Older Adults' Process of Collaborating With a Support Team During Transitions From Hospital to Home: A Grounded Theory Study

BACKGROUND AND OBJECTIVES

Little is known about how older adults engage with multiple sources of support and resources during transitions from hospital to home, a period of high vulnerability. This study aims to describe how older adults identify and collaborate with a support team, including unpaid/family caregivers, health care providers, and professional and social networks, during the transition.

RESEARCH DESIGN AND METHODS

This study utilized grounded theory methodology. One-on-one interviews were conducted with adults aged 60 and older following their discharge from a medical/surgical inpatient unit in a large midwestern teaching hospital. Data were analyzed using open, axial, and selective coding.

RESULTS

Participants (N = 25) ranged from 60 to 82 years of age, 11 were female, and all participants were White, non-Hispanic. They described a process of identifying a support team and collaborating with that team to manage at home and progress their health, mobility, and engagement. Support teams varied, but included collaborations between the older person, unpaid/family caregiver(s), and their health care providers. Their collaboration was impacted by the participant's professional and social networks.

DISCUSSION AND IMPLICATIONS

Older adults collaborate with multiple sources of support and this collaboration is a dynamic process that varies across phases of their transition from hospital to home. Findings reveal opportunities for assessing individual's support and social networks, in addition to health and functional status, to determine needs and leverage resources during transitions in care.

A scoping review of unpaid caregivers' experiences during older adults' hospital-to-home transitions

The objective of this scoping review is to examine current evidence regarding unpaid/family caregivers' experiences during older adults' hospital-to-home transitions to identify gaps and opportunities to involve caregivers in transitional care improvement efforts. Eligible articles focused on caregiver experience, outcomes, or interventions during older adults' hospital-to-home transitions. Our review identified several descriptive studies focused on exploring the caregiver experience of older adult hospital-to-home transitions and caregiver outcomes (such as preparedness, strain, burden, health, and well-being). Qualitative studies revealed challenges at multiple levels, including individual, interpersonal, and systemic. Few interventions have targeted or included caregivers to improve discharge education and address support needs during the transition. Future work should target underrepresented and marginalized groups of caregivers, and caregivers' collaboration with community-based services, social networks, or professional services. Work remains in developing and implementing interventions to support both older adult and caregiver needs.

Older adults' goals of care in the emergency department setting: A qualitative study guided by the 4Ms framework

Background

We sought to identify what matters to older adults (60 years and older) presenting to the emergency department (ED) and the challenges or concerns they identify related to medication, mobility, and mentation to inform how the 4Ms framework could improve care of older adults in the ED setting.

Methods

A qualitative study was conducted using the 4Ms to identify what matters to older adults (≥60 years old) presenting to the ED and what challenges or concerns they identify related to medication, mobility, and mentation. We conducted semi-structured interviews with a convenience sample of patients in a single ED. Interview guide responses and interviewer field notes were entered into REDCap. Interviews were reviewed by the research team (2 coders per interview) who inductively assigned codes. A codebook was created through an iterative process and was used to group codes into themes and sub-themes within the 4Ms framework.

Results

A total of 20 ED patients participated in the interviews lasting 30-60 minutes. Codes identified for "what matters" included problem-oriented expectation, coordination and continuity, staying engaged, being with family, and getting back home. Codes related to the other 4Ms (medication, mobility, and mentation) described challenges. Medication challenges included: non-adherence, side effects, polypharmacy, and knowledge. Mobility challenges included physical activity and independence. Last, mentation challenges included memory concerns, depressed mood, and stress and worry.

Conclusions

Our study used the 4Ms to identify "what matters" to older adults presenting to the ED and the challenges they face regarding medication, mobility, and mentation. Understanding what matters to patients and the specific challenges they face can help shape and individualize a patient-centered approach to care to facilitate the goals of care discussion and handoff to the next care team.

Rural age-friendly ecosystems for older adults: An international scoping review with recommendations to support age-friendly communities

Background and Aims

The population of older adults in rural areas is rising, and they experience higher rates of poverty and chronic illness, have poorer health behaviors, and experience different challenges than those in urban areas. This scoping review seeks to (1) map the state of the science of age-friendly systems in rural areas regarding structural characteristics, processes for delivering age-friendly practices, and outcomes of age-friendly systems, (2) analyze strengths, weakness, opportunities, and threats of age-friendly system implementation, and (3) make person, practice, and policy-level recommendations to support active aging and development of age-friendly communities.

