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To describe the development of the Patient Centeredness Index (PCI), evaluate its psychometric characteristics and evaluate the relationships between scores on the PCI and an established measure of empathy.Patient centeredness helps patients manage multiple chronic conditions with their providers, nurses and other team members. However, no instrument exists for evaluating patient centeredness within primary care practices treating this population.Multi-site instrument development and validation. STROBE reporting guidelines were followed.To identify themes, we consulted literature on patient centeredness and engaged stakeholders who had or were caring for people with multiple chronic conditions (n = 7). We composed and refined items to represent those themes with input from clinicians and researchers. To evaluate reliability and convergent validity, we administered surveys to participants (n = 3622) with chronic conditions recruited from 44 primary care practices for a large-scale cluster randomised clinical trial of the effects of a practice-level intervention on patient and practice-level outcomes. Participants chose to complete the 16-item survey online, on paper or by phone. Surveys assessed demographics, number of chronic conditions and ratings of provider empathy. We conducted exploratory factor analysis to model the interrelationships among items.A single factor explained 93% of total variance. Factor loadings ranged from 0.55-0.85, and item-test correlations were ≥.67. Cronbach's alpha was .93. A moderate, linear correlation with ratings of provider's empathy (r = .65) supports convergent validity.The PCI is a new tool for obtaining patient perceptions of the patient centeredness of their primary care practice. The PCI shows acceptable reliability and evidence of convergent validity among patients managing chronic conditions.The PCI rapidly identifies patients' perspectives on patient centeredness of their practice, making it ideal for administration in busy primary care settings that aim to efficiently address patient-identified needs.Clinicaltrials.org Protocol ID: WLPS-1409-24372.Integrating Behavioural Health and Primary Care for Comorbid Behavioural and Medical Problems (IBHPC).

Objective To review definitions, concepts, and evidence regarding person and family engagement for persons with multiple chronic conditions (MCC) in order to identify opportunities to advance the field. Data source Ovid MEDLINE STUDY DESIGN: We performed a two-step process: (1) a critical review of conceptual models of engagement to identify key concepts most pertinent to engagement among persons with MCC as a "launch pad" to our scoping review, and (2) a scoping review of reviews of engagement for persons living with MCC. Data collection/extraction methods First, we critically reviewed six models of engagement. Second, our scoping review identified 1297 citations, with 67 articles meeting criteria for inclusion. Of these, we focused on reviews, of which there were nine titles/abstracts retained for full text consideration. Six full-text reviews were included in the final analysis. The purpose, review type, population, number/type of included studies, theoretical framework, and findings of each study were extracted and analyzed thematically. Principal findings Conceptual models of engagement differ with respect to areas of emphasis (e.g., systems or clinical encounters) as well as attention to vulnerable populations; involvement of family; consideration of cost-benefit tradeoffs; and attention to outcomes that matter most. Our scoping review of reviews identified just one article explicitly focused on engagement interventions for those with MCC. Other reviews examined elements of self-management and involvement in decision-making, conceptually related to engagement without explicit use of the word. We find that existing evidence has predominantly described individual-level strategies rather than targeting organizations, systems, or policies. Barriers to engagement are not well described, nor are potential downsides to engagement. Family engagement is rarely considered. Conclusions Promising areas of future work include attention to barriers to engagement including trust, goal-based care, the design of structural changes to care delivery, tradeoffs between benefits and costs, and family engagement. This article is protected by copyright. All rights reserved.

Objective To review evidence regarding the use of Health Information Technology (health IT) interventions aimed at improving care for people living with multiple chronic conditions (PLWMCC) in order to identify critical knowledge gaps. Data sources We searched MEDLINE, CINAHL, PsycINFO, EMBASE, Compendex, and IEEE Xplore databases for studies published in English between 2010-2020. Study design We identified studies of health IT interventions for PLWMCC across three domains: self-management support, care coordination, and algorithms to support clinical decision-making. Data collection/extraction methods Structured search queries were created and validated. Abstracts were reviewed iteratively to refine inclusion and exclusion criteria. The search was supplemented by manually searching the bibliographic sections of the included studies. The search included a forward citation search of studies nested within a clinical trial to identify the clinical trial protocol and published clinical trial results. Data was extracted independently by two reviewers. Principal findings The search yielded 1907 articles; 44 were included. Nine randomized controlled trials (RCTs) and 35 other studies including quasi-experimental, usability, feasibility, qualitative studies, or development/validation studies of analytic models. Five RCTs had positive results and the remaining four RCTs showed that the interventions had no effect. The studies address individual patient engagement and assess patient-centered outcomes such as quality of life. Few RCTs assess outcomes such as disability and none assess mortality. Conclusions Despite a growing body of literature on health IT interventions or multicomponent interventions including a health IT component for chronic disease management, current evidence for applying health IT solutions to improve care for PLWMCC is limited. The body of literature included in this review provides critical information on the state of the science as well as the many gaps that need to be filled for digital health to fulfill its promise in supporting care delivery that meets the needs of PLWMCC. This article is protected by copyright. All rights reserved.

