FlourishCare Model of Integrated Care: The Validation of the Flourish Index-Revised (FI-R).

BACKGROUND AND OBJECTIVES: This study validates the Flourish Index-Revised (FI-R), a tool evaluating integrated health care models. The original Flourish Index (FI) was developed in 2018 (Faul et al., 2018) and has been refined to align with the FlourishCare (FC)TM Model (Model) for geriatric primary care. RESEARCH DESIGN AND METHODS: The Model provides integrated biopsychosocial health care 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 (SD=10.86) and mean years of education was 14.30 (SD=2.14). RESULTS: CATPCA showed a four-dimensional structure of biological, psychological, and two 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 two factors. Internal consistency (Cronbach 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 health care models using existing measures in electronic health systems. More work is needed to improve the incorporation of SDOH:sociodemographics into the FI-R.

A Statewide Survey to Understand Barriers to Utilization of the Medical Orders for Scope of Treatment Form among Emergency Medical Service Providers.

Background: Advance care planning allows communication of end-of-life goals. The Kentucky medical orders for scope of treatment (MOST) form became a legal medical order in 2015. The Kentucky MOST Coalition formed in 2017 to implement MOST. Objectives: In 2019, Kentucky MOST Coalition members developed a survey to determine emergency medical services (EMS) providers' understanding and barriers to utilization of MOST. Design: The Kentucky Board of EMS e-mailed the survey to its members. The survey was voluntarily completed by EMS providers. The data were analyzed by Kentucky MOST Coalition. Results: A majority of participants had never (72%) encountered a MOST form. In addition, 69% said they had never received MOST training. However, 60% knew that "the MOST form is a physician order and shall be followed in all settings." Conclusions: The majority of the EMS providers knew basic information about MOST. However, accessibility and education were barriers to utilization of MOST. EMS providers need continuing education. Education surrounding MOST can help to ensure a person-centered approach.

Exploring the intersection of structural racism and ageism in healthcare.

The American Geriatrics Society (AGS) has consistently advocated for a healthcare system that meets the needs of older adults, including addressing impacts of ageism in healthcare. The intersection of structural racism and ageism compounds the disadvantage experienced by historically marginalized communities. Structural racism and ageism have long been ingrained in all aspects of US society, including healthcare. This intersection exacerbates disparities in social determinants of health, including poor access to healthcare and poor outcomes. These deeply rooted societal injustices have been brought to the forefront of the collective public consciousness at different points throughout history. The COVID-19 pandemic laid bare and exacerbated existing inequities inflicted on historically marginalized communities. Ageist rhetoric and policies during the COVID-19 pandemic further marginalized older adults. Although the detrimental impact of structural racism on health has been well-documented in the literature, generative research on the intersection of structural racism and ageism is limited. The AGS is working to identify and dismantle the healthcare structures that create and perpetuate these combined injustices and, in so doing, create a more just US healthcare system. This paper is intended to provide an overview of important frameworks and guide future efforts to both identify and eliminate bias within healthcare delivery systems and health professions training with a particular focus on the intersection of structural racism and ageism.

"Opening eyes to real interprofessional education": results of a national faculty development initiative focused on interprofessional education in oncology palliative care.

The purpose of this study was to evaluate participants' feedback related to their experience in the Interprofessional Education Exchange (iPEX) program, a training initiative for faculty development in interprofessional oncology palliative care education. Participants voluntarily submitted a written reflection using a guide. The research team used qualitative content template analysis techniques to determine codes and categories based on the reflections and selected representative quotations (meaning units) from the data. Fifty-three reflections (100%) submitted by those completing the training were included in the analysis. The most appreciated aspects of the training were the opportunity for exchange of ideas and programs and the time allowed during the workshop for each team to work on developing their unique plan for interprofessional education (IPE) in oncology palliative care at their home institution. The iPEX program proved to be feasible, well-accepted, and valued by participants who reported personal, professional, and team growth and expressed appreciation for program support, content, and the exchange of ideas in a face-to-face setting. The results demonstrate that a faculty development program built on recommendations in the literature contributed to successful efforts to plan and initiate IPE in oncology palliative care.

