Beyond knowledge and confidence: a mixed methods evaluation of a Project ECHO course on dementia for primary care.

Primary care clinicians have an important role in the management of dementia and have expressed interest in continuing education. The authors describe a model they used for providing dementia education in primary care, Project ECHO (Extension for Community Healthcare Outcomes), and an overview of its major features. A partnership including academic institutions and a national healthcare association is then outlined, including the unique features of the ECHO model developed through this partnership. A mixed-methods methodology was used for programmatic evaluation. This use of mixed methods adds vital new knowledge and learner perspectives that are key to planning subsequent ECHO courses related to dementia and primary care. The discussion includes an exploration of the significance of these findings for understanding the motivations of primary care providers for participation in the educational program, as well as the limitations of the current study. A final section explores the next steps in the continued development of the model and its implications for geriatrics education in dementia care, especially the supportive role that ECHO courses can play in meeting the challenges of dementia care.

Pharmacists and Medicare's Annual Wellness Visit: implications for pharmacy education and interprofessional primary care

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Predictors of self-efficacy for sleep in primary care.

AIMS AND OBJECTIVES: To identify factors impacting self-efficacy for sleep. Specifically, the aims were to examine associations between self-efficacy for sleep and (1) socio-demographic variables and (2) potential predictors including sleep severity, depression, dysfunctional beliefs about sleep, quality of life/health status and insomnia treatment acceptability for behavioural treatment. BACKGROUND: Between 50 and 70 million Americans experience insomnia. Costs of treatment, absenteeism and reduced productivity exceed 42 billion dollars annually. Medication for insomnia can result in impaired memory, fatigue, injuries, reduced health, medication habituation, difficulties in work and relationships and enhanced healthcare usage. Studies have suggested that behavioural management can be beneficial; however, factors contributing to success with behavioural management are unclear. DESIGN: This quantitative correlational study used inventory-based measures. METHODS: The Self-Efficacy for Sleep Scale, Insomnia Treatment Acceptability Scale, SF-8™ Health Survey, Center for Epidemiological Studies Depression Scale and Dysfunctional Beliefs about Sleep Scale were completed by 236 individuals with significant insomnia as measured by Insomnia Severity Index scores of 8 or higher. RESULTS: A significant association was found between sleep self-efficacy and race (p < 0·01). All predicator variables except one were found to be significantly correlated with the self-efficacy for sleep (p < 0·01). CONCLUSIONS: For behavioural self-management strategies to be effective for treating insomnia, these reported predictors may need to be assessed and managed. RELEVANCE TO CLINICAL PRACTICE: These findings suggest that nurses may want to assess insomnia severity, health status, level of depression and beliefs about sleep prior to beginning or when encountering barriers to the successful utilisation of behavioural approaches to manage sleep. If a patient is found to possess these limiting factors, the nurse may want to address these issues through medication, education and/or other behavioural approaches. Once addressed, the patient may find behavioural management for insomnia to be quite successful.

Validation of the Insomnia Treatment Acceptability Scale (ITAS) in primary care.

Patients with insomnia respond best to cognitive-behavioral treatments (CBT) if they find the approach acceptable. One tool, the Insomnia Treatment Acceptability Scale (ITAS), has been used to identify such patients, however, its reliability and validity has not been well established especially in primary care. The purpose of this study was to assess the reliability and validity of the ITAS in a primary care setting. A cross-sectional survey was conducted with 236 primary care patients, aged 18 and above, with clinically significant insomnia (Insomnia Severity Index ≥8). Descriptive and summary statistics, Cronbach's alpha, Principal Axis Factor analysis with Promax rotation, and comparison of ITAS subscale scores with self-reported treatment preferences (Chi-Square) are included. Factor analysis identified two factor solutions for the ITAS subscales. The ITAS was shown to be a reliable and valid tool that can be used to facilitate psychological practice and research on interdisciplinary behavioral-medical care.

Acceptability of behavioral treatments for insomnia.

