Home Health Aides' Increased Role in Supporting Older Veterans and Primary Healthcare Teams During COVID-19: a Qualitative Analysis.

BACKGROUND: Home health aides are important but often overlooked members of care teams, providing functional and emotional support to patients. These services became increasingly important during the COVID-19 pandemic as older adults faced disruptions in in-person medical services and family caregiving. Understanding how aides supported healthcare teams is important for informing emergency planning and better integrating home health services with primary care. OBJECTIVE: To describe aides' roles in supporting veterans and working with primary care teams during COVID-19 and identify COVID-related changes in tasks. DESIGN: Semi-structured interviews. PARTICIPANTS: Eight home health aides, 6 home health agency administrators, and 9 primary care team members (3 RNs, 3 social workers, 3 MDs) serving veterans at a large, urban, Veterans Affairs medical center. APPROACH: Combined deductive and inductive analysis to identify a priori concepts (aide roles; changes in tasks and new tasks during COVID-19) and emergent ideas. Aide, administrator, and provider interviews were analyzed separately and compared and contrasted to highlight emergent themes and divergent perspectives. KEY RESULTS: Participants reported an increase in the volume and intensity of tasks that aides performed during the pandemic, as well as the shifting of some tasks from the medical care team and family caregivers to the aide. Four main themes emerged around aides' roles in the care team during COVID-19: (1) aides as physically present "boots on the ground" during medical and caregiving disruptions, (2) aides as care coordination support, (3) aides as mental health support, and (4) intensification of aides' work. CONCLUSIONS: Home health aides played a central role in coordinating care during the COVID-19 pandemic, providing hands-on functional, medical, and emotional support. Integrating aides more formally into healthcare teams and expanding their scope of practice in times of crisis and beyond may improve care coordination for older veterans.

Effect of Health Information Exchange Plus a Care Transitions Intervention on Post-Hospital Outcomes Among VA Primary Care Patients: a Randomized Clinical Trial.

BACKGROUND: Health information exchange (HIE) notifications when patients experience cross-system acute care encounters offer an opportunity to provide timely transitions interventions to improve care across systems. OBJECTIVE: To compare HIE notification followed by a post-hospital care transitions intervention (CTI) with HIE notification alone. DESIGN: Cluster-randomized controlled trial with group assignment by primary care team. PATIENTS: Veterans 65 or older who received primary care at 2 VA facilities who consented to HIE and had a non-VA hospital admission or emergency department visit between 2016 and 2019. INTERVENTIONS: For all subjects, real-time HIE notification of the non-VA acute care encounter was sent to the VA primary care provider. Subjects assigned to HIE plus CTI received home visits and telephone calls from a VA social worker for 30 days after arrival home, focused on patient activation, medication and condition knowledge, patient-centered record-keeping, and follow-up. MEASURES: Primary outcome: 90-day hospital admission or readmission. SECONDARY OUTCOMES: emergency department visits, timely VA primary care team telephone and in-person follow-up, patients' understanding of their condition(s) and medication(s) using the Care Transitions Measure, and high-risk medication discrepancies. KEY RESULTS: A total of 347 non-VA acute care encounters were included and assigned: 159 to HIE plus CTI and 188 to HIE alone. Veterans were 76.9 years old on average, 98.5% male, 67.8% White, 17.1% Black, and 15.1% other (including Hispanic). There was no difference in 90-day hospital admission or readmission between the HIE-plus-CTI and HIE-alone groups (25.8% vs. 20.2%, respectively; risk diff 5.6%; 95% CI - 3.3 to 14.5%, p = .25). There was also no difference in secondary outcomes. CONCLUSIONS: A care transitions intervention did not improve outcomes for veterans after a non-VA acute care encounter, as compared with HIE notification alone. Additional research is warranted to identify transitions services across systems that are implementable and could improve outcomes.

Improving Patient Activation among Older Veterans: Results from a Social Worker-Led Care Transitions Intervention.

