An interprofessional experience preparing a collaborative workforce to care for older adults.

The development and evaluation of an interprofessional education (IPE) pre-professional geriatrics experience involving learners from 10 different health discipline programs is described. The experience provided learners with opportunities to use small-group collaborative approaches in two 3-hour interprofessional sessions. Learners gained exposure to geriatric principles and awareness of the needs of older adults and their families using case studies developed by experienced interprofessional faculty. Learners completed pre- and post-experience surveys and worksheets on their confidence to function in interprofessional teams, knowledge of other disciplines, perceptions of importance of each discipline in providing older adult care, and the qualities considered for a successful team. Data were collected over three offerings of the experience (2016, 2017, 2018) and analyzed using paired sample t-tests and ANOVA. A total of 562 learners participated with outcome measures indicating increased knowledge of older adult services different health professionals provide and increased confidence in knowing when to complete care referrals. Mean increase in learners' confidence to function in interprofessional teams was significant, suggesting the experience was effective in facilitating confidence in functioning and improving views of other disciplines' roles. This experience demonstrated that learners gained exposure to apply geriatric principle skills and critical thinking as interprofessional team members.

The experience of hearing loss in adult survivors of childhood and young adult cancer: A qualitative study.

BACKGROUND: Hearing loss is a prevalent late effect among cancer survivors. Despite the significant social costs, there is a noted delay in seeking care and to the authors' knowledge there are limited data regarding the lived experiences of cancer survivors with hearing loss. The objective of the current study was to explore the lived experience of hearing loss in survivors of childhood and young adult cancers to guide survivorship care. METHODS: A total of 24 survivors participated in semistructured telephone interviews. Inclusion criteria consisted of a clinical visit at the Adult Long-Term Follow-Up Program at Memorial Sloan Kettering Cancer Center in New York City between September 2005 and January 2019; exposure to cranial radiotherapy, platinum chemotherapy, or both; and hearing loss as evidenced by clinical notes, use of hearing aids, or audiogram levels consistent with severe ototoxicity. RESULTS: Three primary themes emerged from the interviews. First, posttreatment hearing loss is associated with isolation and feelings of exclusion. Second, clinicians play an important role in providing survivors with education regarding hearing loss and hearing aids. Finally, hearing loss for survivors may be deprioritized because it is a reminder of the cancer history and is interpreted within the context of other treatment-related late effects. CONCLUSIONS: Clinicians play an important role in initiating the discussion regarding hearing loss with survivors given the importance of hearing in maintaining social relationships, the availability of hearing care interventions, and the invisibility of hearing loss. Education regarding the value of treatment may have implications for how survivors choose to prioritize hearing loss and seek care.

Introduction to The NCMJ's Special Issue on Vision and Hearing Loss.

This article introduces NCMJ's special issue on vision and hearing loss. The 13 articles are organized around four areas: 1) screening and early intervention; 2) technology; 3) prevention; and 4) accommodation, accessibility, and communication. Together the authors discuss a wide range of potential challenges. However, importantly, the authors also provide a wealth of resources for individuals, families, and health care providers.

Predictors of Preference for Hospice Care Among Diverse Older Adults.

UNLABELLED: The purpose of this study was to identify predictors of preference for hospice care and explore whether the effect of these predictors on preference for hospice care were moderated by race. METHODS: An analysis of the North Carolina AARP End of Life Survey (N = 3035) was conducted using multinomial logistic modeling to identify predictors of preference for hospice care. Response options included yes, no, or don't know. RESULTS: Fewer black respondents reported a preference for hospice (63.8% vs 79.2% for white respondents, P < .001). While the proportion of black and white respondents expressing a clear preference against hospice was nearly equal (4.5% and 4.0%, respectively), black individuals were nearly twice as likely to report a preference of "don't know" (31.5% vs 16.8%). Gender, race, age, income, knowledge of Medicare coverage of hospice, presence of an advance directive, end-of-life care concerns, and religiosity/spirituality predicted hospice care preference. Religiosity/spirituality however, was moderated by race. Race interacted with religiosity/spirituality in predicting hospice care preference such that religiosity/spirituality promoted hospice care preference among White respondents, but not black respondents. CONCLUSIONS: Uncertainties about hospice among African Americans may contribute to disparities in utilization. Efforts to improve access to hospice should consider pre-existing preferences for end-of-life care and account for the complex demographic, social, and cultural factors that help shape these preferences.

Visual analog rating of mood by people with aphasia.

