Shared medical appointments to screen for geriatric syndromes: preliminary data from a quality improvement initiative

Older Adults and Unintentional Injury

Clinicians play an important role in the prevention of unintentional injuries. Falls and motor vehicle crashes (MVC) have predictable and overlapping antecedents. Systematic screening for and management of vision impairment, frailty, cognitive impairment, polypharmacy, and inappropriate medications will reduce both falls and MVC risks. Fall-prevention measures, such as strength training, need to be more widely prescribed by physicians and implemented by older adults. Technologically tailored approaches are needed to leverage fall-reduction programs at home, as well as education of older adults regarding home hazards.

Shared-Medical Appointment for Screening and Risk Assessment for Fall Prevention

Background: The median age of Americans is rising and fall risk increases with age. While the causes of falls are multifactorial, falls risk can be reduced. Only a small percentage of older-adults report being asked about fall risk or falls. The CDC has initiated a Stopping Elderly Accidents, Deaths and Injuries (STEADI) toolkit, but penetration into practice has been slow. To address this, we implemented a Falls Prevention Shared Medical Appointment (SMA) at an academic internal medicine clinic. Methods: Patients were referred to the SMA and scheduled per their preference virtually or in-person. Patients attended a nurse visit for appropriate fallrisk related screening, followed by the SMA with two physicians for review of medical history, fall screening results and implementation of fall reduction strategies. Follow-up survey of the patients assessed program effectiveness. Results: Fifty-two patients were seen/assessed between November 2021 and February 2023 with SMAs ranging from 3 to 5 patients with an average age of 77 (=/- 6.7). Questionnaire self-reported risk factors, self-reported strength, and polypharmacy were associated with objective markers of increased fall risk. Survey results indicate acceptability of this model. Conclusion: Falls prevention SMAs can be effective. More work is needed to further delineate and refine cohort selection.

Optimizing Care Delivery by Applying an Innovative Shared Medical Appointment Model for Determination of Cochlear Implant Candidacy

OBJECTIVE

To develop and implement an innovative group appointment with the potential to improve access to cochlear implantation (CI) while maintaining patient satisfaction and experience.

PATIENTS

Adult patients with advanced sensorineural hearing loss.

INTERVENTIONS

Implementation of novel shared medical appointment (SMA) model.

MAIN OUTCOME MEASURES

Patient satisfaction with group visit; anecdotal description of provider efficiency and experience.

RESULTS

Survey data were collected from 166 adults who participated in a group CI candidacy appointment from September 2017 to February 2020 as part of a quality improvement initiative. Provider time is anecdotally optimized by accommodating more patients in a shorter timeframe while effectively triaging those candidates most likely to meet candidacy criteria for a full CI evaluation. Most importantly, patient feedback has been positive which suggests that patients find value in this novel format.

CONCLUSIONS

The current climate of healthcare demands that providers maximize the efficacy and efficiency of patient care. Our large CI program has determined that using an SMA format as an entry point for CI candidacy evaluation offers many benefits. The group appointment improves patient throughput and also provides a positive patient experience. Group visits offer a viable solution for increasing patient access to CI while maintaining quality in a busy academic medical center setting.

Association of Loneliness With Falls: A Study of Older US Adults Using the National Social Life, Health, and Aging Project

Objectives: Falls represent a significant cause of morbidity and mortality in older adults, and are more common among those living alone. We aimed to determine if there is an association between loneliness and falls. Methods: Participants were surveyed in three waves separated by 5 years. We used the three-item UCLA Loneliness Scale to measure loneliness. Results: Data from 2337 respondents, with both loneliness and fall data in at least two consecutive waves, were included. Over three waves, 51% respondents reported a fall and 23% reported ≥ two falls. In multivariate analysis, the odds of having ≥ one fall 5 years later increased by a factor of 1.11 per one point increase on the loneliness scale (OR = 1.11, 95% CI 1.04, 1.19; p < .01). Discussion: Lonely older adults have increased odds of future falls. Strategies for combating loneliness in older adults may help reduce fall-related morbidity and mortality.