Older veterans enrolled in the Veterans Health Administration (VHA) often use both VHA and non-VHA providers for their care. This dual use, especially around an inpatient visit, can lead to fragmented care during the time of transition post-discharge. Interventions that target patient activation may be valuable ways to help veterans manage complex medication regimens and care plans from multiple providers. The Care Transitions Intervention (CTI) is an evidence-based model that helps older adults gain confidence and skills to achieve their health goals post-discharge. Our study examined the impact of CTI upon patient activation for veterans discharged from non-VHA hospitals. In total, 158 interventions were conducted for 87 veterans. From baseline to follow-up there was a significant 1.7-point increase in patient activation scores, from 5.4 to 7.1. This association was only found among those who completed the intervention. The most common barriers to completion were difficulty reaching the veteran by phone, patient declining the intervention, and rehospitalization during the 30 days post-discharge. Care transitions guided by social workers may be a promising way to improve patient activation. However, future research and practice should address barriers to completion and examine the impact of increased patient activation on health outcomes.

Frailty Is Associated With Postoperative Delirium But Not With Postoperative Cognitive Decline in Older Noncardiac Surgery Patients.

BACKGROUND: Postoperative cognitive dysfunction (POCD) and delirium are the most common perioperative cognitive complications in older adults undergoing surgery. A recent study of cardiac surgery patients suggests that physical frailty is a risk factor for both complications. We sought to examine the relationship between preoperative frailty and postoperative delirium and preoperative frailty and POCD after major noncardiac surgery. METHODS: We performed a prospective cohort study of patients >65 years old having major elective noncardiac surgery with general anesthesia. Exclusion criteria were preexisting dementia, inability to consent, cardiac, intracranial, or emergency surgery. Preoperative frailty was determined using the FRAIL scale, a simple questionnaire that categorizes patients as robust, prefrail, or frail. Delirium was assessed with the Confusion Assessment Method for the intensive care unit (CAM-ICU) twice daily, starting in the recovery room until hospital discharge. All patients were assessed with neuropsychological tests (California Verbal Learning Test II, Trail Making Test, subtests from the Wechsler Adult Intelligence Scale, Logical Memory Story A, Immediate and Delayed Recall, Animal and Vegetable verbal fluency, Boston Naming Test, and the Mini-Mental Status Examination) before surgery and at 3 months afterward. RESULTS: A total of 178 patients met inclusion criteria; 167 underwent major surgery and 150 were available for follow-up 3 months after surgery. The median age was 70 years old. Thirty-one patients (18.6%) tested as frail, and 72 (43.1%) prefrail before surgery. After adjustment for baseline cognitive score, age, education, surgery duration, American Society of Anesthesiologists (ASA) physical status, type of surgery, and sex, patients who tested frail or prefrail had an estimated 2.7 times the odds of delirium (97.5% confidence interval, 1.0-7.3) when compared to patients who were robust. There was no significant difference between the proportion of POCD between patients who tested as frail, prefrail, or robust. CONCLUSIONS: After adjustment for baseline cognition, testing as frail or prefrail with the FRAIL scale is associated with increased odds of postoperative delirium, but not POCD after noncardiac surgery.

Regional data exchange to improve care for veterans after non-VA hospitalization: a randomized controlled trial.

BACKGROUND: Coordination of care, especially after a patient experiences an acute care event, is a challenge for many health systems. Event notification is a form of health information exchange (HIE) which has the potential to support care coordination by alerting primary care providers when a patient experiences an acute care event. While promising, there exists little evidence on the impact of event notification in support of reengagement into primary care. The objectives of this study are to 1) examine the effectiveness of event notification on health outcomes for older adults who experience acute care events, and 2) compare approaches to how providers respond to event notifications. METHODS: In a cluster randomized trial conducted across two medical centers within the U.S. Veterans Health Administration (VHA) system, we plan to enroll older patients (≥ 65 years of age) who utilize both VHA and non-VHA providers. Patients will be enrolled into one of three arms: 1) usual care; 2) event notifications only; or 3) event notifications plus a care transitions intervention. In the event notification arms, following a non-VHA acute care encounter, an HIE-based intervention will send an event notification to VHA providers. Patients in the event notification plus care transitions arm will also receive 30 days of care transition support from a social worker. The primary outcome measure is 90-day readmission rate. Secondary outcomes will be high risk medication discrepancies as well as care transitions processes within the VHA health system. Qualitative assessments of the intervention will inform VHA system-wide implementation. DISCUSSION: While HIE has been evaluated in other contexts, little evidence exists on HIE-enabled event notification interventions. Furthermore, this trial offers the opportunity to examine the use of event notifications that trigger a care transitions intervention to further support coordination of care. TRIAL REGISTRATION: ClinicalTrials.gov NCT02689076. "Regional Data Exchange to Improve Care for Veterans After Non-VA Hospitalization." Registered 23 February 2016.

