Perspective: transforming chronic care for older persons

The Landscape of Geriatric Fellow Scholarly Activity Participation: Findings From a National Survey of Program Directors

Introduction As the US population continues to age, there is a critical need for geriatricians to be trained and engaged in research to inform high-quality care for older adults. Our objective was to understand the extent, type, barriers, and facilitators of research training and the attitudes toward research training and scholarly activity among Accreditation Council for Graduate Medical Education (ACGME)-accredited US geriatric fellowship programs. Methods We conducted a cross-sectional survey of geriatric fellowship program directors from September to November 2022. Surveys assessing program characteristics, requirements for scholarly activity, director demographics, and director attitudes toward scholarly activity were distributed via email. We used descriptive statistics to assess fellowship scholarly activity requirements, facilitators, and perceived barriers. Results The survey response rate was 35.3% (41/116 programs). Most programs (82.9%) required participation in scholarly activity and provided protected time (73.2%). Definitions of scholarly activities greatly differed among programs. The most common scholarly activity requirements included participation in a scholarly project (70.7%) or local presentation (46.3%). The short duration of fellowship was the most common major barrier, reported by 70.7% of directors. Lastly, 34.1% of directors indicated satisfaction with the quality of research training provided, while 65.9% of directors reported satisfaction with the opportunities provided to participate in scholarly activities. Conclusions Overall, program requirements, facilitators, and perceived barriers to scholarly activity were heterogeneous among US geriatric program directors. Additionally, only about one-third of directors were satisfied with the research training provided. Our future work will compare the attitudes and reported barriers/facilitators of program director and fellow participants toward participation in scholarly activity.

Older Adults, the "Social Admission," and Nonspecific Complaints in the Emergency Department: Protocol for a Scoping Review

BACKGROUND

Older adults have a higher visit rate and poorer health outcomes in the emergency department (ED) compared to their younger counterparts. Older adults are more likely to require additional resources and hospital admission. The nonspecific, atypical, and complex nature of disease presentation in older adults challenges current ED triage systems. Acute illness in older adults is often missed or commonly disguised in the ED as a social or functional issue. If diagnostic clarity is lacking or safe discharge from the ED is not feasible, then older adults may be labelled a "social admission" (or another synonymous term), often leading to negative health consequences.

OBJECTIVE

This scoping review aims to describe and synthesize the available evidence on patient characteristics, adverse events, and health outcomes for older adults labelled as "social admission" (and other synonymously used terms), as well as those with nonacute or nonspecific complaints in the ED or hospital setting.

METHODS

A literature search of MEDLINE, Embase, Scopus, PsycINFO, and CINAHL was completed. Relevant reference lists were screened. Data have been managed using EndNote software and the Covidence web application. Original data have been included if patients are aged ≥65 years and are considered a "social admission" (or other synonymously used term) or if they present to the ED with a nonacute or nonspecific complaint. Two review team members have reviewed titles and abstracts and will review full-text articles. Disagreements are resolved by consensus or in discussion with a third reviewer. This review does not require research ethics approval.

RESULTS

As of January 2023, we have completed the title and abstract screening and have started the full-text screening. Some remaining full-text articles are being retrieved and/or translated. We are extracting data from included studies. Data will be presented in a narrative and descriptive manner, summarizing key concepts, patient characteristics, and health outcomes of patients labelled as a "social admission" (and other synonymously used terms) and of those with nonacute and nonspecific complaints. We expect the first results for publication in Spring 2023.

CONCLUSIONS

Acute illness in the older adult is not always easily identified. We hope to better understand patient characteristics, adverse events, and health outcomes of older adults labelled as a "social admission," as well as those with nonacute or nonspecific complaints. We aim to identify priorities for future research and identify knowledge gaps that may inform health care providers caring for these vulnerable patients.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/38246.

Knowledge and Attitude of Pharmacy Students Regarding Geriatric Care: Questionnaire-Based Analysis in Malaysia

INTRODUCTION

There is a predicted growth of up to 17% in an older adult of Malaysian above 60 years of age by 2040. This will increase the workload of almost every healthcare provider to ensure optimal geriatric care.

