Using Multiphase Optimization Strategy and Human-Centered Design to Create an Integrated Model of Palliative Care Skills in Home-Based Physical Therapy for Advanced Heart Failure

Background: Many older adults with advanced heart failure receive home health rehabilitation after hospitalization. Yet, integration of palliative care skills into rehabilitation is limited. Objective: Describe using the Multiphase Optimization Strategy (MOST) framework with human-centered design principles to engage clinical partners in the Preparation phase of palliative physical therapy intervention development. Design: We convened a home-based physical therapy advisory team (four clinicians, three clinical leaders) to identify physical therapist needs and preferences for incorporating palliative care skills in rehabilitation and design an intervention prototype. Results: Between 2022 and 2023, we held five advisory team meetings. Initial feedback on palliative care skill preferences and training needs directly informed refinement of our conceptual model and skills in the intervention prototype. Later feedback focused on reviewing and revising intervention content, delivery strategy, and training considerations. Conclusion: Incorporating human-centered design principles within the MOST provided a useful framework to partner with clinical colleagues in intervention design.

Embedding Interprofessional Education in Clinical Settings: Medical and Dental Student Perceptions of a Patient Interview-Storytelling Experience

PROBLEM

Interprofessional education (IPE) is valued but difficult to deliver, given logistical and other barriers. Centering IPE around patients and grounding it in authentic practice settings are challenging within early undergraduate medical education.

APPROACH

This intervention facilitated student-patient conversations to elicit patient reflections on the health care professionals who keep them healthy and care for them when they are unwell. After being introduced to the Interprofessional Education Collaborative (IPEC) core competencies, first-year medical (n = 127) and dental (n = 34) students conducted a brief semistructured patient interview, using an interview card with guiding questions, during a precepted outpatient clinic session in March-May 2021. Students transcribed patients' stories and wrote their own reflections on the interview card. These reflections were used as a stimulus for a class IPE discussion. The authors employed a pragmatic qualitative research approach to explore what students learned about interprofessional collaboration from reflecting on patients' stories.

OUTCOMES

Of the 161 students, 158 (98%) completed an interview card. Sixteen health professions were represented in patients' stories. The patients' stories prompted students to recognize and expand their understanding of the IPEC competencies. Students' responses reflected synthesis of the competencies into 3 themes: students value patient-centered holistic care as the goal of interprofessional collaboration; students reflect emerging professional and interprofessional identities in relating to patients, teams, and systems; and students appreciate interprofessional care is complex and challenging, requiring sustained effort and commitment.

NEXT STEPS

Next steps include continuing to integrate patient voices through structured conversations across the undergraduate and graduate medical education spectrum and adapting the model to support conversations with other health professionals engaged in shared patient care. These experiences could foster ongoing deliberate reflection by students on their professional and interprofessional identity development but would require investments in student time and faculty development.

Top Ten Tips Palliative Care Clinicians Should Know About Providing Care for People With Disabilities

Palliative care (PC) clinicians are well poised to help people with disabilities (PWD) live well in the context of serious illness. PC prioritizes person-centered care with a focus on function, autonomy, and quality of life. This approach aligns with principles of high-quality care for PWD. An understanding of the unique experiences and needs of PWD can advance the delivery of comprehensive, equitable PC for this population. In this article, we provide 10 tips to help PC clinicians develop an informed disability lens in their approach to care.

Breaking the Cycle: Using Serious Illness Communication to Optimize Care Transition Planning in Serious Illness

It is widely recognized that many older adults in their last year of life will cycle between hospitals and skilled nursing facilities-a phenomenon described as "rehabbing to death." Several strategies to address this complex problem have been proposed, including developing and testing serious illness communication models to provide goal-concordant care by aligning what matters most to patients with how they spend their time in the last months of life. Serious illness communication (SIC) includes structured skills clinicians can use with patients and caregivers to assess illness understanding, goals and values, share information, and make recommendations. Despite the potential of SIC models, there is a lack of literature focused on developing and testing SIC strategies in the context of care transition planning for older adults with serious illness. Our interprofessional team developed "Rehabbing to Death: Practical Strategies to Optimize Care Transitions for Patients with Serious Illness," an evidence-based, interprofessional SIC training curriculum for hospital-based rehabilitation clinicians. This 3-session curriculum was designed to enable rehabilitation clinicians to acquire knowledge of trajectories and outcomes for patients living with serious illness and communication skills to use with patients, families, and interprofessional colleagues. Nine rehabilitation clinicians (n = 3 equally from Physical Therapy, Occupational Therapy, and Speech-Language Pathology) participated in our pilot. Sessions were highly attended [100% (n = 9) sessions 1 and 2, 89% (n = 8) session 3]. Participants who completed the curriculum reported increased self-rated confidence in knowledge of serious illness and ability to communicate prognostic information and recommendations for care transitions with patients, families, and colleagues. In addition, 78% of participants would recommend the curriculum to a colleague and strongly agreed that curricular content and skills were relevant to their clinical practice. Pilot results suggest that implementing an SIC curriculum for hospital-based rehabilitation clinicians is feasible, given high rates of completion and satisfaction.

Top Ten Tips Palliative Care Clinicians Should Know About Physical Therapy, Occupational Therapy, and Speech Language Pathology

This article provides guidance on the integral role of physical therapy, occupational therapy (OT), and speech language pathology (SLP) in palliative care (PC), underlining the necessity for effective communication between physicians and therapists, the importance of caregiver education and support, the application of holistic treatment modalities in OT, the underutilization of resources in PC settings, the role of SLP professionals in feeding and nutrition, and the challenges in communication during the advanced stages of illness. The article draws on various studies and expert opinions to elucidate these issues, offering a valuable resource to health care professionals in ensuring high-quality patient-centered PC.

Spilling over at the boiling point: A commentary on the need for dyadic approaches to psychosocial care with older adults and their care-partners in postacute rehabilitation

PURPOSE/OBJECTIVE

Older adults typically receive rehabilitation services following an acute medical event within the context of declining health. Post-acute rehabilitation often serves as a "boiling point" for health needs and is met with numerous shared emotional stressors related to recovery, long-term care, and end-of-life considerations among older patients and their care-partners-referred to together as a dyad. Psychosocial intervention that targets patients and care-partners separately misses the opportunity to support dyads who typically navigate health-related emotional challenges together. In the context of chronic and serious illness, dyadic interventions (i.e., patient and informal care-partner, together) can successfully reduce emotional distress as well as improve communication and collaborative illness management. However, this approach has yet to be applied to older post-acute rehabilitation patients and their care-partners.