A multisite geriatric education program for rural providers in the Veteran Health Care System (GRECC-Connect).

Older patients who live in rural areas often have limited access to specialty geriatric care, which can help in identifying and managing geriatric conditions associated with functional decline. Implementation of geriatric-focused practices among rural primary care providers has been limited, because rural providers often lack access to training in geriatrics and to geriatricians for consultation. To bridge this gap, four Geriatric Research, Education, and Clinical Centers, which are centers of excellence across the nation for geriatric care within the Veteran health system, have developed a program utilizing telemedicine to connect with rural providers to improve access to specialized geriatric interdisciplinary care. In addition, case-based education via teleconferencing using cases brought by rural providers was developed to complement the clinical implementation efforts. In this article, the authors review these educational approaches in the implementation of the clinical interventions and discuss the potential advantages in improving implementation efforts.

Increase in blood pressure precedes distress behavior in nursing home residents with dementia.

BACKGROUND: Distress behaviors in dementia (DBD) likely increase sympathetic nervous system activity. The aim of this study was to examine the associations among DBD, blood pressure (BP), and intensity of antihypertensive treatment, in nursing home (NH) residents with dementia. METHODS: We identified long-stay Veterans Affairs NH residents with dementia in 2019-20 electronic health data. Each individual with a BP reading and a DBD incident according to a structured behavior note on a calendar day (DBD group) was compared with an individual with a BP reading but without a DBD incident on that same day (comparison group). In each group we calculated daily mean BP from 14 days before to 7 days after the DBD incident day. We then calculated the change in BP between the DBD incident day and, as baseline, the 7-day average of BP 1 week prior, and tested for differences between DBD and comparison groups in a generalized estimating equations multivariate model. RESULTS: The DBD and comparison groups consisted of 707 and 2328 individuals, respectively. The DBD group was older (74 vs. 72 y), was more likely to have severe cognitive impairment (13% vs. 8%), and had worse physical function scores (15 vs. 13 on 28-point scale). In the DBD group, mean systolic BP on the DBD incident day was 1.6 mmHg higher than baseline (p < .001), a change that was not observed in the comparison group. After adjusting for covariates, residents in the DBD group, but not the comparison group, had increased likelihood of having systolic BP > = 160 mmHg on DBD incident days (OR 1.02; 95%CI 1.00-1.03). Systolic BP in the DBD group began to rise 7 days before the DBD incident day and this rise persisted 1 week after. There were no significant changes in mean number of antihypertensive medications over this time period in either group. CONCLUSIONS: NH residents with dementia have higher BP when they experience DBD, and BP rises 7 days before the DBD incident. Clinicians should be aware of these findings when deciding intensity of BP treatment.

Which older adults are at highest risk of prescribing cascades? A national study of the gabapentinoid-loop diuretic cascade.

BACKGROUND: Prescribing cascades are important contributors to polypharmacy. Little is known about which older adults are at highest risk of experiencing prescribing cascades. We explored which older veterans are at highest risk of the gabapentinoid (including gabapentin and pregabalin)-loop diuretic (LD) cascade, given the dramatic increase in gabapentinoid prescribing in recent years. METHODS: Using Veterans Affairs and Medicare claims data (2010-2019), we performed a prescription sequence symmetry analysis (PSSA) to assess loop diuretic initiation before and after gabapentinoid initiation among older veterans (≥66 years). To identify the cascade, we calculated the adjusted sequence ratio (aSR), which assesses the temporality of LD relative to gabapentinoid initiation. To explore high-risk groups, we used multivariable logistic regression with prescribing order modeled as a binary dependent variable. We calculated adjusted odds ratios (aORs), measuring the extent to which factors are associated with one prescribing order versus another. RESULTS: Of 151,442 veterans who initiated a gabapentinoid, there were 1,981 patients who initiated a LD within 6 months after initiating a gabapentinoid compared to 1,599 patients who initiated a LD within 6 months before initiating a gabapentinoid. In the gabapentinoid-LD group, the mean age was 73 years, 98% were male, 13% were Black, 5% were Hispanic, and 80% were White. Patients in each group were similar across patient and health utilization factors (standardized mean difference <0.10 for all comparisons). The aSR was 1.23 (95% CI: 1.13, 1.34), strongly suggesting the cascade's presence. People age ≥85 years were less likely to have the cascade (compared to 66-74 years; aOR 0.74, 95% CI: 0.56-0.96), and people taking ≥10 medications were more likely to have the cascade (compared to 0-4 drugs; aOR 1.39, 95% CI: 1.07-1.82). CONCLUSIONS: Among older adults, those who are younger and taking many medications may be at higher risk of the gabapentinoid-LD cascade, contributing to worsening polypharmacy and potential drug-related harms. We did not identify strong predictors of this cascade, suggesting that prescribing cascade prevention efforts should be widespread rather than focused on specific subgroups.