The Interprofessional Education Exchange: The Impact of a Faculty Development Program in Interprofessional Palliative Oncology Education on Trainee Competencies, Skills, and Satisfaction.

Background: The interprofessional education exchange (iPEX) provides education, training, and mentoring to select interprofessional faculty trainee teams for development and implementation of interprofessional education (IPE) in palliative oncology. Objective: To evaluate the impact of the iPEX project on trainees' self-efficacy in IPE skills and IPE competencies. Design: A pre-/post-test design was used to evaluate trainees' progress. Trainees rated project components and developed IPE curricula in palliative oncology. Setting/Subjects: Sixteen United States-based faculty teams consisting of four to five members representing three or more disciplines completed the one-year faculty development project consisting of webinars, online interactive modules, a face-to-face workshop, mentoring, and assistance. The exchange of ideas, means for overcoming obstacles, collaborative teaching techniques, and curriculum development guidelines were integrated into the program. Measurements: Standardized measures of self-efficacy in IPE skills (Interprofessional Facilitation Skills Checklist) and IPE competencies (Core Competencies for Interprofessional Practice Individual Competency Assessment Tool) were used. Trainees rated the effectiveness of the project components on a scale of 1-5 (1 = not at all effective, 5 = extremely effective) and reported their plan for IPE palliative care curricula at their home institution. Results: Pre and post-paired samples t-test scores (n = 78) on both standardized instruments for IPE skills and competencies were significantly different (p < 0.001). Ratings of project components ranged from 3.97 to 4.90. Each team successfully developed a unique plan for IPE in palliative oncology. Conclusions: Multimodal faculty development and mentoring are successful means for improving self-assessed IPE skills and competencies.

Pneumonia in older adults.

PURPOSE OF REVIEW: The purpose of this review is to address the relevant issues surrounding older adults with community-acquired pneumonia (CAP) today. RECENT FINDINGS: Approximately 1 million people >65 years have CAP in the US per year, which is more than previously reported (or realized). Older adults are vulnerable to the increasing prevalence of viral CAP, as the SARS-CoV-2 pandemic emphasizes, but pneumococcus is still the most common pathogen to cause CAP. Racial disparities continue to need to be addressed in order to improve early and late outcomes of older adults with CAP. SUMMARY: The epidemiology of CAP, specifically for older adults is changing. More recent pathogen incidence studies have included culture, as well as newer microbiological methods to determine etiology. Current disparities among disadvantaged populations, including African-Americans, result in more comorbidities which predisposes to more severe CAP. However, outcomes in the hospital between races tend to be similar, and outcomes between age groups tends to be worse for older compared to younger adults. Finally, the cost of CAP is significant compared to diabetes mellitus, myocardial infarction and stroke.

The Relationship Between Culture of Safety and Rate of Adverse Events in Long-Term Care Facilities.

OBJECTIVE: The aim of the study was to assess the relationship of culture of safety dimensions and the rate of unanticipated care outcomes in long-term care facilities (LTCFs) using the Agency for Healthcare Research and Quality framework of resident safety culture. METHODS: Cross-sectional survey data were collected on 13 dimensions of culture of safety in five LTCFs from registered nurses, licensed practical nurses (LPNs), nursing assistants, administrators/managers, administrative support, and rehabilitation staff. Secondary data on falls in the five LTCFs from quarters 1 to 3 of 2014 were obtained from the Centers for Medicare and Medicaid Services in February 2015. Spearman's ρ and the Generalized Estimating Equations using a log link (Poisson distribution) were used. RESULTS: Communication and feedback about incidences reported the highest mean scores (M = 4.35, SD =0.71). Higher rate of falls was associated with a lower level of team work, lower degree of handoffs, and lower levels of organizational learning. The risk for falls increased as the number of residents per facility increased (rate ratio [RR] = 1.02; 95% confidence interval [CI] = 1.01-1.02) and as the number of LPN hours per resident increased (RR = 37.7, 95% CI = 18.5-76.50). Risk for long stay urinary tract infections increased as number of residents increased (RR =1.01, 95% CI =1.01-1.01). Increase in culture of safety score was associated with decrease in risk of falls, long stay urinary tract infections, and short stay ulcers. CONCLUSIONS: With the shortage of registered nurses in LTCFs and new reimbursement regulations, many LTCFs are hiring LPNs to have full staffing and save money. Licensed practical nurses may lack essential knowledge to decrease the rate of falls.

