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Background: In 2007 we published a trial of home-based palliative care (HBPC) conducted in a managed care organization (MCO) that found significant improvements in patient satisfaction with health care, rates of home deaths, and reductions in health care use and costs. A decade later, we undertook a similar trial of HBPC within accountable care organizations (ACOs) funded by the Patient-Centered Outcomes Research Institute. This trial tested the same model using similar eligibility criteria and recruitment strategies as the earlier trial, yet it failed to achieve its enrollment targets. Objectives: To understand key differences in the trials that contributed to the success of one and failure of the other. Methods: We conducted a comparative case study of the original MCO HBPC trial and the subsequent ACO HBPC trial. Two researchers familiar with both trials reviewed both quantitative and qualitative data obtained from previous analyses and publications to develop a rich, in-depth understanding of each study. Results: We identified four differences that explain in large part why the ACO trial failed while the MCO trial succeeded. These differences center on the trials' setting, target populations, outreach strategies, and providers' understanding of palliative care. Discussion: Our findings demonstrate the challenges in conducting research in complex health care systems and how physician and setting structures along with target population and lack of general palliative care knowledge can influence the success of research. Conclusion: Future HBPC trials must consider the strengths and weaknesses of trial design factors when partnering with multiple health care organizations. ClinicalTrials.gov Identifier: NCT03128060. [ABSTRACT FROM AUTHOR]

Background: Lack of knowledge of palliative care has been identified as a primary barrier to access to care, with a recent survey reporting that Hispanics have the lowest rate of palliative care knowledge compared with other racial/ethnic groups. The purpose of this pilot study was to determine if there were trends toward improved palliative care knowledge after viewing four-minute video of a palliative care patient. Methods: We conducted a pre- and posttest pilot study among 50 Spanish-speaking, hospitalized Hispanic patients 40 years old and older in a large public hospital. We used the Palliative Care Knowledge Scale (PaCKS) to assess palliative care knowledge. Two questions measured intention to enroll in palliative care. Paired sample t-tests were conducted to investigate change in PaCKS scores. McNemar's test was used to compare differences in intentions to enroll in palliative care from pretest to posttest. We conducted linear regression analysis to determine factors associated with improved knowledge at posttest. Results: PaCKS scores revealed significant improvement in palliative care knowledge following viewing of the video, with scores increasing from an average of 6.4–11.4 at posttest. Intentions to enroll a family member in palliative care increased from 64% at pretest to 64%–98% at posttest. Intentions to enroll oneself increased from 72% to 92%. Conclusions: Brief exposure to a relatable role model may be effective in improving knowledge and intentions to enroll in palliative care services. More research is needed to determine if these videos are effective in increasing enrollment in palliative care. [ABSTRACT FROM AUTHOR]

Context: As funding for home-based palliative care continues to expand, there is an increasing need to understand barriers to patient referral to and acceptance of home-based palliative care.Objectives: The aim of this study was to elicit perspectives of home-based palliative care administrators and providers on barriers encountered in identification, referral, and enrollment of patients eligible for home-based palliative care.Methods: We conducted a qualitative study employing focus groups of nine home-based palliative care agencies across California. Focus groups were audio-recorded and transcribed. Using thematic analysis, researchers independently coded the transcripts and identified themes from the codes.Results: A total of 25 HBPC staff participated in the nine focus groups. Participants included both clinicians (n = 17) and administrators (n = 8). Our analysis revealed 13 themes that fit under four major thematic categories: 1) lack of formal payment structures (few HBPC payors and variation in payment and services among payors), 2) agency structure barriers (limitations of electronic medical records and multiple lines of business), 3) patient- and family-level barriers (misconceptions and/or lack of palliative care knowledge, uninformed of the referral and/or no warm hand-off, reluctance to have strangers in the home, overwhelmed with health issues and related services, HBPC service refusal/unresponsive to outreach), and 4) physician-level barriers (misconceptions and/or lack of palliative care knowledge, variability in HBPC payment and services, lack of time, patient ownership).Conclusion: HBPC providers identified a myriad of barriers that preclude patient access to HBPC. With growing provision of HBPC services, greater efforts to overcome these barriers are needed. [ABSTRACT FROM AUTHOR]

Background: Although payment for home-based palliative care (HBPC) is slowly spreading, there remains significant challenges in engaging patients and physicians in palliative care programs and research. This challenge was illustrated in our previous HBPC trial that failed to identify and enroll eligible patients in both the study and in HBPC services. Objectives: The objective of this study was to determine challenges to participation in HBPC and in research among patients, caregivers, primary care physicians, HBPC providers, and accountable care organizations (ACOs). Design: We conducted a qualitative study employing individual interviews and focus groups. Setting/Subjects: We recruited patients (n = 17), caregivers (n = 8), primary care providers (n = 31), home-based care providers (n = 25), and ACO administrators and leaders (n = 12) from California, United States. Measurements: We used semistructured interview protocols to elicit perceived barriers to HBPC services and research. Results: We identified four overarching themes related to barriers to HBPC and palliative care research. These themes included: (1) limitations of patient recruitment strategies; (2) timing of stakeholder engagement; (3) lack of palliative care health literacy; and (4) novelty of the HBPC market. Conclusion: These findings point to factors that contributed to the failure, and subsequent closure, of the original randomized controlled trial. Our findings may inform the further development of HBPC and, more generally, palliative care practice and policy. ClinicalTrials.gov Identifier: NCT03128060. [ABSTRACT FROM AUTHOR]