Impact of hospitalizations on problematic medication use among community dwelling persons with dementia.

BACKGROUND: Hospitalizations are frequently disruptive for persons with dementia (PWD) in part due to the use of potentially problematic medications for complications such as delirium, pain, and insomnia. We sought to determine the impact of hospitalizations on problematic medication prescribing in the months following hospitalization. METHODS: We included community-dwelling PWD in the Health and Retirement Study aged ≥66 with a hospitalization from 2008-2018. We characterized problematic medications as medications that negatively affect cognition (strongly anticholinergics/sedative-hypnotics), medications from 2019 Beers criteria, and medications from STOPP-V2. To capture durable changes, we compared problematic medications 4 weeks pre-hospitalization (baseline) to 4 months post-hospitalization period. We used a generalized linear mixed model with Poisson distribution adjusting for age, sex, comorbidity count, pre-hospital chronic medications, and timepoint. RESULTS: Among 1,475 PWD, 504 had a qualifying hospitalization (median age 84 (IQR=79-90), 66% female, 17% Black). There was a small increase in problematic medications from the baseline to post-hospitalization timepoint that did not reach statistical significance (adjusted mean 1.28 vs. 1.40, difference 0.12 (95% CI -0.03, 0.26), p=0.12). Results were consistent across medication domains and certain subgroups. In one pre-specified subgroup, individuals on <5 pre-hospital chronic medications showed a greater increase in post-hospital problematic medications compared to those on ≥5 medications (p=0.04 for interaction, mean increase from baseline to post-hospitalization of 0.25 for those with <5 medications (95% CI 0.05, 0.44) vs. 0.06 (95% CI -0.12, 0.25) for those with ≥5 medications). CONCLUSIONS: Hospitalizations had a small, non-statistically significant effect on longer-term problematic medication use among PWD.

Improving Care Coordination Between Veterans Health Administration Primary Care Teams and Community Home Health Aide Providers: A Qualitative Study.

Effective coordination between medical and long-term services is essential to high-quality primary care for older adults, but can be challenging. Our study assessed coordination and communication through semi-structured interviews with Veterans Health Administration (VHA) primary care clinicians (n = 9); VHA-contracted home health agencies (n = 6); and home health aides (n = 8) caring for veterans at an urban VHA medical center. Participants reported (1) establishing home health services is complex, requiring collaboration between many individuals and systems; (2) communication between medical teams and agencies is often reactive; (3) formal communication channels between medical teams and agencies are lacking; (4) aides are an important source of patient information; and (5) aides report important information, but rarely receive it. Removing structural communication barriers; incentivizing reporting channels and information sharing between aides, agencies, and primary care teams; and integrating aides into interdisciplinary teams may improve coordination of medical and long-term care.

Medication misuse and overuse in community-dwelling persons with dementia.

BACKGROUND: Persons with dementia (PWD) have high rates of polypharmacy. While previous studies have examined specific types of problematic medication use in PWD, we sought to characterize a broad spectrum of medication misuse and overuse among community-dwelling PWD. METHODS: We included community-dwelling adults aged ≥66 in the Health and Retirement Study from 2008 to 2018 linked to Medicare and classified as having dementia using a validated algorithm. Medication usage was ascertained over the 1-year prior to an HRS interview date. Potentially problematic medications were identified by: (1) medication overuse including over-aggressive treatment of diabetes/hypertension (e.g., insulin/sulfonylurea with hemoglobin A1c < 7.5%) and medications inappropriate near end of life based on STOPPFrail and (2) medication misuse including medications that negatively affect cognition and medications from 2019 Beers and STOPP Version 2 criteria. To contextualize, we compared medication use to people without dementia through a propensity-matched cohort by age, sex, comorbidities, and interview year. We applied survey weights to make our results nationally representative. RESULTS: Among 1441 PWD, median age was 84 (interquartile range = 78-89), 67% female, and 14% Black. Overall, 73% of PWD were prescribed ≥1 potentially problematic medication with a mean of 2.09 per individual in the prior year. This was notable across several domains, including 41% prescribed ≥1 medication that negatively affects cognition. Frequently problematic medications included proton pump inhibitors (PPIs), non-steroidal anti-inflammatory drugs (NSAIDs), opioids, antihypertensives, and antidiabetic agents. Problematic medication use was higher among PWD compared to those without dementia with 73% versus 67% prescribed ≥1 problematic medication (p = 0.002) and mean of 2.09 versus 1.62 (p < 0.001), respectively. CONCLUSION: Community-dwelling PWD frequently receive problematic medications across multiple domains and at higher frequencies compared to those without dementia. Deprescribing efforts for PWD should focus not only on potentially harmful central nervous system-active medications but also on other classes such as PPIs and NSAIDs.