BACKGROUND Vision and hearing impairments often co-exist with dementia, and all are independently associated with limitations in daily activities. Our aim was to examine the association of dual sensory impairment with functional limitations, and further examine the combined estimated association of sensory impairment and dementia with these functional limitations. METHODS Cross-sectional analysis of the National Health and Aging Trends Study (NHATS), a population-based cohort of Medicare beneficiaries, was performed. Participants were selected from the 2015 round. Survey weighted Poisson regression models adjusted for dementia, demographics, and health status variables examined the association of self-reported dual sensory impairment (no sensory impairment, single sensory impairment, dual sensory impairment) with scores of limitations in mobility, self-care, and household activities. Models were repeated to take into account the combined effects of dual sensory impairment and dementia. RESULTS Overall, 7124 participants representative of Medicare beneficiaries 65 years or older were included. Of them, 43.9% were 75 years or older and 55.3% were female. Older adults with dual sensory impairment had greater limitations with mobility (prevalence rate ratio [PRR] = 1.45, 95% CI = 1.28-1.63), self-care (PRR = 1.41, 95% CI = 1.25-1.59), and household activities (PRR = 1.54, 95% CI = 1.37-1.72) compared with those without sensory impairment. They also had greater limitations than those with a single sensory impairment across the different activity categories. In models taking into account the combined estimated effect of both sensory impairment and dementia, those with dual sensory impairment and dementia had greater limitations than those without sensory impairment or dementia in each category (mobility: PRR = 1.85, 95% CI = 1.59-2.14, self-care: PRR = 1.86, 95% CI = 1.59-2.18, household: PRR = 2.41, 95% CI = 2.09-2.77). CONCLUSIONS Older adults with dual sensory impairment had greater functional limitations compared with those without sensory impairment and those with a single sensory impairment. Strategies to improve visual and/or hearing function (e.g., sensory aids, rehabilitation) could potentially help prevent or minimize disability, even among those with dementia.

Objective To identify factors affecting implementation of Geriatric Patient Aligned Care Teams (GeriPACT), a patient-centered medical home model for older adults with complex care needs including multiple chronic conditions (MCC), designed to provide them with comprehensive, managed and coordinated primary care. Data sources Qualitative data was collected from key informants at eight VA Medical Centers (VAMCs) geographically spread across the US. Study design Guided by the Consolidated Framework for Implementation Research (CFIR), we collected prospective primary data through semi-structured interviews with GeriPACT team members (e.g. physicians, nurses, social workers, pharmacists), leaders (e.g., executive leaders and middle managers), and other staff referring to the program. Data collection We conducted in-person, semi-structured interviews with 134 key informants. Interviews were recorded with permission and professionally transcribed. Transcripts were coded in NVIVO 11. We used directed content analysis to identify key factors affecting GeriPACT implementation across sites. Principal findings Five key factors affected GeriPACT implementation-5 CFIR constructs within two CFIR domains. Within the intervention characteristics domain, two constructs emerged: 1) the structure of the GeriPACT model, and 2) design, quality and packaging. In the inner setting domain, we identified three constructs: 1) available resources (e.g., staffing and space, and infrastructure and information technology; 2) leadership support and engagement, and 3) networks and communications including teamwork, communication and coordination. Conclusions Older Veterans with MCC have complex primary care needs requiring high levels of care management and coordination. Knowing what key factors affect GeriPACT implementation is critical. Study findings also contribute to the growing implementation science literature on applying CFIR to evaluate factors that affect program implementation, especially to aging research. Further studies on MCC-focused specialty primary care will help facilitate patient-centered care provision for older adults' complex health needs while also leveraging synergistic work across factors affecting implementation. This article is protected by copyright. All rights reserved.

OBJECTIVE: To examine whether the length of participation in a patient‐centered medical home (PCMH), an evidence‐based practice, leads to higher quality care for Medicaid enrollees with multiple co‐morbid chronic conditions and major depressive disorder (MDD). DATA SOURCES: This analysis uses a unique data source that links North Carolina Medicaid claims and enrollment data with other administrative data including electronic records of state‐funded mental health services, a state psychiatric hospital utilization database, and electronic records from a five‐county behavioral health carve‐out program. STUDY DESIGN: This retrospective cohort study uses generalized estimating equations (GEEs) on person‐year‐level observations to examine the association between the duration of PCMH participation and measures of guideline‐concordant care, including the receipt of minimally adequate care for MDD, defined as 6 months of antidepressant use or eight psychotherapy visits each year. DATA COLLECTION/EXTRACTION METHODS: Adults with two or more chronic conditions reflected in administrative data, including MDD. PRINCIPAL FINDINGS: We found a 1.7 percentage point increase in the likelihood of receiving guideline‐concordant care at 4 months of PCMH participation, as compared to newly enrolled individuals with a single month of participation (p