Methods

An international scoping review was conducted of articles that used age-friendly framing, had a sample age of 45 years of age or older, self-identified as rural, and reported empiric data. Searches were conducted in PubMed, CINAHL, AgeLine, PsychINFO, EMBASE, Scopus, and Academic Search Elite on October 26, 2021, and rerun March 10, 2023. Data were charted across three analytic layers: socioecological model, Donabedian's framework, and SWOT analysis.

Results

Results reveal limited data on outcomes relevant to organizations, such as return on investment or healthcare utilization. While the SWOT analysis revealed many strengths of age-friendly systems, including their impact on persons' outcomes, it also revealed several weaknesses, threats, and gaps. Namely, age-friendly systems have weaknesses due to reliance on trained volunteers and staff, communication, and teamwork. System-level threats include community and health system barriers, and challenges in poor/developing areas.

Conclusions

While age-friendly systems in this review were heterogeneous, there is an opportunity to focus on unifying elements including the World Health Organization age-friendly cities framework or 4Ms framework for age-friendly care. Despite the many benefits of age-friendly systems, we must acknowledge limitations of the evidence base, pursue opportunities to examine organizational metrics to support implementation and sustainability of age-friendly systems, and leverage improvements in age-friendliness at a community level.

A qualitative study of unpaid caregivers of persons living with dementia and their interactions with health and community-based services and providers

BACKGROUND AND OBJECTIVES

Unpaid caregivers frequently feel underprepared and without adequate training, support, or access to services and resources to care for persons living with dementia. Health and community-based services and providers are critical to support persons living with dementia and their unpaid caregivers. The objective of this research is to understand how unpaid caregivers of persons living with dementia interact with health and community-based services and providers.

RESEARCH DESIGN AND METHODS

We used a qualitative descriptive approach to analyze data from one-on-one semi-structured interviews with unpaid caregivers of persons living with dementia (N = 25). We used framework analysis to organize themes and sub-themes within the systems approach to healthcare delivery.

FINDINGS

Participants described a need for additional guidance, information, and support from health and community-based services and providers. This need was described by participants at 4 levels: individual, care team, organization, and political and economic environment. Participants were active in proposing potential solutions to challenges at all 4 levels, including improving provider awareness and training in dementia, opportunities to provide resources and referrals upon dementia diagnosis, a central clearinghouse for information and resources for persons living with dementia and caregivers, and opportunities to close service gaps.

DISCUSSION AND IMPLICATIONS

Findings of this study highlight the need for increased involvement of caregivers of persons living with dementia as community stakeholders for improving care and services. Recommendations to promote high quality care and better support unpaid caregivers by developing interventions to address multiple aspects of healthcare delivery are consistent with recent legislation and are important areas of future research.

RURAL AGE-FRIENDLY ECOSYSTEMS: A SCOPING REVIEW WITH RECOMMENDATIONS FOR AGE-FRIENDLY COMMUNITIES

The population of older adults in rural areas is rising, and they experience higher rates of poverty and chronic illness, have poorer health behaviors, and experience different challenges than those in metropolitan areas. Promoting age-friendly rural communities and healthcare is key to improving outcomes and addressing disparities. This international scoping review seeks to 1) map the state of the science of age-friendly systems in rural areas regarding structural characteristics, processes for delivering age-friendly practices, and outcomes of age-friendly systems, 2) analyze strengths, weakness, opportunities, and threats of age-friendly system implementation, and 3) make person, practice, and policy-level recommendations to support active aging. Articles were retrieved from PubMed, CINAHL, AgeLine, PsychINFO, EMBASE, Scopus, and Academic Search Elite on 10/26/21 and included if they used age-friendly framing, self-identified as rural, and reported empiric data. Data were charted across three analytic layers: socioecological model, Donabedian’s framework, and SWOT analysis. While age-friendly systems in this review were heterogeneous, many utilized the World Health Organization age-friendly cities framework. Results reveal limited data on outcomes relevant to organizations. While the SWOT analysis revealed many strengths of age-friendly systems, it also revealed several weaknesses, threats, and gaps. Weaknesses included over-reliance on trained volunteers and staff, communication, and teamwork. Threats included community and health system barriers and challenges in developing regions. Despite the benefits of age-friendly systems, we must acknowledge limitations of the evidence base, pursue opportunities to examine organizational metrics to support implementation and sustainability of age-friendly systems, and leverage improvements in age-friendliness at a community level.

