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Background and Objectives Computerized cognitive interventions (CCIs) have been increasingly implemented among older adults with mild cognitive impairment (MCI). However, older individuals’ attitudes toward technology may limit CCI engagement. This exploratory-developmental study examined whether a “multi-functional interactive computer system” (MICS), which provides pleasurable activities via computer, would improve attitudes toward computers and in turn increase the efficacy of a subsequent CCI. Research Design and Methods A phase one double-blind trial randomized 49 seniors with MCI to a MICS + CCI condition or a CCI-only condition. Attitudes toward technology use was assessed using The Attitudes Toward Computers Questionnaire (ATCQ), and cognition was assessed using episodic memory and executive function composite scores at baseline, the ends of MICS and CCI phases, and 3-month follow-up. Results The MICS + CCI group did not show significantly greater improvement in cognition than the CCI only group. Secondary analyses indicated that improvement in executive function from baseline occurred in both groups. Participants who did show improved attitudes toward computers, whether through MICS or simply computer exposure itself, showed improvement in executive function. Discussion and Implication Participants in the MICS + CCI group used MICS less than expected. A more structured and supervised approach may be needed to facilitate MICS exposure. Improved attitudes toward computers regardless of MICS exposure may benefit candidates for CCI.

Objectives Individuals with dementia have high rates of emergency department (ED) use for acute illnesses. We evaluated the effect of a high-intensity telemedicine program that delivers care for acute illnesses on ED use rates for individuals with dementia who reside in senior living communities (SLCs; independent and assisted living). Design We performed a secondary analysis of data for patients with dementia from a prospective cohort study over 3.5 years that evaluated the effectiveness of high-intensity telemedicine for acute illnesses among SLC residents. Setting and participants We studied patients cared for by a primary care geriatrics practice at 22 SLCs in a northeastern city. Six SLCs were selected as intervention facilities and had access to patient-to-provider high-intensity telemedicine services to diagnose and treat illnesses. Patients at the remaining 15 SLCs served as controls. Participants were considered to have dementia if they had a diagnosis of dementia on their medical record problem list, were receiving medications for the indication of dementia, or had cognitive testing consistent with dementia. Measures We compared the rate of ED use among participants with dementia and access to high-intensity telemedicine services to control participants with dementia but without access to services. Results Intervention group participants had 201 telemedicine visits. In participants with dementia, it is estimated that 1 year of access to telemedicine services is associated with a 24% decrease in ED visits (rate ratio 0.76, 95% confidence interval 0.61, 0.96). Conclusions/Implications Telemedicine in SLCs can effectively decrease ED use by individuals with dementia, but further research is needed to confirm this secondary analysis and to understand how to best implement and optimize telemedicine for patients with dementia suffering from acute illnesses.

Objectives This document offers guidance to clinicians and facilities on the use of telemedicine to deliver medically necessary evaluation and management of change of condition for nursing home residents. Settings and participants Members of the telemedicine workgroup of AMDA—The Society for Post-Acute Long-Term Medicine-developed this guideline through both telephonic and face-to-face meetings between April 2017 and September 2018. The guideline is based on the currently available research, experience, and expertise of the workgroup's members, including a summary of a recently completed systematic mixed studies literature review to determine evidence for telemedicine to reduce emergency department visits or hospitalizations of nursing home residents. Results Research and experience to date support the use of telemedicine as a tool in change of condition assessment and management as a means of reducing unnecessary emergency department visits and hospitalization. Telemedicine-delivered care should be integrated into the primary care of the resident and delivered by providers with competency in post-acute long-term care. The development and sustainability of telemedicine programs is heavily dependent on financial implications. Quality measures should be defined for telemedicine programs in nursing homes. Conclusions/Implications Telemedicine programs in nursing homes can contribute to the delivery of timely, high quality medical care, which reduces unnecessary hospitalization. Reimbursement for telemedicine-driven care should be based upon medical necessity of visits to care and the maintenance of quality standards. More studies are needed to understand which telemedicine tools and processes are most effective in improving outcomes for nursing home residents.

