FlourishCare Model of Integrated Care: The Validation of the Flourish Index-Revised.

BACKGROUND AND OBJECTIVES: This study validates the Flourish Index-Revised (FI-R), a tool evaluating integrated healthcare models. The original Flourish Index (FI) was developed in 2018 and has been refined to align with the FlourishCare (FC) Model (Model) for geriatric primary care. RESEARCH DESIGN AND METHODS: The Model provides integrated biopsychosocial healthcare to older adults. The FI-R uses 25 quality-of-care indicators and 7 contextual community indicators. The FI-R was validated with Categorial Principal Components Analysis (CATPCA) using a sample of 949 patients 50+ who were mostly female (73%), non-Hispanic White (70%), living in urban areas (90%), and married (29%), single (22%), or divorced (19%). The mean age was 73.46 (standard deviation [SD] = 10.86) and mean years of education was 14.30 (SD = 2.14). RESULTS: CATPCA showed a 4-dimensional structure of biological, psychological, and 2 social determinants of health (SDOH) subdomains: health behaviors and community. Final selection of indicators was based on total variance accounted for >0.30, absolute values of item loadings >0.45, and not having cross-loadings >0.45 on 2 factors. Internal consistency (Cronbach's alpha) for the determinants were biological = 0.75, psychological = 0.76, SDOH:community = 0.70, SDOH:health behaviors = 0.50, and total FI-R = 0.95. Sensitivity to change was shown for the total FI-R, psychological determinants, and SDOH:health behaviors, but not for biological determinants. DISCUSSION AND IMPLICATIONS: The validation of the FI-R shows promise for its usability to evaluate integrated healthcare models using existing measures in electronic health systems. More work is needed to improve the incorporation of SDOH:sociodemographics into the FI-R.

World Cafés Create Healthier Communities for Rural, Older Adults Living With Diabetes.

Our global population is aging at an accelerated pace. While the average life expectancy has seen dramatic increases, chronic disease and disability have also increased, with rural America tending to be older, sicker, and poorer. This article examines the implementation and outcomes associated with the community engagement method of the world café that was instrumental in developing a "culture of health" aimed to reduce diabetes-related inequalities for older adults in rural counties of Kentucky. Older residents and the organizations that serve them participated in world cafés, which resulted in collective action due to the wisdom and capacity that evolve from the core element of the method, conversational sharing via multiple small group interactions. Four world cafés were held to explore the desires of the communities related to healthy eating, exercise, smoking cessation, and diabetes care. The world cafés brought a diverse group of community residents and governmental and business leaders to discuss topics that matter to their community, leading to the development of a strategic plan and a scorecard and, ultimately, community empowerment.

Human Flourishing and Integrated Care Models: The Development of the Flourish Index.

BACKGROUND AND OBJECTIVES: In evaluating integrated care models, traditional quality measures do not account for functional and quality of life factors, affecting older adults with multiple chronic conditions. The objective of this study was the development and validation of the Flourish Index (FI), an instrument to evaluate integrated care, using a determinants of health model. RESEARCH DESIGN AND METHODS: The study took place within the evaluation study of the Flourish Model (FM). The FM provides care coordination services using an integrated primary care and community-based services model. Baseline data from 70 older adults were used in the validation study. Twenty-seven quality of care indicators within six determinants of health, namely biological, psychological, individual health behaviors, health services, environmental, and social, formed part of the FI. RESULTS: Categorical principal components analysis showed a 5-dimensional structure with psychological determinants loading on the biological determinants of health. Internal consistency (Cronbach's alpha) for the determinants was as follows: biological/psychological = 0.73, individual = 0.58, environmental = 0.62, health services = 0.65, social = 0.67, total score = 0.97. Sensitivity to change was shown for the total FI score (F1,22 = 8.82, p = .01) and social (F1,22 = 5.82, p = .02), with a trend toward sensitivity for individual health behaviors (F1,22 = 3.95, p = .06) and health services (F1,22 = 3.26, p = .09). DISCUSSION AND IMPLICATIONS: The preliminary analysis of the FI shows promise for the usability of the index to provide insight into the fundamental challenges of aging. It brings greater clarity in caring for older adults and supports quality evaluation of integrated care coordination models.