A virtual breakthrough series collaborative to support deprescribing interventions across Veterans Affairs healthcare settings.

BACKGROUND: Virtual collaborative models are a practical way to implement a supportive environment for multi-team learning. In this project, we aimed to describe the processes and outcomes of a virtual deprescribing collaborative that facilitated implementation of deprescribing interventions around the country. METHODS: Two successive cohorts comprised of multidisciplinary teams from geographically diverse veterans affairs (VA) sites were selected via an application process to participate in a virtual deprescribing collaborative. Each site developed its own deprescribing protocol and took part in regular meetings, mentoring groups, monthly data reporting, and other learning activities over an approximate 9 month period, per cohort. Standard measures were number of veterans served and medications deprescribed. Descriptive and qualitative analyses were utilized. RESULTS: Twenty-one total VA sites were selected to participate in the deprescribing collaborative in two cohorts (Cohort 1, n = 12 sites; Cohort 2, n = 9 sites). The majority of sites' practice areas directly served the older adult population, and the majority of site leads were pharmacists. The most utilized tool used by the collaborative sites was the VA VIONE decision support tool (n = 14) and the most common strategy was individualized medication review. Combining outcomes from both Cohorts 1 and 2, a total of n = 4770 veterans were served, with 8332 medications deprescribed. Eighty-two percent of Cohort 1 sites surveyed reported their deprescribing program was still being utilized after 1 year follow up. CONCLUSIONS: This virtual deprescribing collaborative aided in the successful implementation of both established and novel deprescribing practices across a variety of VA practice sites that care for older adults. The shared learning experience enhanced problem solving and allowed for interdisciplinary teamwork. Overall the collaborative was successful in improving polypharmacy for several thousand older adults.

Association of chronic diseases and impairments with disability in older adults: a decade of change?

BACKGROUND: Little is known about how the relationship between chronic disease, impairment, and disability has changed over time among older adults. OBJECTIVE: To examine how the associations of chronic disease and impairment with specific disability have changed over time. RESEARCH DESIGN: Repeated cross-sectional analysis, followed by examining the collated sample using time interaction variables, of 3 recent waves of the Health and Retirement Study. SUBJECTS: The subjects included 10,390, 10,621 and 10,557 community-dwelling adults aged 65 years and above in 1998, 2004, and 2008. MEASUREMENTS: : Survey-based history of chronic diseases including hypertension, heart disease, heart failure, stroke, diabetes, cancer, chronic lung disease, and arthritis; impairments, including cognition, vision, and hearing; and disability, including mobility, complex activities of daily living (ADL), and self-care ADL. RESULTS: Over time, the relationship of chronic diseases and impairments with disability was largely unchanged; however, the association between hypertension and complex ADL disability weakened from 1998 to 2004 and 2008 [odds ratio (OR) = 1.24; 99% confidence interval (CI), 1.06-1.46; OR = 1.07; 99% CI, 0.90-1.27; OR = 1.00; 99% CI, 0.83-1.19, respectively], as it did for hypertension and self-care disability (OR = 1.32; 99% CI, 1.13-1.54; OR=0.97; 99% CI, 0.82-1.14; OR = 0.99; 99% CI, 0.83-1.17). The association between diabetes and self-care disability strengthened from 1998 to 2004 and 2008 (OR = 1.21; 99% CI, 1.01-1.46; OR = 1.37; 99% CI, 1.15-1.64; OR = 1.52; 99% CI, 1.29-1.79), as it also did for lung disease and self-care disability (OR = 1.64; 99% CI, 1.33-2.03; OR = 1.63; 99% CI, 1.32-2.01; OR = 2.11; 99% CI, 1.73-2.57). CONCLUSIONS: Although relationships between diseases, impairments, and disability were largely unchanged, disability became less associated with hypertension and more with diabetes and lung disease.