The American Board of Post-Acute and Long-Term Care Medicine (ABPLM) contracted with a psychometric firm to perform a 3-phase Job Analysis following best practices. Literature was reviewed, a task force of subject matter experts was convened, a survey was developed and sent via Survey Monkey to attending physicians practicing in post-acute and long-term care settings (PALTC). The task force refined a comprehensive list of the tasks, knowledge, and medical knowledge needed in the role of attending physician in PALTC. These items were written as statements and edited until consensus was reached on their accuracy, conciseness, and lack of overlap. Task statements described distinct, identifiable, and specific practice-related activities relevant across multiple care settings. Knowledge statements described previously acquired information considered necessary to effectively perform such tasks. The survey consisted of 260 items, including 21 demographic questions, 115 task statements, 73 knowledge statements, and 72 medical knowledge statements. The survey was disseminated via e-mail invitations to Society for Post-Acute and Long-Term Care (AMDA) members and through an online link available through ABPLM's website. A total of 389 respondents participated. Survey data were analyzed with statistical analysis software SPSS. For each task and knowledge statement, an Overall Task Rating and Knowledge Rating were developed by combining the importance rating weighted at 65% and (for task) the frequency rating or (for knowledge) the cognitive level weighted at 35%. One task statement and 1 medical knowledge statement had a mean importance rating lower than 2.5 and were dropped from further review, resulting in a final count of 114 task, 73 knowledge, and 71 medical knowledge statements (258 total). The results of this Job Analysis highlight the unique and specific nature of medical care provided by attending physicians across a range of PALTC settings. These findings lay a foundation for Focused Practice Designation or Subspecialty in PALTC and changes in practice and policy.

Background Emergency department (ED) visits for ambulatory care sensitive conditions (ACSCs) are common among older adults. The high-intensity telemedicine model of care has been proposed as an innovative approach to expand access to acute illness care, thereby preventing ED visits. The aim of this study was to assess the effect of a high-intensity telemedicine program for senior living community (SLC) residents on the rate of ED use for ACSCs. Methods We performed a prospective cohort study at a primary care geriatrics practice that provides care to 22 SLCs. Six SLCs selected as intervention facilities, with the remaining SLCs serving as controls. Consenting practice patients at intervention facilities could have patient-to-provider, real-time, or store-and-forward high-intensity telemedicine services to diagnose and treat illnesses. The primary outcome was the rate of ED visits for which the primary diagnosis was an “ambulatory-care-sensitive” condition by the Institute of Medicine, which we compared between control and intervention participants. Results During the study period, control participants had 310 ED visits for ACSCs, for a rate of 0.195 visits/person-year. Intervention participants visited the ED for ACSCs 85 times, for a rate of 0.138 visits/person-year [unadjusted rate ratio (RR): 0.71, 95% confidence interval (CI): 0.53–0.94]. Among intervention participants, ED use for ACSCs decreased at an annual rate of 34% (RR: 0.661, 95% CI: 0.444–0.982), whereas, in the control group there was no statistically significant change in ED use over time (RR: 1.01, 95% CI: 0.90–1.14). Conclusions Providing acute illness care by high-intensity telemedicine to older adults residing in SLCs significantly decreases the rate of ED use for ACSCs over 1 year, compared with no change in the rate of ED use for ACSCs among the control group.

Background Many factors contribute to medication nonadherence including psychological and memory disorders, aging, and pill burden. The Automated Home Medication Dispenser (AHMD) is a medication management system intended to help solve unintentional medication nonadherence. Objective The purpose of this study was to determine if use of the AHMD improved medication adherence. Methods We conducted a 6-month prospective, feasibility study assessing use of the AHMD in 21 patient-caregiver dyads. Patients were referred by their physician because of poor medication adherence and included if they resided in Rochester, NY and on at least two medications in pill form. Pill counts were performed at baseline to assess previous adherence. Prospective medication adherence was assessed using AHMD recorded dosing information. A paired t-test was used to compare previous and prospective adherence. Results The mean age of patients was 75.1 years. Fifteen patients (71.4%) and eight caregivers (38.1%) were women; half (47.6%) of caregivers lived with the patient. The most common patient comorbidities were hypertension (76.2%) and memory disorder (61.9%). Mean adherence increased from 49.0% at baseline to 96.8% after 6 months of AHMD use (p Conclusion In a cohort of unintentionally nonadherent patients, use of the AHMD for 6 months significantly improved medication adherence.