Objective We sought to characterize caregiver medication assistance for older adults with multiple chronic conditions. Design Semi-structured qualitative interviews. Setting Community and academic-affiliated primary care practices. Participants A total of 25 caregivers to older adults participating in an ongoing cohort study with ≥3 chronic conditions. Measurements A semi-structured interview guide, informed by the Medication Self-Management model, aimed to understand health-related and medication-specific assistance caregivers provided. Results Three typologies of caregiver assistance with medications emerged: Actively Involved, Peripherally Involved, and Not Involved. A total of 10 caregivers were Actively Involved, which was defined as when the caregiver perceived a need for and offered assistance, and the patient accepted the assistance. Peripherally Involved (n = 6) was defined as when the caregiver perceived a need and offered assistance; however, the patient rejected this assistance, yet relied on the caregiver as a backup in managing his or her medications. To combat resistance from the patient, caregivers in this typology disguised assistance and deployed workaround strategies to monitor medication-taking behaviors to ensure safety. Lastly, nine caregivers were classified as Not Involved, defined as when the caregiver did not perceive a need to offer assistance with medications, and the patient managed his or her medicines independently. A strong preference toward autonomy in medication management was shared across all three typologies. Conclusion These findings suggest that caregivers value independent medication management by their care recipient, up until safety is seriously questioned. Clinicians should not assume caregivers are actively and consistently involved in older adults' medication management; instead, they should initiate conversations with patients and caregivers to better understand and facilitate co-management responsibilities, especially among those whose assistance is rejected by older adults.

BACKGROUND/OBJECTIVES The number of older adults with complex health needs is growing, and this population experiences disproportionate morbidity and mortality. Interventions led by community health workers (CHWs) can improve clinical outcomes in the general adult population with multimorbidity, but few studies have investigated CHW-delivered interventions in older adults. DESIGN We systematically reviewed the impact of CHW interventions on health outcomes among older adults with complex health needs. We searched for English-language articles from database inception through April 2020 using seven databases. PROSPERO protocol registration CRD42019118761. SETTING Any U.S. or international setting, including clinical and community-based settings. PARTICIPANTS Adults aged 60 years or older with complex health needs, defined in this review as multimorbidity, frailty, disability, or high-utilization. INTERVENTIONS Interventions led by a CHW or similar role consistent with the American Public Health Association's definition of CHWs. MEASUREMENTS Pre-defined health outcomes (chronic disease measures, general health measures, treatment adherence, quality of life, or functional measures) as well as qualitative findings. RESULTS Of 5671 unique records, nine studies met eligibility criteria, including four randomized controlled trials, three quasi-experimental studies, and two qualitative studies. Target population and intervention characteristics were variable, and studies were generally of low-to-moderate methodological quality. Outcomes included mood, functional status and disability, social support, well-being and quality of life, medication knowledge, and certain health conditions (e.g., falls, cognition). Results were mixed with several studies demonstrating significant effects on mood and function, including one high-quality RCT, while others noted no significant intervention effects on outcomes. CONCLUSION CHW-led interventions may have benefit for older adults with complex health needs, but additional high-quality studies are needed to definitively determine the effectiveness of CHW interventions in this population. Integration of CHWs into geriatric clinical settings may be a strategy to deliver evidence-based interventions and improve clinical outcomes in complex older adults.

BACKGROUND: Community health centers (CHCs) are federally funded safety-net clinics that provide care to low income and medically underserved persons. The proportion of CHC patients age ≥65 doubled in the last ten years, yet little is known about this population. We aim to describe the demographic and clinical characteristics of the older adult CHC population. DESIGN. Cross sectional analysis SETTING. The nationally representative 2014 Health Center Patient Survey. PARTICIPANTS. CHC patients ≥55 years MEASURES. We used descriptive statistics to characterize older adults across demographic and clinical variables. To determine differences by age, we stratified into three groups (55–64, 65–74, 75+ years). We used t-tests and chi-squared to calculate p values and survey weights to make national estimates. RESULTS: We included 1875 older adults ≥55 years, representing over 4.2 million people. Older adults were mostly age 55–64 (60%), female (51%), and white (60%). The majority (73%) had Medicare or Medicaid and 47% reported fair or poor health. Regardless of age, older adults had an average of 3 chronic conditions and 0.6 impairments in activities of daily living (ADL). Health care utilization was not significantly different across age groups with most taking ≥5 prescription medications (54%) and one in five reporting ≥2 emergency department visits or ≥1 hospitalization in the last year. CONCLUSIONS: Adults 55–64 who attend CHCs have similar disease burden as adults ≥65. As the population of older adults who access CHCs grow, our findings highlight the opportunity to enhance focus on key principles of geriatric medicine, such as measurement of functional impairment for those who are

Older patients tend to have multimorbidity represented by multiple chronic diseases or geriatric conditions due to aging changes of organs, which require a variety of medical management. Currently, there are no sufficient disease treatment guidelines for older people with multimorbidity, therefore physicians have difficulty managing multimorbidity, such as which diseases should be treated intensively or to what extent the conditions should be improved. Furthermore, there are other points to be considered when initiating the treatment of diseases. For example, physicians must assess physical function. Some people have no difficulty with ambulation, but some are bedridden and have difficulty getting up on their own. As there are differences in disease severity, comorbid conditions and life expectancy, there should be differences in deciding treatment and prescribing drugs. It may be necessary to change the option for treatment depending on cognitive function, the living environment and the care environment, using comprehensive geriatric assessments. In addition, when treating multimorbidity, patients tend to have polypharmacy, which is a risk for adverse drug events. Because of this, it is necessary to consider dose reduction and drug discontinuation in patients with polypharmacy. Because of the global increase in older patients with multimorbidity, developing an essential method for managing multimorbidity is an urgent issue. More research and practices are necessary to achieve high-quality care in patients with multimorbidity. Geriatr Gerontol Int ••; ••: ••-•• Geriatr Gerontol Int 2020; ••: ••-••.

