Organizational interventions to improve health outcomes of older persons

Myocardial infarction and physical function: the REasons for Geographic And Racial Differences in Stroke prospective cohort study

Objective

To examine associations between myocardial infarction (MI) and multiple physical function metrics.

Methods

Among participants aged ≥45 years in the REasons for Geographic And Racial Differences in Stroke prospective cohort study, instrumental activities of daily living (IADL), activities of daily living (ADL), gait speed, chair stands, and Short Form-12 physical component summary (PCS) were assessed after approximately 10 years of follow-up. We examined associations between MI and physical function (no MI [n = 9,472], adjudicated MI during follow-up [n = 288, median 4.7 years prior to function assessment], history of MI at baseline [n = 745], history of MI at baseline and adjudicated MI during follow-up [n = 70, median of 6.7 years prior to function assessment]). Models were adjusted for sociodemographic characteristics, health behaviours, depressive symptoms, cognitive impairment, body mass index, diabetes, hypertension, and urinary albumin to creatinine ratio. We examined subgroups defined by age, gender, and race.

Results

The average age at baseline was 62 years old, 56% were women, and 35% Black. MI was significantly associated with worse IADL and ADL scores, IADL dependency, chair stands, and PCS, but not ADL dependency or gait speed. For example, compared to participants without MI, IADL scores (possible range 0-14, higher score represents worse function) were greater for participants with MI during follow-up (difference: 0.37 [95% CI 0.16, 0.59]), MI at baseline (0.26 [95% CI 0.12, 0.41]), and MI at baseline and follow-up (0.71 [95% CI 0.15, 1.26]), p < 0.001. Associations tended to be greater in magnitude among participants who were women and particularly Black women.

Conclusion

MI was associated with various measures of physical function. These decrements in function associated with MI may be preventable or treatable.

State of Science: Bridging the Science-Practice Gap in Aging, Dementia and Mental Health

The workforce available to care for older adults has not kept pace with the need. In response to workforce limitations and the growing complexity of healthcare, scientists have tested new models of care that redesign clinical practice. This article describes why new models of care in aging, dementia, and mental health diffuse inadequately into the healthcare systems and communities where they might benefit older adults. We review a general framework for the diffusion of innovations and highlight the importance of other features of innovations that deter or facilitate diffusion. Although scientists often focus on generating evidence-based innovations, end-users apply their own criteria to determine an innovation's value. In 1962, Rogers suggested six features of an innovation that facilitate or deter diffusion suggested: relative advantage, compatibility with the existing environment, ease or difficulty of implementation, trial-ability or ability to "test drive", adaptability, and observed effectiveness. We describe examples of models of care in aging, dementia and mental health that enjoy a modicum of diffusion into practice and place the features of these models in the context of deterrents and facilitators for diffusion. Developers of models of care in aging, dementia, and mental health typically fail to incorporate the complexities of health systems, the barriers to diffusion, and the role of emotion into design considerations of new models. We describe agile implementation as a strategy to facilitate the speed and scale of diffusion in the setting of complex adaptive systems, social networks, and dynamic macroenvironments.

How do residents of aged care homes perceive physical activity and functional independence? A qualitative study

Limited evidence exists concerning knowledge and understanding of how to optimally support residents' physical activity, mobility and functional independence in residential aged care homes. An interpretive qualitative study was conducted to explore residents' perceptions and experiences of opportunities for physical activity and functional independence, and how physical activity and functional independence are challenged in their care home environment. Purposefully sampled 24 participants (male = 13) from five not-for-profit residential aged care homes in the outskirts of a metropolitan area in Australia, were interviewed between August and September 2017. Maintaining independence was found to be the utmost priority for nearly all participants in this study. Yet, many did not make the connection between physical activity and independence, and regarded 'exercise' as an inappropriate activity for them, perceiving it as high-impact, high-intensity activity in commercial gyms that was only appropriate for the young. Walking and gardening were found to be most popular. Walking could be a physical activity, social activity, solo recreational activity and a means of maintaining mobility and functional independence-all of which residents considered to be appropriate to them and achievable. The study identified key factors influencing physical activity and functional independence of residents: levels of activity prior to living in residential aged care, ageism, social capital and loss of a loved one, pain and staff support. Findings highlight the need for a 'flexible and inclusive' approach in facilitating the resident's physical activity, and a greater role for staff in encouraging residents' engagement in, and communicating the benefits and requirements of, physical activity, through, for example, motivational interviewing.

Identifying and overcoming implementation challenges: Experience of 59 noninstitutional long-term services and support pilot programs in the Veterans Health Administration

Background:

From 2010 to 2013, the Department of Veterans Affairs (VA) funded a large pilot initiative to implement noninstitutional long-term services and supports (LTSS) programs to support aging Veterans. Our team evaluated implementation of 59 VA noninstitutional LTSS programs.

Purpose:

The specific objectives of this study are to (a) examine the challenges influencing program implementation comparing active sites that remained open and inactive sites that closed during the funding period and (b) identify ways that active sites overcame the challenges they experienced.

Methodology:

Key informant semistructured interviews occurred between 2011 and 2013. We conducted 217 telephone interviews over four time points. Content analysis was used to identify emergent themes. The study team met regularly to define each challenge, review all codes, and discuss discrepancies. For each follow-up interview with the sites, the list of established challenges was used as a priori themes. Emergent data were also coded.

Results:

The challenges affecting implementation included human resources and staffing issues, infrastructure, resources allocation and geography, referrals and marketing, leadership support, and team dynamics and processes. Programs were able to overcome challenges by communicating with team members and other areas in the organization, utilizing information technology solutions, creative use of staff and flexible schedules, and obtaining additional resources.

Discussion:

This study highlights several common challenges programs can address during the program implementation. The most often mentioned strategy was effective communication. Strategies also targeted several components of the organization including organizational functions and processes (e.g., importance of coordination within a team and across disciplines to provide good care), infrastructure (e.g., information technology and human resources), and program fit with priorities in the organization (e.g., leadership support).

Implications:

Anticipating potential pitfalls of program implementation for future noninstitutional LTSS programs can improve implementation efficiency and program sustainability. Staff at multiple levels in the organization must fully support noninstitutional LTSS programs to address these challenges.

