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Key Points Question What are the common goals and health care preferences of older adults with multiple health conditions? Findings In this cross-sectional study, 163 older adults reported 459 goals, most commonly encompassing activities with family and friends (24.2%), shopping (6.1%), exercising (4.6%), and living independently (4.4%). Medications most commonly cited as helpful were nonopioid pain medications (65.5% of users), sleep medications (52.9% of users), and inhalants (42.2% of users), whereas statins (25.8% of users) and antidepressants (32.5% of users) were the most commonly reported bothersome medications. Meaning Participants identified realistic and doable goals and health care preferences; this information can inform decision-making., This cross-sectional study describes the outcome goals and health care preferences of older adults with multiple chronic conditions., Importance Older adults with multiple chronic conditions (MCCs) vary in their health outcome goals and the health care that they prefer to receive to achieve these goals. Objective To describe the outcome goals and health care preferences of this population with MCCs. Design, Setting, and Participants This cross-sectional study included participants in the Patient Priorities Care study who underwent health priorities identification from February 1, 2017, to August 31, 2018, in a primary care practice. Patients eligible to participate were 65 years or older, English speaking, and had at least 3 chronic conditions; in addition, they used at least 10 medications, saw at least 2 specialists, or had at least 2 emergency department visits or 1 hospitalization during the past year. Of 236 eligible patients, 163 (69%) agreed to participate in this study. Data were analyzed from August 1 to October 31, 2020. Exposures Guided by facilitators, participants identified their core values, as many as 3 actionable and realistic outcome goals, health-related barriers to these goals, and as many as 3 helpful and 3 bothersome health care activities. Main Outcomes and Measures Frequencies were ascertained for outcome goals and health care preferences. Preferences included health care activities (medications, health care visits, procedures, diagnostic tests, and self-management) reported as either helpful or bothersome. Results Most of the 163 participants were White (158 [96.9%]) and women (109 [66.9%]), with a mean (SD) age of 77.6 (7.6) years. Of 459 goals, the most common encompassed meals and other activities with family and friends (111 [24.2%]), shopping (28 [6.1%]), and exercising (21 [4.6%]). Twenty individuals (12.3%) desired to live independently without specifying necessary activities. Of 312 barriers identified, the most common were pain (128 [41.0%]), fatigue (45 [14.4%]), unsteadiness (42 [13.5%]), and dyspnea (19 [6.1%]). Similar proportions of patients identified at least 1 medication that was helpful (130 [79.8%]) or bothersome (128 [78.5%]). Medications most commonly cited as helpful were pain medications, including nonopiods (36 of 55 users [65.5%]) and opioids (15 of 27 users [55.6%]); sleep medications (27 of 51 users [52.9%]); and respiratory inhalants (19 of 45 [42.2%]). Most often mentioned as bothersome were statins (25 of 97 users [25.8%]) and antidepressants (13 of 40 users [32.5%]). Thirty-two participants (19.6%) reported using too many medications. Health care visits were identified as helpful by 43 participants (26.4%); 15 (9.2%) reported too many visits. Procedures were named helpful by 38 participants (23.3%); 24 (14.7%) cited unwanted procedures. Among 48 participants with diabetes, monitoring of glucose levels was doable for 18 (37.5%) and too bothersome for 9 (18.8%). Conclusions and Relevance Participants identified realistic and actionable goals while varying in health care activities deemed helpful or bothersome. The goals and health care preferences of more diverse populations must be explored. Previous work suggests that clinicians can use this information in decision-making.

Older adults with multiple chronic conditions (MCCs) receive care that is fragmented and burdensome, lacks evidence, and most importantly is not focused on what matters most to them. An implementation feasibility study of Patient Priorities Care (PPC), a new approach to care that is based on health outcome goals and healthcare preferences, was conducted. This study took place at 1 primary care and 1 cardiology practice in Connecticut and involved 9 primary care providers (PCPs), 5 cardiologists, and 119 older adults with MCCs. PPC was implemented using methods based on a practice change framework and continuous plan-do-study-act (PDSA) cycles. Core elements included leadership support, clinical champions, priorities facilitators, training, electronic health record (EHR) support, workflow development and continuous modification, and collaborative learning. PPC processes for clinic workflow and decision-making were developed, and clinicians were trained. After 10 months, 119 older adults enrolled and had priorities identified; 92 (77%) returned to their PCP after priorities identification. In 56 (46%) of these visits, clinicians documented patient priorities discussions. Workflow challenges identified and solved included patient enrollment lags, EHR documentation of priorities discussions, and interprofessional communication. Time for clinicians to provide PPC remains a challenge, as does decision-making, including clinicians' perceptions that they are already doing so; clinicians' concerns about guidelines, metrics, and unrealistic priorities; and differences between PCPs and patients and between PCPs and cardiologists about treatment decisions. PDSA cycles and continuing collaborative learning with national experts and peers are taking place to address workflow and clinical decision-making challenges. Translating disease-based to priorities-aligned decision-making appears challenging but feasible to implement in a clinical setting.

Objectives To develop a values‐based, clinically feasible process to help older adults identify health priorities that can guide clinical decision‐making. Design Prospective development and feasibility study. Setting Primary care practice in Connecticut. Participants Older adults with 3 or more conditions or taking 10 or more medications (N=64). Intervention The development team of patients, caregivers, and clinicians used a user‐centered design framework—ideate → prototype → test →redesign—to develop and refine the value‐based patient priorities care process and medical record template with trained clinician facilitators. Measurements We used descriptive statistics of quantitative measures (percentage accepted invitation and completed template, duration of process) and qualitative analysis of barriers and enablers (challenges and solutions identified, facilitator perceptions). Results We developed and refined a process for identifying patient health priorities that was typically completed in 35 to 45 minutes over 2 sessions; 64 patients completed the process. Qualitative analyses were used to elucidate the characteristics and training needed for the patient priorities facilitators, as well as perceived benefits and challenges of the process. Refinements based on our experience and feedback include streamlining the process for greater feasibility, balancing fidelity to the process while customizing to individuals, encouraging patients to share their priorities with their clinicians, and simplifying the template transmitted to clinicians. Conclusion Trained facilitators conducted this process in a busy primary care practice, suggesting that patient priorities identification is feasible and acceptable, although testing in additional settings is necessary. We hope to show that clinicians can align care with patients' health priorities.