Background Most persons with dementia have multiple chronic conditions; however, it is unclear whether co-existing chronic conditions contribute to health-care use and cost. Methods Persons with dementia and ≥2 chronic conditions using the National Health and Aging Trends Study and Medicare claims data, 2011 to 2014. Results Chronic kidney disease and ischemic heart disease were significantly associated with increased adjusted risk ratios of annual hospitalizations, hospitalization costs, and direct medical costs. Depression, hypertension, and stroke or transient ischemic attack were associated with direct medical and societal costs, while atrial fibrillation was associated with increased hospital and direct medical costs. No chronic condition was associated with informal care costs. Conclusions Among older adults with dementia, proactive and ambulatory care that includes informal caregivers along with primary and specialty providers, may offer promise to decrease use and costs for chronic kidney disease, ischemic heart disease, atrial fibrillation, depression, and hypertension.

Objective To analyze the effects of a standardized community health worker (CHW) intervention on hospitalization. Data Sources/Study Setting Pooled data from three randomized clinical trials (n = 1340) conducted between 2011 and 2016. Study Design The trials in this pooled analysis were conducted across diseases and settings, with a common study design, intervention, and outcome measures. Participants were patients living in high‐poverty regions of Philadelphia and were predominantly Medicaid insured. They were randomly assigned to receive usual care versus IMPaCT, an intervention in which CHWs provide tailored social support, health behavior coaching, connection with resources, and health system navigation. Trial one (n = 446) tested two weeks of IMPaCT among hospitalized general medical patients. Trial two (n = 302) tested six months of IMPaCT among outpatients at two academic primary care clinics. Trial three (n = 592) tested six months of IMPaCT among outpatients at academic, Veterans Affairs (VA), and Federally Qualified Health Center primary care practices. Data Collection/Extraction Methods The primary outcome for this study was all‐cause hospitalization, as measured by total number of hospital days per patient. Hospitalization data were collected from statewide or VA databases at 30 days postenrollment in Trial 1, twelve months postenrollment in Trial 2, and nine months postenrollment in Trial 3. Principal Findings Over 9398 observed patient months, the total number of hospital days per patient in the intervention group was 66 percent of the total in the control group (849 days for 674 intervention patients vs 1258 days for 660 control patients, incidence rate ratio (IRR) 0.66, P

There is a paucity of summarized evidence concerning coping with multiple chronic conditions. An integrative review approach was used to synthesize current evidence on: (i) coping in forms of perceptions and strategies, (ii) relationship between coping and health-related outcomes, and (iii) factors related to coping. Five electronic databases were searched without time limitation. Thirty-two studies met inclusion criteria and were included for full-text review: 24 qualitative, seven quantitative, and one mixed-methods study. Studies were assessed for quality using an appraisal system of rigor and relevance. A constant comparison method was used to synthesize findings from eligible studies. This review synthesized perceptions of multiple chronic conditions involving negative moods and physical limitations, and strategies of coping with multiple chronic conditions including problem- and emotion-focused strategies. Findings suggested that coping is a promising path to manage multiple chronic conditions and emphasized that appropriate coping might have positive impacts on health-related outcomes. Five impact factors including age, gender, clusters of multiple chronic conditions, social support, and ethnicity and culture were associated with people's coping. Future healthcare plans should address the physical and psychological needs of people with multiple chronic conditions and highlight the importance of modifying their illness perceptions and enhancing appropriate coping strategies.

Background Multiple chronic conditions (MCCs) are highly prevalent in primary care. Coping is an important psychological factor that influences patients' ability to adapt physically and mentally to MCCs. Testing a reliable and valid psychometric inventory is necessary to identify coping strategies before developing coping-oriented interventions. Purpose The purpose of this study is to examine the psychometric properties of the Chinese version of the Brief Coping Orientation to Problems Experienced (Brief COPE-CN) inventory in patients with MCCs. Method This study adopted a cross-sectional design. A convenience sample of 290 Chinese patients with MCCs was recruited from a tertiary hospital in East China. The Brief COPE-CN, sociodemographic characteristics and clinical data were collected using a self-reported questionnaire from November 2017 to May 2018. Factor analysis and reliability analysis were performed. Results The mean age of the participants was 58.5 years (range from 23 to 95 years), and approximately half of the participants were female (49.3%). Most participants had two chronic conditions (82.1%) and reported having had MCCs for more than 2 years. The explanatory factor analysis (EFA) identified five factors in the Brief COPE-CN that explained 58.4% of the total variance. The Cronbach's α coefficients ranged from .65 to .85 for the five subscales. Conclusions The psychometric properties of the Brief COPE-CN were acceptable for use with Chinese patients with MCCs. With further evaluation, this instrument may help health-care professionals understand patients' coping and develop coping-based interventions to promote coping in this population.

