Improving measurement of functional status among older adults in primary care: A pilot study.

Despite its importance for clinical care and outcomes among older adults, functional status-the ability to perform basic activities of daily living (ADLs) and instrumental ADLs (IADLs)-is seldom routinely measured in primary care settings. The objective of this study was to pilot test a person-centered, interprofessional intervention to improve identification and management of functional impairment among older adults in Veterans Affairs (VA) primary care practices. The four-component intervention included (1) an interprofessional educational session; (2) routine, standardized functional status measurement among patients aged ≥75; (3) annual screening by nurses using a standardized instrument and follow-up assessment by primary care providers; and (4) electronic tools and templates to facilitate increased identification and improved management of functional impairment. Surveys, semi-structured interviews, and electronic health record data were used to measure implementation outcomes (appropriateness, acceptability and satisfaction, feasibility, fidelity, adoption/reach, sustainability). We analyzed qualitative interviews using rapid qualitative analysis. During the study period, all 959 eligible patients were screened (100% reach), of whom 7.3% (n = 58) reported difficulty or needing help with ≥1 ADL and 11.8% (n = 113) reported difficulty or needing help with ≥1 IADL. In a chart review among a subset of 50 patients with functional impairment, 78% percent of clinician notes for the visit when screening was completed had content related to function, and 48% of patients had referrals ordered to address impairments (e.g., physical therapy) within 1 week. Clinicians highly rated the quality of the educational session and reported increased ability to measure and communicate about function. Clinicians and patients reported that the intervention was appropriate, acceptable, and feasible to complete, even during the COVID pandemic. These findings suggest that this intervention is a promising approach to improve identification and management of functional impairment for older patients in primary care. Broader implementation and evaluation of this intervention is currently underway.

Using multiple qualitative methods to inform intervention development: Improving functional status measurement for older veterans in primary care settings.

Functional status, or the ability to perform activities of daily living, is central to older adults' health and quality of life. However, health systems have been slow to incorporate routine measurement of function into patient care. We used multiple qualitative methods to develop a patient-centered, interprofessional intervention to improve measurement of functional status for older veterans in primary care settings. We conducted semi-structured interviews with patients, clinicians, and operations staff (n = 123) from 7 Veterans Health Administration (VHA) Medical Centers. Interviews focused on barriers and facilitators to measuring function. We used concepts from the Consolidated Framework for Implementation Science and sociotechnical analysis to inform rapid qualitative analyses and a hybrid deductive/inductive approach to thematic analysis. We mapped qualitative findings to intervention components. Barriers to measurement included time pressures, cumbersome electronic tools, and the perception that measurement would not be used to improve patient care. Facilitators included a strong interprofessional environment and flexible workflows. Findings informed the development of five intervention components, including (1) an interprofessional educational session; (2) routine, standardized functional status measurement among older patients; (3) annual screening by nurses using a standardized instrument and follow-up assessment by primary care providers; (4) electronic tools and templates to facilitate increased identification and improved management of functional impairment; and (5) tailored reports on functional status for clinicians and operations leaders. These findings show how qualitative methods can be used to develop interventions that are more responsive to real-world contexts, increasing the chances of successful implementation. Using a conceptually-grounded approach to intervention development has the potential to improve patient and clinician experience with measuring function in primary care.

When Functional Impairment Develops Early: Perspectives from Middle-Aged Adults.

BACKGROUND: Difficulty performing basic daily activities such as bathing and dressing ("functional impairment") affects more than 15% of middle-aged people, and this proportion is increasing. Little is known about the experiences and needs of individuals who develop functional impairment in middle age. OBJECTIVE: To examine the experiences and needs of adults who developed functional impairment in middle age. DESIGN: Qualitative study using semi-structured interviews. PARTICIPANTS: Forty patients aged 50-64 years who developed functional impairment in middle age, recruited from four primary care clinics in San Francisco. APPROACH: Interviews included open-ended questions about participants' daily life, ability to perform activities of daily living (ADLs), and needs related to functional impairment. We analyzed interviews using qualitative thematic analysis. KEY RESULTS: Interviews revealed several themes related to the psychosocial and physical impacts of developing functional impairment in middle age. Participants noted that losses associated with functional impairment, such as loss of independence, control, and social roles, caused conflict in their sense of identity. To cope with these losses, participants used strategies including acceptance, social comparison, adjusting standards, and engaging in valued life activities. Participants reflected on the intersection of their functional impairment with the aging process, noting that their impairments seemed premature compared to the more "natural" aging process in older adults. In terms of physical impacts, participants described how a lack of accommodations in the built environment exacerbated their impairments. While participants used behavioral strategies to overcome these challenges, unmet needs remained, resulting in downstream physical and psychological impacts including safety risks, falls, frustration, and fear. CONCLUSIONS: Unmet psychosocial and physical needs were common among middle-aged adults with functional impairment and led to negative downstream effects. Eliciting and addressing unmet needs may help mitigate downstream health consequences for this growing population, optimizing function and quality of life.

"The More They Know, the Better Care They Can Give": Patient Perspectives on Measuring Functional Status in Primary Care.

