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.
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 ....
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
.
Health & ageing in international context Wieland, G Darryl
Indian journal of medical research (New Delhi, India : 1994),
04/2012, Letnik:
135, Številka:
4
Journal Article
Recenzirano
Odprti dostop
Geriatricians have come to understand frailty as "a state of high vulnerability for adverse health outcomes, including disability, dependency, falls, need for long-term care, and mortality…theorized ...to result from age- and/or disease-associated physiologic accumulation of sub-threshold decrements affecting multiple physiologic systems, and detectable by looking at clinical, functional, behavioral and biological markers 15 ." In the aforementioned strength-training trial in older hip-fracture patients, targeted interventions included gait/balance training, osteoporosis, nutrition, vitamin D/calcium, depression, cognition, vision, home safety, polypharmacy, hip protectors, self-efficacy and social support. ...they underscore the need to clarify the concepts of and linkages between co-morbidity, disability, frailty and other geriatric syndromes 15,16 .
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.
Context:The US Congress in 2010 established the Program of Comprehensive Assistance for Family Caregivers (PCAFC) in the Department of Veterans Affairs’ (VA) healthcare system, expanding services for ...family caregivers of eligible veterans with injuries sustained or aggravated in the line of duty on or after 11 September 2001. The program includes a Caregiver Support Coordinator, stipends for caregivers, education/training, and additional services.Objective: The primary goal of this study was to examine the types of services that family caregivers of veterans use and value, how services are used and any limitations family caregivers’ experienced. Given that few interventions assess caregiver satisfaction with services, there is a gap in the existing literature addressing these outcomes.Methods: We assessed how caregivers use and value services with a national, web-based survey (N=1,407 caregivers) and semi-structured phone interviews (N=50 caregivers).Findings: Caregivers rated all services as helpful and especially valued financial support to be with the veteran, training in skills for symptom management, and assistance with navigating the healthcare system. A majority reported more confidence in caregiving, knowing about resources for caregiving and feeling better prepared to support the veteran’s progress and healthcare engagement. However, only a minority reported awareness of the full range of PCAFC services.Limitations: There was a low response rate to the survey, which may have implications for generalisability to the whole population of caregivers accessing PCAFC. Additionally, we rely on self-report rather than objective measures of service use and outcomes.Implications: This is the first in-depth examination of experiences of caregivers of using the innovative PCAFC model of support. It acknowledges the important role of caregivers in health and long-term (social) care delivery and can be used to inform development of strategies outside the VA healthcare system to recognise caregivers. Findings suggest that a system-wide program to effectively include caregivers as part of the care team should include mechanisms to help connect caregivers with an array of resources, options from which to find those which best fit their personal needs and preferences.
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.
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 aim of this study is to describe the characteristics of caregivers in PCAFC and examine associations between caregiver characteristics and caregiver well‐being outcomes. We found higher depressive symptoms among longer duration caregivers, coupled with high rates of reductions in hours worked, which suggests 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.
Long-term care settings are often hindered hy lack of knowledge regarding palliative care interventions at the end of life and a more rehabilitative orientation toward care, which may no longer be ...appropriate for these patients, '!his study provides compelling data on the large numbers of older adulls in long-term facilities who coukl hcnulil lrom good end-oI-IiIc care. The settings of long-term care and community-based advanced-illness care serve as natural intersection piiints lor palliative care and geriatric care providers Io collaborate and influence policy for belter care for older patients at the end of life.
OBJECTIVE: To assess the relationship between ethnicity and decision‐makers expressing healthcare wishes in a group of frail older persons enrolled in the Program of All‐inclusive Care for the ...Elderly (PACE).
DESIGN: A retrospective chart review of 1193 participants in the PACE program.
SETTING: Program of All‐inclusive Care for the Elderly, a comprehensive managed care demonstration program serving frail older participants at 10 sites across the nation.
PARTICIPANTS: A total of 1193 older adults, all of whom met state criteria for nursing home level of care. Three hundred were non‐Hispanic whites, 364 were black, 156 were Hispanic, and 288 were Asian.
MEASUREMENTS: Demographic characteristics of the patients and the presence or absence of an alternative decision‐maker; the characteristics of alternative decision‐makers included the relationship to the participant as recorded in the patient's medical record.
RESULTS: Ninety‐one percent of white patients expressed their own healthcare wishes in contrast to only 85% of Hispanic, 83% of Asian, and 67% of black patients. An alternative decision‐maker was identified for about 15% of Asians and Hispanics and for one‐third of blacks, but only about 8% of whites had an alternative decision‐maker. Black and Hispanic patients were most likely to have a daughter as an alternative decision‐maker, Asians were most likely to have a son, and whites patients were most likely to have a spouse as an alternative decision‐maker. Blacks, particularly black men, were the most likely to have a relative other than a spouse or child as an alternative decision‐maker.
CONCLUSIONS: In this population, we found significant ethnic variation in the person identified to be the decision‐maker in a group of frail older people. Ethnic variation reflected sociodemographic as well as cultural differences. However, there are important limitations to this study, and caution should be used in extrapolating the results to other populations or in attributing the results to ethnicity alone. An awareness of cross‐cultural patterns in identified or de facto decision‐makers can be significant for healthcare workers when they approach patients and their families about issues surrounding end of life decisions.
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