Older Adults Hospitalized for Pneumonia in the United States: Incidence, Epidemiology, and Outcomes.

OBJECTIVES: To define the current incidence, epidemiology, and mortality of older adult patients hospitalized with community-acquired pneumonia (CAP) in Louisville, KY and thus estimate the burden of CAP in the older adult population of the United States. To define risk factors associated with early and late outcomes. DESIGN: This was a secondary analysis of older adults (aged ≥65 years) from the University of Louisville Pneumonia Study, a prospective population-based cohort study of all hospitalized adults with CAP between June 1, 2014, and May 31, 2016. SETTING: The study took place in all nine acute care hospitals for adults in Louisville, KY. PARTICIPANTS: Residents in the city of Louisville, KY, who were diagnosed with CAP between the inclusion dates were included and who were aged 65 years or older. MEASUREMENTS: Incidence of CAP and outcomes were measured. A total of nine risk factors were also assessed for any potential association with time to clinical stability, length of stay (LOS), and mortality. RESULTS: During the 2-year study, from a Louisville population of 102 264 adults aged 65 years or older, 4760 were hospitalized with CAP. The incidence of older adults hospitalized with CAP was 2093 per 100 000 population. This corresponds to 967 470 older adults in the United States hospitalized per year with CAP. The median time to clinical stability was 2 days, and the median LOS was 6 days. The 30-day all-cause mortality was 17%. The 1-year all-cause mortality was 38% (829 patients), which corresponds to 361 982 deaths in the United States with CAP in older adults. CONCLUSION: The estimated burden of CAP in older adults is substantial in the United States. Nearly 1 million older adults are hospitalized for CAP, and over a third of those die within 1 year. J Am Geriatr Soc 68:1007-1014, 2020.

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.

Medicine as It Should Be: Teaching Team and Teamwork during a Palliative Care Clerkship.

BACKGROUND: Interprofessional Education (IPE) is an important component of medical education. Rotations with palliative care interdisciplinary teams (IDTs) provide an optimal environment for IPE and teaching teamwork skills. OBJECTIVE: Our objective was to assess the learning of senior medical students during a palliative care rotation. DESIGN: A constant comparison method based on grounded theory was used in this qualitative study. SETTING/SUBJECTS: Senior medical students completed a semi-structured reflective writing exercise after a required one-week palliative care clerkship. Sixty randomly selected reflective writings were analyzed. MEASUREMENTS: The reflective writings were analyzed to evaluate the student's experiences. RESULTS: Dominant themes identified were related to teams and teamwork. Eight specific themes were identified: value of IDT for team members; value of IDT for patient/family; importance of each team member; reliance on other team members; roles of team members; how teams work; team communication; and interdisciplinary assessment and care planning. Students described exposure to novel experiences and planned to incorporate newly learned behaviors in their future practice. CONCLUSION: By participating in palliative care IDTs, medical students consistently learned about teamwork within healthcare. Additionally, they learned the importance of such teamwork to patients and the team itself. Rotations with palliative care IDTs have a significant role to play in IPE and preparing medical students to practice on teams.

Implementing Chief Resident Immersion Training (CRIT) in the Care of Older Adults: Overcoming Barriers and Promoting Facilitators.

