A Pilot Study to Evaluate a New Hep-GRP Care Pathway to Improve Outcomes Among Canadian Older Adults with Liver Cirrhosis.

Background: Older adults with cirrhosis have complex medical needs that are not satisfied by organ specific management. Interdisciplinary approach may mitigate comorbidity and improve patient satisfaction. Methods: A pilot study consisted of dual specialist interdisciplinary referral pathway and mixed virtual care delivery model are prospectively evaluated in older adults (65 years and older) with cirrhosis during the COVID-19 pandemic between September and December 2022. Participant attitudes towards telemedicine were surveyed. Results: 68 participants with cirrhosis were consecutively assessed by hepatology. The mean age was 73 years. 39 (57%) screened positive for one or more geriatric syndrome(s). Comprehensive geriatric assessments were conducted via telemedicine in 18 participants, with additional referrals to physiotherapy and nutritional education. Compared to a historic cohort matched for age, sex, and Child-Pugh class, acute health service utilization measured by ER visits among those received dual specialist interdisciplinary consultation were lowered by 1.11 per patient at three-month follow up period (p = .0006, 95% CI 0.47-1.74). Majority participants (87.6%) preferred telemedicine or mixed method visits. Conclusion: An interdisciplinary approach to older adults with cirrhosis will likely be beneficial, and routine screening for geriatric syndrome may lead to reduced acute health-care utilization in the short term. Telemedicine and virtual screening tools in seniors should be fully explored to improve access to care.

Family physicians' preferences for education to support family caregivers: a sequential mixed methods study.

BACKGROUND: One in four Canadians is a family caregiver. Family caregivers (carers, care-partners) are relatives or chosen family, friends, or neighbors who provide 75 to 90% of the care for people with physical or mental illness, disabilities, or frailty living in community homes and assist with 15 to 30% of the care in congregate care. However, a recent (2022) Statistics Canada population health study reports 44% of family caregivers are distressed. Family physicians and primary care teams are well-positioned to support family caregivers; yet, family caregiver needs assessments tend to be ad hoc and their most common needs remain unmet. Research recommends training healthcare professionals to enhance their knowledge and skills to support family caregivers. METHODS: The objective of this sequential mixed methods research, a survey followed by qualitative interviews, was to explore family physicians' desire and preferences for education about supporting family caregivers. 85 family physicians completed the online survey and eight took part in the interviews. Results from the survey and interviews were compared, contrasted, and interpreted together. RESULTS: Primary care physicians expressed a desire to be better equipped to assess and support FCGs' needs. Even though most physicians (61%) were very/confident about addressing family caregivers' needs, 72% were highly/interested in education to support family caregivers of their patients. Topics with the most interest were assessing family caregivers needs in an organized way, assisting family caregivers to access resources, and address system and practice barriers to support family caregivers. The overarching theme running through the interviews was physicians hope for education to help change the patient-focused culture to inclusion of FCGs. The three themes reflect physicians' conviction about including family caregivers in patient care: We need to take care of their caregivers, Practice and system barriers thwart including family caregivers, and Practical education might help. CONCLUSIONS: This study of family physicians' preferences for education to support family caregivers will inform the development of education about supporting family caregivers for family physicians and trainees.

Supporting First Nations Family Caregivers and Providers: Family Caregivers', Health and Community Providers', and Leaders' Recommendations.

Family caregivers and care providers are increasingly becoming more distressed and reaching a breaking point within current systems of care. First Nations family caregivers and the health and community providers employed in First Nations communities have to cope with colonial, discriminatory practices that have caused intergenerational trauma and a myriad of siloed, disconnected, and difficult-to-navigate federal-, provincial/territorial-, and community-level policies and programs. Indigenous participants in Alberta's Health Advisory Councils described Indigenous family caregivers as having more difficulty accessing support than other Alberta caregivers. In this article, we report on family caregivers', providers', and leaders' recommendations to support First Nations family caregivers and the health and community providers employed in First Nations. We used participatory action research methods in which we drew on Etuaptmumk (the understanding that being in the world is the gift of multiple perspectives) and that Indigenous and non-Indigenous views are complementary. Participants were from two First Nation communities in Alberta and included family caregivers (n = 6), health and community providers (n = 14), and healthcare and community leaders (n = 6). Participants advised that family caregivers needed four types of support: (1) recognize the family caregivers' role and work; (2) enhance navigation and timely access to services, (3) improve home care support and respite, and (4) provide culturally safe care. Participants had four recommendations to support providers: (1) support community providers' health and wellbeing; (2) recruit and retain health and community providers; (3) improve orientation for new providers; and (4) offer providers a comprehensive grounding in cultural awareness. While creating a program or department for family caregivers may be tempting to address caregivers' immediate needs, improving the health of First Nations family caregivers requires a population-based public health approach that focuses on meaningful holistic system change to support family caregivers.