PURPOSE

This study aimed to assess pharmacy students' knowledge and attitudes towards geriatric pharmacy education and older patients to determine their preparation in delivering appropriate medical care to the geriatric population.

METHODS

Self-administered questionnaires were distributed among pharmacy students in different Malaysian universities. The survey included several sections to assess multiple aspects such as sociodemographic information, assessment of knowledge using a validated 28-item Geriatric Knowledge Assessment Scale (GKAS), and attitudes towards geriatrics education.

RESULTS

The response rate was around 70% of the respondents. The mean (± standard deviation) age of the cohort was 22.28 (±1.12) years. Despite around 78% of pharmacy students claiming that their knowledge of geriatric care is adequate, their GKAS score showed that only around 20% have high geriatric knowledge. Around 80% of them showed a positive attitude on the importance of taking courses focused on geriatric care and demonstrated interest to further knowledge and training in geriatric care. However, more than half of the students were uncertain of their answers towards their attitudes regarding older patients.

CONCLUSION

Given the growing role of pharmacists in the ageing population, this study highlights the importance of geriatric care education among potential pharmacists. Therefore, we urge the need to improve/develop geriatrics education and training into the pharmacy curriculum to ensure sufficient preparation for actual practice after graduation.

The development of a geriatric postgraduate education assessment instrument using a modified Delphi procedure

There is currently wide variation in the structure and content of higher medical training in geriatric medicine across Europe and no common framework within which existing efforts can be compared. We set out to develop an audit tool to compare training between countries. An initial review of indexed and grey literature was used to develop an audit tool which was used as the basis of an Internet-based modified Delphi process incorporating the views of 14 expert geriatricians from across Europe. Items in the audit tool were included or excluded when supported by ≥75% or <50% of respondents, respectively. Items supported by 50-74% of respondents were carried forward with additional suggestions and modifications included following Round 1. Thirteen experts representing 12 countries responded to both rounds. 40/45 items were supported at Round 1. Five items were carried forward. A further 13 elements were introduced for consideration at Round 2. Consensus was gained after the second round. The final tool describes 52 items across four domains: general considerations, topics referring to knowledge in patient care, different roles that should be considered in medical training and topics regarding assessment. The resulting tool can be used as a basis for comparing higher medical training programmes in geriatric medicine between countries. Individual countries can use this to audit current practice. At an European Union level, the insights gained through such audit will form the basis of future work to develop an agreed postgraduate curriculum in the specialty.

Training health care professionals for 21st-century practice: a systematic review of educational interventions on chronic care

PURPOSE

To systematically review the evidence for high-quality and effective educational strategies to train health care professionals across the education continuum on chronic disease care.

METHOD

A search of English-language publications and conference proceedings was performed in November 2013 and updated in April 2014. Studies that evaluated a newly developed curriculum targeting chronic disease care with learner outcomes were included. Two primary reviewers and one adjudicating reviewer evaluated the studies and assessed their quality using the validated Medical Education Research Study Quality Instrument (MERSQI). Studies were also mapped onto elements of Wagner's chronic care model (CCM) to evaluate their use of established evidence-based models for chronic care delivery. Miller's classification of clinical competence was used to assess the quality of learner achievements for each educational intervention.

RESULTS

A total of 672 articles were found for this review. Twenty-two met criteria for data extraction. The majority of studies were of moderate quality according to MERSQI scoring. Only three studies reported both learner and patient outcomes. The highest-quality studies incorporated more elements of Wagner's CCM and showed high-level learner competence according to Miller's classification. Successful interventions redesigned health care delivery systems to include team-based care, emphasized training of health care professionals on patient self-management, and included learner-based quality improvement initiatives.

CONCLUSIONS

The growing number of children and adults with chronic disease necessitates improved educational interventions for health care professionals that involve evidence-based models for restructuring chronic care delivery, aim for high-level learner behavioral outcomes, and evolve through quality improvement initiatives.

