A virtual breakthrough series collaborative to support deprescribing interventions across Veterans Affairs healthcare settings.

BACKGROUND: Virtual collaborative models are a practical way to implement a supportive environment for multi-team learning. In this project, we aimed to describe the processes and outcomes of a virtual deprescribing collaborative that facilitated implementation of deprescribing interventions around the country. METHODS: Two successive cohorts comprised of multidisciplinary teams from geographically diverse veterans affairs (VA) sites were selected via an application process to participate in a virtual deprescribing collaborative. Each site developed its own deprescribing protocol and took part in regular meetings, mentoring groups, monthly data reporting, and other learning activities over an approximate 9 month period, per cohort. Standard measures were number of veterans served and medications deprescribed. Descriptive and qualitative analyses were utilized. RESULTS: Twenty-one total VA sites were selected to participate in the deprescribing collaborative in two cohorts (Cohort 1, n = 12 sites; Cohort 2, n = 9 sites). The majority of sites' practice areas directly served the older adult population, and the majority of site leads were pharmacists. The most utilized tool used by the collaborative sites was the VA VIONE decision support tool (n = 14) and the most common strategy was individualized medication review. Combining outcomes from both Cohorts 1 and 2, a total of n = 4770 veterans were served, with 8332 medications deprescribed. Eighty-two percent of Cohort 1 sites surveyed reported their deprescribing program was still being utilized after 1 year follow up. CONCLUSIONS: This virtual deprescribing collaborative aided in the successful implementation of both established and novel deprescribing practices across a variety of VA practice sites that care for older adults. The shared learning experience enhanced problem solving and allowed for interdisciplinary teamwork. Overall the collaborative was successful in improving polypharmacy for several thousand older adults.

A Home Repair and Modification Program Embedded Within Mount Sinai Visiting Doctors.

The purpose of this study was to conduct an evaluation of a home modification and repair pilot program implemented within Mount Sinai Visiting Doctors. This program enrolled patients via referral from the home-based clinical team between August 15, 2019 and December 31, 2020. Patient functional status and home modification and repair needs were assessed by a social worker and subsequent interventions were tracked. This study includes two separate, concurrent analyses: (1) descriptive analyses based on data on program enrollees, repairs, and costs and (2) provider perspectives on the program. The program enrolled 33 patients. The average spending per patient was $528. The clinical team found this program feasible to implement and helped reduce burnout. Future program implementation and expansion will require more investment in staffing to ensure timely needs assessment and service delivery, and the addition of an occupational therapist to better assess and meet patient functional needs.

A national qualitative study of Hospital-at-Home implementation under the CMS Acute Hospital Care at Home waiver.

BACKGROUND: The Centers for Medicare & Medicaid Services (CMS) announced the Acute Hospital Care at Home (AHCaH) waiver program in November 2020 to help expand hospital capacity to cope with the COVID-19 pandemic. The AHCaH waived the 24/7 on-site nursing requirement and enabled hospitals to obtain full hospital-level diagnosis-related group (DRG) reimbursement for providing Hospital-at-Home (HaH) care. This study sought to describe AHCaH implementation processes and strategies at the national level and identify challenges and facilitators to launching or adapting a HaH to meet waiver requirements. METHODS: We conducted semi-structured interviews to explore barriers and facilitators of HaH implementation. The analysis was informed by the Exploration, Preparation, Implementation, and Sustainment (EPIS) implementation framework. Interviews were audio recorded for transcription and thematic coding. PRINCIPAL FINDINGS: We interviewed a sample of clinical leaders (N = 18; clinical/medical directors, operational and program managers) from 14 new and pre-existing U.S. HaH programs diverse by size, urbanicity, and geography. Participants were enthusiastic about the AHCaH waiver. Participants described barriers and facilitators at planning and implementation stages within three overarching themes influencing waiver program implementation: 1) institutional value and assets; 2) program components, such as electronic health records, vendors, pharmacy, and patient monitoring; and 3) patient enrollment, including eligibility and geographic limits. CONCLUSIONS: Implementation of AHCaH waiver is a complex process that requires building components in compliance with the requirements to extend the hospital into the home, in coordination with internal and external partners. The study identified barriers that potential adopters and proponents should consider alongside the strategies that some organizations have found useful. Clarity regarding the waiver's future may expedite HaH model dissemination and ensure longevity of this valuable model of care delivery.

Geriatrics and palliative medicine leadership is needed now more than ever: What are the training gaps?

BACKGROUND: Geriatrics and palliative medicine specialists are uniquely trained to provide expert coordinated care for older adults and seriously ill and complex patients. Health system leadership geared towards this patient population is critically important as society ages. Currently, there is no standardized approach to teaching core leadership skills. To assess the leadership training needs of geriatrics and palliative medicine fellowship graduates, we conducted a needs assessment to identify (1) early career leadership trajectories and challenges and (2) knowledge and skills deemed essential for effective leadership. METHODS: Individuals identified as leaders in geriatrics and/or palliative medicine completed an electronic survey and a semi-structured qualitative interview. These leaders were divided into two categories: Icahn School of Medicine at Mount Sinai (ISMMS) trained leaders or non-ISMMS trained leaders. The semi-structured interviews were recorded, transcribed, and reviewed using thematic analysis. RESULTS: Within 1 year of fellowship graduation, 50% of ISMMS trained leaders had leadership positions; within 6 years, 100% had a leadership role. Based on qualitative interviews, both ISMMS trained leaders and non-ISMMS trained leaders perceived leadership training gaps in two domains: (1) knowledge and (2) skills. Knowledge and skill gap themes included communication and management, mentorship and negotiation, program development, knowledge, and apprenticeship. CONCLUSION: Geriatrics and palliative medicine physicians obtained leadership roles quickly after fellowship. Both ISMMS trained leaders and non-ISMMS trained leaders often felt unprepared, learned "on the job," and sought out additional leadership training. Early leadership training is needed to prepare fellowship graduates for the pressing demands of accelerated leadership.