The Dyad Model for Interprofessional Academic Patient Aligned Care Teams.

Combining interprofessional education, clinical or workplace learning, and physician resident teachers in the ambulatory setting, the dyad model enhances teamwork skills and increases nurse practitioner students' clinical competence.

Transitioning Former Military Medics to Civilian Health Care Jobs: A Novel Pilot Program to Integrate Medics Into Ambulatory Care Teams for High-Risk Patients.

Despite their medical training, record of military service, and the unmet needs within the health care sector, numerous challenges face veterans who seek to leverage their health care skills for employment after leaving the military. Creative solutions are necessary to successfully leverage these skills into jobs for returning medics that also meet the needs of health care systems. To achieve this goal, we created a novel ambulatory care health technician position on the basis of existing literature and modeled after a program which incorporates former military medics in emergency departments. Through a quality improvement approach, a position description, interview process, training program with clinical competencies, and team integration plan were developed and implemented. To date, two medics have been hired, successfully trained on relevant skill sets, and are currently caring for medical outpatients (under the supervision of licensed clinical personnel) as crucial interdisciplinary team members. Taken together, a multifaceted approach is required to effectively harness military medics' skills and experiences to meet identified health delivery needs.

Development and Implementation of Team-Based Panel Management Tools: Filling the Gap between Patient and Population Information Systems.

Effective team-based models of care, such as the Patient-Centered Medical Home, require electronic tools to support proactive population management strategies that emphasize care coordination and quality improvement. Despite the spread of electronic health records (EHRs) and vendors marketing population health tools, clinical practices still may lack the ability to have: (1) local control over types of data collected/reports generated, (2) timely data (eg, up-to-date data, not several months old), and accordingly (3) the ability to efficiently monitor and improve patient outcomes. This article describes a quality improvement project at the hospital system level to develop and implement a flexible panel management (PM) tool to improve care of subpopulations of patients (eg, panels of patients with diabetes) by clinical teams. An in-depth case analysis approach is used to explore barriers and facilitators in building a PM registry tool for team-based management needs using standard data elements (eg, laboratory values, pharmacy records) found in EHRs. Also described are factors that may contribute to sustainability; to date the tool has been adapted to 6 disease-focused subpopulations encompassing more than 200,000 patients. Two key lessons emerged from this initiative: (1) though challenging, team-based clinical end users and information technology needed to work together consistently to refine the product, and (2) locally developed population management tools can provide efficient data tracking for frontline clinical teams and leadership. The preliminary work identified critical gaps that were successfully addressed by building local PM registry tools from EHR-derived data and offers lessons learned for others engaged in similar work. (Population Health Management 2016;19:232-239).

Evaluating a hepatitis c quality gap: missed opportunities for HCV-related cares.

OBJECTIVES: Diagnosis of chronic hepatitis C virus (HCV) is a 2-step process involving hepatitis C antibody (HCVab) testing followed by viral ribonucleic acid (RNA) testing. The HCV status of those with a positive HCVab without viral testing cannot be determined. This study sought to describe the HCV-related care provided to patients in this care gap. STUDY DESIGN: Retrospective cohort study of active patients with a positive HCVab test who did not complete viral testing. METHODS: Electronic medical records (EMRs) were reviewed to determine if each subject's first positive HCVab result was acknowledged by a provider. For results acknowledged, we described provider actions in response to the result. When providers performed specific clinical actions within 1 year of the positive HCVab test, we captured the type of action taken. When the unsubstantiated diagnosis was documented in the EMR, we determined if the diagnosis was mentioned by subsequent providers. RESULTS: Positive HCVab results were not acknowledged in 31% of subjects. In 35%, providers added chronic HCV to the problem list in the EMR, resulting in a higher likelihood of subsequent providers mentioning the diagnosis in their EMR documentation. In 143 subjects whose providers recommended HCV-related clinical actions within 1 year of the positive result, 45% were educated about HCV and 42% had their liver enzymes monitored. CONCLUSIONS: With more widespread testing anticipated and more effective treatments available, health systems should ensure the HCV diagnostic process results in the delivery of an accurate and timely HCV diagnosis, to reduce the risk of harm to patients.

Implementation and evaluation of a multicomponent quality improvement intervention to improve efficiency of hepatitis C screening and diagnosis.

