes of chronic conditions often are rehospitalized within 30 days of discharge. Numerous studies reveal that poor management of the complex needs of this population remains the norm. METHODS: This prospective, intent-to-treat, randomized controlled trial (RCT) will assess the effects of replicating the rigorously studied Transitional Care Model (TCM) in four U.S. healthcare systems. The TCM is an advanced practice registered nurse led, team-based, care management intervention that supports older adults throughout vulnerable care episodes that span hospital to home. This RCT will compare health and economic outcomes demonstrated by at-risk older adults hospitalized with heart failure, chronic obstructive pulmonary disease or pneumonia randomized to receive usual discharge planning (control group, N = 800) to those observed by a similar group of older adults randomized to receive the TCM protocol (N = 800). The primary outcome is number of rehospitalizations at 12 months post-discharge, with secondary resource use outcomes measured at multiple intervals. Patient experience with care, health and quality of life outcomes will be assessed at 90 days post-discharge. DISCUSSION: Based on health and economic benefits demonstrated in multiple NIH funded RCTs, the study team hypothesizes that the intervention group, both within and across participating health systems, will have decreased acute care resource use and costs at 12 months and better ratings of the care experience and health and quality of life through 90 days post-discharge compared to the control group. The impact of COVID-19 on implementation of this study also is discussed.

A Systematized Approach to Advancing the Quality of Community-Based Palliative Care.

Despite growing recognition of the importance of community-based palliative care, optimizing the use of services continues to be a challenge. Until recently, key barriers were reimbursement and limited access. As services have become increasingly available, engagement of patients and their caregivers has emerged as a major obstacle. The Palliative Activation SystemTM (PAS) is a comprehensive, quality improvement methodology designed to promote enhanced engagement of seriously ill adults and their caregivers in optimizing the use of community-based palliative care services and accelerate clinicians' progress in meeting patients' and caregivers' care goals. This paper describes the design of the PAS. Experts in patient engagement and the development and evaluation of palliative care programs advised organizational leaders in the development of this methodology. The "Patient and Family Engagement" framework proposed by Carman and colleagues (2013) guided this work. The framework informed the selection of three core concepts-care alignment, illness trajectory, and social determinants of health-as foundational to the goals of the PAS. Additionally, this framework guided the selection of measures that will be used to assess progress in achieving enhanced engagement. This background work, coupled with findings from interviews with patients and caregivers who are current recipients of palliative care services, resulted in the implementation and ongoing testing of strategies targeting clinicians and organizational leaders and designed to enhance engagement. Lessons learned from the design phase of the PAS will advance the efforts of other organizations committed to increasing patient and caregiver engagement and enhancing attainment of their goals.

Implementation of a Coronavirus Disease 2019 Vaccination Condition of Employment in a Community Nursing Home.

The rate of coronavirus disease 2019 (COVID-19) vaccination uptake by US nursing home staff remains low despite the increased risks of viral transmission and related morbidity and mortality in this setting. This study describes vaccine uptake activities including a COVID-19 vaccination condition of employment (COE) policy in one community nursing home. This case study summarizes the timeline of vaccination uptake activities, staff vaccination rates over time, and stakeholder perspectives around the implementation of a COVID-19 vaccination COE. Organizational data were used to calculate vaccination rates from January 1, 2021 until May 1, 2021 among all nursing home staff. Interviews were held with the executive leadership team, human resources leadership, and nursing home staff to understand the process of implementation. During a 4-month period, nursing home leaders provided 8 written handouts about COVID-19 to all staff, hosted 5 on-site vaccination clinics in partnership with area pharmacies, conducted 2 virtual presentations for staff in addition to individual outreach and internal communications. Fewer than one-half of the staff were vaccinated prior to the decision to pursue a vaccine COE on February 9, 2021. The decision to pursue a COVID-19 vaccination COE was supported by executive leadership and nursing home staff to protect the health and safety of each other and their residents. By May 1, 2021 a total of 221 of the 246 (89.8%) nursing home staff members received a COVID-19 vaccination. The facility reached 100% compliance with the vaccination COE policy with 18 people who chose to resign and 7 people who were exempt or on a leave of absence. In combination with frequent, personalized outreach, a COVID-19 vaccination COE resulted in high staff vaccination rates and minimal staff turnover. This case study provides a detailed summary of vaccination uptake activities within an organizational context to inform efforts at other healthcare facilities.

Demographic Characteristics Driving Disparities in Receipt of Long-term Services and Supports in the Community Setting.

BACKGROUND: Research suggests that growth in Black and Hispanic (minority) older adults' nursing home (NH) use may be the result of disparities in access to community-based and alternative long-term services and supports (LTSS). OBJECTIVE: We aimed to determine whether minority groups receiving care in NHs versus the community had fewer differences in their functional needs compared with the differences in nonminority older adults, suggesting a disparity. METHODS: We identified respondents aged 65 years or above with a diagnosis of Alzheimer disease or dementia in the 2016 Health and Retirement Study who reported requiring LTSS help. We performed unadjusted analyses to assess the difference in functional need between community and NH care. Functional need was operationalized using a functional limitations score and 6 individual activities of daily living. We compared the LTSS setting for minority older adults to White older adults using difference-in-differences. RESULTS: There were 186 minority older adults (community=75%, NH=25%) and 357 White older adults (community=50%, NH=50%). Between settings, minority older adults did not differ in education or marital status, but were younger and had greater income in the NH versus the community. The functional limitations score was higher in NHs than in the community for both groups. Functional needs for all 6 activities of daily living for the minority group were greater in NHs compared with the community. CONCLUSION: Functional need for minority older adults differed by setting while demographics varied in unexpected ways. Factors such as familial and financial support are important to consider when implementing programs to keep older adults out of NHs.

Opportunities and challenges presented by recent pedagogical innovations in doctoral nursing education.

The demand to expand the nurse scientist pipeline over the past decade has generated numerous pedagogical innovations in nursing doctoral education. A PhD nursing education summit was held at the University of Pennsylvania in October 2019 to discuss pedagogical innovations. The main pedagogical innovations discussed by Summit attendees included: 1) the expansion of both 3-year PhD programs and BSN to PhD programs; 2) changes in learning opportunities and curricula content; and 3) the role of postdoctoral fellowships. This overview examines the numerous opportunities and challenges generated by these innovations. Opportunities include producing scholars with research careers that are potentially longer than historically seen in the nursing profession, as well as the emergence of unique educational and mentoring opportunities both during and after doctoral studies. Challenges involve the impact condensed program timelines have had on both the content and delivery of curricula, as well as the research expertise and skillsets of nursing PhD program graduates. There is a need to conduct a national coordinated evaluation of PhD program using shared metrics in order to better evaluate the effect of these pedagogical innovations on the development of nurse scientists, and ultimately, the discipline.