NegotiAge: Development and pilot testing of an artificial intelligence-based family caregiver negotiation program.

BACKGROUND: Family caregivers of people with Alzheimer's disease experience conflicts as they navigate health care but lack training to resolve these disputes. We sought to develop and pilot test an artificial-intelligence negotiation training program, NegotiAge, for family caregivers. METHODS: We convened negotiation experts, a geriatrician, a social worker, and community-based family caregivers. Content matter experts created short videos to teach negotiation skills. Caregivers generated dialogue surrounding conflicts. Computer scientists utilized the dialogue with the Interactive Arbitration Guide Online (IAGO) platform to develop avatar-based agents (e.g., sibling, older adult, physician) for caregivers to practice negotiating. Pilot testing was conducted with family caregivers to assess usability (USE) and satisfaction (open-ended questions with thematic analysis). RESULTS: Development: With NegotiAge, caregivers progress through didactic material, then receive scenarios to negotiate (e.g., physician recommends gastric tube, sibling disagrees with home support, older adult refusing support). Caregivers negotiate in real-time with avatars who are designed to act like humans, including emotional tactics and irrational behaviors. Caregivers send/receive offers, using tactics until either mutual agreement or time expires. Immediate feedback is generated for the user to improve skills training. Pilot testing: Family caregivers (n = 12) completed the program and survey. USE questionnaire (Likert scale 1-7) subset scores revealed: (1) Useful-Mean 5.69 (SD 0.76); (2) Ease-Mean 5.24 (SD 0.96); (3) Learn-Mean 5.69 (SD 0.74); (4) Satisfy-Mean 5.62 (SD 1.10). Items that received over 80% agreements were: It helps me be more effective; It helps me be more productive; It is useful; It gives me more control over the activities in my life; It makes the things I want to accomplish easier to get done. Participants were highly satisfied and found NegotiAge fun to use (91.7%), with 100% who would recommend it to a friend. CONCLUSION: NegotiAge is an Artificial-Intelligent Caregiver Negotiation Program, that is usable and feasible for family caregivers to become familiar with negotiating conflicts commonly seen in health care.

Transforming a Negotiation Framework to Resolve Conflicts among Older Adults and Family Caregivers.

BACKGROUND: Family caregivers of older people with Alzheimer's dementia (PWD) often need to advocate and resolve health-related conflicts (e.g., determining treatment necessity, billing errors, and home health extensions). As they deal with these health system conflicts, family caregivers experience unnecessary frustration, anxiety, and stress. The goal of this research was to apply a negotiation framework to resolve real-world family caregiver-older adult conflicts. METHODS: We convened an interdisciplinary team of national community-based family caregivers, social workers, geriatricians, and negotiation experts (n = 9; Illinois, Florida, New York, and California) to examine the applicability of negotiation and conflict management frameworks to three older adult-caregiver conflicts (i.e., caregiver-older adult, caregiver-provider, and caregiver-caregiver). The panel of caregivers provided scenarios and dialogue describing conflicts they experienced in these three settings. A qualitative analysis was then performed grouping the responses into a framework matrix. RESULTS: Upon presenting the three conflicts to the caregivers, 96 responses (caregiver-senior), 75 responses (caregiver-caregiver), and 80 responses (caregiver-provider) were generated. A thematic analysis showed that the statements and responses fit the interest-rights-power (IRP) negotiation framework. DISCUSSION: The interests-rights-power (IRP) framework, used in business negotiations, provided insight into how caregivers experienced conflict with older adults, providers, and other caregivers. Future research is needed to examine applying the IRP framework in the training of caregivers of older people with Alzheimer's dementia.

Dissemination of a long-term care planning tool, PlanYourLifespan.org, through community-based stakeholder leaders.

