Objectives
To measure the rates of hospitalization, readmission, and potentially avoidable hospitalization (PAH) in the Program of All‐Inclusive Care for the Elderly (PACE).
Design
Retrospective ...study.
Setting
PACE.
Participants
PACE enrollees.
Measurements
Hospitalization and PAH rates were measured per 1,000 person‐years. Readmission was defined as any return to the hospital within 30 days of prior hospital discharge. PAHs were defined as hospitalizations for conditions that previously established criteria have identified as possibly preventable or manageable without hospitalization.
Results
Rate of hospitalization was 539/1,000, vs 962/1,000 for dually eligible aged or disabled waiver (ADW) enrollees. Thirty‐day readmission was 19.3%, compared with 22.9% for the national population of dually eligible older enrollees. PAH rate was 100/1,000, compared with 250/1,000 for dually eligible ADW enrollees. Considerable variation was observed between sites.
Conclusion
PACE enrollees experienced lower rates of hospitalization, readmission, and PAH than similar populations. Variations in hospitalization rates between PACE sites suggest opportunities for quality improvement.
OBJECTIVES: To characterize the functional trajectories during the last 2 years of life of patients with progressive frailty, with and without cognitive impairment, and to assess whether it was ...possible to identify discrete functional indicators that signal the end of life.
DESIGN: A retrospective analysis of functional trajectories during the last 24 months of life.
SETTING: Twelve demonstration sites of the Program of All‐inclusive Care for the Elderly (PACE). PACE cares for frail older people who meet criteria for nursing home placement, with the goal of keeping the patient at home.
PARTICIPANTS: Nine hundred seventeen patients who died while enrolled in PACE.
MEASURES: At PACE entry and every 3 months thereafter, data were collected about the degree of dependence (none, partial, or full) in bathing, eating, and walking and the degree of incontinence (none, bladder, or bowel). Cognitive impairment was defined as six or more errors on the Short Portable Mental Status Questionnaire. To describe the end‐of‐life trajectories of patients, data were analyzed from observational windows of time, beginning with the patients' dates of death and extending backward in time to 24 months before death. Each analytical window was 3 months in duration. For each of the functional measures, the probability of functional deterioration in the last 2 years of life in patients with (64%) and without (36%) cognitive impairment was also compared.
RESULTS: The mean age at death was 84; 69% of patients were women. For patients with and without cognitive impairment, a prolonged, steady increase in the rates of functional dependence that were evident at least 1 year before death, rather than sudden increases in functional dependence shortly before death, characterized the functional trajectories. It was not possible for any of the four measures to detect a time point before death at which there was an abrupt decline in function likely to signal impending death.
For each measure, patients with cognitive impairment declined earlier, were more likely than patients without cognitive impairment to have the maximal level of dependence in the 0‐ to 3‐month window before death (e.g., 56% vs 30% for mobility, P < .001), and were more likely to decline in the 2 years before death (e.g., 56% vs 36% for mobility, P < .001).
CONCLUSION: Patients with advanced frailty, with or without cognitive impairment, have an end‐of‐life functional course marked by slowly progressive functional deterioration, with only a slight acceleration in the trajectory of functional loss as death approaches. Patients with cognitive impairment have particularly high rates of functional impairment at the time of death. These results suggest that end‐of‐life care systems that are targeted toward patients with functional trajectories clearly suggesting impending death (such as the Medicare hospice benefit) are poorly suited to older people dying with progressive frailty.
On Lok Lifeways (On Lok), the original Program of All-inclusive Care for the Elderly (PACE), provides comprehensive health care for over a thousand community-dwelling frail seniors in San Francisco ...and Fremont, California. Prior to 2005, participants were referred to off-site contracted psychiatrists and psychologists for all mental health services. In 2005, On Lok introduced an on-site mental and behavioral health (MBH) team that included a psychologist, a bilingual psychiatric social worker, and a marriage and family therapist. Two part-time psychiatrists were added to the core team in 2006 and another full-time marriage and family therapist was added in 2008. We report our experience of implementing an on-site MBH program. In particular, we observed quadrupling of the number of appointments to mental health clinicians. There was a reduction in psychiatric inpatient utilization from 129.4 days/1000 patients in 2004 to 27.1 days/1000 patients in 2005. This reduction was sustained in 2006 and 2007 (41.2 and 23.6/1000 patients respectively). Inclusion of mental and behavioral health clinicians on geriatric interdisciplinary teams at On Lok appeared to improve the quality of care we provided by increasing timely access to mental health services, reduced the rate of psychiatric inpatient admissions, and reduced reported anxiety and stress of On Lok interdisciplinary teams caring for elders with mental health diagnoses.