Objectives: Medication‐related problems remain one of the largest health risks for older adults, yet there are few resources available to effectively reduce medication‐related problems for community dwelling older adults. The aim of this pilot program was to determine the effectiveness of a multifaceted medication intervention on medication adherence and self‐efficacy in medication use. Design: A single sample, pre‐post‐test design. Setting: This pilot study was conducted at Independence at Home, a Senior Care Action Network (SCAN) community service in Southern California. Participants: One hundred and eighty community‐dwelling, diverse older adults with potential medication‐related problems and their caregivers. Intervention: The Community Medication Education, Data, & Safety (C‐MEDS) Program identified community‐dwelling older adults with potential medication‐related problems and provided in‐depth personalized medication safety, management and support, based on an in‐home assessment and interventions delivered by trained geriatrics experts including pharmacists, nurses, a community health worker, and a pharmacy technician. Measurements: The primary outcomes included medication use self‐efficacy, measured by the MUSE, and select medication adherence measures. Adherence was measured via pill count and via the MedAdhIR tool, a scale that measures risk for medication non‐adherence. Results: Following participation in the C‐MEDS program, community‐dwelling older adult C‐MEDS graduates (n = 105) had higher self‐efficacy in managing medications (P <.001). Additionally, C‐MEDS graduates also exhibited increased adherence to three types of medications (statins, diabetes‐related, and certain hypertension drugs; P <.001). Moreover, risk of non‐adherence declined significantly following C‐MEDS graduation (P <.001). Conclusion: C‐MEDS holds promise as an effective intervention among community‐dwelling older adults in improving medication self‐efficacy, medication adherence among select medications, and reducing risk for non‐adherence. Additional studies are needed to assess replicability and impact on clinical outcomes. [ABSTRACT FROM AUTHOR]

Background: Little is known about strategies for enrolling patients in home-based palliative care programs despite the need to conduct effectiveness studies of this emerging industry.Purpose: We used medical claims data from Accountable Care Organizations in California to identify patients for a randomized controlled trial of home-based palliative care. We report outcomes from this strategy and the implications for future research.Results: Claims data identified 1357 patients. Research assistants could not reach 986 patients (72.7%), usually because the phone calls went unanswered (38.5%) and many patients' phone numbers were missing or incorrect (16.3%). Of 371 patients reached, 163 opted out. Of 208 patients screened, 177 were ineligible for the trial. Just 10 patients were enrolled.Recommendations: Our findings suggest that medical claims data may not be useful for engaging patients potentially eligible for palliative care research trials. We recommend that alternative identification and recruitment strategies be considered. [ABSTRACT FROM AUTHOR]

Background: Studies show significant associations between the various dimensions of religiousness and end-of-life (EOL) decisions, such as individuals with high religiosity are more likely to choose aggressive care at EOL. However, these studies focused largely on smaller cancer populations. To our knowledge, there is no existing literature about the association between religiosity and EOL decisions within a national sample of older adults. Objective: The objective of this study was to investigate the association between religiosity and advance directive (AD) completion, and among those with an AD, documented EOL care preferences, using a nationally representative sample. Methods: This was an observational study. Descriptive statistics and logistic regression were conducted with 6051 decedents from the Health and Retirement Study using self-reported frequency of religious service attendance, importance of religion, and religious affiliation. Measurements: The dependent variables were AD completion and care preference. The independent variables were self-reported frequency of religious service attendance, importance of religion, and religious affiliation. Results: Protestants and Catholics had significantly lower odds of AD completion, compared with those with no religious preferences. Decedents who reported religion as very important had significantly lower odds of AD completion than decedents who said religion is not too important. Furthermore, decedents who attended religious services at least once a week, compared with those who do not attend, had significantly higher odds of completing an AD. Among those who completed an AD, neither religiosity nor religious affiliation was significantly associated with preference for prolonged care. Conclusions: Our study demonstrates the influence religiosity has on the development of ADs, prompting seriously ill patients' religious needs to be recognized and supported. It further suggests that religious services may provide a good opportunity for promoting knowledge and completion of ADs. [ABSTRACT FROM AUTHOR]

Introduction: Studies show that home-based palliative care (HBPC) improves participant outcomes and satisfaction with care while also decreasing hospitalizations and emergency department visits. U.S. health care payment reforms create financial opportunities to offer HBPC. Consequently, more HBPC programs are emerging, heightening the need to evaluate their effectiveness. Methods: This randomized, controlled trial is comparing the effectiveness of an evidence-based model of HBPC and enhanced usual primary care for participants who receive primary care from medical groups and clinics organized under an accountable care organization or Medicare Advantage plan. Palliative care services are reimbursed by our partnering health plan provider. The five-year trial will enroll 1155 seriously ill participants (and ∼884 of their caregivers) with heart failure, chronic obstructive pulmonary disease, or advanced cancer. We are collecting data via telephone surveys with participants at baseline and one and two months postenrollment and with caregivers at baseline, one and two months postenrollments, and following the death of a loved one. We are collecting participant-reported outcome measures of pain, symptoms, anxiety, depression, participant-provider communication, and hope. Caregiver outcome measures include caregiver burden, communication with providers, anxiety, and depression. Additional outcomes are participant survival time and participants' emergency department visits and hospitalizations. Study Implementation: Challenges and Contributions: Our research team has encountered several significant challenges in early study implementation. These include engaging primary care providers in the study and coordinating logistics with a health plan. Both challenges have contributed to a lag in participant enrollment. Despite these challenges, our study holds tremendous promise to accelerate adoption and spread of an evidence-based HBPC model across the country. [ABSTRACT FROM AUTHOR]