BACKGROUND: Given recent advances in hepatitis C virus (HCV) treatment, health systems must ensure that patients with a positive HCV antibody receive timely determination of their HCV status through viral testing. At the Louis Stokes Cleveland Department of Veterans Affairs Medical Center, viral testing was completed within six months of the first instance of a positive HCV antibody test for only 45% of patients. Beginning in 2008, three sequential improvements were implemented to close this care gap. METHODS: The three sequential improvements phases were as follows: (1) improving patient-centeredness of screening process in ambulatory patients, (2) local implementation of the Department of Veterans Affairs national HCV reflex testing policy, and (3) local evaluation of the efficiency and effectiveness of local implementation of reflex testing. RESULTS: From 2005 through 2013, 40 to 150 unique patients/quarter required viral testing following a positive antibody test. The firsts and second-phase improvements resulted in a 68% and 96% completion rate for timely viral testing during respective improvement phases. In the third improvement phase, remaining process problems related to the reflex testing process were identified using a locally developed electronic HCV population management application, resulting in a sustained rate of 100% completion of timely viral testing. Interrupted time series analysis revealed that the implementation of HCV reflex testing had the largest impact on the ability to complete timely viral testing. CONCLUSIONS: A continuous quality improvement approach, supported by an HCV population management application, achieved the complete closure of an important HCV care gap. Reflex testing should be initiated at facilities that have yet to adopt this approach.

Implementation of quality improvement skills by primary care teams: case study of a large academic practice.

BACKGROUND: Continuous quality improvement (QI) is important to primary care in general, and is emphasized as a key tenet of the primary care patient-centered medical home (PCMH) model. While team-based QI activities within the PCMH model are expected, concerns exist as to how successful efforts have been at implementing team-driven QI projects. OBJECTIVE: To (a) identify opportunities and challenges to QI efforts in a large primary care practice in order to (b) develop action plans to facilitate QI work into primary care teams. DESIGN: We obtained qualitative and quantitative information about existing primary care team QI initiatives. PARTICIPANTS: Eleven interdisciplinary primary care teams and 4 facilitators/coaches. METHODS: We conducted unstructured interviews and gathered documentation from primary care team members about QI efforts to (a) characterize team-based QI progress and (b) identify barriers and facilitators. RESULTS: In the 18 months since local leadership prioritized conducting team-based QI projects, team members described multiple exposures to QI training, coaching resources, and data/analysis support. No team developed a formal aim statement. Six of the 11 teams completed any steps beyond the initial team discussion. Four teams attempted to apply an intervention. Challenges included team time and competing demands/priorities; 3 of the 4 teams attempting to implement a project credited a data/informatics facilitator for their progress. CONCLUSIONS: In this large academic primary care clinic setting, interdisciplinary team training in QI, support for data collection, and dedicated coaching resources produced few sustainable continuous QI initiatives. Several potentially modifiable barriers to initiation, completion, and sustainability of QI initiatives by primary care teams were identified.

Pilot study to assess subjective and objective reporting of potential adverse drug reactions in older versus younger HIV-infected patients using antiretroviral therapy.

Limited data exist on tolerability of antiretroviral therapy (ART) in older HIV-infected patients compared to their younger counterparts. There is also concern for overlap of ART toxicities with concomitant conditions potentially leading to an increased burden of ART-related adverse drug reactions (ADRs). A prospective, descriptive-comparative study was conducted to compare incidence and severity of ADRs secondary to ART in older (≥ 50 years) versus younger (<50 years) HIV-infected patients. No differences were found in the presence or severity of subjective or objective ADRs between groups. The burden of intolerance appeared to be high for certain ADRs in both age groups. Regardless of age, subjects with certain concomitant illnesses had higher rates of potential ADRs. Providers need to be aware of patient characteristics that lead to increased rates of ART intolerance; for patients with an increased comorbidity burden, providers need to be attentive to the potential impact on ART tolerability.

Pilot study evaluating a practice-based learning and improvement curriculum focusing on the development of system-level quality improvement skills.

