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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.

Background: New opportunities to expand home-based palliative care (HBPC) highlight the need for novel data that explores how HBPC providers currently navigate this nascent business., Objectives: To investigate how HBPC providers and their organizations sustain their operations in a rapidly evolving market., Study Design: This was an exploratory, qualitative study., Setting: We conducted focus groups with staff of nine HBPC organizations that held provider contracts with a large California insurance provider., Measurement: A research team member experienced in qualitative methods conducted semi-structured focus group interviews with HBPC agency staff who were knowledgeable about their agency's patient recruitment and enrollment processes. Interview sessions of roughly an hour long were audio-recorded and transcribed verbatim. We used thematic analysis procedures to identify codes and themes., Results: We identified seven themes: market competition, market diversity, HBPC reimbursement, service standardization, hiring practices, marketing, strategic enrollment processes, and outcomes monitoring. The participants called for more standardization in their field. In discussing key business operations-hiring, marketing, patient enrollment, outcomes monitoring-they demonstrated inventiveness and willingness to innovate in order to succeed in a complex healthcare sector., Conclusion: Our study expands on the literature by providing a glimpse of the challenges encountered by HBPC providers and their organizations and the myriad strategies they undertake to navigate a health-service area that lacks standardized practice and payment guidelines. Our findings suggest that HBPC agencies will continue to struggle in the absence of standardization in practice, payment, and quality oversight.

Background: Patients with serious respiratory illness and their caregivers suffer considerable burdens, and palliative care is a fundamental right for anyone who needs it. However, the overwhelming majority of patients do not receive timely palliative care before the end of life, despite robust evidence for improved outcomes. Goals: This policy statement by the American Thoracic Society (ATS) and partnering societies advocates for improved integration of high-quality palliative care early in the care continuum for patients with serious respiratory illness and their caregivers and provides clinicians and policymakers with a framework to accomplish this. Methods: An international and interprofessional expert committee, including patients and caregivers, achieved consensus across a diverse working group representing pulmonary-critical care, palliative care, bioethics, health law and policy, geriatrics, nursing, physiotherapy, social work, pharmacy, patient advocacy, psychology, and sociology. Results: The committee developed fundamental values, principles, and policy recommendations for integrating palliative care in serious respiratory illness care across seven domains: 1 ) delivery models, 2 ) comprehensive symptom assessment and management, 3 ) advance care planning and goals of care discussions, 4 ) caregiver support, 5 ) health disparities, 6 ) mass casualty events and emergency preparedness, and 7 ) research priorities. The recommendations encourage timely integration of palliative care, promote innovative primary and secondary or specialist palliative care delivery models, and advocate for research and policy initiatives to improve the availability and quality of palliative care for patients and their caregivers. Conclusions: This multisociety policy statement establishes a framework for early palliative care in serious respiratory illness and provides guidance for pulmonary-critical care clinicians and policymakers for its proactive integration.

Care experiences of sexual minority (SM) adults are largely characterized by the need for receiving care and providing care to their chosen family. This is due, in part, to the lack of family and social support and higher rates of health disparities. Using data from the "Maintaining Dignity: Understanding and Responding to the Challenges Facing Older LGBT Americans" AARP survey ( N = 1694), we examined factors associated with past and anticipated future care experiences among older SMs. Older SM individuals reported high rates of providing care (70%), anticipating future provision of care (71%), and needing care from a loved one (73%). Being older, identifying as female, and having a disability were highly associated with past care experiences. Being female, being in a relationship, and having better self-rated health were highly associated with future anticipated care experiences. These outcomes indicate the importance of having services that are inclusive in serving the SM community.

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.

