Understanding the implementation and sustainability needs of evidence-based programs for racial and ethnic minoritized older adults in under-resourced communities with limited aging services.

BACKGROUND: Evidence-based programs (EBPs) for older adults effectively improve health outcomes. However, there is a limited understanding of the unique needs of service providers as they consider adopting, implementing, and maintaining programs for older minority adults in low-income communities with limited aging services. METHODS: We conducted semi-structured interviews with key informants of community-based organizations (CBOs) to understand implementation and sustainability needs of CBOs within four racial and ethnically diverse Los Angeles County geographic areas. We performed thematic analysis of interview transcripts. RESULTS: Interviews were conducted with representatives from 25 senior-serving agencies providing aging-related EBPs. CBO representatives reported implementing EBPs in 8 domains: Falls Prevention (68%), Mental Health (64%), Caregiver Health (48%), Chronic Disease Management (48%), Diabetes Management (36%), Arthritis Management (28%), Physical Activity (24%), and Multiple Conditions Management (8%). Themes are presented using the six domains of the Bass and Judge framework for factors impacting successful and sustained EBP implementation. CBOs in low-income and diverse communities described unique challenges with tailoring interventions based on local community context (literacy, language), cultural context, and locally available resources (technology, safe community spaces, transportation) and faced resource-intensive administrative burdens through staff turnover, data collection, sustainable funding, and networking. CONCLUSIONS: Serving racial and ethnic communities has unique challenges that require tailored approaches and additional resources to ensure equitable access to EBPs for all communities. We describe suggestions for enhancing the effective adoption of EBPs among service agencies in under-resourced and diverse aging communities serving populations with aging-related health disparities.

Describing engagement practices for the Enhance Diversity Study using principles of Tailored Panel Management.

The purpose of this chapter is to examine engagement strategies used in a large, multisite evaluation study through the lens of Estrada, Woodcock, and Schultz's (2014) tailored panel management. The evaluation, called the Enhance Diversity Study (EDS), is part of an effort funded by the National Institutes of Health (NIH) to increase diversity in NIH-funded research. The chapter discusses engagement with a large national cohort of student participants and outlines survey administration complexities, tailored engagement approaches, and annual survey response trends. It shows how the EDS expanded Estrada and colleagues' concepts of credibility by integrating branding strategies that permeated all aspects of the study. The resulting practices, as modified over time, extend knowledge of how to increase survey response rates across a multisite, multiprogram, longitudinal evaluation. As data collection continues, subsequent analysis may provide more clarity on the impact of these strategies on retention. Future researchers should explore the impacts of incorporating fully developed branding strategies to enhance study commitment and cohort retention. While past research has guided surveys through phone, mail, and multimodal distribution, more research is needed to understand how to engage participants and retain them in an increasingly competitive and digital world.

Personalized Goal Attainment in Dementia Care: Measuring What Persons with Dementia and Their Caregivers Want.

OBJECTIVES: To develop a process of goal-setting and measurement of goal attainment in a dementia care management program. DESIGN: Observational. SETTING: Dementia care management program in an urban academic medical center. PARTICIPANTS: Persons with dementia (N=101) and their caregivers; nurse practitioner dementia care managers (N=5). INTERVENTION: Specification of a personalized health goal and action plan and measurement of goal attainment using goal attainment scaling in a clinical care visit. MEASUREMENTS: Goal attainment at 6 and 12 months; focus groups of 5 dementia care managers. RESULTS: Eighty-four percent of participant goals were nonmedical, 47% were related to quality of life, and 29% were caregiver support goals. Eighty-eight percent of participants felt that the goal they set was meaningful and 74% that the goal-setting process captured something different from usual care, and 85% found the process helpful in planning for future care. At 6 months, 74% of dyads had achieved or exceeded their expected level of goal attainment. Dementia care managers felt that the goal-setting process improved their understanding of what was most important to the patient, helped set expectations about disease progression and care needs, and provided positive reinforcement when goals were accomplished and an opportunity for revision when goals were not met. CONCLUSION: Goal setting using goal attainment scaling can be incorporated into the care of persons with dementia to establish and attain person-centered goals. Research is needed to further develop personalized goal attainment as an outcome measure for dementia care. J Am Geriatr Soc 66:2120-2127, 2018.