BACKGROUND: Geriatrics research generally cumulates in academic journal publications, with variable diffusion to patients and communities. PlanYourLifespan.org is a free, evidence-based tool that assists older adults, and their loved ones, to better understand and plan for their long-term support needs. There is a need to effectively disseminate geriatrics research, such as PlanYourLifespan.org, to communities that may directly benefit from this research. OBJECTIVE: To leverage community-based stakeholder leaders, utilizing a train-the-trainer program, to disseminate PlanYourLifespan.org and evaluate the extent of the dissemination. METHODS: Using a train-the-trainer strategy, community stakeholder leaders from the original study paired up with newly recruited community stakeholder leaders. New community stakeholder leaders were trained on dissemination, using a "how-to-disseminate" web-based toolkit-developed as part of this project. Newly trained community stakeholder leaders subsequently trained additional community stakeholder leaders who conducted and tracked dissemination activities in their communities. Google Analytics tracked newly created PlanYourLifespan.org accounts, login sessions, and daily website visitors. RESULTS: Five newly trained community stakeholder leaders disseminated PlanYourLifespan.org over a three-month period. Cumulatively, on the day of the dissemination activity, there were 11,361 PlanYourLifespan.org log-ins (average: 378.7 log-ins/activity day), 89,068 log-ins (average: 2969 log-ins/activity week) one-week after the activity, and 319,154 log-ins (average: 10,638 log-ins/activity month) one month after the dissemination activity. Approximately 9.4 new PlanYourLifespan.org accounts were created one-week post dissemination activity and over 1100 new accounts in the one-month period thereafter. CONCLUSIONS: Wide dissemination of PlanYourLifespan.org occurred by leveraging a train-the-trainer approach with community stakeholder leaders. Researchers should consider collaborating early on with community stakeholders to meaningfully disseminate results.

Aspects of cognition that impact aging-in-place and long-term care planning.

BACKGROUND: Older adults frequently defer decisions about their aging-in-place/long-term care (AIP-LTC) needs. As a result, when older adults experience worsening Alzheimer's disease, family members/friends become surrogate decision makers. We sought to understand what aspects of cognition impact older adult AIP-LTC planning. METHODS: As part of the PlanYourLifespan (PYL)-LitCog study, we longitudinally examined AIP-LTC decision-making among a cohort (LitCog) of community-based older adults (65 years and older) recruited from hospital-associated primary care clinics in Chicago, Illinois, with extensive cognitive testing. PlanYourLifespan.org (PYL) is an evidence-based online intervention that facilitates AIP-LTC planning. Subjects underwent baseline testing, received the PYL online intervention, and then were surveyed at 1, 6, and 12 months about AIP-LTC decision-making. Cross-sectional logistic regression analysis was conducted examining cognitive variables that impacted AIP-LTC decision-making. RESULTS: Of the 293 older adults interviewed (mean age 73.0 years, 40.4% non-White), subjects were more likely to have made AIP-LTC decisions if they had adequate inductive reasoning (ETS letter sets total-OR = 1.14 (95% CI = 1.03-1.27; p < 0.05)) and adequate working memory (size judgment span total-OR = 1.76 (95% CI = 1.13-2.73; p < 0.05)). There were no differences in decision-making observed in verbal abilities, long-term memory, or processing speed. All analyses were adjusted for participant gender, race, age, and decision-making response at baseline. CONCLUSION: Inductive reasoning and working memory are critical to AIP-LTC decision-making. Screening routinely for these specific cognitive domains is important in targeting and helping older adults prepare in time for their future AIP-LTC needs.

Effects of Improv Training on Older Adults in a Long Term Care Facility.

Adjusting to life in a long term care facility (LTCF) can be challenging for older adults. Improvisation (shortened to improv) is a unique activity that encourages creativity and adaptive cognitive stimulation, through performing short scenes with content suggestions. We sought to assess whether improv training, in the form of a course entitled Humor Doesn't Retire (HDR), could impact patient-centered outcomes in a LTCF. About 15 adults (mean age 83.6 years) living in a LTCF participated in the 8-week HDR course with pre and 1-month post mixed method surveys assessing validated Patient Reported Outcomes Measurement Information System (PROMIS) measures and qualitative open-ended responses. Participants experienced significant improvements in social isolation and perceived stress (p < .05), and trend improvements in positive affect, self-efficacy, and anxiety. Participants described themes of increased attentiveness, becoming more relaxed, increased cognitive stimulation, and improved communication skills. In conclusion, LTCFs may want to consider offering improv training to positively improve the lives of older adult residents.

Negotiation Training for Case Managers to Improve Older Adult Acceptance of Services.

PURPOSE OF STUDY: Older adults frequently choose not to accept recommended social support services (e.g., caregiver and home therapy). Social workers/case managers (SWs/CMs) are often caught in the conflict encouraging patients to accept services, but facing resistance. As a result, older adults may experience unsafe home scenarios and hospital discharges. This research sought to examine whether business school negotiation and dispute resolution (NDR) training could ease these conflicts and potentially improve outcomes for both older adults and SWs/CMs. PRACTICE SETTINGS: Urban health care system (pilot), national case management conference (implementation). METHODOLOGY AND SAMPLE: Researchers tailored the NDR training, offered at graduate business schools, for SWs/CMs. Researchers then pilot tested the NDR training at an urban hospital and implemented it with a national cohort of SWs/CMs at a national case management conference. Participants completed a survey that ascertained conflicts, utility of the NDR program, real-world applicability, and future directions. RESULTS: Eighty-five SW/CM participants, from 22 states, completed the NDR training and survey. Participants reported experiencing conflicts frequently in their workday. Post-NDR training, respondents were very positive about the knowledge gained from the course, specifically noting themes of learning the negotiation basics, tactics (e.g., framing), and integrative strategies (e.g., win-win/expanding to multi-issue discussions). All participants planned to use the NDR skills in the future. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: The NDR training program can provide SWs/CMs with formal strategies to facilitate older adults' acceptance of social services while balancing patient autonomy. Learning negotiating techniques can be "win-win" for both older adults' home safety and case manager well-being.