Self-reported exhaustion, physical activity, and grip strength predict frailty transitions in older outpatients with chronic diseases

Effective screening instruments are necessary for evaluating the outcomes of early interventions for the prevention or delay of disability in older persons. This study examined how transitions in frailty items over 1 year and the baseline components of a comprehensive geriatric assessment were associated with improvements in frailty at a 2-year follow-up in a sample of older patients.This was a single-center prospective observational study of older patients aged 65 years and over with chronic diseases (n = 103), who were followed through a hospital-based program over 2 years. Frailty was evaluated via the modified Fried Frailty Index and a comprehensive geriatric assessment.We noted significant improvements in weight loss (P = .016) and self-reported exhaustion (P = .006), and a less decrease in grip strength (P = .009) at the 1-year follow-up. Furthermore, baseline cerebral vascular accident diagnosis (P = .022), high polypharmacy (P = .037), a higher Geriatric Depression Scale score (P = .033), and a lower Mini Nutritional Assessment score (P = .039) were significantly associated with improved frailty at the 2-year follow-up. Furthermore, improvement in self-reported exhaustion (odds ratio [OR]: 4.7, 1.4-16.1, P = .014) and physical activity (OR: 3.8, 1.0-13.7, P = .046), and a less decrease in grip strength (OR: 4.0, 1.3-12.5, P = .017) at the 1-year follow-up were significantly associated with improved frailty at the 2-year follow-up.Self-reported exhaustion, physical activity, and grip strength are easy, quick, and feasible screening tests for improvements in frailty in clinical practice.

Prosecutors' Perspectives on Elder Justice Using an Elder Abuse Forensic Center

Prosecution is a rare outcome in elder financial exploitation. Previous studies have shown that elder abuse forensic centers-multidisciplinary teams that help investigate and respond to elder mistreatment-increase prosecution rates by enhancing teamwork across agencies. Research is needed to identify what aspects of this intervention model lead to better elder justice outcomes. Six District Attorneys (DAs) were interviewed about their experiences working with other agencies at an elder abuse forensic center (the "Center") and how participating in case discussions influenced their professional perspectives on elder abuse. Transcripts were analyzed qualitatively revealing three themes: (1) "goal-driven" versus "mission-driven" professional orientations; (2) role blurring; and (3) value added from participating in the Center team. Important factors for increasing rates of prosecution were: (1) having key decision-makers present at the meeting; (2) the forensic expertise provided by the geriatrician and neuropsychologist; and (3) cross-discipline learning. Influenced by the other disciplines, DAs sought goals beyond prosecution as the default approach to resolving elder financial abuse and advocated for interventions that could best respond to the victim's needs, such as restitution or protection.

The development, implementation and evaluation of a transitional care programme to improve outcomes of frail older patients after hospitalisation

BACKGROUND

fragmented healthcare systems are poorly suited to treat the increasing number of older patients with multimorbidity.

OBJECTIVE

to report on the development, implementation and evaluation of a regional transitional care programme, aimed at improving the recovery rate of frail hospitalised older patients.

METHODS

the programme was drafted in co-creation with organisations representing older adults, care providers and knowledge institutes. Conducting an action research project, the incidence of adverse outcomes within 3 months after hospital admission, and long-term care expenses (LTCE) were compared between samples in 2010-11 (pre-programme) and 2012-13 (post-programme) in frail and non-frail patients. Hospitalised patients aged ≥70 years were included in four hospitals in the targeted region.

RESULTS

developed innovations addressed (i) improved risk management; (ii) delivery of integrated, function-oriented care; (iii) specific geriatric interventions; and (iv) optimisation of transfers. The incidence of adverse outcomes was compared in 813 and 904 included patients respectively in the two samples. In frail patients, the incidence of adverse outcomes decreased from 49.2% (149/303) in the pre-programme sample to 35.5% (130/366) in the post-programme sample. The risk ratio (RR), adjusted for heterogeneity between hospitals, was 0.72 (95% CI: 0.60-0.87). In non-frail patients the incidence of adverse outcomes remained unchanged (RR: 1.02, 95% CI: 0.76-1.36). LTCE were similar in the two samples.

CONCLUSIONS

by involving stakeholders in designing and developing the transitional care programme, commitment of healthcare providers was secured. Feasible innovations in integrated transitional care for frail older patients after hospitalisation were sustainably implemented from within healthcare organisations.

Community-Based Health Coaching, Exercise, and Health Service Utilization

Objectives: The outcomes of the California Public Employees Retirement System’s Health Matters program, a replication of a health promotion and fitness program known as the Senior Wellness Program (SWP), are reported. Method: A randomized controlled design ( n = 504) was used. Eligibility included one or more qualifying chronic health conditions, age 65 or older, member of a participating health plan, and owner of a CalPERS long-term care insurance policy. Disability risk factors were measured via questionnaires and included health status, pain, exercise, depression, and social activity. Activity was compiled in project records. Results: At 12 months, Health Matters members were engaged in significantly more stretching and aerobic exercise than the controls. Depressive symptoms decreased among those with moderate or higher symptom scores. Discussion: Health Matters extends the SWP model to younger, more active, and healthier individuals with improvements in duration of exercise and stretching; use of other health promotion activities was low.

Evaluation of a primary care nurse case management intervention for chronically ill community dwelling older people

AIM

The purpose of this study was to test the effectiveness of a collaborative primary care nurse case management intervention emphasising collaboration between physicians, nurses and patients, risk identification, comprehensive assessment, collaborative planning, health monitoring, patient education and transitional care on healthcare utilisation and cost for community dwelling chronically ill older persons.

BACKGROUND

Primary care teams comprised of nurses and primary care physicians have been suggested as a model for providing quality care to the chronically ill, but this type of intervention has not been systematically evaluated.

DESIGN

A non-randomised, 36 month comparison of two geographically distinct primary care populations was conducted.

METHODS

Six hundred and seventy-seven persons aged 65 and older were determined to be at high-risk for mortality, functional decline, or increased health service use. The treatment group (n = 400) received the intervention and the comparison group (n = 277) received usual care. Health plan claims files provided data on number of hospitalisations and bed days, emergency department (ED) visits, physician visits and total cost of care.

RESULTS

After adjustment for baseline variables, there were no significant differences between the treatment and comparison group in the percentage of patients hospitalised or ED visits. However, among those hospitalised in the treatment group, the likelihood of being re-hospitalised was significantly reduced by 34% (p = 0·032). After adjusting for the cost of the intervention, although not statistically significant, the reduced hospital use resulted in cost savings of $106 per patient per month in the treatment group.