Patient and caregiver goals for dementia care.

PURPOSE: Most health outcome measures for chronic diseases do not incorporate specific health goals of patients and caregivers. To elicit patient-centered goals for dementia care, we conducted a qualitative study using focus groups of people with early-stage dementia and dementia caregivers. METHODS: We conducted 5 focus groups with 43 participants (7 with early-stage dementia and 36 caregivers); 15 participants were Spanish-speaking. Verbatim transcriptions were independently analyzed line-by-line by two coders using both deductive and inductive approaches. Coded texts were grouped into domains and developed into a goal inventory for dementia care. RESULTS: Participants identified 41 goals for dementia care within five domains (medical care, physical quality of life, social and emotional quality of life, access to services and supports, and caregiver support). Caregiver goals included ensuring the safety of the person with dementia and managing caregiving stress. Participants with early-stage dementia identified engaging in meaningful activity (e.g., work, family functions) and not being a burden on family near the end of life as important goals. Participants articulated the need to readdress goals as the disease progressed and reported challenges in goal-setting when goals differed between the person with dementia and the caregiver (e.g., patient safety vs. living independently at home). While goals were similar among English- and Spanish-speaking participants, Spanish-speaking participants emphasized the need to improve community education about dementia. CONCLUSIONS: Patient- and caregiver-identified goals for care are different than commonly measured health outcomes for dementia. Future work should incorporate patient-centered goals into clinical settings and assess their usefulness for dementia care.

Testing the initial efficacy of a mailed screening and brief feedback intervention to reduce at-risk drinking in middle-aged and older adults: the comorbidity alcohol risk evaluation study.

OBJECTIVES: To determine the initial efficacy of a mailed screening and brief intervention to reduce at-risk drinking in persons aged 50 and older. DESIGN: Pilot randomized controlled trial. SETTING: University of California at Los Angeles Department of Medicine Community Offices and Primary Care Network. PARTICIPANTS: Individuals aged 50 and older who were identified as at-risk drinkers according to the Comorbidity Alcohol Risk Evaluation Tool (CARET) (N = 86). INTERVENTION: Participants were assigned randomly to receive personalized mailed feedback outlining their specific risks associated with alcohol use, an educational booklet on alcohol and aging, and the National Institutes of Health Rethinking Drinking: Alcohol and Your Health booklet (intervention group) or nothing (control group). MEASUREMENTS: Alcohol-related assessments at baseline and 3 months; CARET-assessed at-risk drinking, number of risks, and types of risks. RESULTS: At 3 months, fewer intervention group participants than controls were at-risk drinkers (66% vs 88%), binge drinking (45% vs 68%), using alcohol with a medical or psychiatric condition (3% vs 17%), or having symptoms of such a condition (29% vs 49%). CONCLUSION: A brief mailed intervention may be an effective approach to intervening with at-risk drinkers aged 50 and older.

Effect of a falls quality improvement program on serious fall-related injuries.

OBJECTIVES: To determine whether a program that improves the quality of care for falls reduces the number of episodes of care for serious fall-related injuries. DESIGN: Nonrandomized controlled trial. SETTING: Four community-based primary care practices. PARTICIPANTS: Individuals aged 75 and older who screened positive for fall risk. INTERVENTION: A multicomponent quality improvement program (Assessing Care of Vulnerable Elders Practice Redesign for Improved Medical Care for Elders) involving face-to-face clinician education about falls and decision support to prompt primary care providers to implement appropriate care, including referral to appropriate community resources, in response to individuals screening positive for fall risk. MEASUREMENTS: Episodes of care for selected fall-related injuries, based on healthcare claims. RESULTS: Of 1,791 individuals with data available for analysis, 1,187 were in the intervention group, and 604 were in the control group. Mean age was 83, and more than two-thirds of the sample were women. After adjusting for potential confounders, there were no statistically significant differences between intervention and control groups in episodes of care for fall-related injuries during the 12-month (incidence rate ratio (IRR) 1.27, 95% confidence interval (CI) = 0.93-1.73) or 24-month (IRR 1.18, 95% CI = 0.93-1.49) period after initiation of the intervention. CONCLUSION: Despite improving the care of falls, this quality improvement initiative did not result in a change in the number of episodes of care for serious fall-related injuries. Future work in community-based settings should test higher-intensity interventions to reduce fall-related injuries.