Mental health is impacted by social, economic, and environmental influences related to where people live. Mental health problems commonly co-occur with long-term physical conditions and impact individuals' health synergistically. Multiple chronic conditions (MCCs) including mental health problems are becoming a public health challenge globally. However, there is limited information about urban-rural differences in mental health among patients with MCCs in China. The present study aimed to identify differences in mental health between urban and rural patients with MCCs. Using a cross-sectional design, 347 patients with MCCs were recruited from a tertiary hospital in North Anhui, China. A self-reported questionnaire, including socio-demographic and clinical variables, the 12-item Short-Form survey version 2 on quality of life, and the Hospital Anxiety and Depression Scale, was administered to outpatients. Findings showed that rural participants reported more symptoms of anxiety and depression and had worse mental health compared to urban participants. Unemployment status, lower educational level, more long-term health conditions, and a higher degree of anxiety were associated with worse mental health. This study highlights disparities in mental health among patients with MCCs living in urban and rural areas of China. Appropriate mental health support programmes should be developed for patients with MCCs, especially for those living in rural areas.

Objectives: To compare the prevalence of disability between migrants and non‐migrants at three and 24 months post‐injury, and to identify key predictors of post‐injury disability among migrants. Methods: Disability among 2,850 injured participants, including 677 migrants to New Zealand, was measured prospectively using the World Health Organization Disability Assessment Schedule. Results: Migrants experienced higher risk of disability than non‐migrants at three months post‐injury (aRR=1.14, 95%CI 1.03–1.26). Both groups had similar disability prevalence, but higher than pre‐injury, at 24 months. For migrants, strong predictors of disability at three months post‐injury were: higher injury severity, pre‐injury obesity, and perceiving the injury as a threat of disability. Having multiple chronic conditions was a predictor of disability at both time points. Conclusions: Disability was persistent for migrants and non‐migrants to 24 months post‐injury. The disability risk at three months was higher for migrants. Certain predictors associated with disability were identified. Implications for public health: Despite having accessed healthcare services for their injury, migrants (compared with non‐migrants) had higher risks of disability at least in the first three months post‐injury. Interventions should be focused during this critical period on identified key predictors to promote faster recovery and reduce disability.

The number of older adults is increasing worldwide, including in Asian countries. Various problems associated with medical care for older adults are being highlighted in aging societies. As the number of chronic diseases increases with age, older adults are more likely to have multiple chronic diseases simultaneously (multimorbidity). Multimorbidity results in poor health‐related outcomes, leading to increased use and cost of healthcare. Above all, it leads to deterioration in older adults’ quality of life. However, it is unclear whether any medical interventions are effective for multimorbidity, which means medical practitioners currently offer medical care “in the dark.” It is therefore necessary for researchers and medical professionals involved in geriatric medicine to establish ways to manage multimorbidity among older adults. This means that the development of research in this field is essential., ファイル公開：2020/08/01

Ask any clinical ethics consultant, and they can tell you about their transformative cases. Some stick with us because all roads led nowhere. Cassandra Lee had a history of pulling out lines and tubes and a distaste of warming blankets. Her admission marked her thirtieth over the past year. Many of the challenges facing the hospital caring for her were not unique: significant psychiatric issues, prolonged nonadherence to medical advice, and end-of-life decision-making combined to create an ethically dense and vexing situation. Ms. Lee, like so many patients, was suffering because of system failures.

Objectives Nearly half of the population living with human immunodeficiency virus (HIV) in the United States is now older than 50 years with at least 6% over age 65. Between 35% and 50% live with mild to moderate cognitive impairment. Older persons living with HIV (PLWH) also have a substantial burden of HIV-associated non-acquired immunodeficiency syndrome medical conditions and are at risk for frailty, geriatric syndromes, and early mortality compared with HIV-uninfected peers. We sought to define the magnitude of geriatric conditions and multimorbidity in PLWH older than 60 years who are living with symptomatic cognitive impairment. In a subset of participants, we examined associations between these geriatric conditions. Design Retrospective cohort study. Setting HIV Elders Study at the University of California, San Francisco, Memory and Aging Center. Participants Participants were HIV infected, virally suppressed, 60 years or older, and clinically diagnosed with mild neurocognitive disorder (MND). Measurements We conducted standardized assessment of geriatric conditions and everyday function and investigated multimorbidity burden using the Veterans Aging Cohort Study (VACS) index. Results Among 141 older PLWH with MND, 58% report incontinence, 55% meet criteria for pre-frailty, and a substantial proportion report dependence with instrumental activities of daily living (52%) or activities of daily living (41%). The mean VACS index score is 33 (standard deviation = 14), suggesting a 13.8% 5-year all-cause mortality risk. Conclusions Older PLWH with symptomatic cognitive impairment carry a substantial burden of other geriatric conditions. Our work supports the need for comprehensive geriatric systems of care for cognitively impaired individuals aging with HIV. J Am Geriatr Soc 67:1913-1916, 2019.

It is common for primary care providers (PCPs) to manage complex multimorbidity. When caring for patients with multimorbidity, PCPs face challenges to tackle several issues within a short consultation in order to address patients' complex needs. Furthermore, some PCPs may lack access to a multidisciplinary team and need to manage multimorbidity within the confine of a PCP-patient partnership only. Instead of attempting to address multiple health issues within a single consultation, it would be more feasible and time effective for PCPs and patients to jointly prioritize the health issue to focus on. Using the Malaysian primary care setting as a case study, a dual-layer-shared decision-making approach is proposed whereby PCPs and patients make decisions on which disease(s) (layer 1) and treatment(s) (layer 2) to prioritize. This dual-layer model aims to address the challenges of short consultation time and limited healthcare resources by encouraging PCPs and patients to discuss, negotiate, and agree on the decision during the consultation to ensure patients' health needs are addressed.

