Implementation and Evaluation of a mHealth-Based Community Health Worker Feedback Loop for Hispanics with and at Risk for Diabetes.

BACKGROUND: Gaps in accessibility and communication hinder diabetes care in poor communities. Combining mobile health (mHealth) and community health workers (CHWs) into models to bridge these gaps has great potential but needs evaluation. OBJECTIVE: To evaluate a mHealth-based, Participant-CHW-Clinician feedback loop in a real-world setting. DESIGN: Quasi-experimental feasibility study with intervention and usual care (UC) groups. PARTICIPANTS: A total of 134 participants (n = 67/group) who were all low-income, uninsured Hispanics with or at-risk for type 2 diabetes. INTERVENTION: A 15-month study with a weekly to semimonthly mHealth Participant-CHW-Clinician feedback loop to identify participant issues and provide participants monthly diabetes education via YouTube. MAIN MEASURES: We used pre-defined feasibility measures to evaluate our intervention: (a) implementation, the execution of feedback loops to identify and resolve participant issues, and (b) efficacy, intended effects of the program on clinical outcomes (baseline to 15-month HbA1c, systolic blood pressure (SBP), diastolic blood pressure (DBP), and weight changes) for each group and their subgroups (at-risk; with diabetes, including uncontrolled (HbA1c ≥ 7%)). KEY RESULTS: CHWs identified 433 participant issues (mean = 6.5 ± 5.3) and resolved 91.9% of these. Most issues were related to supplies, 26.3% (n = 114); physical health, 23.1% (n = 100); and medication access, 20.8% (n = 90). Intervention participants significantly improved HbA1c (- 0.51%, p = 0.03); UC did not (- 0.10%, p = 0.76). UC DBP worsened (1.91 mmHg, p < 0.01). Subgroup analyses revealed HbA1c improvements for uncontrolled diabetes (intervention: - 1.59%, p < 0.01; controlled: - 0.72, p = 0.03). Several variables for UC at-risk participants worsened: HbA1c (0.25%, p < 0.01), SBP (4.05 mmHg, p < 0.01), DBP (3.21 mmHg, p = 0.01). There were no other significant changes for either group. CONCLUSIONS: A novel mHealth-based, Participant-CHW-Clinician feedback loop was associated with improved HbA1c levels and identification and resolution of participant issues. UC individuals had several areas of clinical deterioration, particularly those at-risk for diabetes, which is concerning for progression to diabetes and disease-related complications. CLINICAL TRIAL: NCT03394456, accessed at https://clinicaltrials.gov/ct2/show/NCT03394456.

Patterns of Telehealth Use for Mental Health Treatment Among Hispanic Veterans.

Background: Video-to-home telehealth (VTH) is promising for increasing access to mental health (MH) services. VA Video Connect (VVC) facilitates video-based teleconferencing between patients and providers and can reduce barriers while maintaining clinical effectiveness. Little is known about the preferences of Hispanic veterans for VTH. Methods: A retrospective cohort investigation of VTH for MH care utilization among veterans having at least one MH visit from October 2019 to September 2020. The veterans consisted of 155,492 Hispanic/Latino and 1,544,958 non-Hispanic/Latino. VVC involved face-to-face synchronous video-based teleconferencing between patients and providers, enabling care at home or another private location. The main measures included the percentage of MH encounters delivered through VVC. Results: Compared with non-Hispanic veterans, Hispanic veterans had 3.28% greater percentage of VVC MH encounters. Furthermore, there was a 2.65% increase per month in percentage of VVC MH encounters. Conclusions: Contrary to preconceived notions, Hispanic veterans access VTH at higher rates than their non-Hispanic counterparts.

Outcomes from an interprofessional, dementia-focused, telementoring program: a brief report.