Introduction: Health care costs remain high at the end of life. It is not known if there is a relationship between advance directive (AD) completion and hospital out-of-pocket costs. This analysis investigated whether AD completion was associated with lower hospital out-of-pocket costs at end of life., Methods: We used Health and Retirement Study participants who died between 2000 and 2014 (N = 9228) to examine the association between AD completion status and hospital out-of-pocket spending in the last 2 years of life through the use of a two-part model controlling for socioeconomic status, death-related characteristics and health insurance coverage., Results: About 44% of decedents had completed ADs. Having an AD was significantly associated with $673 lower hospital out-of-pocket costs, with a higher magnitude of savings among younger decedents. Decedents who completed ADs 3 months or less before death had higher out-of-pocket costs ($1854 on average) than those who completed ADs more than 3 months before death ($1176 on average)., Conclusions: AD completion was significantly associated with lower hospital out-of-pocket costs, with greater out-of-pocket savings among younger decedents. Early AD completers experienced lower costs than decedents who completed ADs closer to death., (© 2022 The Authors. Journal of Hospital Medicine published by Wiley Periodicals LLC on behalf of Society of Hospital Medicine.)

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., (Copyright © 2022 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

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.

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., (© 2021. The Author(s).)

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.

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.

Background: Until recently, consumers have had limited resources to assess quality of hospices agencies, contributing to growing numbers of consumers turning to online review sites, such as Yelp. However, little is known about the content of hospice Yelp reviews and how these relate to recently available Center for Medicare and Medicaid Services' Hospice Compare (HC) site data. Objective: To better understand what consumers report on Yelp about hospice care and explore how these areas relate to HC data. Design: We examined 692 consumer Yelp reviews of 67 hospices in California and compared identified themes with quality measures presented on the HC site. Setting/Subjects: We used a purposive sample of California Hospice's with Yelp reviews. Measurements: Qualitative consumer comments about their experience with hospice care were analyzed by using a grounded theory approach. Results: We found that overall Yelp comments were positive, however Yelp themes were more extensive and diverse than those on HC. Conclusion: We recommend that consumers consider both HC and online review sites such as Yelp when evaluating a hospice.

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., (Copyright © 2020 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

Objectives: To identify characteristics and readmission risks associated with opting out of a social work-driven transition intervention., Study Design: Secondary data analysis of a randomized controlled pilot study at a large nonprofit urban community hospital., Methods: Hospitalized English-speaking, cognitively intact adults 65 years or older with expected discharge back to the community were eligible for enrollment. Additionally, patients met at least 1 of the 3 criteria: 1) 75 years or older, 2) taking 5 or more medications, or 3) had 1 or more prior inpatient stays or emergency department visits in the previous 6 months. The transition intervention consisted of up to 2 in-home visits (the first occurring within 48 hours after discharge) and up to 4 telephone follow-up calls (for a maximum of 6 total contacts) by a transition social worker. This study analyzed participants randomized to the intervention arm on measures including demographics, medical diagnoses, presence of advance directive, and all-cause 30-day hospital readmissions., Results: Of the 90 patients randomized to the Social Work Intervention Focused on Transitions intervention group, 10% were readmitted within 30 days and nearly one-third refused (ie, opted out of) the home visit component of the intervention. Multivariate analyses revealed that those opting out of the intervention had 3 times greater odds of having a respiratory condition compared with intervention recipients (odds ratio [OR], 3.10; 95% CI, 1.09-8.80; P = .034). Additionally, opting out of the intervention (OR, 6.75; 95% CI, 1.05-43.52; P = .045) and having a diagnosis of cancer (OR, 29.59; 95% CI, 2.01-435.45; P = .014) significantly predicted readmission., Conclusions: Findings suggest that some at-risk patients may not be receptive to services and programs aimed at improving care transitions, resulting in a higher risk for readmission.

Poster abstracts are evaluated based on the following criteria: significance of the problem to healthy aging or medication management; innovativeness of ideas, methods, and/or approach; methodological rigor of methods and approach; presentation of finding; implications identified for future research, practice, and/or policy; and clarity of writing. Submissions are not evaluated through the peer-reviewed process used by The Consultant Pharmacist . Industry support is indicated, where applicable. Presenting author is in italics. The poster abstract presentation is supported by the ASCP Foundation.

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., (Copyright © 2015 Elsevier Inc. All rights reserved.)