The lack of an adequately prepared workforce is a critical barrier to delivering high-quality community-based care for individuals living with serious illness. This article presents 16 consensus-based recommendations to improve the capacity of the workforce in this area within the next 5 years, focusing on older adults. The recommendations were developed at a summit of 40 national leaders from practice, payment, labor, advocacy, and research arenas. The consensus-based recommendations include specific steps for geriatrics leaders including curriculum reforms to increase skills in the care of older and seriously ill populations, expanding experiential learning opportunities for students to increase interest in careers in geriatric and palliative care, developing and improving curriculum in interprofessional and cultural competency skills, preparing clinicians to support incorporation of home care aides and family caregivers as healthcare team members, development of skills to support shared decision making with patients, and requiring specific skills related to serious illness care in licensing, accreditation, and continuing education regulations. Together, these recommendations put forward a charge to healthcare leaders to act to ensure a workforce that will optimize support for those with serious illness living in the community. J Am Geriatr Soc 67:S392-S399, 2019.

Objectives Patient Health Priorities Identification (PHPI) is a values-based process in which trained facilitators assist older adults with multiple chronic conditions identify their health priorities. The purpose of this study was to evaluate patients' perceptions of PHPI. Design Qualitative study using thematic analysis. Setting In-depth semistructured telephone and in-person interviews. Participants Twenty-two older adults who participated in the PHPI process. Measurements Open-ended questions about patient perceptions of the PHPI process, perceived benefits of the process, enablers and barriers to PHPI, and recommendations for process enhancement. Results Patient interviews ranged from 9 to 63 minutes (median = 20 min; interquartile range = 15-26). The mean age was 80 years (standard deviation = 7.96), 64% were female, and all patients identified themselves as white. Of the sample, 73% reported no caregiver involvement in their healthcare; 36% lived alone. Most patients felt able to complete the PHPI process with ease. Perceived benefits included increased knowledge and insight into disease processes and treatment options, patient activation, and enhanced communication with family and clinicians. Patients identified several factors that were both enablers and barriers to PHPI including facilitator characteristics, patient demographic and clinical characteristics, social support, relationships between the patient and their primary care provider, and the changing health priorities of the patient. Recommendations for process enhancement included more frequent and flexible facilitator contacts, selection of patients for participation based on specific patient characteristics, clarification of process aims and expectations, involvement of family, written reminders of established health priorities, short duration between facilitation and primary care provider follow-up, and the inclusion of health-related tasks in facilitation visits. Conclusions Patients found the PHPI process valuable in identifying actionable health priorities and healthcare goals leading to enhanced knowledge, activation, and communication regarding their treatment options and preferences. PHPI may be useful for aligning the healthcare that patients receive with their values-based priorities.

Objective The study's purpose was to describe the cumulative duration of 19 chronic conditions among Medicare fee-for-service (FFS) beneficiaries and examine variation in total expenditures explained by cumulative duration and condition counts. Design, setting, study design, and data extraction In a retrospective cohort of FFS beneficiaries age ≥68, 2015 Medicare enrollment and claims data (N = 20 124 230) were used to identify the presence or absence of 19 diagnosed chronic conditions, and to construct MCC categories (0-1, 2-3, 4-5, 6+) and cumulative duration of each of 19 conditions from the date of first possible occurrence in claims (1/1/1999) to the end of follow-up (date of death or 12/31/2015). Total Medicare expenditures were estimated using linear models adjusted for demographic characteristics. Principal findings Multimorbidity was common (71.7 percent with 2+ conditions). The mean cumulative duration of all 19 conditions was 23.6 person-years, which varied greatly by age and number of conditions. Condition counts were more predictive of Medicare expenditures than cumulative duration (R-squared for continuous measures = 0.461 vs 0.272; R-squared for quartiles = 0.408 vs 0.266). Conclusions The cumulative duration of chronic conditions varied widely for Medicare beneficiaries, especially for those with 6+ conditions, but was less predictive of total expenditures than condition counts.

Older adults are prescribed a growing number of medications. Polypharmacy, commonly considered the receipt of five or more medications, is associated with a range of adverse outcomes. There is a debate about the reason(s) why. On one side is the assertion that older persons are being prescribed too many medications, with the number of medications increasing the risk of adverse events. On the other side is the observation that polypharmacy is associated both with overprescribing of inappropriate medications and underprescribing of appropriate medications. This leads to the concept of "inappropriate" vs "appropriate" polypharmacy, with the latter resulting from the prescription of many correct medications to persons with multiple chronic conditions. Few studies have examined the health outcomes associated with adding and/or removing medications to address this debate directly. The criteria used to identify underutilized medications are based on results of randomized controlled trials that may not be generalizable to older adults. Several randomized controlled trials and many more observational studies provide evidence that these criteria overestimate medication benefits and underestimate harms. In addition, evidence suggests that the marginal effects of medications added to an already complex regimen differ from their effects when considered individually. Although in selected circumstances adding medications results in benefit to patients, patients with multimorbidity and frailty/disability have susceptibilities that can decrease the likelihood of medication benefit and increase the likelihood of harms. The identification of appropriate polypharmacy requires more robust criteria to evaluate the net effects of complex medication regimens.

