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Chronic Care, Dementia Care Management, and Financial Considerations

Coe, Norma; Boyd, Cynthia; Chodosh, Joshua
The needs of persons living with Alzheimer's disease and Alzheimer's disease-related dementia (AD/ADRD) are challenged by tremendous complexity impacting both care delivery and financing. Most persons living with dementia (PLWD) also suffer from other chronic medical or mental health conditions, which further burden quality of life and function. In addition to difficult treatment choices, optimal dementia care models likely involve people and services that are not typical pieces of the health care delivery system but are all critical partners-care partners, social workers, and community services, to name a few. More than 200 models of dementia care have demonstrated some efficacy. However, these successful interventions that might address much of the care needed by PLWD are uninsured in the United States, where insurance coverage has focused on acute care needs. This poses great difficulties for both care provision and care financing. In this article, we review these 3 key challenges: dementia care for those with chronic comorbid disease; care models that require people who are not typical providers in traditional care delivery systems; and the mandate to provide high-quality care that is currently not funded by usual health care insurance. We propose promising next steps that could substantially improve the lives of PLWD and the lives of their care partners, and highlight some of the many research questions that remain.
PMID: 34081893
ISSN: 1538-9375
CID: 4891902

Providing Hearing Assistance to Low-Income Adults at Risk for Social Isolation: Preliminary Findings [Letter]

Chodosh, Joshua; Batra, Romilla; Likar, Denise; Segal-Gidan, Freddi; Gomez, Annette; Radcliffe, Kate; Osterweil, Dan; Weinstein, Barbara E; Blustein, Jan
PMID: 33711311
ISSN: 1538-9375
CID: 4809652

Environmental Noise in New York City Long-Term Care Facilities: A Window into the COVID-19 Pandemic [Letter]

Martin, Jennifer L; Hernandez, Diana; Cadogan, Mary P; Brody, Abraham A; Alessi, Cathy A; Mitchell, Michael N; Song, Yeonsu; Smilowitz, Jessica; Vedvyas, Alok; Qian, Yingzhi; Zhong, Hua; Chodosh, Joshua
PMCID:7885630
PMID: 33722568
ISSN: 1538-9375
CID: 4817532

The HEAR-VA Pilot Study: Hearing Assistance Provided to Older Adults in the Emergency Department

Chodosh, Joshua; Goldfeld, Keith; Weinstein, Barbara E; Radcliffe, Kate; Burlingame, Madeleine; Dickson, Victoria; Grudzen, Corita; Sherman, Scott; Smilowitz, Jessica; Blustein, Jan
BACKGROUND/OBJECTIVES/OBJECTIVE:Poor communication is a barrier to care for people with hearing loss. We assessed the feasibility and potential benefit of providing a simple hearing assistance device during an emergency department (ED) visit, for people who reported difficulty hearing. DESIGN/METHODS:Randomized controlled pilot study. SETTING/METHODS:The ED of New York Harbor Manhattan Veterans Administration Medical Center. PARTICIPANTS/METHODS:One hundred and thirty-three Veterans aged 60 and older, presenting to the ED, likely to be discharged to home, who either (1) said that they had difficulty hearing, or (2) scored 10 or greater (range 0-40) on the Hearing Handicap Inventory-Survey (HHI-S). INTERVENTION/METHODS:Subjects were randomized (1:1), and intervention subjects received a personal amplifier (PA; Williams Sound Pocketalker 2.0) for use during their ED visit. MEASUREMENTS/METHODS:Three survey instruments: (1) six-item Hearing and Understanding Questionnaire (HUQ); (2) three-item Care Transitions Measure; and (3) three-item Patient Understanding of Discharge Information. Post-ED visit phone calls to assess ED returns. RESULTS:Of the 133 subjects, 98.3% were male; mean age was 76.4 years (standard deviation (SD) = 9.2). Mean HHI-S score was 19.2 (SD = 8.3). Across all HUQ items, intervention subjects reported better in-ED experience than controls. Seventy-five percent of intervention subjects agreed or strongly agreed that ability to understand what was said was without effort versus 56% for controls. Seventy-five percent of intervention subjects versus 36% of controls said clinicians provided them with an explanation about presenting problems. Three percent of intervention subjects had an ED revisit within 3 days compared with 9.0% controls. CONCLUSION/CONCLUSIONS:Veterans with hearing difficulties reported improved in-ED experiences with use of PAs, and were less likely to return to the ED within 3 days. PAs may be an important adjunct to older patient ED care but require validation in a larger more definitive randomized controlled trial.
PMID: 33576037
ISSN: 1532-5415
CID: 4780132

Promoting hearing assistance for social engagement (Phase) in los angeles communities [Meeting Abstract]