Context: Given recent Medicare rules reimbursing clinicians for engaging in advance care planning, there is heightened need to understand factors associated with the timing of advance directive (AD) completion before death and how the timing impacts care decisions.Objective: The purpose of this study was to investigate patterns in timing of AD completion and the relationship between timing and documented care preferences. We hypothesize that ADs completed late in the course of illness or very early in the disease trajectory will reflect higher preferences for aggressive care.Methods: We conducted a retrospective study using logistic regressions to analyze data from the Health and Retirement Study, a nationally representative longitudinal survey of older adults.Results: The analytic sample included exit interviews conducted from 2000 to 2012 among 2904 proxy reporters of deceased participants who had an AD. Nearly three-quarters (71%) of ADs were completed a year or more before death. Being younger or a racial/ethnic minority, and having lower education, a diagnosis of cancer or lung disease, and an expected death were associated with completing an AD within the three months before death, while having the lowest quartile of assets and memory problems were inversely associated with AD completion. Minorities, those with lower education, expected death, and timing of AD completion were associated with electing aggressive care.Conclusion: Early documentation of care wishes may not be associated with an increased likelihood of electing aggressive care; however, ADs completed in the last months of life have higher rates of election of aggressive care. [ABSTRACT FROM AUTHOR]

Objectives To determine the perspectives of seriously ill individuals on reasons for 30-day hospital readmission. Design A prospective qualitative study was conducted employing individual interviews conducted at bedside. Setting Department of Veterans Affairs Greater Los Angeles Healthcare System. Participants Seriously ill individuals with heart failure or cancer receiving inpatient palliative care and readmitted to the hospital within 30 days of hospital discharge were recruited to participate. Nine were interviewed. Measurements A semistructured interview protocol was used to elicit participant perspectives on readmission causes. Results All participants were male and had a mean age of 70.1 ± 9.5. Participants were ethnically diverse (three African Americans, three Caucasians, three Hispanic or mixed ethnic background). Six lived alone, and four did not have caregiver support. Qualitative analysis of transcripts revealed three themes relating to reasons for hospital readmission: lack of caregiver support and motivation to provide self-care, acceptance of condition and desire for aggressive care, and access to care and poor quality of care. Conclusion Participants identified potentially avoidable reasons for hospital readmission as well as causes that require rethinking regarding how community support is targeted and delivered. Participant preference for aggressive care, inability to provide self-care, and lack of caregiver support suggest the need for new and innovative mechanisms to support seriously ill community-dwelling individuals. [ABSTRACT FROM AUTHOR]

Despite international growth in policies to increase the identification and response to elder abuse and neglect, there remain considerable barriers to treating the problem. Some of these barriers may be attributed to how older adults from different racial/ethnic backgrounds define, experience and seek to remedy elder mistreatment. Using focus group discussions based on case vignettes, this paper examines how older adults from different racial and ethnic backgrounds in the United States of America perceive elder mistreatment. Five focus groups were conducted with African Americans, English-speaking Latinos, Spanish-speaking Latinos, non-Latino Whites and African American care-givers for older adults. While similar definitions and meanings of elder abuse were expressed across the different racial/ethnic groups, Latino participants introduced additional themes of machismo, respect, love and early intervention to stop abuse, suggesting that perceptions/beliefs about elder mistreatment are determined by culture and degree of acculturation in addition to race/ethnicity. Most differences in attitudes occurred within groups, demonstrating that perceptions vary by individual as well as by culture. In identifying scenarios that constitute elder mistreatment, some participants felt that certain cases of abuse are actually the persistence of intimate partner violence into old age. Participants also indicated that victims may prefer to tolerate mistreatment in exchange for other perceived benefits (e.g. companionship, security); and out of fear that they could be placed in an institution if mistreatment is reported. Findings suggest the need for person-centred intervention and prevention models that integrate the cultural background, care needs and individual preferences of older adults. [ABSTRACT FROM PUBLISHER]

The article discusses research which examined the impact of inpatient palliative care consultations on family members' understanding of the patient's condition, knowledge of available care options and decision-making ability. It cites family members' involvement in end-of-life decision making. Themes which emerged from the study include perceived quality of the inpatient palliative care consultation, family readiness, effect on decision making and focus on comfort and quality of life.

Despite dramatic increases in hospice enrollment, ethnic disparities persist. With rapidly growing populations of Asian Americans, research is needed to elucidate factors that contribute to hospice underenrollment in subgroups of Asian populations. The purpose of this study was to explore older Chinese Americans' knowledge, understanding, and perceptions of hospice care. Three focus groups were conducted, one each in English, Mandarin, and Cantonese, all recruited from a Chinese social service agency. Focus groups were audiotaped and transcribed and then coded for themes. Thirty-four Chinese Americans participated in the groups, all but one reporting primary language other than English. Themes included lack of knowledge, death timing, burden (financial, emotional, physical toward family or government), peaceful death (relief of suffering), and quality of care (and its influence on perception of best care location). Findings indicate the need for hospice education and outreach to Chinese Americans. Additionally, to address concerns about burden and death in the home, efforts to improve access to hospice facilities are needed. Findings from this study provide direction for healthcare providers to address potential barriers to increasing access to hospice of Chinese Americans. [ABSTRACT FROM AUTHOR]

