serious illness conversations (SIC), particularly for persons living with cognitive impairment (PLCI), inconsistently happen in primary care. Pragmatic, scalable strategies are needed to promote SIC for PLCI.
Pragmatic, prospective single-arm pilot study that occurred between July 1, 2021 and May 30, 2022 across seven primary care practices in North Carolina.
Community-dwelling patients aged 65 and older with known or probable mild cognitive impairment or dementia (with decision-making capacity) and their care partners (if available).
SIC telehealth intervention (TeleVoice) via video or telephone to assist PLCI in discussing their current goals, values, and future medical preferences, while facilitating documentation within the EHR.
Main feasibility outcomes included reach/enrollment, intervention completion, and adoption rates at the clinic and provider level. Primary effectiveness outcomes included SIC documentation and quality within the EHR and usage of advance care planning billing (ACP) codes.
Of the 163 eligible PLCI approached, 107 (66%) enrolled (mean age 83.7 years, 68.2% female, 16.8% Black, 22% living in a geographic area of high socioeconomic disadvantage) and 81 (76%) completed the SIC telehealth intervention; 45 care partners agreed to participate (mean age 71.5 years, 80% female). Adoption at clinic level was 50%, while 75% of providers within these clinics participated. Among PLCI that completed the intervention, SIC documentation and usage of ACP billing codes was 100% and 96%, respectively, with 96% (n = 78) having high-quality SIC documentation. No significant differences were observed between telephone and video visits.
These findings provide preliminary evidence to support the feasibility of conducting SICs through telehealth to specifically meet the needs of community-dwelling PLCI. Further investigation of the sustainability of the intervention and its long-term impact on patient and caregiver outcomes is needed.
Hip fracture and depression are important public health issues among older adults, but how pre-fracture depression impacts recovery after hip fracture is unknown, especially among males who often experience greater depression severity. Days at home (DAH), or the days spent outside a hospital or healthcare facility, is a novel, patient-centered outcome that can capture meaningful aspects of fracture recovery. How pre-fracture depression impacts DAH after fracture, and related sex differences, remains unclear.
Participants included 63,618 Medicare fee-for-service beneficiaries aged 65+ years, with a hospitalization claim for hip fracture surgery between 2010 and 2017. The primary exposure was a diagnosis of depression at hospital admission, and the primary outcome was total DAH over 12 months post-discharge. Longitudinal associations between pre-fracture depression and the count of DAH among beneficiaries were estimated using Poisson regression models after adjustment for covariates; sex-by-depression interactions were also assessed. Incidence rate ratios (IRRs) and 95% confidence intervals (CIs) reflecting relative differences were estimated from these models.
Overall, beneficiaries with depression were younger, White females, and spent 11 fewer average DAH compared to counterparts without depression when demographic factors (age and sex) (IRR = 0.91; 95% CI = 0.90, 0.92; p < 0.0001) and social determinants of health (race, Medicaid dual eligibility, and poverty) were adjusted for (IRR = 0.92; 95% CI = 0.91, 0.93; p < 0.0001), but this association attenuated after adjusting for medical complexities (IRR = 0.99; 95% CI = 0.98, 1.01; p = 0.41) and facility and geographical factors (IRR = 1.0037; 95% CI = 0.99, 1.02; p = 0.66). There was no evidence of effect modification by sex.
The comorbidity burden of preexisting depression may impact DAH among both male and female Medicare beneficiaries with hip fracture. Results suggest a holistic health approach and secondary prevention of depressive symptoms after hip fracture.
A growing number of older adults live in senior affordable housing, many with limited support systems and representing underserved or disadvantaged populations. Staff in these buildings are in a unique position to identify and address the healthcare and biopsychosocial needs of their residents and link them to services and supports.
Staff in four affordable housing sites received training on the 4Ms approach to caring for older adults and conducting resident health assessments. They learned to collect comprehensive health information using a 4Ms Resident Health Risk Assessment (4Ms-RHRA) and results are entered into a customized electronic database. Embedded flags identify potential risk factors and initiate a follow-up process for documenting interventions and tracking referrals to healthcare and supportive services.
Eighty-one percent of the 221 4Ms-RHRAs completed with residents (63% female, mean age 71.1 years, 73% live alone) were flagged for at least one concern (Mean = 2.2 flags). Items addressing What Matters were most frequently flagged: resident's “most important health issue” (55%) and Advance Care Planning (ACP: 48%). In response, staff provided Advance Directive forms and Five Wishes pamphlets to interested residents and reminded residents to review ACP documents annually.
Training affordable housing staff, precepting faculty, and students to conduct health assessments based on the 4Ms framework and longitudinally track interventions related to resident-centered needs and manage long-term service and supports is a first step in creating an interprofessional workforce capable of addressing the complex needs of older individuals in affordable housing.
The Age-Friendly Health Systems model, encompassing four key elements (4Ms)—What Matters, Medication, Mentation, Mobility—is integral to delivering high-quality care to older adult patients. In May 2020, the MinuteClinic at CVS implemented the 4Ms model in all 1100+ store locations nationwide. To prepare healthcare providers to deliver 4Ms care, educational modules were developed to provide an understanding of the gerontology principles that support the 4Ms model of care. Our goal was to evaluate the effectiveness of these education modules on improving reliable 4Ms delivery during retail clinic visits.
Educational modules were provided to nurse practitioners and physician associates to complete in a self-directed manner. These included an orientation module with scenarios comparing usual care and 4Ms care, 12 monthly grand rounds focusing on 4Ms case studies, and 10 video vignettes on 4Ms integration. We examined the association between number of education modules completed with the average number of Ms delivered per visit (M-Score) using descriptive statistics and a generalized linear mixed-effects model.
Over 70% of 2783 providers completed at least one education module. Rates of 4Ms care delivery were 1.37 (1.36–1.39, p < 0.001) times higher among those that completed an orientation course compared to those that did not. Higher uptake of education exhibited a dose–response relationship with rate ratios between 1.77 (1.74–1.80, p < 0.001) for 1–2 modules beyond orientation, up to 2.94 (2.90–2.99, p < 0.001) for eight or more modules.
The self-directed learning environment (e.g., providers self-select the number and type of courses) reflects real-world variation in engagement. Despite this variation, significant improvements in 4Ms delivery were observed at any level of educational exposure, underscoring the value of prioritizing education time with quality improvement initiatives.
Community health workers (CHWs) are frontline public health personnel who serve as liaisons between vulnerable patient populations and the healthcare system. They are instrumental in health promotion and education for urban-dwelling older adults. However, no research exists on training that CHWs receive on age-friendly health care. This article explores CHW education on the 4Ms of an Age-Friendly Health System and identifies areas where additional training may be necessary.
As part of a two-pronged qualitative needs assessment, four focus groups were held with a total of 17 CHWs and semistructured interviews were conducted with 10 clinicians, including both healthcare providers and social workers. Focus group and interview transcripts were then analyzed for major themes in Dedoose, a qualitative coding software.
Clinicians most often identified Mentation and Mobility as areas where CHWs can have the greatest impact. Correspondingly, CHWs felt under-equipped to assist patients in these areas and expressed strong interest in additional training. In general, CHWs and clinicians agreed that Medications and What Matters do not fall under CHW scope of practice.
Our findings confirm the critical role that CHWs can play in promoting the health and well-being of urban-dwelling older adults. However, we also demonstrate that many CHWs lack adequate training in age-friendly care. To meet the social and medical needs of a rapidly aging US population, there is a pertinent need to develop a novel community health worker training curriculum on Mentation and Mobility.
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