Discharge Information and Support for Patients Discharged from the Emergency Department: Results from a Randomized Controlled Trial.

BACKGROUND: Little research has been done on primary care-based models to improve health care use after an emergency department (ED) visit. OBJECTIVE: To examine the effectiveness of a primary care-based, nurse telephone support intervention for Veterans treated and released from the ED. DESIGN: Randomized controlled trial with 1:1 assignment to telephone support intervention or usual care arms (ClinicalTrials.gov: NCT01717976). SETTING: Department of Veterans Affairs Health Care System (VAHCS) in Durham, NC. PARTICIPANTS: Five hundred thirteen Veterans who were at high risk for repeat ED visits. INTERVENTION: The telephone support intervention consisted of two core calls in the week following an ED visit. Call content focused on improving the ED to primary care transition, enhancing chronic disease management, and educating Veterans and family members about VHA and community services. MAIN MEASURES: The primary outcome was repeat ED use within 30 days. KEY RESULTS: Observed rates of repeat ED use at 30 days in usual care and intervention groups were 23.1% and 24.9%, respectively (OR = 1.1; 95% CI = 0.7, 1.7; P = 0.6). The intervention group had a higher rate of having at least 1 primary care visit at 30 days (OR = 1.6, 95% CI = 1.1-2.3). At 180 days, the intervention group had a higher rate of usage of a weight management program (OR = 3.5, 95% CI = 1.6-7.5), diabetes/nutrition (OR = 1.8, 95% CI = 1.0-3.0), and home telehealth services (OR = 1.7, 95% CI = 1.0-2.9) compared with usual care. CONCLUSIONS: A brief primary care-based nurse telephone support program after an ED visit did not reduce repeat ED visits within 30 days, despite intervention participants' increased engagement with primary care and some chronic disease management services. TRIALS REGISTRATION: ClinicalTrials.gov NCT01717976.

The Effect of Support and Training for Family Members on Access to Outpatient Services for Veterans with Posttraumatic Stress Disorder (PTSD).

The VA Program of Comprehensive Assistance for Family Caregivers (PCAFC) provides landmark support for family caregivers of post-9/11 veterans. This study examines PCAFC support for veterans with and without PTSD and assesses whether program effect differs by PTSD status using a pre-post, non-equivalent, propensity score weighted comparison group design (n = 24,280). Veterans with and without PTSD in PCAFC accessed more mental health, primary, and specialty care services than weighted comparisons. PCAFC participation had stronger effects on access to primary care for veterans with PTSD than for veterans without PTSD. For veterans with PTSD, PCAFC support might enhance health service use.

Comprehensive primary care for older patients with multiple chronic conditions: "Nobody rushes you through".

Older patients with multiple chronic health conditions and complex health care needs often receive care that is fragmented, incomplete, inefficient, and ineffective. This article describes the case of an older woman whose case cannot be managed effectively through the customary approach of simply diagnosing and treating her individual diseases. Based on expert consensus about the available evidence, this article identifies 4 proactive, continuous processes that can substantially improve the primary care of community-dwelling older patients who have multiple chronic conditions: comprehensive assessment, evidence-based care planning and monitoring, promotion of patients' and (family caregivers') active engagement in care, and coordination of professionals in care of the patient--all tailored to the patient's goals and preferences. Three models of chronic care that include these processes and that appear to improve some aspects of the effectiveness and the efficiency of complex primary care--the Geriatric Resources for Assessment and Care of Elders (GRACE) model, Guided Care, and the Program of All-inclusive Care for the Elderly (PACE)--are described briefly, and steps toward their implementation are discussed.

New Variations on the Theme of Multidimensional Geriatric Assessment.

Geriatric assessment-broadly defined-has become foundational to systems of care for frail elderly people at risk for functional decline, death, intensification of services, and long-term institutionalization [...].

Connecting Caregivers to Support: Lessons Learned From the VA Caregiver Support Program.

Development and evaluation of supportive caregiver interventions has become a national priority. This study's aim was to evaluate how caregivers participating in the Department of Veterans Affairs (VA) Caregiver Support Program (CSP) use and value supportive services. Qualitative semi-structured interviews (N = 50 caregivers) were the core of a mixed-methods design, and surveys (N = 160) were supplemental. Caregivers who had used CSP services valued emotional, functional, and health care navigational support, calling support groups and the program coordinator their "lifeline." However, many described a lack of connection with the program-not knowing about or successfully engaging in program services-and needed more information about available resources. Caregivers in rural areas or caring for individuals with specific diseases reported needing tailored services to meet their unique needs. Policy makers and practitioners should proactively promote supportive services for caregivers. Future research should explore strategies for reducing barriers to accessing tailored support to meet the needs of a diverse caregiver population.

Invisible partners in care: Snapshot of well-being among caregivers receiving comprehensive support from Veterans Affairs.

