Home-Based Care for Lesbian, Gay, Bisexual, Transgender, Queer or Questioning, or another diverse gender identity Older Adults.

The home-based medicine ecosystem is rapidly expanding. With this expansion, it is increasingly important to understand the unique needs of homebound older adults. There is likely significant intersectionality across the lesbian, gay, bisexual, transgender, queer or questioning, or another diverse gender identity (LGBTQ+) older adult population and the homebound population. This article begins to outline some strategies and approaches to entering the home of LGBTQ+ older adults in inclusive and trauma-informed ways and encourages home-based care teams, organizations, and health systems to utilize existing resources created by the LGBTQ+ aging community to provide universal skills training for the workforce.

Applying a trauma-informed approach to home visits.

The concept of trauma and traumatic stress and its impact on health and mental health has been studied for nearly half a century. Trauma-informed care (TIC) is person-centered care designed and delivered based on knowledge of the ubiquity of trauma. It requires building an understanding of the role that trauma plays in the lives and health outcomes of survivors. In doing so, it helps promote physical, psychological, and emotional safety for both clinicians and patients. Trauma and traumatic events are cumulative over the lifespan, and individuals who have experienced trauma are at higher risk for re-traumatization and poorer health outcomes. TIC approaches have been applied in many healthcare settings successfully; however, to date, there have not been any recommendations made about applying these approaches to care of homebound older adults, even though it may be surmised that this population is at an especially high risk for prior trauma and entering a person's safe space could be especially sensitive for trauma survivors. This paper serves to provide specific recommendations for applying a trauma-informed approach to a home visit and provides recommendations to home-based primary care groups and health systems about implementing universal trauma-informed care to homebound older adults.

The medicare annual wellness visit: an opportunity to improve geriatric knowledge among internal medicine resident physicians.

The Medicare Annual Wellness Visit (AWV) screens for risk factors of functional decline in older adults. However, the extent to which internal medicine resident physicians ("residents") perform the AWV and feel confident in addressing its clinical topics has not been formally assessed. The number of AWVs completed by 47 residents and 15 general internists in a primary care clinic were calculated for June 2020 through May 2021. In June 2021, the residents were surveyed about their knowledge, skills, and confidence regarding the AWV. Residents averaged four completed AWVs, whereas general internists averaged 54 completed AWVs. 85% of residents responded to the survey; 67% of these resident respondents felt somewhat confident or confident that they understood the purpose of the AWV, and 53% felt similarly confident explaining the AWV to patients. Residents felt somewhat confident or confident treating depression/anxiety (95%), substance use (90%), falls (72%), and completing an advance directive (72%). The topics fewer residents felt somewhat confident or confident addressing were fecal incontinence (50%), IADLs (45%), and physical/emotional/sexual abuse (45%). By better understanding topics where residents are least confident, we identify opportunities for curriculum development in geriatric care and potentially increase the utility of the AWV as a screening tool.

Oxylipin biosynthetic gene families of Cannabis sativa.

Cannabis sativa is a global multi-billion-dollar cash crop with numerous industrial uses, including in medicine and recreation where its value is largely owed to the production of pharmacological and psychoactive metabolites known as cannabinoids. Often underappreciated in this role, the lipoxygenase (LOX)-derived green leaf volatiles (GLVs), also known as the scent of cut grass, are the hypothetical origin of hexanoic acid, the initial substrate for cannabinoid biosynthesis. The LOX pathway is best known as the primary source of plant oxylipins, molecules analogous to the eicosanoids from mammalian systems. These molecules are a group of chemically and functionally diverse fatty acid-derived signals that govern nearly all biological processes including plant defense and development. The interaction between oxylipin and cannabinoid biosynthetic pathways remains to be explored. Despite their unique importance in this crop, there has not been a comprehensive investigation focusing on the genes responsible for oxylipin biosynthesis in any Cannabis species. This study documents the first genome-wide catalogue of the Cannabis sativa oxylipin biosynthetic genes and identified 21 LOX, five allene oxide synthases (AOS), three allene oxide cyclases (AOC), one hydroperoxide lyase (HPL), and five 12-oxo-phytodienoic acid reductases (OPR). Gene collinearity analysis found chromosomal regions containing several isoforms maintained across Cannabis, Arabidopsis, and tomato. Promoter, expression, weighted co-expression genetic network, and functional enrichment analysis provide evidence of tissue- and cultivar-specific transcription and roles for distinct isoforms in oxylipin and cannabinoid biosynthesis. This knowledge facilitates future targeted approaches towards Cannabis crop improvement and for the manipulation of cannabinoid metabolism.

Inequities in the care of older adults: Identifying education gaps in geriatric medicine fellowship.

The past year amplified inequities in the care of older adults. Milestones focused on social determinants of health (SDOH) are lacking within Geriatric fellowship training. A virtual learning collaborative GERIAtrics Fellows Learning Online And Together (GERI-A-FLOAT) was developed to connect trainees nationwide. To address gaps in education around SDOH, a needs assessment was conducted to inform a curricular thread. A voluntary, anonymous survey was distributed to fellows through a broad network. We sought to understand prior curricula trainees had that were specifically focused on SDOH and older adults. Respondents prioritized topic areas for the curriculum. Seventy-five respondents completed the survey. More than 50% of participants indicated no training on homelessness, immigration, racism, or LGBTQ+ health at any level of medical training, with more than 70% having no training in sexism or care of formerly incarcerated older adults. The most commonly taught concepts were ableism, ageism, and poverty. Respondents prioritized the topic of racism, ageism, and ableism. There is a lack of consistent SDOH curricula pertaining to older adults across all levels of training. This needs assessment is guiding a curricular thread for GERI-A-FLOAT and ideally larger milestones for fellowships. The time is now to prepare future geriatricians to serve as change agents.