Rationale and study design for decision making & implementation of aging-in-place/long term care plans among older adults.

BACKGROUND: Remaining in one's own home and community is a priority for many older adults as they age. Decision-making and planning is critical to ensure successful aging-in-place (AIP), especially when individuals experience age-related changes such as cognitive decline. Objectives: We are testing how decision-making and planning for AIP is impacted by changes in older adults' cognition and function, chronic conditions, social influences, environmental factors and identifying the mediating/moderating interactions between factors. We will also assess whether decision-making and planning for AIP translates into timely adoption of plans and goal concordance between older adults and their surrogate/caregiver decision makers. METHODS: We will conduct a longitudinal single-group interventional clinical trial of community-dwelling older adults who are enrolled in LitCog, (R01AG03611) and expose them to an online intervention, PlanYourLifespan.org, which facilitates decision-making and planning for AIP. Enrolled participants (n = 398) will complete interviews at baseline, one month, and every six months up to 42 months in conjunction with the LitCog study, where cognitive, social, functional, and health literacy data is collected. Additionally, we will collect data on decision-making, resource use, communication of plans, timing of plan implementation, and goal concordance. PROJECTED OUTCOMES: Findings from this study may generate evidence on how age-related changes in older adults may affect decision-making and implementation in relation to AIP as well as the impact of social relationships and support. Ultimately these findings may help shape the design of programs and practices that may improve the lives of older adults and the capacity of institutions to adapt to societal aging and AIP.

Longitudinal Follow-Up of Long-Term Care Planning Using PlanYourLifespan.org.

Many older adults wish to age-in-place but do not have long-term care plans for when they may require more assistance. PlanYourLifespan.org (PYL) is an evidence-based tool that helps older adults understand and plan for their long-term care needs. We examined the long-term effects of PYL use on user perceptions and planning of long-term care services. Individuals who previously accessed PYL were invited to complete an online, nation-wide mixed methodology survey about end-user outcomes related to PYL. Among 115 completed surveys, users found PYL helpful with long-term planning for their future needs. Over half of website users reported having conversations with others because of PYL use. However, 40% of respondents reported not having a conversation with others about their plans; common themes for barriers to planning included procrastination and a lack of immediate support needs. Although PYL helps with planning, many people are still not communicating their long-term care plans.

Training Hospitalists in Negotiations to Address Conflicts with Older Adults around Their Social Needs.

Hospitalists care for a growing population of older patients with unique social needs that can often be addressed by providing caregiver help in the home. The importance of addressing social needs is well-recognized, yet older patients sometimes refuse these services. This refusal of services may result in rehospitalization and increased morbidity for patients. We aimed to overcome this refusal of social support through an innovative workshop training hospitalists in negotiation and dispute resolution. Hospitalists at a tertiary care, urban academic medical center completed a one-hour interactive workshop on negotiation and dispute resolution focused on addressing older patients' refusal of social services. One month post workshop, participants reported increased confidence in engaging patients and families in conflicts and felt empowered to negotiate in both their clinical practice and personal lives. Training hospitalists to negotiate with older adults needing social services is feasible and positively impacts the ability to provide geriatric care.

Use of Electronic Health Records by Older Adults, 85 Years and Older, and Their Caregivers.

