Community health worker training on older adults: A qualitative needs assessment.

BACKGROUND: Community health workers (CHWs) are frontline public health personnel who serve as liaisons between vulnerable patient populations and the healthcare system. They are instrumental in health promotion and education for urban-dwelling older adults. However, no research exists on training that CHWs receive on age-friendly health care. This article explores CHW education on the 4Ms of an Age-Friendly Health System and identifies areas where additional training may be necessary. METHODS: As part of a two-pronged qualitative needs assessment, four focus groups were held with a total of 17 CHWs and semistructured interviews were conducted with 10 clinicians, including both healthcare providers and social workers. Focus group and interview transcripts were then analyzed for major themes in Dedoose, a qualitative coding software. RESULTS: Clinicians most often identified Mentation and Mobility as areas where CHWs can have the greatest impact. Correspondingly, CHWs felt under-equipped to assist patients in these areas and expressed strong interest in additional training. In general, CHWs and clinicians agreed that Medications and What Matters do not fall under CHW scope of practice. CONCLUSIONS: Our findings confirm the critical role that CHWs can play in promoting the health and well-being of urban-dwelling older adults. However, we also demonstrate that many CHWs lack adequate training in age-friendly care. To meet the social and medical needs of a rapidly aging US population, there is a pertinent need to develop a novel community health worker training curriculum on Mentation and Mobility.

Substance Use Disorder Care in Skilled Nursing Facilities: Characterizing Resident Experiences.

OBJECTIVES: Patients with substance use disorder (SUD) may face many challenges when being cared for in skilled nursing facilities (SNFs), such as stigma and inadequate access to treatment. This study aims to learn from the perspectives of SNF residents with SUD. METHODS: Nineteen semistructured interviews were conducted at 5 SNFs in the Chicago Metropolitan Area. Additionally, Likert-type responses and substance use screening tests were collected. Qualitative data were analyzed using Dedoose version 9.0.107 (Sociocultural Research Consultants, LLC, Los Angeles, CA). RESULTS: Qualitative analyses identified 4 themes: (1) the SNF can be a positive site for recovery, (2) barriers to recovery in SNFs are variable, (3) lived experiences with SUD care and harm reduction are heterogeneous, and (4) the needs of residents with SUD encompass multiple domains. Results highlighted the variability of access to counseling and SUD treatment, as well as the prevalence of stigma, substance use, and overdose in SNFs. Results revealed the need for access to social work support, activities, counseling services, and improved staff knowledge of treating SUD. CONCLUSIONS: SNF residents living with SUD experience variable quality of care and may have difficulty accessing counseling and medical treatments for SUD, depending on the available resources in the facility to which they were admitted. The quality of care for residents living with SUD requires further study as more patients with SUD require SNF care.

The Design and Early Results of a Structured Longitudinal Training Program for Undergraduate Students to Increase Diversity in Aging-Research.

Background: The Cultivating Health and Aging Researchers by Integrating Science, Medicine, and Aging (CHARISMA) program at the University of Chicago (UC), is an NIA-funded longitudinal clinical research training program for undergraduate students from groups underrepresented in the sciences and medicine. CHARISMA students participate in an aging-focused: 1) realistic research career experience, 2) didactic curriculum, and 3) multi-tiered mentorship program. This manuscript describes CHARISMA and early quantitative data demonstrating its success. Methods: Students apply for and are accepted into CHARISMA in year-long intervals, with programming lasting from June to May. Short-term outcomes are measured using student surveys, including an adapted 23-question version of the critical research appraisal inventory (CRAI), the Geriatrics Attitude Scale for Primary Care Residents, and questions rating the overall program, mentor, importance of aging research, and career interests. Results: Twenty-two students have completed CHARISMA. After completing CHARISMA, student aggregate CRAI scores increased (6.8 to 7.5, p = 0.04). Additionally, the substantial majority of students completing CHARISMA were definitely, very or somewhat Additionally, 87% (19/22), 73% (16/22), and 82% (18/22) of students were definitely, very, or somewhat interested in pursuing a career in medicine that serves older adults, pursuing a career in clinical research, or pursuing a career focused on aging-related research. Conclusion: Early data demonstrates that CHARISMA increases undergraduate student knowledge of and interest in aging-related clinical research.

Perceived Facilitators and Barriers to Implementing Culturally Inclusive Diets into Hospitals and Long-Term Care Facilities.

