A Strategy for Identifying and Disseminating Best Practice Innovations in the Care of Patients with Multiple Chronic Conditions or End-of-Life Care Needs.

Patients with multiple chronic conditions and those with end-of-life care needs experience high health care costs and needs for skilled coordination and well-trained staff. Focusing on these populations presents an opportunity to improve the patient experience toward the goal of more patient-centered care and reduced costs. Although innovative programs that provide better care to these patient populations have been developed, these innovations are often localized and not actively disseminated to other settings. This paper describes a quality-improvement project aimed at developing a process to identify best practices implemented in community-based clinical settings, develop a platform to share and disseminate these best practices, and facilitate the adoption of successful practices across other similar settings. The facilitation process involved structured coaching by clinicians and researchers experienced with practice change and quality improvement. The coaching component ensured that implementation teams receive guidance in the planning and adoption process, stay on track with implementation, and have access to timely support in addressing unanticipated barriers.

Dementia and Falls Management in Underserved Populations: The Cognition and Mobility Care Management Program.

BACKGROUND/OBJECTIVES: Cognitive and mobility impairments are common and underdiagnosed chronic conditions that afflict community-dwelling older adults. This study describes the organization, implementation, and evaluation of an intervention for underserved and ethnically diverse older patients with dementia and/or falls risk. DESIGN: Observation, baseline and 1 year after intervention. SETTING: Community-based primary care county clinics in inland southern California. PARTICIPANTS: A total of 272 persons, aged 70 years and older, who screened positive for falls and/or dementia and enrolled in the Cognition and Mobility Care Management program during the study period. INTERVENTION: A nurse care manager performed a patient and caregiver evaluation and created and implemented a care plan with medical, behavioral, and psychosocial interventions in partnership with patients and their primary care providers. MEASUREMENTS: Process outcomes included rates of positive screening for dementia and fall risk, referral, enrollment, and visit completion. Patient outcomes included fall history, mobility and cognitive assessments, and depression scales. Patients and/or caregivers completed questionnaires rating perceived benefits of enrollment after 1 year in the program. RESULTS: Medical assistants screened 573 patients aged 70 years and older during the study period; 78% screened positive for dementia and/or fall risk. Of the patients who screened positive, 94% were referred; 91% of contacted patients elected to enroll, and 272 patients completed an intake visit (meanage = 77 years; 65% female; 75% Latino; 10% African American). The patients and caregivers who completed satisfaction questionnaires 1 year after enrollment rated the program highly, and 92% would recommend the program to others. CONCLUSION: A primary care-based screening and comanagement program to identify and manage dementia and falls risk in primarily Latino and African American older adult patients living in an underserved area was well received, with high satisfaction and perceived benefit from patients and caregivers.

Geriatric Workforce Development for the Underserved: Using RCQI Methodology to Evaluate the Training of IHSS Caregivers.

Caregivers play an important role in the in-home care of community dwelling older adults living with Alzheimer's disease or related dementias (ADRD); however, many of these caregivers lack training in caring for this vulnerable population. In 2015, we developed and implemented an interactive, community-based, knowledge and skills-based training program for In-Home Supportive Services (IHSS) caregivers. This report shares the results of a process evaluation of this training program as it evolved over the course of three training sessions in Riverside County, California. Our iterative evaluation process reveals the unique needs of training and assessing a population of demographically diverse adult learners and provides guidance for those planning to implement similar training in underserved communities. Factors such as reliance on self-reported abilities, language readability level, and test anxiety may have confounded attempts to capture learner feedback and actual knowledge gains from our caregiver training program.

Training for In-Home Supportive Services Caregivers in an Underserved Area.

Despite the complexity of care associated with older adults who have been diagnosed with Alzheimer's disease and related dementias, many in-home paid caregivers receive little to no training in competent care for these older adults. The In-Home Supportive Services program in California provides care for elderly, blind, and disabled people with the goal of ensuring the care recipients may remain safely in their own homes. Yet, these caregivers are not required to receive training in any specific disease or condition prior to providing caregiving services. A Geriatrics Workforce Enhancement Program and the Riverside County Department of Social Services jointly developed and implemented three different interactive, community-based, knowledge and skills-based training courses for IHSS caregivers. Analysis of pre/post course evaluations across all three courses demonstrated statistically significant gains in knowledge and self-rated skills among the participants.

Team-Based Interprofessional Competency Training for Dementia Screening and Management.