Assessing the wellbeing of family caregivers of multimorbid and homebound older adults-A scoping literature review.

BACKGROUND: The prevalence of homebound older adults in the United States more than doubled during the COVID-19 pandemic with greater burden on family caregivers. Higher caregiver burden, more specifically higher treatment burden, contributes to increased rates of nursing home placement. There exist a multitude of tools to measure caregiver well-being and they vary substantially in their focus. Our primary aim was to perform a scoping literature review to identify tools used to assess the facets of caregiver well-being experienced by caregivers of persons with multiple chronic conditions (MCC) with a special focus on those caregivers of homebound adult patients. METHODS: The search was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) extension for scoping reviews. After refining search terms, searches were performed of the peer-reviewed and gray literature. RESULTS: After removal of duplicate studies, a total of 5534 total articles were screened for relevance to our study. After all screening and review were completed, 377 total articles remained for full review which included 118 different quantitative tools and 20 different qualitative tools. We identified the 15 most commonly utilized tools in patients with MCC. The Zarit Burden Interview was the most commonly used tool across all of the studies. Of the 377 total studies, only eight of them focused on the homebound population and included 13 total tools. CONCLUSIONS: Building on prior categorization of well-being tools, our work has identified several tools that can be used to measure caregiver well-being with a specific focus on those caregivers providing support to older adults with MCC. Most importantly, we have identified tools that can be used to measure caregiver well-being of family caregivers providing support to homebound older adults, an ever-growing population who are high cost and high utilizers of health care services.

Home Based Palliative Care: Known Benefits and Future Directions.

Purpose of Review: To summarize key recent evidence regarding the impact of Home-Based Palliative Care (HBPalC) and to highlight opportunities for future study. Recent Findings: HBPalC is cost effective and benefits patients and caregivers across the health care continuum. Summary: High-quality data support the cost effectiveness of HBPalC. A growing literature base supports the benefits of HBPalC for patients, families, and informal caregivers by alleviating symptoms, reducing unwanted hospitalizations, and offering support at the end of life. Numerous innovative HBPalC models exist, but there is a lack of high-quality evidence comparing specific models across subpopulations. Our wide literature search captured no research regarding HBPalC for underserved populations. Further research will also be necessary to guide quality standards for HBPalC.

Healthcare-Seeking Behaviors Among Medicare Beneficiaries by Functional Hearing Status.

Objective: Hearing loss is associated with higher health expenditures and poor healthcare utilization. This study aims to build on these findings by characterizing the association between hearing status and healthcare-seeking behaviors among Medicare beneficiaries. Methods: Cross-sectional log-binominal regression was used to assess the association between self-report hearing and healthcare-seeking behaviors (avoidance or delay of care, personal health concerns, and sharing health status) using the 2016 Medicare Current Beneficiary Survey (N = 12,140). Results: Beneficiaries with trouble hearing had significantly higher risks of avoiding and delaying health care compared to those without trouble hearing. Conversely, trouble hearing was not associated with concern for health status or sharing health status. Discussion: These findings may help explain higher costs associated with hearing loss as avoidance of care can exacerbate health problems. Further work is needed to understand underlying causes and whether addressing hearing loss modifies the observed association.

COVID-19 Pandemic Response: Development of Outpatient Palliative Care Toolkit Based on Narrative Communication.

CONTEXT: The coronavirus disease 2019 (COVID-19) pandemic laid bare the immediate need for primary palliative care education for many clinicians. Primary care clinicians in our health system reported an urgent need for support in advance care planning and end-of-life symptom management for their vulnerable patients. This article describes the design and dissemination of palliative care education for primary care clinicians using an established curriculum development method. OBJECTIVES: To develop a succinct and practical palliative care toolkit for use by primary care clinicians during the COVID-19 pandemic, focused on 2 key elements: (i) advance care planning communication skills based on the narrative 3-Act Model and (ii) comfort care symptom management at the end of life. RESULTS: The toolkit was finalized through an iterative process involving a team of end-users and experts in palliative care and primary care, including social work, pharmacy, nursing, and medicine. The modules were formatted into an easily navigable, smartphone-friendly document to be used at point of care. The toolkit was disseminated to our institution's primary care network with practices spanning our state. Early feedback has been positive. CONCLUSION: While we had been focused primarily on the inpatient setting, our palliative care team at Johns Hopkins Bayview Medical Center pivoted existing infrastructure and curriculum development expertise to meet the expressed needs of our primary care colleagues during the COVID-19 pandemic. Through collaboration with an interprofessional team including end-users, we designed and disseminated a concise palliative care toolkit within 6 weeks.

Sociodemographic Factors Associated with Types of Projects Implemented by Volunteer Lay Health Educators in Their Congregations.

This study focused on the association between type of community health interventions and lay health educator variables. Lay health educators are volunteers from local faith communities who complete a healthcare training program, taught by physicians in-training. Lay health educators are instructed to implement health-related initiatives in their respective communities after graduation. Of the 72 graduates since 2011, we surveyed 55 lay health educators to gain insight into their involvement with their congregation and the type of health projects they have implemented. We dichotomized the health projects into "raising awareness" and "teaching new health skills." Using adjusted logistic regression models, variables associated with implementing health projects aimed at teaching health skills included length of time as a member of their congregation, current employment, and age. These results may help future programs prepare lay health community educators for the type of health interventions they intend to implement in their respective communities.