OBJECTIVES: To identify perceived facilitators and barriers to implementing culturally inclusive foods into hospitals and long-term care (LTC) from the perspectives of registered dietitians and food service directors. DESIGN: Cross-sectional survey. SETTING AND PARTICIPANTS: Online nationwide survey of registered dietitians and food service directors working in hospitals or LTC. METHODS: We analyzed and compared participants' perceived barriers to implementing culturally inclusive foods in hospitals and LTC, assessed through a question in which we provided respondents with 13 different barriers and asked them to report the top 3. Then, we conducted a qualitative analysis of perceived facilitators, which respondents described in open-ended comments. RESULTS: The most common perceived barriers to implementing culturally inclusive foods were cost of ingredients (44%) and staff cultural knowledge and competence (44%). LTC respondents perceived barriers including (1) willingness of staff to adopt new practices, (2) time, (3) staff burnout, and (4) local/facility-level regulatory barriers more frequently than hospital respondents. Administrative buy-in, staff diversity, and patient considerations (eg, feedback and demand) were perceived facilitators to implementing culturally inclusive foods. CONCLUSIONS AND IMPLICATIONS: Implementing culturally inclusive foods into hospitals and LTC requires administrative buy-in, willingness to change, and resources including staff diversity and cultural knowledge and awareness. Incorporating patient feedback and preferences into decisions related to dietary offerings could further motivate menu modifications. Further examination of organizational and state policies regulating diet, particularly in LTC settings, is necessary to understand both how to implement culturally inclusive foods and further, to inform investigation of health outcomes (physical and mental) associated with increasing culturally inclusive food offerings in these facilities.

Palliative Care and Characterization of Symptoms in Patients Undergoing Cytoreductive Surgery/Hyperthermic Intraperitoneal Chemotherapy.

INTRODUCTION: Palliative care for advanced cancer patients has been associated with improvements in symptom management and quality of life (QoL). Patients with peritoneal metastases undergoing cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) often report symptoms adversely affecting QoL. We characterized and compared symptoms elucidated by palliative care versus surgical providers in this setting. METHODS: CRS/HIPEC patients who saw both surgical oncology and palliative care providers from 2016 to 2020 at a tertiary care center were identified from a retrospective database. Documentation of QoL-associated symptoms in surgical oncology and palliative care visits was recorded and analyzed. RESULTS: A total of 118 patients were included in this study. The most common primary histologies were appendiceal (36.4%) and colorectal (28.8%). Symptoms most frequently reported by palliative care were pain (60.2%) and fatigue (54.2%). The median number of symptoms documented was three (2, 5) in palliative care notes and two (0, 3) in surgical oncology notes (P < 0.001). Palliative care providers documented most symptoms statistically more frequently than surgical oncology providers. CONCLUSIONS: Patients who underwent CRS/HIPEC experienced various QoL-associated symptoms. Palliative care providers elicited more symptoms than surgical oncology providers. Additional studies are needed to explore the impact on outcomes of perioperative palliative care in this challenging patient population.

Barriers to Care for Nursing Home Residents With Substance Use Disorders: A Qualitative Study.

OBJECTIVES: Over the past decade, the numbers of older adults with opioid and substance use disorders (OUD/SUD) have increased. As this population enters nursing homes (NHs) in increasing numbers, it is crucial to consider their capacity to manage issues related to OUD/SUD. This study aimed to examine current NH protocols for care coordination of residents with OUD/SUD as well as facility-related barriers to providing care to this vulnerable population within the NH. METHODS: Twenty-four semistructured interviews were conducted with NH staff including directors of nursing, administrators, nurses, and physicians in July 2020. Staff were recruited from 11 different post-acute care and long-term care facilities located in urban and suburban communities of Chicago. Interviews were conducted virtually (via teleconference platform or by telephone) and subsequently coded using ATLAS.ti 8 (ATLAS.ti Scientific Software Development GmbH, Berlin, Germany) using constant comparative method. RESULTS: Qualitative analyses identified 3 themes around NH barriers to care for residents with SUD/OUD: (1) staff preparedness, (2) staff perceptions of addiction, and (3) overall lack of resources. Results revealed a strong need for the development of consistent policies, as well as standardized, educational interventions for NH staff that target SUD/OUD management in this vulnerable population. CONCLUSIONS: The evaluation and impact of persons with SUD/OUD entering NHs are an important topic that requires further study. More resources and staff training are necessary to ensure that residents with SUD/OUD have access to appropriate care within these settings.