Despite a burgeoning older-adult population, the number of health-care professionals with geriatric expertise continues to lag behind. In 2014, the American Geriatrics Society's position statement encouraged interprofessional training for health-care professionals. Telementoring remotely connects clinicians with specialists for education and group mentoring. This dementia-focused, 11-month, 1-hour each, telementoring program was modeled on the Alzheimer's Association ECHO. Our interprofessional expert panel consisted of a geriatrician, a geriatric psychiatrist, an adult nurse practitioner (with geriatric expertise), two geriatric pharmacists, a licensed social worker (coordinating a dementia day program), and a project coordinator. Learners were residents in family medicine and general psychiatry, physician assistant residents in mental health and geriatric psychiatry fellows (total = 31). There was a significant improvement in learner intentions to change medication prescribing by midpoint assessment (p = 0.04). Learners reported few barriers to incorporating skills they learned. An interprofessional telementoring program can help nongeriatric practitioners improve skills in caring for older adults.

Long-Term Effectiveness of the TIME Intervention to Improve Diabetes Outcomes in Low-Income Settings: a 2-Year Follow-Up.

BACKGROUND: We previously found that a 6-month multidimensional diabetes program, TIME (Telehealth-Supported, Integrated Community Health Workers, Medication-Access) resulted in improved clinical outcomes. OBJECTIVE: To follow TIME participant clinical outcomes for 24 months PARTICIPANTS: Low-income Latino(a)s with type 2 diabetes DESIGN AND INTERVENTION: We collected post-intervention clinical data for five cohorts (n = 101, mean n = 20/cohort) who participated in TIME programs from 2018 to 2020 in Houston, Texas. MAIN MEASURES: We gathered HbA1c (primary outcome), weight, body mass index (BMI), and blood pressure data at baseline, 6 months (intervention end), and semiannually thereafter until 24 months after baseline to assess sustainability. We also evaluated participant loss to follow-up until 24 months. KEY RESULTS: Participants decreased HbA1c levels during the intervention (p < 0.0001) and maintained these improvements at each timepoint from baseline to 24 months (p range: < 0.0001 to 0.015). Participants reduced blood pressure levels during TIME and maintained these changes at each timepoint from baseline until 18 months (systolic p range < 0.0001 to 0.0005, diastolic p range: < 0.0001 to 0.008) but not at 24 months (systolic: p = 0.065; diastolic: p = 0.85). There were no significant weight changes during TIME or post-intervention: weight (p range = 0.07 to 0.77), BMI (p range = 0.11 to 0.71). Attrition rates (loss to follow-up during the post-intervention period) were 5.9% (6 months), 24.8% (12 months), 35.6% (18 months), and 41.8% (24 months). CONCLUSIONS: It is possible for vulnerable populations to maintain long-term glycemic and blood pressure improvements using a multiple dimensional intervention. Attrition rates rose over time but show promise given the majority of post-intervention timepoints occurred during the COVID-19 pandemic when low-income populations were most susceptible to suboptimal healthcare access. Future studies are needed to evaluate longitudinal outcomes of diabetes interventions conducted by local clinics rather than research teams.

Getting Connected: a Retrospective Cohort Investigation of Video-to-Home Telehealth for Mental Health Care Utilization Among Women Veterans.

BACKGROUND: Increasingly, women are serving in the military and seeking care at the Veterans Health Administration (VHA). Women veterans face unique challenges and barriers in seeking mental health (MH) care within VHA. VA Video Connect (VVC), which facilitates video-based teleconferencing between patients and providers, can reduce barriers while maintaining clinical effectiveness. OBJECTIVE: Primary aims were to examine gender differences in VVC use, describe changes in VVC use over time (including pre-COVID and 6 months following the beginning of COVID), and determine whether changes over time differed by gender. DESIGN: A retrospective cohort investigation of video-to-home telehealth for MH care utilization among veterans having at least 1 MH visit from October 2019 to September 2020. PARTICIPANTS: Veterans (236,268 women; 1,318,024 men). INTERVENTIONS (IF APPLICABLE): VVC involves face-to-face, synchronous, video-based teleconferencing between patients and providers, enabling care at home or another private location. MAIN MEASURES: Percentage of MH encounters delivered via VA Video Connect. KEY RESULTS: Women veterans were more likely than men to have at least 1 VVC encounter and had a greater percentage of MH care delivered via VVC in FY20. There was an increase in the percentage of MH encounters that were VVC over FY20, and this increase was greater for women than men. Women veterans who were younger than 55 (compared to those 55 and older), lived in urban areas (compared to those in rural areas), or were Asian (compared to other races) had a greater percentage of MH encounters that were VVC since the start of the pandemic, controlling for the mean percentage of VVC MH encounters in the 6 months pre-pandemic. CONCLUSIONS: VVC use for MH care is greater in women veterans compared to male veterans and may reduce gender-specific access barriers. Future research and VVC implementation efforts should emphasize maximizing patient choice and satisfaction.