Family Physician Prescribing Practices and Perspectives on Shared Decision-Making Regarding the Use of Oral Anticoagulants for Stroke Prevention in Patients 75 Years or Older With Atrial Fibrillation.

INTRODUCTION: Atrial Fibrillation (AF) is common in older adults, yet guideline-recommended oral anti-coagulants (OACs) for stroke prevention are underused in this population. With a growing population of older adults at risk of AF seeking primary care, the objective of the study was to determine the management practices and perspectives of family physicians on the initiation of OACs for stroke prevention in AF patients 75 years or older, including their engagement of patients in shared decision-making. METHODS: This was an online survey of family physicians affiliated with a Primary Care Network in Alberta, Canada. RESULTS: Patient's risk (of falls, bleeding, or stroke) was the most common factor (17/20, 85%) physicians considered when deciding to initiate OAC in older adult patients with AF. Physicians used the CHADS2VASC (13/14, 93%) and HASBLED (11/15, 73%) tools to determine stroke and bleeding risks, respectively. Majority (11/15, 73%) of the physicians agreed that they feel confident initiating OAC for AF patients ≥75, while 20% (3/15) were neutral. All physicians agreed that their patients participated in shared decision-making to initiate OAC for stroke prevention. CONCLUSION: Family physicians strongly consider patient risks and utilize risk-assessment tools when initiating OAC in older adults with AF. Despite all physicians reporting the use of shared decision-making and that their patients were educated on the indications for OAC, confidence in initiating treatment was variable. Further exploration into factors impacting physician confidence is needed.

Three Perspectives on the Experience of Support for Family Caregivers in First Nations Communities.

There is a dearth of research on how family caregivers are supported in First Nations. We interviewed family caregivers, health and community providers, and leaders in two Alberta First Nations Communities about their experiences of care and support for the family caregivers in their communities. We employed a qualitative, collaborative participatory action research methodology. We drew on Etuaptmumk, the Mi'kmaw understanding of being in the world is the gift of multiple perspectives. Participants in this research included family caregivers (n = 6), health and community providers (n = 14), and healthcare and community leaders (n = 6). The overarching caregiving theme is the "Hierarchy of challenge". Six themes capture the challenges faced by family caregivers: (one) "Caregiving is a demanding job": yet "No one in a sense is taking care of them"; (two) difficult navigation: "I am unable to access that"; (three) delayed assessments and treatment "And I don't know how they're being missed"; (four) disconnected health records: "It's kind of on you to follow up"; (five) racism, "It's treated differently"; and, (six) social determinants of health, "A lot of these factors have been developing for the longest time". This study provides evidence that family caregivers' need to care for and to maintain their own wellbeing is not top of mind in policy or programs in these First Nations communities. As we advocate for support for Canadian family caregivers, we need to ensure that Indigenous family caregivers are also recognized in policy and programs.

Rural Family Caregiving: A Closer Look at the Impacts of Health, Care Work, Financial Distress, and Social Loneliness on Anxiety.

Even before the COVID-19 pandemic, earlier acute care patient discharges, restricted admissions to long-term care, and reduced home care services increased the amount and complexity of family caregivers' care work. However, much less is known about rural caregivers' experiences. Thus, our aim in this sequential mixed-methods study was to understand how COVID-19 affected rural family caregivers. Thematically analyzed interviews and linear regression on survey data were used to understand family caregiver stress. Fourteen rural caregivers participated in interviews. They acknowledged that they benefitted from the circle of support in rural communities; however, they all reported having to cope with fewer healthcare and social services. 126 rural caregivers participated in the online survey. About a third (31%) of these caregivers had moderate frailty, indicating that they could benefit from support to improve their health. In linear regression, frailty, social loneliness, financial hardship, and younger age were associated with caregiver anxiety. Contrary to the qualitative reports that people in rural communities are supportive, over two-thirds of the rural caregivers completing the survey were socially lonely. Rural family caregivers are vulnerable to anxiety and social loneliness due to the nature of caregiving and the lack of healthcare and social service supports in rural areas. Primary healthcare and home care teams are well-positioned to assess caregivers' health and care situation as well as to signpost them to needed supports that are available in their areas.