RESEARCH METHOD/DESIGN

In this commentary, we outline the need for dyadic psychosocial intervention approaches with older adults and their family care-partners in the context of post-acute rehabilitation.

RESULTS

First, we provide evidence for the potential benefits of a dyadic approach to psychosocial care. Next, we review theoretical models as well as clinically relevant confounding factors that can inform dyadic psychosocial case conceptualization and intervention. Finally, we offer a real-world clinical case example that demonstrates the opportunity for dyadic intervention to address common psychosocial challenges seen by psychologists in post-acute rehabilitation settings.

CONCLUSIONS/IMPLICATIONS

Our goal is to encourage rehabilitation psychologists to view dyadic intervention as a first-line approach to psychosocial care with the growing population of older adults and their family care-partners in post-acute rehabilitation settings. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Functional status and therapy for older adults with diffuse large B-cell lymphoma in nursing homes: A population-based study

OBJECTIVES

To characterize the prevalence of functional and cognitive impairments, and associations between impairments and treatment among older patients with diffuse large B cell lymphoma (DLBCL) receiving nursing home (NH) care.

METHODS

We used the Surveillance, Epidemiology, and End Results-Medicare database to identify beneficiaries diagnosed with DLBCL 2011-2015 who received care in a NH within -120 ~ +30 days of diagnosis. Multivariable logistic regression was used to compare receipt of chemoimmunotherapy (including multi-agent, anthracycline-containing regimens), 30-day mortality, and hospitalization between NH and community-dwelling patients, estimating odds ratios (OR) and 95% confidence interval (CI). We also examined overall survival (OS). Among NH patients, we examined receipt of chemoimmunotherapy based on functional and cognitive impairment.

RESULTS

Of the eligible 649 NH patients (median age: 82 years), 45% received chemoimmunotherapy; among the recipients, 47% received multi-agent, anthracycline-containing regimens. Compared with community-dwelling patients, those in a NH were less likely to receive chemoimmunotherapy (OR: 0.34, 95%CI: 0.29-0.41), had higher 30-day mortality (OR: 2.00, 95%CI: 1.43-2.78) and hospitalization (OR: 1.51, 95%CI: 1.18-1.93), and poorer OS (hazard ratio: 1.36, 95%CI: 1.11-1.65). NH patients with severe functional (61%) or any cognitive impairment (48%) were less likely to receive chemoimmunotherapy.

CONCLUSIONS

High rates of functional and cognitive impairment and low rates of chemoimmunotherapy were observed among NH residents diagnosed with DLBCL. Further research is needed to better understand the potential role of novel and alternative treatment strategies and patient preferences for treatment to optimize clinical care and outcomes in this high-risk population.

The Healthcare Experience of Autistic Patients in Orthopaedic Surgery and Closely Related Fields: A Scoping Review

Orthopaedic and related care has the potential to present unique obstacles for patients with a range of autism manifestations. In this review, we aim to describe and analyze the literature on autistic patients' experience within orthopaedics and closely related fields. This literature search utilized the PubMed, Embase, and Cumulative Index to Nursing and Allied Health Literature databases. Three major concepts were built into the search terms: (1) patients on the autism spectrum; (2) patient experience; and (3) movement sciences, including orthopaedics, physical medicine and rehabilitation (PM&R), occupational therapy (OT), and physical therapy (PT). Our search yielded 35 topical publications, with the major topic areas addressed as follows: (1) clinical and perioperative management, (2) therapy interventions, (3) participation in exercise and social play, (4) sensory management and accommodations, (5) caregiver/parent training and involvement in care, (6) healthcare needs and barriers to care, and (7) utilization of technology. In the current literature, there are no studies that attempt to directly assess autistic patient experience with care practices and clinical environments in orthopaedics. Rigorous, direct examination of the experience of autistic patients within clinical orthopaedic settings is urgently needed to address this gap.

Trends in post-acute care and outcomes for Medicare beneficiaries hospitalized for heart failure between 2008 and 2015

BACKGROUND

Heart failure (HF) is the leading cause of hospitalization among older adults in the United States and results in high rates of post-acute care (PAC) utilization. Federal policies have focused on shifting PAC to less intensive settings and reducing length of stay to lower spending. This study evaluates the impact of policy changes on PAC use among Medicare beneficiaries hospitalized with HF between 2008 and 2015 by (1) characterizing trends in PAC use and cost and (2) evaluating changes in readmission, mortality, and days in the community, overall and by frailty.

METHODS

Annual cross-section prospective cohorts of all HF admissions between 1/1/2008 and 9/30/2015 among a 20% random sample of all Medicare Fee-for-Service beneficiaries (n = 718,737). The Claims-based Frailty Index (CFI) was used to classify frailty status. Multivariable regression models were used to evaluate trends in first discharge location, readmissions, mortality, days alive in the community, and costs; overall and by frailty status.

RESULTS

Frailty was prevalent among HF patients: 54.1% were prefrail, 37.0% mildly frail, and 6.9% moderate to severely frail. Between 2008 and 2015, almost 4% more HF beneficiaries received PAC, with most of the increase concentrated in skilled nursing facilities (SNF) (+2.3%) and home health agencies (HHA) (+1.1%), and PAC cost increased by $123 (3.5%). Over the 180-days follow-up after hospitalization, hospital readmissions decreased significantly (-3.4% at 30-day; -6.3% at 180-day), days alive in the community increased (+1.5), and 180-day Medicare costs declined $2948 (-18.7%) without negative impact in mortality (except a minor increase in the pre-frail group). Gains were greatest among the frailest patients.

CONCLUSIONS

Medicare beneficiaries hospitalized with HF spent more time in the community and experienced lower rehospitalization rates at lower cost without significant increases in mortality. However, important opportunities remain to optimize care for frail older adults hospitalized with HF.

Using a Claims-Based Frailty Index to Investigate Frailty, Survival, and Healthcare Expenditures among Older Adults Hospitalized for COVID-19 at an Academic Medical Center

BACKGROUND

Frailty is associated with mortality in older adults hospitalized with COVID-19, yet few studies have quantified healthcare utilization and spending following COVID-19 hospitalization.