Objectives Research with lesbian, gay, and bisexual (LGB) older widows rarely focuses on familial relationships. Studies on heterosexual spousal bereavement indicate older widows face issues influencing identity but show resilience by maintaining close relationships with adult children and extended family. Though research with older LGB widows suggests similarities around loss and resilience, grief and family engagement are markedly different. Methods Guided by Relational Cultural Theory, which illuminates how LGB women cope through connection/disconnection, this qualitative descriptive study employed semistructured, open-ended interviews with 16 LGB women, 60–85 years of age from across the United States who had lost a spouse or partner within the past 5 years. We conducted interviews regarding the perception of self as bereaved LGB women and sustained or altered relationships with biological and chosen families following the loss of their spouses/partners. Results Findings are illustrated in three themes around acceptance, support, and identity. Participants: (a) experienced differing levels of acceptance, tolerance, and inclusion from biological families; (b) experienced family or friends "disappearing" or providing critical support following a spouse/partner's death; and (c) negotiated challenges by creating or seeking out families of choice, new communities, and a better understanding of themselves. Discussion While LGB widows share some grief experiences with heterosexual widows, they also experience varying biological family acceptance and support, as well as the need for friends and families of choice as advocates. It is important to recognize the unique consequences of spousal loss for this population and be cognizant of the differences in normative grief. [ABSTRACT FROM AUTHOR]

Background: Inpatient palliative consultation are generally provided to seriously ill hospitalized patients with the intent to alleviate pain and suffering and develop a plan of care for the patient. Although numerous benefits of this service have been documented, little is known about hospital readmission rates and factors associated with these readmissions. Objective: Our aim was to investigate factors associated with 30-day hospital readmission among patients receiving a consultation from an inpatient palliative care (ICP) team. Design: We conducted a retrospective cohort study. Setting/Subjects: Data from 408 managed care patients 65 years old and older were collected in 2007-2009 following an IPC consultation and subsequent hospital discharge. Measurements: IPC and medical service use records were utilized. Results: Among IPC patients, 10% of those discharged from the hospital were readmitted within 30 days. Factors associated with hospital readmission included being discharged from the hospital with no care in the home or to a nursing facility. Receipt of hospice or home-based palliative care post-discharge was associated with significantly lower odds of hospital readmission. Conclusions: This study found that receipt of palliative care following hospital discharge was an important factor in reducing 30-day hospital readmissions. Further study is needed to evaluate the effectiveness of longitudinal palliative care models in reducing 30-day hospital readmissions among seriously ill patients. [ABSTRACT FROM AUTHOR]

This article describes problems identified by older primary care patients enrolled in Problem Solving Therapy (PST), and explores factors associated with successful problem resolution. PST patients received 1 to 8, 45-min sessions with a social worker. Patients identified problems in their lives and directed the focus of subsequent sessions as consistent with the steps of PST. The 107 patients identified 568 problems, 59% of which were resolved. Most commonly identified problems included health related issues such as need for exercise or weight loss activities, medical care and medical equipment needs, home and garden maintenance, and gathering information on their medical condition. Problems identified by patients were 2.2 times more likely to be solved than those identified by a health care professional. Using PST in primary care may facilitate patients in addressing key health and wellness issues. [ABSTRACT FROM AUTHOR]

Objectives: To test a brochure comprising hospice patient role model stories aimed at improving attitudes and knowledge of hospice among older African Americans. Design: Pre-post community-based study. Setting: Community-based organizations including senior centers, community exercise programs, churches, and senior care management services in greater Los Angeles area. Participants: Seventy-one African Americans aged 65 and older. Intervention: Hospice brochure containing theoretically driven role model stories portraying African Americans' experience with hospice, their initial attitudes and beliefs about hospice, factors influencing their enrollment in the program, and outcomes following enrollment. Measurements: Change from baseline in attitudes toward, knowledge of, and intentions to enroll in hospice. Results: Mean knowledge scores (range, 0-9) increased from 5.76 (standard deviation [SD] = 2.12) at pretest to 6.95 (SD = 1.90) at posttest ( t = −6.14, p < 0.001). Average attitude toward hospice (range, 12-72) improved 12.5% from 41.16 (SD = 5.20) to 46.29 (SD = 5.45) ( t = −7.52, p < 0.001). Intentions to enroll a family member in hospice increased from 84.5% to 92.9% ( p = 0.002) and intentions to seek hospice care for themselves increased from 83.1% to 95.8% ( p < 0.001). Conclusion: This small pre-post pilot study found that exposure to a hospice brochure containing theoretically driven, culturally parallel, role model stories was effective in improving knowledge of and attitudes toward hospice as well as intentions to enroll a family member or self in hospice care. Further study is needed to determine the impact of using this brochure within a clinical setting. [ABSTRACT FROM AUTHOR]