CONCLUSIONS

The results indicate that a collaborative primary care nurse case management intervention has the potential to be an effective alternative to current primary care delivery system practice.

RELEVANCE TO CLINICAL PRACTICE

The study suggests that a chronic care intervention emphasising collaboration between physicians, nurses and patients, may be more effective when implemented in integrated provider networks.

Initiatives on early detection and intervention to proactively identify health and social problems in older people: experiences from the Netherlands

Background

Over the last years, several initiatives on early detection and intervention have been put in place to proactively identify health and social problems in (frail) older people. An overview of the initiatives currently available in the Netherlands is lacking, and it is unknown whether they meet the preferences and needs of older people. Therefore, the objectives of this study were threefold: 1. To identify initiatives on early detection and intervention for older people in the Netherlands and compare their characteristics; 2. To explore the experiences of professionals with these initiatives; and 3. To explore to what extent existing initiatives meet the preferences and needs of older people.

Methods

We performed a qualitative descriptive study in which we conducted semi-structured interviews with seventeen experts in preventive elderly care and three group interviews with volunteer elderly advisors. Data were analysed using the framework analysis method.

Results

We identified eight categories of initiatives based on the setting (e.g. general practitioner practice, hospital, municipality) in which they were offered. Initiatives differed in their aims and target groups. The utilization of peers to identify problems and risks, as was done by some initiatives, was seen as a strength. Difficulties were experienced with identifying the target group that would benefit from proactive delivery of care and support most, and with addressing prevalent issues among older people (e.g. psychosocial issues, self-reliance issues).

Conclusion

Although there is a broad array of initiatives available, there is a discrepancy between supply and demand. Current initiatives insufficiently address needs of (frail) older people. More insight is needed in “what should be done by whom, for which target group and at what moment”, in order to improve current practice in preventive elderly care.

Initiatives on early detection and intervention to proactively identify health and social problems in older people: experiences from the Netherlands

BACKGROUND

Over the last years, several initiatives on early detection and intervention have been put in place to proactively identify health and social problems in (frail) older people. An overview of the initiatives currently available in the Netherlands is lacking, and it is unknown whether they meet the preferences and needs of older people. Therefore, the objectives of this study were threefold: 1. To identify initiatives on early detection and intervention for older people in the Netherlands and compare their characteristics; 2. To explore the experiences of professionals with these initiatives; and 3. To explore to what extent existing initiatives meet the preferences and needs of older people.

METHODS

We performed a qualitative descriptive study in which we conducted semi-structured interviews with seventeen experts in preventive elderly care and three group interviews with volunteer elderly advisors. Data were analysed using the framework analysis method.

RESULTS

We identified eight categories of initiatives based on the setting (e.g. general practitioner practice, hospital, municipality) in which they were offered. Initiatives differed in their aims and target groups. The utilization of peers to identify problems and risks, as was done by some initiatives, was seen as a strength. Difficulties were experienced with identifying the target group that would benefit from proactive delivery of care and support most, and with addressing prevalent issues among older people (e.g. psychosocial issues, self-reliance issues).

CONCLUSION

Although there is a broad array of initiatives available, there is a discrepancy between supply and demand. Current initiatives insufficiently address needs of (frail) older people. More insight is needed in "what should be done by whom, for which target group and at what moment", in order to improve current practice in preventive elderly care.

Short-term outcomes of seniors aged 80 years and older with acute illness: hospitalist care by geriatricians and other internists compared

BACKGROUND

Although acute geriatric units have improved the outcomes of hospitalized seniors, it is uncertain as to whether hospitalist care by geriatricians outside of these units confers similar benefit.

OBJECTIVE

To determine whether hospitalist care by geriatricians reduces short-term mortality and readmission, and length of stay (LOS) for seniors aged 80 years and older with acute medical illnesses compared with care by other internists.

DESIGN

Retrospective cohort study using administrative and chart review data on demographic, admission-related, and clinical information of hospital episodes.

SETTING

General internal medicine department of an acute-care hospital in Singapore from 2005 to 2008.

PATIENTS

Seniors aged 80 years and older with specific focus on 2 subgroups with premorbid functional impairment and acute geriatric syndromes.

INTERVENTION

Hospitalist care by geriatricians compared with care by other internists.

MEASURES

Hospital mortality, 30-day mortality or readmission, and LOS.

RESULTS

For 1944 hospital episodes (intervention: 968, control: 976), there was a nonsignificant trend toward lower hospital mortality (15.5% vs 16.9%) but not 30-day mortality or readmission, or LOS for care by geriatricians compared with care by other internists. A marginally stronger trend toward lower hospital mortality for care by geriatricians among those with acute geriatric syndromes (20.2% vs 23.1%) was observed. Similar treatment effects were found after adjustment for demographic, admission-related, and clinical factors.

CONCLUSIONS

For seniors aged 80 years and over with acute medical illness, hospitalist care by geriatricians did not significantly reduce short-term mortality, readmission, or LOS, compared with care by other internists.

Diffusion of a collaborative care model in primary care: a longitudinal qualitative study

BACKGROUND

Although collaborative team models (CTM) improve care processes and health outcomes, their diffusion poses challenges related to difficulties in securing their adoption by primary care clinicians (PCPs). The objectives of this study are to understand: (1) how the perceived characteristics of a CTM influenced clinicians' decision to adopt -or not- the model; and (2) the model's diffusion process.

METHODS

We conducted a longitudinal case study based on the Diffusion of Innovations Theory. First, diffusion curves were developed for all 175 PCPs and 59 nurses practicing in one borough of Paris. Second, semi-structured interviews were conducted with a representative sample of 40 PCPs and 15 nurses to better understand the implementation dynamics.

RESULTS

Diffusion curves showed that 3.5 years after the start of the implementation, 100% of nurses and over 80% of PCPs had adopted the CTM. The dynamics of the CTM's diffusion were different between the PCPs and the nurses. The slopes of the two curves are also distinctly different. Among the nurses, the critical mass of adopters was attained faster, since they adopted the CTM earlier and more quickly than the PCPs. Results of the semi-structured interviews showed that these differences in diffusion dynamics were mostly founded in differences between the PCPs' and the nurses' perceptions of the CTM's compatibility with norms, values and practices and its relative advantage (impact on patient management and work practices). Opinion leaders played a key role in the diffusion of the CTM among PCPs.