As many as 50% of people satisfying diagnostic criteria for dementia are undiagnosed. A team-based training program for dementia screening and management was developed targeting four professions (medicine, nursing, pharmacy, social work) whose scope of practice involves dementia care. An interprofessional group of 10 faculty members was trained to facilitate four interactive competency stations on dementia screening, differential diagnoses, dementia management and team care planning, and screening for and managing caregiver stress. Registrants were organized into teams of five members, with at least one member of each profession per team. The teams rotated through all stations, completing assigned tasks through interprofessional collaboration. A total of 117 professionals (51 physicians, 11 nurses, 20 pharmacists, 24 social workers, 11 others) successfully completed the program. Change scores showed significant improvements in overall competence in dementia assessment and intervention (very low = 1; very high = 5; average change 1.12, P < .001), awareness of importance of dementia screening (average change 0.85, P < .001), and confidence in managing medication (average change 0.86, P < .001). Eighty-seven participants (82.9%) reported feeling confident or very confident using the dementia toolkit at their home institution. In a survey administered 3 months after the session, 48 respondents reported that they had changed their approach to administering the Mini-Cog test (78%), differential diagnosis (49%), assessment of caregiver stress (74%), and accessing community support and services (69%). In conclusion, team-based interprofessional competency training is a team teaching model that can be used to enhance competency in dementia screening and management in medical, nursing, pharmacy, and social work practitioners.

Cost Analysis and Policy Implications of a Pediatric Palliative Care Program.

CONTEXT: In 2010, California launched Partners for Children (PFC), a pediatric palliative care pilot program offering hospice-like services for children eligible for full-scope Medicaid delivered concurrently with curative care, regardless of the child's life expectancy. OBJECTIVES: We assessed the change from before PFC enrollment to the enrolled period in 1) health care costs per enrollee per month (PEPM), 2) costs by service type and diagnosis category, and 3) health care utilization (days of inpatient care and length of hospital stay). METHODS: A pre-post analysis compared enrollees' health care costs and utilization up to 24 months before enrollment with their costs during participation in the pilot, from January 2010 through December 2012. Analyses were conducted using paid Medicaid claims and program enrollment data. RESULTS: The average PEPM health care costs of program enrollees decreased by $3331 from before their participation in PFC to the enrolled period, driven by a reduction in inpatient costs of $4897 PEPM. PFC enrollees experienced a nearly 50% reduction in the average number of inpatient days per month, from 4.2 to 2.3. Average length of stay per hospitalization dropped from an average of 16.7 days before enrollment to 6.5 days while in the program. CONCLUSION: Through the provision of home-based therapeutic services, 24/7 access to medical advice, and enhanced, personally tailored care coordination, PFC demonstrated an effective way to reduce costs for children with life-limiting conditions by moving from costly inpatient care to more coordinated and less expensive outpatient care. PFC's home-based care strategy is a cost-effective model for pediatric palliative care elsewhere.

A Practice Improvement Education Program Using a Mentored Approach to Improve Nursing Facility Depression Care-Preliminary Data.

Depression is common in nursing facility residents. Depression data obtained using the Minimum Data Set (MDS) 3.0 offer opportunities for improving diagnostic accuracy and care quality. How best to integrate MDS 3.0 and other data into quality improvement (QI) activity is untested. The objective was to increase nursing home (NH) capability in using QI processes and to improve depression assessment and management through focused mentorship and team building. This was a 6-month intervention with five components: facilitated collection of MDS 3.0 nine-item Patient Health Questionnaire (PHQ-9) and medication data for diagnostic interpretation; education and modeling on QI approaches, team building, and nonpharmacological depression care; mentored team meetings; educational webinars; and technical assistance. PHQ-9 and medication data were collected at baseline and 6 and 9 months. Progress was measured using team participation measures, attitude and care process self-appraisal, mentor assessments, and resident depression outcomes. Five NHs established interprofessional teams that included nursing (44.1%), social work (20.6%), physicians (8.8%), and other disciplines (26.5%). Members participated in 61% of eight offered educational meetings (three onsite mentored team meetings and five webinars). Competency self-ratings improved on four depression care measures (P = .05 to <.001). Mentors observed improvement in team process and enthusiasm during team meetings. For 336 residents with PHQ-9 and medication data, depression scores did not change while medication use declined, from 37.2% of residents at baseline to 31.0% at 9 months (P < .001). This structured mentoring program improved care processes, achieved medication reductions, and was well received. Application to other NH-prevalent syndromes is possible.

Intergenerational Support and the Emotional Well-being of Older Jews and Arabs in Israel.

This investigation examined the cultural context of intergenerational support among older Jewish and Arab parents living in Israel. The authors hypothesized that support from adult children would be more positively consequential for the psychological well-being of Arab parents than of Jewish parents. The data derived from 375 adults age 65 and older living in Israel. Psychological well-being was measured with positive and negative affect subscales of the Positive and Negative Affect Schedule. Overall, positive affect was highest when filial expectations for support were congruent with whether or not instrumental support was received. Findings by cultural background revealed that, among older Jews, receiving instrumental support raised positive affect and stronger filial expectations lowered it. Among older Arabs, receiving financial support raised positive affect and receiving instrumental support lowered it. Culture appears to serve as a potent force in determining which types of intergenerational support functions are expected and accepted means of serving the everyday needs of older parents.

Beyond solidarity, reciprocity and altruism: moral capital as a unifying concept in intergenerational support for older people.