Developing and validating a comprehensive measure of coordination in patient aligned care teams.

BACKGROUND/OBJECTIVE: Despite numerous extant measures assessing context-specific elements of care coordination, we are unaware of any comprehensive, team-based instrument that measures the requisite mechanisms and conditions required to coordinate successfully. In this study we develop and validate the psychometric properties of the Coordination Practices Survey, a context-agnostic measure of coordination for primary care teams. METHODS: Coordination items were developed based on a systematic literature review; items from previously developed scales were adapted and new items were created as needed; all items were refined after subject matter expert review and feedback. We collected data from Primary Care teams drawn from 1200 Veterans Health Administration (VHA) medical centers and outpatient clinics nationwide. 1645 primary care team members from 512 patient aligned care teams in the Veterans Health Administration completed the survey from 2015 to 2016. Psychometric properties were assessed after data collection using Cronbach's alpha, intraclass correlations and multilevel confirmatory factor analysis to assess the factor structure. RESULTS: Our findings confirmed the psychometric properties of two distinguishable subscales of coordination: (a) Accountability and (b) Common Understanding. The within- and between-team latent structure of each subscale exhibited adequate fit to the data, as well as appropriately high Cronbach's alpha and intraclass correlations. There was insufficient variability in responses to the predictability subscale to properly assess its psychometric properties. CONCLUSION: With context-specific validation, our subscales of accountability and common understanding may be used to assess coordination processes in other contexts for both research and operational applications.

An Examination of Positive and Negative Dementia Caregiving Experiences.

OBJECTIVES: We examined associations among three measures of caregiver experiences (i.e., positive aspects of caring [PAC], caregiver burden, and mutuality) in 228 dyads involving persons with dementia (PWD) and their informal caregivers. The associations between predisposing, enabling, and need factors and each of these three measures of caregiver experiences were also examined. METHODS: We used baseline data from a randomized controlled trial of a psychosocial intervention aimed at preventing aggression in PWD. Associations among PAC, caregiver burden, and mutuality were examined. The Behavioral Model of Health Services Utilization guided the selection of predisposing, enabling, and need components. RESULTS: Enabling characteristics (e.g., race/ethnicity, caregiver education and employment and PWD education) and most predisposing characteristics (e.g., caregiver age, PWD age, relationship type) were not associated with any caregiving experience measures. Need characteristics (e.g., levels of memory and functional impairment, behavioral problems, depression, pleasant events) were associated with the caregiving experience. CONCLUSIONS: Bivariate correlations between PAC, caregiver burden, and mutuality were between -0.20 and -0.58. Predisposing, enabling, and need factors were differentially associated with outcomes, with need characteristics being most frequently associated with various aspects of caregiving. CLINICAL IMPLICATIONS: Assessment of both positive and negative aspects of caregiving is important. Particular attention to depression and interventions that improve depressive symptoms may increase PAC and mutuality and reduce caregiver burden.

Aggression Prevention Training for Individuals With Dementia and Their Caregivers: A Randomized Controlled Trial.