CONCLUSION

CTM diffusion is a social phenomenon that requires a major commitment by clinicians and a willingness to take risks; the role of opinion leaders is key. Paying attention to the notion of a critical mass of adopters is essential to developing implementation strategies that will accelerate the adoption process by clinicians.

The CareWell-primary care program: design of a cluster controlled trial and process evaluation of a complex intervention targeting community-dwelling frail elderly

Background

With increasing age and longevity, the rising number of frail elders with complex and numerous health-related needs demands a coordinated health care delivery system integrating cure, care and welfare. Studies on the effectiveness of such comprehensive chronic care models targeting frail elders show inconclusive results. The CareWell-primary care program is a complex intervention targeting community-dwelling frail elderly people, that aims to prevent functional decline, improve quality of life, and reduce or postpone hospital and nursing home admissions of community dwelling frail elderly.

Methods/design

The CareWell-primary care study includes a (cost-) effectiveness study and a comprehensive process evaluation. In a one-year pragmatic, cluster controlled trial, six general practices are non-randomly recruited to adopt the CareWell-primary care program and six control practices will deliver ‘care as usual’. Each practice includes a random sample of fifty frail elders aged 70 years or above in the cost-effectiveness study. A sample of patients and informal caregivers and all health care professionals participating in the CareWell-primary care program are included in the process evaluation. In the cost-effectiveness study, the primary outcome is the level of functional abilities as measured with the Katz-15 index. Hierarchical mixed-effects regression models / multilevel modeling approach will be used, since the study participants are nested within the general practices. Furthermore, incremental cost-effectiveness ratios will be calculated as costs per QALY gained and as costs weighed against functional abilities. In the process evaluation, mixed methods will be used to provide insight in the implementation degree of the program, patients’ and professionals’ approval of the program, and the barriers and facilitators to implementation.

Discussion

The CareWell-primary care study will provide new insights into the (cost-) effectiveness, feasibility, and barriers and facilitators for implementation of this complex intervention in primary care.

Trial registration

The CareWell-primary care study is registered in the ClinicalTrials.gov Protocol Registration System: NCT01499797

Analysis of case management programs for patients with dementia: a systematic review

BACKGROUND

People suffering from dementia are particularly vulnerable to the gaps between the health and social service systems. Case management is a professional field that seeks to fill in these gaps and remedy this fragmentation.

METHODS

We report the results of a systematic literature review of the impact of case management programs on clinical outcomes and the utilization of resources by persons with dementia. We focused on randomized controlled trials (RCTs) and attempted to identify the factors that might contribute to greater program efficacy. Because the evaluation methods in these studies varied, we used the effect size method to estimate the magnitude of the statistically significant effects reported.

RESULTS

Our search strategy identified 17 references relating to six RCTs. Four of these six RCTs reported moderately statistically significant effects (effect size, 0.2-0.8) on their primary end point: the clinical outcome in three and resource utilization in one. Two of the RCTs reported weak or no effects (effect size, <0.2) on their primary end point. Because of the wide variety of the end points used, an overall effect size could not be calculated. Parameters that appear to be related to greater case management efficacy are the integration level between the health and social service organizations and the intensity of the case management.

CONCLUSIONS

Integration and case management intensity seem to determine the magnitude of the clinical effects in this new professional field. Further studies are needed to clarify the economic impact.

Quality of care indicators for the structure and organization of inpatient rehabilitation care of children with traumatic brain injury

OBJECTIVES

To develop evidence-based and expert-driven quality indicators for measuring variations in the structure and organization of acute inpatient rehabilitation for children after traumatic brain injury (TBI) and to survey centers across the United States to determine the degree of variation in care.

DESIGN

Quality indicators were developed using the RAND/UCLA modified Delphi method. Adherence to these indicators was determined from a survey of rehabilitation facilities.

SETTING

Inpatient rehabilitation units in the United States.

PARTICIPANTS

A sample of rehabilitation programs identified using data from the National Association of Children's Hospitals and Related Institutions, Uniform Data System for Medical Rehabilitation, and the Commission on Accreditation of Rehabilitation Facilities yielded 74 inpatient units treating children with TBI. Survey respondents comprised 31 pediatric and 28 all age units.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Variations in structure and organization of care among institutions providing acute inpatient rehabilitation for children with TBI.

RESULTS

Twelve indicators were developed. Pediatric inpatient rehabilitation units and units with higher volumes of children with TBI were more likely to have: a census of at least 1 child admitted with a TBI for at least 90% of the time; adequate specialized equipment; a classroom; a pediatric subspecialty trained medical director; and more than 75% of therapists with pediatric training.

CONCLUSIONS

There were clinically and statistically significant variations in the structure and organization of acute pediatric rehabilitation based on the pediatric focus of the unit and volume of children with TBI.

Randomized multilevel intervention to improve outcomes of residents in nursing homes in need of improvement

OBJECTIVES

A comprehensive multilevel intervention was tested to build organizational capacity to create and sustain improvement in quality of care and subsequently improve resident outcomes in nursing homes in need of improvement.

DESIGN/SETTING/PARTICIPANTS

Intervention facilities (N = 29) received a 2-year multilevel intervention with monthly on-site consultation from expert nurses with graduate education in gerontological nursing. Attention control facilities (N = 29) that also needed to improve resident outcomes received monthly information about aging and physical assessment of elders.

INTERVENTION

The authors conducted a randomized clinical trial of nursing homes in need of improving resident outcomes of bladder and bowel incontinence, weight loss, pressure ulcers, and decline in activities of daily living. It was hypothesized that following the intervention, experimental facilities would have higher quality of care, better resident outcomes, more organizational attributes of improved working conditions than control facilities, higher staff retention, similar staffing and staff mix, and lower total and direct care costs.

RESULTS

The intervention did improve quality of care (P = .02); there were improvements in pressure ulcers (P = .05) and weight loss (P = .05). Organizational working conditions, staff retention, staffing, and staff mix and most costs were not affected by the intervention. Leadership turnover was surprisingly excessive in both intervention and control groups.

CONCLUSION AND IMPLICATIONS

Some facilities that are in need of improving quality of care and resident outcomes are able to build the organizational capacity to improve while not increasing staffing or costs of care. Improvement requires continuous supportive consultation and leadership willing to involve staff and work together to build the systematic improvements in care delivery needed. Medical directors in collaborative practice with advanced practice nurses are ideally positioned to implement this low-cost, effective intervention nationwide.