The purpose of this article is to review, contrast and synthesise several major intellectual streams that have guided theoretical development and empirical research in the area of intergenerational family support to older people: (a) normative-integrative approaches that focus on cohesion between family members based on bonds of solidarity and norms of filial obligation, and (b) transactional approaches that are primarily concerned with identifying motives for resource transfers across generational lines. We propose the concept of moral capital - defined as the stock of internalised social norms that obligate children to care for and support their older parents - the transmission of which lies at the intersection of self-interest (for parents) and altruism (for children). Using data from a multigenerational family study, we present an empirical analysis showing that a strong positive correspondence in the filial obligations of adult children and their older mothers - arguably the result of intergenerational transmission - elevated the supportive behaviour of children. We suggest that moral capital may be a useful unifying concept that bridges disciplinary and theoretical divides in the study of intergenerational transfers to elderly people by helping resolve the paradox of how self-interest and selflessness can co-exist within families.

Nonmedical interventions for children with ASD: recommended guidelines and further research needs.

OBJECTIVE: To use the findings of a systematic review of scientific evidence to develop consensus guidelines on nonmedical interventions that address cognitive function and core deficits in children with autism spectrum disorders (ASDs) and to recommend priorities for future research. METHODS: The guidelines were developed by a Technical Expert Panel (TEP) consisting of practitioners, researchers, and parents. A systematic overview of research findings was presented to the TEP; guideline statements were drafted, discussed, debated, edited, reassessed, and presented for formal voting. RESULTS: The strength of evidence of efficacy varied by intervention type from insufficient to moderate. There was some evidence that greater intensity of treatment (hours per week) and greater duration (in months) led to better outcomes. The TEP agreed that children with ASD should have access to at least 25 hours per week of comprehensive intervention to address social communication, language, play skills, and maladaptive behavior. They agreed that applied behavioral analysis, integrated behavioral/developmental programs, the Picture Exchange Communication System, and various social skills interventions have shown efficacy. Based on identified gaps, they recommend that future research focus on assessment and monitoring of outcomes, addressing the needs of pre/nonverbal children and adolescents, and identifying the most effective strategies, dose, and duration to improve specific core deficits. CONCLUSIONS: The creation of treatment guidelines and recommendations for future research represents an effort by leading experts to improve access to services for children with ASDs while acknowledging that the research evidence has many gaps.

Better outcomes, lower costs: palliative care program reduces stress, costs of care for children with life-threatening conditions.

This policy brief examines the Partners for Children (PFC) program--California's public pediatric community-based palliative care benefit to children living with life-threatening conditions and their families. Preliminary analysis of administrative and survey data indicates that participation in the PFC program improves quality of life for the child and family. In addition, participation in the program resulted in a one-third reduction in the average number of days spent in the hospital. Shifting care from a hospital setting to in-home community-based care resulted in cost savings of $1,677 per child per month on average--an 11% decrease in spending on a traditionally high-cost population. As the three-year pilot program draws to an end, policymakers are considering the advisability of extending the program beyond the 11 counties that now participate. This policy brief provides recommendations that policymakers, families and advocates should consider to ensure sustainability and successful expansion of the program

Proposed regulations could limit access to affordable health coverage for workers' children and family members.

Key Findings. The Patient Protection and Affordable Care Act (ACA) is designed to offer premium subsidies to help eligible individuals and their families purchase insurance coverage when affordable job-based coverage is not available. However, the law is unclear on how this affordability protection is applied in those instances where self-only coverage offered by an employer is affordable but family coverage is not. Regulations recently proposed by the Department of the Treasury would make family members ineligible for subsidized coverage in the exchange if an employee is offered affordable self-only coverage by an employer, even if family coverage is unaffordable. This could have significant financial consequences for low- and moderate-income families that fall in this gap. Using an alternative interpretation of the law could allow the entire family to enter the exchange when family coverage is unaffordable, which would broaden access to coverage. However, this option has been cited as cost prohibitive. In this brief we consider a middle ground alternative that would base eligibility for the individual worker on the cost of self-only coverage, but would use the additional cost to the employee for family coverage as the basis for determining affordability and eligibility for subsidies for the remaining family members. We find that: Under the middle ground alternative scenario an additional 144,000 Californians would qualify for and use premium subsidies in the California Health Benefit Exchange, half of whom are children. Less than 1 percent of those with employer-based coverage would move to subsidized coverage in the California Health Benefit Exchange as a result of having unaffordable coverage on the job.

Older Parent - Child Relationships in Six Developed Nations: Comparisons at the Intersection of Affection and Conflict.

Intergenerational solidarity and ambivalence paradigms suggest that emotional relationships between generations consist of both positive and negative sentiments. We applied latent class analysis to measures of affection and conflict in 2,698 older parent - child relationships in 6 developed nations: England, Germany, Israel, Norway, Spain, and the United States (Southern California). The best fitting model consisted of 4 latent classes distributed differently across nations but with a cross-nationally invariant measurement structure. After controlling for demographics, health, coresidence, contact, and support, the following classes were overrepresented in corresponding nations: amicable (England), detached (Germany and Spain), disharmonious (United States), ambivalent (Israel). We discuss policy and cultural differences across societies that may explain why the prevalence of particular emotional types varied by nation.