Falls Prevention for Older Adults.

This article summarizes a 2022 clinical practice guideline on falls prevention and management in older adults from the World Falls Guidelines Initiative.

Exploring Models of Exposure to Primary Care Careers in Training: a Narrative Review.

Multiple models of clinical exposure to primary care exist within undergraduate medical education (UME) and graduate medical education (GME). In this narrative review, we explore the evidence behind these different models of exposure, their alignment with positive promoters of primary care careers, and the pros and cons of each. Without positive exposure to primary care during training, sustaining the future primary care work force becomes increasingly challenging. Here, we explore multiple models of clinical exposure in UME, including longitudinal integrated clerkships, primary care tracks, and primary care clerkships. Within GME, we will review the impact of primary care tracks, Area Health Education Centers, block scheduling models, and continuity clinic scheduling models. The goal of this narrative review is to allow educators to think broadly and intentionally about the array of models to develop positive primary care experiences and perceptions in training, ultimately sustaining the primary care workforce.

Diagnosis and Management of Nonalcoholic Fatty Liver Disease.

This JAMA Clinical Guidelines Synopsis summarizes the American Association of Clinical Endocrinology's 2022 clinical practice guideline for diagnosis and management of nonalcoholic fatty liver disease.

Development and Piloting of a Community-Partnered Heart Failure Training Course for Home Health Care Workers.

BACKGROUND: Despite their unique contributions to heart failure (HF) care, home healthcare workers (HHWs) have unmet educational needs and many lack HF caregiving self-efficacy. To address this, we used a community-partnered approach to develop and pilot a HF training course for HHWs. METHODS: We partnered with the Training and Employment Fund, a benefit fund of the largest healthcare union in the United States, to develop a 2-hour virtual HF training course that met HHWs' job-specific needs. English and Spanish-speaking HHWs interested in HF training, with access to Zoom, were eligible. We used a mixed methods design with pre/postsurveys and semi-structured interviews to evaluate the course: (a) feasibility, (b) acceptability, and (c) effectiveness (change in knowledge [Dutch Heart Failure Knowledge Scale range 0-15] and caregiving self-efficacy [HF Caregiver Self-efficacy Scale range 0-100]). RESULTS: Of the 210 HHWs approached, 100 were eligible and agreed, and 70 enrolled. Of them, 53 (employed by 15 different home care agencies) participated. Posttraining data showed significant improvements (pretraining mean [SD] versus posttraining mean [SD]; P value) in HF knowledge (11.21 [1.90] versus 12.21 [1.85]; P=0.0000) and HF caregiving self-efficacy (75.21 [16.57] versus 82.29 [16.49]; P=0.0017); the greatest gains occurred among those with the lowest pre-training scores. Participants found the course engaging, technically feasible, and highly relevant to their scope of care. CONCLUSIONS: We developed and piloted the first HF training course for HHWs, which was feasible, acceptable, and improved their HF knowledge and caregiving self-efficacy. Our findings warrant scalability to the workforce at large with a train-the-trainer model.

Health Priorities of Multi-Morbid Ambulatory Patients in New York City During the COVID-19 Pandemic: A Qualitative Analysis.

During the COVID-19 pandemic, adults with chronic conditions delayed or avoided seeking preventative and general medical care, leading to adverse consequences for morbidity and mortality. In order to bring patients back into care, we, in this qualitative study, sought to understand the foremost health-related needs of our multi-morbid ambulatory patients to inform future outreach interventions. Via a telephone-based survey of our high-risk patients, defined using a validated EPIC risk model for hospitalization and ED visits, we surveyed 214 participants an open-ended question, "What is your top health concern that you would like to speak with a doctor or nurse about". We found 4 major themes: 1) primary care matters, 2) disruptions in health care, 3) COVID-19's impact on physical and mental health, and 4) amplified social vulnerabilities. Our results suggest that interventions that reduce barriers to preventative services and disruptions to healthcare delivery are needed.

Factors Associated with Never Having Had A Video Visit.

INTRODUCTION: Disparities in access to video-visit services have been described during the COVID-19 pandemic. Thus, we aimed to examine factors associated with not having a video-visit among a medically high-risk ambulatory population. METHODS: In this cross-sectional study, our telephone-based survey was designed to understand the health-related challenges, social needs, and access to and attitudes toward video-visit. RESULTS: In the multivariable analysis, having fewer symptoms unrelated to COVID, more barriers to medications, and less confidence with video-visit software were significantly associated with an increased prevalence of not having a video-visit. CONCLUSIONS: Our findings suggest that additional efforts are needed to eliminate disparate video-visit use.

Eliciting the educational priorities of home care workers caring for adults with heart failure.