BACKGROUND: Considerable attention has been given to the identification of depression in stroke survivors with aphasia, but there is more limited information about other mood states. Visual analog scales are often used to collect subjective information from people with aphasia. However, the validity of these methods for communicating about mood has not been established in people with moderately to severely impaired language. OBJECTIVE: The dual purposes of this study were to characterize the relative endorsement of negative and positive mood states in people with chronic aphasia after stroke and to examine congruent validity for visual analog rating methods for people with a range of aphasia severity. METHODS: Twenty-three left-hemisphere stroke survivors with aphasia were asked to indicate their present mood by using two published visual analog rating methods. The congruence between the methods was estimated through correlation analysis, and scores for different moods were compared. RESULTS: Endorsement was significantly stronger for "happy" than for mood states with negative valence. At the same time, several participants displayed pronounced negative mood compared to previously published norms for neurologically healthy adults. Results from the two rating methods were moderately and positively correlated. CONCLUSIONS: Positive mood is prominent in people with aphasia who are in the chronic stage of recovery after stroke, but negative moods can also be salient and individual presentations are diverse. Visual analog rating methods are valid methods for discussing mood with people with aphasia; however, design optimization should be explored.

Family caregiver involvement for long-term care residents at the end of life.

OBJECTIVES: To examine family caregiver involvement for long-term care (LTC) residents during the last month of life. Researchers examined direct (personal care and meals) and indirect (management and monitoring) types of caregiver involvement and the relationship between the type of involvement and predisposing, enabling, and need characteristics. Researchers also examined whether the frequency of involvement changed during the end-of-life (EOL) period. METHOD: Researchers used an expanded version of Andersen's Behavioral Model to conceptualize predictors of family involvement for 438 residents in 125 residential care/assisted living and nursing home settings. Bivariate and multivariate analyses examined relationships among variables. RESULTS: More than one-half of family caregivers monitored, managed care and assisted with meals, and 40% assisted with personal care tasks. The enabling characteristic of days visited and the need characteristic of caregiver role strain were related to each of the 4 types of involvement. However, the other correlates were distinct to the type of involvement. DISCUSSION: Families are involved in EOL care in LTC settings. Higher role strain is related to more involvement in each of the 4 types of involvement, suggesting that whether involvement is by desire, perceived need, or both, there is cause to more critically examine the family caregiver's desired role and need for support.

Patient preferences for stroke rehabilitation.

PURPOSE: Early aggressive rehabilitation therapies maximize functional recovery. We examined patient-reported preferences for their initial rehabilitation therapy setting during their acute stroke hospitalization and whether there was an association between their preferences and their actual discharge destination. METHOD: Eligible stroke patients were surveyed during their acute hospital stay at either a primary stroke center or a rural community hospital in North Carolina. Patients were questioned about their knowledge of inpatient rehabilitation, preferences for the initial rehabilitation therapy setting and intensity, and how far from home they were willing to travel to receive therapies. The primary outcome was their actual discharge destination. The exposure variable was their preference for initial rehabilitation therapy setting. Logistic regression models assessed the relationship between the outcome and exposure while controlling for other variables of interest. RESULTS: Among 53 patients surveyed in the study, 85% preferred to be discharged home. After controlling for other factors, discharge to the actual destination of home was associated with a preference for an initial rehabilitation therapy setting of home (OR, 7.19; 95% CI, 1.10-46.89). CONCLUSION: Patient preference for the initial rehabilitation therapy setting is home. Providers should inquire about patient preference and provide information about treatment options to help inform decision making.

An exploratory study of advance care planning in seriously ill African-American elders.

INTRODUCTION: The process of advance care planning (ACP) is often difficult to initiate and complete in minority populations, and African Americans are less likely to participate in ACP than non-Hispanic whites. We explored the perceptions of ACP among seriously ill African-American older adults. METHOD: Qualitative semistructured interviews and editing analysis of 10 community-dwelling African-American elders in North Carolina. RESULTS: Three major themes were identified. First, participants had little to no familiarity with ACP; none reported that they participated in any substantive discussions regarding ACP. Inconsistent sources of healthcare information, in which there was little congruence in the information given and discordant of sources of information, were a second theme. Finally, participants denoted a deferred autonomy, in which they postponed involvement in future care decision-making but viewed themselves as active in their day-to-day living. CONCLUSION: Seriously ill African-American elders report both individual-level and health systems-level barriers to ACP. Efforts to improve ACP need to take into account the differences between the current, autonomy-based model of ACP within biomedicine and the values of minority older adults approaching the end of life.

Communication, decision making, and cancer: what African Americans want physicians to know.