Effectiveness of Advance Care Planning Group Visits Among Older Adults in Primary Care

BACKGROUND

Group visits can support health behavior change and self-efficacy. In primary care, an advance care planning (ACP) group visit may leverage group dynamics and peer mentorship to facilitate education and personal goal setting that result in ACP engagement.

OBJECTIVE

To determine whether the ENgaging in Advance Care Planning Talks (ENACT) group visits intervention improves ACP documentation and readiness in older adults.

METHODS

This randomized clinical trial was conducted among geriatric primary care patients from the University of Colorado Hospital Seniors Clinic, Aurora, CO, from August 2017 to November 2019. Participants randomized to ENACT group visits (n = 55) participated in two 2-hour sessions with discussions of ACP topics and use of ACP tools (i.e., Conversation Starter Kit, Medical Durable Power of Attorney form, and PREPARE videos). Participants randomized to the control arm (n = 55) received the Conversation Starter Kit and a Medical Durable Power of Attorney form by mail. The primary outcomes included presence of ACP documents or medical decision-maker documentation in the electronic health record (EHR) at 6 months, and a secondary outcome was ACP readiness (validated four-item ACP Engagement Survey) at 6 months.

RESULTS

Participants were a mean of 77 years old, 60% female, and 79% white. At 6 months, 71% of ENACT participants had an advance directive in the EHR (26% higher) compared with 45% of control arm participants (P < .001). Similarly, 93% of ENACT participants had decision-maker documentation in the EHR (29% higher) compared with 73% in the control arm (P < .001). ENACT participants trended toward higher readiness to engage in ACP compared with control (4.56 vs 4.13; P = .16) at 6 months.

CONCLUSION

An ACP group visit increased ACP documentation and readiness to engage in ACP behavior change. Primary care teams can explore implementation and adaptation of ACP group visits into routine care, as well as longer-term impact on patient health outcomes. J Am Geriatr Soc 68:2382-2389, 2020.

Characteristics and Components of Medical Group Visits for Chronic Health Conditions: A Systematic Scoping Review

Objectives: Chronic health conditions are a major challenge to the health care system. Medical Group Visits (MGVs) are a valuable health care delivery model used in a variety of medical settings and patient populations. We conducted a systematic scoping review of MGV research literature for chronic health conditions to summarize the characteristics and individual components of MGVs in the United States of America and Canada. Design: We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses scoping review methodology and searched five databases using nine widely used MGV-related terms. Subjects: We included studies conducted in the United States and Canada, whose participants were >18 years old and attended an MGV conducted in a medical setting by a billable health care provider. We excluded groups related to diabetes, pregnancy, and cancer. Results: Of 3777 studies identified, we found 55 eligible studies of which 9 are randomized controlled trials and 46 are observational studies. The majority of studies were conducted in academic medical centers, were observational in design, and recruited patients using physician referrals. The three most frequently studied groups include a combination of several chronic conditions (n = 12), chronic pain conditions (n = 10), and cardiovascular disease (n = 9). Curriculum components included didactics (n = 55), experiential activities (n = 27), and socializing components (n = 12). Didactic areas include (1) medical topics such as symptoms management (n = 27) of which 14 included pain management, and (2) lifestyle/educational component (n = 33) that comprised of talks on nutrition (n = 29), exercise (n = 20), stress (n = 16), and sleep (n = 10). The top integrative medicine (IM) modalities (n = 13) included: mindfulness techniques (n = 8), meditation (n = 6), and yoga (n = 5). Substantial heterogeneity was observed in the recruitment, implementation, curriculum components, and outcomes reported. Conclusion: The MGV is a model of patient-centered care that has captured the attention of researchers. IM modalities are well represented in the curriculum components of MGVs. Further investigation into the components identified by this study, may help in better targeting of group interventions to patients and contexts, where it is most likely to be effective.

A Group Visit Initiative Improves Advance Care Planning Documentation among Older Adults in Primary Care

INTRODUCTION

Group visits for advance care planning (ACP) may help patients document preferences for decision makers and future care. We assessed the impact of a primary care-based ACP group visit (ACP-GV) intervention on older adults' ACP documentation and why patients participated.