Practice Improvement Projects in an Interdisciplinary Palliative Care Training Program.

CONTEXT: Demand for palliative care (PC) continues to increase with an insufficient number of specialists to meet the need. This requires implementation of training curricula to expand the workforce of interdisciplinary clinicians who care for persons with serious illness. OBJECTIVES: To evaluate the impact of utilizing individual practice improvement projects (PIP) as part of a longitudinal PC curriculum, the Coleman Palliative Medicine Training Program (CPMTP-2). METHODS: Participants developed their PIPs based on their institutional needs and through a mentor, and participated in monthly meetings and bi-annual conferences, thereby allowing for continued process improvement and feedback. RESULTS: Thirty-seven interdisciplinary participants implemented 30 PIPs encompassing 7 themes: (1) staff education; (2) care quality and processes; (3) access to care; (4) documentation of care delivered; (5) new program development; (6) assessing gaps in care/patient needs; and (7) patient/family education. The majority of projects did achieve completion, with 16 of 30 projects reportedly being sustained several months after conclusion of the required training period. Qualitative feedback regarding mentors' expertise and availability was uniformly positive. CONCLUSION: The CPMTP-2 demonstrates the positive impact of PIPs in the development of skills for interdisciplinary learners as part of a longitudinal training program in primary PC. Participation in a PIP with administrative support may lead to operational improvement within PC teams.

Goals of care discussions: perceptions of radiation and medical oncologists.

BACKGROUND: Goals of care discussions (GOCD) are essential when counseling patients with cancer. Respective roles of radiation oncologists (RO) and medical oncologists (MO) in GOCD can be unclear. This study aims to clarify the dynamics and barriers to GOCD. METHODS: Five hundred and fifty-four ROs and 1604 MOs at NCI-designated comprehensive cancer centers were sent an anonymous electronic survey regarding demographics, opinions, training in GOCD, GOCD frequency, and three vignettes. Response formats were Yes/No, Likert-type, and free response. Chi-square and Wilcoxon rank-sum tests were performed. Likert-type scores were reported as median [interquartile range]. RESULTS: There were 76 (13.7%) RO and 153 (9.5%) MO who completed surveys. Sixty-three percent of RO and 66% of MO reported GOCD with > 50% of patients (p = 0.90). GOCD were initiated for declining performance status (74%) and poor life expectancy (69%). More MO (42%) received formal GOCD training compared to RO (18%) (p < 0.01). MO were more comfortable conducting GOCD than RO (p < 0.01). RO-conducted GOCD were rated to be less important by MO compared to RO (p < 0.05). Thirty-six percent of MO reported being "not at all" or "somewhat" comfortable with RO-conducted GOCD. RO-initiated GOCD with new patients were rated less appropriate by RO compared to MO perceptions of RO-initiated GOCD (p < 0.01). CONCLUSIONS: While MO and RO conduct GOCD with similar frequency, MO are more comfortable conducting GOCD and are more likely to have formal training. MO rate importance of RO involvement lower than RO. Further research is needed to understand interdisciplinary dynamics that may impact GOCD and subsequent patient care outcomes.

Management and outcomes of a COVID-19 outbreak in a nursing home with predominantly Black residents.

BACKGROUND/OBJECTIVES: Few studies present clinical management approaches and outcomes of coronavirus disease 2019 (COVID-19) outbreaks in skilled nursing facilities (SNFs). We describe outcomes of a clinical management pathway for a large COVID-19 outbreak in an urban SNF with predominantly racial minority (>90% black), medically complex, older residents. DESIGN: Single-center, retrospective, and observational cohort study (March 1, 2020-May 31, 2020). SETTING AND PARTICIPANTS: All subacute and long-term care residents at an urban SNF between March 1, 2020 and May 31, 2020 (Chicago, IL). INTERVENTION: A multicomponent management pathway was developed to manage a large COVID-19 outbreak in an SNF. MEASUREMENTS: Chart review was used to extract demographics, comorbidities, symptoms, lab results, and clinical outcomes over 12 weeks, which were summarized and compared between residents with and without COVID-19. RESULTS: A multicomponent clinical management pathway was used to care for residents with COVID-19, which included frequent scheduled clinical and laboratory evaluation, use of intravenous fluids, supplemental oxygen, antibiotics when indicated, and goals-of-care discussions. Of the 204 residents, 172 (84.3%) tested positive for SARS-CoV-2 during the 3-month period, with 50.5% symptomatic, 9.3% presymptomatic, and 24.5% asymptomatic, with a 30-day mortality rate of 15.7%. Predominant symptoms were low-grade fever >99 °F, anorexia, delirium, and fatigue. While in the facility, approximately one-quarter of residents experienced hypernatremia [Na > 145 mEq/L] (24.5%), acute kidney injury [Cr > 0.03 mg/dL or 1.5× baseline] (29.7%), or leukopenia [WBC < 4.8 1000/mm3 ] (39.4%). CONCLUSION: We present the first available clinical strategy guiding the medical management of a COVID-19 syndrome in an urban SNF, caring for largely black residents, which may lead to improved mortality.