Nursing homes (NHs) are an important target for antibiotic stewardship (AS). We describe a collaborative model to reduce Clostridioides difficile infections (CDIs) in NHs through optimization of antibiotic use including a reduction in high-risk antibiotics such as fluoroquinolones.Quasi-experimental, pre- and post-intervention study.Six NHs in Monroe County, NY.A hospital-based AS expert team assisted NHs in identifying targets for improving antibiotic use. Interventions included (1) collaboration with a medical director advisory group to develop NH consensus guidelines for testing and treatment of 2 syndromes (urinary tract infections and pneumonia) for which fluoroquinolone use is common, (2) provision of multifaceted NH staff education on these guidelines and education of residents and family members on the judicious use of antibiotics, and (3) sharing facility-specific and comparative antibiotic and CDI data. We used Poisson regression to estimate antibiotic use per 1000 resident days (RD) and CDIs per 10,000 RD, pre- and post-intervention. Segmented regression analysis was used to estimate changes in fluoroquinolone and total antibiotic rates over time.Postintervention, the monthly rate of fluoroquinolone days of therapy (DOT) per 1000 RD significantly decreased by 39% [rate ratio (RR) 0.61, 95% confidence interval (CI) 0.59-0.62, P .001] across all NHs and the total antibiotic DOT decreased by 9% (RR 0.91, 95% CI 0.90-0.92, P .001). Interrupted time series analysis of fluoroquinolone and total DOT rates confirmed these changes. The quarterly CDI rate decreased by 18% (RR 0.82, 95% CI 0.68-0.99, P = .042).A hospital-NH partnership with a medical director advisory group achieved a significant reduction in total antibiotic and fluoroquinolone use and contributed to a reduction in CDI incidence. This approach offers one way for NHs to gain access to AS expertise and resources and to standardize practices within the local community.

Accessing timely acute medical care is a challenge for older adults. This article describes an innovative healthcare model that uses high-intensity telemedicine services to provide rapid acute care for older adults without requiring them to leave their senior living community (SLC) residences. This program, based in a primary care geriatrics practice that cares for SLC residents, is designed to offer acute care through telemedicine for complaints that are felt to need attention before the next available outpatient visit but not to require emergency department (ED) resources. This option gives residents access to care in their residence. Measures used to evaluate the program include successful completion of telemedicine visits, satisfaction of residents and caregivers with telemedicine care, and site of care that would have been recommended had telemedicine been unavailable. During the first 2 years of the program's operation, 281 of 301 requested telemedicine visits were completed successfully. Twelve residents were sent to an ED for care after the telemedicine visit. Ninety-four percent of residents reported being satisfied or very satisfied with telemedicine care. Had telemedicine not been available, residents would have been sent to an ED (48.1%) or urgent care center (27.0%) or been scheduled for an outpatient visit (24.4%). The project demonstrated that high-intensity telemedicine services for acute illnesses are feasible and acceptable and can provide definitive care without requiring ED or urgent care use. Continuation of the program will require evaluation demonstrating equal or better resident-level outcomes and the development of sustainable business models.