Objective: To ascertain perspectives of multiple stakeholders on contributors to inappropriate care for older adults with multiple chronic conditions. Method: Perspectives of 36 purposively sampled patients, clinicians, health systems, and payers were elicited. Data analysis followed a constant comparative method. Results: Structural factors triggering burden and fragmentation include disease-based quality metrics and need to interact with multiple clinicians. The key cultural barrier identified is the assumption that “physicians know best.” Inappropriate decision making may result from inattention to trade-offs and adherence to multiple disease guidelines. Stakeholders recommended changes in culture, structure, and decision making. Care options and quality metrics should reflect a focus on patients’ priorities. Clinician–patient partnerships should reflect patients knowing their health goals and clinicians knowing how to achieve them. Access to specialty expertise should not require visits. Discussion: Stakeholders’ recommendations suggest health care redesigns that incorporate patients’ health priorities into care decisions and realign relationships across patients and clinicians.

Geriatric preparation of specialty nurses is critical because their direct care and administrative responsibilities profoundly impact the care of countless older patients in all settings. For a decade, the Hartford Institute for Geriatric Nursing, NYU College of Nursing, has worked with 54 national specialty nursing associations, and intensely with 14, to develop strategies for new standards for quality care for older patients. A successful blueprint for specialty associations to sustain and enhance these outcomes will be presented.

Older adults with multiple conditions receive care that is often fragmented, burdensome, and of unclear benefit. An advisory group of patients, caregivers, clinicians, health system engineers, health care system leaders, payers, and others identified three modifiable contributors to this fragmented, burdensome care: decision making and care focused on diseases, not patients; inadequate delineation of roles and responsibilities and accountability among clinicians; and lack of attention to what matters to patients and caregivers (ie, their health outcome goals and care preferences). The advisory group identified patient priority-directed care as a feasible, sustainable approach to addressing these modifiable factors.

The goal of Nurse Competence in Aging (NCA), the project described in this article, has been to help specialty nursing associations move forward with activities to educate their members in geriatric care and to help these associations develop activities and products that serve as ongoing resources to their members and help sustain the organizational commitment to geriatrics. All associations participating in NCA have disseminated information about geriatric issues to their members, and many have implemented geriatric special interest groups and awards recognizing members for their geriatric work. Most associations have produced lasting organizational and infrastructural change to infuse geriatric issues into their overall education and information provided to members. In addition, many of the associations have advanced geriatric excellence among their members by promoting formal competencies, addressing association scope and standards of practice, enhancing specialty exams with geriatric content, promoting continuing education in geriatrics, or supporting dual certification in geriatrics together with their own specialties. The full scope and overall outcomes of association activities are reported in the article Ensuring Competence of Specialty Nurses in Care of Older Adults, pages, 9-14. In this article, 6 associations are highlighted as exemplars for their successful integration of geriatric content into already existing materials, their development of excellent new resources, their creation of lasting infrastructures for geriatric activities, and their making a priority of embedding geriatric information throughout their communication with members. See also Case Study page 16.

AJN t September 2006 t Vol. 106, No. 9 93 and produce better outcomes. Yet few nurses have had the opportunity to gain such knowledge, either through education or at work. Nurse Competence in Aging (NCA) is a fiveyear initiative created in 2002 through an alliance of the ANA, the American Nurses Credentialing Center (ANCC), and the John A. Hartford Foundation Institute for Geriatric Nursing (Hartford Institute). Funded by the Atlantic Philanthropies, through the American Nurses Foundation, the initiative addresses the need to ensure competence in geriatrics among nursing specialties in which nurses serve older patients. Collectively, the associations that represent these specialties have a membership of over 400,000 practicing nurses, who work in settings such as critical care and medical–surgical units, oncology, rehabilitation, and hospice. The main objective of the NCA initiative is to help associations to embrace the concept of, and individual nurses to adopt, “dual professionalism” in geriatrics and another specialty practice. (Throughout this article the term nurses refers to RNs; the term geriatrics refers to both geriatric and gerontological practice.)

Nurses who have specialized education in geriatrics share a deep appreciation for the unique needs of older adults in the health care system. As the population ages, it becomes increasingly clear that all nurses must be competent to care for older adults, showing sensitivity to the physiological, functional, and psychological changes that set this population apart from younger people. Yet as we know, there are currently not enough nurses with geriatric preparation to go around. Together with specialty nursing associations, the Hartford Institute for Geriatric Nursing at NYU College of Nursing, the mission of which is to bring all nurses in line with best practices in care of elders, has created a Global Vision Statement on Care of Older Adults, outlining how the nurse workforce must become equipped to meet the changing and specific health care needs of older adults (http://consultgerirn.org/ specialty_practice/Global_Vision_Statement). The statement acknowledges specialty nursing organizations’ motivation to sharpen their focus on care for older adults in educational offerings and communication with members. So far, 25 national specialty nursing organizations have joined 7 geriatric nursing organizations, representing more than 320,000 nurses, in committing themselves jointly to providing the best evidence-based and up-to-date care of older adults. Endorsements by additional specialty nursing organizations are welcomed.