Family Caregiving during the COVID-19 Pandemic in Canada: A Mediation Analysis.

Family caregiving is a public health issue because of caregivers' significant contribution to the health and social care systems, as well as the substantial impact that giving and receiving care has on the health and quality of life of care receivers and caregivers. While there have been many studies that associate caregivers' care work, financial difficulty, navigation, and other caregiving factors with family caregivers' psychological distress, we were interested not only in the factors related to family caregiver anxiety but also in hypothesizing how those effects occur. In this study, we used Andrew Hayes' PROCESS moderation analysis to explore the link between caregiver frailty, weekly care hours, and perceptions of financial difficulty, social support, and anxiety. In this analysis, we included 474 caregivers with relatively complete data on all of the variables. In regression analysis after controlling for gender and age, social loneliness (ß = 0.245), frailty (ß = 0.199), financial difficulty (ß = 0.196), care time (ß = 0.143), and navigation confidence (ß = 0.131) were all significant. We then used PROCESS Model 6 to determine the significance of the direct, indirect, and total effects through the serial mediation model. The model pathway from frailty to care time to financial difficulty to social loneliness to anxiety was significant. The proportions of family caregivers who were moderately frail, anxious, and experiencing social loneliness after eighteen months of the COVID-19 pandemic found in this survey should be of concern to policymakers and healthcare providers.

Optimizing the integration of family caregivers in the delivery of person-centered care: evaluation of an educational program for the healthcare workforce.

BACKGROUND: While family caregivers provide 70-90% of care for people living in the community and assist with 10-30% of the care in congregate living, most healthcare providers do not meaningfully involve family caregivers as partners in care. Recent research recommends that the healthcare workforce receive competency-based education to identify, assess, support, and partner with family caregivers across the care trajectory. OBJECTIVE: This paper reports a mixed-methods evaluation of a person-centered competency-based education program on Caregiver-Centered Care for the healthcare workforce. METHODS: This foundational education was designed for all healthcare providers and trainees who work with family caregivers and is offered free online (caregivercare.ca). Healthcare providers from five healthcare settings (primary, acute, home, supportive living, long-term care) and trainees in medicine, nursing, and allied health were recruited via email and social media. We used the Kirkpatrick-Barr health workforce training evaluation framework to evaluate the education program, measuring various healthcare providers' learner satisfaction with the content (Level 1), pre-post changes in knowledge and confidence when working with family caregivers (Level 2), and changes in behaviors in practice (Level 3). RESULTS: Participants were primarily healthcare employees (68.9%) and trainees (21.7%) and represented 5 healthcare settings. Evaluation of the first 161 learners completing the program indicated that on a 5-point Likert scale, the majority were satisfied with the overall quality of the education (Mean(M) = 4.69; SD = .60). Paired T-tests indicated that out of a score of 50, post-education changes in knowledge and confidence to work with family caregivers was significantly higher than pre-education scores (pre M = 38.90, SD = 6.90; post M = 46.60, SD = 4.10; t(150) = - 16.75, p < .0001). Qualitative results derived from open responses echoed the quantitative findings in satisfaction with the education delivery as well as improvements in learners' knowledge and confidence. CONCLUSION: Health workforce education to provide person-centered care to all family caregivers is an innovative approach to addressing the current inconsistent system of supports for family caregivers. The education program evaluated here was effective at increasing self-reported knowledge and confidence to work with family caregivers.

Outcomes of a Decision-Making Capacity Assessment Model at the Grey Nuns Community Hospital.