OBJECTIVE

To evaluate whether survival and follow-up healthcare utilization and expenditures varied as a function of claims-based frailty status for older adults hospitalized with COVID-19.

DESIGN

Retrospective cohort study.

PARTICIPANTS

136 patients aged 65 and older enrolled in an Accountable Care Organization (ACO) risk contract at an academic medical center and hospitalized for COVID-19 between March 11, 2020 - June 3, 2020.

MEASUREMENTS

We linked a COVID-19 Registry with administrative claims data to quantify a frailty index and its relationship to mortality, healthcare utilization, and expenditures over 6 months following hospital discharge. Kaplan Meier curves and Cox Proportional Hazards models were used to evaluate survival by frailty. Kruskal-Wallis tests were used to compare utilization. A generalized linear model with a gamma distribution was used to evaluate differences in monthly Medicare expenditures.

RESULTS

Much of the cohort was classified as moderate to severely frail (65.4%), 24.3% mildly frail, and 10.3% robust or pre-frail. Overall, 27.2% (n=37) of the cohort died (n=26 during hospitalization, n=11 after discharge) and survival did not significantly differ by frailty. Among survivors, inpatient hospitalizations during the 6-month follow-up period varied significantly by frailty (p=0.02). Mean cost over follow-up was $856.37 for the mild and $4914.16 for the moderate to severe frailty group, and monthly expenditures increased with higher frailty classification (p <.001).

CONCLUSIONS

In this cohort, claims-based frailty was not significantly associated with survival but was associated with follow-up hospitalizations and Medicare expenditures.

Association of Function, Symptoms, and Social Support Reported in Standardized Outpatient Clinic Questionnaires With Subsequent Hospital Discharge Disposition and 30-Day Readmissions

OBJECTIVE

To determine whether patient-reported information, routinely collected in an outpatient setting, is associated with readmission within 30 days of discharge and/or the need for post-acute care after a subsequent hospital admission.

DESIGN

Retrospective cohort study. Six domains of patient-reported information collected in the outpatient setting (psychological distress, respiratory symptoms, musculoskeletal pain, family support, mobility, and activities of daily living [ADLs]) were linked to electronic health record hospitalization data. Mixed effects logistic regression models with random intercepts were used to identify the association between the 6 domains and outcomes.

SETTING

Outpatient clinics and hospitals in a Midwestern health system.

PARTICIPANTS

7671 patients who were hospitalized 11,445 times between May 2004 and May 2014 (N=7671).

INTERVENTION

None.

MAIN OUTCOME MEASURES

30-day hospital readmission and discharge home vs facility.

RESULTS

Domains were significantly associated with 30-day readmission and placement in a facility. Specifically, mobility (odds ratio [OR]=1.30; 95% confidence interval [CI], 1.16, 1.46), ADLs (OR=1.27; 95% CI, 1.13, 1.42), respiratory symptoms (OR=1.26; 95% CI, 1.12, 1.41), and psychological distress (OR=1.20; 95% CI, 1.07, 1.35) had the strongest associations with 30-day readmission. The ADL (OR=2.52; 95% CI, 2.26, 2.81), mobility (OR=2.35; 95% CI, 2.10, 2.63), family support (OR=2.28; 95% CI, 1.98, 2.62), and psychological distress (OR=1.38; 95% CI, 1.25, 1.52) domains had the strongest associations with discharge to an institution.

CONCLUSIONS

Patient-reported function, symptoms, and social support routinely collected in outpatient clinics are associated with future 30-day readmission and discharge to an institutional setting. Whether these data can be leveraged to guide interventions to address patient needs and improve outcomes requires further research.

Advancing Communication and Decision-making for Older Adults Discharged to Skilled Nursing Facilities-Not Where but Why?

This Viewpoint addresses the active role that clinicians can take in communicating with older patients in postacute care as they reflect and make decisions regarding their future.

Association of Physical Therapy Treatment Frequency in the Acute Care Hospital With Improving Functional Status and Discharging Home

BACKGROUND

Physical therapists (PTs) are consulted to address functional deficits during hospitalization, but the effect of PT visit frequency on patients' outcomes is not clear.

OBJECTIVE

The objective of this study was to examine whether PT visit frequency is independently associated with functional improvement, discharge home, and both outcomes combined.

RESEARCH DESIGN

This was a retrospective cohort study.

SUBJECTS

Patients discharged from hospitals in 1 health system between 2017 and 2020, stratified by diagnostic subgroup: cardiothoracic and vascular, general medical/surgical, neurological, oncology, and orthopedic.

MEASURES

PT visit frequency was categorized as ≤2, >2-4, >4-7, >7 visits/week. Functional improvement was defined as ≥5-point improvement in Activity Measure for Post-Acute Care mobility score. Other outcomes were discharge home and both outcomes combined.

RESULTS

There were 243,779 patients included. Proportions within frequency categories ranged from 11.0% (>7 visits/wk) to 40.5% (≤2 visits/wk) and varied by subgroup. In the full sample, 36% of patients improved function, 64% were discharged home, and 27% achieved both outcomes. In adjusted analyses, relative to ≤2 visits/week, the adjusted relative risk (aRR) for functional improvement increased incrementally with higher frequency (aRR=1.20, 95% confidence interval: 1.14-1.26 for >2-4 visits to aRR=1.78, 95% confidence interval: 1.55-2.03 for >7 visits). For all patients and within subgroups, the higher frequency was also associated with a greater likelihood of discharging home and achieving both outcomes.

CONCLUSIONS

More frequent PT visits during hospitalization may facilitate functional improvement and discharge home. Most patients, however, receive infrequent visits. Further research is needed to determine the optimal delivery of PT services to meet individual patient needs.

Functional Status and Survival in Older Nursing Home Residents With Advanced Non-Small-Cell Lung Cancer: A SEER-Medicare Analysis

PURPOSE

Many older patients with advanced lung cancer have functional limitations and require skilled nursing home care. Function, assessed using activities of daily living (ADL) scores, may help prognostication. We investigated the relationship between ADL impairment and overall survival among older patients with advanced non-small-cell lung cancer (NSCLC) receiving care in nursing homes.