METHODS

Older adults (>65 years) in primary care participated in a 2-session ACP-GV intervention that promotes group dynamics, peer-based learning, and goal setting. Charts were reviewed at baseline, 3 months, and 12 months for documentation of decision makers and ACP forms. We described patients' reasons for participating through analysis of transcripts.

RESULTS

118 patients (mean age 76 years; 62% female and 82% white) participated in 16 ACP-GV cohorts. From baseline to 3-month follow-up, documentation of decision maker preferences increased from 39% to 81%, and was 89% at 12-month follow-up. Patients with completed ACP forms increased from 20% to 57% at 3 months, and was 67% at 12 months. Reasons for participating included recognizing the importance of ACP, curiosity, participation recommended by primary care provider, desire to talk with family/friends, and desire to complete advance directives.

CONCLUSIONS

This ACP-GV intervention increased ACP documentation among patients with diverse reasons for participating. This is a patient-centered approach to ACP in primary care.

Development and preliminary validation of an Observation List for detecting mental disorders and social Problems in the elderly in primary and home care (OLP)

OBJECTIVE

Even though the prevalence of mental disorders and social problems is high among elderly patients, it is difficult to detect these in a primary (home) care setting. Goal was the development and preliminary validation of a short observation list to detect six problem areas: anxiety, depression, cognition, suspicion, loneliness, and somatisation.

METHODS

A draft list of indicators identified from a short review of the literature and the opinions of 22 experts was evaluated by general practitioners (GPs) and home care organisations for feasibility. It was then used by GPs and home care personnel to observe patients, who also completed validated tests for psychological disorders (General Health Questionnaire 12 item version (GHQ-12)), depression (Geriatric Depression Scale 15-item version (GDS-15)), anxiety and suspicion (Symptom Checklist-90 (SCL-90)), loneliness (University of California, Los Angeles (UCLA)), somatisation (Illness Attitude Scale (IAS)), and cognition (Mini-Mental State Examination (MMSE)).

RESULTS

GPs and home care personnel observed 180 patients (mean age 78.4 years; 66% female) and evaluated the draft list during a regular visit. Cronbach's α was 0.87 for the draft list and ≥0.80 for the draft problem areas (loneliness and suspicion excepted). Principal component analysis identified six components (cognition, depression + loneliness, somatisation, anxiety + suspicion, depression (other signs), and an ambiguous component). Convergent validity was shown for the indicators list as a whole (using the GHQ-12), and the subscales of depression, anxiety, loneliness, cognition, and somatisation. Using pre-set agreed criteria, the list was reduced to 14 final indicators divided over five problem areas.

CONCLUSION

The Observation List for mental disorders and social Problems (OLP) proved to be preliminarily valid, reliable, and feasible for use in primary and home care settings. Copyright © John Wliey & Sons, Ltd.

Advance Care Planning Meets Group Medical Visits: The Feasibility of Promoting Conversations

PURPOSE

Primary care needs new models to facilitate advance care planning conversations. These conversations focus on preferences regarding serious illness and may involve patients, decision makers, and health care providers. We describe the feasibility of the first primary care-based group visit model focused on advance care planning.

METHODS

We conducted a pilot demonstration of an advance care planning group visit in a geriatrics clinic. Patients were aged at least 65 years. Groups of patients met in 2 sessions of 2 hours each facilitated by a geriatrician and a social worker. Activities included considering personal values, discussing advance care planning, choosing surrogate decision-makers, and completing advance directives. We used the RE-AIM framework to evaluate the project.

RESULTS

Ten of 11 clinicians referred patients for participation. Of 80 patients approached, 32 participated in 5 group visit cohorts (a 40% participation rate) and 27 participated in both sessions (an 84% retention rate). Mean age was 79 years; 59% of participants were female and 72% white. Most evaluated the group visit as better than usual clinic visits for discussing advance care planning. Patients reported increases in detailed advance care planning conversations after participating (19% to 41%, P = .02). Qualitative analysis found that older adults were willing to share personal values and challenges related to advance care planning and that they initiated discussions about a broad range of relevant topics.

CONCLUSION

A group visit to facilitate discussions about advance care planning and increase patient engagement is feasible. This model warrants further evaluation for effectiveness in improving advance care planning outcomes for patients, clinicians, and the system.