Increasing the Capacity of Primary Care Through Enabling Technology.

Primary care is the foundation of effective and high-quality health care. The role of primary care clinicians has expanded to encompass coordination of care across multiple providers and management of more patients with complex conditions. Enabling technology has the potential to expand the capacity for primary care clinicians to provide integrated, accessible care that channels expertise to the patient and brings specialty consultations into the primary care clinic. Furthermore, technology offers opportunities to engage patients in advancing their health through improved communication and enhanced self-management of chronic conditions. This paper describes enabling technologies in four domains (the body, the home, the community, and the primary care clinic) that can support the critical role primary care clinicians play in the health care system. It also identifies challenges to incorporating these technologies into primary care clinics, care processes, and workflow

Effect of a novel transition program on disability after stroke: A trial protocol

Importance: A gap in care for stroke survivors exists at the point of transition from inpatient rehabilitation to home, when survivors encounter new environmental barriers because of the cognitive and sensorimotor sequelae of stroke. Resolving these barriers and improving independence in the community have the potential to significantly improve stroke survivors\u27 long-term morbidity. Objective: To investigate the efficacy and safety of a novel enhanced rehabilitation transition program to reduce environmental barriers and improve daily activity performance and community participation among stroke survivors. Design, Setting, and Participants: This is a phase 2b, single-blind, parallel-group, randomized clinical trial. Participants will be randomized using a 1:1 allocation ratio, stratified by Functional Independence Measure and age, to either attentional control or the intervention. Community Participation Transition After Stroke (COMPASS) is a complex intervention that uses 2 complementary evidence-based interventions: home modifications and strategy training delivered in the home. Community participation after stroke, measured by the Reintegration to Normal Living Index, is the primary outcome. Secondary outcomes include quality of life after stroke, measured by the Stroke Impact Scale, and daily activity performance and magnitude of environmental barriers in the home, both measured by the In-Home Occupational Performance Evaluation. An intention-to-treat analysis will be used. A total of 180 participants, who are 50 years or older, were independent in activities of daily living prior to stroke, and are undergoing inpatient rehabilitation following stroke with a plan to be discharged home, will be included in the study. Discussion: Stroke is a leading cause of serious long-term disability in the United States. The COMPASS study is ongoing. To date, 99 participants have been recruited and 77 randomized, with 37 in the treatment group and 40 in the control group. Resumption of previous activities immediately after discharge can improve immediate and long-term community participation. Results from this study will fill a critical gap in stroke rehabilitation evidence by providing important information about the long-term community participation and daily activity performance among stroke survivors as well as environmental barriers in their homes. Trial Registration: ClinicalTrials.gov identifier: NCT03485820

An Integrative Health Approach for Geriatrics With Neurocognitive Disorders Living in a Care Facility

Integrative health (IH) has been shown in the literature to decrease resistance to cares and behaviors and improve apathy levels, patient-staff relationships, and quality of life in patients with neurocognitive disorders (NCD), formerly known as dementia, yet there continues to be a lack of implementation of these modalities. Coinciding with this, many CNAs working in care facilities are faced with decreases in job satisfaction due to disconnect they experience with these patients. This project was designed for CNAs to pilot a soothing touch protocol to a Midwestern care facility’s residents to improve CNA’s job satisfaction; increase connectivity, peace, and closeness; and promote a higher quality of life in this vulnerable population. The Plan-Do-Study-Act (PDSA) model was used for implementing this piloted change. This project demonstrated that stakeholder support along with face-to-face experiential education of this complementary intentional soothing touch protocol led to a successful implementation with 100% of CNAs reporting it was a manageable, feasible, and effective way to calm residents and 100% of CNAs stating they would continue to implement the protocol into their cares after the completion of this project

Medication Management: The Macrocognitive Workflow of Older Adults With Heart Failure