OBJECTIVE: International appeals call for interventions to prevent aggression and other behavioral problems in individuals with dementia (IWD). Aggression Prevention Training (APT), based on intervening in three contributors to development of aggression (IWD pain, IWD depression, and caregiver-IWD relationship problems) aims to reduce incidence of aggression in IWD over 1 year. DESIGN: Randomized, controlled trial. SETTING: Three clinics that assess, diagnose, and treat dementia. PARTICIPANTS: Two hundred twenty-eight caregiver-IWD dyads who screened positive for IWD pain, IWD depression, or caregiver-IWD relationship problems randomized to APT or Enhanced Usual Primary Care (EU-PC). INTERVENTION: APT, a skills-based intervention delivered over 3 months to address pain/depression/caregiver-IWD relationship issues. EU-PC included printed material on dementia and community resources; and eight brief, weekly support calls. MEASUREMENTS: The primary outcome was incidence of aggression over 1 year, determined by the Cohen Mansfield Agitation Inventory-Aggression Subscale. Secondary outcomes included pain, depression, caregiver-IWD relationship, caregiver burden, positive caregiving, behavior problems, and anxiety. RESULTS: Aggression incidence and secondary outcomes did not differ between groups. However, in those screening positive for IWD depression or caregiver-IWD relationship problems, those receiving EU-PC had significant increases in depression and significant decreases in quality of the caregiver-IWD relationship, whereas those receiving APT showed no changes in these outcomes over time. CONCLUSION: The cost to patients, family, and society of behavioral problems in IWD, along with modest efficacy of most pharmacologic and nonpharmacologic interventions, calls for more study of novel preventive approaches.

Psychometric properties of worry and anxiety measures in a sample of african american and caucasian older adults.

Objective: The aim of our study was to examine the psychometric properties of commonly used anxiety and worry assessment measures in a community-based, low-income sample of African American and Caucasian older adults.Method: African American and Caucasian participants from three community-based clinical trials testing treatments for late-life worry/anxiety were pooled to examine the factor structure, internal consistency reliability, and convergent, discriminant, and predictive validity of the Penn State Worry Questionnaire-Abbreviated (PSWQ-A), Generalized Anxiety Disorder-7 (GAD-7) and Geriatric Anxiety Inventory-short form (GAI-SF).Results: All three measures demonstrated an adequate fit to a one-factor structure. Internal consistency reliability was adequate for the PSWQ-A and GAD-7 in the total sample and racial subgroups but was acceptable for the GAI-SF only in the African American subgroup. The PSWQ-A and GAD-7 demonstrated good convergent, discriminant, and predictive validity. The GAI-SF has adequate convergent and divergent validity in the African American subgroup.Conclusion: Our study offers preliminary evidence for use of the PSWQ-A and GAD-7 for assessment of anxiety in a sample of low-income, predominantly African American participants. These measures may facilitate identification of anxiety symptoms, which are often overlooked in this population. More research is needed to examine the accuracy of these measures in other racial/ethnic groups.

Positive and negative religious coping as predictors of distress among minority older adults.

OBJECTIVES: The study replicated and extended previous findings by investigating relationships between positive and negative religious coping and psychological distress in minority older adults. METHODS: Older adults were evaluated during screening and baseline procedures of a psychotherapy clinical trial for late-life worry and anxiety. Participants were age 50 years or older and recruited from low-income and predominantly minority neighborhoods. Participants screening positive for worry (PSWQ-A ≥ 23) with no significant cognitive impairment (Six-Item Screener for cognitive impairment ≤2) completed a diagnostic interview and baseline assessments. Positive and negative religious coping were assessed with the positive and negative coping subscales of the Brief Religious Coping scale. Psychological distress was assessed with measures of depression, anxiety, and worry. A set of multiple linear regression models were used to evaluate the relationship between religious coping and each measure of psychological distress. RESULTS: Negative religious coping was associated with greater anxiety, worry, and depression. Positive and negative religious coping interacted such that positive religious coping buffered the effects of negative religious coping on anxiety and depression. Significant main effects and interactions remained after controlling for age, gender, race, years of education, and study. CONCLUSIONS: The findings of this study are consistent with prior work showing that negative religious coping is associated with greater psychological distress. This study replicates previous findings that positive religious coping may buffer the harmful effects of negative religious coping and extends understandings of the specific psychological impacts that positive and negative religious coping may have on older, minority adults.