BACKGROUND: Although home care workers (HCWs) are increasingly caring for adults with heart failure (HF), many feel unprepared and lack HF training. To serve as the foundation for a future educational intervention, we aimed to elicit HCWs' HF educational needs. METHODS: We partnered with the largest healthcare union in the US to recruit 41 HCWs employed by 17 home care agencies. Using the nominal group technique, we asked HCWs to respond to three questions: When caring for an HF patient: (1) What information do you want? (2) What symptoms worry you? (3) What situations do you struggle with? Participants ranked their responses by priority. Data were consolidated by question. RESULTS: For question 1, participants ranked HF signs and symptoms most highly, followed by HF treatment and medications. For question 2, chest pain was most worrisome, followed by neurologic changes and shortness of breath. For question 3, participants struggled with encouraging patients to follow a heart-specific diet. CONCLUSIONS: HCWs expressed a need to learn more about signs and symptoms of HF and ways to assist patients with HF self-care. These findings can inform the development of an HF training program for HCWs that specifically addresses their expressed needs.

Eliciting the educational needs and priorities of home care workers on end-of-life care for patients with heart failure using nominal group technique.

BACKGROUND: Home care workers, as paid caregivers, assist with many aspects of home-based heart failure care. However, most home care workers do not receive systematic training on end-of-life care for heart failure patients. AIM: To elicit the educational needs and priorities of home care workers caring for community- dwelling adults with heart failure at the end-of-life. DESIGN: Nominal group technique involving a semi-quantitative structured group process and point rating system was used to designate the importance of priorities elicited from home care workers. Individual responses to the question, "If you have ever cared for a heart failure patient who was dying (or receiving end-of-life care on hospice), what are some of the challenges you faced?", were aggregated into categories using directed content analysis methods. SETTING/PARTICIPANTS: Forty-one home care workers were recruited from a non-profit training and education organization in New York City. RESULTS: Individual responses to the question were aggregated into five categories: (1) how to cope and grieve; (2) assisting patients with behavior changes, (3) supporting patients to improve their quality of life, (4) assisting patients with physical symptom management, and (5) symptom recognition and assessment. CONCLUSIONS: Our findings confirm the need for the formal development and evaluation of an educational program for home care workers to improve the care of heart failure patients at the end-of-life. There is also a need for research on integrating home care workers into the interprofessional healthcare team to support optimal health outcomes for patients with heart failure.

Understanding the Workflow of Home Health Care for Patients with Heart Failure: Challenges and Opportunities.

BACKGROUND: Readmission rates are high among heart failure (HF) patients who require home health care (HHC) after hospitalization. Although HF patients who require HHC are often sicker than those who do not, HHC delivery itself may also be suboptimal. OBJECTIVE: We aimed to describe the workflow of HHC among adults discharged home after a HF hospitalization, including the roles of various stakeholders, and to determine where along these workflow challenges and opportunities for improvement exist. DESIGN AND PARTICIPANTS: In this qualitative study, we used purposeful sampling to approach and recruit a variety of key stakeholders including home health aides, nurses, HF patients, family caregivers, physicians, social workers, home care agency leaders, and policy experts. The study took place in New York, NY, from March to October 2018. APPROACH: Using a semi-structured topic guide, we elicited participants' experiences with HHC in HF through a combination of one-on-one interviews and focus groups. Data were recorded, transcribed, and analyzed thematically. We also asked selected participants to depict in a drawing their understanding of HHC workflow after hospitalization for HF patients. We synthesized the drawings into a final image. KEY RESULTS: Study participants (N = 80) described HHC for HF patients occurring in 6 steps, with home health aides playing a main role: (1) transitioning from hospital to home; (2) recognizing clinical changes; (3) making decisions; (4) managing symptoms; (5) asking for help; and (6) calling 911. Participants identified challenges and opportunities for improvement for each step. CONCLUSIONS: Our findings suggest that HHC for HF patients occurs in discrete steps, each with different challenges. Rather than a one-size-fits-all approach, various interventions may be required to optimize HHC delivery for HF patients in the post-discharge period.

"It's Like They Forget That the Word 'Health' Is in 'Home Health Aide'": Understanding the Perspectives of Home Care Workers Who Care for Adults With Heart Failure.

Background Home care workers ( HCW s) increasingly provide long-term and posthospitalization care for community-dwelling adults with heart failure ( HF ). They observe, assist, and advise these patients, yet few studies have examined their role in HF . As the foundation for future interventions, we sought to understand the perspectives of HCW s caring for adults with HF . Methods and Results We conducted 8 focus groups in partnership with the Home Care Industry Education Fund, a benefit fund of the 1199 Service Employees International Union United Healthcare Workers East, the largest healthcare union in the United States. English- and Spanish-speaking HCW s with HF clients were eligible to participate. Data were analyzed thematically. Forty-six HCW s employed by 21 unique home care agencies participated. General and HF -specific themes emerged. Generally, HCW s (1) feel overworked and undervalued; (2) find communication and care to be fragmented; (3) are dedicated to clients and families but are caught in the middle; and, despite this, (4) love their job. With respect to HF , HCW s (1) find it frightening and unpredictable; (2) are involved in HF self-care without any HF training; and (3) find the care plan problematic. Conclusions Although frequently involved in HF self-care, most HCW s have not received HF training. In addition, many felt poorly supported by other healthcare providers and the care plan, especially when their clients' symptoms worsened. Interventions that provide HF -specific training and aim to improve communication between members of the home health care team may enhance HCW s' ability to care for adults with HF and potentially lead to better patient outcomes.