PURPOSE: To explore and identify communication and decision making with health care providers for African Americans living with cancer and for their families. METHODS: We used focus group interviews to identify and explore cultural perceptions, expectations, and desires as they relate to quality of life domains. PARTICIPANTS: Of the 42 African American participants, 33 were women. Half of the participants (n = 21) were caregivers of a family member with cancer; the others were cancer survivors and some of them had also cared for a loved one with cancer. RESULTS: Participants focused on effective communication and decision making as fundamental to overall quality of life. Furthermore, physicians were viewed as having the responsibility to establish and monitor effective communication with patients and families. Within the domain of effective communication, participants stressed that health care providers needed to know the person and family and to tailor communication with them based on that knowledge. Within the domain of decision making, participants emphasized having a sense of control over treatment choices. They also expressed concerns for populations made vulnerable by advanced age, poverty, or low levels of formal education. DISCUSSION: Our participants indicated that relationship-centered care, in which one's sense of personhood is sought, acknowledged, and worked with, is foundational for effective communication and decision making.

An exploratory study of spiritual care at the end of life.

PURPOSE: Although spiritual care is a core element of palliative care, it remains unclear how this care is perceived and delivered at the end of life. We explored how clinicians and other health care workers understand and view spiritual care provided to dying patients and their family members. METHODS: Our study was based on qualitative research using key informant interviews and editing analysis with 12 clinicians and other health care workers nominated as spiritual caregivers by dying patients and their family members. RESULTS: Being present was a predominant theme, marked by physical proximity and intentionality, or the deliberate ideation and purposeful action of providing care that went beyond medical treatment. Opening eyes was the process by which caregivers became aware of their patient's life course and the individualized experience of their patient's current illness. Participants also described another course of action, which we termed cocreating, that was a mutual and fluid activity between patients, family members, and caregivers. Cocreating began with an affirmation of the patient's life experience and led to the generation of a wholistic care plan that focused on maintaining the patient's humanity and dignity. Time was both a facilitator and inhibitor of effective spiritual care. CONCLUSIONS: Clinicians and other health care workers consider spiritual care at the end of life as a series of highly fluid interpersonal processes in the context of mutually recognized human values and experiences, rather than a set of prescribed and proscribed roles.

Physician communication with family caregivers of long-term care residents at the end of life.

OBJECTIVES: To assess family perceptions of communication between physicians and family caregivers of individuals who spent their last month of life in long-term care (LTC) and to identify associations between characteristics of the family caregiver, LTC resident, facility, and physician care with these perceptions. DESIGN: Retrospective study of family caregivers of persons who died in LTC. SETTING: Thirty-one nursing homes (NHs) and 94 residential care/assisted living (RC/AL) facilities. PARTICIPANTS: One family caregiver for each of 440 LTC residents who died (response rate 66.0%) was interviewed 6 weeks to 6 months after the death. MEASUREMENTS: Demographic and facility characteristics and seven items rating the perception of family caregivers regarding physician-family caregiver communication at the end of life, aggregated into a summary scale, Family Perception of Physician-Family caregiver Communication (FPPFC) (Cronbach alpha=0.96). RESULTS: Almost half of respondents disagreed that they were kept informed (39.9%), received information about what to expect (49.8%), or understood the doctor (43.1%); the mean FPPFC score (1.73 on a scale from 0 to 3) was slightly above neutral. Linear mixed models showed that family caregivers reporting better FPPFC scores were more likely to have met the physician face to face and to have understood that death was imminent. Daughters and daughters-in-law tended to report poorer communication than other relatives, as did family caregivers of persons who died in NHs than of those who died in RC/AL facilities. CONCLUSION: Efforts to improve physician communication with families of LTC residents may be promoted using face-to-face meetings between the physician and family caregivers, explanation of the patient's prognosis, and timely conveyance of information about health status changes, especially when a patient is actively dying.

Research partnership with underserved African-American communities to improve the health of older persons with disability: a pilot qualitative study.

BACKGROUND AND AIMS: Underserved ethnic minorities are often under-represented in clinical investigations, often in the context of poor relationships between academic institutions and their minority communities. The aim of this study was to investigate an African-American community's perceptions about the barriers that hinder participation in research studies and, more broadly, on the status of institution/community relationships. METHODS: We conducted a pilot qualitative study, based on semi- structured interviews of leaders of African-American communities in Winston-Salem, North Carolina. Relevant themes were abstracted from the interviews by a standardized iterative process. RESULTS: Interviewees identified barriers to participation of African- Americans in research, and suggested that existing barriers may be overcome with an innovative model of a community/institution relationship, which would include open communication and cooperation, mutually beneficial programs, holistic approaches to health and disease, participatory and balanced partnerships with communities, and the establishment of multiethnic advisory boards. CONCLUSIONS: This study suggests strategies that public health researchers should consider to establish effective institution/community relationships, in order to enhance participation of underserved ethnic minorities in research studies, and to improve the health status of their most disabled and demanding seniors.