Impact of Patient-Centered Medical Home Implementation on Diabetes Control in the Veterans Health Administration.

BACKGROUND: Given its widespread dissemination across primary care, the Veterans Health Administration (VA) is an ideal setting to examine the impact of the patient-centered medical home (PCMH) on diabetes outcomes. OBJECTIVE: To assess the impact of PCMH implementation on diabetes outcomes among patients receiving care in the Veterans Health Administration. DESIGN: Retrospective cohort analysis and multilevel logistic regression. PATIENTS: Twenty thousand eight hundred fifty-eight patients in one Midwest VA network who had a diabetes diagnosis in both 2009 and 2012 and who received primary care between October 1, 2008 and September 30, 2009. MAIN MEASURES: Glycemic and lipid control using VA quality indicators [hemoglobin (Hb) A1c < 9%, low-density lipoprotein cholesterol (LDL-C) < 100 mg/dL]. KEY RESULTS: Odds of glycemic control were lower in 2012 than 2009 (OR = 0.72, 95% CI = 0.67-0.77, p < 0.001), and this change in control over time varied by race (OR of the interaction between time and race = 1.18, 95% CI = 1.02-1.36, p = 0.028). While the disparity in glycemic control between white and black patients persisted post-PCMH, the magnitude of the disparity was smaller in 2012 compared to 2009 (2012: OR = 1.32, 95% CI = 1.18-1.47, p < 0.0001 and 2009: OR = 1.59, 95% CI = 1.39-1.82, p < 0.0001). Odds of lipid control did not significantly change between 2009 and 2012 and change did not vary by race and/or gender. CONCLUSIONS: Although there were no significant improvements in odds of lipid control, and odds of glycemic control decreased following PCMH implementation, there was evidence of reduced racial disparities in glycemic control post-PCMH implementation.

Community-Based Outreach and Treatment for Underserved Older Adults With Clinically Significant Worry: A Randomized Controlled Trial.

OBJECTIVE: To determine whether Calmer Life (CL) improved worry, generalized anxiety disorder-related (GAD-related) symptoms, anxiety, depression, sleep, trauma-related symptoms, functional status, and quality of life better than Enhanced Community Care with Resource Counseling (ECC-RC) at 6 months and 9 months. METHODS: A randomized, controlled, comparative-effectiveness study involving underserved, low-income, mostly minority neighborhoods in Houston, Texas, looked at individuals ≥50 with significant worry and interest in psychosocial treatment. Interventions were CL, cognitive behavioral therapy with resource counseling, facilitation of communication with primary care providers about worry/anxiety, integration of religion/spirituality, person-centered skill content and delivery and nontraditional community providers, ECC-RC, and enhanced standard community-based information/ resource counseling addressing basic unmet and mental health needs. Primary outcomes were worry and GAD-related symptom severity. Secondary outcomes were anxiety, depression, sleep difficulties, trauma-related symptoms, functional status, quality of life, service use and satisfaction. RESULTS: Similar, moderate improvements followed CL and ECC-RC on worry, GAD-related symptoms, anxiety, depression, sleep, trauma-related symptoms, and mental health quality of life at 6 and 9 months, but with symptoms at both times and higher satisfaction with CL at both. Fewer ECC-RC participants reported a hospital admission in the prior 3 months than those in CL at 6 and 9 months; at 9 months, fewer reported a visit with a provider in the previous 3 months. CONCLUSION: Both interventions showed similar improvements at 6 and 9 months, but symptoms remained that might require care. Either intervention or a combination may be useful for low-income older adults with identified worry/anxiety.