METHODS

Using the SEER-Medicare database linked with Minimum Data Set assessments, we identified patients age 65 years and older with NSCLC who received care in nursing homes from 2011 to 2015. We used Cox regression and Kaplan-Meier survival curves to examine the relationship between ADL scores and overall survival among all patients; among patients who received systemic cancer chemotherapy or immunotherapy within 3 months of NSCLC diagnosis; and among patients who did not receive any treatment.

RESULTS

We included 3,174 patients (mean [standard deviation] age, 77 [7.4] years [range, 65-102 years]; 1,664 [52.4%] of female sex; 394 [12.4%] of non-Hispanic Black race/ethnicity), 415 (13.1%) of whom received systemic therapy, most commonly with carboplatin-based regimens (n = 357 [86%] patients). The median overall survival was 3.1 months for patients with ADL score < 14, 2.8 months for patients with ADL score between 14 and 17, 2.3 months for patients with ADL score between 18-19, and 1.8 months for patients with ADL score 20+ (log-rank P < .001). The ADL score was associated with increased risk of death (hazard ratio [HR], 1.20; 95% CI, 1.16 to 1.25 per standard deviation). One standard deviation increase in the ADL score was associated with lower overall survival rate among treated (HR, 1.14; 95% CI, 1.02 to 1.27) and untreated (HR, 1.20; 95% CI, 1.15 to 1.26) patients.

CONCLUSION

ADL assessment stratified mortality outcomes among older nursing home adults with NSCLC, and may be a useful clinical consideration in this population.

Global Risk Indicator and Therapy for Older Patients With Diffuse Large B-Cell Lymphoma: A Population-Based Study

PURPOSE

To examine the impact of global risk, a measure comprising age, comorbidities, function, and cognitive statuses, on treatment selection and outcomes among older home care recipients with diffuse large B-cell lymphoma.

METHODS

From SEER-Medicare, we selected home care recipients diagnosed with diffuse large B-cell lymphoma in 2011-2015, who had pretreatment Outcome and Assessment Information Set (OASIS) evaluations. We created a global risk indicator categorizing patients as low-, moderate-, or high-risk on the basis of OASIS assessments. We examined the association of global risk with receipt of therapy and among chemotherapy recipients, with mortality, emergency department visits, hospitalization, and intensive care unit admission within 30 days from first treatment in logistic models, reporting adjusted odds ratios (OR) with 95% CI. We compared overall survival across risk groups estimating adjusted hazard ratios.

RESULTS

Of the 1,232 patients (median age, 80 years), 65% received chemotherapy. High-risk patients (v moderate-risk) were less likely to receive any chemotherapy (OR, 0.50; 95% CI, 0.39 to 0.64) and curative regimens (OR, 0.59; 95% CI, 0.40 to 0.86) if treated, although even in the moderate-risk group, only 61% received curative regimens. High-risk patients were more likely to experience acute mortality (OR, 2.24; 95% CI, 1.43 to 3.52), emergency department visits (OR, 1.35; 95% CI, 1.00 to 1.83), hospitalization (OR, 1.60; 95% CI, 1.19 to 2.17), or intensive care unit admission (OR, 1.52; 95% CI, 1.04 to 2.22) and had inferior overall survival (hazard ratio, 1.41; 95% CI, 1.11 to 1.78).

CONCLUSION

Global risk on the basis of OASIS is easily available, suggesting a potential way to improve patient selection for curative treatment and institution of preventive measures.

Spinal Cord Injury-Functional Index/Capacity: Responsiveness to Change Over Time

OBJECTIVE

To establish responsiveness of 3 Spinal Cord Injury-Functional Index/Capacity (SCI-FI/C) item banks in the first year after spinal cord injury (SCI).

DESIGN

Longitudinal patient-reported outcomes assessment replicated through secondary analysis of an independent data set.

SETTING

A total of 8 SCI Model Systems rehabilitation hospitals in the United States.

PARTICIPANTS

Study 1 participants included 184 adults with recent (≤4 months) traumatic SCI and 221 community-dwelling adults (>1 year post injury) (N=405). Study 2 participants were 418 individuals with recent SCI (≤4 months) (N=418).

INTERVENTIONS

In study 1, SCI-FI/C computer adaptive tests were presented in a standardized interview format either in person or by phone call at baseline and 6-month follow-up. Responsiveness was examined by comparing 6-month changes in SCI-FI scores within and across samples (recently injured vs community-dwelling) because only the recent injury sample was expected to exhibit change over time. Effect sizes were also computed. In study 2, the study 1 results were cross-validated in a second sample with recent SCI 1 year after baseline measurement. Study 2 also compared the SCI-FI/C measures' responsiveness to that of the Self-reported Functional Measure (SRFM) and stratified results by injury diagnosis and completeness.

MAIN OUTCOME MEASURES

The SCI-FI Basic Mobility/C, Self-care/C and Fine Motor/C item banks (study 1 and study 2); Self-reported Functional Measure SRFM (study 2 only).

RESULTS

In study 1, changes in SCI-FI/C scores between baseline and 6-month follow-up were statistically significant (P<.01) for recently injured individuals. SCI-FI Basic Mobility/C, Self-care/C, and Fine Motor/C item banks demonstrated small to medium effect sizes in the recently injured sample. In the community-dwelling sample, all SCI-FI/C effects were negligible (ie, effect size<0.08). Study 2 results were similar to study 1. As expected, SCI-FI Basic Mobility/C and Self-care/C were responsive to change for all individuals in study 2, whereas the SCI-FI Fine Motor/C was responsive only for individuals with tetraplegia and incomplete paraplegia. The SRFM demonstrated a medium effect size for responsiveness (effect size=0.65).

CONCLUSIONS

The SCI-FI Basic Mobility/C and Self-care/C banks demonstrate adequate sensitivity to change at 6 months and 1 year for all individuals with SCI, while the SCI-FI/C Fine Motor item bank is sensitive to change in individuals with tetraplegia or incomplete paraplegia. All SCI-FI/C banks demonstrate stability in a sample not expected to change. Results provide support for the use of these measures for research or clinical use.

Healthcare utilization and costs among high-need and frail Mexican American Medicare beneficiaries

Objectives

To examine Medicare health care spending and health services utilization among high-need population segments in older Mexican Americans, and to examine the association of frailty on health care spending and utilization.