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., (© 2015, Copyright the Authors Journal compilation © 2015, The American Geriatrics Society.)

Background: Family members are commonly involved in end-of-life decision making and typically involved in inpatient palliative care consultations. Although much research has documented patient outcomes following inpatient palliative care consultation, little is known about family member perceptions of the consultation., Aim: The purpose of this study was to determine how inpatient palliative care consultations impacted family members' understanding of the patient's condition, knowledge of available care options, and decision-making ability., Design: An exploratory, qualitative study was conducted employing individual interviews among family members of seriously ill patients, recruited purposively. Interviews were conducted in person, at the hospital, or via telephone, using a semistructured protocol., Setting/participants: Family members of seriously ill patients were recruited from a nonprofit, community hospital., Results: Interviews were conducted among 23 family members. Four themes were identified and included: perceived qualities of the inpatient palliative care consultation, family readiness, impact on decision-making process, and focus on comfort and quality of life. While most comments reflected positive aspects of the inpatient palliative care consult, such as improved pain control and communication, and increased access to medical professionals and time to discuss patient conditions, some themes reflected a lack of adequate preparation for the inpatient palliative care consultation and readiness for discussing prognosis., Conclusion: Family members report discussion with the inpatient palliative care team results in improved communication and knowledge, which contributes to decision-making ability. However, palliative care consultation may be improved by developing stronger protocols for introducing palliative care and by including the attending physician in the process to preclude conflicting, inconsistent information and recommendations.

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., (© 2013, Copyright the Authors Journal compilation © 2013, The American Geriatrics Society.)

Objectives: To identify factors associated with physician referrals to end-of-life (EOL) care., Study Design: Cross-sectional, web-based survey., Methods: Participants were managed care physicians (n = 545) from the Southern California region of a national nonprofit health maintenance organization who treated a patient in their office within 6 months of the patient's death from a chronic condition. Measures included self-reports of referrals to EOL services, comfort level discussing EOL with patients, personal/family experience with hospice, and demographic characteristics., Results: Participants were most commonly US born (69.1%), married (83.8%), and male (66.0%) with a mean age of 47 years (SD = 8.9 years). About half were Caucasian (51.7%). Logistic regression revealed that family/internal medicine physicians were nearly 9 times more likely to make EOL referrals (95% confidence interval [CI] 3.879-19.434), and physicians comfortable discussing EOL care were nearly 7 times more likely to refer (95% CI 3.465-12.750). Younger age was significantly associated with EOL referrals; with every 1-year decrease in age, physicians were 5% more likely to refer (95% CI 0.911-0.985). Family/internal medicine physicians (95% CI 1.259-2.899) and those comfortable discussing EOL care (95% CI 2.964-9.685) were also more likely to make frequent (4 or more) referrals, Conclusions: This study highlights factors associated with EOL referrals that may be enhanced at the organizational level through training and educating physicians. Results suggest that organizations should work toward improving physician ease and comfort with EOL conversations. This study serves as an important step toward understanding and reducing physician-level barriers to EOL referrals.

Objective: To assess the efficacy of a home care program designed to improve access to medical care for older adults with multiple chronic conditions who are at risk for hospitalization., Study Design: Randomized controlled trial in which participants were assigned to the home care intervention (Choices for Healthy Aging [CHA]) program or usual care., Methods: The intervention group consisted of 298 older adults at risk of hospitalization as determined by a risk stratification tool. Measures included satisfaction with medical care, medical service use, and costs of medical care., Results: The intervention group reported significantly greater satisfaction with care than usual care recipients (t test = 2.476; P = .014). CHA patients were less likely than usual care patients to be admitted to the hospital (25.6% and 37.1%, respectively; P = .02). There were no differences in terms of costs of care between the home care and usual care groups., Conclusions: Provision of home care to older adults at high risk of hospitalization may improve satisfaction with care while reducing hospitalizations. Lack of difference in medical costs suggests that managed care organizations need to consider targeting rather than using risk stratification measures when designing programs for high-risk groups.