Sustaining clinical programs during difficult economic times: a case series from the Hospital Elder Life Program

OBJECTIVES

To explore strategies used by clinical programs to justify operations to decision-makers using the example of the Hospital Elder Life Program (HELP), an evidence-based, cost-effective program to improve care for hospitalized older adults.

DESIGN

Qualitative study design using 62 in-depth, semistructured interviews conducted with HELP staff members and hospital administrators between September 2008 and August 2009.

SETTING

Nineteen HELP sites in hospitals across the United States and Canada that had been recruiting patients for at least 6 months.

PARTICIPANTS

HELP staff and hospital administrators.

MEASUREMENTS

Participant experiences sustaining the program in the face of actual or perceived financial threats, with a focus on factors they believe are effective in justifying the program to decision-makers in the hospital or health system.

RESULTS

Using the constant comparative method, a standard qualitative analysis technique, three major themes were identified across interviews. Each focuses on a strategy for successfully justifying the program and securing funds for continued operations: interact meaningfully with decision-makers, including formal presentations that showcase operational successes and informal means that highlight the benefits of HELP to the hospital or health system; document day-to-day, operational successes in metrics that resonate with decision-maker priorities; and garner support from influential hospital staff that feed into administrative decision-making, particularly nurses and physicians.

CONCLUSION

As clinical programs face financially challenging times, it is important to find effective ways to justify their operations to decision-makers. Strategies described here may help clinically effective and cost-effective programs sustain themselves and thus may help improve care in their institutions.

Understanding Dissemination and Implementation of a New Intervention in Assisted Living Settings

Function-focused care (FFC) was developed to change the philosophy of care in assisted living (AL) to one in which nurses, direct care workers (DCWs) and other members of the health care team work with residents to optimize function and time spent in physical activities. The purpose of this article is to describe dissemination and implementation of FFC within the two assisted living communities in Maryland that were randomized to our FFC for assisted living intervention (FFC-AL). The reach, efficacy/effectiveness, adoption, implementation, and maintenance (RE-AIM) model was used to evaluate dissemination and implementation of FFC in these communities. A total of 171 residents and 96 DCWs consented to participate in the study and outcomes based on data collected from the participants as well as evidence for dissemination and implementation at the site level are provided. Findings can be used to guide others in dissemination and implementation of similar interventions in AL communities.

Collaborative depression treatment in older and younger adults with physical illness: pooled comparative analysis of three randomized clinical trials

OBJECTIVE

There have been few comparisons of the effectiveness of collaborative depression care between older versus younger adults with comorbid illness, particularly among low-income populations.

DESIGN

Intent-to-treat analyses are conducted on pooled data from three randomized controlled trials that tested collaborative care aimed at improving depression, quality of life, and treatment receipt.

SETTINGS

Trials were conducted in oncology and primary care safety net clinics and diverse home healthcare programs.

PARTICIPANTS

Thousand eighty-one patients with major depressive symptoms and cancer, diabetes, or other comorbid illness.

INTERVENTION

Similar intervention protocols included patient, provider, sociocultural, and organizational adaptations.

MEASUREMENTS

The Patient Health Questionnaire (PHQ)-9 depression, Short-Form Health Survey-12/20 quality of life, self-reported hospitalization, ER, intensive care unit utilization, and antidepressant, psychotherapy treatment receipt are assessed at baseline, 6, and 12 months.

RESULTS

There are no significant differences in reducing depression symptoms (p ranged 0.18-0.58), improving quality of life (t = 1.86, df = 669, p = 0.07 for physical functioning at 12 months, and p ranged 0.23-0.99 for all others) patients aged between >/=60 years versus 18-59 years. Both age group intervention patients have significantly higher rates of a 50% PHQ-9 reduction (older: Wald chi[df = 1] = 4.82, p = 0.03; younger: Wald chi[df = 1] = 6.47, p = 0.02), greater reduction in major depression rates (older: Wald chi[df = 1] = 7.72, p = 0.01; younger: Wald chi[df = 1] = 4.0, p = 0.05) than enhanced-usual-care patients at 6 months and no significant age group differences in treatment type or intensity.

CONCLUSION

Collaborative depression care in individuals with comorbid illness is as effective in reducing depression in older patients as younger patients, including among low-income, minority patients. Patient, provider, and organizational adaptations of depression care management models may contribute to positive outcomes.

The prevalence of subjective frailty and factors associated with frailty in Taiwan

This study estimated the prevalence of frailty and identified the factors associated with frailty in Taiwan using data from the Survey of Health and Living Status of the Elderly. A nationwide probability sample including 2,238 individuals aged > or =65 years was interviewed in 2003. Based on the Cardiovascular Health Study conducted by Fried, five phenotypes of frailty were selected: poor appetite, exhaustion, low physical activity, poor walking ability, and poor twisting ability of fingers. Participants were classified as nonfrail, prefrail, and frail if they met 0, 1 or 2, and > or =3 criteria. The prevalences of nonfrailty, prefrailty, and frailty were 55.1%, 40.0%, and 4.9%, respectively. The prevalence of frailty increased with age and was greater in women. Frailty was associated with less education, no spouse, disability, higher rates of comorbid chronic diseases, depressive symptoms, and geriatric syndromes. Specific drug use, such as hypnotics, analgesics, herbal drugs, and parenteral fluid supplements was positively associated with frailty. The use of multivitamins, fish oil, and vitamin E was negatively associated with frailty. The prevalence of frailty is lower in Taiwan than in Western countries. Depressive symptoms, geriatric syndromes, and specific medication use are potential fields for frailty prevention in community-dwelling older adults.

A novel model of integrated care for the elderly: COPA, Coordination of Professional Care for the Elderly

Despite strong evidence for the efficacy of integrated systems, securing the participation of health professionals, particularly primary care physicians (PCPs), has proven difficult. Novel approaches are needed to resolve these problems. We developed a model - COPA - that is based on scientific evidence and an original design process in which health professionals, including PCPs, and managers participated actively. COPA targets very frail community-dwelling elders recruited through their PCP. It was designed to provide a better fit between the services provided and the needs of the elderly in order to reduce excess healthcare use, including unnecessary emergency room (ER) visits and hospitalizations, and prevent inappropriate long-term nursing home placements. The model's originality lies in: 1) having reinforced the role played by the PCP, which includes patient recruitment and care plan development; 2) having integrated health professionals into a multidisciplinary primary care team that includes case managers who collaborate closely with the PCP to perform a geriatric assessment (InterRAI MDS-HC) and implement care management programs; and 3) having integrated primary medical care and specialized care by introducing geriatricians into the community to see patients in their homes and organize direct hospitalizations while maintaining the PCP responsibility for medical decisions. Since COPA is currently the subject of both a quasi-experimental study and a qualitative study, we are also providing preliminary findings. These findings suggest that the model is feasible and well accepted by PCPs and patients. Moreover, our results indicate that the level of service utilization in COPA was less than what is reported at the national level, without any compromises in quality of care.