BACKGROUND: Older adults with chronic disease struggle to manage complex medication regimens. Health information technology has the potential to improve medication management, but only if it is based on a thorough understanding of the complexity of medication management workflow as it occurs in natural settings. Prior research reveals that patient work related to medication management is complex, cognitive, and collaborative. Macrocognitive processes are theorized as how people individually and collaboratively think in complex, adaptive, and messy nonlaboratory settings supported by artifacts. OBJECTIVE: The objective of this research was to describe and analyze the work of medication management by older adults with heart failure, using a macrocognitive workflow framework. METHODS: We interviewed and observed 61 older patients along with 30 informal caregivers about self-care practices including medication management. Descriptive qualitative content analysis methods were used to develop categories, subcategories, and themes about macrocognitive processes used in medication management workflow. RESULTS: We identified 5 high-level macrocognitive processes affecting medication management-sensemaking, planning, coordination, monitoring, and decision making-and 15 subprocesses. Data revealed workflow as occurring in a highly collaborative, fragile system of interacting people, artifacts, time, and space. Process breakdowns were common and patients had little support for macrocognitive workflow from current tools. CONCLUSIONS: Macrocognitive processes affected medication management performance. Describing and analyzing this performance produced recommendations for technology supporting collaboration and sensemaking, decision making and problem detection, and planning and implementation

Human factors analysis, design, and evaluation of Engage, a consumer health IT application for geriatric heart failure self-care

Human factors and ergonomics (HFE) and related approaches can be used to enhance research and development of consumer-facing health IT systems, including technologies supporting the needs of people with chronic disease. We describe a multiphase HFE study of health IT supporting self-care of chronic heart failure by older adults. The study was based on HFE frameworks of "patient work" and incorporated the three broad phases of user-centered design: study or analysis; design; and evaluation. In the study phase, data from observations, interviews, surveys, and other methods were analyzed to identify gaps in and requirements for supporting heart failure self-care. The design phase applied findings from the study phase throughout an iterative process, culminating in the design of the Engage application, a product intended for continuous use over 30 days to stimulate self-care engagement, behavior, and knowledge. During the evaluation phase, we identified a variety of usability issues through expert heuristic evaluation and laboratory-based usability testing. We discuss the implications of our findings regarding heart failure self-care in older adults and the methodological challenges of rapid translational field research and development in this domain

Considerations in Designing Human-Computer Interfaces for Elderly People

As computing devices continue to become more heavily integrated into our lives, proper design of human-computer interfaces becomes a more important topic of discussion. Efficient and useful human-computer interfaces need to take into account the abilities of the humans who will be using such interfaces, and adapt to difficulties that different users may face – such as the difficulties that elderly users must deal with. Interfaces that allow for user-specific customization, while taking into account the multiple difficulties that older users might face, can assist the elderly in properly using these newer computing devices, and in doing so possibly achieving a better quality of life through the advanced technological support that these devices offer. In this paper, we explore common problems the elderly face when using computing devices and solutions developed for these problems. Difficulties ultimately fall into several categories: cognition, auditory, haptic, visual, and motor-based troubles. We also present an idea for a new adaptive operating system with advanced customizations that would simplify computing for older users

An Analysis of the Work System Framework for Examining Information Exchange in a Healthcare Setting

Lack of communication is a leading root cause of sentinel events (any unanticipated event in a healthcare setting resulting in a patient’s death or serious physical or psychological injury and not related to the natural course of the patient\u27s illness). Deficits in communication of essential information when patients transfer between different healthcare services can cause interruptions in the continuity of care, inappropriate treatment, and potential harm to the patient. Research has shown that providing the right information about the right patient to healthcare providers at the right time could eliminate up to 18 percent of the general adverse events. In this paper, we assess the applicability of the work system framework (WSF) to evaluate the health information-exchange processes that occur when patients are transferred from home healthcare services and nursing homes to hospitals. From our analysis, we identify possible improvements in both work practices and the flow of health information among healthcare providers. Further, we propose a modified work system snapshot template tailored for evaluating the health information-exchange process. The proposed modifications include changing the WSF terminology to healthcare terms (including patient safety indicators) and adding new performance measurement indicators that are relevant to healthcare

Performance-Shaping Factors Affecting Older Adults' Hospital-to-Home Transition Success: A Systems Approach