BACKGROUND: Healthcare providers may not offer patient portal (PP) access to electronic health records (EHRs) to their patients older than 85 years, due to the false impression that they do not utilize technology. It is imperative that older adults be given equal opportunity to use technology in regard to their healthcare. OBJECTIVE: To characterize the content and frequency of use of PP messaging tethered to EHRs by older adults, aged 85 years and older, and their caregivers. DESIGN, SETTING, AND PARTICIPANTS: User-initiated communications from electronic PPs (MyChart) tethered to an EHR (Epic) for patients who were 85 years and older, receiving care at outpatient internal medicine and geriatric clinics at an academic health center from July 1, 2016, to December 31, 2016, were reviewed retrospectively and analyzed with mixed methods. RESULTS: A total of 1254 user-initiated messages, sent by 62 patients aged 85 years and older (mean age = 87.9 years; n = 576 messages; mean = 9.9 messages per person) and 82 caregivers (n = 678 messages; mean = 7.8 messages per person), were analyzed. Qualitative analysis revealed 12 main themes: clinical issues, medication/vaccine questions, medication refills, laboratory orders/results, therapy/durable medical equipment, care coordination, care transitions, scheduling, appreciation/thank you, administrative/billing, telephone requests, and death notification. Caregivers significantly initiated messages more for care transitions (P < .001). Patients significantly initiated messages more for scheduling (P = .04) and medication refills (P = .04). Patients who had heart failure, coronary artery disease, or Alzheimer's disease were significantly more likely to have caregivers using the PP as their proxy (30.7% vs 21.6%; P = .01). CONCLUSIONS: Adults, aged 85 years and older, and their caregivers utilize PPs tethered to EHRs. Healthcare providers should ensure inclusivity and offer access to EHRs to older adult populations, especially those aged 85 years and older. J Am Geriatr Soc 68:1078-1082, 2020.

Conflicts Experienced by Caregivers of Older Adults With the Health-Care System.

BACKGROUND: Family caregivers of older adults frequently navigate the health system for their loved ones. As older adults experience more medical issues, the interactions between caregivers and the health system can be fraught with conflicts. OBJECTIVE: To characterize the conflicts that caregivers of older adults experience with the health-care system. METHODS: A cross-sectional national online survey with open-ended questions was conducted among family caregivers ascertaining experiences with the health-care system. Qualitative thematic analysis was completed using constant comparative analysis and review by a third author. RESULTS: Over a 2-month period, 97 caregivers completed the survey. Common themes where caregivers experienced conflicts were Difficulty With Accessing/Communicating With Providers, Delivery of Emergency Care, Disjointed Transitional Care, Unaddressed Clinical Concerns, and Financial. Caregivers reported needing to act as patient advocates in the conflicts with the health-care system. CONCLUSION: Understanding the conflicts that family caregivers encounter with the health system provides potential targets for future interventions to combat the challenges faced by caregivers of older adults and ultimately improve delivery of geriatric care.

The Effects of a Multicomponent Colorectal Cancer Screening Intervention on Knowledge, Recommendation, and Screening among Underserved Populations.

This trial tested a multicomponent intervention to increase colorectal cancer (CRC) screening among underserved patients. Participants were randomized to: (1) physician + patient intervention, (2) physician-only intervention, or (3) usual care (UC). Study outcomes included patient knowledge, physician recommendation of CRC screening, and screening completion via colonoscopy or stool tests. Among 538 participants, those exposed to the physician + patient intervention had significantly increased knowledge over patients in physician-only (p=.0008) or UC arms (p=.0003). However, there were no statistically significant differences in completion of CRC screening, with 10%, 20%, and 16% of UC, physician-only, and physician + patient participants screened, respectively. In UC, all completed screenings were colonoscopy, whereas in the physician-only and physician + patient arms, 39% and 46% of completed tests were via stool test, respectively. The multicomponent intervention did not increase overall CRC screening, yet results underscore the need to provide patients options for completing CRC screening.

Voice-Controlled Intelligent Personal Assistants to Support Aging in Place.

BACKGROUND/OBJECTIVES: Many older adults wish to age in place, and voice-controlled intelligent personal assistants (VIPAs; eg, Amazon Echo and Google Home) potentially could support unmet home needs. No prior studies have researched the real-world use of VIPAs among older adults. We sought to explore how older adults and caregivers utilize VIPAs. DESIGN/MEASUREMENT: Retrospective review of all verified purchase reviews of the Amazon Echo posted on Amazon.com between January 2015 and January 2018, with filtering for health-related older adult key words. Open-ended reviews were qualitatively analyzed to identify relevant themes. RESULTS: On retrieval, there were 73 549 reviews; and with subsequent key word filtering, 125 total reviews were subsequently analyzed. Five major themes were identified: (1) entertainment ("For two very senior citizens…we have really had fun with Echo. She tells us jokes, answers questions, plays music.); (2) companionship ("A senior living alone…I now have Alex to talk to."); (3) home control; (4) reminders ("I needed something that would provide me with information I couldn't remember well, such as the date, day, or my schedule…I highly recommend for anyone with memory challenges"); and (5) emergency communication. Several felt it reduced burdening caregivers. "…You also feel guilt from fear of overburdening your caregivers. Alexa has alleviated much of this." Specifically, caregivers found that: "By making playlists of songs from her youth whoever is providing care, family or professional caregiver, can simply request the right song for the moment in order to sooth, redirect, or distract Mom." Alternatively, negative reviewers felt the VIPA misunderstood them or could not adequately respond to specific health questions. CONCLUSION: VIPAs are a low-cost artificial intelligence that can support older adults in the home and potentially reduce caregiver burden. This study is the first to explore VIPA use among older adults, and further studies are needed to examine the direct benefits of VIPAs in supporting aging in place. J Am Geriatr Soc 68:176-179, 2019.