[Geriatric post-graduate training: Current recommendations and opinion of the trainees]

OBJECTIVE

To evaluate the level of compliance with the official curriculum residence programme by geriatrics trainees, and to analyse their level of satisfaction.

MATERIAL AND METHODS

A questionnaire was developed including these sections: trainee filiation, and questions related to their clinical training, academic formation, research training, satisfaction, and other comments. The survey was performed in Survey Monkey and sent to a geriatric trainee per hospital in March 2014. The results were collected between March and April of 2014.

RESULTS

Responses were received from 41% of the trainees of 23 Geriatric Teaching Units. Rates of over 95% were observed as regards clinical rotations in the basic period, while in the specific period these percentages varied between 34% and 69%, probably because some of the trainees had not yet arrived at the period in which these rotations are programmed. An external rotation could be performed by 83% of the trainees, and 90% do the recommended number of shifts. The mean number of instruction sessions per week was 2.3, and the number of meetings with the tutor was 2.5 times per year. The median number of presentations in congresses was 3.7 per trainee, with 0.2 publications during training. Each trainee attended 1.2 national meetings, 0.3 European meetings, and 0.1 American. Most of the trainees (85%) were satisfied or very satisfied with their training.

CONCLUSIONS

Geriatrics curricula for trainees are followed in the basic aspects, but not so much in the specific ones. The average level satisfaction of the trainees is very high. The recommended training activities within the specific department (sessions, etc.) are not always fulfilled. The research activity, evaluated by publications and presentations at meetings, is low. Following these data, reflection and the establishment of improvements are required in Geriatrics training at post-graduate level.

New workforce development in dementia care: screening for "caring": preliminary data

The United States has a significant shortage of trained geriatricians and of nurses, social workers, and paraprofessionals educated to care for elderly adults. As the aging population continues to grow, providing high-quality care will require new models that better address the many needs of aging individuals and their caregivers, using cost-effective strategies. Responding to this need, the Indiana University Center for Aging Research implementation scientists developed, tested, and are now scaling up a successful collaborative care coordination model for older adults with dementia, depression, or both: the Aging Brain Care program. This model now includes a newly created frontline care provider position, the Care Coordinator Assistant. The Care Coordinator Assistant works with individuals and caregivers to monitor biopsychosocial needs and deliver evidence-based and individualized care protocols, with close supervision from the registered nurse Care Coordinator. Recognizing that current hiring practices for frontline providers were insufficient to screen for critical abilities expected in this new position, including the ability to express "caring" and empathy, a new screening process was created building on the Multiple Mini Interview (MMI) format. The Care Coordinator Assistant MMI comprised six stations, each created to simulate challenging scenarios that will be frequently encountered and to assess important candidate abilities. Overall, the six-station MMI, with two to three items per station, provided factorially valid measures and good predictive ability. The process did not appear to be overly burdensome for candidates, and interviewers noted that it was helpful in discriminating between candidates.

The development of academic geriatric medicine in the United States 2005 to 2010: an essential resource for improving the medical care of older adults

Academic geriatric medicine programs are critical for training the physician workforce to care effectively for aging Americans. This article updates the progress made by U.S. medical schools from 2005 to 2010 in developing these programs. Academic leaders in geriatrics in accredited allopathic and osteopathic medical schools were surveyed in the winter of 2010 (60% response rate), and results were compared with findings from a similar 2005 survey (68% response rate). Physician faculty in geriatrics increased from 9.6 (mean) full-time equivalents (FTEs) in 2005 to 11.2 by 2010. In 2010, faculty and staff effort was mostly devoted to clinical practice (mean = 37%) and education (mean = 33%), with only seven responding schools devoting more than 40% of faculty effort to research. Schools that have been designated as Centers of Excellence had a median 20 FTE physician faculty, compared with seven at the other schools (P < .001). In 2010, 27% of medical schools required a geriatrics clerkship, and 87% (n = 83) had an elective geriatric clerkship. In summary, more fellows and faculty were recruited and trained in 2010 than in 2005, and some academic programs have emerged with strong education, research, and clinical initiatives. Medical student exposure to geriatrics curriculum has increased, but few academic geriatricians are pursuing research careers, and the number of practicing geriatricians is declining. New approaches to training the entire physician workforce to care for older adults will be required to ensure adequate medical care for aging Americans.