Background and Objectives Facilitating older adults’ successful hospital-to-home transitions remains a persistent challenge. To address this challenge, we applied a systems lens to identify and understand the performance-shaping factors (PSFs) related older adults’ hospital-to-home transition success. Research Design and Methods This study was a secondary analysis of semi-structured interviews from older adults (N = 31) recently discharged from a hospital and their informal caregivers (N = 13). We used a Human Factors Engineering approach to guide qualitative thematic analysis to develop four themes concerning the system conditions shaping hospital-to-home transition success. Results The four themes concerning PSFs were: (a) the hospital-to-home transition was a complex multiphase process—the process unfolded over several months and required substantial, persistent investment/effort; (b) there were unmet needs for specialized tools—information and resources provided at hospital discharge were not aligned with requirements for transition success; (c) alignment of self-care routines with transition needs—pre-hospitalization routines could be supportive/disruptive and could deteriorate/be re-established; and (d) changing levels of work demand and capacity during the transition—demand often exceeded capacity leading to work overload. Discussion and Implications Our findings highlight that the transition is not an episodic event, but rather a longitudinal process extending beyond the days just after hospital discharge. Transition interventions to improve older adults’ hospital-to-home transitions need to account for this complex multiphase process. Future interventions must be developed to support older adults and informal caregivers in navigating the establishment and re-establishment of routines and managing work demands and capacity during the transition process

Barriers to Nurses’ Promoting Mobility in Hospitalized Older Adults

Objectives: To examine the association between nurses’ knowledge, attitude and external barriers and the nurse’s mobility-promoting behavior. Nurse perception of the priority organizations place on mobility, and the relationship of nurses’ level of experience to nurse prioritization for promoting mobility was also investigated. Design: Cross-sectional, descriptive, correlation study with convenience sampling. Setting: Two community-based hospitals in the Pacific Northwest of the U.S. Participants: Eighty-five nurses caring for 98 inpatients 65 and older. Measurement: Nurses’ knowledge, attitude and external barriers were examined with a validated 5-point Likert Scale. Patient-related and other clinical barriers and the nurses mobility-promoting behavior was obtained with the validated self-recorded mobility log. Patient Basic Metabolic Index (BMI) and severity of illness was obtained though data extraction. Results: Nurses viewed the promotion of mobility as important, yet mobilizing older patients was infrequent. Nurses perceived a number of barriers to promoting mobility: Patient condition, the perception that patients could be harmed during mobilization, perceptions of heavy workload, difficulty prioritizing nursing care, and staffing shortages. While novice nurses had lower priority to promote mobility compared to more experienced nurses, novice nurses tended to promote more mobility. Conclusion: As nurses care for hospitalized older adults the convergence of interpersonal, patient, and environmental complexities acting as barriers to mobility need to be considered. It is important to understand the needs of beginning, less experienced nurses to overcome the barriers to promoting mobility. This study shows that even experienced nurses need to overcome barriers to promoting mobility. Hospitals need to address the needs of the novice nurse while enhancing the practice of more experienced nurses in order to support nurse-promoted mobility. The findings from this study show that nurses knowledge, attitude, and external barriers could play a role in the low levels of mobility in hospitalized older adults

Exploring the Perceived Meaning of Community-Based Lifestyle Wellness Programs, Interprofessional Collaboration, and the Relationship to Occupational Therapy: A Phenomenological Approach

Community-based health care providers use interprofessional collaborative strategies to support the lifestyle wellness needs of older adult clients at risk for chronic disease. A phenomenological approach was taken to explore a sample of community-based health care professionals’ shared meanings of lifestyle wellness programming, interprofessional collaboration, and the Lifestyle Redesign® program and to determine the perceived relationship to occupational therapy, if any. The qualitative descriptive thematic analysis within the Framework of Occupational Justice context revealed positive perceptions of lifestyle wellness programming and interprofessional collaboration but limited awareness of Lifestyle Redesign® and occupational therapy’s distinct role in community-based preventive wellness. Occupational therapy leaders can proactively enhance interprofessional collaboration to bridge these knowledge gaps and mainstream comprehensive occupation-based, client-centered lifestyle wellness interventions for older adults in the community. Future mixed methods surveys, focus groups, or participatory action research are recommended to build upon the findings from this preliminary study