BACKGROUND: We developed a practice-based learning and improvement (PBLI) curriculum to address important gaps in components of content and experiential learning activities through didactics and participation in systems-level quality improvement projects that focus on making changes in health care processes. METHODS: We evaluated the impact of our curriculum on resident PBLI knowledge, self-efficacy, and application skills. A quasi-experimental design assessed the impact of a curriculum (PBLI quality improvement systems compared with non-PBLI) on internal medicine residents' learning during a 4-week ambulatory block. We measured application skills, self-efficacy, and knowledge by using the Systems Quality Improvement Training and Assessment Tool. Exit evaluations assessed time invested and experiences related to the team projects and suggestions for improving the curriculum. RESULTS: The 2 groups showed differences in change scores. Relative to the comparison group, residents in the PBLI curriculum demonstrated a significant increase in the belief about their ability to implement a continuous quality improvement project (P  =  .020), comfort level in developing data collection plans (P  =  .010), and total knowledge scores (P < .001), after adjusting for prior PBLI experience. Participants in the PBLI curriculum also demonstrated significant improvement in providing a more complete aim statement for a proposed project after adjusting for prior PBLI experience (P  =  .001). Exit evaluations were completed by 96% of PBLI curriculum participants who reported high satisfaction with team performance. CONCLUSION: Residents in our curriculum showed gains in areas fundamental for PBLI competency. The observed improvements were related to fundamental quality improvement knowledge, with limited gain in application skills. This suggests that while heading in the right direction, we need to conceptualize and structure PBLI training in a way that integrates it throughout the residency program and fosters the application of this knowledge and these skills.

Development and preliminary evaluation of a practice-based learning and improvement tool for assessing resident competence and guiding curriculum development.

BACKGROUND: Although practice-based learning and improvement (PBLI) is now recognized as a fundamental and necessary skill set, we are still in need of tools that yield specific information about gaps in knowledge and application to help nurture the development of quality improvement (QI) skills in physicians in a proficient and proactive manner. We developed a questionnaire and coding system as an assessment tool to evaluate and provide feedback regarding PBLI self-efficacy, knowledge, and application skills for residency programs and related professional requirements. METHODS: Five nationally recognized QI experts/leaders reviewed and completed our questionnaire. Through an iterative process, a coding system based on identifying key variables needed for ideal responses was developed to score project proposals. The coding system comprised 14 variables related to the QI projects, and an additional 30 variables related to the core knowledge concepts related to PBLI. A total of 86 residents completed the questionnaire, and 2 raters coded their open-ended responses. Interrater reliability was assessed by percentage agreement and Cohen κ for individual variables and Lin concordance correlation for total scores for knowledge and application. Discriminative validity (t test to compare known groups) and coefficient of reproducibility as an indicator of construct validity (item difficulty hierarchy) were also assessed. RESULTS: Interrater reliability estimates were good (percentage of agreements, above 90%; κ, above 0.4 for most variables; concordances for total scores were R  =  .88 for knowledge and R  =  .98 for application). CONCLUSION: Despite the residents' limited range of experiences in the group with prior PBLI exposure, our tool met our goal of differentiating between the 2 groups in our preliminary analyses. Correcting for chance agreement identified some variables that are potentially problematic. Although additional evaluation is needed, our tool may prove helpful and provide detailed information about trainees' progress and the curriculum.

Benefits and costs of pay for performance as perceived by residents: a qualitative study.

PURPOSE: To describe and interpret pay-for-performance (P4P) systems as perceived by internal medicine residents to develop curricula that relate P4P measures to quality improvement initiatives. METHOD: In 2008-2009, the authors conducted a qualitative study in which 97 internal medicine residents completed a mandatory survey soliciting their views of the advantages and disadvantages of P4P. The authors analyzed responses to identify and categorize emergent themes. RESULTS: Eighty-two residents (85%) noted advantages, from which 13 themes emerged. Two were general themes: P4P improves overall delivery of quality care by enabling quality care and by motivating providers to improve or provide quality care. The other themes formed three categories: P4P enables contemplation and knowledge enhancement (e.g., by promoting reflection) and has potential impacts both on physicians' delivery of better care (e.g., by facilitating vigilance and closer follow-up) and on the care delivery process (e.g., by increasing pay/satisfaction). Eighty-seven residents (90%) indicated disadvantages, from which 16 themes emerged. The four categories of the themes reflected P4P's impacts on patient perceptions (e.g., by decreasing patient satisfaction and access), on clinical care (e.g., by fostering abuse/gaming and compromising focus, care, and safety), on resources and efficiency, and on providers that may undermine morale. CONCLUSIONS: Residents' reported advantages and disadvantages were often in direct opposition to each other (e.g., P4P enables quality care but also compromises focus, care, and safety). These opposing responses form a continuum that the authors believe will require providers to perform a balancing act to practice successfully in a P4P environment.