Study of Shadowing Experiences among Chaplains in the Coleman Palliative Medicine Fellowship.

While shadowing is a relatively common practice in the education of many health professionals, it is not widely used in chaplaincy education. Findings from our qualitative study of 12 chaplains who participated in the Coleman Palliative Medicine Training Program suggest it may offer benefits for practicing chaplains. In interviews with seven fellows who shadowed more experienced palliative care (PC) chaplains and the five mentors who were shadowed at their work settings, participants reported opportunities for mutual learning, self-reflection, and collegiality. Fellows observed how members of a PC team collaborate and contribute equally to the care of patients. Mentors found shadowing was a rare opportunity to share their chaplaincy practice with colleagues. It helped them to appreciate different aspects of their work settings and to distinguish between PC and generalist chaplaincy. We discuss the challenges participants experienced while shadowing and offer recommendations for incorporating the practice more widely into chaplaincy education.

Three-Tiered COVID-19 Cohorting Strategy and Implications for Memory-Care.

An outbreak of SARS-CoV-2 in a skilled nursing facility (SNF) can be devastating for residents and staff. Difficulty identifying asymptomatic and presymptomatic cases and lack of vaccination or treatment options make management challenging. We created, implemented, and now present a guide to rapidly deploy point-prevalence testing and 3-tiered cohorting in an SNF to mitigate an outbreak. We outline key challenges to SNF cohorting.

Expanding the Interdisciplinary Palliative Medicine Workforce: A Longitudinal Education and Mentoring Program for Practicing Clinicians.

CONTEXT: The disparity between gaps in workforce and availability of palliative care (PC) services is an increasing issue in health care. To meet the demand, team-based PC requires additional educational training for all clinicians caring for persons with serious illness. OBJECTIVES: To describe the educational methodology and evaluation of an existing regional interdisciplinary PC training program that was expanded to include chaplain and social worker trainees. METHODS: From 2015 to 2017, 26 social workers, chaplains, physicians, nurses, and advanced practice providers representing 22 health systems completed a two-year training program. The curriculum comprises biannual interdisciplinary conferences, individualized mentoring and clinical shadowing, self-directed e-learning, and profession-focused seminar series for social workers and chaplains. Site-specific practice improvement projects were developed to address gaps in PC at participating sites. RESULTS: PC and program development skills were self-assessed before and after training. Among 12 skills common to all disciplines, trainees reported significant increases in confidence across all 12 skills and significant increases in frequency of performing 11 of 12 skills. Qualitative evaluation identified a myriad of program strengths and challenges regarding the educational format, mentoring, and networking across disciplines. CONCLUSION: Teaching PC and program development knowledge and skills to an interdisciplinary regional cohort of practicing clinicians yielded improvements in clinical skills, implementation of practice change projects, and a sense of belonging to a supportive professional network.

Racial and ethnic disparity in palliative care and hospice use.