Hospitalization Among Medicare-Reimbursed Skilled Home Health Recipients

This article presents a summary and critique of the published empirical evidence between the years 2002 and 2011 regarding rehospitalization among Medicare-reimbursed, skilled home health recipients. The knowledge gained will be applied to a discussion regarding ACH among geriatric home health recipients and areas for future research. The referenced literature in MEDLINE, PubMed and Cochrane databases was searched using combinations of the following search terms: home care and home health and Medicare combined with acute care hospitalization, rehospitalization, hospitalization, and adverse events and limited to studies conducted in the United States. Twenty-five research studies published in the last eight years investigated hospitalization among patients receiving Medicare-reimbursed, skilled home health. Empirical findings indicate telehomecare can reduce hospitalizations and emergency room use. The identification of risk factors for hospitalization relate to an elder's sociodemographic, clinical and functional status that can be identified upon admission and interventions taken in order to reduce hospitalizations. Disease management, frontloading nurse visits, the structure of home health services and OBQI are also among the interventions identified to reduce hospitalizations. However, the body of evidence is limited by a paucity of research and the over reliance on small sample sizes. Few published studies have explored methods that effectively reduce hospitalization among Medicare-reimbursed skilled home health recipients. Further research is needed to clarify the most effective ways to structure home health services to maximize benefits and reduce hospitalization among this chronically ill geriatric population.

Activity of daily living staging, chronic health conditions, and perceived lack of home accessibility features for elderly people living in the community

OBJECTIVE

To examine the cross-sectional associations between activity of daily living (ADL) limitation stage and specific physical and mental conditions, global perceived health, and unmet needs for home accessibility features of community-dwelling adults aged 70 and older.

DESIGN

Cross-sectional.

SETTING

Community.

PARTICIPANTS

Nine thousand four hundred forty-seven community-dwelling persons interviewed through the Second Longitudinal Study of Aging (LSOA II).

MEASUREMENTS

Six ADLs organized into five stages ranging from no difficulty (0) to unable (IV).

RESULTS

ADL stage showed strong ordered associations with perceived health, dementia severe enough to require proxy use, and history of stroke. For example, the relative risks (RRs) defined as risk of being at Stages I, II, III, or IV divided by risk of being at Stage 0 for those with dementia ranged from 3.2 (95% confidence interval (CI)=2.4-4.4) to 41.9 (95% CI=19.6-89.6) times the RRs for those without dementia. The RR ratios (RRR) comparing respondents who perceived unmet need for accessibility features in the home to those without these perceptions peaked at Stage III (RRR=17.8, 95% CI=13.0-24.5) and then declined at Stage IV. All models were adjusted for age, sex, and race.

CONCLUSIONS

ADL stages showed clinically logical associations with other health-related concepts, supporting external validity. Findings suggest that specificity of chronic conditions will be important in developing strategies for disability reduction. People with partial rather than complete ADL limitation appeared most vulnerable to unmet needs for home accessibility features.

Medicine in the 21st century: recommended essential geriatrics competencies for internal medicine and family medicine residents

BACKGROUND

Physician workforce projections by the Institute of Medicine require enhanced training in geriatrics for all primary care and subspecialty physicians. Defining essential geriatrics competencies for internal medicine and family medicine residents would improve training for primary care and subspecialty physicians. The objectives of this study were to (1) define essential geriatrics competencies common to internal medicine and family medicine residents that build on established national geriatrics competencies for medical students, are feasible within current residency programs, are assessable, and address the Accreditation Council for Graduate Medical Education competencies; and (2) involve key stakeholder organizations in their development and implementation.