Characteristics of older at-risk drinkers who drive after drinking and those who do not drive after drinking.

OBJECTIVE: To describe and compare characteristics of older adults who drive after drinking and those who do not, whether an intervention addressing at-risk drinking reduces risk among those reporting driving after drinking, and reasons reported for driving after drinking. METHODS: Secondary data analysis of a randomized trial testing the efficacy of a multifaceted intervention to reduce at-risk drinking among adults with a mean age of 68 years in primary care (N = 631). RESULTS: Almost a quarter of at-risk drinkers reported driving after drinking (N = 154). Compared to those who did not drive after drinking, those who did were more likely to be younger, male, and working. They consumed a higher average number of drinks per week, had more reasons they were considered at-risk drinkers, and were more likely to meet at-risk drinking criteria due to amount of drinking and binge drinking. Those driving after drinking at baseline reduced the frequency of this behavior at 3 and 12 months and there were no statistically significant differences in the proportions of persons still engaging in driving after drinking among those who were assigned to intervention or control groups. Reasons for driving after drinking included not thinking that it was a problem and having to get home. CONCLUSIONS: Driving after drinking is common in this population of older, at-risk drinkers recruited in primary care settings and, like younger adults, men and those reporting binge drinking are more likely to engage in this behavior. Given that this behavior is dangerous and the population of older adults is fast growing, interventions addressing driving after drinking are needed.

Why do older unhealthy drinkers decide to make changes or not in their alcohol consumption? Data from the Healthy Living as You Age study.

OBJECTIVES: To understand characteristics of older at-risk drinkers and reasons why they decide to change or maintain their alcohol consumption. DESIGN: Secondary analysis of data from a randomized controlled trial to reduce drinking in at-risk drinkers. SETTING: Three primary care sites in southern California. PARTICIPANTS: Six hundred thirty-one adults aged 55 and older who were at-risk drinkers at baseline, 521 of whom who completed a 12-month assessment. MEASUREMENTS: Sociodemographic and alcohol-related characteristics of 12-month assessment completers and noncompleters and among those completing the 12-month assessment by telephone or mail were compared using descriptive statistics. Reasons why respondents maintained or changed average alcohol consumption were asked of those who completed a 12-month assessment by telephone. Factors that might motivate at-risk drinkers to reduce drinking were asked about, and frequencies were calculated for these responses. RESULTS: Participants were primarily male, white, highly educated, and in good health. Those who responded to the 12-month assessment by mail were more likely to be working, to be in the intervention arm, and to drink more. Most who reduced alcohol consumption and heavy drinking did so because they thought it would benefit them. Those who did not thought that drinking was not a problem for them. Both groups cited their environment and circumstances as influencing their drinking. Remaining at-risk drinkers reported that medical evidence that alcohol was harming them would motivate them to reduce drinking. CONCLUSION: Older adults report that they reduce their drinking when they recognize that their drinking habits may be causing them harm; one's environment can hinder or help one to reduce drinking.

Effect of nurse practitioner comanagement on the care of geriatric conditions.