A Systematic Review of the Needs of Dementia Caregivers Across Care Settings

The U.S. population of older adults living with dementia is projected to double by 2060. They rely on over 16 million family and unpaid caregivers to provide for their increasingly complex needs and care transitions. Caregivers frequently feel underprepared and without adequate support or access to resources. This systematic review seeks to identify the needs of family and unpaid caregivers of older adults living with dementia across various care settings in the U.S. A systematic search was conducted to identify articles pertaining to the needs of caregivers of older adults living with dementia. The data extraction tool was developed using aspects from the Care Transitions Framework and the Family Caregiver Alliance. Data were organized based on 3 domains of caregiver needs and the care setting(s) of the older adults living with dementia and their caregivers. A total of 31 articles were eligible for inclusion. The majority met the MMAT screening criteria, but more than half only met 2 or less of the 5 quality criteria. Caregivers’ needs were identified in the care settings of home/community-residing, assisted living, long-term care, skilled nursing, and memory care. Most articles either did not specify a care setting or included more than 1 and did not report the findings separately. Caregivers in each care setting, except memory care, identified needs in all 3 of the following domains: (1) social support—formal and informal, (2) confidence, competence, and strengths in the caregiving role, and (3) values and preferences.

A scoping review of interventions for older adults transitioning from hospital to home

BACKGROUND/OBJECTIVES

Older adults are at high risk for adverse outcomes as they transition from hospital to home. Transitional care interventions primarily focus on care coordination and medication management and may miss key components. The objective of this study is to examine the current scope of hospital-to-home transitional care interventions that impact health-related outcomes and to examine other key components including engagement by older adults and their caregivers.

DESIGN

Scoping review.

METHODS

Eligible articles focused on hospital transition to home intervention, measured primary outcomes posthospitalization, used randomized controlled trial designs, and included primarily adults aged 60 years and older. Articles included in this review were reviewed in full and all data were extracted that related to study objective, setting, population, sample, intervention, primary and secondary outcomes, and main results.

RESULTS

Five hundred sixty-seven records were identified by title. Forty-four articles were deemed eligible and included. Most common transitional care intervention components were care continuity and coordination, medication management, symptom recognition, and self-management. Few studies reported a focus on caregiver needs or goals. Common modes of intervention delivery included by phone, in person while the patient was hospitalized, and in person in the community following hospital discharge. The most common outcomes were readmission and mortality.

CONCLUSION

To improve outcomes beyond healthcare utilization, a paradigm shift is required in the design and study of care transition interventions. Future interventions should explore methods or novel interventions for caregiver engagement; leverage an interdisciplinary team or care coordination hub with engagement from underrepresented specialties such as social work and occupational therapy; and examine opportunities for interventions designed specifically to address older adult and caregiver-reported needs and their well-being.

Nurses' experiences with an inpatient geriatric consulting service at a Midwestern Veterans' hospital: The elder veteran program

This qualitative project used conventional content analysis of interview data to examine nurses' experience with and perception of the Elder Veteran Program, an inpatient geriatric consulting service, at a midwestern Veterans' hospital. Nurses were recruited from nursing units utilizing the program and completed individual interviews (N = 10). Participants described the impact of the program within four categories: providing comprehensive care to patients, contributing to individual growth of nurses, promoting team-based care, and as a resource. Participants described several barriers and facilitators to implementation of the program on their unit, including workload and time, shifts and availability of program staff, perceived need, inclusion criteria, perception of program staff, education of nurses, communication, and the inpatient environment. This project provides opportunities for further examination of healthcare providers' experience with inpatient geriatric programs, how those experiences may relate to effectiveness of programs, and important areas of support for hospital staff.

Examination of Advanced Function and Its Correlates in a Cohort of Community-Dwelling Older Adults

Function in older adults includes multiple domains, from basic to “advanced,” but we remain limited in detection of advanced function (engagement in social, leisure, and productive activities). The objective is to describe advanced function and examine relationships with basic function and health outcomes in community-dwelling older adults aged 55-65 years. This is an analysis of existing data from a large, ongoing cohort study, The Wisconsin Registry for Alzheimer’s Prevention (WRAP R01 AG027161). We used a 1:1 prospective case–control design to examine whether older adults with lower advanced function (lower functioning group) at wave 3 showed lower IADLs and poorer health outcomes in wave 4, compared to those with higher advanced function (higher functioning group). The lower functioning group had a mean advanced function score of 74.4 (SD = 10.1), compared to 98.7 (SD = 11.1) in the higher functioning group. The mean IADL scores were similar in the two groups (p = 0.123). The lower functioning group had significantly lower self-rated health (mean = 3.52; SD = .79) than higher functioning group (3.70; 0.79) and a significantly lower proportion of individuals with unimpaired, stable cognition (77%) than the higher functioning group (85%). The lower functioning group had higher rates of comorbidities (4.25 vs. 3.96), mortality (4 vs. 1), and depressive symptoms (CES-D: 7.17 vs. 6.09), although results were not significant at α=0.05. This study provides a foundation for examining advanced function, which may be an early indicator of poor health outcomes in older adults.