BACKGROUND: Behavioral treatments for insomnia are safe and efficacious but may not be embraced by patients in primary care. Understanding factors associated with acceptability can enhance successful use of these modalities. The objective of this study was to identify demographic and clinical/psychosocial correlates of behavioral insomnia treatment acceptability. METHODS: This nonexperimental, inventory-based, cross-sectional study enrolled patients from a hospital-sponsored primary care clinic and 2 urban academic family practices. Participants (n = 236) were 18 years of age or older who had clinically significant insomnia (Insomnia Severity Index score ≥ 8) and were recruited consecutively at these sites. A study coordinator obtained informed consent then distributed survey materials. Participants received a $10 honorarium. The main outcome measure was the Acceptability Insomnia Treatment Acceptability Scale-Behavioral subscale (ITAS-B). RESULTS: Only acceptability of medications (r = 0.259) and dysfunctional beliefs (r = 0.234) scores had significant bivariate correlations with ITAS-B scores (P < .001). Medication acceptability, dysfunctional beliefs, and self-efficacy accounted for 12.45% of ITAS-B variance in linear regression. CONCLUSIONS: Screening for dysfunctional beliefs about sleep may identify patients with interest in behavioral approaches. Improving self-efficacy for sleep may improve acceptance of behavioral insomnia therapies. Interest in behavioral and medication treatments are not mutually exclusive. However, the modest variance reported here suggests other factors impact acceptance of behavioral treatments.

Psychosocial correlates of insomnia severity in primary care.

PURPOSE: Insomnia is a substantive primary care issue that leads to adverse outcomes. These can be improved by addressing factors that accentuate insomnia severity. Accordingly, this study identifies correlates of insomnia severity and determines whether these relationships vary with sociodemographic attributes. METHODS: This correlational cross-sectional study was conducted in a hospital-sponsored primary care clinic and 2 urban, academic family practice centers. Participants consisted of 236 patients 18 years old or older with clinically significant insomnia (Insomnia Severity Index scores of 7 or more). Surveys instruments included the Insomnia Severity Index, SF-8 (Medical Outcomes Study SF-8 global health status measure), CES-D (Center for Epidemiologic Studies-Depression Scale), DBAS (Dysfunctional Beliefs about Sleep scale), SE-S (Self-Efficacy for Sleep Scale), and a researcher-designed demographic survey. Analytic techniques included descriptive statistics to characterize the study sample, Pearson or Spearman Correlation Coefficients to examine individual associations with insomnia severity, and step-wise linear regression to identify net predictors. RESULTS: Insomnia severity was significantly correlated with health status, depression, self-efficacy, and dysfunctional beliefs (P < .001) but not with sociodemographic attributes. Linear regression demonstrated insomnia severity was best predicted by low self-efficacy and high depression scores. DISCUSSION: These findings indicate that clinicians treating insomnia should not only manage comorbid depression but also facilitate self-efficacy for sleep-inducing behavioral change.

Psychologists and primary care physicians: a training model for creating collaborative relationships.

For over a decade insurance reform, changes in health care delivery, reimbursement policies, and managed care have increased pressure on psychologists to diversify beyond traditional practices. Despite the negative impact of failing to make a transformation, most psychologists have not modified their practice and most training programs do not prepare psychologists to provide integrated care. The current paper describes the importance of primary care and psychology partnering to create integrated care models and makes the case that such partnerships are not only beneficial to patients but to both professions. The paper concludes with a description of a training model that has been implemented at the institution of the authors that provides opportunities for psychologists to learn how to practice in primary care settings.

Pressure ulcers: prevention, evaluation, and management.

A pressure ulcer is a localized injury to the skin or underlying tissue, usually over a bony prominence, as a result of unrelieved pressure. Predisposing factors are classified as intrinsic (e.g., limited mobility, poor nutrition, comorbidities, aging skin) or extrinsic (e.g., pressure, friction, shear, moisture). Prevention includes identifying at-risk persons and implementing specific prevention measures, such as following a patient repositioning schedule; keeping the head of the bed at the lowest safe elevation to prevent shear; using pressure-reducing surfaces; and assessing nutrition and providing supplementation, if needed. When an ulcer occurs, documentation of each ulcer (i.e., size, location, eschar and granulation tissue, exudate, odor, sinus tracts, undermining, and infection) and appropriate staging (I through IV) are essential to the wound assessment. Treatment involves management of local and distant infections, removal of necrotic tissue, maintenance of a moist environment for wound healing, and possibly surgery. Debridement is indicated when necrotic tissue is present. Urgent sharp debridement should be performed if advancing cellulitis or sepsis occurs. Mechanical, enzymatic, and autolytic debridement methods are nonurgent treatments. Wound cleansing, preferably with normal saline and appropriate dressings, is a mainstay of treatment for clean ulcers and after debridement. Bacterial load can be managed with cleansing. Topical antibiotics should be considered if there is no improvement in healing after 14 days. Systemic antibiotics are used in patients with advancing cellulitis, osteomyelitis, or systemic infection.