A Systematic Literature Review of Instruments to Measure Coordination.

EXECUTIVE SUMMARY: Organizing patient care and improving team coordination have been identified by the Institute of Medicine and the Agency for Healthcare Research and Quality as essential components of high-quality care. Research is lacking, however, on the measurement of care team coordination and its mechanisms. Using an organizational psychology framework developed by Okhuysen and Bechky (O&B) as a guide, the authors identify strengths and gaps in the existing literature related to the measurement of coordination and its associated constructs. The authors conducted a review of peer-reviewed articles in healthcare, management, and psychology journals that contain survey items that could be used to measure the domains in the O&B framework. An initial search yielded 468 articles published from 1978 to 2014, 37 of which came from healthcare journals. From this set, 1,401 candidate survey items were extracted from 74 articles. Of these, 279 items were categorized into at least one O&B domain. Retained items were drawn from scales representing 51 constructs related to teamwork, roles, trust, coordination broadly, and ancillary constructs. Two constructs, physical proximity and plans and rules, were directly represented both in the O&B framework and as standalone constructs in the literature. The remaining constructs contributed items that indirectly assess components of the O&B framework domains. Despite decades of research on coordination, valid survey items for measuring the mechanisms and integrating conditions described by the O&B framework as leading to successful team coordination are scarce, and virtually nonexistent in healthcare, as measures of care team coordination.

Teaching Caregivers of Persons with Dementia to Address Pain.

OBJECTIVES: To compare the efficacy of Preventing Aggression in Veterans with Dementia (PAVeD) with that of usual care in decreasing incidence of aggression (primary outcome) and pain and improving depression, pleasant events, caregiver burden, and patient-caregiver relationship quality (secondary outcomes). DESIGN: Randomized controlled trial with assessments at baseline and 3, 6, 9, and 12 months SETTING: Houston, TX. PARTICIPANTS: A total of 203 community-dwelling veterans with pain and dementia and their caregivers. INTERVENTION: PAVeD, 6 to 8 weekly sessions of 45-minute home visits with masters-level clinicians providing instruction to caregivers on recognizing pain, enhancing communication, and making daily activities pleasant and enjoyable, and at least two elective sessions. MEASUREMENTS: Cohen-Mansfield Agitation Inventory (primary outcome), Philadelphia Geriatric Pain Intensity Scale, Geriatric Depression Scale, Pleasant Events Schedule-AD, Burden Interview, Mutuality Scale (secondary outcomes), Client Satisfaction Questionnaire. RESULTS: There were no significant differences in aggression incidence between intervention and control groups, although the PAVeD group had significantly better mutuality than controls. CONCLUSIONS: PAVeD may need to address a broader range and more in-depth coverage of aggression risk factors with person-centered tailoring to target certain types of distress. Interventions to prevent aggression may also need to address medical providers in addition to caregivers.

Pain Among Community-Dwelling Older Adults with Dementia: Factors Associated with Undertreatment.

OBJECTIVE: To identify factors associated with no analgesic treatment in community-dwelling older adults with mild-to-moderate dementia and moderate-to-severe pain. DESIGN: Secondary analysis of a randomized controlled trial. SETTING: Michael E. DeBakey Veterans Affairs Medical Center. SUBJECTS: Two hundred and two older adults (mean age = 79.27 years). METHODS: Guided by the Behavioral Model of Health Service Utilization, participants completed questionnaires regarding predisposing (age, gender, race, educational level, care partner relationship), enabling (income), and need (pain interference, depressive symptoms, cognitive functioning) characteristics. RESULTS: Hierarchical logistic regression analyses revealed that participants with greater income (odds ratio [OR] = 0.79, 95% confidence interval [CI] = 0.63-0.99) and greater pain interference (OR = 0.79, 95% CI = 0.63-0.99) were less likely to have no analgesic treatment. We also examined whether other factors such as depressive symptoms influenced the relationship between pain interference and pain treatment. Those with less pain interference were more likely to have no analgesic treatment (OR = 1.04, 95% CI = 1.01-1.08), but only if they had lower levels of depressive symptoms (b = -0.52, P = 0.005). CONCLUSION: The initiation of analgesic trials is complicated for individuals with dementia and comorbid pain and depressive symptomology. Future research should focus on identifying the most effective assessment and treatment procedures to best direct clinical care for this population.