Leveraging Patient/Community Partnerships to Disseminate Patient Centered Outcomes Research in Geriatrics.

Background: With the growth of patient-centered outcomes research (PCOR), partnerships between researchers and patients have presented novel opportunities for disseminating results. A large gap exists in disseminating patient-centered research results to older adult patient end-users. We sought to examine the experiences of patient/community partners in disseminating PCOR results and characterize lessons learned that may facilitate future researcher-patient/community dissemination partnerships. Methods: Patient/community partners who participated in geriatrics-focused PCORI-funded research and were active in disseminating results, as part of their planned activities, were recruited for one-to-one qualitative interviews. Constant comparative and thematic analysis were used to identify and describe common themes that emerged in a survey of open-ended questions. Results: Ten individuals (four community partners, six patients) aged 55-87 years were interviewed. Analysis revealed that for successful dissemination, subjects felt it was vital to reach out to people affected by the results, leverage personal stories, and tap into pre-developed programming. Patient/Community partners identified potential audiences through word-of-mouth, community requests, and mapping a list of audiences-targeting those directly affected as well as those who worked with the audience (e.g., not specifically medical). Patient/community partners recommended that researchers engage patient/community partners for suggestions on audiences, show empathy, include diverse populations, and maintain a community-focus. One community partner stated, "Why wouldn't we help disseminate results? It's a no-brainer. We know people!" Conclusion: Patient/community partners provide effective ways to communicate results, new audiences to reach, improved communication with different audiences, and improved credibility of the findings. The lessons learned have implications for assisting future research-patient/community partnerships in the dissemination of their patient-centered research.

Stressors Facing Home-Based Primary Care Providers.

The numbers of homebound patients in the United States are increasing. Home-based primary care (HBPC) is an effective model of interdisciplinary care that has been shown to have high patient satisfaction rates and excellent clinical outcomes. However, there are few clinicians that practice HBPC and clinicians that do face additional stressors. This study sought to better understand the stressors that HBPC providers face in caring for homebound patients. This was a cross-sectional qualitative survey and analysis of HBPC providers. Responses were categorized into four themes: The patient in the home setting, caregiver support, logistics, and administrative concerns. This research is the first to analyze the stressors that providers of HBPC face in serving the needs of complex homebound patients. Awareness and attention to these issues will be important for the future sustainability of home-based primary care.

Tele-Follow-Up of Older Adult Patients from the Geriatric Emergency Department Innovation (GEDI) Program.

The objective of this study was to characterize the content and interventions performed during follow-up phone calls made to patients discharged from the Geriatrics Emergency Department Innovation (GEDI) Program and to demonstrate the benefit of these calls in the care of older adults discharged from the emergency department (ED). This study utilizes retrospective chart review with qualitative analysis. It was set in a large, urban, academic hospital emergency department utilizing the Geriatric Emergency Department Innovations (GEDI) Program. The subjects were adults aged 65 and over who visited the emergency department for acute care. Follow-up telephone calls were made by geriatric nurse liaisons (GNLs) at 24⁻72 h and 10⁻14 days post-discharge from the ED. The GNLs documented the content of the phone calls, and these notes were analyzed through a constant comparative method to identify emergent themes. The results showed that the most commonly arising themes in the patients' questions and nurses' responses across time-points included symptom management, medications, and care coordination (physician appointments, social services, therapy, and medical equipment). Early follow-up presented the opportunity for nurses to address needs in symptom management and care coordination that directly related to the ED admission; later follow-up presented a unique opportunity to resolve sub-acute issues that were not addressed by the initial discharge plan and to manage newly arising symptoms and patient needs. Thus, telephone follow-up after emergency department discharge presents an opportunity to better connect older adults with appropriate outpatient care and to address needs arising shortly after discharge that may not have otherwise been detected. By following up at two discrete time-points, this intervention identifies and addresses distinct patient needs.