Faculty Bibliography

Caring for older adults with multiple chronic conditions (MCCs) is challenging. The American Geriatrics Society (AGS) previously developed The AGS Guiding Principles for the Care of Older Adults with Multimorbidity using a systematic review of the literature and consensus (Table 1). The objective of the current work was to translate these principles into a framework of Actions and accompanying Action Steps for decision-making for clinicians who provide both primary and specialty care to older people with MCCs. A workgroup of geriatricians, cardiologists, and generalists: 1) articulated the core MCC Actions and the Action Steps needed to carry out the Actions; 2) provided decisional tips and communication scripts for implementing the Actions and Action Steps, using commonly encountered situations: 3) performed a scoping review to identify evidence-based, validated tools for carrying out the MCC Actions and Action Steps; and 4) identified potential barriers to, and mitigating factors for, implementing the MCC Actions. The recommended MCC Actions include: 1) Identify and communicate patients' health priorities and health trajectory; 2) Stop, start, or continue care based on health priorities, potential benefit versus harm and burden, and health trajectory; and 3) align decisions and care among patients, caregivers, and other clinicians with patients' health priorities and health trajectory. The tips and scripts for carrying out these Actions are included in the full MCC Action Framework available in the supplement (www.GeriatricsCareOnline.org).

OBJECTIVES/OBJECTIVE:To develop a values-based, clinically feasible process to help older adults identify health priorities that can guide clinical decision-making. DESIGN/METHODS:Prospective development and feasibility study. SETTING/METHODS:Primary care practice in Connecticut. PARTICIPANTS/METHODS:Older adults with 3 or more conditions or taking 10 or more medications (N=64). INTERVENTION/METHODS:The development team of patients, caregivers, and clinicians used a user-centered design framework-ideate → prototype → test →redesign-to develop and refine the value-based patient priorities care process and medical record template with trained clinician facilitators. MEASUREMENTS/METHODS:We used descriptive statistics of quantitative measures (percentage accepted invitation and completed template, duration of process) and qualitative analysis of barriers and enablers (challenges and solutions identified, facilitator perceptions). RESULTS:We developed and refined a process for identifying patient health priorities that was typically completed in 35 to 45 minutes over 2 sessions; 64 patients completed the process. Qualitative analyses were used to elucidate the characteristics and training needed for the patient priorities facilitators, as well as perceived benefits and challenges of the process. Refinements based on our experience and feedback include streamlining the process for greater feasibility, balancing fidelity to the process while customizing to individuals, encouraging patients to share their priorities with their clinicians, and simplifying the template transmitted to clinicians. CONCLUSION/CONCLUSIONS:Trained facilitators conducted this process in a busy primary care practice, suggesting that patient priorities identification is feasible and acceptable, although testing in additional settings is necessary. We hope to show that clinicians can align care with patients' health priorities.

Older adults with multiple chronic conditions (MCCs) receive care that is fragmented and burdensome, lacks evidence, and most importantly is not focused on what matters most to them. An implementation feasibility study of Patient Priorities Care (PPC), a new approach to care that is based on health outcome goals and healthcare preferences, was conducted. This study took place at 1 primary care and 1 cardiology practice in Connecticut and involved 9 primary care providers (PCPs), 5 cardiologists, and 119 older adults with MCCs. PPC was implemented using methods based on a practice change framework and continuous plan-do-study-act (PDSA) cycles. Core elements included leadership support, clinical champions, priorities facilitators, training, electronic health record (EHR) support, workflow development and continuous modification, and collaborative learning. PPC processes for clinic workflow and decision-making were developed, and clinicians were trained. After 10 months, 119 older adults enrolled and had priorities identified; 92 (77%) returned to their PCP after priorities identification. In 56 (46%) of these visits, clinicians documented patient priorities discussions. Workflow challenges identified and solved included patient enrollment lags, EHR documentation of priorities discussions, and interprofessional communication. Time for clinicians to provide PPC remains a challenge, as does decision-making, including clinicians' perceptions that they are already doing so; clinicians' concerns about guidelines, metrics, and unrealistic priorities; and differences between PCPs and patients and between PCPs and cardiologists about treatment decisions. PDSA cycles and continuing collaborative learning with national experts and peers are taking place to address workflow and clinical decision-making challenges. Translating disease-based to priorities-aligned decision-making appears challenging but feasible to implement in a clinical setting.

OBJECTIVE:To ascertain perspectives of multiple stakeholders on contributors to inappropriate care for older adults with multiple chronic conditions. METHOD/METHODS:Perspectives of 36 purposively sampled patients, clinicians, health systems, and payers were elicited. Data analysis followed a constant comparative method. RESULTS:Structural factors triggering burden and fragmentation include disease-based quality metrics and need to interact with multiple clinicians. The key cultural barrier identified is the assumption that "physicians know best." Inappropriate decision making may result from inattention to trade-offs and adherence to multiple disease guidelines. Stakeholders recommended changes in culture, structure, and decision making. Care options and quality metrics should reflect a focus on patients' priorities. Clinician-patient partnerships should reflect patients knowing their health goals and clinicians knowing how to achieve them. Access to specialty expertise should not require visits. DISCUSSION/CONCLUSIONS:Stakeholders' recommendations suggest health care redesigns that incorporate patients' health priorities into care decisions and realign relationships across patients and clinicians.

Background/UNASSIGNED:The Community Healthy Activities Model Program for Seniors (CHAMPS) survey, summarized into weekly caloric expenditures, is a common physical activity (PA) assessment tool among older adults. Specific types of PA reported in the CHAMPS have not been systematically analyzed. We applied latent class analysis to identify the patterns of PA among sedentary older adults with diabetes reported in the CHAMPS survey. Methods/UNASSIGNED:Latent class models of PA were identified using the CHAMPS survey data reported by 115 individuals aged ≥60 years with type 2 diabetes whom volunteered for a clinical study of PA. Multinomial logistic regression was used to assess independent predictors of a specific latent class, including age, sex, and performance in physical function tests. Results/UNASSIGNED: = 0.03). Conclusions/UNASSIGNED:Individual PA response in CHAMPS can be categorized using latent class models into meaningful patterns which can inform PA interventions. Customized PA programs should consider the heterogeneity of the activities among sedentary older adults. Trial Registration/UNASSIGNED:ClinicalTrials.gov Identifier NCT00344240; retrospectively registered 23 June 2006.