Expanding the geriatric mental health workforce through utilization of non-licensed providers.

OBJECTIVES: We evaluate policy and practice strategies for bolstering the geriatric mental healthcare workforce and describe costs and considerations of implementing one approach. METHOD: Narrative overview of the literature and policy retrieved from searches of databases, hand searches, and authoritative texts. We identified three proposed strategies to increase the geriatric mental healthcare workforce: (1) production of more geriatric mental health providers; (2) team-based care; and (3) non-licensed providers. We evaluate each in terms of challenges and potential and provide estimates of costs, policy, and practice considerations for training, employing, and supervising non-licensed mental health providers. RESULTS: Use of non-licensed providers is key to reforms needed to allow a more older adults to access necessary mental healthcare. Licensed and non-licensed providers have achieved similar improvements for generalized anxiety disorder among patients, although non-licensed providers did so at a lower cost. CONCLUSION: Supervised non-licensed providers can extend the reach of licensed providers for specific mental health conditions, resulting in lower costs and increased number of patients treated. Although several barriers to implementation exist, policy and infrastructure changes that may support this type of care delivery model are emerging from reforms in financing and associated delivery initiatives created by the Affordable Care Act.

Sedative-Hypnotic Use Among Older Adults Participating in Anxiety Research.

Older adults are prescribed sedative-hypnotic medications at higher rates than younger adults. These are not recommended for older adults due to risk of sedation, cognitive impairment, and falls. Severe generalized anxiety disorder (GAD) is a possibly appropriate use of these medications in older people, but little is available on use of sedative-hypnotic medications among older adults with GAD. This study examined the frequency and predictors of sedative-hypnotic medication use among older adults screening positive for anxiety. 25.88% ( n = 125) of participants reported taking sedative-hypnotics over the past 3 months; 16.36% ( n = 79) reported taking benzodiazepines, and 12.22% ( n = 59) reported taking hypnotic sleep medications. Depressive symptoms were more strongly associated with sedative-hypnotic use than insomnia or worry. Major depressive disorder and posttraumatic stress disorder, but not GAD, predicted sedative-hypnotic use. Other medications and treatments are more appropriate and efficacious for depression, anxiety, and insomnia in this population.

Predictors of Outcomes for Older Adults Participating in Calmer Life, a Culturally Tailored Intervention for Anxiety.

OBJECTIVE: Determine predictors of reduced worry and anxiety for older adults participating in the pilot phase of Calmer Life, a modular, personalized cognitive-behavioral treatment for worry. METHODS: Underserved adults (N = 54) over age 50 participated. Therapists were either experts (Ph.D. or Master's) or nonexpert providers (case managers, community health workers, and bachelor's level). Participants completed the Penn State Worry Questionnaire-Abbreviated (PSWQ-A) and the Geriatric Anxiety Inventory-Short Form (GAI-SF) before treatment and at 3 months. RESULTS: Demographic and clinical variables were individually entered into separate regression equations, controlling for pretreatment scores, to determine their associations with post-treatment 1) PSWQ-A and 2) GAI-SF scores. Only younger age and African American race were significant (p < .05) univariate predictors of higher post-treatment PSWQ-A scores. African American race was also a significant predictor of higher post-treatment GAI-SF scores. CONCLUSIONS: African American participants had higher post-treatment PSWQ-A and GAI-SF scores than White and Hispanic participants. Younger age was also associated with more severe PSWQ-A post-treatment scores. CLINICAL IMPLICATIONS: Younger participants may experience additional stressors (e.g., caregiving, working) compared with older participants. Smaller decreases in anxiety in African Americans point to the need for continued focus and additional modification of interventions.