Introduction The support of families in the care of children with medical complexity (CMC) requires the integration of health care providers' (HCPs') medical knowledge and family experience. Care plans largely represent HCP information, and care maps demonstrate the family experience. Understanding the intersection between a care plan and a care map is critical, as it may provide solutions to the widely recognized tension between HCP-directed care and patient- and family-centered care (PFCC). Method This study used qualitative methods to explore the experience and usefulness of care maps. Parents of CMC who already had a care plan, created care maps (n = 15). Subsequent interviews with parents (n = 15) and HCPs (n = 30) of CMC regarding both care maps and care plans were conducted and analyzed using thematic analysis. Results Data analysis exploring the relationship and utility of care plans and care maps revealed six primary themes related to using care plans and care maps that were grouped into two primary categories: (a) utility of care plans and maps; and (b) intersection of care plans and care maps. Discussion Care plans and care maps were identified as valuable complementary documents. Their integration offers context about family experience and respects the parents' experiential wisdom in a standard patient care document, thus promoting improved understanding and integration of the family experience into care decision making.

In July 2018, the Centers for Medicare and Medicaid Services (CMS) released its proposed Medicare Physician Fee Schedule rule for calendar year 2019 (MPFS2019). The proposal sets forth CMS‐recommended updates to Medicare payment policies, payment rates, and quality provisions for services provided in the next calendar year. From year to year, the rule also can serve as a vehicle for soliciting input on new payment proposals and changes to existing policies. Among the payment and quality proposals in the MPFS2019 proposal, CMS proposed extensive changes to Current Procedural Terminology codes that are the framework for documentation and payment for office‐based evaluation and management (E/M) services. The American Geriatrics Society (AGS) believes the proposed payment methodology changes for E/M services would have had a significant negative impact on care for older Americans. On September 10, 2018, the AGS submitted its comments on this proposal and other aspects of the rule, and the AGS also submitted a comment letter signed by 41 organizations from an AGS‐led multispecialty coalition. The coalition also worked collaboratively on outreach to Congress, which included visits to Capitol Hill and a coalition letter stressing our collective support for reducing the burden of documentation for clinicians and our opposition to the proposed changes in payment methodology. In all letters, we noted that the AGS and members of our coalition hoped to work collaboratively with CMS and other stakeholders to develop a refined approach that would achieve the best possible outcomes for patients, particularly frail older Americans with multiple chronic conditions. In releasing their final MPFS2019, CMS postponed the E/M coding collapse for at least two years, a decision that speaks to the hard work of the AGS, its members, and the multi‐specialty coalition, and which opens the door for further discussions about the future of payment for E/M services so critical to older people. J Am Geriatr Soc 67:145–150, 2019.

BACKGROUND/OBJECTIVES Over a million older patients in the United States are admitted yearly for emergency general surgery (EGS) conditions. Seven procedure types dominate: colon, small bowel, gallbladder, ulcer disease, adhesiolysis, appendix, and laparotomy operations. A higher comorbidity burden is known to increase mortality in this population, but the impact of specific comorbidity combinations is unknown. Our objectives were to (1) characterize the distribution of procedures, comorbidities, and outcomes for older patients undergoing EGS; and (2) apply a data-driven approach (association rule mining) to identify comorbidity combinations associated with disproportionately high mortality. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional study of patients 65 years and older who underwent one of the seven procedures previously cited, taken from the 2011 Nationwide Inpatient Sample. A total of 280 885 patient encounters were identified. MEASUREMENTS In-hospital mortality, procedures, and comorbidities based on the Elixhauser Comorbidity Index. RESULTS Overall mortality was 5.6%. The most common procedures were gallbladder (33.7%), ulcer surgery (21.5%), and adhesiolysis (21.0%). Mortality increased for all procedures as patients aged. Comorbidities associated with the highest mortality included coagulopathy (adjusted odds ratio [aOR] = 3.74; 95% confidence interval [CI] = 3.41-4.11; p < .001), fluid and electrolyte disorders (FED) (aOR = 2.89; 95% CI = 3.66-3.14; p < .001), and liver disease (aOR = 1.89; 95% CI = 1.61-2.22; p < .001). Three-way comorbidity combinations most highly associated with mortality were coagulopathy, FED, and peripheral vascular disease (aOR = 5.10; 95% CI = 4.17-6.24; p < .001), and coagulopathy, FED, and chronic pulmonary disease (aOR = 4.83; 95% CI = 4.00-5.82; p < .001). CONCLUSION For older patients, combinations of comorbidities portend additional risk beyond single comorbidities, and the associated risk burden is driven by the specific constellation of comorbidities present. Future work must continue to examine the effect of co-occurring diseases to provide personalized and realistic prognostication for older patients undergoing EGS. J Am Geriatr Soc 67:503-510, 2019.

