Use of the Patient-Identified Top Health Priority in Care Decision-making for Older Adults With Multiple Chronic Conditions

Critical Illness, Major Surgery, and Other Hospitalizations and Active and Disabled Life Expectancy

Importance

Estimates of active and disabled life expectancy, defined as the projected number of remaining years without and with disability in essential activities of daily living, are commonly used by policymakers to forecast the functional well-being of older persons.

Objective

To determine how estimates of active and disabled life expectancy differ based on exposure to intervening illnesses and injuries (or events).

Design, Setting, and Participants

This prospective cohort study was conducted in south-central Connecticut from March 1998 to December 2021 among 754 community-living persons aged 70 years or older who were not disabled. Data were analyzed from January 25 to September 18, 2024.

Exposures

Exposure to intervening events, which included critical illness, major elective and nonelective surgical procedures, and hospitalization for other reasons, was assessed each month.

Main Outcomes and Measures

Disability in 4 essential activities of daily living (bathing, dressing, walking, and transferring) was ascertained each month. Active and disabled life expectancy were estimated using multistate life tables under a discrete-time Markov process assumption.

Results

The study included 754 community-living older persons who were not disabled (mean [SD] age, 78.4 [5.3] years; 487 female [64.6%]; 67 Black [8.9%], 4 Hispanic [0.5%], 682 non-Hispanic White [90.5%], and 1 other race [0.1%]). Within 5-year age increments from 70 to 90 years, active life expectancy decreased monotonically as the number of admissions for critical illness and other hospitalization increased. For example, at age 70 years, sex-adjusted active life expectancy decreased from 14.6 years (95% CI, 13.9-15.2 years) in the absence of a critical illness admission to 11.3 years (95% CI, 10.3-12.2 years), 8.1 years (95% CI, 6.3-9.9 years), and 4.0 years (95% CI, 2.6-5.7 years) in the setting of 1, 2, or 3 or more critical illness admissions, respectively. Corresponding values for other hospitalization were 19.4 years (95% CI, 18.0-20.8 years), 13.5 years (95% CI, 12.2-14.7 years), 10.0 years (95% CI, 8.9-11.2 years), and 7.0 years (95% CI, 6.1-7.9 years), respectively. Consistent monotonic reductions were observed for sex-adjusted estimates in active life expectancy for nonelective but not elective surgical procedures as the number of admissions increased; for example, at age 70 years, estimates of active life expectancy were 13.9 years (95% CI, 13.3-14.5 years), 11.7 years (95% CI, 10.5-12.8 years), and 9.2 years (95% CI, 7.4-11.0 years) for 0, 1, and 2 or more nonelective surgical admissions, respectively; corresponding values were 13.4 years (95% CI, 12.8-3-14.1 years), 14.6 years (95% CI, 13.5-15.5 years), and 12.6 years (95% CI, 11.5-13.8 years) for elective surgical admissions. Sex-adjusted disabled life expectancy decreased as the number of admissions increased for critical illness and other hospitalization but not for nonelective or elective surgical procedures; for example, at age 70 years, disabled life expectancy decreased from 4.4 years (95% CI, 3.5-5.8 years) in the absence of other hospitalization to 3.4 years (95% CI, 2.8-4.1 years), 3.4 years (95% CI, 2.7-4.2 years), and 2.3 years (95% CI, 1.9-2.8 years) in the setting of 1, 2, or 3 or more other hospitalizations, respectively.

Conclusions and Relevance

This study found that active life expectancy among community-living older persons who were not disabled was considerably diminished in the setting of serious intervening illnesses and injuries. These findings suggest that prevention and more aggressive management of these events, together with restorative interventions, may be associated with improved functional well-being among older persons.

Perceived Connections Between Personal Values and Health in High-Risk Patients with Multimorbidity: A Qualitative Study

BACKGROUND

Aligned with increasing organizational and policy focus on whole person care, particularly for patients with multimorbidity, health systems are operationalizing how to assess what patients find meaningful in life for personalized health planning. Few studies have examined how patients with multimorbidity at high risk of adverse events perceive connections between what is most important in life (i.e., personal values) and health, healthcare, and healthcare decisions. This knowledge is critical to optimizing how, when, and under what circumstances the topics are addressed in healthcare settings.

