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The article explores education outcomes for those receiving training in patient priorities aligned care. The authors report on developing an interactive, virtual training for fellows in geriatric medicine, geriatric psychiatry, palliative care, internal medicine and geriatric pharmacy students studying at the Yale School of Medicine, the Baylor College of Medicine and the Mountain Area Health Education Center. Discussion and results of the project are also offered.

BACKGROUND/OBJECTIVES Aligning healthcare decisions with patients' priorities may improve care for older adults with multiple chronic conditions (MCCs). We conducted a pilot study to assess the feasibility of identifying patient priorities in routine geriatrics care and to compare clinicians' recommendations for patients who did or did not have their priorities identified. DESIGN Retrospective chart review. SETTING Veterans Administration Medical Center Geriatrics Clinic. PARTICIPANTS Older adults with MCCs receiving Patient Priorities Care (PPC; n = 35) were matched with patients receiving usual care (UC; n = 35). Both PPC and UC patients were cared for by three primary care providers (PCPs) in an ambulatory geriatric clinic. INTERVENTION In the PPC group, a clinician facilitator met with each patient to identify their healthcare priorities and transmitted patients' priorities in the electronic health record (EHR). Trained PCPs then sought to align healthcare decisions with patients' priorities. In the UC group, patients received usual care from the same PCPs. MEASUREMENTS We matched patients by clinician seen, patient's age, number of active conditions, medications, hospitalizations, functional status, and prior hospitalizations. EHRs were reviewed to identify care decisions including medications added or stopped, referrals and consults added or avoided, referrals to community services and supports, self‐management activities added or avoided, and total number of changes to care. Mean differences in recommended care between PPC and UC patients from the same PCPs were examined. RESULTS: Clinician facilitators could identify patient priorities during routine clinic encounters. Compared with patients in the UC group, those in the PPC group had, on average, fewer medications added (P =.05), more referrals to community services and supports (P =.03), and more priorities‐aligned self‐management tasks added (P =.005). CONCLUSION: These findings support the feasibility of identifying and documenting patient priorities during routine encounters. Results also suggest that clinicians use patient priorities in recommending care. [ABSTRACT FROM AUTHOR]

Objective: Oncologic breast surgeries carry a risk for persistent postsurgical pain. This study was a randomized pilot and feasibility study of a single-session Acceptance and Commitment Therapy (ACT) intervention compared with treatment as usual among women undergoing surgery for breast cancer or ductal carcinoma in situ.Methods: Participants were recruited via letter of invitation and follow-up phone call from a single site in the United States from 2015 to 2017. Participants were at risk for persistent postsurgical pain, based on young age (<50), a preexisting chronic pain condition, or elevated anxiety, depression, or pain catastrophizing.Results: The 54 participants were female with a mean age of 52.91 years (SD=11.80). At 3-month postsurgery, 11% of the sample reported moderate-severe pain (>3 on a 0-10 numeric rating scale) in the operative breast or with arm movement. Written qualitative responses indicated that the majority of participants who received the intervention understood the concepts presented and reported continued practice of exercises learned in the session. The between group effect sizes for moderate-severe pain and elevated anxiety at 3-month post-surgery were small (Phi=0.08 and 0.16, respectively). The between group effect sizes for depression, pain acceptance, and pain catastrophizing at 3-month postsurgery were minimal.Conclusions: This study found small positive effects on postsurgical pain and anxiety for a single-session ACT intervention among women with breast cancer. This study supports the use of ACT with this population. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. See related editorial by William B. Applegate et al [ABSTRACT FROM AUTHOR]

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. See related editorial by William B. Applegate et al. [ABSTRACT FROM AUTHOR]

Objective To determine whether a 1-day behavioral intervention, aimed at enhancing psychological flexibility, improves headache outcomes of migraine patients with comorbid depression. Background Migraine is often comorbid with depression, with each disorder increasing the risk for onset and exacerbation of the other. Managing psychological triggers, such as stress and depression, may result in greater success of headache management. Method Sixty patients with comorbid migraine and depression were assigned to a 1-day Acceptance and Commitment Training plus Migraine Education workshop ( ACT-ED; N = 38) or to treatment as usual ( TAU; N = 22). Patients completed a daily headache diary prior to, and for 3 months following, the intervention. Clinical variables examined included headache frequency/severity, medication use, disability, and visit to a health care professional. Comparisons were made between baseline findings and findings at the 3-month follow up. Results Participants assigned to the ACT-ED condition exhibited significant improvements in headache frequency, headache severity, medication use, and headache-related disability. In contrast, the TAU group did not exhibit improvements. The difference in headache outcomes between ACT-ED and TAU was not statistically significant over time (ie, the treatment by time interaction was nonsignificant). These results complement those of a previous report showing effects of ACT-ED vs TAU on depression and disability. Conclusion A 1-day ACT-ED workshop targeting psychological flexibility may convey benefit for patients with comorbid migraine and depression. These pilot study findings merit further investigation using a more rigorously designed large-scale trial. [ABSTRACT FROM AUTHOR]

The characteristics of stimuli that elicit skin conductance responses (SCRs) have been conceptualized in varied ways, with strong emphasis on the significance or arousing quality of stimuli. Our goal was to determine whether “significance” can be shown to have an effect on SCRs independent of “arousal,” using words as stimuli. Ratings of words indicated that significance is partially independent of arousal. In Study 1, SCRs from 43 participants during presentation of 20 significant, nonarousing words with a negative valence that were either depression related or potentially self-referent and 20 nonsignificant words matched on valence and arousal showed a main effect of significance. In Study 2 ( N=44), significant, nonarousing words were sampled more broadly to examine the effects of self-reference and valence. Significance, rather than just negativity or self-reference, elicited SCRs independently of arousal. SCRs to significant words may reflect cognitive and attentional processes that, in turn, might prove useful for the assessment of the cognitive aspects of anxiety. [ABSTRACT FROM AUTHOR]