Implementing Models of Geriatric Care—Behind the Scenes

Innovative geriatric clinical programs have proliferated in the 21st century, and many have been highlighted in the Journal of the American Geriatrics Society (JAGS). The Affordable Care Act has supported the accelerated innovation of publicized and unpublicized program development, adaptation, and implementation. Many JAGS articles report work conducted in programs with significant improvements in quality; high satisfaction for patients and providers; and for some, reductions in costs. Despite considerable detail, enabling implementers to attempt to adopt reported programs or adapt them to local environments, much less is typically conveyed about the subtleties of the implementation process that led to a successful outcome. Moreover, where we have been given a window into successful initiatives, far less is known about those that failed and even less about why some succeeded but others failed. With a focus on our shared needs as a geriatrics community, to foster the exchange of more‐comprehensive models of successful and failed implementation, we propose publications that address implementation itself—a second layer of reporting about the “hidden” elements that may have been decisive factors in taking an efficacious test, treatment, or model and putting it into real‐world practice. We propose a new platform for sharing a broader range of healthcare quality improvement initiatives—successes and failures. We include several salient characteristics that could be measured and described in support of dynamic, sustainable, evidence‐based implementation of geriatrics programs

Interaction between cognitive impairment and discharge destination and its effect on rehospitalization

OBJECTIVES: To evaluate the effect of cognitive impairment on rehospitalization in older adults. DESIGN: One-year longitudinal study. SETTING: Medical service of an urban, 340-bed public hospital in Indianapolis between July 2006 and March 2008. PARTICIPANTS: Individuals aged 65 and older admitted to the medical service (N = 976). MEASUREMENTS: Rehospitalization was defined as any hospital admission after the index admission. Participant demographics, discharge destination, Charlson Comorbidity Index, Acute Physiology Score, and prior hospitalizations were measured as the confounders. Participants were considered to have cognitive impairment if they had two or more errors on the Short Portable Mental Status Questionnaire. RESULTS: After adjusting for confounders, a significant interaction between cognitive impairment and discharge location was found to predict rehospitalization rate (P = .008) and time to 1-year rehospitalization (P = .03). Participants with cognitive impairment discharged to a facility had a longer time to rehospitalization (median 142 days) than participants with no cognitive impairment (median 98 days) (hazard ratio (HR) = 0.77, 95% confidence interval (CI) = 0.58-1.02, P = .07), whereas participants with cognitive impairment discharged to home had a slightly shorter time to rehospitalization (median 182 days) than those without cognitive impairment (median 224 days) (HR = 1.15, 95% CI = 0.92-1.43, P = .23). These two nonsignificant HRs in opposite directions were significantly different from each other (P = .03). CONCLUSION: Discharge destination modifies the association between cognitive impairment and rehospitalization. Of participants discharged to a facility, those without cognitive impairment had higher rehospitalization rates, whereas the rates were similar between cognitively impaired and intact participants discharged to the community

Predicting the Next Eye Pathogen: Analysis of a Novel Adenovirus

For DNA viruses, genetic recombination, addition, and deletion represent important evolutionary mechanisms. Since these genetic alterations can lead to new, possibly severe pathogens, we applied a systems biology approach to study the pathogenicity of a novel human adenovirus with a naturally occurring deletion of the canonical penton base Arg-Gly-Asp (RGD) loop, thought to be critical to cellular entry by adenoviruses. Bioinformatic analysis revealed a new highly recombinant species D human adenovirus (HAdV-D60). A synthesis of in silico and laboratory approaches revealed a potential ocular tropism for the new virus. In vivo, inflammation induced by the virus was dramatically greater than that by adenovirus type 37, a major eye pathogen, possibly due to a novel alternate ligand, Tyr-Gly-Asp (YGD), on the penton base protein. The combination of bioinformatics and laboratory simulation may have important applications in the prediction of tissue tropism for newly discovered and emerging viruses