OBJECTIVES: To determine whether community-based primary care physician (PCP)-nurse practitioner (NP) comanagement implementing the Assessing Care of Vulnerable Elders (ACOVE)-2 model: (case finding, delegation of data collection, structured visit notes, physician and patient education, and linkage to community resources) can improve the quality of care for geriatric conditions. DESIGN: Case study. SETTING: Two community-based primary care practices. PARTICIPANTS: Patients aged 75 and older who screened positive for at least one condition: falls, urinary incontinence (UI), dementia, and depression. INTERVENTION: The ACOVE-2 model augmented by NP comanagement of conditions. MEASUREMENTS: Quality of care according to medical record review using ACOVE-3 quality indicators (QIs). Individuals receiving comanagement were compared with those who received PCP care alone in the same practices. RESULTS: Of 1,084 screened individuals, 658 (61%) screened positive for more than one condition; 485 of these were randomly selected for chart review and triggered a mean of seven QIs. A NP saw 49% for comanagement. Overall, individuals received 57% of recommended care. Quality scores for all conditions (falls, 80% vs 34%; UI, 66% vs 19%; dementia, 59% vs 38%) except depression (63% vs 60%) were higher for individuals who saw a NP. In analyses adjusted for sex and age of patient, number of conditions, site, and a NP estimate of medical management style, NP comanagement remained significantly associated with receiving recommended care (P < .001), as did NP estimate of medical management style (P = .02). CONCLUSION: NP comanagement is associated with better quality of care for geriatric conditions in community-based primary care than usual care using the ACOVE-2 model.

Primary care-based intervention to reduce at-risk drinking in older adults: a randomized controlled trial.

AIMS: To examine whether a multi-faceted intervention among older at-risk drinking primary care patients reduced at-risk drinking and alcohol consumption at 3 and 12 months. DESIGN: Randomized controlled trial. SETTING: Three primary care sites in southern California. PARTICIPANTS: Six hundred and thirty-one adults aged ≥ 55 years who were at-risk drinkers identified by the Comorbidity Alcohol Risk Evaluation Tool (CARET) were assigned randomly between October 2004 and April 2007 during an office visit to receive a booklet on healthy behaviors or an intervention including a personalized report, booklet on alcohol and aging, drinking diary, advice from the primary care provider and telephone counseling from a health educator at 2, 4 and 8 weeks. MEASUREMENTS: The primary outcome was the proportion of participants meeting at-risk criteria, and secondary outcomes were number of drinks in past 7 days, heavy drinking (four or more drinks in a day) in the past 7 days and risk score. FINDINGS: At 3 months, relative to controls, fewer intervention group participants were at-risk drinkers [odds ratio (OR) 0.41; 95% confidence interval (CI) 0.22-0.75]; they reported drinking fewer drinks in the past 7 days [rate ratio (RR) 0.79; 95% CI 0.70-0.90], less heavy drinking (OR 0.46; 95% CI 0.22-0.99) and had lower risk scores (RR 0.77 95% CI 0.63-0.94). At 12 months, only the difference in number of drinks remained statistically significant (RR 0.87; 95% CI 0.76-0.99). CONCLUSIONS: A multi-faceted intervention among older at-risk drinkers in primary care does not reduce the proportions of at-risk or heavy drinkers, but does reduce amount of drinking at 12 months.

Do health educator telephone calls reduce at-risk drinking among older adults in primary care?

BACKGROUND: Alcohol screening and brief intervention for unhealthy alcohol use has not been consistently delivered in primary care as part of preventive healthcare. OBJECTIVE: To explore whether telephone-based intervention delivered by a health educator is efficacious in reducing at-risk drinking among older adults in primary care settings. DESIGN: Secondary analyses of data from a randomized controlled trial. PARTICIPANTS: Subjects randomized to the intervention arm of the trial (n = 310). INTERVENTIONS: Personalized risk reports, advice from physicians, booklet about alcohol and aging, and up to three telephone calls from a health educator. All interventions were completed before the three-month follow-up. MEASUREMENTS: Risk outcomes (at-risk or not at-risk) at 3 and 12 months after enrollment. MAIN RESULTS: In univariate analyses, compared to those who remained at risk, those who achieved not at-risk outcome at 3 months were more likely to be women, Hispanic or non-white, have lower levels of education, consume less alcohol, drink less frequently, and have lower baseline number of risks. In mixed-effects logistic regression models, completing all three health educator calls increased the odds of achieving not at-risk outcome compared to not completing any calls at 3 months (OR 5.31; 95% CI 1.92-14.7; p = 0.001), but not at 12 months (OR 2.01; 95% CI 0.71-5.67; p = 0.18). CONCLUSIONS: Telephone-based intervention delivered by a health educator was moderately efficacious in reducing at-risk drinking at 3 months after enrollment among older adults receiving a multi-faceted intervention in primary care settings; however, the effect was not sustained at 12 months.