BACKGROUND AND AIMS: Since May 2011, over 23 000 caregivers of Veterans seriously injured on or after September 11, 2001 have enrolled in the Program of Comprehensive Assistance for Family Caregivers (PCAFC). PCAFC provides caregivers training, a stipend, and access to health care. The aim of this study is to describe the characteristics of caregivers in PCAFC and examine associations between caregiver characteristics and caregiver well-being outcomes. METHODS: We sent a web survey invitation to 10 000 PCAFC caregivers enrolled as of September 2015. Using linear and logistic regressions, we examine associations between PCAFC caregiver characteristics and caregiver outcomes: perceived financial strain, depressive symptoms (Center for Epidemiologic Studies Depression Scale [CESD-10]), perceived quality of Veteran's Veterans Health Administration (VHA) care, and self-reported caregiver health. RESULTS: We had complete survey data for 899 respondents. Since becoming a caregiver, approximately 50% of respondents reported reducing or stopping work. Mean time spent providing care was 3.8 years (median 3, IQR 1-5) with an average of 4.9 weekdays (median 5, IQR 5-5) and 1.9 weekend days (median 2, IQR 2-2). The mean CESD-10 score was 8.2 (median 7, 4-12), at the cutoff for screening positive for depressive symptoms. A longer duration of caregiving was associated with having 0.08 increase in rating of financial strain (95% CI, 0.02-0.14). Caregiver rating of the Veteran's health status as "fair" or better was a strong predictor of better caregiver outcomes, ie, self-reported caregiver health. However, higher levels of education were associated with worse caregiver outcomes, ie, lower global satisfaction with VHA care, higher CESD-10 score, and higher rating of financial strain. CONCLUSIONS: Higher depressive symptoms among longer duration caregivers, coupled with high rates of reductions in hours worked, suggest interventions are needed to address the long-term emotional and financial needs of these caregivers of post-9/11 Veterans and identify subpopulations at risk for worse outcomes.

The middle of the road: results from the aging semantic differential with four cohorts of medical students.

OBJECTIVES: To explore the presence of negative stereotypical attitudes among medical students and the extent to which attitudes changed over time. DESIGN: Analysis of pre- and postexperience administration of attitude measures to four cohorts of medical students (two cohorts as quasi-controls and two cohorts as curriculum "treatment" groups). SETTING: The curriculum of a community-based medical school in the United States. PARTICIPANTS: Four sequential cohorts of medical students. INTERVENTION: Experience in a required comprehensive vertically integrated curriculum. MEASUREMENTS: The Aging Semantic Differential (ASD), using an 85-year-old woman as the cue image. RESULTS: The reliability scores for all administrations were acceptable. The two control cohorts demonstrated no change in attitude scores, whereas the treatment cohorts reflected a slight shift toward more-positive scores. However, all cohorts had scores for all sittings that were in the neutral range; on average students routinely scored 70% of the 32 items neither positively nor negatively. CONCLUSION: These students seemed not to hold negative stereotypes as measured using the ASD. Although two of the 32 items prompted negative stereotyping, and six items elicited positive stereotyping, attitudes were neutral about older adults. Characteristics of the ASD itself or of the response set used in this study may have affected the results.

From bedside to bench: research in comorbidity and aging.

As their patients age, clinicians are increasingly confronted with diseases, impairments, or conditions that complicate the diagnosis and treatment of index diseases and with the management challenge of the overall burden of morbidity in their patients. Nevertheless, there has been little applicable conceptual work and empirical research on the nature, impact, and management of comorbid and multiple morbid conditions. Advancing research in this area has been the goal of a recent National Institute on Aging Task Force on Comorbidity Research Issues, as well as a working conference of the American Geriatrics Society. Both efforts highlighted current knowledge and thinking about comorbidity in the context of caring for an aging population, in preparation for research ultimately leading to better understanding of comorbidity and improvement in clinical practice. This Perspective provides a brief overview of these developments.

The national evaluation of senior mentor programs: older adults in medical education.

OBJECTIVES: To identify models for senior mentor programs (SMPs), critical factors in program development, achievement of goals and objectives, effect on medical school environment, and future of programs. DESIGN: Ten SMPs were systematically selected to represent a variety of medical schools, geographic regions, and program types. The National Senior Mentor Program Evaluation relied upon archived data within the programs and new data collected during site visits. Archived data included internally conducted program evaluations, student course evaluations, and survey and focus group results. Site visit data were collected from key informant interviews with program staff and faculty, medical school leadership and students, and older adults serving as mentors. SETTING: Ten U.S. medical schools with SMPs. PARTICIPANTS: Evaluation participants at each site included program faculty, key medical school administrators, participating students, and mentors. MEASUREMENTS: Program evaluation. RESULTS: All 10 programs demonstrated a positive effect on student attitudes toward older adults. Student acceptance of the programs was strong, and mentor acceptance and support were extraordinary. Eight of the 10 programs were operating in 2008 and having considerable effect on medical school environments. Most of the operating programs expect to be continuing for 5 or more years into the future. CONCLUSIONS: The findings of the national evaluation point toward continuation and likely growth of the senior mentor phenomenon in U.S. medical education.