BACKGROUND: With an increasing elderly population, the number of persons with dementia is expected to increase and, consequently, the number of persons needing decision-making capacity assessments (DMCA) is too. However, many healthcare professionals do not feel ready to provide DMCAs. Since 2006, we implemented a DMCA Model that includes a care pathway, worksheets, education, and mentoring. The objective of this study was to assess the impact of the utilization of this patient-centered DMCA model on the need for Capacity Interviews. METHODS: This was a retrospective quality assurance chart review of patients referred for DMCA to the Geriatric Service at the Grey Nuns Community Hospital from 2006-2020. The Geriatric Service is run by Family Physicians with extra training in Care of the Elderly. We extracted patient demographics, elements of the DMCA process, and whether Capacity Interviews were performed. We used descriptive statistics to summarize the data. RESULTS: Eighty-eight patients were referred for DMCAs, with a mean age of 76 years (SD = 10.5). Dementia affected 43.2% (38/88) of patients. Valid reasons for conducting a DMCA were evident in 93% (80/86) of referrals, and DMCAs were performed in 72.6% (61/84). 85.3% (58/68) of referrals identified the need for DMCA in two to four domains, most commonly accommodation, healthcare, and finances. Two to three disciplines, frequently social workers and occupational therapists, were involved in conducting the DMCAs for 67.2% (39/58) of patients. The Capacity Assessment Process Worksheet was used 63.2% of the time. Capacity Interviews were conducted in only 20.7% of referrals. Following the DMCAs, 48.2% (41/85) of those assessed were deemed to lack capacity. CONCLUSION: This study suggests that the DMCA Model implemented has decreased the need for Capacity Interviews while simultaneously respecting patient autonomy. This is an important finding as DMCAs carried out following this process reduced the need for both a Capacity Interview and declarations of incapacity while simultaneously respecting patient autonomy and supporting patients in their decisions in accordance with the legislation.

Facilitators, barriers and considerations for the implementation of healthcare innovation: A qualitative rapid systematic review.

Family caregiving scholars recommend that health providers receive competency-based education to partner with and support family caregivers to care and to maintain their own health. While it may be relatively easy to develop competency-based education for healthcare providers, ensuring widespread uptake and spread and scale of healthcare education is critical to ensuring consistent person-centered support for all family caregivers (FCGs) throughout the care trajectory. The development of novel healthcare innovations requires implementation strategies for uptake and spread, with implementation involving the use of strategies to integrate a novel innovation into healthcare. Research suggests that there are many factors involved in successful implementation and a synthesis of potential factors is warranted. The purpose of this review is to provide an in-depth examination of facilitators, barriers and considerations for implementation of a novel healthcare innovation that will be used to develop an implementation plan for spread and scale of our competency-based education for health providers to learn about person-centered care for FCGs. A systematic review of published and grey literature was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA [Moher et al., 2015]) guidelines. The systematic review involved searching four databases for original research articles that described barriers, facilitators and/or other considerations when implementing innovations. Twenty-eight articles were included in the qualitative thematic analyses and described three areas of implementation research: barriers, facilitators and recommendations. There were major and parallel themes that emerged under facilitators and barriers. There were a wide variety of strategies that were identified as recommendations. The findings were synthesised into five considerations for implementation: Research and information sharing, intentional implementation planning, organisational underpinnings, creating the clinical context and facilitative training. This review provides an integrative overview of identified facilitators, barriers and recommendations for implementation that may aid in developing implementation strategies that can be tailored to the local context or innovation being implemented.

Potentially Inappropriate Medication Use in the Elderly.

It is estimated that approximately half of adults, older than 65 years of age, have been prescribed potentially inappropriate medications (PIMs). This study's objective was to determine the prevalence of PIM use among older patients. Two retrospective chart reviews were performed on 200 and 164 older patients who underwent comprehensive geriatric assessments (CGAs) at outpatient geriatrics clinics at the Glenrose Rehabilitation Hospital (Glenrose) in 2012-13 and at the Misericordia Community Hospital (Misericordia) in 2016-17, respectively. Outcome measures included demographics; prevalence of PIM use; common PIMs used; whether PIM use was addressed, and if so, how; and total number of oral medications. At the Glenrose, the prevalence of PIM use was 45 per cent (90/200). Of the 90 patients who had used PIMs, 46.7 per cent (42/90) had at least one of their medications stopped or modified. At the Misericordia, the prevalence of PIM use was 57.3 per cent (94/164). Of the 94 patients who used PIMs, 47.9 per cent (45/94) had at least one of their medications stopped or modified. These results suggest that an increased awareness of PIM among physicians is needed to further decrease PIM use.