"Hopes and wishes": Goals of high-need, high-cost older patients and their caregivers

OBJECTIVE

Integration of patient-identified goals is a critical element of shared decision-making and patient-provider communication. There is limited information on the goals of patients with multiple medical conditions and high healthcare utilization. We aimed to identify and categorize the goals described by "high-need, high-cost" (HNHC) older patients and their caregivers.

METHODS

Using conventional content analysis, we used data from interviews conducted with 17 HNHC older patients (mean age 72.5 years) and 4 caregivers.

RESULTS

HNHC older patients and their caregivers used language such as "hopes, wishes, and wants" to describe their goals, which fell into eight categories: alleviating discomfort, having autonomy and control, decreasing treatment burden, maintaining physical functioning and engagement, leaving a legacy, extending life, having satisfying and effective relationships, and experiencing security.

CONCLUSION

Our results contribute to knowledge of goals of HNHC patients and provides guidance for improving the patient-provider relationship and communication between HNHC older patients and their healthcare providers.

PRACTICE IMPLICATIONS

Our findings can inform provider efforts to assess patient goals and engage high-need, high-cost older patients in shared decision-making. Further, this study contributes to an improved understanding of HNHC older patients to support continued development of effective care models for this population.

Getting Back to Normal: A Grounded Theory Study of Function in Post-hospitalized Older Adults

BACKGROUND AND OBJECTIVES

The literature on transitions after hospitalization is based on a medicalized model focusing primarily on medication management and readmission, but little is known about the process older adults engage in to maintain their normal life posthealth event or how older adults define what the transition is. This grounded theory study aimed to describe how older adults understand and define a transition process, what actions they take based on their understanding, and what consequences they experience as they transition.

RESEARCH DESIGN AND METHODS

Adults aged 65 and older discharged from a large Midwestern teaching hospital (N = 14) were interviewed using in-depth one-on-one interviews. Data were analyzed using open, axial, and selective coding.

RESULTS

All participants described the process of transition as moving from a state of normal function to loss, and then working back to a normal state. A conceptual model was developed to illustrate the complexity of movement related to how older adults understand and manage the transition. All participants described starting out being normal until they experienced a major health event (acute or chronic illness). Losing normal involved experiencing a lower level of function both inside and outside the home. Working back to normal was accomplished by two different pathways: those "working to regain" focused on getting back to the level they were at prior to the major health event, whereas those "working to maintain" often involved redefining a new normal. The consequences of the two pathways were quite different, with those working to maintain describing several negative consequences.

DISCUSSION AND IMPLICATIONS

This study provides a detailed understanding of how older adults transition and the complexity of that transition. Findings provide a foundation for broadening our understanding of function beyond typical activities of daily living and reveal a more complex transition process that can span months to years.

WORKING BACK TO NORMAL FUNCTION FOLLOWING HOSPITALIZATION: A GROUNDED THEORY STUDY

Transitions older adults experience post hospital discharge have primarily focused on the process of moving care from one setting to another (e.g. hospital to home). Older adults often experience a significant transition in terms of losing functional status after a hospital stay. Little is known about how older adults regain their functional ability, the type of work they engage in to recover, and conditions that influence their ability to work after a hospital stay. The objective of this Grounded Theory study was to understand strategies older adults use post discharge as they work to regain their functional status and what conditions facilitate or limit their ability to work toward returning to normal. A qualitative study was conducted. Adults aged 65 and older discharged from a large Midwestern teaching hospital (N = 14) were interviewed using in-depth one-on-one interviews. Data were analyzed using open, axial, and selective coding. Participants described key strategies they employed to regain their normal function following hospitalization and illness: doing exercises, expanding physical space, resuming prior activities and daily cares, and tracking improvement with benchmarks. Several conditions such as, presence of informal (family, friends) and formal (healthcare providers) support, perceived threats (relocation), and having poor physical or physiologic function, acted as barriers and facilitators to participants ability to work back to normal function. This study provides empirical data on work older adults engage in to transition back to normal function during the post discharge period. It presents opportunities for better supporting their work of regaining function.