METHODS

Initial candidate competencies were defined through small group meetings and a survey of more than 100 experts, followed by detailed item review by 26 program directors and residency clinical educators from key professional organizations. Throughout, an 8-member working group made revisions to maintain consistency and compatibility among the competencies. Support and participation by key stakeholder organizations were secured throughout the project.

RESULTS

The process identified 26 competencies in 7 domains: Medication Management; Cognitive, Affective, and Behavioral Health; Complex or Chronic Illness(es) in Older Adults; Palliative and End-of-Life Care; Hospital Patient Safety; Transitions of Care; and Ambulatory Care. The competencies map directly onto the medical student geriatric competencies and the 6 Accreditation Council for Graduate Medical Education Competencies.

CONCLUSIONS

Through a consensus-building process that included leadership and members of key stakeholder organizations, a concise set of essential geriatrics competencies for internal medicine and family medicine residencies has been developed. These competencies are well aligned with concerns for residency training raised in a recent Medicare Payment Advisory Commission report to Congress. Work is underway through stakeholder organizations to disseminate and assess the competencies among internal medicine and family medicine residency programs.

Physician satisfaction with chronic care processes: a cluster-randomized trial of guided care

PURPOSE

Chronically ill older patients with multiple conditions are challenging to care for, and new models of care for this population are needed. This study evaluates the effect of the Guided Care model on primary care physicians' impressions of processes of care for chronically ill older patients.

METHODS

In Guided Care a specially educated registered nurse works at the practice with 2 to 5 primary care physicians, performing 8 clinical activities for 50 to 60 chronically ill older patients. The care model was tested in a cluster-randomized controlled trial between 2006 and 2009. All eligible primary care physicians in 14 pods (teams of physicians and their chronically ill older patients) agreed to participate (n = 49). Pods were randomly assigned to provide either Guided Care or usual care. Physicians were surveyed at baseline and 1 year later. We assessed the effects of Guided Care using responses from 38 physicians who completed both survey questionnaires. We measured physicians' satisfaction with chronic care processes, time spent on chronic care, knowledge of their chronically ill older patients, and care coordination provided by physicians and office staff.

RESULTS

Compared with the physicians in the control group, those in the Guided Care group rated their satisfaction with patient/family communication and their knowledge of the clinical characteristics of their chronically ill older patients significantly higher (rho<0.05 in linear regression models). Other differences did not reach statistical significance.

CONCLUSIONS

Based on physician report, Guided Care provides important benefits to physicians by improving communication with chronically ill older patients and their families and in physicians' knowledge of their patients' clinical conditions.

Successful models of comprehensive care for older adults with chronic conditions: evidence for the Institute of Medicine's "retooling for an aging America" report

The quality of chronic care in America is low, and the cost is high. To help inform efforts to overhaul the ailing U.S. healthcare system, including those related to the "medical home," models of comprehensive health care that have shown the potential to improve the quality, efficiency, or health-related outcomes of care for chronically ill older persons were identified. Using multiple indexing terms, the MEDLINE database was searched for articles published in English between January 1, 1987, and May 30, 2008, that reported statistically significant positive outcomes from high-quality research on models of comprehensive health care for older persons with chronic conditions. Each selected study addressed a model of comprehensive health care; was a meta-analysis, systematic review, or trial with an equivalent concurrent control group; included an adequate number of representative, chronically ill participants aged 65 and older; used valid measures; used reliable methods of data collection; analyzed data rigorously; and reported significantly positive effects on the quality, efficiency, or health-related outcomes of care. Of 2,714 identified articles, 123 (4.5%) met these criteria. Fifteen models have improved at least one outcome: interdisciplinary primary care (1), models that supplement primary care (8), transitional care (1), models of acute care in patients' homes (2), nurse-physician teams for residents of nursing homes (1), and models of comprehensive care in hospitals (2). Policy makers and healthcare leaders should consider including these 15 models of health care in plans to reform the U.S. healthcare system. The Centers for Medicare and Medicaid Services would need new statutory flexibility to pay for care by the nurses, social workers, pharmacists, and physicians who staff these promising models.