Overcoming barriers to interprofessional education in gerontology: the Interprofessional Curriculum for the Care of Older Adults.

A fragmented workforce consisting of multiple disciplines with varying levels of training and limited ability to work as a team often provides care to older adults. Interprofessional education (IPE) is essential for preparing practitioners for the effective teamwork required for community-based, holistic, person-centered care of the older adults. Despite numerous programs and offerings to advance education and interdisciplinary patient care, there is an unmet need for geriatric IPE, especially as it relates to community-dwelling older adults and caregivers in medically underserved areas. A core group of university faculty from multiple disciplines received funding from the Health Resources and Services Administration Geriatric Workforce Enhancement Program to collaborate with community-based providers from several Area Agencies on Aging in the creation and implementation of the Interprofessional Curriculum for the Care of Older Adults (iCCOA). This geriatric curriculum is interprofessional, comprehensive, and community-based. Learners include third-year nursing students, nurse practitioner students, third-year medical students, internal medicine and family medicine residents, master's level social work students, third-year pharmacy students, pharmacy residents, third-year dental students, dental hygiene students, community-based organization professionals, practicing community organizers, and community health navigators. This article describes the efforts, successes, and challenges experienced with this endeavor, including securing funding, ensuring equal representation of the disciplines, adding new components to already crowded curricula, building curriculum on best practices, improving faculty expertise in IPE, managing logistics, and ensuring comprehensive evaluation. The results summarize the iCCOA components, as well as the interprofessional domains, knowledge, and competencies.

Sexual functioning among young adult cancer patients: A 2-year longitudinal study.

BACKGROUND: Cancer-related sexual dysfunction has been reported among adolescents and young adults (AYAs); however, its prevalence over time has not been examined. This longitudinal study investigated sexual dysfunction in AYAs over the course of 2 years after the initial diagnosis. METHODS: Young adult patients (18-39 years old) completed the Medical Outcomes Study Sexual Functioning Scale within the first 4 months of their diagnosis (n = 123) and again 6 (n = 107) and 24 months later (n = 95). An ordered multinomial response model analyzed changes in the probability of reporting sexual dysfunction over time and the independent effects of demographic, clinical, and psychosocial variables. RESULTS: More than half of the participants reported sexual functioning to be problematic at each assessment. The probability of reporting sexual dysfunction increased over time (P < .01) and was greater for cancer patients who were female (P < .001), older (P < .01), married or in a committed relationship (P < .001), treated with chemotherapy (P < .05), and reporting comorbid psychological distress (P < .001) and lower social support (P < .05). For women, being in a relationship increased the likelihood of reporting sexual problems over time; for men, the likelihood of reporting sexual problems increased regardless of their relationship status. CONCLUSIONS: A substantial proportion of young adults report ongoing problems with sexual functioning in the first 2 years after their cancer diagnosis. These findings justify the need to evaluate and monitor sexual functioning throughout a continuum of care. Cancer 2018;124:398-405. © 2017 American Cancer Society.

Depression symptoms in older adults with cancer: A multilevel longitudinal study.

OBJECTIVE: Data from the Health and Retirement Study were used to test a conceptual model integrating stress and coping, conservation of resources, and life-course theories, to investigate predictors of depression symptoms over 8 years among a nationally representative sample of older adults aged 50-91 years. The main investigative questions were: (1) Do older adults with cancer have a different 8-year symptomatic depression trajectory than those without cancer? (2) Do the differences in life-course factors, internal, external, and health-related resources within and between older adults have a differential effect on 8-year symptomatic depression trajectories for individuals with and without a cancer diagnosis? METHODS: We used a two-level longitudinal panel design to test a multilevel growth model. We examined individual differences in depression symptoms between 2000 and 2008, and tested multiple potential predictors. All those with a first diagnosis of cancer in 1998-2000 were included in the study (n = 200) together with a representative subsample of all noncancer cases (n = 1,190). RESULTS: Significant two-way interaction effects were detected between having cancer and the absence of spouse/partner in the home, and cancer and lower life expectancy; each resulted in higher probabilities of depression. A significant three-way interaction effect was detected between cancer, gender, and social support; women with a cancer history and low social support had the highest probability of depression. CONCLUSION: Assessment and intervention in the "survivorship" phase of cancer should target older adults with higher levels of depression early in the cancer experience, those with no partner present in home, those with lower life expectancy, and women with low social support.