OBJECTIVES: Prior research has demonstrated differences across race and ethnicity, as well as across geographic location, in palliative care and hospice use for patients near the end of life. However, there remains inconsistent evidence regarding whether these disparities are explained by hospital-level practice variation. The goals of this study were to evaluate whether inpatient palliative care consultation use and discharge to hospice differed by race/ethnicity and whether hospital-level variations explained these differences. STUDY DESIGN: Retrospective, cross-sectional study. METHODS: This study evaluated 5613 patients who were discharged to hospice or died during their hospital stay between 2012 and 2014 in 4 urban hospitals with an inpatient palliative care service. The main outcomes were receipt of an inpatient palliative care consultation and discharge to hospice. RESULTS: The sample was 43% white, 44% African American, and 13% Hispanic. After adjusting for patient characteristics and hospital site, race/ethnicity was not significantly associated with receipt of inpatient palliative care consultation. Hispanic race/ethnicity was associated with a higher likelihood of discharge to hospice (odds ratio, 1.22; P = .036), and inpatient palliative care consultation was associated with 4 times higher likelihood of discharge to hospice (P <.001). Hospital site was also associated with both receipt of inpatient palliative care consultation and discharge to hospice. CONCLUSIONS: Our results illustrate significant variation across hospitals in palliative care consultation use and discharge to hospice. No significant racial/ethnic disparities in the use of either palliative care or hospice at the end of life were found within hospitals.

ECHO-Chicago Geriatrics: using telementoring to "geriatricize" the primary care workforce.

BACKGROUND: The primary care workforce is under-prepared to care for the growing older adult population. Extension for Community Healthcare Outcomes (ECHO) is a continuing education intervention that connects subspecialists and community health care providers (HCPs) via videoconferencing technology for didactic and case-discussion sessions. Methods: We asked participants to complete 8 to 12 educational telementoring sessions. These sessions were conducted between February 2016 and October 2017. Pre/post surveys of self-efficacy and frequency of practice behaviors were collected from eligible participants. Results: 121 HCPs from multiple sites participated. Of these, 89 (non-trainee status) were eligible to complete surveys. Sixty-two participants (69.7%) completed pre/post surveys. Participants were queried regarding 15 geriatrics competencies. Self-efficacy significantly increased across all competencies after series participation (p < 0.05). Frequency of 8 out of 11 queried geriatrics-centered practice behaviors also increased significantly (p < 0.05). Discussion: ECHO-Chicago Geriatrics offers a novel strategy for improving community HCPs' geriatrics self-efficacy and frequency of geriatrics-centered practice behaviors.

Medication management in older adults and interprofessional education: A needs assessment.

Elderly, multi-morbid patients are at high risk for suffering adverse drug events. Safe medication management is a key process in preventing these adverse events, and requires interprofessional teamwork. We performed a needs assessment survey of graduating medical students and faculty to evaluate student training in medication management, in particular students' preparedness in the three minimum geriatrics competencies pertaining to medication management, interprofessional educational opportunities, and optimal learning methods. Response rates were 45/105 (43%) for students and 38/93 (41%) for faculty. The majority of students felt that they did not receive sufficient training in medication management in older adults. Faculty either agreed with students or were unsure whether students received sufficient training. Neither students nor faculty felt that students were extremely prepared to carry out the three minimum geriatrics competencies at the time of medical school graduation. Students and faculty identified direct patient care experiences as the optimal learning method, and inappropriate medications as the highest priority topic. Students and faculty felt that students do not receive sufficient interprofessional educational opportunities. The results of this study are currently being used to create customized interprofessional educational experiences for medical students related to medication management in older adults.

Development of the PC-7, a Quantifiable Assessment of Spiritual Concerns of Patients Receiving Palliative Care Near the End of Life.

Background: Attending to the religious/spiritual (R/S) concerns of patients is a core component of palliative care. A primary responsibility of the chaplain is to conduct a thorough assessment of palliative care patients' R/S needs and resources. Problems with current approaches to spiritual assessment in all clinical contexts, including palliative care, include limited evidence for their validity, reliability, or clinical usefulness; narrative content; and lack of clinical specificity. Objectives: The aim of our work was to develop an evidence-based, quantifiable model for the assessment of unmet spiritual concerns of palliative care patients near the end of life. Design: The PC-7 model was developed by a team of chaplains working in palliative care. Phase 1 used literature in the field and the chaplains' clinical practice to identify key concerns in the spiritual care of palliative care patients. Phase 2 focused on developing indicators of those concerns and reliability in the chaplains' rating of them. Results: Key concerns in the model include the following. Need for meaning in the face of suffering; need for integrity, a legacy; concerns about relationships; concern or fear about dying or death; issues related to treatment decision making; R/S struggle; and other concerns. An approach to scoring the patients' degree of unmet spiritual concerns was adapted from the literature. Assessing cases from the chaplains' practice led to high levels of agreement (reliability). Conclusion: Using the PC-7 model, chaplains can describe and quantify the key spiritual concerns of palliative care patients. Further research is needed to test its validity, reliability, and clinical usefulness.