Background: Few studies have examined ease of integrating palliative care programs into hospital culture. The purpose of this article is to report findings from focus groups conducted among physicians and nurses to elicit their perceptions of an inpatient palliative care team consultation service after 1 year of operation. Methods: The study consisted of four homogeneous focus groups drawn from a purposive sample of physicians (2 groups; total n = 16) and nurses (2 groups; n = 17) at a large urban managed care center. Structured interview protocols were used to elicit participant perceptions regarding the impact of implementation. Focus groups were audiotaped and transcribed verbatim. We analyzed the data using grounded theory techniques to elicit themes and subthemes. Results: Five major themes emerged regarding the positive and/or transformational impact of the program on patient/family services, medical staff, the hospital, quality of care, and time. Physician and staff observations regarding perceived barriers to integration included subthemes pertaining to the sharing of information, patient/family resistance and cultural differences, and the need for increased services. Conclusions: The vast majority of comments expressed were related to positive aspects of the program. However, barriers exist that prevent some terminally ill patients from receiving these services. Findings from this study have implications for the need for education and training among providers on palliative and hospice services and, in particular, on the benefits of an inpatient palliative care team for patients, regardless of their attitudes toward end-of-life care programs. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To determine whether an in-home palliative care intervention for terminally ill patients can improve patient satisfaction, reduce medical care costs, and increase the proportion of patients dying at home. DESIGN: A randomized, controlled trial. SETTING: Two health maintenance organizations in two states. PARTICIPANTS: Homebound, terminally ill patients (N=298) with a prognosis of approximately 1 year or less to live plus one or more hospital or emergency department visits in the previous 12 months. INTERVENTION: Usual versus in-home palliative care plus usual care delivered by an interdisciplinary team providing pain and symptom relief, patient and family education and training, and an array of medical and social support services. MEASUREMENTS: Measured outcomes were satisfaction with care, use of medical services, site of death, and costs of care. RESULTS: Patients randomized to in-home palliative care reported greater improvement in satisfaction with care at 30 and 90 days after enrollment ( P<.05) and were more likely to die at home than those receiving usual care ( P<.001). In addition, in-home palliative care subjects were less likely to visit the emergency department ( P=.01) or be admitted to the hospital than those receiving usual care ( P<.001), resulting in significantly lower costs of care for intervention patients ( P=.03). CONCLUSION: In-home palliative care significantly increased patient satisfaction while reducing use of medical services and costs of medical care at the end of life. This study, although modest in scope, presents strong evidence for reforming end-of-life care. [ABSTRACT FROM AUTHOR]

Purpose: To examine differences in site of death and costs of services by primary diagnosis for patients receiving home-based palliative care as compared to usual care at the end of life. Design and Methods: A nonequivalent group design was employed with 298 terminally ill patients diagnosed with cancer, CHF, or COPD enrolled. The treatment group received an interdisciplinary home-based palliative care program and the comparison group received usual Kaiser Permanente services. Data collected included patient demographics, Severity of illness, service use, and site of death. Results: Among all diseases, patients enrolled in palliative care were more likely to die at home. Enrollment in palliative care was significant associated with cost reductions for patients with cancer, COPD, and CHF. No significant difference was found between diagnostic groups in terms of magnitude of cost savings. Implications: Provision of interdisciplinary home-based palliative care at end of life can effectively increase the likelihood of dying at home for patients with CHF, COPD, and cancer while realizing, significant cost savings. [ABSTRACT FROM AUTHOR]

This is a retrospective study using secondary data to investigate variation in site of death by ethnicity and to determine how hospice enrollment affects site of death. Data for this study were obtained between 1996 and 2000 from linked Medi-Cal and Medicare claims from 18 California counties participating in a state legislated effort to improve chronic care services in California. Subjects examined in this study included 38,519 decedents aged 65 and older who died between 1997 and 2000 and were dually eligible the entire year immediately before death. Demographic variables were site of death, cause of death, hospice use, and care setting in the year before death. Results revealed that blacks and Latinos were significantly more likely than whites to die at home, although being black or Asian was negatively associated with hospice use. This variation did not change when hospice use was controlled. Thus, although minorities were more likely to die at home, they were less likely to receive hospice care. Because patients dying at home without hospice care report higher rates of pain than those who have hospice care, physicians must work to ensure that minority patients understand all end-of-life care options, including hospice, and how these care options can be delivered in a culturally competent manner. [ABSTRACT FROM AUTHOR]

Studies of Geriatric Care Management Programs have had mixed results at best. Little evidence exists to attest to the effectiveness of these programs in improving patient outcomes and decreasing avoidable acute care service use. In response to these data, Kaiser Permanente's Geriatric Care Management program initiated a randomized trial to test an integrated, multifaceted depression treatment model within the care management framework and its ability to detect and treat moderately and severely depressed older adults. This paper presents case studies of the geriatric care managers' practice changes associated with this intervention as well as case studies of two depressed clients, their experiences and outcomes associated with this study. Implications of this model are discussed. [ABSTRACT FROM AUTHOR]

Medication errors are common among older adults, particularly among those who are at heightened risk due to transfer between care settings. Determining accurate medications for hospitalized patients is a complicated process. This paper presents findings from a small pilot study conducted to identity medication documentation problems at the point of hospital discharge among older adults and the problems encountered in developing new technological systems to address these problems. A prospective study was conducted within a managed care medical center that included patient and physician surveys and chart reviews. A review of 104 medical records revealed several problems in the documentation of patient medication including legibility, use of medical abbreviations and incomplete and missing entries. While patients overall were satisfied with medications communication efforts at discharge, physicians surveyed reported that these methods were inadequate in transmitting medication lists to primary care physicians, patients and other care providers. Patients reported taking more drugs than what were listed in the medical record. These findings led to the development, testing, and implementation of an electronic medication sheet. Despite the success in developing this new system, few physicians engaged in its use, with most preferring to continue with their standard discharge practices of written communication. [ABSTRACT FROM AUTHOR]

The article reviews a successful community-based end-of-life home care program. Specifically, physician visits were compared in the models of care studied, and it was concluded that the community-based model patients benefited significantly over the standard model of care patients due to the use of physicians. [ABSTRACT FROM AUTHOR]