BACKGROUND: Despite its importance to care and outcomes for older adults, functional status is seldom routinely measured in primary care. Understanding patient perspectives is necessary to develop effective, patient-centered approaches for measuring function, yet we know little about patient views on this topic. OBJECTIVE: To examine patient and caregiver perspectives on measuring activities of daily living (ADLs) and instrumental ADLs (IADLs). DESIGN: Qualitative study using semi-structured interviews. PARTICIPANTS: Twenty-eight patients aged 65 or older and five caregivers in primary care clinics at one Veterans Affairs Medical Center. APPROACH: We conducted interviews to elicit patient and caregiver perspectives on the importance of measuring function, including preferences for method of screening and assessment, wording of questions, and provider communication style. We analyzed interviews using qualitative thematic analysis. KEY RESULTS: We identified several themes related to measuring function in primary care. First, most participants reported that measuring function is part of quality, holistic care. However, a minority of participants noted that discussing function, especially IADLs, was not medically relevant. Second, in terms of preferences for measuring function, participants noted that interdisciplinary approaches to measuring function are optimal and that face-to-face assessment is most "intimate" and can prompt reflection on one's limitations. However, some participants indicated that self-assessment is less invasive than in-person assessment. Third, participants had varied preferences regarding communicating about function. Participants noted that asking about difficulty with activities versus need for help are distinct and complementary concepts and that providing context is essential when discussing sensitive topics such as functional decline. CONCLUSIONS: Most patients and caregivers reported that measuring function was important, preferred face-to-face assessment, and emphasized the importance of providing context when asking about function. These findings suggest that incorporating patient and caregiver preferences for measuring function can improve satisfaction and experience with functional assessment in primary care.

"We Have a Long Way to Go:" A Case Study Examination of Older Women Veterans' Experiences in VA Primary Care.

Women Veterans are a growing population with complex care needs. While previous research has examined the experiences of women Veterans, little attention has been paid to the specific experiences of older women Veterans. These case studies present the experiences of 2 older women Veterans who have been enrolled in Veterans Affairs (VA) health care for several decades. Results suggest that these older women Veterans have faced gender-specific challenges and barriers throughout their time accessing VA care. The experiences of these participants suggest that they have gender-sensitive needs that are not always addressed by VA primary care and that women's groups are important mechanisms by which they have gained psychological support in a gender-sensitive environment. These cases suggest that access to gender-sensitive services and women-centered spaces are important for these 2 older women Veterans and should be explored in future research.

What Is a Medication-Related Problem? A Qualitative Study of Older Adults and Primary Care Clinicians.

BACKGROUND: Older adults often take multiple medications, leading to a myriad of medication-related problems. Addressing these problems requires thoughtful approaches that align with patients' perspectives and experiences. OBJECTIVE: To (1) identify and categorize medication-related problems from the patient perspective and (2) understand patient and clinician attitudes toward these problems and experiences with addressing these problems. DESIGN: Qualitative, semi-structured interviews with patients and focus groups with physicians and pharmacists. PARTICIPANTS: Twenty older adults recruited from an academic medical center and from a community senior center; 14 primary care physicians and 6 pharmacists affiliated with an academic medical center. APPROACH: Hybrid deductive-inductive thematic analysis. KEY RESULTS: Older adults identified a variety of medication-related problems that could be classified into four broad categories: (1) obtaining medications (e.g., problems with cost and insurance coverage); (2) taking medications (e.g., organization and remembering to take pills); (3) medication effects, including side effects and concerns over lack of effectiveness; and (4) communication and care coordination, including information related to medications. Many of the problems described by older adults were framed within the person's socioemotional context, including the impact of medications on interpersonal relationships, emotional wellbeing, and activities that add meaning and quality to life. In contrast, clinicians almost exclusively focused on discrete medication issues without reference to this larger context and expressed relatively little interest in learning more about their patients' perspectives. CONCLUSIONS: Older adults experience medication-related problems as inseparable from their broader life context. Incorporating the social and emotional context of medications and related communication into a problem-focused framework can guide clinicians in specific actions and interventions to address medication-related problems from the patient perspective.

Making Function Part of the Conversation: Clinician Perspectives on Measuring Functional Status in Primary Care.

OBJECTIVES: Although there is increasing interest in using functional status to guide clinical decision making, function is seldom routinely assessed in primary care. We explored clinician perspectives on barriers and facilitators to routine measurement of older adults' functional status in primary care settings. DESIGN: Qualitative study using semistructured interviews. SETTING: Primary care and geriatrics clinics at six Veterans Affairs Medical Centers. PARTICIPANTS: Twenty-four primary care providers, including 17 from primary care clinics and 7 from geriatrics clinics. MEASUREMENTS: We conducted interviews to elicit clinician perspectives about functional status measurement, including barriers and facilitators to routine assessment. We analyzed transcripts iteratively using a hybrid inductive and deductive thematic approach. RESULTS: Interviews revealed three distinct aspects to measuring function: screening and assessment, documentation, and use of data to inform care. Barriers and facilitators to screening and assessment included time availability, clinic processes, and degree of interdisciplinary environment. Barriers and facilitators to documentation included the usability and integration of electronic instruments into workflows and the availability of a standardized location to document function in the electronic medical record. Barriers and facilitators to use of data included the availability of a standardized location to retrieve data on function, the availability of appropriate referrals and services, and provider knowledge of available resources to address functional impairments. To address these barriers, providers emphasized the critical importance of connecting measurement of function directly to improved patient care. CONCLUSION: Although clinicians emphasized the importance of measuring function, they also cautioned against additional workload burdens, cumbersome electronic documentation, and measurement of function without ensuring that these data are used to improve care. Approaches to functional status measurement must address these barriers to improve care and outcomes for older adults. J Am Geriatr Soc 67:493-502, 2019.