Researchers often use the term "successful aging" to mean freedom from disability, yet the perspectives of elders living with late-life disability have not been well described. The purpose of this ...study was to explore the meaning of successful aging among a diverse sample of community-dwelling elders with late-life disability.
Using qualitative grounded theory methodology, we interviewed 56 African American, White, Cantonese-speaking Chinese, and Spanish-speaking Latino disabled elders who participate in On Lok Lifeways, a Program of All-inclusive Care for the Elderly. Through semi-structured interviews with open-ended questions, we explored the elders' perceptions of what successful aging and being old meant to them.
Despite experiencing late-life disability, most participants felt they had aged successfully. An overarching theme was that aging results in Living in a New Reality, with two subthemes: Acknowledging the New Reality and Rejecting the New Reality. Participants achieved successful aging by using adaptation and coping strategies to align their perception of successful aging with their experiences. Themes were common across race/ethnic groups but certain strategies were more prominent among different groups.
Across race and ethnic groups, most of these participants with late-life disability felt they had aged successfully. Thus, successful aging involves subjective criteria and has a cultural context that is not captured in objective measurements. Understanding elders' perception will help establish common ground for communication between clinicians and elders and identify the most appropriate interventions to help elders achieve and maintain the experience of successful aging.
ABSTRACT
BACKGROUND
Prognosis is critical in individualizing care for older adults with late life disability. Evidence suggests that preferences for prognostic information may be culturally ...determined. Yet little is known about the preferences of diverse elders for discussing prognosis.
OBJECTIVE
To determine the preferences for discussing prognosis of a diverse sample of older adults with late-life disability
DESIGN & PARTICIPANTS
We interviewed 60 older adults with mean age 78 and mean 2.5 Activities of Daily Living dependencies. Participants were recruited from San Francisco’s On Lok program, the first Program of All-inclusive Care for the Elderly (PACE). Participants were interviewed in English, Spanish, and Cantonese, and responded to scenarios in which their doctors estimated they had 5 years and 1 year left to live. Open-ended questions explored the reasons for their responses. Results were analyzed qualitatively using grounded theory.
KEY RESULTS
Sixty-five percent of participants wanted to discuss the prognosis if their doctor estimated they had <5 years to live and 75% if the estimate was <1 year. Three themes were prominent among patients who wanted to discuss prognosis: to prepare, to make the most of the life they had left, and to make medical or health-related decisions. Those who preferred not to discuss prognosis described emotional difficulty, the uncertainty of prognosis, or that it would not be useful. Nearly all participants said that doctors should not make assumptions based on race or ethnicity, though differences between ethnic groups emerged.
CONCLUSIONS
Most patients in this diverse sample of disabled elders were interested in discussing prognosis, while a substantial minority was not. Among those participants who preferred to discuss prognosis, many said that prognostic information would be important as they made difficult medical and personal decisions in late-life. Clinicians should inquire about preferences for discussing prognosis before sharing prognostic estimates.
Objectives
To determine whether glycosylated hemoglobin (HbA1c) levels predict functional decline in older adults.
Design
Longitudinal cohort study.
Participants
Community‐dwelling, nursing home ...(NH)‐eligible individuals with diabetes mellitus enrolled at On Lok between October 2002 and December 2008 (367 participants, 1,579 HbA1c measurements).
Setting
On Lok Lifeways, the original model for Programs of All‐Inclusive Care for the Elderly.
Measurements
The outcomes were functional decline or death at 2 years. The primary predictor was HbA1c. Age, sex, race and ethnicity, baseline function, comorbid conditions, length of time enrolled at On Lok, insulin use, and clustering of HbA1c within participants were adjusted for with mixed‐effects Poisson regression.
Results
Mean age was 80, and 185 participants (50%) were taking insulin. Sixty‐three percent of participants experienced functional decline, and 75% experienced death or functional decline during the study period. At 2 years, higher HbA1c was associated with less functional decline or death (P for trend = .006). Accounting for clustering and confounding factors, HbA1c of 8.0% to 8.9% was associated with a lower likelihood (relative risk = 0.88, 95% confidence interval = 0.79–0.99) of functional decline or death than HbA1c of 7.0% to 7.9%.
Conclusion
In community‐dwelling, NH‐eligible individuals with diabetes mellitus, HbA1c of 8.0% to 8.9% is associated with better functional outcomes at 2 years than HbA1c of 7.0% to 7.9%, suggesting that the current American Geriatrics Society guideline recommending a HbA1c target of 8.0% or less for older adults with limited life expectancy may be lower than necessary to maintain function.
