Faculty Bibliography

BACKGROUND/UNASSIGNED:Forty-five percent of hospice patients currently have a primary or secondary diagnosis of Alzheimer's disease or related disorders. However, few programs have focused specifically on assisting hospices in providing evidence-based symptom management to persons living with dementia (PLWD). OBJECTIVE/UNASSIGNED:To adapt and pilot the training component of Aliviado Dementia Care, a dementia symptom management quality improvement program originally developed for home healthcare, for use by social workers as part of the hospice interdisciplinary team. DESIGN/UNASSIGNED:A prospective pre-post design was utilized, measuring knowledge, confidence, and attitudes at baseline, and immediately and 1-month post-training. Analysis was performed using paired t-tests and repeated measures ANOVA. SUBJECTS/UNASSIGNED:Hospice social workers currently practicing in the United States with at least 1 year of experience. MEASUREMENTS/UNASSIGNED:The Dementia Symptom Knowledge Assessment and a post-training continuing education evaluation form. RESULTS/UNASSIGNED:Forty-six subjects were enrolled, of whom 26 completed the first post-test and 23 both post-tests. There was a poor baseline level of knowledge and confidence in caring for PLWD. Significant improvements occurred following training, particularly in implementing non-pharmacologic interventions for behavioral and psychological symptoms of dementia (BPSD) (16.64% increase, p < .0001) and confidence in managing behavioral symptoms (16.86%, p = .01) and depression (25.18%, p < .0001). Changes were maintained over time. All respondents were either very satisfied or satisfied with the quality and content of the program. CONCLUSIONS/UNASSIGNED:The training modules of Aliviado Dementia Care were successfully tailored for use by hospice social workers, showing significant improvement in knowledge and confidence in caring for behavioral symptoms in PLWD. Future work will examine whether the larger program, including this training, can subsequently improve patient outcomes in hospice.

With the onset of the COVID-19 pandemic, telehealth was thrust to the forefront, becoming one of the most predominant forms of care almost overnight. Despite years of research, practice, and policymaking, tenets for providing telehealth in an interdisciplinary, family- and person-centered fashion, and across a wide breadth of settings remain underdeveloped. In addition, although telehealth has the potential to increase equity in care, it can also further exacerbate disparities. The current article discusses the opening created by the pandemic and provides recommendations for how to make permanent changes in telehealth policy and practice to allow for interdisciplinary, person- and family-centered care while also taking care to address issues of equity and ethics and privacy issues related to telehealth and remote monitoring. [Journal of Gerontological Nursing, 46(9), 9-13.].

CONTEXT/BACKGROUND:As the aging population grows, the incidence of dementia continues to increase substantially. However, the lack of a significant geriatric health care workforce as well as little dementia training among generalist health care workers leads to suboptimal care for persons living with dementia (PLWD). In particular, few evidence-based interventions exist to improve the quality of dementia care among hospice interdisciplinary teams caring for PLWD. Aliviado Dementia Care-Hospice Edition is a quality assurance and performance improvement program that includes training, mentoring, and workflow enhancements, which aims to improve quality of hospice care provided to PLWD and their caregivers. OBJECTIVES/OBJECTIVE:To determine the effectiveness of the Aliviado Dementia Care program in increasing dementia symptom knowledge of hospice interdisciplinary team members. METHODS:About 53 hospice team members from two diverse hospices, consisting of social workers, chaplains, physicians, and nurses, participated in the Aliviado training program. In this prepost trial, 39 participants completed the Dementia Symptom Knowledge Assessment before and after completion of the program. RESULTS:Paired t-tests showed significant differences before and after Aliviado training in depression knowledge and confidence, as well as behavioral and psychological symptoms of dementia (BPSD) knowledge, confidence, and interventions. The greatest percent change increases were in depression (15.2%) and BPSD (13.3%) confidence as well as BPSD interventions (18.4%). Qualitative feedback consistently emphasized that trainees could now effectively assess their patients for specific symptoms such as pain and agitation. CONCLUSION/CONCLUSIONS:Aliviado is an evidence-based system-level intervention that improves clinical knowledge, attitudes, and confidence in treating PLWD enrolled in hospice.

Sixteen million caregivers currently provide care to more than 5 million persons living with dementia (PLWD) in the United States. Although this population is growing and highly complex, evidence-based management remains poorly integrated within healthcare systems. Therefore, the National Institute on Aging IMPACT Collaboratory was formed to build the nation's ability to conduct embedded pragmatic clinical trials (ePCTs) for PLWD and their caregivers. The pilot core of the IMPACT Collaboratory seeks to provide funds for upward of 40 pilots for ePCTs to accelerate the testing of nonpharmacologic interventions with the goal that these pilots lead to full-scale ePCTs and eventually the embedding of evidence-based care into healthcare systems. The first two challenges for the pilot core in building the pilot study program were (1) to develop a transparent, ethical, and open nationwide process for soliciting, reviewing, and selecting pilot studies; and (2) to begin the process of describing the necessary components of a pilot study for an ePCT. During our initial funding cycle, we received 35 letters of intent, of which 17 were accepted for a full proposal and 14 were submitted. From this process we learned that investigators lack knowledge in ePCTs, many interventions lack readiness for an ePCT pilot study, and many proposed studies lack key pragmatic design elements. We therefore have set three key criteria that future pilot studies must meet at a minimum to be considered viable. We additionally discuss key design decisions investigators should consider in designing a pilot study for an ePCT. J Am Geriatr Soc 68:S14-S20, 2020.