Strategies older adults use in their work to get back to normal following hospitalization

Loss of function is a significant concern among hospitalized older adults, and prior research suggests they engage in dedicated work to regain "normal" function following hospitalization. This paper aims to describe the strategies older adults use to return to normal function and the conditions that influence their ability to do so. Recently discharged adults aged 65 and older (N = 14) completed in-depth one-on-one interviews. Data were analyzed using open, axial, and selective coding. Participants described strategies they used to regain their normal function following hospitalization: doing exercises, expanding physical space, resuming activities and daily cares, and tracking improvement with benchmarks. Several conditions, such as presence of informal and formal support, perceived threats, and poor physical or physiologic function, acted as barriers and facilitators to participants' ability to work back to normal function. Findings increase our understanding of patients' work to regain normal function and have important implications for practice.

Impact of Fall Prevention on Nurses and Care of Fall Risk Patients

Purpose of the Study

Falls are common events for hospitalized older adults, resulting in negative outcomes both for patients and hospitals. The Center for Medicare and Medicaid (CMS) has placed pressure on hospital administrators by identifying falls as a "never event", resulting in a zero falls goal for many hospitals. Staff nurses are responsible for providing direct care to patients and for meeting the hospital no falls goal. Little is known about the impact of "zero falls" on nurses, patients and the organization.

Design and Methods

A qualitative study, using Grounded Dimensional Analysis (GDA) was conducted to explore nurses' experiences with fall prevention in hospital settings and the impact of those experiences on how nurses provide care to fall risk patients. Twenty-seven registered nurses and certified nursing assistants participated in in-depth interviews. Open, axial and selective coding was used to analyze data. A conceptual model which illustrates the impact of intense messaging from nursing administration to prevent patient falls on nurses, actions nurses take to address the message and the consequences to nurses, older adult patients and to the organization was developed.

Results

Intense messaging from hospital administration to achieve zero falls resulted in nurses developing a fear of falls, protecting self and unit, and restricting fall risk patients as a way to stop messages and meet the hospital goal.

Implications

Results of this study identify unintended consequences of fall prevention message on nurses and older adult patients. Further research is needed understand how nurse care for fall risk patients.

Important Care and Activity Preferences in a Nationally Representative Sample of Nursing Home Residents

OBJECTIVES

Person-centered care (PCC), which considers nursing home resident preferences in care delivery, has been linked to important outcomes such as improved quality of life, resident satisfaction with care, and mood and reduced behavioral symptoms for residents with dementia. Delivery of PCC fundamentally relies on knowledge of resident preferences. The Minimum Data Set (MDS) 3.0 Preference Assessment Tool (PAT) is a standardized, abbreviated assessment that facilitates systematic examination of preferences from a population of nursing home residents. However, it is unknown how well the PAT discriminates preferences across residents or items. The purpose of this study was to use MDS 3.0 PAT data to describe (1) overall resident preferences, (2) variation in preferences across items, and (3) variation in preferences across residents.

DATA

Data from admission MDS assessments between October 1, 2011 and December 31, 2011 were used for this study.

SAMPLE

A nationally representative sample of 244,718 residents over the age of 65 years who were able to complete the resident interview version of preference, cognition, and depression assessments were included.

MEASUREMENTS

Importance ratings of 16 daily care and activity preferences were the primary outcome measures. Resident factors including function (MDS Activities of Daily Living-Long Form), depression (Patient Health Questionnaire-9), cognitive impairment (Brief Interview for Mental Status), and sociodemographics (age, race, sex, and marital status) were used as predictors of important preferences.

ANALYSIS

Overall preferences were examined using descriptive statistics. Proportional differences tests were used to describe variation across items. Logistic regression was used to describe variation in preferences across residents.

RESULTS

The majority of residents rated all 16 preferences important. However, there was variation across items and residents. Involvement of family in care and individualizing daily care and activities were rated important by the largest proportion of residents. Several resident factors including cognitive impairment, depression, sex, and race were significant predictors of preferences.

CONCLUSIONS

Findings demonstrate the PAT captures variation in preferences across items and residents. Residents with possible depression and cognitive impairment were less likely to rate preferences important than residents without those conditions. Non-Caucasian and male residents reported some preferences differently than Caucasian and female residents. Additional assessment and care planning may be important for these residents. More research is needed to determine the factors that influence preferences and the ways to incorporate them into care.