Objective The objective of this work was to assess the effectiveness of a population-level patient-centered intervention for multimorbid patients based on risk stratification for case finding in 2014 compared with the baseline scenario in 2012. Data source Clinical and administrative databases. Study design This was an observational cohort study with an intervention group and a historical control group. A propensity score by a genetic matching approach was used to minimize bias. Generalized linear models were used to analyze relationships among variables. Data collection We included all eligible patients at the beginning of the year and followed them until death or until the follow-up period concluded (end of the year). The control group (2012) totaled 3558 patients, and 4225 patients were in the intervention group (2014). Principal finding A patient-centered strategy based on risk stratification for case finding and the implementation of an integrated program based on new professional roles and an extensive infrastructure of information and communication technologies avoided 9 percent (OR: 0.91, CI: 0.86-0.96) of hospitalizations. However, this effect was not found in nonprioritized groups whose probability of hospitalization increased (OR: 1.19, CI = 1.09-1.30). Conclusions In a before-and-after analysis using propensity score matching, a comprehensive, patient-centered, integrated care intervention was associated with a lower risk of hospital admission among prioritized patients, but not among patients who were not prioritized to receive the intervention.

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.

Aim To describe a research protocol for a study designed to examine self-care in patient and caregiver dyads in coping with multiple chronic conditions, to evaluate the influence of dyad self-care on: (a) patient mortality, quality of life, hospital admissions, and the unplanned access of care; and (b) the positive aspects of caregiving. The specific conceptual framework that we developed for this study considers the predictors of self-care (at patient, caregiver, and dyadic levels), the process of self-care and the outcomes of self-care in patient and caregiver dyads with multiple chronic conditions. These elements in patient and caregiver dyads have not been well-studied to date. Design This is a multicentre longitudinal study with data collection at 0, 6, and 12 months. Methods We will use generic and specific tools to assess the predictors of self-care, the process of self-care and the outcomes of self-care in the dyads. The data will be analysed with descriptive and inferential statistics and multilevel modelling to control for the interdependent nature of dyadic data. The study was approved by an ethics committee and was funded by a grant from the Centre of Excellence for Nursing Scholarship Rome, in November 2015. Discussion This study seeks to determine the predictors and outcomes of self-care in patient and caregiver dyads within the context of multiple chronic conditions. Impact The results of this study will inform clinical practice and research by identifying variables that are modifiable and therefore amenable to interventions.

Objectives To explore patient and caregiver experiences, preferences, and attitudes toward the provision and receipt of caregiving assistance with medical tasks. Design Qualitative study consisting of in‐depth interviews with 20 patient–caregiver dyads. Setting Community and academic‐affiliated primary care clinics. Participants Individuals aged 65 or older with 2 or more health conditions and their family caregivers (n=20 patient–caregiver dyads). Measurements Open‐ended questions were asked about the tasks that the patient and caregiver performed to manage the patient's health conditions; questions were designed to elicit participant reactions and attitudes toward the help they provided or received. Transcripts were analyzed using the constant comparative method. Results Participant preferences and attitudes toward the receipt and provision of disease management tasks were highly personal. Participant responses clustered into 2 caregiving typologies: supportive caregiving relationships and conflicted caregiving relationships. Supportive relationships were characterized by patient–caregiver agreement about caregiver level of involvement, agreement about one another's competency to perform disease‐related tasks, mutual understanding, collaborative decision‐making and disease management, and use of family and formal caregiving. Conflicted relationships were characterized by disagreement about caregiver level of involvement, disagreement about one another's competency to perform disease management tasks, underappreciation of one another's experiences, disagreement over decision‐making and disease management, and use of formal caregiving. Conclusions The views that patient–caregiver dyads expressed in this study illustrate the varied preferences and attitudes toward caregiving assistance with multiple health conditions. These findings support a dyadic approach to evaluating and addressing patient and caregiver needs and attitudes toward provision of assistance.

BACKGROUND: Older people with multi-morbidity are major users of healthcare and are often discharged from hospital with ongoing care needs. This care is frequently provided by informal caregivers and the time immediately after discharge is challenging for caregivers with new and/or additional tasks, resulting in anxiety and stress.AIM: This study aimed to describe mental health, with particular reference to anxiety and depression and reactions to caregiving, and to investigate any associations between the two, in next of kin of older people with multi-morbidity after hospitalisation. It also aimed to explore the association between the demographic characteristics of the study group and mental health and reactions to caregiving.METHODS: This was a cross-sectional questionnaire study using the Hospital Anxiety and Depression Scale and the Caregiver Reaction Assessment. The study group consisted of 345 next of kin of older people (65+) with multi-morbidity discharged home from 13 medical wards in Sweden. Data were analysed using descriptive and analytical statistics. To identify whether reactions to caregiving and next of kin characteristics were associated with anxiety and depression, a univariate logistic regression analysis was performed.RESULTS: More than one quarter of respondents showed severe anxiety and nearly one in 10 had severe depressive symptoms. The frequencies of anxiety and depression increased significantly with increased negative reactions to caregiving and decreased significantly with positive reactions to caregiving. Regarding caregiving reactions, the scores were highest for the positive domain Caregiver esteem, followed by the negative domain Impact on health. Women scored significantly higher than men on Impact on health and spouses scored highest for Impact on schedule and Caregiver esteem.CONCLUSIONS: Nurses and other healthcare professionals may need to provide additional support to informal caregivers before and after discharging older people with significant care needs from hospital. This might include person-centred information, education and training. (Less)