Integrating care for older adults with cognitive impairment

The number of older adults with Alzheimer's disease and related disorders is expected to triple over the next 50 years. While we may be on the cusp of important therapeutic advances, such advances will not alter the disease course for millions of persons already affected. Hoping for technology to spare the health care system from the need to care for older adults with dementia is no longer tenable. Most older adults with dementia will receive their medical care in the primary care setting and this setting is not prepared to provide for the complex care needs of these vulnerable elders. With an increasing emphasis on earlier diagnosis of dementia, primary care in particular will come under increasing strain from this new care responsibility. While primary care may remain the hub of care for older adults, it cannot and should not be the whole of care. We need to design and test new models of care that integrate the larger health care system including medical care as well as community and family resources. The purpose of this paper to describe the current health care infrastructure with an emphasis on the role of primary care in providing care for older adults with dementia. We summarize recent innovative models of care seeking to provide an integrated and coordinated system of care for older adults with dementia. We present the case for a more aggressive agenda to improving our system of care for older adults with dementia through greater training, integration, and collaboration of care providers. This requires investments in the design and testing of an improved infrastructure for care that matches our national investment in the search for cure.

Urban-rural differences in the effect of a Medicare health promotion and disease self-management program on physical function and health care expenditures

PURPOSE

To evaluate the impact of a multicomponent health promotion and disease self-management intervention on physical function and health care expenditures among Medicare beneficiaries. To determine if these outcomes vary by urban or rural residence.

DESIGN AND METHODS

We analyzed data from a 22-month randomized controlled trial of a health promotion/disease self-management program that included 766 elderly Medicare beneficiaries from western New York, West Virginia, and Ohio. Physical function was measured by changes in self-reported dependencies in activities of daily living over the study period. Total health care expenditures were measured by aggregating expenditures from major sources (acute, postacute, and long-term care). We used ordinary least squares models to examine the effects of the intervention on both physical function and cost outcomes during the 22-month period.

RESULTS

The results indicated that the intervention reduced physical functional decline by 54% (p = .03) in the study sample. Stratified analyses showed that the intervention effect was much stronger in the rural sample. Mean total health care expenditures were 11% ($3,100, p = .30) lower in the intervention group. The effects of the intervention on average health care expenditures were similar among urban and rural participants.

IMPLICATIONS

The intervention offered a promising strategy for reducing decline in physical function and potentially lowering total health care expenditures for high-risk Medicare beneficiaries, especially for those in rural areas. Future studies need to investigate whether the findings can be replicated in other types of rural areas through a refined intervention and better targeting of the study population.

Healthcare professionals and managers' participation in developing an intervention: a pre-intervention study in the elderly care context

BACKGROUND

In order to increase the chances of success in new interventions in healthcare, it is generally recommended to tailor the intervention to the target setting and the target professionals. Nonetheless, pre-intervention studies are rarely conducted or are very limited in scope. Moreover, little is known about how to integrate the results of a pre-intervention study into an intervention. As part of a project to develop an intervention aimed at improving care for the elderly in France, a pre-intervention study was conducted to systematically gather data on the current practices, issues, and expectations of healthcare professionals and managers in order to determine the defining features of a successful intervention.

METHODS

A qualitative study was carried out from 2004 to 2006 using a grounded theory approach and involving a purposeful sample of 56 healthcare professionals and managers in Paris, France. Four sources of evidence were used: interviews, focus groups, observation, and documentation.

RESULTS

The stepwise approach comprised three phases, and each provided specific results. In the first step of the pre-intervention study, we gathered data on practices, perceived issues, and expectations of healthcare professionals and managers. The second step involved holding focus groups in order to define the characteristics of a tailor-made intervention. The third step allowed validation of the findings. Using this approach, we were able to design and develop an intervention in elderly care that met the professionals' and managers' expectations.

CONCLUSION

This article reports on an in-depth pre-intervention study that led to the design and development of an intervention in partnership with local healthcare professionals and managers. The stepwise approach represents an innovative strategy for developing tailored interventions, particularly in complex domains such as chronic care. It highlights the usefulness of seeking out the insight of healthcare professionalnd managers and emphasizes the need to intervene at different levels. Further research will be needed in order to develop a more thorough understanding of the impacts of such strategies on the final outcomes of intervention implementations.

Clinician- and organization-level factors in the adoption of evidence-based care for depression in primary care

BACKGROUND AND PURPOSE

Although more individuals are receiving care for depression than those in the past, they often do not receive high-quality care. Strategies to improve quality have focused on changing clinician behavior and more recently on reducing practice barriers. Both strategies hold promise but have had widely varying success either because practices have not successfully removed barriers or because removing barriers alone is not sufficient for improving care. It is unknown under which circumstances clinicians with a high propensity toward recognizing depression and providing depression care can overcome barriers. We explore organizational and clinician factors affecting patient receipt of guideline-concordant services.

METHODOLOGY/APPROACH

We use data from adult patients with major depression receiving care in a geographically diverse group of primary care practices participating in the Quality Improvement for Depression study. We estimate the effects of barriers and clinician propensity on six aspects of depression care and adequate treatment.

FINDINGS

Barriers and propensity interact in affecting depression services. In comparison with similar clinicians in practices with few barriers, high-propensity clinicians working in practices with more barriers are less likely to provide depression education and are likely to provide fewer follow-up calls and fewer follow-up visits. High-propensity clinicians are more likely to offer antidepressants in practices with more barriers.

PRACTICE IMPLICATIONS

To improve the quality of care, efforts should both eliminate practice barriers and increase clinician propensity to provide care. Future research on factors associated with quality improvement can benefit from an approach which specifies how organizational and clinician factors interact to enact change.

Does a functional activity programme improve function, quality of life, and falls for residents in long term care? Cluster randomised controlled trial

OBJECTIVE

To assess the effectiveness of an activity programme in improving function, quality of life, and falls in older people in residential care.