Silver paper: the future of health promotion and preventive actions, basic research, and clinical aspects of age-related disease--a report of the European Summit on Age-Related Disease

BACKGROUND. In September 2008, under the French Presidency of the European Union and with the support of the Polish Minister of Health, a European Summit on Age-Related Disease was organised inWroclaw (Poland). At this meeting, European politicians, gerontologists and geriatricians gathered to discuss a common approach to future challenges related to age-related disease. Politicians and decision-makers from the European Union and Ministers of Health and their deputies from many European countries raised the problems and difficulties to be tackled in a growing population with a high burden of disease, and asked scientists to write a consensus document with recommendations for future actions and decisions. Scientists and clinicians worked in parallel in three different groups, on health promotion and preventive actions, basic research in age-related disease, and clinical aspects of disease in older people. Beforehand, the format of the paper with recommendations was discussed, and it was finally agreed that, for a better understanding by decision- makers, it would be divided in two different columns: one with facts that were considered settled and agreed by most experts (under the heading We know), and a second with recommendations related to each fact (We recommend). No limit on the number of topics to be discussed was settled. After careful and detailed discussion in each group, which in most cases included the exact wording of each statement, chairpersons presented the results in a plenary session, and new input from all participants was received, until each of the statements and recommendations were accepted by a large majority. Areas with no consensus were excluded from the document. Immediately after the Summit, the chairpersons sent the document both to the main authors and to a list of experts (see footnote) who had made presentations at the summit and agreed to review and critically comment on the final document, which is presented below. As regards the scientific aspects of the planning of the Summit, several organisations, under the leadership of the EUGMS, were asked both to review the program and to suggest names of speakers and participants. After the Summit, the Boards of these organizations (European Union Geriatric Medicine Society (EUGMS), International Association of Gerontology and Geriatrics-European Region (IAGGER), European Association of Geriatric Psychiatry (EAGP), International Society of Gerontechnology (ISG) and International Society for the Study of the Aging Male (ISSAM) agreed to consider the document as an official paper, and help with its dissemination. The name Silver Paper was used, recalling the grey or silvery hair of our older citizens, as an easy reference. It has been sent officially to several bodies of the European Union and to Health Ministers of most European countries; and will be published in other languages in local journals. Its declared intention is to foster changes in policies which may, in the future, reduce the burden of disease in old age.

Transforming medical professionalism to fit changing health needs

BACKGROUND

The professional organization of medical work no longer reflects the changing health needs caused by the growing number of complex and chronically ill patients. Key stakeholders enforce coordination and remove power from the medical professions in order allow for these changes. However, it may also be necessary to initiate basic changes to way in which the medical professionals work in order to adapt to the changing health needs.

DISCUSSION

Medical leaders, supported by health policy makers, can consciously activate the self-regulatory capacity of medical professionalism in order to transform the medical profession and the related professional processes of care so that it can adapt to the changing health needs. In doing so, they would open up additional routes to the improvement of the health services system and to health improvement. This involves three consecutive steps: (1) defining and categorizing the health needs of the population; (2) reorganizing the specialty domains around the needs of population groups; (3) reorganizing the specialty domains by eliminating work that could be done by less educated personnel or by the patients themselves. We suggest seven strategies that are required in order to achieve this transformation.

SUMMARY

Changing medical professionalism to fit the changing health needs will not be easy. It will need strong leadership. But, if the medical world does not embark on this endeavour, good doctoring will become merely a bureaucratic and/or marketing exercise that obscures the ultimate goal of medicine which is to optimize the health of both individuals and the entire population.

The ageing immune system: is it ever too old to become young again?

Ageing is accompanied by a decline in the function of the immune system, which increases susceptibility to infections and can decrease the quality of life. The ability to rejuvenate the ageing immune system would therefore be beneficial for elderly individuals and would decrease health-care costs for society. But is the immune system ever too old to become young again? We review here the promise of various approaches to rejuvenate the function of the immune system in the rapidly growing ageing population.