The Chief Resident Immersion Training (CRIT) in the Care of Older Adults curriculum was developed at Boston University School of Medicine to improve the care of older adults through an educational intervention. The curriculum targeted chief residents (CRs) because their role as mediators between learners and faculty provides the greatest potential impact for transmitting knowledge. The goals of CRIT are to: (1) provide education on geriatric principles and on teaching/leadership skills, (2) foster interdisciplinary collaboration, and (3) complete an action project. This study demonstrates successful implementation of CRIT at a different academic institution in a rural state. The CRs indicated that their confidence in their ability to apply and teach geriatrics improved after CRIT. In addition, the CRs indicated that CRIT improved their confidence in their overall skills as CRs. The barriers and facilitators to implementation are addressed in order to promote successful adoption of CRIT at other institutions, including those in rural states.

A case of inappropriate apolipoprotein e testing in Alzheimer's disease due to lack of an informed consent discussion.

BACKGROUND/OBJECTIVE: Apolipoprotein E (APOE) genetic testing is used to assist in the diagnosis of Alzheimer's Disease (AD). Whenever genetic testing is performed, an informed consent process should occur. METHODS: In this case, a patient with memory loss presented to the neurologist. The neurologist ordered a lumbar puncture (LP). The LP was performed by a neuroradiologist who also ordered APOE genetic testing. The patient received no genetic counseling, nor was an informed consent document offered. RESULTS: After the testing was completed, the neurologist faced an ethical dilemma. His solution was to offer the genetic testing to the patient in order to have an informed consent process. It was clear that the patient and her adult children did not want the genetic testing and that they would have been burdened with the results. The neurologist opted not to disclose the results. CONCLUSION: Genetic counseling and a signed informed consent document are required prior to any genetic testing. In this case, neither occurred and it led to an ethical dilemma that was ultimately resolved by the neurologist. As the population ages and AD becomes more prevalent, there is a need to expand the workforce of genetic counselors and educate physicians who commonly treat AD about genetic testing.

Families' perceptions of end-of-life care in Veterans Affairs versus non-Veterans Affairs facilities.

BACKGROUND: The Veterans Affairs (VA) has made significant investments in care for veterans. However, it is not known whether these investments have produced improvements in end-of-life care in the VA compared to other settings. Therefore, the goal of this study was to compare families' perceptions of end-of-life care among patients who died in VA and non-VA facilities. DESIGN: Retrospective 32-item telephone surveys were conducted with family members of patients who died in VA and non-VA facilities. SETTING: Five Veterans Affairs medical centers and their affiliated nursing homes and outpatient clinics. PARTICIPANTS: Patients were eligible if they received any care from a participating VA facility in the last month of life and if they died in an inpatient setting. One family member per patient completed the survey. RESULTS: In bivariate analysis, patients who died in VA facilities (n = 520) had higher mean satisfaction scores compared to those who died in non-VA facilities (n = 89; 59 versus 51; rank sum test p = 0.002). After adjusting for medical center, the overall score was still significantly higher for those dying in the VA (beta = 0.07; confidence interval [CI] = 0.02-0.11; p = 0.004), as was the domain measuring care around the time of death (beta = 0.11; CI = 0.04-0.17; p = 0.001). CONCLUSION: Families of patients who died in VA facilities rated care as being better than did families of those who died in non-VA facilities. These results provide preliminary evidence that the VA's investment in end-of-life care has contributed to improvements in care in VA facilities compared to non-VA facilities.

Unlocking the closed door: arguments for open access hospice.

The traditional view of standard hospice (SH) care is that once begun, the doorway toward curative and other forms of nonpalliative treatment is irrevocably locked. We will argue that such a traditional view needs to be reassessed in light of new arguments and data regarding access to these avenues of treatment. We will argue that patients should be supported in their transition from SH to open access hospice (OAH). Open access hospice should be available to all patients because of ethical arguments, patient satisfaction arguments, and costs of care arguments. More randomized controlled research trials need to be performed to study the impact of OAH versus SH. This research should focus on patient satisfaction, cost, and survival.