DESIGN

Cluster randomised controlled trial with one year follow-up.

SETTING

41 low level dependency residential care homes in New Zealand.

PARTICIPANTS

682 people aged 65 years or over.

INTERVENTIONS

330 residents were offered a goal setting and individualised activities of daily living activity programme by a gerontology nurse, reinforced by usual healthcare assistants; 352 residents received social visits.

MAIN OUTCOME MEASURES

Function (late life function and disability instruments, elderly mobility scale, FICSIT-4 balance test, timed up and go test), quality of life (life satisfaction index, EuroQol), and falls (time to fall over 12 months). Secondary outcomes were depressive symptoms and hospital admissions.

RESULTS

473 (70%) participants completed the trial. The programme had no impact overall. However, in contrast to residents with impaired cognition (no differences between intervention and control group), those with normal cognition in the intervention group may have maintained overall function (late life function and disability instrument total function, P=0.024) and lower limb function (late life function and disability instrument basic lower extremity, P=0.015). In residents with cognitive impairment, the likelihood of depression increased in the intervention group. No other outcomes differed between groups.

CONCLUSION

A programme of functional rehabilitation had minimal impact for elderly people in residential care with normal cognition but was not beneficial for those with poor cognition. Trial registration Australian Clinical Trials Register ACTRN12605000667617.

Integrated care: incentives, approaches, and future considerations

The research and demonstration programs sponsored by CMS collectively address all the dimensions of the continuum of care ranging across multiple settings of care, providers, disease types, and severity of conditions. This article reviews current CMS activities and discusses several delivery programs in local communities that include disease management and the Program in All-Inclusive Care for the Elderly (PACE) and the contributions these have made to care integration and social policy development. Methods for accelerating knowledge development affecting the development of social policy, particularly collaborative efforts with PACE programs at the local level are discussed.

Organizational Relationships Between Nursing Homes and Hospitals and Quality of Care During Hospital–Nursing Home Patient Transfers

OBJECTIVES

To identify organizational factors and hospital and nursing home organizational relationships associated with more-effective processes of care during hospital-nursing home patient transfer.

DESIGN

Mailed survey.

SETTING

Medicare- or Medicaid-certified nursing homes in New York State.

PARTICIPANTS

Nursing home administrators, with input from other nursing home staff.

MEASUREMENTS

Key predictor variables were travel time between the hospital and the nursing home, affiliation with the same health system, same corporate owner, trainees from the same institution, pharmacy or laboratory agreements, continuous physician care, number of beds in the hospital, teaching status, and frequency of geriatrics specialty care in the hospital. Key dependent variables were hospital-to-nursing home communication, continuous adherence to healthcare goals, and patient and family satisfaction with hospital care.

RESULTS

Of 647 questionnaires sent, 229 were returned (35.4%). There was no relationship between hospital-nursing home interorganizational relationships and communication, healthcare goal adherence, and satisfaction measures. Geriatrics specialty care in the hospital (r=0.157; P=.04) and fewer hospital beds (r=-0.194; P=.01) were each associated with nursing homes more often receiving all information needed to care for patients transferred from the hospital. Teaching status (r=0.230; P=.001) and geriatrics specialty care (r=0.185; P=.01) were associated with hospital care more often consistent with healthcare goals established in the nursing home.

CONCLUSION

No management-level organizational relationship between nursing home and hospital was associated with better hospital-to-nursing home transfer process of care. Geriatrics specialty care and characteristics of the hospital were associated with better hospital-to-nursing home transfer processes.

Improving treatment of depression among low-income patients with cancer: the design of the ADAPt-C study

OBJECTIVE

This article describes the randomized clinical trial methodology for a population-based study of oncology patients receiving cancer care in a public sector medical center. The primary goal is to test the effectiveness of socioculturally tailored collaborative care intervention in improving depression and quality of life outcomes among low-income ethnic minority patients with major depression and cancer.

METHODS

The Patient Health Questionnaire (PHQ-9) depression scale was used to identify patients meeting criteria for major depression (one cardinal depression symptom plus a PHQ-9 score of > or =10). Study-eligible patients were >/=90 days from cancer diagnosis who were receiving acute cancer treatment or follow-up care in oncology clinics. Patients with advanced disease limiting life expectancy to <6 months, acutely suicidal or on antipsychotic medication were excluded. Allowing for attrition due to death or loss to follow-up, the study was powered at the 80% level to detect a 20% difference between study arms in the proportion of patients with >/=50% reduction in PHQ-9 symptoms at 12 months.

RESULTS

Of 2330 patients screened, 23.2% met criteria. An 82.4% enrollment rate resulted in 446 primarily women being recruited and randomized to intervention or usual care.

CONCLUSION

The study applies methods used in primary care depression trials with adaptations for oncology care clinics and for low-income minority patients.

Communication in interdisciplinary team meetings: what are we talking about?

Interdisciplinary teams are central to the care of the older patient in long-term care settings. Critical to the success of caring for these patients is the communication between providers about patient care. This study examines professional communication practices in interdisciplinary team meetings, a common forum for discussing patient care. Two teams at a long-term care facility specializing in patients with Alzheimer's participated in this qualitative exploratory study. All team members participated in semi-structured interviews. In addition, seven team meetings in which 31 patients were discussed were audio and video taped. Team members discussed the importance of team meetings to help coordinate care provided to patients, while also expressing concern about the effectiveness of the meetings to reach this goal. Through detailed discourse analyses of transcripts of the meetings, we identified three different communication practices in team meetings: giving report, writing report, and collaborative discussion. Only the latter practice met the goals indicated by the team members to coordinate and make joint decisions about patient care and allowed for team members to collaboratively solve problems. We discuss one case study to exemplify how the use of these communication practices results in the omission of information central to making decisions regarding patient care.

Make No Assumptions: Communication Between Persons With Disabilities and Clinicians

Fundamentally improving health care quality requires providing care that respects patients' preferences, needs, and values. This goal holds special resonance for persons with disabilities, many of whom find others defining and circumscribing their lives and opportunities. Achieving patient centeredness demands open communication between patients and clinicians, unhampered by prior and often erroneous assumptions about patients' goals, aspirations, and abilities. Building on this communication, optimal care involves collaboration between patients and clinicians, each bringing his or her particular expertise to the table. Interviews with individuals with diverse disabilities revealed a common theme of faulty communication between patients and clinicians. Some shortfalls relate to basic failures to accommodate communication needs, whereas others result from clinicians' erroneous perceptions of medical aspects of persons' underlying conditions, the role of assistive technologies, and how disability affects people's daily lives. Crafting collaborative care partnerships between patients and clinicians requires transforming traditional patient-clinician relationships. Following two basic precepts immeasurably improves communication between clinicians and patients with disabilities: first, make no assumptions, and second, just ask patients about their needs and preferences.