A Tale of Two Solitudes: Loneliness and Anxiety of Family Caregivers Caring in Community Homes and Congregate Care.

We surveyed 604 family caregivers residing in the province of Alberta to better understand the impact of the COVID-19 pandemic on anxiety, loneliness, and care work. We assessed anxiety with the Six-Item State Anxiety Scale and loneliness with the DeJong-Gierveld Loneliness Scale. The COVID-19 pandemic created two contexts giving rise to feelings of solitude for family caregivers. Family caregivers of Albertans living in private community homes were overwhelmed with caregiving needs while those caring for Albertans living in congregate settings were restricted from caregiving. The results indicated that before the COVID-19 pandemic, 31.7% of family caregivers were anxious and 53.5% were lonely. The proportions of those who were anxious rose to 78.8% and lonely to 85.9% during the pandemic. The qualitative responses of family caregivers connected being overwhelmed with care work either in community homes or as the designated essential caregiver in congregate living settings, as well as being unable to care in congregate care settings, with anxiety and loneliness. The caregivers reporting improvements in their health and relationships with care-receivers credited spending time with the receiver doing pleasant activities together, rather than purely performing onerous care tasks. Policymakers need to consider organizing health and community services to ensure family caregivers are not overwhelmed with care tasks or excluded from caring in congregate care.

Neglected Needs of Family Caregivers during the COVID-19 Pandemic and What They Need Now: A Qualitative Study.

COVID-19 has had a negative impact on family caregivers, whether the care receivers lived with the caregiver, in a separate community home, in supportive living, or in long-term care. This qualitative study examines the points of view of family caregivers who care in diverse settings. Family caregivers were asked to describe what could have been done to support them during the COVID-19 pandemic and to suggest supports they need in the future as the pandemic wanes. Thorne's interpretive qualitative methodology was employed to examine current caregiver concerns. Thirty-two family caregivers participated. Family caregivers thought the under-resourced, continuing care system delayed pandemic planning, and that silos in health and community systems made caregiving more difficult. Family caregivers want their roles to be recognized in policy, and they cite the need for improvements in communication and navigation. The growth in demand for family caregivers and their contributions to the healthcare system make it critical that the family caregiver role be recognized in policy, funding, and practice.

The Care-of-the-Elderly Health Guide.

INTRODUCTION: The Evidence-Based Care of the Elderly Health Guide is a clinical guide with cross-references for care recommendations. This guide is an innovative adaptation of the Rourke Baby Record to support elderly care. In 2003, the guide was published with an endorsement from the Health Care-of-the-Elderly Committee of the College of Family Physicians of Canada. Since then, physicians have used the guide as a checklist and a monitoring tool for care to elderly patients. OBJECTIVE: We will update the 2003 Care-of-the-Elderly Health Guide with current published evidence-based recommendations. METHODS: This was a mixed methods study consisting of (1) the creation of a list of topics and corresponding guidelines or recommendations, (2) two focus group discussions among family physicians (n = 12) to validate the list for relevance to practice, and (3) a modified Delphi technique in a group of ten experts in Care of the Elderly and geriatrics to attain consensus on whether the guidelines/recommendations represent best practice and be included. RESULTS: The initial list contained 43 topics relevant to family practice, citing 49 published guidelines or recommendations. The focus group participants found the list of topics and guidelines potentially useful in clinical practice and emphasized the need for user-friendliness and clinical applicability. In the first online survey of the modified Delphi technique, 93% (63/66) of the references attained consensus that these represented standards of care. The other references (3/66) attained consensus in the second online survey. The final list contained 47 topics, citing 66 references. CONCLUSION: The Care-of-the-Elderly Health Guide is a quick reference to geriatric care, reviewed for relevance by family physicians and a panel of experts. The Guide is intended to be used in primary care practice.

Family Physician's and Primary Care Team's Perspectives on Supporting Family Caregivers in Primary Care Networks.