Methods

Retrospective cohort study of the innovative linkage of Medicare data with the Hispanic Established Populations for the Epidemiologic Study of the Elderly (H-EPESE) were used. There were 863 participants, which contributed 1,629 person years of information. Frailty, cognition, and social risk factors were identified from the H-EPESE, and chronic conditions were identified from the Medicare file. The Cost and Use file was used to calculate four categories of Medicare spending on: hospital services, physician services, post-acute care services, and other services. Generalized estimating equations (GEE) with a log link gamma distribution and first order autoregressive, correlation matrix was used to estimate cost ratios (CR) of population segments, and GEE with a logit link binomial distribution was applied to estimate odds ratios (OR) of healthcare use.

Results

Participants in the major complex chronic illness segment who were also pre-frail or frail had higher total costs and utilization compared to the healthy segment. The CR for total Medicare spending was 3.05 (95% CI, 2.48–3.75). Similarly, this group had higher odds of being classified in the high-cost category 5.86 (95% CI, 3.35–10.25), nursing home care utilization 11.32 (95% CI, 3.88–33.02), hospitalizations 4.12 (95% CI, 2.88–5.90) and emergency room admissions 4.24 (95% CI, 3.04–5.91).

Discussion

Our findings highlight that frailty assessment is an important consideration when identifying high-need and high-cost patients.

Leveraging Podcasts to Introduce Medical Students to the Broader Community of Health Care Professionals

INTRODUCTION

Safe, patient-centered, and cost-effective care requires effective collaboration within interprofessional teams. Education programs for health care professionals are often siloed, providing students with limited interprofessional education (IPE) opportunities to learn from, with, and about other professions. Podcasts offer a novel approach to facilitate IPE, allowing for asynchronous conversations with interprofessional colleagues.

METHODS

We developed four podcasts with various health care professionals for 135 preclinical medical students preparing to transition into clinical rotations. The podcasts were coupled with an hour-long interactive session with the podcast interviewees conducted via videoconference. The curriculum explored the distinct education paths, roles, and responsibilities of various health care disciplines. Strategies for communicating effectively with and learning from interprofessional team members were emphasized.

RESULTS

There were 197 unique downloads of the podcasts, and 95 students attended the interactive session. Most students reported that the podcasts and follow-up live session enhanced their learning (100% and 98% of students who completed the postcurriculum survey, respectively). Responses to the postcurriculum survey revealed students learned strategies for engaging in productive interprofessional conversations, the importance of leveraging the distinct roles and responsibilities of diverse health professionals, the value of learning from other health professionals, and the use of respectful language.

DISCUSSION

This IPE curriculum built around podcasts enhances medical student learning and represents an innovative approach to improving access to IPE in a virtual learning environment. This modality can be adapted to meet the needs of a wide spectrum of learners and can be coupled with in-person learning.

Leveraging survey and claims data to identify high-need Medicare beneficiaries in the National Health and Aging Trends Study

BACKGROUND

Multiple algorithms have been developed to identify and characterize the high-need (HN) Medicare population. However, they vary in components and yield different populations, and were developed for varying purposes. We compared the performance of existing survey and claims-based definitions in identifying HN beneficiaries and predicting poor outcomes among a community-dwelling population.

METHODS

A retrospective cohort study using Round 5 (2015) of the National Health and Aging Trends Study (NHATS) linked with Medicare claims. We applied HN definitions from previous studies to our cohort of community-dwelling, fee-for-service beneficiaries (n = 4201) using sampling weights to obtain nationally representative estimates. The Bélanger et al. (2019) definition defines HN as individuals with complex conditions, multi-morbidity, acute and post-acute healthcare utilization, dependency in activities of daily living, and frailty. The Hayes et al. (2016) definition defines HN as individuals with 3+ chronic conditions and a functional limitation. We applied each definition to survey and claims data. Outcomes were hospitalization or mortality in the subsequent year.

RESULTS

The proportion of NHATS respondents classified as HN varied greatly across definitions, ranging from 3.1% using the claims-based Hayes definition to 32.9% using the survey-based Bélanger definition. HN respondents had significantly higher mortality and hospitalization rates in 2016. Although all definitions had good specificity, none were able to predict outcomes in the following year with good accuracy.

CONCLUSIONS

While mortality and hospitalization rates were significantly higher among respondents classified as HN, existing claims and survey-based HN definitions were not able to accurately predict future outcomes in a community-dwelling, nationally representative sample measured by the area under the curve.

Ability of the Functional Assessment in Acute Care Multidimensional Computerized Adaptive Test (FAMCAT) to Predict Discharge to Institutional Post-Acute Care

OBJECTIVE

To characterize the ability of the patient-reported Functional Assessment in Acute Care Multidimensional Computerized Adaptive Test (FAMCAT) domains to predict discharge disposition when administered during acute care stays.

DESIGN

Cohort Study. Logistic regression models were estimated to identify the ability of FAMCAT domains to predict discharge to an institution for post-acute care (PAC).

SETTING

Academic Medical Center PARTICIPANTS: Patients admitted to General Medicine Services from June 2016 to June 2019, n = 4,240 INTERVENTIONS: Not applicable.

MAIN OUTCOME MEASURE(S)

discharge to an institution RESULTS: In this sample, 10.5% of patients were discharged to an institution for rehabilitation versus home. FAMCAT domain scores were highly predictive of discharge to institutional PAC. Daily Activity and Basic Mobility domains had excellent discriminative ability for discharge to an institution (c-statistic 0.83 and 0.87, respectively). In best fit models accounting for additional characteristics, discrimination was outstanding for Daily Activity (c-statistic 0.91, 95% CI: 0.89, 0.94) and Basic Mobility (c-statistic 0.92, 95% CI: 0.89, 0.94).

CONCLUSION(S)

The FAMCAT Daily Activity and Mobility domains demonstrated excellent discrimination for identifying patients who discharged to an institutional setting for rehabilitation, and outstanding discrimination when adjusted for salient patient factors associated with discharge disposition. Estimates obtained in this investigation are comparable to the best discrimination achieved with clinician-rated measures to identify patients who would require institutional PAC.