OBJECTIVES: To develop and validate a prognostic index for mortality in community‐living, frail elderly people.
DESIGN: Cohort study of Program of All‐Inclusive Care for the Elderly (PACE) ...participants enrolled between 1988 and 1996.
SETTING: Eleven PACE sites, a community‐based long‐term care program that cares for frail, chronically ill elderly people who meet criteria for nursing home placement.
PARTICIPANTS: Three thousand eight hundred ninety‐nine PACE enrollees. The index was developed in 2,232 participants and validated in 1,667.
MEASUREMENTS: Time to death was predicted using risk factors obtained from a geriatric assessment performed by the PACE interdisciplinary team at the time of enrollment. Risk factors included demographic characteristics, comorbid conditions, and functional status.
RESULTS: The development cohort had a mean age of 79 (68% female, 40% white). The validation cohort had a mean age of 79 (76% female, 65% white). In the development cohort, eight independent risk factors of mortality were identified and weighted, using Cox regression, to create a risk score: male sex, 2 points; age (75–79, 2 points; 80–84, 2 points; ≥85, 3 points); dependence in toileting, 1 point; dependence in dressing (partial dependence, 1 point; full dependence, 3 points); malignant neoplasm, 2 points; congestive heart failure, 3 points; chronic obstructive pulmonary disease, 1 point; and renal insufficiency, 3 points. In the development cohort, respective 1‐ and 3‐year mortality rates were 6% and 21% in the lowest‐risk group (0–3 points), 12% and 36% in the middle‐risk group (4–5 points), and 21% and 54% in the highest‐risk group (>5 points). In the validation cohort, respective 1‐ and 3‐year mortality rates were 7% and 18% in the lowest‐risk group, 11% and 36% in the middle‐risk group, and 22% and 55% in the highest‐risk group. The area under the receiver operating characteristic curve for the point score was 0.66 and 0.69 in the development and validation cohorts, respectively.
CONCLUSION: A multidimensional prognostic index was developed and validated using age, sex, functional status, and comorbidities that effectively stratifies frail, community‐living elderly people into groups at varying risk of mortality.
Background
To explore clinician choice of whether to discuss prognosis with their frail older patients.
Design
Qualitative interview study.
Setting
Primary care clinicians were recruited from nursing ...homes, community‐based clinics, and academic medical centers.
Participants
Three geriatric nurse practitioners, nine geriatricians, five general internists, and three family medicine physicians with a mean age of 44 and a mean 12 years in practice. Seventeen clinicians had patient panels with 80% or more community‐dwelling outpatients, 13 had patient panels with 50% or more patients aged 85 and older, and 16 had patient panels with 25% or more of patients in a minority group (Asian, African American, Hispanic).
Measurements
Clinicians were asked to describe their practice of discussing long‐term (<5‐year) and short‐term (<1‐year and 3‐month) prognosis. Responses were analyzed qualitatively using constant comparison until thematic saturation was reached.
Results
Clinicians reported individualizing the decision to discuss prognosis with their frail older patients based on clinical circumstances. Common reasons for discussing prognosis included patient had a specific condition with a limited prognosis, to give patients time to prepare, to promote informed medical decision‐making, and when patients or families prompted the conversation. Common reasons not to discuss included maintaining hope and avoiding anxiety, cognitive impairment or patient unable to understand prognosis, respect for patients' cultural values, and long‐term prognosis too uncertain to be useful.
Conclusion
Clinicians caring for frail older adults are generally willing to discuss short‐ but not long‐term prognosis. Clinicians balance individual factors when deciding whether to discuss prognosis.
The program of All-inclusive Care for the Elderly (PACE) is a community-based, long-term care model designed for older adults that are nursing home eligible. Bound by original design and regulations, ...these programs have primarily utilized a center-based ("staff") primary care physician model. However, some believe that this might hinder expansion of the PACE model. In response to this concern, three PACE programs have explored the use of "community-based" primary care physicians (CBPCPs). In an attempt to evaluate the impact of this variation in the model, we surveyed the medical director, 2 community-based primary care physicians and 6 non-physician staff members at one of these sites. Responders generally support the use of CBPCPs as a useful and productive alternative way to expand PACE services to a wider audience of eligible patients. Because some staff members perceive that CBPCPs utilize hospital and NH services at a higher rate, continued education of both CBPCPs and staff members regarding the expectations from this relationship is needed.
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