Teaching quality improvement in the midst of performance measurement pressures: mixed messages?

BACKGROUND: While the importance of teaching quality improvement (QI) is recognized, formal opportunities to teach it are limited and are not always successful at getting physician trainee buy-in. We summarize findings that emerged from a QI curriculum designed to promote physician trainee insights into the evaluation and improvement of quality of care. METHODS: Grounded-theory approaches to thematic coding of responses from 24 trainees to open-ended items about aspects of a QI curriculum. The 24 trainees were subsequently divided into 9 teams that provided group responses to open-ended items about assessing quality care. Coding was also informed by notes from group discussions. RESULTS: Successes associated with QI projects reflected several aspects of optimizing care such as approaches to improving processes and enabling providers. Counterproductive themes included aspects of compromising care such as creating blinders and complicating care delivery. Themes about assessing care included absolute versus process trade-offs, time frame, documentation completeness, and the underrecognized role of the patient/provider dynamic. CONCLUSIONS: Our mapping of the themes provides a useful summary of issues and ways to approach the potential lack of buy-in from physician trainees about the value of QI and the "mixed-messages" regarding inconsistencies in the application of presumed objective performance measures.

Conceptualizing handover strategies at change of shift in the emergency department: a grounded theory study.

BACKGROUND: The importance and complexity of handovers is well-established. Progress for intervening in the emergency department change of shift handovers may be hampered by lack of a conceptual framework. The objectives were to gain a better understanding of strategies used for change of shift handovers in an emergency care setting and to further expand current understanding and conceptualizations. METHODS: Observations, open-ended questions and interviews about handover strategies were collected at a Veteran's Health Administration Medical Center in the United States. All relevant staff in the emergency department was observed; 31 completed open-ended surveys; 10 completed in-depth interviews. The main variables of interest were strategies used for handovers at change of shift and obstacles to smooth handovers. RESULTS: Of 21 previously identified strategies, 8 were used consistently, 4 were never used, and 9 were used occasionally. Our data support ten additional strategies. Four agent types and 6 phases of the process were identified via grounded theory analysis. Six general themes or clusters emerged covering factors that intersect to define the degree of handover smoothness. CONCLUSION: Including phases and agents in conceptualizations of handovers can help target interventions to improve patient safety. The conceptual model also clarifies unique handover considerations for the emergency department setting.

Tailoring an intervention to the context and system redesign related to the intervention: a case study of implementing shared medical appointments for diabetes.

BACKGROUND: Incorporating shared medical appointments (SMAs) or group visits into clinical practice to improve care and increase efficiency has become a popular intervention, but the processes to implement and sustain them have not been well described. The purpose of this study was to describe the process of implementation of SMAs in the local context of a primary care clinic over time. METHODS: The setting was a primary care clinic of an urban academic medical center of the Veterans Health Administration. We performed an in-depth case analysis utilizing both an innovations framework and a nested systems framework approach. This analysis helped organize and summarize implementation and sustainability issues, specifically: the pre-SMA local context; the processes of tailoring and implementation of the intervention; and the evolution and sustainability of the intervention and its context. RESULTS: Both the improvement intervention and the local context co-adapted and evolved during implementation, ensuring sustainability. The most important promoting factors were the formation of a core team committed to quality and improvement, and the clinic leadership that was supported strongly by the team members. Tailoring had to also take into account key innovation-hindering factors, including limited resources (such as space), potential to alter longstanding patient-provider relationships, and organizational silos (disconnected groups) with core team members reporting to different supervisors. CONCLUSION: Although interventions must be designed to meet the needs of the sites in which they are implemented, specific guidance tailored to the practice environment was lacking. SMAs require complex changes that impact on care routines, collaborations, and various organizational levels. Although the SMA was not envisioned originally as a form of system redesign that would alter the context in which it was implemented, it became clear that tailoring the intervention alone would not ensure sustainability, and therefore adjustments to the system were required. The innovation necessitated reconfiguring some aspects of the primary care clinic itself and other services from which the patients and the team were derived. In addition, the relationships among different parts of the system were altered.

Younger women's perceptions of coping with breast cancer.