Improving the Delivery of Function-Directed Care During Acute Hospitalizations: Methods to Develop and Validate the Functional Assessment in Acute Care Multidimensional Computerized Adaptive Test (FAMCAT)

OBJECTIVE

To (1) develop a patient-reported, multidomain functional assessment tool focused on medically ill patients in acute care settings; (2) characterize the measure's psychometric performance; and (3) establish clinically actionable score strata that link to easily implemented mobility preservation plans.

DESIGN

This article describes the approach that our team pursued to develop and characterize this tool, the Functional Assessment in Acute Care Multidimensional Computer Adaptive Test (FAMCAT). Development involved a multistep process that included (1) expanding and refining existing item banks to optimize their salience for hospitalized patients; (2) administering candidate items to a calibration cohort; (3) estimating multidimensional item response theory models; (4) calibrating the item banks; (5) evaluating potential multidimensional computerized adaptive testing (MCAT) enhancements; (6) parameterizing the MCAT; (7) administering it to patients in a validation cohort; and (8) estimating its predictive and psychometric characteristics.

SETTING

A large (2000-bed) Midwestern Medical Center.

PARTICIPANTS

The overall sample included 4495 adults (2341 in a calibration cohort, 2154 in a validation cohort) who were admitted either to medical services with at least 1 chronic condition or to surgical/medical services if they required readmission after a hospitalization for surgery (N=4495).

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Not applicable.

RESULTS

The FAMCAT is an instrument designed to permit the efficient, precise, low-burden, multidomain functional assessment of hospitalized patients. We tried to optimize the FAMCAT's efficiency and precision, as well as its ability to perform multiple assessments during a hospital stay, by applying cutting edge methods such as the adaptive measure of change (AMC), differential item functioning computerized adaptive testing, and integration of collateral test-taking information, particularly item response times. Evaluation of these candidate methods suggested that all may enhance MCAT performance, but none were integrated into initial MCAT parameterization.

CONCLUSIONS

The FAMCAT has the potential to address a longstanding need for structured, frequent, and accurate functional assessment among patients hospitalized with medical diagnoses and complications of surgery.

Prevalence of functional limitations and their associations with systemic cancer therapy among older adults in nursing homes with advanced non-small cell lung cancer

OBJECTIVES

To determine the relationship of self-care task disabilities with the use of systemic cancer therapies for advanced non-small cell lung cancer (NSCLC) in nursing home patients.

MATERIALS AND METHODS

Using the Surveillance, Epidemiology, and End Results-Medicare database linked with Minimum Data Set assessments, we identified nursing home residents with advanced NSCLC from 2011 to 2015. We considered disability in activities of daily living (ADL) including dressing, personal hygiene, toilet use, locomotion on unit, transfer, bed mobility, and eating. We estimated the association between ADL disabilities and receipt of systemic cancer therapies within 3 months of diagnosis.

RESULTS

Of the 3174 patients, 2702 (85.2%) experienced disability in one or more ADLs and 64.7% had disability in 5-7 ADLs. A total of 415 (13.1%) patients received systemic therapy. There was a strong association between disability in each ADL and receipt of therapy including dressing (OR, 0.52 [95% CI, 0.42-0.65]), toileting (odds ratio, OR, 0.52 [95% confidence interval, CI, 0.42-0.65]), personal hygiene (OR, 0.48 [95% CI, 0.39-0.59]), transfers (OR, 0.51 [95% CI, 0.41-0.64]), bed mobility (OR, 0.55 [95% CI, 0.44-0.69]), locomotion (OR, 0.57 [95% CI, 0.46-0.71]), or eating (OR, 0.45 [95% CI, 0.31-0.67]). Compared to patients having no ADL disability, patients were less likely to receive chemotherapy if they had disability in 1-2 ADLs (OR, 0.95 [95% CI, 0.66-1.37]), 3-4 ADLs (OR, 0.81 [95% CI, 0.56-1.15]), or 5-7 ADLs (OR, 0.43 [95% CI, 0.33-0.56]).

CONCLUSIONS

Systemic cancer therapy is not commonly used in this population and is strongly predicted by disability in self-care tasks.

Frailty and Function in Heart Failure: Predictors of 30-Day Hospital Readmission?

BACKGROUND AND PURPOSE

Although there have been decreases noted in 30-day readmission rates for persons with heart failure since enactment of the Hospital Readmissions Reduction Program, costs related to heart failure readmissions remain high. Consequently, there is a need to better identify persons with heart failure who are at risk for 30-day hospital readmission. Therefore, this study aimed to compare the ability of measures of function and frailty to predict 30-day hospital readmissions for adults 65 years and older with heart failure.

METHODS

Secondary data analysis using the 2011 National Health and Aging Trends Study analysis merged with Medicare claims data. Logistic regression modeling was used to compare the ability of function (Short Physical Performance Battery) and frailty (Fried's Physical Frailty Phenotype) to predict 30-day readmission. Receiver operating characteristic curves were constructed to examine the ability of function and frailty to identify those who were readmitted.

RESULTS AND DISCUSSION

Frailty and function demonstrated comparable ability to predict 30-day readmissions (R2 = 0.087 and R2 = 0.087, respectively). Neither measure identified persons at risk for readmission (AUCSPPB = 0.608; AUCPFP = 0.587).

CONCLUSIONS

Functional assessment demonstrated comparable ability to predict 30-day readmissions in persons with heart failure compared with frailty. However, neither measure was able to identify persons at high risk for readmission. Although frailty status is emphasized in research for older adults with heart failure, functional status is an important patient-level factor associated with readmission.

Making the Case for Patient-Reported Outcome Measures in Big-Data Rehabilitation Research: Implications for Optimizing Patient-Centered Care

Advances in data science and timely access to health informatics provide a pathway to integrate patient-reported outcome measures (PROMs) into clinical workflows and optimize rehabilitation service delivery. With the shift toward value-based care in the United States health care system, as highlighted by the recent Centers for Medicare and Medicaid Services incentive and penalty programs, it is critical for rehabilitation providers to systematically collect and effectively use PROMs to facilitate evaluation of quality and outcomes within and across health systems. This editorial discusses the potential of PROMs to transform clinical practice, provides examples of health systems using PROMs to guide care, and identifies barriers to aggregating data from PROMs to conduct health services research. The article proposes 2 priority areas to help advance rehabilitation health services research: (1) standardization of collecting PROMs data in electronic health records to facilitate comparing health system performance and quality and (2) increased partnerships between rehabilitation providers, researchers, and payors to accelerate health system learning. As health care reform continues to emphasize value-based payment strategies, it is essential for the field of physical medicine and rehabilitation to be at the forefront of demonstrating its value in the care continuum.