Context: Despite the widespread recognition of the need for new models of care to better serve patients at the end-of-life, little evidence exists documenting the effectiveness of these models. Objective: To evaluate the effectiveness of a palliative program for end-of-life care. Design: A comparison group study was conducted between March 1999 and August 2000 comparing subjects enrolled in a palliative care intervention to those receiving usual care. Setting: Home Health Department at Kaiser Permanente, TriCentral Service Area. Subjects: During the course of the 2-year study, 558 subjects were enrolled. A subgroup of 300 patients who had died during the course of the study was selected for analysis; 161 were enrolled in the Palliative Care Program and 139 in the comparison group. Intervention: The Kaiser Permanente Palliative Care Project is a multidisciplinary care management approach for home-based end of life care and treatment. The program is designed to facilitate the transition from acute to palliative care during the last 12 months of life with the goal of improving quality of life through the provision of symptom control and pain relief, emotional and spiritual support, and patient education. Main outcome measures: Medical service use and satisfaction with services. Results: Palliative care patients had increased satisfaction with services at 60 days after enrollment and significantly fewer emergency department visits, hospital days, skilled nursing facility days, and physician visits than those in the comparison group. Those enrolled in palliative care averaged a 45% decrease in costs as compared to usual care patients. Conclusion: Through integrating palliative care into curative care practices earlier in the disease trajectory, chronically ill patients nearing the end of life report improved satisfaction with care and demonstrate less acute care use resulting in lower costs of care. In addition, patients enrolled in the palliative care program were more likely to die at home than comparison group patients. [ABSTRACT FROM AUTHOR]

This article describes a geriatric care management project that is testing whether geriatric care management plus a brief purchase of service (POS) intervention will lower medical costs, improve satisfaction with care, increase care plan adherence, and improve perceived quality of life. Kaiser Permanente members aged 65 and older who were eligible for geriatric care management and consented to participate in the study were randomized to one of four study groups: information and referral via mail, telephone care management, geriatric care management, or geriatric care management with POS capability. The POS intervention provides up to $2,000 of designated, paid services including in-home supportive services, transportation, respite, or medical equipment within the first 6 months of care management enrollment. Approximately 1,400 senior members were referred to the geriatric care management program, and 451 were randomly assigned to one of the four study groups. Those enrolled in the geriatric care management program were significantly more likely to be ethnic minorities and have lower income than the general Kaiser Permanente senior enrollment. Barriers encountered in implementing the POS intervention included establishing contractual agreements between Kaiser Permanente and private and community agencies, locating adequate and sufficient community agencies to provided needed services, monitoring service contracts, and delaying use of the POS benefit. [ABSTRACT FROM AUTHOR]

Describes a theory-based HIV prevention intervention implemented for the development and testing of a community-level intervention to reduce AIDS risk among historically underserved groups in the United States. Development of role model stories; Description of at-risk population; Increasing the credibility of the intervention and the acceptance of the message.

Background: Lesbian, gay, and bisexual (LGB) older women have unmet communication needs around palliative and end-of-life care. Past research has found communication differences for LGB women patients. Consequently, older LGB women may experience healthcare communication barriers around advance care planning. Aim: To explore experiences of bereaved LGB older women to understand perspectives regarding advance care planning communication between clinicians, patients, and dyads. Design: Guided by queer gerontology as a theoretical framework, this qualitative descriptive study employed individual interviews with purposively recruited participants. Interviews were conducted in person using a semi structured protocol and analyzed using inductive thematic analysis. Setting/participants: Sixteen LGB women, age 60 years or older from across the United States who had lost a spouse/partner within the past 5 years. Results: Four main themes emerged from the transcripts, LGB older women: (1) experience unclear advance care planning communication and end-of-life care support from clinicians, (2) often avoid advance care planning discussions with spouse or partners, (3) lack of knowledge about palliative or end-of-life care, and (4) have more positive experiences when there is consistent communication with spouse or partner and clinicians during a spouse/partner's illness and end-of-life. Discussion: While certain experiences and opinions may reflect those of non-LGB older adults, novel advance care planning barriers exist for LGB older women. Greater understanding among clinicians is needed regarding advance care planning conversations with LGB dyads. We recommend four improvements in training, recognition, acceptance, and dyad-based communication interventions. [ABSTRACT FROM AUTHOR]

We examine the end-of-life (EOL) experiences, communications, and grief support during and after their loved one's death of older lesbian, gay, and bisexual women (LGB) ages 60 to 85 who have lost a spouse or partner. Queer gerontology was used as a theoretical framework, and descriptive qualitative analytical methods were used to discern themes. Through semi-structured interviews with a purposive sample of 16 participants, we identified two main themes: Gathering the Women and Compassionate Care. Although older LGB women may have some similar support needs as non-LGB adults, other needs are distinct but often unmet. While our participants' interactions with health care professionals were overtly positive, there was often a lack of communication about grief resources, including lesbian and women-specific grief groups. Overall researchers, policymakers, and practitioners should be mindful of the importance of fully integrating and including populations into their care practices to avoid creating systems of superficial tolerance. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented regarding the need to evaluate palliative care programs that will match the needs of patients to close the service gap that was published in a previous 2016 issue.