Objectives Older adults dwelling in senior living communities (SLCs) often experience barriers to medical care when they experience acute illness. The potential of telemedicine as a substitute for standard routes of evaluating and caring for individuals with acute illness (e.g., in-person or telephone-based interactions with primary care providers and emergency department [ED] visits) was explored in this study. Methods In this cross-sectional, observational study, the authors conducted a 6-month retrospective review of the medical records of adults enrolled in a university-affiliated geriatrics practice that offers on-site primary medical care in SLCs. For each episode of acute care, patient demographics, medical history, and chief complaint were collected and presented to an expert panel of physicians, who determined whether telemedicine could have been used to provide acute evaluation and care. The care actually provided, including outcomes, was also noted. Descriptive statistics were used to characterize the population and potential for telemedicine care. Results The medical records of 646 patients were reviewed, accounting for 1,535 unique episodes of acute care. The expert panel identified 576 visits (38%) as potentially appropriate for telemedicine-based acute care, with 38, 47, and 27% of phone, in-home, and ED visits being eligible, respectively. Chief complaints most likely to be deemed potentially appropriate were falls and dermatologic, respiratory, and gastrointestinal illnesses, representing 58% of visits identified for telemedicine-based acute care. Conclusions Telemedicine has a potentially significant role in the provision of acute care for older adults residing in SLCs. Studies are needed to evaluate the feasibility, acceptability, effectiveness, and efficiency of acute care telemedicine for this population. Resumen El Potencial de la Telemedicina para Proporcionar Atencion Medica Aguda a Adultos en Comunidades Residenciales para Mayores Objetivos Los ancianos en comunidades residenciales para mayores (CRM) a menudo experimentan barreras a la atencion medica cuando ellos sufren una enfermedad aguda. Se exploro en este estudio el potencial de la telemedicina como un sustituto de los mecanismos estandar de evaluacion y atencion a los individuos con enfermedad aguda (ej: interacciones personales o telefonicas con los medicos de atencion primaria (MAP) y visitas a los servicios de urgencias (SU)). Metodologia En este estudio observacional transversal, se llevo a cabo una revision retrospectiva de 6 meses de las historias medicas de los adultos en un centro geriatrico afiliado a la universidad que ofrece atencion primaria en CRM. Para cada episodio de atencion aguda, se recogieron las caracteristicas demograficas, la historia medica y la queja principal y se presentaron a un panel de medicos expertos, que determinaron si la telemedicina podia haberse usado para proporcionar la evaluacion y la atencion aguda. La asistencia proporcionada, incluyendo los resultados, tambien se anoto. La estadistica descriptiva se utilizo para caracterizar la poblacion y la atencion potencial para la telemedicina. Resultados Se revisaron las historias medicas de 646 pacientes, y se contabilizaron 1.535 episodios unicos de atencion aguda. El panel de expertos identifico 576 visitas (38%) como potencialmente apropiadas para la atencion aguda mediante telemedicina, y fueron elegibles un 38%, 47% y 27% de llamadas, y visitas al domicilio y a urgencias, respectivamente. Las quejas principales mas probablemente consideradas apropiadas fueron las caidas y las enfermedades dermatologicas, respiratorias y gastrointestinales, que representaron el 58% de las visitas identificadas para atencion aguda mediante telemedicina. Conclusiones La telemedicina tiene un papel potencialmente significativo en la provision de atencion aguda a los ancianos que residen en una CRM. Se necesitan estudios para evaluar la viabilidad, la aceptabilidad, la efectividad y la eficiencia de la atencion aguda mediante telemedicina para esta poblacion.

Primary care medical practices dedicated to the needs of older adults who dwell in independent and assisted living residences in senior living communities (SLCs) have been developed. To date, the demographic and acute medical care use patterns of patients in these practices have not been described.A descriptive study using a 6-month retrospective record review of adults enrolled in a medical primary care practice that provides on-site primary medical care in SLCs.Greater Rochester, New York.Participants were 681 patients residing in 19 SLCs.Demographic and clinical data were collected. Use of acute medical care by patients in the SLC program, including phone consultation, provider emergent/urgent in-home visit, emergency department (ED) visit, and hospital admissions, were recorded. ED visit and hospital admissions at the 2 primary referral hospitals for the practice were reviewed for chief complaint and discharge plan.A total of 635 (93%) of 681 records were available. The median age was 85 years (interquartile range [IQR] 77, 89). Patients were predominantly female (447, 70%) and white (465, 73%). Selected chronic medical diseases included dementia/cognitive impairment (367, 58%), cardiac disease (271, 43%), depression (246, 39%), diabetes (173, 27%), pulmonary disease (146, 23%), renal disease (118, 19%), cancer (115, 18%), and stroke/TIA (93,15%). The median Mini Mental State Examination score was 25 (IQR 19, 28; n = 446). Patients took a median of 10 medications (IQR 7, 12). Important medication classes included cardiovascular (512, 81%), hypoglycemics (117, 18%), benzodiazepines (71, 11%), dementia (194, 31%), and anticoagulants (51, 8%). Patients received acute care 1876 times (median frequency 3, IQR 2, 6) for 1504 unique medical issues. Falls were the most common complaint (399, 20%). Of these 1876 episodes, patients accessed acute care via telephone (1071, 57%), provider visit at the SLC (417, 22%), and ED visit (388, 21%). Of the cases conducted via telephone, 693 (67%) were resolved by phone, 253 (24%) required home visits, 15 (1%) required subspecialist follow-up, and 81 (8%) required ED evaluation. Of the cases prompting a home visit by a medical provider, 399 (96%) were resolved during the visit, 13 (3%) required subspecialist follow-up, and 4 (1%) required ED evaluation. Of the 389 cases conducted via ED visit, 164 (42%) were admitted to the hospital and 2 (0.5%) died.SLC primary care medical practices serve a population that is older, has significant medical comorbidity, and frequently accesses acute medical care. Although many acute care issues for this population are handled via phone, home visits and/or ED use is common. Understanding the acute care health utilization patterns of SLC dwellers is critical to designing systems to optimally address the acute care needs of aging older adults.