"Another day in paradise": a photovoice journey of rural older adults living with diabetes.

This article provides the results of a photovoice project conducted with older adults affected by diabetes living in three rural counties in the southern region of the United States. Photovoice is a community-based participatory action methodology that puts the tools of research in the hands of participants. This project was an initial community engagement activity that promoted trust-building and formed part of a larger comprehensive community needs assessment. The process revealed themes of personal and community resilience focused on the daily living with diabetes, formal and informal supports, barriers to taking care of their diabetes, accessibility to fruits and vegetables, changes to food preparation and consumption, and exercise supports and barriers. The impact of the photovoice project on the participants and the implications for practice are discussed.

Inequitable access to health services for older adults with diabetes: potential solutions on a state level.

Diabetes is a serious global public health challenge. The cost for health services for diabetes care has increased 41% over the past 5 years. Despite escalating health expenditure, the United States continues to have higher rates of diabetes than many other developed countries. There is a need for health care reform in the United States not only in reducing health care costs but also in improving the quality of preventative care. This study presents the testing of a multilevel model investigating variables on the individual and state levels to develop a better understanding of the most important contextual pathways that can lead to providing older adults (50+) with type 2 diabetes with the recommended preventative quality care they require. The model was tested using a three-level repeated cross-sectional design with data from various existing data sources, using a national sample of 181,870 individuals aged 50 years and older. Results showed that differences in state health care systems contributed to inequitable access. Specifically, in a state where there was a higher percentage of adults 65 and older coupled with a shortage of health care professionals, the likelihood of receiving the recommended preventative quality care decreased. Also, older adults living in states with a higher percentage of people with diagnosed diabetes but with a lower-than-average annual per capita health care expenditure fared worse in receiving quality preventative care. Last, older adults in wealthy states with higher percentages of uninsured people had the lowest odds of receiving quality preventative care. Health care reform, similar to what is currently promoted by the Patient Protection and Affordable Care Act of 2010, is recommended to improve the performance of all health care systems in all states.

Evaluation of the English version of the End-of-Life Nursing Education Questionnaire.

BACKGROUND: End-of-Life Nursing Education Consortium (ELNEC) train-the-trainer workshops prepare participants to teach ELNEC content to others. In 2010, researchers in Japan developed and validated the End-of-Life Nursing Education Questionnaire (ELNEQ) to measure the impact of ELNEC workshops on participants' readiness to teach the content. OBJECTIVE: The study's objective was to evaluate the psychometric properties of the English version of the ELNEQ. DESIGN AND SUBJECTS: The study was a pre-test/posttest cross-sectional survey design with 113 participants. MEASUREMENTS: The English version of the ELNEQ is composed of 20 items measuring five domains related to teaching end-of-life (EOL) content: confidence in teaching; motivation for teaching; preparedness to teach; preparedness to lead initiatives; and expected influence on participants. RESULTS: Reliability was established for all domains (Cronbach's α±range 0.83-0.99) and the scale as a whole (Cronbach's α±= 0.92), as was content validity at the item level. Confirmatory factor analysis showed excellent fit for both the first order and second order factor models. Sensitivity was confirmed as comparisons between pre- and posttest results on all scales and overall were significant. CONCLUSIONS: The English version of the ELNEQ is a psychometrically sound instrument for measuring the impact of ELNEC train-the-trainer workshops.

Intervention research with minority older adults: challenges encountered, solutions enacted, and implications for future work.

Minority older adults are the fastest-growing segment of the older adult population, and a disproportionate number have the greatest psychosocial needs. It is the need to understand and bridge existing racial and ethnic disparities that makes research with minority older adults so necessary. However, these very vulnerabilities may lead to ethical dilemmas in undertaking research with this population, particularly because for many minority older adults, interventions offered through research may be the only treatment option available. This article discusses this and other ethical issues that may arise in the development and implementation of research protocols with minority older adults. By presenting specific examples of research challenges encountered the authors aim to encourage discussion about the clinically and ethically responsible ways of anticipating, preparing for, and addressing ethical research with minority older adults in ways that foster research integrity, best serve study participants, and contribute to greater knowledge and understanding for bridging disparities.