Perspectives of certified nursing assistants and administrators on staffing the nursing home frontline during the COVID-19 pandemic.

OBJECTIVE: To identify best practices to support and grow the frontline nursing home workforce based on the lived experience of certified nursing assistants (CNAs) and administrators during COVID-19. STUDY SETTING: Primary data collection with CNAs and administrators in six New York metro area nursing homes during fall 2020. STUDY DESIGN: Semi-structured interviews and focus groups exploring staffing challenges during COVID-19, strategies used to address them, and recommendations moving forward. DATA COLLECTION: We conducted interviews with 6 administrators and held 10 focus groups with day and evening shift CNAs (n = 56) at 6 nursing homes. Data were recorded and transcribed verbatim and analyzed through directed content analysis using a combined inductive and deductive approach to compare perceptions across sites and roles. PRINCIPAL FINDINGS: CNAs and administrators identified chronic staffing shortages that affected resident care and staff burnout as a primary concern moving forward. CNAs who felt most supported and confident in their continued ability to manage their work and the pandemic described leadership efforts to support workers' emotional health and work-life balance, teamwork across staff and management, and accessible and responsive leadership. However, not all CNAs felt these strategies were in place. CONCLUSIONS: Based on priorities identified by CNAs and administrators, we recommend several organizational/industry and policy-level practices to support retention for this workforce. Practices to stabilize the workforce should include 1) teamwork and person-centered operational practices including transparent communication; 2) increasing permanent staff to avoid shortages; and 3) evaluating and building on successful COVID-related innovations (self-managed teams and flexible benefits). Policy and regulatory changes to promote these efforts are necessary to developing industry-wide structural practices that target CNA recruitment and retention.

Attitudes toward deprescribing among older adults with dementia in the United States.

BACKGROUND: People with dementia (PWD) take medications that may be unnecessary or harmful. This problem can be addressed through deprescribing, but it is unclear if PWD would be willing to engage in deprescribing with their providers. Our goal was to investigate attitudes toward deprescribing among PWD. METHODS: This was a cross-sectional study of 422 PWD aged ≥65 years who completed the medications attitudes module of the National Health and Aging Trends Study (NHATS) in 2016. Proxies provided responses when a participant was unable to respond due to health or cognitive problems. Attitudinal outcomes comprised responses to two statements from the patients' attitudes toward deprescribing questionnaire and its revised version (representing belief about the necessity of one's medications and willingness to deprescribe); another elicited the maximum number of pills that a respondent would be comfortable taking. RESULTS: The weighted sample represented over 1.8 million PWD; 39% were 75 to 84 years old and 38% were 85 years or older, 60% were female, and 55% reported six or more regular medications. Proxies provided responses for 26% of PWD. Overall, 22% believed that they may be taking one or more medicines that they no longer needed, 87% were willing to stop one or more of their medications, and 50% were uncomfortable taking five or more medications. Attitudinal outcomes were similar across sociodemographic and clinical factors. PWD taking ≥6 medications were more likely to endorse a belief that at least one medication was no longer necessary compared to those taking <6 (adjusted probability 29% [95% confidence interval (CI), 22%-38%] vs. 13% [95% CI, 8%-20%]; p = 0.004); the same applied for willingness to deprescribe (92% [95% CI, 87%-95%] vs. 83% [95% CI, 76%-89%]; p = 0.04). CONCLUSIONS: A majority of PWD are willing to deprescribe, representing an opportunity to improve quality of life for this vulnerable population.

Recent trends in chronic disease, impairment and disability among older adults in the United States.