Numerous studies have demonstrated an association between coping strategies and better quality of life after breast cancer. Because younger women consistently show greater psychological morbidity than older women after breast cancer diagnosis, there is great interest in the coping strategies of younger women. The present cross-sectional study used quantitative and qualitative methods to examine coping strategies used by 201 women who were aged 50 years or younger at diagnosis and were 6 months to 3.5 years postdiagnosis. Quantitative results from a modified version of the Ways of Coping scale revealed that the most frequently used coping strategies were positive cognitive restructuring, wishful thinking, and making changes. Qualitative analyses based on open-ended questioning of how women best coped with different stressful aspects of their diagnosis showed that women reported finding different strategies useful depending on the stressor. For example, social support was helpful in dealing with anger or depression, whereas positive cognitive restructuring was more helpful for concerns about the future. Analyses also confirmed that most coping strategies cited in commonly administered coping scales were used frequently by these women. However, several coping strategies not generally measured were also deemed valuable, including engaging in physical activity, using medications, and resting. These findings suggest that clinicians should identify patients' particular stressors and help with coping techniques targeting particular concerns.

Are provider self-efficacy and attitudes related to cardiovascular prevention associated with better treatment outcomes?

Cardiovascular risk factor control is inadequate in many high-risk patients. Although many provider-directed educational interventions attempt to address this issue by enhancing provider self-efficacy, a link between greater self-efficacy and better patient outcomes has not been established. Primary care providers (PCPs) in outpatient clinics of a large Veteran's Administration (VA) facility were asked to complete 4 subscales assessing self-efficacy and attitudes related to cardiovascular prevention (CVP). Using a cross-sectional study design, responses were linked with process and CVP outcomes related to blood pressure (BP) and low-density lipoprotein-cholesterol (LDL-C) control and the Framingham Risk Score (FRS), a summary measure of risk factor control, in diabetic patients observed by participating PCPs between December 1, 2004 and December 31, 2005. Multivariable, multilevel models assessed associations between these patient outcomes and provider self-efficacy and CVP-related attitudes, after accounting for patient characteristics, including baseline risk factor control, provider characteristics, and patient clustering within provider practices. Fifty-nine PCPs (86%) providing care to 1495 patients with diabetes completed the survey. Mean scores for provider efficacy and CVP-related attitudes were moderate to high. Higher self-efficacy scores were associated with initiation of medications in previously untreated individuals with inadequate BP or lipid control at baseline. Despite adequate power, however, multilevel models demonstrated neither consistent nor substantive associations between providers' self-efficacy and CVP-related attitudes and patient outcome measures. These findings underscore the need for interventions to enhance cardiovascular risk factor control that look beyond educational strategies to address a broader range of factors with potential influence on patient outcomes and the delivery of preventive care.

Insulin use in elderly diabetic patients.

The prevalence of type 2 diabetes is increasing among older adults as is their diabetes-related mortality rate. Studies suggest that tighter glucose control reduces complications in elderly patients. However, too low a glycosylated hemoglobin (HbA1c) value is associated with increased hypoglycemia. Moreover, the appropriateness of most clinical trial data and standards of care related to diabetes management in elderly patients is questionable given their heterogeneity. Having guidelines to safely achieve glycemic control in elderly patients is crucial. One of the biggest challenges in achieving tighter control is predicting when peak insulin action will occur. The clinician's options have increased with new insulin analogs that physiologically match the insulin peaks of the normal glycemic state, enabling patients to achieve the tighter diabetes control in a potentially safer way. We discuss the function of insulin in managing diabetes and how the new insulin analogs modify that state. We offer some practical considerations for individualizing treatment for elderly patients with diabetes, including how to incorporate these agents into current regimens using several methods to help match carbohydrate intake with insulin requirements. Summarizing guidelines that focus on elderly patients hopefully will help reduce crises and complications in this growing segment of the population.

Comparison of black and white families' experiences and perceptions regarding organ donation requests.