OBJECTIVE

To understand how high-risk patients with multimorbidity perceive connections between personal values and health, healthcare, and healthcare decisions.

DESIGN

Qualitative study.

PARTICIPANTS

Patients ≥ 75th percentile risk of hospitalization or mortality using a validated prediction score, with ≥ 2 diagnoses among depression, hypertension, chronic kidney disease, or diabetes, engaged in Veterans Health Administration primary care.

APPROACH

Individual semi-structured telephone interview, analyzed with content analysis.

KEY RESULTS

Patients (N=27) averaged 68 years old; 17 (63%) were male. Three main themes emerged: (1) personal values were rarely discussed in healthcare settings or reflected in healthcare decision-making, sometimes given perceived lower relevance by patients; (2) when personal values were perceived as affecting health decisions, it was within specific contexts or circumstances (e.g., deciding on surgery); (3) eliciting personal values in healthcare settings could have positive or negative consequences, related to conditions of disclosure and resultant action taken in the care plan, and not all patients wanted to disclose values.

CONCLUSIONS

In this study, high-risk patients with multimorbidity reported rarely discussing values in healthcare settings, and if so, only perceived relevant connections between values and health in specific contexts. While some participants felt sharing values benefitted care, not all felt comfortable with disclosure. Patient preferences for eliciting and incorporating values are relevant to integrating patient personal values in healthcare settings.

Patient Priorities Care Increases Long-Term Service and Support Use: Propensity Match Cohort Study

OBJECTIVES

Patient priorities care (PPC) is an evidence-based approach designed to help patients achieve what matters most to them by identifying their health priorities and working with clinicians to align the care they provide to the patient's priorities. This study examined the impact of the PPC approach on long-term service and support (LTSS) use among veterans.

DESIGN

Quasi-experimental study examining differences in LTSS use between veterans exposed to PPC and propensity-matched controls not exposed to PPC adjusting for covariates.

SETTING AND PARTICIPANTS

Fifty-six social workers in 5 Veterans Health Administration (VHA) sites trained in PPC in 2018, 143 veterans who used the PPC approach, and 286 matched veterans who did not use the PPC approach.

METHODS

Veterans with health priorities identified through the PPC approach were the intervention group (n = 143). The usual care group included propensity-matched veterans evaluated by the same social workers in the same period who did not participate in PPC (n = 286). The visit with the social worker was the index date. We examined LTSS use, emergency department (ED), and urgent care visits, 12 months before and after this date for both groups. Electronic medical record notes were extracted with a validated natural language processing algorithm (84% sensitivity, 95% specificity, and 92% accuracy).

RESULTS

Most participants were white men, mean age was 76, and 30% were frail. LTSS use was 48% higher in the PPC group compared with the usual care group [odds ratio (OR), 1.48; 95% CI, 1.00-2.18; P = .05]. Among those who lived >2 years after the index date, new LTSS use was higher (OR, 1.69; 95% CI, 1.04-2.76; P = .036). Among nonfrail individuals, LTSS use was also higher in the PPC group (OR, 1.70; 95% CI, 1.06-2.74; P = .028). PPC was not associated with higher ED or urgent care use.

CONCLUSIONS AND IMPLICATIONS

PPC results in higher LTSS use but not ED or urgent care in these veterans. LTSS use was higher for nonfrail veterans and those living longer. The PPC approach helps identify health priorities, including unmet needs for safe and independent living that LTSS can support.

Patient Priorities-Aligned Care for Older Adults With Multiple Conditions: A Nonrandomized Controlled Trial

Importance

Older adults with multiple conditions receive health care that may be burdensome, of uncertain benefit, and not focused on what matters to them. Identifying and aligning care with patients' health priorities may improve outcomes.

Objective

To assess the association of receiving patient priorities care (PPC) vs usual care (UC) with relevant clinical outcomes.