In 2016 fee-for-service Medicare began reimbursing physicians for advance care planning conversations with enrollees during outpatient visits and waived the copayment for advance care planning when it was part of the Medicare annual wellness visit. Advance care planning is intended to help providers treat patients in ways consistent with their wishes and may also reduce unnecessary health care use and spending. Examining fee-for-service Medicare claims, we found a substantial increase in outpatient advance care planning claims between 2016 and 2019, although prevalence remained below 7.5 percent for all patient subgroups analyzed. Roughly half of beneficiaries with advance care planning claims received the service at an annual wellness visit; the remainder received it at a different outpatient visit. Among those with claims, Black, Hispanic, and Medicaid dual-eligible patients and patients with comorbidities were less likely to have a claim at an annual wellness visit, largely because they have fewer such visits overall. Medicare's annual wellness visits offer the potential to expand enrollees' access to advance care planning at no expense to them, in advance of serious illness, and to populations less likely to undertake advance care planning generally. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to an article on the terminal care of seriously ill patients and their wishes regarding resuscitation.

Background: The physician orders for life-sustaining treatment (POLST) form allows seriously ill individuals to express their preferences for end-of-life treatments. Despite increased POLST use, little is known about the quality of completed forms. Objective: We examined the quality of POLST forms prepared for nursing home residents, including whether they had required signatures and clinically consistent care preferences. Design: We conducted a chart review of POLST forms for a sample of nursing home residents in California. Setting/Sample: We completed POLST audits for 938 residents in 13 nursing homes in Los Angeles. Measures: We recorded whether POLST forms were signed by both the patient (or proxy) and the physician, and whether the patient's treatment choices regarding resuscitation and medical intervention were consistent, as required by the California form. Results: Overall, 69.6% of audited POLST forms had at least one indicator of poor quality. Most lacked a required signature (15.8% lacked a physician signature and 17.4% lacked a patient/proxy signature) and 5.6% had conflicting treatment preferences. Conclusion: We found 30.4% of POLST forms for nursing home residents were not complete or documented clinically contradictory treatment preferences. Improvement in the quality of POLST forms is needed. [ABSTRACT FROM AUTHOR]

Background: End-stage liver disease (ESLD) patients carry heavy symptom burdens and risk receiving aggressive and sometimes unwanted care at end of life. Palliative care (PC), which aims to alleviate symptoms and facilitate goal-concordant care in serious illness, may offer substantial benefits for ESLD patients but is not widely provided. Objectives: To assess the impact of PC integrated within hepatology (PCIH) services on health care utilization, advance care planning (ACP), and hospice enrollment. Design: We compared patients who received PCIH (n = 55) to a retrospective cohort (n = 57) receiving usual care in an outpatient hepatology clinic. Setting/Subjects: From June 2016 to November 2017, we enrolled patients receiving care in a U.S. public hospital clinic who met the following inclusion criteria: (1) ESLD with a Model for End-Stage Liver Disease score ≥20, (2) hepatology approval for PC referral, and (3) at least one advanced complication of ESLD. Measurements: We assessed patient demographics, clinical information, health care insurance status, health care utilization, completion of psychosocial assessments, and ACP using two-sided Fisher's exact test and Mann–Whitney U tests. Results: Patients receiving PCIH more frequently had goals of care discussions (87.3% vs. 21.2% p ≤ 0.01), completed ACP documentation (56.4% vs. 7.0%, p ≤ 0.01), psychosocial assessments (98.2% vs. 35.1%, p ≤ 0.01), and hospice enrollment (25.5% vs. 7.0%, p = 0.01). Patients receiving PCIH who were hospitalized also had fewer mean hospitalization days (13 vs. 19.7 days, p ≤ 0.01). Conclusions: Embedding PC services in a hepatology clinic is a promising strategy to improve care for ESLD patients in public hospitals. [ABSTRACT FROM AUTHOR]

Although advance care planning ( ACP) is associated with better care at the end of life, better quality of death, and less psychological distress in survivors, ethnic disparities in ACP completion rates have been documented and may be attributable to lack of knowledge about ACP or differences in cultural values and preferences. Despite rapid increases in the size of the Asian-American population, little is known about ACP preferences of Chinese Americans. The purpose of this study is to explore the knowledge, attitudes, and preferences of older Chinese Americans toward ACP. Focus groups with Chinese older adults (n = 34) were conducted in Mandarin, Cantonese, and English, and transcripts were analyzed using a grounded theory approach. Identified themes included knowledge and experience with ACP and end-of-life care options, health as a factor in timing of ACP and communication, and communication of end-of-life care preferences. Knowledge of and experience with ACP and end-of-life decision-making varied according to focus group, although few participants had an advance directive. Findings suggest that Chinese older adults prefer to use indirect communication strategies, such as commenting on the circumstances of others rather than directly stating their wishes, and informal contexts, such as during a family dinner rather than formal meeting, to convey their care preferences to loved ones and may employ similar tactics when communicating with clinicians. This is particularly important given the recent decision by the Centers for Medicare and Medicaid Services to provide reimbursement to physicians for engaging in advance care planning conversations. [ABSTRACT FROM AUTHOR]