Just give me hope: lived experiences of Medicaid patients with advanced cancer.

The purpose of this phenomenological exploration was to describe the lived experiences of persons diagnosed with advanced cancer who receive Medicaid. Themes emerged from the transcribed interviews of 10 participants in accordance with the cancer trajectory. Before diagnosis, participants were uninsured or underinsured and had more severe symptoms prior to late diagnosis. Upon diagnosis, they desired hopeful, respectful communication and experienced strong emotional reactions. There was also an abrupt change in the use of health care resources. During cancer treatment, they experienced social isolation from family and friends while receiving strong psychosocial support from the health care team. Throughout the cancer trajectory, they focused on living, reclaiming normalcy, and expressed resiliency and spirituality. Findings support the need to recognize the "fighting spirit" of patients regardless of prognosis or socioeconomic status; the impact of hopeful, respectful communication; and the value of oncology social work assistance when navigating the cancer experience. Lack of health care coverage prior to severe symptoms prevented earlier diagnosis and contributed to poor physical outcomes. Medicaid eligibility enabled these patients to receive quality health care and focus on living beyond cancer.

Social work knowledge of community-based services for older adults: an educational model for social work students.

Social workers are often the key link between older adults, their families and community-based services. Thus, knowledge about older adults and community-based care is imperative for social work practice. Evaluation data are provided on a national multisite effort (N = 353) from 35 schools to assure graduate social work student's competency related to community services for older adults. Results suggest that the educational model as described in this article sets forth positive outcomes in the education of aging savvy social workers. Ongoing social work education is needed to meet the burgeoning needs of the geriatric population.

Innovative interdisciplinary training in and delivery of evidence-based geriatric services: creating a bridge with social work and physical therapy.

With focus on interdisciplinary education models, social work and physical therapy faculty from two proximate universities partnered to create an evidence-based geriatric assessment and brief intervention research, training, and service project for community-dwelling older adults. Assessment tools and interventions were selected from the literature to develop the service protocols. These selected protocol skills were taught to interdisciplinary teams of students and professionals in social work and physical therapy, and learning outcomes were evaluated. This article describes the process of implementing this innovative multipartner project, the obstacles faced, and lessons learned. Adult learning theory and social cognitive theory served to underpin the project. The objectives were achieved, and evaluation noted many positive experiences in training and service delivery. This multipartner, interdisciplinary project concept can be replicated to improve educational outcomes for students and professionals as they prepare and learn to serve community-dwelling older adults.

Impact of geriatric assessment and self-management support on community-dwelling older adults with chronic illnesses.

PURPOSE: The purpose of this study was to assess the effectiveness of interdisciplinary geriatric home-based assessment and self-management support services to community-dwelling older adults. DESIGN: A quasi-experimental, pre-post test design tested two types of service delivery models. The first protocol included geriatric assessment services, with a brief self-management care plan intervention. The second protocol added a telephone support intervention. RESULTS: All participants showed significant progress in improved self-efficacy, self-rated health, functional status and physical mobility (specifically lower extremity muscle strength), mental health (specifically reduced depression) and in reduced fall hazards in their physical home environment. The telephone support intervention protocol did not provide additional value to the first protocol. IMPLICATIONS: This study demonstrates the value of non-medical intervention strategies for community dwelling older adults with chronic illnesses.

Development and validation of a scale to measure socioeconomic well-being in persons with cancer.

Socioeconomic factors substantially impact the quality of life (QOL) of persons diagnosed with cancer, yet socioeconomic well-being seldom is included as an essential domain when overall QOL is measured. This study details the development and psychometric analysis of a scale for measuring socioeconomic well-being in persons diagnosed with cancer. Coleman's theory of social class was used to define and develop the construct. The resulting scale consisting of two subscales--Material and Social Capital-demonstrated acceptable reliability, content and construct validity at both scale and item levels, and acceptable discriminant, convergent, and incremental validity.