Design, Setting, and Participants

In this nonrandomized controlled trial with propensity adjustment, enrollment occurred between August 21, 2020, and May 14, 2021, with follow-up continuing through February 26, 2022. Patients who were aged 65 years or older and with 3 or more chronic conditions were enrolled at 1 PPC and 1 UC site within the Cleveland Clinic primary care multisite practice. Data analysis was performed from March 2022 to August 2023.

Intervention

Health professionals at the PPC site guided patients through identification of values, health outcome goals, health care preferences, and top priority (ie, health problem they most wanted to focus on because it impeded their health outcome goal). Primary clinicians followed PPC decisional strategies (eg, use patients' health priorities as focus of communication and decision-making) to decide with patients what care to stop, start, or continue.

Main Outcomes and Measures

Main outcomes included perceived treatment burden, Patient-Reported Outcomes Measurement Information System (PROMIS) social roles and activities, CollaboRATE survey scores, the number of nonhealthy days (based on healthy days at home), and shared prescribing decision quality measures. Follow-up was at 9 months for patient-reported outcomes and 365 days for nonhealthy days.

Results

A total of 264 individuals participated, 129 in the PPC group (mean [SD] age, 75.3 [6.1] years; 66 women [48.9%]) and 135 in the UC group (mean [SD] age, 75.6 [6.5] years; 55 women [42.6%]). Characteristics between sites were balanced after propensity score weighting. At follow-up, there was no statistically significant difference in perceived treatment burden score between groups in multivariate models (difference, -5.2 points; 95% CI, -10.9 to -0.50 points; P = .07). PPC participants were almost 2.5 times more likely than UC participants to endorse shared prescribing decision-making (adjusted odds ratio, 2.40; 95% CI, 0.90 to 6.40; P = .07), and participants in the PPC group experienced 4.6 fewer nonhealthy days (95% CI, -12.9 to -3.6 days; P = .27) compared with the UC participants. These differences were not statistically significant. CollaboRATE and PROMIS Social Roles and Activities scores were similar in the 2 groups at follow-up.

Conclusions and Relevance

This nonrandomized trial of priorities-aligned care showed no benefit for social roles or CollaboRATE. While the findings for perceived treatment burden and shared prescribing decision-making were not statistically significant, point estimates for the findings suggested that PPC may hold promise for improving these outcomes. Randomized trials with larger samples are needed to determine the effectiveness of priorities-aligned care.

Trial Registration

ClinicalTrials.gov Identifier: NCT04510948.

Implementation of patient priorities-aligned care in a home-based primary care program

BACKGROUND

Older adults may be limited in their ability to access care that meets their health goals owing to disease burden, financial instability, and psychosocial barriers. A home-based primary care (HBPC) program established in 2020 within a large family medicine practice uses the Patient Priorities Care (PPC) approach to identify and address patients' health priorities. When incorporated as part of the HBPC model of care, the PPC approach has the potential to enhance person-centered care for older adults in a way that best supports their health goals.

OBJECTIVE

The objective of this study is to summarize common recommendations for alignment of care with patients' health outcome goals after implementation of the PPC approach in an HBPC population.

METHODS

This retrospective study was exempt from review by an institutional review board. After enrollment in the HBPC program, patients participated in a PPC priorities identification conversation to identify their health outcome goals and care preferences. Through chart review, 2 researchers independently categorized these goals based on the set of values they most reflect: connecting, managing health, enjoying life, and functioning. Aspects of care in place before enrollment in HBPC were considered to determine any adjustments that needed to be made to align care with patients' identified priorities.

RESULTS

The most common value associated with patients' most desired health outcome goal was functioning (n = 33, 66%). For secondary and tertiary health outcome goals, the most common value identified was managing health (secondary, n = 28, 56%; tertiary, n = 22, 44%). Common recommendations made to align care with patients' identified priorities included stopping potentially harmful medications, starting medications for untreated conditions, starting physical or occupational therapy, and adjusting medications.