A Novel Method for Assessing Task Complexity in Outpatient Clinical-Performance Measures.

BACKGROUND: Clinical-performance measurement has helped improve the quality of health-care; yet success in attaining high levels of quality across multiple domains simultaneously still varies considerably. Although many sources of variability in care quality have been studied, the difficulty required to complete the clinical work itself has received little attention. OBJECTIVE: We present a task-based methodology for evaluating the difficulty of clinical-performance measures (CPMs) by assessing the complexity of their component requisite tasks. DESIGN: Using Functional Job Analysis (FJA), subject-matter experts (SMEs) generated task lists for 17 CPMs; task lists were rated on ten dimensions of complexity, and then aggregated into difficulty composites. PARTICIPANTS: Eleven outpatient work SMEs; 133 VA Medical Centers nationwide. MAIN MEASURES: Clinical Performance: 17 outpatient CPMs (2000-2008) at 133 VA Medical Centers nationwide. Measure Difficulty: for each CPM, the number of component requisite tasks and the average rating across ten FJA complexity scales for the set of tasks comprising the measure. KEY RESULTS: Measures varied considerably in the number of component tasks (M = 10.56, SD = 6.25, min = 5, max = 25). Measures of chronic care following acute myocardial infarction exhibited significantly higher measure difficulty ratings compared to diabetes or screening measures, but not to immunization measures ([Formula: see text] = 0.45, -0.04, -0.05, and -0.06 respectively; F (3, 186) = 3.57, p = 0.015). Measure difficulty ratings were not significantly correlated with the number of component tasks (r = -0.30, p = 0.23). CONCLUSIONS: Evaluating the difficulty of achieving recommended CPM performance levels requires more than simply counting the tasks involved; using FJA to assess the complexity of CPMs' component tasks presents an alternate means of assessing the difficulty of primary-care CPMs and accounting for performance variation among measures and performers. This in turn could be used in designing performance reward programs, or to match workflow to clinician time and effort.

Calmer Life: A Culturally Tailored Intervention for Anxiety in Underserved Older Adults.

OBJECTIVES: To evaluate the feasibility of the Calmer Life and Enhanced Community Care interventions delivered by community and expert providers and test their preliminary effectiveness on worry, generalized anxiety disorder (GAD) severity, anxiety, depression, sleep, health-related quality of life, and satisfaction. DESIGN: Small randomized trial, with measurements at baseline and 3 months. SETTING: Underserved, low-income, mostly minority communities in Houston, TX. PARTICIPANTS: Forty underserved adults 50 years and older, with significant worry and principal or coprincipal GAD or anxiety disorder not otherwise specified. INTERVENTION: Combination of person-centered, flexible skills training to reduce worry; resource counseling to target unmet basic needs; and facilitation of communication with primary care providers developed through a community-academic partnership with social service and faith-based organizations. Religion/spirituality may be incorporated. PRIMARY OUTCOMES: worry (Penn State Worry Questionnaire-Abbreviated), GAD severity (GAD-7), anxiety (Geriatric Anxiety Inventory-Short Form). SECONDARY OUTCOMES: depression (Patient Health Questionnaire-8 and Geriatric Depression Scale-Short Form), sleep (Insomnia Severity Index), health-related quality of life (12-item Medical Outcomes Study Short Form), satisfaction (Client Satisfaction Questionnaire and exit interviews). RESULTS: Provider training was valid; mean ratings for community providers were well above average, with none less than adequate. Reach was excellent. Participants receiving the Calmer Life intervention had greater improvement in GAD severity and depression than those receiving Enhanced Community Care. Satisfaction with both treatments was equivalent. CONCLUSIONS: A larger comparative-effectiveness trial needs to examine outcomes following the Calmer Life intervention relative to standard community-based care and to evaluate more fully issues of implementation potential.