Broadening the Conception of Food Insecurity Among Older Adults: Development of a Summary Indicator in the NHATS

Comprehensive measurement of food insecurity among older adults has focused on financial barriers to food access. Using data from the community-dwelling older adults in Round 5 of the U.S. National Health and Aging Trends Study (n=7,070), we constructed a summary indicator of food insecurity and inadequate food access incorporating items related to food scarcity within three domains: functional, social support, and financial limitations. We analyzed the construct validity of the summary indicator for known biopsychosocial factors associated with food insecurity among older adults. In 2015, 4.3% of community-dwelling older adults, approximately 1,673,775 million people, were characterized as food insecure or lacking adequate food access. Multivariable regression models identified that being homebound, frail, and experiencing community disability were associated with food insecurity and inadequate food access. These findings indicate food insecurity and inadequate food access among older adults is associated with functional and mobility characteristics and not isolated to financial barriers.

Conceptualizing Food Insecurity Among Older Adults: Development of a Summary Indicator in the National Health and Aging Trends Study

OBJECTIVES

Measurement of food insecurity in older adults is focused on financial barriers to food access. Given that older adults are particularly susceptible to additional access-related barriers including functional limitations and lack of social support, the objective of this study was to construct a summary indicator of food insecurity incorporating these domains.

METHODS

We used nationally representative survey data from Round 5 of the National Health and Aging Trends Study (NHATS; n = 7,070). We constructed a summary indicator of food insecurity using factors within the following three domains: functional, social support, and financial limitations. First, we identified the prevalence of food insecurity among the sample as defined by the new summary indicator. Then, we estimated unadjusted and adjusted logistic regression models to assess the association between the expanded measure of food insecurity and biopsychosocial factors.

RESULTS

In 2015, 4.3% (95% confidence interval [CI] 3.75-4.94) of community-dwelling older adults, approximately 1,673,775 million people, were characterized as having food insecurity. Multivariable-adjusted regression models identified that being homebound (odds ratio [OR] 3.49, 95% CI 2.03, 6.00), frail (OR 9.50, 95% CI 4.92-18.37), and experiencing community disability (OR 5.19, 95% CI 3.90-6.90) was associated with food insecurity.

DISCUSSION

Food insecurity among older adults is broader than lacking adequate financial resources to obtain food; it is also associated with social and functional limitations. A more comprehensive conceptualization will aid future study on the impact of food insecurity on health status, utilization, and outcomes to inform senior nutrition program targeting and services.

Measuring Activity Limitations Within the National Health and Aging Trends Study (NHATS)

BACKGROUND AND OBJECTIVES

To better understand the disablement process among older adults, improved measures of activity limitations are needed. Traditional population-level measures lack the ability to distinguish precise gradations of activity limitation and are unable to detect degrees of differences over a wide range of ability levels. Therefore, we used contemporary measurement methods to improve upon current methodologies for characterizing activity limitations within the National Health and Aging Trends Study (NHATS) .

RESEARCH DESIGN AND METHODS

We used the NHATS Round 1 cohort to assess the feasibility of constructing an Activity Limitations scale using Rasch item response theory methods. Factor analysis was used to develop the scale from a set of existing items in the NHATS Mobility, Self-Care, and Household Activity domains. Psychometric properties of the scale were evaluated and the scale was used to examine change in activity limitations among the sample from 2011 to 2015.

RESULTS

Results supported an 18-item scale (N = 7,609). Rasch infit and outfit statistics were within acceptable range for all items (Cronbach's alpha = 0.95; sample score reliability = 0.83). From 2011 to 2015, 5.88% older adults demonstrated increase in function, 15% showed decrease in function, and 78% of the sample showed no change (did not exceed ± MDC90).

DISCUSSION AND IMPLICATIONS

Findings demonstrate that a unidimensional, interval scale of activity limitations can be constructed using traditional survey measures nested within the NHATS. Results revealed concerns regarding ceiling effects within the current self-report items of activity limitations suggesting future work is needed to expand the range of ability currently represented in the NHATS Activity Limitation items.

Persistence of High-Need Status Over Time Among Fee-for-Service Medicare Beneficiaries

Although administrative claims data can be used to identify high-need (HN) Medicare beneficiaries, persistence in HN status among beneficiaries and subsequent variation in outcomes are unknown. We use national-level claims data to classify Fee-for-Service (FFS) Medicare beneficiaries as HN annually among beneficiaries continuously enrolled between 2013 and 2015. To examine persistence of HN status over time, we categorize longitudinal patterns in HN status into being never, newly, transiently, and persistently HN and examine differences in patients' demographic characteristics and outcomes. Among survivors, 23% of beneficiaries were HN at any time-4% persistently HN, 13% transiently HN, and 6% newly HN. While beneficiaries who were persistently HN had higher mortality, utilization, and expenditures, classification as HN at any time was associated with poor outcomes. These findings demonstrate longitudinal variability of HN status among FFS beneficiaries and reveal the pervasiveness of poor outcomes associated with even transitory HN status over time.

Individual and Environmental Determinants of Late-Life Community Disability for Persons Aging With Cardiovascular Disease

OBJECTIVE

The aim of the study was to estimate the prevalence of late-life community disability for adults 65 yrs and older with cardiovascular disease versus those without. This study also investigated the contributions of environmental and individual risk factors on late-life community disability for persons with cardiovascular disease.

DESIGN

This is a secondary data analysis of the 2016 round of the National Health and Aging Trends Study. The study sample included community-dwelling Americans with cardiovascular disease (n = 1490) and without (n = 4819). Logistic regression was used to estimate associations between individual risk factors, environmental factors, and community disability for those with cardiovascular disease.

RESULTS

Individuals with cardiovascular disease had a significantly higher prevalence of late-life community disability than those without (44.8% vs. 29.0%). For persons with cardiovascular disease, lack of transportation, home modification, and needing assistance with mobility increased the odds of community disability. Younger age and lower comorbidity were associated with decreased odds of community disability. When accounting for environmental factors in multivariate analyses, sex, race, and education were not significantly associated with community disability.