BACKGROUND: Research, practice, and policy have focused on educating family caregivers to sustain care but failed to equip healthcare providers to effectively support family caregivers. Family physicians are well-positioned to care for family caregivers. METHODS: We adopted an interpretive description design to explore family physicians and primary care team members' perceptions of their current and recommended practices for supporting family caregivers. We conducted focus groups with family physicians and their primary care team members. RESULTS: Ten physicians and 42 team members participated. We identified three major themes. "Family physicians and primary care teams can be a valuable source of support for family caregivers" highlighted these primary care team members' broad recognition of the need to support family caregiver's health. "What stands in the way" spoke to the barriers in current practices that precluded supporting family caregivers. Primary care teams recommended, "A structured approach may be a way forward." CONCLUSION: A plethora of research and policy documents recommend proactive, consistent support for family caregivers, yet comprehensive caregiver support policy remains elusive. The continuity of care makes primary care an ideal setting to support family caregivers. Now policy-makers must develop consistent protocols to assess, and care for family caregivers in primary care.

Developing a Decision-Making Capacity Assessment Clinical Pathway for Use in Primary Care: a Qualitative Exploratory Case Study.

BACKGROUND: With an ageing population, the incidence of dementia will increase, as will the number of persons requiring decision-making capacity assessments. For over 10 years, we have trained family physicians in conducting decision-making capacity assessments. Physician feedback post-training, however, has highlighted the need to integrate the decision-making capacity assessment process into the primary care context. The purpose of this study was to develop a decision-making capacity assessment clinical pathway for implementation in primary care. METHODS: A qualitative exploratory case-study design was used to obtain participants' perspectives regarding the utility of a visual algorithm detailing a decision-making capacity assessment clinical pathway for use in primary care. Three focus groups were conducted with family physicians (n=4) and allied health professionals (n=6) in two primary care clinics in Alberta. A revised algorithm was developed based on their feedback. RESULTS: In the focus groups, participants identified inconsistencies and a lack of standardization regarding decision-making capacity assessments within primary care, and provided feedback regarding a decision-making capacity assessment clinical pathway to make it more applicable to primary care. Participants described this pathway as appealing and straightforward; they also made suggestions to make it more primary care-centric. Participants indicated that the presented pathway would improve teamwork and standardization of decision-making capacity assessments within primary care. CONCLUSIONS: Use of a decision-making capacity assessment clinical pathway has the potential to standardize decision-making capacity assessment processes in primary care, and support least intrusive and least restrictive patient outcomes for community-dwelling older adults.

Characteristics and Outcomes of Physician-to-Physician Telephone Consultation Programs: Environmental Scan.

BACKGROUND: Telephone consultations between physicians provide quick access to medical advice, allowing patients to be cared for by calling physicians in their local settings. OBJECTIVE: As part of a quality assurance study of a physician-to-physician consultation program in Alberta, Canada, this environmental scan aims to identify the characteristics and outcomes of physician-to-physician telephone consultation programs across several countries. METHODS: We searched 7 databases to identify English publications in 2007-2017 describing physician-to-physician consultations using telephones as the main technology. To identify Canadian programs, the literature search was supplemented with an additional internet search. RESULTS: The literature search yielded 2336 citations, of which 17 publications were included. Across 7 countries, 14 telephone consultation programs provided primary care providers with access to various specialists through hotlines, paging systems, or call centers. The programs reported on the avoidance of hospitalizations, emergency department visits and specialty visits, caller satisfaction with the telephone consultation, and cost avoidance. CONCLUSIONS: Telephone consultation programs between health care providers have facilitated access to specialist care and prevented acute care use. .

Decision-making capacity assessment education.

BACKGROUND/OBJECTIVES: As the elderly population and associated number of persons with dementia increase, so does the need for decision-making capacity assessments (DMCAs). Many healthcare professionals (HCPs), however, do not feel prepared to conduct DMCAs. We have provided 4-h DMCA workshops to HCPs since 2006 and offered physicians either a 3-h or 2-day DMCA workshop from 2013 to present. We evaluated the effectiveness of the workshops on self-reported key concepts of capacity. DESIGN: Pre-/post-test design. SETTING: DMCA workshops for physicians across Canada and HCPs within Alberta. PARTICIPANTS: Two hundred and eighty-one physicians and 835 HCPs. MEASUREMENTS: Pre-/post-workshop ratings on level of comfort with and understanding of 15 core DMCA concepts using 4-point Likert-type items. RESULTS: For the DMCA workshops among physicians, ten 3-h workshops were held in 2014-2015 with 166 participants and seven 2-day workshops, between 2014 and 2018, with 115 participants. With respect to the self-report on core DMCA concepts, at least 62.7% (range: 62.7%-89.6%) of physician participants had higher post-workshop ratings (sign test; p < 0.001) than pre-workshop ratings for all core DMCA concepts. For the DMCA workshops among HCPs, 4-h workshops were delivered to 835 HCP participants from 2008 to 2012. At least 49.6% of participants (range: 49.6%-78.9%) had increased post-workshop ratings (sign test; p < 0.001) for all level of comfort items with and understanding of core DMCA concepts. CONCLUSION: There is a need for DMCA training for physicians and HCPs. The content and method of the workshops are effective at enhancing self-reported level of comfort with and understanding of core DMCA concepts.