High-intensity telemedicine has been shown to reduce the need for emergency department (ED) care for older adult senior living community (SLC) residents with acute illnesses. We evaluated the effect of SLC engagement in the telemedicine program on ED use rates.We performed a secondary analysis of data from a prospective cohort study evaluating the effectiveness of high-intensity telemedicine for SLC residents. We compared the annual rate of change in ED use among subjects who resided in SLC units that were more engaged in telemedicine services with that among subjects who resided in SLC units that were less engaged in telemedicine and control subjects who lived at facilities without access to telemedicine services.During the study, subjects had 503 telemedicine visits, with 362 (72.0%) in the more engaged SLCs and 141 (28.0%) in the less engaged SLCs. For subjects residing in more engaged SLCs, ED use decreased at an annualized rate of 28% (rate ratio [RR] = 0.72; 95% confidence interval [CI], 0.58-0.89), whereas in the less engaged (RR = 0.962; 95% CI, 0.776-1.19) and control (RR = 0.909, 95% CI, 0.822-1.07) groups there was no significant change in ED use (p = 0.036 for group × time interaction).Individuals residing in more engaged SLCs experienced a greater decrease in ED use compared with subjects residing in less engaged SLCs or those without access to high-intensity telemedicine for acute illnesses. We identified potential factors associated with more engaged SLCs, but further research is needed to understand resident and staff engagement and how to increase it.

The failure to provide timely acute illness care can lead to adverse consequences or emergency department (ED) use. We evaluated the effect on ED use of a high-intensity telemedicine program that provides acute illness care for senior living community (SLC) residents.We performed a prospective cohort study over 3.5 years. Six SLCs cared for by a primary care geriatrics practice were intervention facilities, with the remaining 16 being controls. Consenting patients at intervention facilities could access telemedicine for acute illness care. Patients were provided patient-to-provider, real-time, or store-and-forward high-intensity telemedicine (i.e., technician-assisted with resources beyond simple videoconferencing) to diagnose and treat acute illnesses. The primary outcome was the rate of ED use.We enrolled 494 of 705 (70.1%) subjects/proxies in the intervention group; 1,058 subjects served as controls. Control and intervention subjects visited the ED 2,238 and 725 times, respectively, with 47.3% of control and 43.4% of intervention group visits resulting in discharge home. Among intervention subjects, ED use decreased at an annualized rate of 18% (rate ratio [RR]=0.82; 95% confidence interval [CI], 0.70-0.95), whereas in the control group there was no statistically significant change in ED use (RR=1.01; 95% CI, 0.95-1.07; p=0.009 for group-by-time interaction). Primary care use and mortality were not significantly different.High-intensity telemedicine significantly reduced ED use among SLC residents without increasing other utilization or mortality. This alternative to traditional acute illness care can enhance access to acute illness care and should be integrated into population health programs.

To address the challenge of educating primary care physicians in the care of older adults,(1,2) the University of Arizona College of Medicine's Reynolds Program of Applied Geriatrics publishes Elder Care Provider Fact Sheets in the Arizona Geriatrics Society Journal twice a year. These two-page, practical, evidenced-based Provider Fact Sheets summarize important geriatric topics, provide useful clinical assessments and interventions, and are featured on the Arizona Reynold's Program of Applied Geriatrics Web site (http://www.reynolds.med.arizona.edu/EduProducts/physicianfacts.cfm).

To address the challenge of educating primary care physicians in the care of older adults, the University of Arizona College of Medicine's Reynolds Program of Applied Geriatrics publishes Elder Care Provider Fact Sheets in the Arizona Geriatrics Society Journal twice a year. These two-page, practical, evidenced-based Provider Fact Sheets summarize important geriatric topics, provide useful clinical assessments and interventions, and are featured on the Arizona Reynold's Program of Applied Geriatrics Web site (http://www.reynolds.med.arizona.edu/EduProducts/physicianfacts.cfm).