CONTEXT: Black families donate at a lower rate than white families. To help develop effective interventions, we compared black and white families' experiences. OBJECTIVE: To compare the organ donation request experiences of black and white patients' families with the hope of identifying factors to better inform consent-rate interventions among blacks. DESIGN: Chart reviews were conducted on files of all deceased patients. Audiotaped in-person interviews were conducted with family members, and telephone interviews were conducted with involved healthcare providers and organ procurement organization staff. SETTING: Nine trauma hospitals located in southwest Pennsylvania and northeast Ohio. PARTICIPANTS: A sample of 415 families of organ donor-eligible patients (61 black, 354 white). MEASURES: Measures of families' attitudes about and experiences with donation and transplantation. RESULTS: White families were more likely to be correctly perceived as receptive to donation. Black families viewed as receptive were less likely to be engaged in discussing as many donation-related issues as white families (p <.01). They were also less likely to have spoken to an organ procurement organization representative (p =.024) and were given fewer opportunities to consider the decision with healthcare provider or organ procurement organization staff. Black families had less knowledge about their family member's wishes, expressed less-favorable attitudes toward organ donation and the health care system, and, finally, were less likely than white families to donate organs (p =.001). A minority of black families (32.8%) knew about the need for more black donors. CONCLUSIONS: Interventions to increase consent among blacks need to encourage openness about organ donation within the black community and change healthcare provider and organ procurement organization attitudes and practices toward black families as potential donor families.

Knowing patients' preferences about organ donation: does it make a difference?

BACKGROUND: The purpose of this study was to examine in detail the impact of knowledge of a donor-eligible patient's preferences on organ donation decisions. METHODS: Nine trauma hospitals located in southwest Pennsylvania and northeast Ohio were selected. Data came from chart review of all dead patients and interviews with family members involved in the decision process (n = 360 patients 16 years of age or older). RESULTS: Of the families interviewed, 52.5% had to guess the patient's preferences about donation. When making the decision, 81.9% of the families considered how the patient might have felt about donation. Not knowing the patient's wishes related to refusal to donate (54.5% vs. 45.5%, p < 0.001). After adjusting for other factors, important predictors of donation were considering patients' feelings (5.03 times more likely to donate) and knowing preferences (6.90 times more likely to donate if they knew wishes were to donate and 0.03 times less likely to donate if they knew wishes were to not donate compared with not knowing preferences). CONCLUSION: Having knowledge of a patient's preference to donate increased the likelihood of donating by 6.90 times, and having enough information about the patient's wishes increased satisfaction with the decision by 3.32 times. Families only infrequently made decisions counter to patients' own wishes concerning organ donation.

Decoupling: what is it and does it really help increase consent to organ donation?

Although the notion of decoupling is simple and potentially controllable by organ donation requestors, evidence to date of its potential has been inconsistent. The impact of the timing of requests was analyzed using data from a study of organ donor-eligible patients and their families (N = 420), involving 9 trauma hospitals located in southwest Pennsylvania and northeast Ohio. In-depth interviews where conducted with family members, healthcare professionals, and organ procurement organization staff involved in the process. Only a weak effect was found for the impact of timing on the decision using a bivariate, correlational analysis. Moreover, we found that raising the issue before rather than after the pronouncement of death was most strongly associated with consent to donation. This effect disappeared after examining decoupling in relation to other factors. However, active consideration of the patient's donation wishes and a clear understanding of the families' initial inclination toward donation were associated with consent to organ donation.

Long-term impact of preventive proactivity on quality of life of the old-old.

OBJECTIVE: This research explored the long-term benefits of engaging in proactive health promotion efforts among old-old residents of Sunbelt retirement communities to empirically test components of the Preventive and Corrective Proactivity (PCP) Model of Successful Aging. Specifically, we examined the contributions of exercise, tobacco use, moderate alcohol use, and annual medical checkups to multidimensional quality of life indicators of physical health, psychological well-being, and mortality. METHOD: Data were obtained from a longitudinal study of adaptation to aging. Annual in-home interviews were conducted with 1000 older adults over a 9-year period. Whether health promotion behaviors at baseline predicted quality of life outcomes 8 years later was examined, controlling for the baseline outcome, sociodemographic variables, and, as an additional test, baseline health conditions. RESULTS: Exercise was predictive of fewer IADL limitations and greater longevity, positive affect, and meaning in life 8 years later. Avoiding tobacco was predictive of longevity. Before controlling for health conditions, exercise predicted decreased risk of basic activities of daily living limitations and having more goals; moderate alcohol use predicted longevity; annual health checkup predicted more IADL limitations; and having once smoked predicted having more IADL limitations and negative affect. CONCLUSIONS: Among the old-old, exercise had long-term and multifaceted benefits over an 8-year period. Tobacco avoidance also contributed to long-term positive outcomes. These results lend support to the long-term preventive value of health-promoting proactivity spontaneously engaged in by old-old persons proposed in the framework of the PCP model.