Chodosh, J; Batra, R; Likar, D; Segal-Gidan, F I; Gomez, A; Radcliffe, K; Osterweil, D; Weinstein, B; Blustein, J
Background: Hearing loss compounds social isolation. We tested acceptability and benefit of simple hearing assistance devices- Personal Amplifiers (PAs)-provided to older people with hearing loss and risk for social isolation, loneliness and depression.
Method(s): We conducted a pre-post pilot trial with 1-and 2-month follow-up of residents of six low-income senior apartment buildings in Los Angeles (n = 74) who had hearing difficulties, based on either (A) >= 10 (range 0-40) on the Hearing Handicap Inventory - Survey; or (B) hearing loss based on a clinically validated audiological iPad assessment (SHOEBOXTM) with surveys at 0, 1 and 2 months using 4 instruments: (1) Social Isolation Score (SIS); (2) Patient Health Questionnaire (PHQ-9); (3) Sense of Social Support scale; and (4) DG Loneliness Scale. We assessed PA use and perceived benefit using the International Outcome Inventory for Alternative Interventions (IOI-AI).
Result(s): Baseline characteristics and degree of hearing problems did not vary significantly among 74 initial enrollees. Fortytwo residents completed 1-and 2-month surveys. Mean age was 78.2 years; 64% were women; 83% scored >=10 on HHI-S and 83% met SHOEBOX criteria for hearing loss. At baseline, 31% met SIS criteria for social isolation (>=2; mean=1.0; SD:0.98); 41% met DG criteria for loneliness; and 19% had low social support. Mean PHQ-9 was 7.0, (SD:5.3); 26% had moderate to severe mood symptoms. At 2-month follow up, 87% reported PA use of >= one hour/day, and 76% indicated that the device changed life enjoyment 'quite a lot.' Psychosocial measures improved over time.
Conclusion(s): In a vulnerable older population with hearing difficulties, simple PAs were enthusiastically received and may have improved social functioning and mood. Further work with stronger study designs is needed to shed more light on the effectiveness of this approach
EMBASE:634826887
ISSN: 1532-5415
CID: 4870562

Home blood pressure monitoring for hypertension management during COVID-19 pandemic [Meeting Abstract]

Ding, X; Maheswaran, S; Chodosh, J
Background: Home blood pressure measurement (HBPM) has been a time-honored supplement to periodic in-office measurement to facilitate primary care physician (PCP) diagnosis of hypertension (HTN), its ongoing control and medication management. PCPs, in response to COVID-19, adopted telemedicine as the sole means of care, elevating HBPM as the essential HTN surveillance tool. We assessed the feasibility of this approach in a Veteran Affairs (VA) geriatric clinic.
Method(s): Study subjects included all the Veterans seen by New York Harbor VA geriatrics fellows' clinic between January 1, 2019 and March 1, 2020 and who have HTN listed as an electronic health record (EHR) diagnosis. Those with systolic blood pressure (SBP) > 140 mmHg were prioritized. We called these patients to assess adherence to BP self-care and reconcile medications, to identify reasons for poor adherence and to offer solutions. Patients were called again within two months to re-assess adherence, collect BP measures and adjust medications as needed.
Result(s): Among 102 patients diagnosed with HTN, 41 had not achieved the goal of SBP <140 mmHg prior to this intervention. We reached 78% (n=32) of these 41 patients (requiring 1-3 phone calls). All reported medical adherence, but none were found to consistently check BP at home with any frequency or proper technique. For the 14 patients having no BP monitor at home, we sent a monitor to 10 through prescription and enrolled 4 in a home telehealth (HT) program that uses daily remote measurement. We provided detailed instruction of proper HBPM during the initial interview. At follow-up, 47% (n=15) practiced HBPM and reported BP readings within goal, indicating no need for change in care. Of these 15, 11 had their own BP monitors; 2 achieved control through the HT program. However, only 2 of the 10 patients who received the prescribed BP monitor started HBPM and demonstrated good control.
Conclusion(s): Given our reliance on telemedicine, HBPM is feasible for outpatient HTN management. Close PCP follow-up to encourage consistent HBPM practice may improve and sustain the success of this strategy. The quality of self-reported data should be assessed during office visits
EMBASE:634826730
ISSN: 1532-5415
CID: 4870592