A Descriptive Analysis of an Ambulatory Kidney Palliative Care Program

Background: Many patients with serious kidney disease have an elevated symptom burden, high mortality, and poor quality of life. Palliative care has the potential to address these problems, yet nephrology patients frequently lack access to this specialty. Objectives: We describe patient demographics and clinical activities of the first 13 months of an ambulatory kidney palliative care (KPC) program that is integrated within a nephrology practice. Design/Measurements: Utilizing chart abstractions, we characterize the clinic population served, clinical service utilization, visit activities, and symptom burden as assessed using the Integrated Palliative Care Outcome Scale-Renal (IPOS-R), and patient satisfaction. Results: Among the 55 patients served, mean patient age was 72.0 years (standard deviation [SD] = 16.7), 95% had chronic kidney disease stage IV or V, and 46% had a Charlson Comorbidity Index \u3e8. The mean IPOS-R score at initial visit was 16 (range = 0-60; SD = 9.1), with a mean of 7.5 (SD = 3.7) individual physical symptoms (range = 0-15) per patient. Eighty-seven percent of initial visits included an advance care planning conversation, 55.4% included a medication change for symptoms, and 35.5% included a dialysis decision-making conversation. Overall, 96% of patients who returned satisfaction surveys were satisfied with the care they received and viewed the KPC program positively. Conclusions: A model of care that integrates palliative care with nephrology care in the ambulatory setting serves high-risk patients with serious kidney disease. This KPC program can potentially meet documented gaps in care while achieving patient satisfaction. Early findings from this program evaluation indicate opportunities for enhanced patient-centered palliative nephrology care

Study protocol: BRInging the Diabetes prevention program to GEriatric Populations

In the Diabetes Prevention Program (DPP) randomized, controlled clinical trial, participants who were  ≥ 60 years of age in the intensive lifestyle (diet and physical activity) intervention had a 71% reduction in incident diabetes over the 3-year trial. However, few of the 26.4 million American adults age ≥65 years with prediabetes are participating in the National DPP. The BRInging the Diabetes prevention program to GEriatric Populations (BRIDGE) randomized trial compares an in-person DPP program Tailored for Older AdulTs (DPP-TOAT) to a DPP-TOAT delivered via group virtual sessions (V-DPP-TOAT) in a randomized, controlled trial design (N = 230). Eligible patients are recruited through electronic health records (EHRs) and randomized to the DPP-TOAT or V-DPP-TOAT arm. The primary effectiveness outcome is 6-month weight loss and the primary implementation outcome is intervention session attendance with a non-inferiority design. Findings will inform best practices in the delivery of an evidence-based intervention

The University of California at Los Angeles Alzheimers and Dementia Care program for comprehensive, coordinated, patient-centered care: preliminary data.

Dementia is a chronic disease that requires medical and social services to provide high-quality care and prevent complications. As a result of time constraints in practice, lack of systems-based approaches, and poor integration of community-based organizations (CBOs), the quality of care for dementia is poorer than that for other diseases that affect older persons. The University of California at Los Angeles (UCLA) Alzheimers and Dementia Care (UCLA ADC) program partners with CBOs to provide comprehensive, coordinated, patient-centered care for individuals with Alzheimers disease and other dementias. The goals of the program are to maximize function, independence, and dignity; minimize caregiver strain and burnout; and reduce unnecessary costs. The UCLA ADC program consists of five core components: recruitment and a dementia registry, structured needs assessments of individuals in the registry and their caregivers, creation and implementation of individualized dementia care plans based on needs assessments and input from the primary care physicians, monitoring and revising care plans as needed, and around-the-clock access for assistance and advice. The program uses a comanagement model with a nurse practitioner Dementia Care Manager working with primary care physicians and CBOs. Based on the first 150 individuals served, the most common recommendations in the initial care plans were referrals to support groups (73%) and Alzheimers Association Safe Return (73%), caregiver training (45%), and medication adjustment (41%). The program will be evaluated on its ability to achieve the triple aim of better care for individuals, better health for populations, and lower costs