CONCLUSION

Through the PPC approach, patients' values were identified and care was assessed to aid in attainment of individualized health outcome goals and tailor care to What Matters most.

Aging is not an Illness: Exploring Geriatricians' Resistance to Serious Illness Conversations

CONTEXT

Serious illness conversations help clinicians align medical decisions with patients' goals, values, and priorities and are considered an essential component of shared decision-making. Yet geriatricians at our institution have expressed reluctance about the serious illness care program.

OBJECTIVES

We sought to explore geriatricians' perspectives on serious illness conversations.

METHODS

We conducted focus groups with interprofessional stakeholders in geriatrics.

RESULTS

Three key themes emerged that help explain the reluctance of clinicians caring for older patients to have or document serious illness conversations: 1) aging in itself is not a serious illness; 2) geriatricians often focus on positive adaptation and social determinants of health and in this context, the label of "serious illness conversations" is perceived as limiting; and 3) because aging is not synonymous with illness, important goals-of-care conversations are not necessarily documented as serious illness conversations until an acute illness presents itself.

CONCLUSION

As institutions work to create system-wide processes for documenting conversations about patients' goals and values, the unique communication preferences of older patients and geriatricians should be specifically considered.

Guiding Post-Hospital Recovery by 'What Matters:' Implementation of Patient Priorities Identification in a VA Community Living Center

BACKGROUND

Patient priorities care (PPC) is an effective age-friendly health systems (AFHS) approach to aligning care with goals derived from 'what matters'. The purpose of this quality improvement program was to evaluate the fidelity and feasibility of the health priorities identification (HPI) process in VA Community Living Centers (CLC).

METHODS

PPC experts worked with local CLC staff to guide the integration of HPI into the CLC and utilized a Plan-Do-Study-Act (PDSA) model for this quality improvement project. PPC experts reviewed health priorities identification (HPI) encounters and interdisciplinary team (IDT) meetings for fidelity to the HPI process of PPC. Qualitative interviews with local CLC staff determined the appropriateness of the health priorities identification process in the CLC.

RESULTS

Over 8 months, nine facilitators completed twenty HPI encounters. Development of a Patient Health Priorities note template, staff education and PPC facilitator training improved fidelity and documentation of HPI encounters in the electronic health record. Facilitator interviews suggested that PPC is appropriate in this setting, not burdensome to staff and fostered a person-centered approach to AFHS.

CONCLUSIONS

The HPI process is an acceptable and feasible approach to ask the 'what matters' component of AFHS in a CLC setting.

Veterans Health Administration Models of Community-Based Long-Term Care: State of the Science

The complex care needs of older adults arising at the intersection of age-related illnesses, military service, and social barriers have presented challenges to the US Department of Veterans Affairs (VA) for decades. In response, the VA has invested in centers that integrate research, education, and clinical innovation, using approaches aligned with a learning health care system, to create, evaluate, and implement new care models. This article presents an integrative review of 6 community care models developed within the VA to manage multimorbidity, complex social needs, and avoid institutional care, examining how these models address complex care needs among older adults. The models reviewed include Home Based Primary Care, Medical Foster Home, the VA Caregiver Support Program, the Resources Enhancing Alzheimer's Caregiver Health (REACH)-VA program, the Caregivers of Older Adults Cared for at Home (COACH) program, and Veteran Directed Care. Core components and evaluation outcomes for each model are summarized, along with implications for more widespread implementation and research. Each model promotes coordinated care, integrates behavioral health, and leverages interprofessional expertise. All models are cost-neutral or incur only modest cost increases to improve outcomes. Broader implementation will require interprofessional workforce development, payment model realignment, and infrastructure to evaluate outcomes in new settings. The VA provides a blueprint for infrastructure that could be adapted to other domestic and international settings. Care models successfully implemented within the VA's single-payer system hold promise to address persistent dilemmas in long-term care, such as management of multimorbidity and social drivers of health, integration and support of family caregivers, and mental health integration. These models also demonstrate the value of incorporating care approaches that have been developed or tested outside the United States and argue for greater cross-fertilization of ideas from different health systems.