BACKGROUND: Previous studies have compared the safety profiles of alternative analgesics, yet the conclusions vary greatly.
METHOD(S): Observational, national cohort of US Veterans (>=50 years) with osteoarthritis receiving an outpatient analgesic prescription (acetaminophen, NSAIDs, opioid, or topical analgesic) after being 180+ days analgesic naive according to VHA pharmacy records. Inverse probability of treatment weights (IPTW) were used to adjust for selection bias. We used survival analyses to assess the risk of composite safety events (cardiovascular, gastrointestinal, fracture, hepatotoxicity, respiratory) across medication groups 365 days post-analgesic receipt, with subsequent analgesic prescriptions and death as competing risks.
RESULT(S): From 2010-2018, 271,505 Veterans (mean age=64.3 years; 93.5% male) were balanced across 47 confounders (max absolute mean standardized difference=0.09). Veterans prescribed acetaminophen and opioids had an increased risk of cardiovascular (HR 1.32 and 1.23; p<0.001), gastrointestinal (HR 1.51 and 1.52; p<0.001), fracture (HR 1.86 and 1.57; p<0.001), and respiratory events (HR 1.51 and 1.39; p<0.001) compared to those prescribed NSAIDs. Hepatotoxicity risk was greatest with opioids and topicals (HR 1.77 and 1.49; p<0.001) compared to NSAIDs.
CONCLUSION(S): Early findings show the comparative safety of analgesics varies depending on the outcome event in question. The estimated effects of acetaminophen with this analytic approach indicate higher risks for certain safety events relative to other analgesic types, counter to presumed clinical practice. Caution should be taken when interpreting these results as residual, unobserved confounding across groups likely remains

OBJECTIVE/UNASSIGNED:Seriously ill adults with multiple chronic conditions (MCC) who receive palliative care may benefit from improved symptom burden, health care utilization and cost, caregiver stress, and quality of life. To guide research involving serious illness and MCC, palliative care can be integrated into a conceptual model to develop future research studies to improve care strategies and outcomes in this population. METHODS/UNASSIGNED:The adapted conceptual model was developed based on a thorough review of the literature, in which current evidence and conceptual models related to serious illness, MCC, and palliative care were appraised. Factors contributing to patients' needs, services received, and service-related variables were identified. Relevant patient outcomes and evidence gaps are also highlighted. RESULTS/UNASSIGNED:Fifty-eight articles were synthesized to inform the development of an adapted conceptual model including serious illness, MCC, and palliative care. Concepts were organized into 4 main conceptual groups, including Factors Affecting Needs (sociodemographic and social determinants of health), Factors Affecting Services Received (health system; research, evidence base, dissemination, and health policy; community resources), Service-Related Variables (patient visits, service mix, quality of care, patient information, experience), and Outcomes (symptom burden, quality of life, function, advance care planning, goal-concordant care, utilization, cost, death, site of death, satisfaction). DISCUSSION/UNASSIGNED:The adapted conceptual model integrates palliative care with serious illness and multiple chronic conditions. The model is intended to guide the development of research studies involving seriously ill adults with MCC and aid researchers in addressing relevant evidence gaps.

Previous transitional care research has focused on transitions occurring between community and hospital settings. Little is known regarding intrahospital transitions and how they affect care quality. A systematic review was therefore conducted to synthesize the literature regarding clinical outcomes associated with intrahospital transitions. Literature published between January 2003 and December 2018 and indexed in Medline/PubMed, CINAHL, and PsychINFO were reviewed using PRISMA guidelines. Articles were limited to English language and peer-reviewed. Articles were excluded if they focused on transitions occurring from or to the hospital, discharge/discharge planning, or postdischarge follow-up. Data abstraction included study characteristics, sample characteristics, and reported clinical outcomes. Fourteen studies met inclusion criteria, primarily using cross-sectional, cohort, or retrospective chart review quantitative designs. Data were analyzed and synthesized based on outcomes reported. Major outcomes emerging from the articles included delirium, hospital length of stay, mortality, and adverse events. Delirium, hospital length of stay, and morbidity and mortality rates were associated with delayed transfers and transfers to inappropriate units. In addition, increased fall risk and infection rates were associated with higher rates of transfer. Intrahospital transitions represent critical periods of time where the quality of care being provided may be diminished, negatively affecting patient safety and outcomes.