Measuring international normalized ratios in long-term care: a comparison of commercial laboratory and point-of-care device results.

OBJECTIVES: Point-of-care (POC) anticoagulation testing devices can potentially improve warfarin therapeutics in long-term care; however, there is variable accuracy reported for these devices and scant data when used in older adults. Accordingly, we undertook this study to determine the accuracy of a POC device (Hemosense INratio) in long-term care settings and examine factors associated with discrepant results. DESIGN: Case series. SETTING: Two, demographically comparable continuing-care retirement communities in the Southeastern United States. PARTICIPANTS: Long-term (nursing home and assisted living) residents with atrial fibrillation, venous thromboembolism, or prior cerebrovascular accident (16 at site 1; 8 at site 2). MEASUREMENTS: INR results calculated by the Hemosense device were compared with those determined by venipuncture-collected samples run in commercial laboratories. Patient demographic and clinical data were collected, as was performance by tester. RESULTS: Correlation varied between sites and, at site 1, between testers. Accuracy at site 1 was comparable to published reports for 2 of the 3 testers, with rather disconcerting discrepancy rates of 17.8% and 23.1%. However, correlation for the third tester was much better, with only a 7% discrepancy rate based on clinician rating of Hemosense-Reference lab differences. Correlation at site 2 was considerably worse than site 1, to the point that the Hemosense could not be safely adopted. CONCLUSION: POC devices may not be appropriate for commercial laboratory tests substitution without prior performance evaluation. Running POC INRs concurrent with laboratory-determined INRS can determine test reliability. Timing of Hemosense testing in relation to when laboratory INRs were drawn is one likely explanation for our results, although user differences may also contribute significantly. Further research in larger, more diverse populations, using a variety of POC devices, and with direct comparison of older and younger patients is needed.

Working with families in long-term care.

Effective communication with families can improve clinical process and outcomes in long-term care. Such communication may be challenging to long-term care clinicians, who may feel they lack requisite skills or are uncomfortable with potentially charged and negative emotions that may result. These barriers can be overcome by using models of family behavior and of physician involvement in family counseling to foster understanding and organize family meetings. We present such models in this article. The first of these, the Pearlin Stress Process Model offers a framework for understanding family adaptation to long-term care. Within the Pearlin model, family function is a critical intervening variable. Structural Family Systems Theory is therefore examined next to guide to recognition of family characteristics that impact communication. We focus on translation of these theories to long-term care practice through clinical case vignettes. Applying the Levels of Physician Involvement in family oriented care to long-term care, we then suggest an organizing, stepwise process for the family meeting itself. We conclude with strategies for conflict management and a discussion of the importance of the interdisciplinary team in family care.

Perceived health and geriatric risk stratification: observations from family practice.

OBJECTIVE: To examine the association between perceived health and self-reported presence of certain geriatric conditions. Perceived health (the way people rate their own health) is a summary measure of health status that predicts functional decline, health care use, and mortality, but has not been examined as a measure of the prevalence of key geriatric conditions among older adults. DESIGN: Cross-sectional surveys addressing perceived health and other study variables were mailed to practice patients. SETTING: An urban university-based family medicine residency program. PARTICIPANTS: In a random sample of 400 patients (from 1327 potential participants) older than 65 years (excluding those with known dementia), more than half (262) responded with usable surveys. MAIN OUTCOME MEASURES: Self-reported geriatric syndromes, such as perceived memory loss, depression, falls, incontinence, weight loss, problems with walking, and difficulties with instrumental activities of daily living. RESULTS: Of 262 respondents, 102 reported that they perceived their health as poor or fair and were much more likely than people who perceived their health as robust (good, very good, or excellent) to report memory impairment (49.6% vs 23.1%), depression (38.0% vs 13.5%), falls (26.5% vs 12.5%), incontinence (48.5% vs 34.6%), weight loss (33.3% vs 15.4%), needing help with walking (27.3% vs 13.1%), and difficulties with activities of daily living (57.6% vs 24.4%). CONCLUSION: These results support the hypothesis that assessment of perceived health can help differentiate low-risk elderly people requiring usual surveillance for geriatric conditions from high-risk elderly people who require timely evaluation and management.