Faculty Bibliography

The number of individuals with dementia is expected to increase dramatically over the next 20 years. Given the complicated clinical, sociobehavioral, and caregiving skills that are needed to comprehensively assess and manage individuals with dementia, the gold standard of care requires involvement of interprofessional teams. This systematic review examined 4,023 abstracts, finding 18 articles from 16 studies where an interprofessional dissemination program was performed. Most studies found some improvement in clinician knowledge or confidence, or patient outcomes, though methods and patient and clinician populations were disparate. Although a significant evidence base for assessing and managing individuals with dementia has been developed, few studies have examined how to disseminate this research, and even fewer in an interprofessional manner. These findings suggest that greater emphasis needs to be placed on disseminating existing evidence-based care and ensuring that programs are interprofessional in nature so that excellent, patient-centered care is provided.

BACKGROUND: Patients experiencing homelessness represent a disproportionate share of emergency department (ED) visits due to poor access to primary care and high levels of unmet health care needs. This is in part due to the difficulty of communicating and following up with patients who are experiencing homelessness. OBJECTIVE: To determine the prevalence and types of "new media" use among ED patients who experience homelessness. METHODS: This was a cross-sectional observational study with sequential enrolling of patients from three emergency departments 24/7 for 6 weeks. In total, 5788 ED patients were enrolled, of whom 249 experienced homelessness. Analyses included descriptive statistics, and unadjusted and adjusted odds ratios. RESULTS: 70.7% (176/249) of patients experiencing homelessness own cell phones compared to 85.90% (4758/5539) of patients in stable housing (P=.001) with the former more likely to own Androids, 70% (53/76) versus 43.89% (1064/2424), and the latter more likely to have iPhones, 44.55% (1080/2424) versus 17% (13/76) (P=.001). There is no significant difference in new media use, modality, or frequency for both groups; however, there is a difference in contract plan with 50.02% (2380/4758) of stably housed patients having unlimited minutes versus 37.5% (66/176) of homeless patients. 19.78% (941/4758) of patients in stable housing have pay-as-you-go plans versus 33.0% (58/176) of homeless patients (P=.001). Patients experiencing homelessness are more likely to want health information on alcohol/substance abuse, mental health, domestic violence, pregnancy and smoking cessation. CONCLUSIONS: This study is unique in its characterization of new media ownership and use among ED patients experiencing homelessness. New media is a powerful tool to connect patients experiencing homelessness to health care.

OBJECTIVES: We examined the proportion of homeless veterans among users of Veterans Affairs (VA) emergency departments (EDs) and compared sociodemographic and clinical characteristics of homeless and nonhomeless VA emergency department users nationally. METHODS: We used national VA administrative data from fiscal year 2010 for a cross-sectional study comparing homeless (n = 64,091) and nonhomeless (n = 866,621) ED users on sociodemographics, medical and psychiatric diagnoses, and other clinical characteristics. RESULTS: Homeless veterans had 4 times the odds of using EDs than nonhomeless veterans. Multivariate analyses found few differences between homeless and nonhomeless ED users on the medical conditions examined, but homeless ED users were more likely to have been diagnosed with a drug use disorder (odds ratio [OR] = 4.12; 95% confidence interval [CI] = 3.97, 4.27), alcohol use disorder (OR = 3.67; 95% CI = 3.55, 3.79), or schizophrenia (OR = 3.44; 95% CI = 3.25, 3.64) in the past year. CONCLUSIONS: In a national integrated health care system with no specific requirements for health insurance, the major differences found between homeless and nonhomeless ED users were high rates of psychiatric and substance abuse diagnoses. EDs may be an important location for specialized homeless outreach (or "in" reach) services to address mental health and addictive disorders.

Background: The HABC Monitor was developed to provide dementia care providers with a clinical tool for managing dementia symptoms similar to the blood pressure cuff used by clinicians and patients for managing hypertension. The HABC Monitor is an inexpensive, simple, user-friendly, easily standardized, sensitive-to-change, and widely available multi-domain instrument for clinical providers and informal caregivers to measure and monitor the severity of dementia symptoms. Two parallel versions of the tool were developed - the Caregiver Version (CG Version) that measures and monitors the severity of dementia symptoms through caregiver reports and the Self Report Version (SR Version) that relies on patient report. We have found in our memory care clinic that patients with less than severe cognitive impairment are able to complete the HABC Monitor and to provide valuable information that can be used in conjunction with reports from their corresponding caregiver. In our previous work, we found strong psychometric evidence for the reliability and validity of the CG Version as a clinically practical tool for measuring and monitoring the severity of dementia symptoms through caregiver report. The purpose of this study was to assess the reliability and validity of the SRVersion. Methods: The HABC-Monitor has three patient symptom domains (cognitive, functional, and behavioral/psychological) with parallel items for both the CG Version and the SRVersion. The Caregiver Quality of Life domain is included on the CG Version but not the SRVersion. Patients (n = 291) were consecutively approached and consented during a patient's routine visit to their primary care provider. The SR Version was administered to each patient during a subsequent phone interview. Results: The HABC-Monitor demonstrated excellent fit for the confirmatory factor analysis model (RMSEA = 0.020, CFI = 0.974, WRMR = 0.837); good internal consistency (0.78-0.92); and adequate knowngroups validity, indicated by significant separation of TICSm !

Urban legend has often characterized frequent emergency department (ED) patients as mentally ill substance users who are a costly drain on the health care system and who contribute to ED overcrowding because of unnecessary visits for conditions that could be treated more efficiently elsewhere. This study of Medicaid ED users in New York City shows that behavioral health conditions are responsible for a small share of ED visits by frequent users, and that ED use accounts for a small portion of these patients' total Medicaid costs. Frequent ED users have a substantial burden of disease, and they have high rates of primary and specialty care use. They also have linkages to outpatient care that are comparable to those of other ED patients. It is possible to use predictive modeling to identify who will become a repeat ED user and thus to help target interventions. However, policy makers should view reducing frequent ED use as only one element of more-comprehensive intervention strategies for frequent health system users.

BACKGROUND AND OBJECTIVE: Computerized decision aids could facilitate shared decision-making at the point of outpatient clinical care. The objective of this study was to investigate whether a computerized shared decision aid would be feasible to implement in an inner-city clinic by evaluating the current practices in shared decision-making, clinicians' use of computers, patient and clinicians' attitudes and beliefs toward computerized decision aids, and the influence of time on shared decision-making. METHODS: Qualitative data analysis of observations and semi-structured interviews with patients and clinicians at an inner-city outpatient clinic. FINDINGS: The findings provided an exploratory look at the prevalence of shared decision-making and attitudes about health information technology and decision aids. A prominent barrier to clinicians engaging in shared decision-making was a lack of perceived patient understanding of medical information. Some patients preferred their clinicians make recommendations for them rather than engage in formal shared decision-making. Health information technology was an integral part of the clinic visit and welcomed by most clinicians and patients. Some patients expressed the desire to engage with health information technology such as viewing their medical information on the computer screen with their clinicians. All participants were receptive to the idea of a decision aid integrated within the clinic visit although some clinicians were concerned about the accuracy of prognostic estimates for complex medical problems. IMPLICATIONS: We identified several important considerations for the design and implementation of a computerized decision aid including opportunities to: bridge clinician-patient communication about medical information while taking into account individual patients' decision-making preferences, complement expert clinician judgment with prognostic estimates, take advantage of patient waiting times, and make tasks involved during the clinic visit more efficient. These findings should be incorporated into the design and implementation of a computerized shared decision aid at an inner-city hospital.