Background: A primary barrier to physician disclosure of terminal prognosis is concern that patients will lose hope. Inpatient palliative care (IPC) teams are especially posed to mediate this barrier, but little is known about patient perceptions and experience of IPC. Objective: This study aimed to elicit seriously ill patients' perspective and experience of an IPC consultation, and to explore patient attitudes toward information derived from the consultation. Methods: An exploratory, qualitative study was conducted at a large nonprofit community hospital in the Los Angeles area. An established IPC team conducted individualized consults with patients and families within 24 hours of referral. Eligible participants were English-speaking adults, aged 18 or over, who had received an IPC consultation within the previous week during their hospitalization. Purposive recruitment of patients was conducted by the IPC social worker. Interviews were conducted at bedside using a semistructured interview protocol employing open-ended questions. Results: Twelve seriously ill patients were interviewed. Four themes were identified from the interview transcripts: (1) holistic care approach, (2) knowledge/information gained, (3) hope and enlightenment, and (4) patient readiness. Conclusions: Results suggest that disclosure of a terminal prognosis does not mean loss of patient hope. Instead, hope was redefined on a goal other than cure. Presenting patients with information and increasing their knowledge about care options and resources may facilitate patients in identifying meaningful goals that are better aligned with their prognosis. [ABSTRACT FROM AUTHOR]

Objective To investigate the prevalence of depression symptoms among Latinos with diabetes following transition from hospital to home and the relationship of depressive symptoms to diabetes symptom severity and self-management activities. Methods 203 Latino patients with diagnosed diabetes completed a survey assessing depressive symptoms (PHQ-9), diabetes symptom severity, and diabetes self-management activities (SDSCA). Characteristics and diabetes outcomes between patients with and without probable major depression were compared. Associations between PHQ-9 scores and diabetes outcomes were assessed. Multivariate regression models evaluated the relationship between depressive symptoms and diabetes outcomes and exercise after controlling for patient characteristics. Results 31.5% of participants indicated probable major depression (PHQ-9 ≥ 10). More severe diabetes symptoms and less reported exercise were associated with higher PHQ-9 scores. Regression models showed no relationship between self-management and depression. More severe diabetes symptoms were significantly associated with being female, married, and having probable major depression. Odds of exercising were reduced by 6% for every one-unit increase in PHQ-9 score. Conclusions The prevalence of probable depressive symptoms is high in this population. Having depressive symptoms is an indicator of poorer diabetes symptoms. Screening for depressive symptoms may help identify individuals who need additional support with diabetes symptom and self-management. [ABSTRACT FROM AUTHOR]

Little is known about the experiences of health professionals in reporting suspected elder abuse and neglect (EAN) or the perceptions of Adult Protective Services (APS) in responding to reports. The purpose of this article is to examine the attitudes and perceptions of health professionals in responding to elder mistreatment and to compare these attitudes and perceptions to those of APS workers who investigate abuse. Focus groups were conducted with APS workers (n = 9) and two types of health professionals: geriatric care managers (n = 4) and hospice staff (n = 13). Transcripts were coded inductively, and emergent themes were compared across groups using thematic analysis. Health professionals and APS workers acknowledged similar challenges resolving cases of EAN—particularly victim refusal of services or denial of abuse, limited APS authority, and large caseloads. APS workers identified unnecessary referrals and poor communication among providers as barriers to effectiveness. Health care workers noted they sometimes ignored mandatory reporting requirements, preferring to work directly with patients and families to remedy abuse. Results suggest that mandatory reporting may be a necessary but insufficient approach. Cross-agency collaboration between APS and health professionals may help enhance communications, clarify expectations, and potentially improve outcomes. Person-centered responses that link victims with community based services should also be explored to improve victim cooperation and to increase confidence in the adult protection system. [ABSTRACT FROM AUTHOR]

The article presents a study on older Japanese Americans' perceptions toward hospice care and advance care discussion and planning. Topics covered include how Asians and Pacific Islanders utilize hospice at very low rates compared with whites and other minority groups and the results of the study suggesting that one reason Japanese Americans minimally utilize hospice may be lack of knowledge and misconceptions about hospice and end-of-life care.

The primary aim of this article is to identify, from the perspective of primary care physicians and nurses, the challenges encountered in provision of health care to older adults and to identify potential roles, challenges, and benefits of integrating social workers into primary care teams. As more older adults live longer with multiple chronic conditions, primary care has been confronted with complex psychosocial problems that interact with medical problems pointing to a potential role for a social worker. From a policy perspective, the lack of strong evidence documenting the benefits that will accrue to patients and providers is a key barrier preventing the wider use of social workers in primary care. This article presents findings from three focus groups with primary care physicians and nurses to examine the perspectives of these key providers about the benefits and challenges of integrating social workers into the primary care team. [ABSTRACT FROM AUTHOR]

Background: Researchers are encountering increasing challenges in recruiting participants for palliative and healthcare research. This paper aims to understand challenges to and methods for engaging physicians and seriously ill patients and their caregivers in research studies. Methods: Between October 2019 to July 2020, we conducted qualitative interviews with 25 patients, proxies, and caregivers participants who were eligible for a randomized controlled trial of home-based palliative care and 31 physicians from participating accountable care organizations. Using thematic analysis, we analyzed participants' responses to identify concepts and key ideas within the text. From these initial concepts, core themes around barriers to research and preferred research recruitment approaches were generated. Results: Themes from patient and caregiver interviews included time constraints, privacy concerns, lack of research familiarity, disconnect with research institution, self-perceived health status, and concerns with study randomization. Physician-identified barriers focused on time constraints and study randomization. Patient and caregiver recommendations for study recruitment included in-person recruitment, recruitment at healthcare providers' offices, recruitment via mail, additional study information, and frequent calls. Physician recommendations were related to placement of flyers at clinics, financial incentives, and formal events. Conclusions: Findings demonstrated that although patients and caregivers prefer that their physicians recruit them for health-related research studies, physicians identified time constraints as a consistent barrier to research involvement. [ABSTRACT FROM AUTHOR]