Post-Discharge Health Status and Symptoms in Patients with Severe COVID-19

Weerahandi, Himali; Hochman, Katherine A; Simon, Emma; Blaum, Caroline; Chodosh, Joshua; Duan, Emily; Garry, Kira; Kahan, Tamara; Karmen-Tuohy, Savannah L; Karpel, Hannah C; Mendoza, Felicia; Prete, Alexander M; Quintana, Lindsey; Rutishauser, Jennifer; Santos Martinez, Leticia; Shah, Kanan; Sharma, Sneha; Simon, Elias; Stirniman, Ana Z; Horwitz, Leora I
BACKGROUND:Little is known about long-term recovery from severe COVID-19 disease. Here, we characterize overall health, physical health, and mental health of patients 1 month after discharge for severe COVID-19. METHODS:This was a prospective single health system observational cohort study of patients ≥ 18 years hospitalized with laboratory-confirmed COVID-19 disease who required at least 6 l of oxygen during admission, had intact baseline cognitive and functional status, and were discharged alive. Participants were enrolled between 30 and 40 days after discharge. Outcomes were elicited through validated survey instruments: the PROMIS® Dyspnea Characteristics and PROMIS® Global Health-10. RESULTS:A total of 161 patients (40.6% of eligible) were enrolled; 152 (38.3%) completed the survey. Median age was 62 years (interquartile range [IQR], 50-67); 57 (37%) were female. Overall, 113/152 (74%) participants reported shortness of breath within the prior week (median score 3 out of 10 [IQR 0-5]), vs 47/152 (31%) pre-COVID-19 infection (0, IQR 0-1), p < 0.001. Participants also rated their physical health and mental health as worse in their post-COVID state (43.8, standard deviation 9.3; mental health 47.3, SD 9.3) compared to their pre-COVID state, (54.3, SD 9.3; 54.3, SD 7.8, respectively), both p < 0.001. Physical and mental health means in the general US population are 50 (SD 10). A total of 52/148 (35.1%) patients without pre-COVID oxygen requirements needed home oxygen after hospital discharge; 20/148 (13.5%) reported still using oxygen at time of survey. CONCLUSIONS:Patients with severe COVID-19 disease typically experience sequelae affecting their respiratory status, physical health, and mental health for at least several weeks after hospital discharge.
PMCID:7808113
PMID: 33443703
ISSN: 1525-1497
CID: 4747152

How can we address poor sleep in nursing homes?

Martin, Jennifer L; Chodosh, Joshua
PMID: 33781360
ISSN: 1741-203x
CID: 4830582

Implementation of Telemental Health (TMH) psychological services for rural veterans at the VA New York Harbor Healthcare System

Chen, Cory K; Palfrey, Amy; Shreck, Erica; Silvestri, Brittney; Wash, Lauren; Nehrig, Nicole; Baer, Alyssa L; Schneider, Jennifer A; Ashkenazi, Sagiv; Sherman, Scott E; Chodosh, Joshua
Meeting the mental health needs of our current veteran population is one of the primary challenges facing the Veteran's Health Administration (VHA). Particularly for veterans residing in rural areas, the lack of providers, high provider turnover, and the burden of traveling long distances to VHA facilities may contribute to difficulties accessing mental health care. Telemental Health (TMH) services help bridge the geographic gap between mental health providers and veterans who need mental health services. The VHA TMH Hub initiative has attempted to leverage changes in technology-facilitated care by developing a model in which a facility "hub" could expand mental health resources to remote "spoke" clinics and veterans' residences. This paper describes the implementation of the VA New York Harbor Health care System (VA NYH) TMH Hub, which was one of 6 programs funded by the VHA Office of Rural Health (ORH) in September 2016. We will describe the structure of the program, services provided, veterans served, and our efforts to integrate quality improvement, research, and clinical training into the operations of the program. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
PMID: 30742470
ISSN: 1939-148x
CID: 3684642

An Exploratory Qualitative Study of Patient and Caregiver Perspectives of Ambulatory Kidney Palliative Care

Bristol, Alycia A; Chaudhry, Sobaata; Assis, Dana; Wright, Rebecca; Moriyama, Derek; Harwood, Katherine; Brody, Abraham A; Charytan, David M; Chodosh, Joshua; Scherer, Jennifer S
OBJECTIVES/UNASSIGNED:The ideal clinical model to deliver palliative care to patients with advanced kidney disease is currently unknown. Internationally, ambulatory kidney palliative care clinics have emerged with positive outcomes, yet there is limited data from the United States (US). In this exploratory study we report perceptions of a US-based ambulatory kidney palliative care clinic from the perspective of patient and caregiver attendees. The objective of this study was to inform further improvement of our clinical program. METHODS/UNASSIGNED:Semi-structured interviews were conducted to elicit the patient and caregiver experience. Eleven interviews (8 patients with chronic kidney disease stage IV or V and 3 caregivers) were analyzed using qualitative description design. RESULTS/UNASSIGNED:We identified 2 themes: "Communication addressing the emotional and physical aspects of disease" and "Filling gaps in care"; Subthemes include perceived value in symptom management, assistance with coping with disease, engagement in advance care planning, program satisfaction and patient activation. SIGNIFICANCE OF RESULTS/UNASSIGNED:Qualitative analysis showed that attendees of an ambulatory kidney palliative care clinic found the clinic enhanced the management of their kidney disease and provided services that filled current gaps in their care. Shared experiences highlight the significant challenges of life with kidney disease and the possible benefits of palliative care for this population. Further study to determine the optimal model of care for kidney palliative care is needed. Inclusion of the patient and caregiver perspective will be essential in this development.
PMID: 33438435
ISSN: 1938-2715
CID: 4746812