Depression care for the elderly: reducing barriers to evidence-based practice

This paper provides an overview of five key bodies of evidence identifying: (1) Characteristics of depression among older adults -- its prevalence, risk factors and illness course, and impact on functional status, mortality, use of health services, and health care costs; (2) Effective Interventions, including pharmacologic, psychotherapies, care management, and combined intervention models; (3) Known Barriers to depression care including patient, provider and service system barriers; (4) Effective Organizational and Educational Strategies to reduce barriers to depression care; and (5) Key Factors in Translating Research into Practice. There is strong empirical support for implementing strategies to improve depression care for older adults.

Geriatric Resources for Assessment and Care of Elders (GRACE): A New Model of Primary Care for Low-Income Seniors

The majority of older adults receive health care in primary care settings, yet many fail to receive the recommended standard of care for preventive services, chronic disease management, and geriatric syndromes. The Geriatric Resources for Assessment and Care of Elders (GRACE) model of primary care for low-income seniors and their primary care physicians (PCPs) was developed to improve the quality of geriatric care so as to optimize health and functional status, decrease excess healthcare use, and prevent long-term nursing home placement. The catalyst for the GRACE intervention is the GRACE support team, consisting of a nurse practitioner and a social worker. Upon enrollment, the GRACE support team meets with the patient in the home to conduct an initial comprehensive geriatric assessment. The support team then meets with the larger GRACE interdisciplinary team (including a geriatrician, pharmacist, physical therapist, mental health social worker, and community-based services liaison) to develop an individualized care plan including activation of GRACE protocols for evaluating and managing common geriatric conditions. The GRACE support team then meets with the patient's PCP to discuss and modify the plan. Collaborating with the PCP, and consistent with the patient's goals, the support team then implements the plan. With the support of an electronic medical record and longitudinal tracking system, the GRACE support team provides ongoing care management and coordination of care across multiple geriatric syndromes, providers, and sites of care. The effectiveness of the GRACE intervention is being evaluated in a randomized, controlled trial.

Transitional care: a critical dimension of the home healthcare quality agenda

Focusing on the critical transitions of patients and their caregivers across healthcare settings and among providers is a promising approach to enhancing care coordination and improving quality. This article describes the research base for the transitional care of older adults and offers recommendations to advance the science, translate best practices into home healthcare settings, and improve the transitions of high-risk older adults to and from home healthcare. Home healthcare is a component of the healthcare industry uniquely positioned to improve transitional care and outcomes for the growing population of older adults with continuous complex needs.

Challenges in improving care for high-risk seniors in Medicare

Despite strong interest in improving care for high-risk elders, demonstration projects typically show negative results. This paper examines one large foundation-sponsored initiative to gain insight on why success often is so elusive. The findings indicate that specific flaws in concept, design, and implementation each make it more challenging for demonstrations to achieve their intended goals, especially those involving cost and utilization reductions. We speculate that part of the reason for this is that organizational and political processes lead to fundamentally conservative demonstrations that assume that small amounts of resources directed at incremental change can be effective in generating substantial change in organizations and can do so rapidly.

After adoption: sustaining the innovation. A case study of disseminating the hospital elder life program

OBJECTIVES

To examine key factors that influence sustainability in the diffusion of the Hospital Elder Life Program (HELP) as an example of an evidence-based, multifaceted, innovative program to improve care for hospitalized older adults.

DESIGN

Longitudinal, qualitative study between November 2000 and November 2003 based on 102 in-depth interviews every 6 months during HELP implementation.

SETTING

Thirteen hospitals implementing HELP.

PARTICIPANTS

Forty-two hospital staff members (physician, nursing, volunteer, and administrative staff) implementing HELP, conducted 102 interviews.

MEASUREMENTS

Staff experiences sustaining the program, including challenges and strategies that they viewed as successful in addressing these challenges.

RESULTS

Of the 13 hospitals studied, 10 were sustaining HELP at the end of the study period; three terminated the program (after 24 months, 12 months, and 6 months). Critical factors were identified as influencing whether the program was sustained: the presence of clinical leadership, the ability and willingness to adapt the original HELP protocols to local hospital circumstances and constraints, and the ability to obtain longer-term resources and funding for HELP.

CONCLUSION

Recognizing the need for sustained clinical leadership and funding as well as the inevitable modifications required to sustain innovative programs can promote more-realistic goals and expectations for health services researchers, clinicians, and policy makers in their laudable efforts to translate research into practice.

Preventive home care of frail older people: a review of recent case management studies

Preventive actions targeting community-dwelling frail older people will be increasingly important with the growing number of very old and thereby also frail older people. This study aimed to explore and summarize the empirical literature on recent studies of case/care management interventions for community-dwelling frail older people and especially with regard to the content of the interventions and the nurse's role and outcome of it. Very few of the interventions took either a preventive or a rehabilitative approach using psycho-educative interventions focusing, for instance, on self-care activities, risk prevention, health complaints management or how to preserve or strengthen social activities, community involvement and functional ability. Moreover, it was striking that very few included a family-oriented approach also including support and education for informal caregivers. Thus it seems that the content of case/care management needs to be expanded and more influenced by a salutogenic health care perspective. Targeting frail older people seemed to benefit from a standardized two-stage strategy for inclusion and for planning the interventions. A comprehensive geriatric assessment seemed useful as a base. Nurses, preferably trained in gerontological practice, have a key role in case/care management for frail older people. This approach calls for developing the content of case/care management so that it involves a more salutogenic, rehabilitative and family-oriented approach. To this end it may be useful for nurses to strengthen their psychosocial skills or develop close collaboration with social workers. The outcome measures examined in this study represented one of three perspectives: the consumer's perspective, the perspective of health care consumption or the recipient's health and functional ability. Perhaps effects would be expected in all three areas and thus these should be included in evaluative studies in addition to measures for family and/or informal caregiver's strain and satisfaction.