Physicians and Family Caregivers: Two Perspectives of Physicians' Roles in Long-Term Care.

OBJECTIVES: We explored the roles of attending physicians of long-term care (LTC) residents in supporting their family caregivers (FCGs). DESIGN: In this mixed-methods study, we conducted surveys and focus group interviews with physicians and FCGs. SETTING AND PARTICIPANTS: There were 78 FCGs and 18 physicians in the survey, and 18 FCGs and 9 physicians in the focus groups. They were recruited from 5 urban LTC settings. RESULTS: Although 83.3% of physicians reported they had experience caring for FCGs, 71.8% of FCGs perceived they had not received support from the physicians. There was no statistically significant difference between the FCGs' and physicians' mean responses to the mirrored survey questions. Both groups gave similar ratings, means neutral and agree indicative of ambivalence, on physician's knowledge to identify FCGs who need assistance, ability to assess FCG stress, and aid those experiencing distress and needing advocacy. Analysis of the focus groups revealed the overarching theme: ambiguity about the LTC residents' physicians' role in supporting FCGs. Although physicians noted that residents and families come as a unit, there was ambivalence about the physician's role in supporting FCGs. FCG roles in LTC are also vague. There were 3 sub-themes: "accord on the surface"; "tension in the interface"; and "smoothing the relationship." Both groups thought FCG medical care was beyond the purview of the resident's physician. Physicians and FCGs provided different explanations for the tensions in the FCG/physician interface. Physicians attributed tension to FCG stress and inadequate knowledge, whereas FCGs thought physicians' communication could be improved. Suggestions to smooth the relationship were to align FCG expectations to reality of LTC and different staffing models. CONCLUSIONS AND IMPLICATIONS: Family physicians, policy makers, and FCGs will need to work on polices to ensure LTC physicians' roles in supporting FCGs and FCGs' roles in LTC are delineated and supported.

Improving transitions from acute care to home among complex older adults using the LACE Index and care coordination.

BACKGROUND: Improving transitions in care is a major focus of healthcare planning. The objective of this study was to determine the improvement in transitions from an intervention identifying complex older adult patients in acute care and supporting their discharge into the community. METHODS: This was a quality assurance study evaluating an intervention on high-risk patients admitted in an acute care hospital. In phase 1, the Length of Stay, Acuity of the Admission, Charlson Comorbidity Index Score, and Emergency Department Use (LACE Index) was selected to assess a patient's risk for readmission and a standard discharge protocol was developed. In phase 2, the intervention was implemented: (1) all patients were screened for the risk of readmission using the LACE Index; and (2) the high-risk patients were provided care coordination including follow-up phone calls focused on medications, equipment and homecare services. Emergency department (ED) revisits and hospital readmissions were measured. RESULTS: The LACE Index identified 433/1621 (27%) patients at high risk for readmission. Care coordination was achieved within 72 hours in 79% of patients. The 433 high-risk patients receiving the intervention, compared with a group without intervention (n=231), had lower lengths of stay (12.7 days vs 16.6 days); similar 7-day ED revisits (10.6% vs 10.8%) and 30-day ED revisits (30.5% vs 33.3%); lower 90-day readmissions (39.3% vs 44.6%); and lower 6-month readmissions (50.9% vs 58.4%). The 7-day and 30-day readmissions were similar in both groups. CONCLUSIONS: Identifying complex patients at high risk for readmission and supporting them during transitions from acute care to home potentially decreases lengths of hospital stay and prevents short-term ED revisits and long-term readmissions.