BACKGROUND: To examine concurrent prevalence trends of chronic disease, impairment and disability among older adults. METHODS: We analyzed the 1998, 2004 and 2008 waves of the Health and Retirement Study, a nationally representative survey of older adults in the United States, and included 31,568 community dwelling adults aged 65 and over. Measurements include: prevalence of chronic diseases including hypertension, heart disease, stroke, diabetes, cancer, chronic lung disease and arthritis; prevalence of impairments, including impairments of cognition, vision, hearing, mobility, and urinary incontinence; prevalence of disability, including activities of daily living (ADLs) and instrumental activities of daily living (IADLs). RESULTS: The proportion of older adults reporting no chronic disease decreased from 13.1% (95% Confidence Interval [CI], 12.4%-13.8%) in 1998 to 7.8% (95% CI, 7.2%-8.4%) in 2008, whereas the proportion reporting 1 or more chronic diseases increased from 86.9% (95% CI, 86.2%-89.6%) in 1998 to 92.2% (95% CI, 91.6%-92.8%) in 2008. In addition, the proportion reporting 4 or more diseases increased from 11.7% (95% CI, 11.0%-12.4%) in 1998 to 17.4% (95% CI, 16.6%-18.2%) in 2008. The proportion of older adults reporting no impairments was 47.3% (95% CI, 46.3%-48.4%) in 1998 and 44.4% (95% CI, 43.3%-45.5%) in 2008, whereas the proportion of respondents reporting 3 or more was 7.2% (95% CI, 6.7%-7.7%) in 1998 and 7.3% (95% CI, 6.8%-7.9%) in 2008. The proportion of older adults reporting any ADL or IADL disability was 26.3% (95% CI, 25.4%-27.2%) in 1998 and 25.4% (95% CI, 24.5%-26.3%) in 2008. CONCLUSIONS: Multiple chronic disease is increasingly prevalent among older U.S. adults, whereas the prevalence of impairment and disability, while substantial, remain stable.

Cognitive analysis of a medication reconciliation tool: applying laboratory and naturalistic approaches to system evaluation.

Adverse drug events can occur as a result of handoffs in patient care. To reduce the possibility of this occurring, the process of medication reconciliation (whereby the patient's medication history is compared to current and previous medications to ensure accuracy) is becoming recognized as becoming increasingly important. To address this, computerized medication reconciliation tools have been developed. This paper describes a combined approach to evaluating the impact of such a tool. The approach has included both an artificial laboratory-based evaluation component (involving observing subjects interacting with standardized patient cases), as well as a naturalistic condition (involving real patient cases). The results indicate that there are differences in the way that subjects interact with the medication reconciliation tool, with significant differences identified in the amount of time spent and accuracy of medication documentation between physician and pharmacist users.

Perceptions of event notification following discharge to improve geriatric care: qualitative interviews of care team members from a 2-site cluster randomized trial.

OBJECTIVE: To assess primary care teams' perceptions of a health information exchange (HIE) event notification intervention for geriatric patients in 2 Veterans Health Administration (VHA) medical centers. MATERIALS AND METHODS: We conducted a qualitative evaluation of an event notification alerting primary care teams to non-VHA hospital admissions and emergency department visits. Data were collected through semistructured interviews (n = 23) of primary care team physicians, nurses and medical assistants. Study design and analysis were guided by the Consolidated Framework for Implementation Research (CFIR). RESULTS: Team members found the alerts necessary, helpful for filling information gaps, and effective in supporting timely follow-up care, although some expressed concern over scheduling capacity and distinguishing alerts from other VHA notices. Participants also suggested improvements including additional data on patients' diagnosis and discharge instructions, timing alerts to patients' discharge (including clear next steps), including additional team members to ensure alerts were acted upon, and implementing a single sign-on. DISCUSSION: Primary care team members perceived timely event notification of non-VHA emergency department visits and hospital admissions as potentially improving post-discharge follow-up and patient outcomes. However, they were sometimes unsure of next steps and suggested the alerts and platform could be streamlined for easier use. CONCLUSIONS: Event notifications may be a valuable tool in coordinating care for high-risk older patients. Future intervention research should explore the optimal amount and types of information and delivery method across sites and test the integration of alerts into broader care coordination efforts.

Outcomes of Hospital at Home for Older Adults with and without High Levels of Social Support.

The evaluation of social support within hospital at home (HaH) programs has been limited. We performed a secondary analysis of a prospective cohort evaluation of 295 participants receiving HaH care and 212 patients undergoing traditional hospitalization from November of 2014 to August of 2017. We examined the confounding and moderating effects of instrumental and informational social support upon length of stay and 30-day rehospitalization, emergency department (ED) visit, and skilled nursing facility admission. Instrumental social support attenuated the effects of HaH upon any ED visit (base model: OR 0.61, p = 0.037; controlling for social support: OR 0.71, p = 0.15). The association of HaH with other outcomes remained unchanged. Interactions between HaH and informational or instrumental social support for all outcomes were not significant. Lack of high levels of social support had little effect on the positive outcomes of HaH care, suggesting similar benefits of HaH services for patients with lower levels of social support.