A nationwide VA palliative care quality measure: the family assessment of treatment at the end of life.

OBJECTIVES: To evaluate the FATE (Family Assessment of Treatment at End of Life) Survey for use as a nationwide quality measure in the VA health care system. DESIGN: Nationwide telephone survey. SETTING: Five VA medical centers. PARTICIPANTS: Eligible patients received inpatient or outpatient care from a participating VA facility in the last month of life. One respondent/patient was selected using predefined eligibility criteria and invited to participate. MEASUREMENTS: The FATE survey consists of 32 items in 9 domains: Well-being and dignity (4 items), Information and communication (5 items), Respect for treatment preferences (2 items), Emotional and spiritual support (3 items), Management of symptoms (4 items), Choice of inpatient facility (1 item), Care around the time of death (6 items), Access to VA services (4 items), and Access to VA benefits after the patient's death (3 items). RESULTS: Interviews were completed with 309 respondents. The FATE showed excellent psychometric characteristics, with good homogeneity (e.g., Cronbach (alpha = 0.91) and no evidence of significant ceiling effects. The FATE also demonstrated good discriminant validity. For instance, FATE scores varied across facilities (range 44-72; Kruskal Wallis test p < 0.001). Patients who were seen by a palliative care service had better scores (mean 66 versus 52; rank sum test p < 0.001), as did patients who were referred to hospice (67 versus 49; rank sum test p < 0.001). CONCLUSIONS: The FATE survey offers an important source of quality data that can be used to improve the end-of-life care of all veterans, regardless of the type of care they receive or their site of death.

Meeting American Council of Graduate Medical Education guidelines for a palliative medicine fellowship through diverse community partnerships.

BACKGROUND: The field of hospice and palliative medicine has grown to include more than 50 fellowship training programs. In 2007 hospice and palliative medicine received American Board of Medical Specialties (ABMS) recognition as a subspecialty of medicine. Palliative medicine fellowships will begin formal accreditation under the American Council of Graduate Medical Education (ACGME) in 2008. OBJECTIVE: This paper details how one academic institution complied with draft ACGME Program Requirements for Fellowship Education in Hospice and Palliative Medicine addressing training sites and experiences by utilizing innovative community partnerships. RESULTS: Through carefully designed collaborative partnerships with community organizations three draft ACGME requirements for accreditation were met. It is anticipated that the program will receive full accreditation through the ACGME in 2008.

Do palliative consultations improve patient outcomes?

OBJECTIVES: To determine whether inpatient palliative consultation services improve outcomes of care. DESIGN: Retrospective telephone surveys conducted with family members of veterans who received inpatient or outpatient care from a Department of Veterans Affairs (VA) medical facility in the last month of life. SETTING: Five VA Medical Centers or their affiliated nursing homes and outpatient clinics. PARTICIPANTS: Veterans had received inpatient or outpatient care from a participating VA in the last month of life. One family member completed each survey. MEASUREMENTS: The telephone survey assessed nine aspects of the care the patient received in his or her last month of life: the patient's well-being and dignity (4 items), adequacy of communication (5 items), respect for treatment preferences (2 items), emotional and spiritual support (3 items), management of symptoms (4 items), access to the inpatient facility of choice (1 item), care around the time of death (6 items), access to home care services (4 items), and access to benefits and services after the patient's death (3 items). RESULTS: Interviews were completed with 524 respondents. In a multivariable linear regression model, after adjusting for the likelihood of receiving a palliative consultation (propensity score), palliative care patients had higher overall scores: 65 (95% confidence interval (CI)=62-66) versus 54 (95% CI=51-56; P<.001) and higher scores for almost all domains. Earlier consultations were independently associated with better overall scores (beta=0.003; P=.006), a difference that was attributable primarily to improvements in communication and emotional support. CONCLUSION: Palliative consultations improve outcomes of care, and earlier consultations may confer additional benefit.