CONCLUSION

Late-life community disability is highly prevalent for persons aging with cardiovascular disease. Intervention strategies to deter late-life community disablement should focus on improving access to transportation and improving the community environment in which older adults live.

High-Need Phenotypes in Medicare Beneficiaries: Drivers of Variation in Utilization and Outcomes

OBJECTIVES

High-need (HN) Medicare beneficiaries heavily use healthcare services at a high cost. This population is heterogeneous, composed of individuals with varying degrees of medical complexity and healthcare needs. To improve healthcare delivery and decrease costs, it is critical to identify the subpopulations present within this population. We aimed to (1) identify distinct clinical phenotypes present within HN Medicare beneficiaries, and (2) examine differences in outcomes between phenotypes.

DESIGN

Latent class analysis was used to identify phenotypes within a sample of HN fee-for-service (FFS) Medicare beneficiaries aged 65 years and older using Medicare claims and post-acute assessment data.

SETTING

Not applicable.

PARTICIPANTS

Two cross-sectional cohorts were used to identify phenotypes. Cohorts included FFS Medicare beneficiaries aged 65 and older who survived through 2014 (n = 415 659) and 2015 (n = 416 643).

MEASUREMENTS

The following variables were used to identify phenotypes: acute and post-acute care use, functional dependency in one or more activities of daily living, presence of six or more chronic conditions, and complex chronic conditions. Mortality, hospitalizations, healthcare expenditures, and days in the community were compared between phenotypes.

RESULTS

Five phenotypes were identified: (1) comorbid ischemic heart disease with hospitalization and skilled nursing facility use (22% of the HN sample), (2) comorbid ischemic heart disease with home care use (23%), (3) home care use (12%), (4) high comorbidity with hospitalization (32%), and (5) Alzheimer's disease/related dementias with functional dependency and nursing home use (11%). Mortality was highest in phenotypes 1 and 2; hospitalizations and expenditures were highest in phenotypes 1, 3, and 4.

CONCLUSIONS

Our findings represent a first step toward classifying the heterogeneity among HN Medicare beneficiaries. Further work is needed to identify modifiable utilization patterns between phenotypes to improve the value of healthcare provided to these subpopulations. J Am Geriatr Soc 68:70-77, 2019.

Functional Trajectories of Persons with Cardiovascular Disease in Late Life

OBJECTIVES

Physical function declines with aging and is accelerated for persons with cardiovascular disease (CVD). While CVD increases the risk of functional decline in late life, little is known about differences in trajectories of functional decline. To determine whether there is more than 1 trajectory of functional decline in Americans with cardiovascular disease (CVD) who are functionally independent.

DESIGN

Secondary analysis of National Health and Aging Trends Study (NHATS). Latent class growth modeling was used to estimate trajectories of function over 4 years of follow-up.

SETTING

Annual structured in-home interviews.

PARTICIPANTS

Americans aged 65 and older with CVD who were functionally independent at baseline (N = 392).

MEASUREMENTS

We compared trajectories of function in individuals with CVD with trajectories of those without and examined the association between risk factors (sex, age at baseline, education level, comorbidity) and trajectory group membership. Function was measured using the Short Physical Performance Battery.

RESULTS

Three functional trajectories emerged: rapid functional decline (23.8%), gradual functional decline (44.2%), and stable function (32.0%). Similar trajectories were seen for those without CVD, with a smaller proportion in the rapid functional decline group (16.2%). Women, older participants, and those with less education and greater comorbidity were less likely to be in the stable function group than the rapid functional decline group.

CONCLUSION

Although function declines in late life for independently functioning persons with CVD, some individuals remain stable, and others decline gradually or rapidly. Persons with CVD were more likely to experience rapid functional decline than those without, suggesting that CVD increases the risk of rapid functional decline. Risk factors predicted functional trajectory group membership, not just overall decline. J Am Geriatr Soc 67:37-42, 2019.

Racial Differences in Patterns of Use of Rehabilitation Services for Adults Aged 65 and Older

OBJECTIVES

To examine racial differences in the use of rehabilitation services and functional improvement during receipt of services.

DESIGN

Secondary analysis of the 2016 National Health and Aging Trends Study (NHATS).

SETTING

Standardized in-person home interviews.

PARTICIPANTS

Community-dwelling Medicare enrollees (N = 6,309), 1,276 of whom reported receiving rehabilitation services in the previous 12 months.

MEASUREMENTS

Self-reported use of rehabilitation services, setting (inpatient, outpatient, home based), reason for use, and perceptions of change in functioning after receiving services.

RESULTS

Controlling for sex, dual eligibility for Medicaid, age, number of chronic conditions, functional mobility at the prior round, income, and geographic region, the odds of receiving rehabilitation services in any setting was 1.38 times as great in whites as in blacks (95% confidence interval = 1.09-1.75). Of those receiving therapy, whites were more likely to receive home-based and inpatient rehabilitation services, but there were no racial differences in improvement in function.

CONCLUSION

Strategies are needed to identify possible barriers to use of rehabilitation services for vulnerable groups of aging individuals who need rehabilitation services, particularly older blacks.

Prospective Assessment of Frailty Using the Fried Criteria in Patients Undergoing Left Ventricular Assist Device Therapy

Frail patients are more prone to adverse events after cardiac surgery, particularly after implantation of left ventricular assist devices. Thus, frailty assessment may help identify patients unlikely to benefit from left ventricular assist device therapy. The purpose was to establish a suitable measure of frailty in adults with end-stage heart failure. In a prospective cohort of 75 patients (age 58 ± 12 years) with end-stage heart failure, we assessed the association between frailty (5-component Fried criteria) and the composite primary outcome of inpatient mortality or prolonged length of stay, as well as extubation status, time on ventilator, discharge status, and long-term mortality. Fried frailty criteria were met in 44 (59%) patients, but there was no association with the primary outcome (p = 0.10). However, an abridged set of 3 criteria (exhaustion, inactivity, and grip strength) was predictive of the primary outcome (odds ratio 2.9, 95% confidence interval 1.1 to 7.4), and of time to extubation and time to discharge. In patients with advanced heart failure, the 5-component Fried criteria may not be optimally sensitive to clinical differences. In conclusion, an abridged set of 3 frailty criteria was predictive of the primary outcome and several secondary outcomes, and may therefore be a clinically useful tool in this population.