"Hopes and wishes": Goals of high-need, high-cost older patients and their caregivers.

OBJECTIVE: Integration of patient-identified goals is a critical element of shared decision-making and patient-provider communication. There is limited information on the goals of patients with multiple medical conditions and high healthcare utilization. We aimed to identify and categorize the goals described by "high-need, high-cost" (HNHC) older patients and their caregivers. METHODS: Using conventional content analysis, we used data from interviews conducted with 17 HNHC older patients (mean age 72.5 years) and 4 caregivers. RESULTS: HNHC older patients and their caregivers used language such as "hopes, wishes, and wants" to describe their goals, which fell into eight categories: alleviating discomfort, having autonomy and control, decreasing treatment burden, maintaining physical functioning and engagement, leaving a legacy, extending life, having satisfying and effective relationships, and experiencing security. CONCLUSION: Our results contribute to knowledge of goals of HNHC patients and provides guidance for improving the patient-provider relationship and communication between HNHC older patients and their healthcare providers. PRACTICE IMPLICATIONS: Our findings can inform provider efforts to assess patient goals and engage high-need, high-cost older patients in shared decision-making. Further, this study contributes to an improved understanding of HNHC older patients to support continued development of effective care models for this population.

Impact of Hospital Context on Transitioning Patients From Hospital to Skilled Nursing Facility: A Grounded Theory Study.

Background: Twenty-five percentage of patients who are transferred from hospital settings to skilled nursing facilities (SNFs) are rehospitalized within 30 days. One significant factor in poorly executed transitions is the discharge process used by hospital providers. Objective: The objective of this study was to examine how health care providers in hospitals transition care from hospital to SNF, what actions they took based on their understanding of transitioning care, and what conditions influence provider behavior. Design: Qualitative study using grounded dimensional analysis. Participants: Purposive sample of 64 hospital providers (15 physicians, 31 registered nurses, 8 health unit coordinators, 6 case managers, 4 hospital administrators) from 3 hospitals in Wisconsin. Approach: Open, axial, and selective coding and constant comparative analysis was used to identify variability and complexity across transitional care practices and model construction to explain transitions from hospital to SNF. Key Results: Participants described their health care systems as being Integrated or Fragmented. The goal of transition in Integrated Systems was to create a patient-centered approach by soliciting feedback from other disciplines, being accountable for care provided, and bridging care after discharge. In contrast, the goal in Fragmented Systems was to move patients out quickly, resulting in providers working within silos with little thought as to whether or not the next setting could provide for patient care needs. In Fragmented Systems, providers achieved their goal by rushing to complete the discharge plan, ending care at discharge, and limiting access to information postdischarge. Conclusions: Whether a hospital system is Integrated or Fragmented impacts the transitional care process. Future research should address system level contextual factors when designing interventions to improve transitional care.

Apples and Oranges: Four Definitions of Multiple Chronic Conditions and their Relationship to 30-Day Hospital Readmission.

OBJECTIVES: To determine the extent of agreement between four commonly used definitions of multiple chronic conditions (MCCs) and compare each definition's ability to predict 30-day hospital readmissions. DESIGN: Retrospective cohort study. SETTING: National Medicare claims data. PARTICIPANTS: Random sample of Medicare beneficiaries discharged from the hospital from 2005 to 2009 (n = 710,609). MEASUREMENTS: Baseline chronic conditions were determined for each participant using four definitions of MCC. The primary outcome was all-cause 30-day hospital readmission. Agreement between MCC definitions was measured, and sensitivities and specificities for each definition's ability to identify patients experiencing a future readmission were calculated. Logistic regression was used to assess the ability of each MCC definition to predict 30-day hospital readmission. RESULTS: The sample prevalence of hospitalized Medicare beneficiaries with two or more chronic conditions ranged from 18.6% (Johns Hopkins Adjusted Clinical Groups (ACG) Case-Mix System software) to 92.9% (Medicare Chronic Condition Warehouse (CCW)). There was slight to moderate agreement (kappa = 0.03-0.44) between pair-wise combinations of MCC definitions. CCW-defined MCC was the most sensitive (sensitivity 95.4%, specificity 7.4%), and ACG-defined MCC was the most specific (sensitivity 32.7%, specificity 83.2%) predictor of being readmitted. In the fully adjusted model, the risk of readmission was higher for those with chronic condition Special Needs Plan (c-SNP)-defined MCCs (odds ratio (OR) = 1.50, 95% confidence interval (CI) = 1.47-1.52), Charlson Comorbidity Index-defined MCCs (OR = 1.45, 95% CI = 1.42-1.47), ACG-defined MCCs (OR = 1.22, 95% CI = 1.19-1.25), and CCW-defined MCCs (OR = 1.15, 95% CI = 1.11-1.19) than for those without MCCs. CONCLUSION: MCC definitions demonstrate poor agreement and should not be used interchangeably. The two definitions with the greatest agreement (CCI, c-SNP) were also the best predictors of 30-day hospital readmissions.

Bringing Healthy Aging to Scale: A Randomized Trial of a Quality Improvement Intervention to Increase Adoption of Evidence-Based Health Promotion Programs by Community Partners.

OBJECTIVE: To evaluate the effectiveness of a quality improvement intervention to increase delivery of 2 evidence-based health promotion workshops, Stepping On and Chronic Disease Self-Management Program (CDSMP), in rural communities. DESIGN: A cluster-randomized wait-list control group design. SETTING: Rural Wisconsin counties with trained workshop leaders but no workshops in the prior year were eligible to participate. INTERVENTION: Sixteen counties were randomized to receive the NIATx intervention or wait-list control. The 1-year intervention consisted of training and coaching county aging unit staff to apply NIATx methods to increase and sustain the number of Stepping On or CDSMP workshops in their community. MAIN OUTCOMES: Mann-Whitney tests examined effect on workshops held, participants, and workshop completers. The paired Wilcoxon signed rank test explored change in participants' health behaviors and health care utilization. RESULTS: Counties receiving the NIATx intervention significantly increased the number of workshops per county per year as compared with baseline (1.5 vs 0.19, P < .001) and sustained improvements during the year following the intervention. Stepping On participants, during the 6 months postintervention, had reduced falls risk behaviors (P < .001), 0.43 fewer falls (P < .01), and 0.028 fewer medical record-verified emergency department visits for falls-related injuries (P < .05) compared with the 6 months before the intervention. CDSMP participants had reduced social isolation (P = .018) and improved physician communication skills (P = .005). IMPLICATIONS: Our study demonstrates that coaching rural service organizations in use of the quality improvement process, NIATx, may increase implementation reach of evidence-based health promotion/disease prevention programs. Initiative findings indicate that this approach may be a new and potentially important strategy to increase reach of health promotion programs for older adults in community settings. CONCLUSION: A quality improvement approach effectively increases and sustains delivery of evidence-based health promotion/workshops for older adults in rural communities. Counties or states struggling to engage older adults in evidence-based health promotion workshops could integrate quality improvement into policies and practices to increase workshop availability. Once engaged, older adults experience improved health behaviors from both programs and reduced falls and emergency department utilization from Stepping On.

Implementation of 2011 Duty Hours Regulations through a Workload Reduction Strategy and Impact on Residency Training.

BACKGROUND: Training programs have implemented the 2011 ACGME duty hour regulations (DHR) using "workload compression" (WLC) strategies, attempting to fit similar clinical responsibilities into fewer working hours, or workload reduction (WLR) approaches, reducing the number of patient encounters per trainee. Many have expressed concern that these strategies could negatively impact patient care and learner outcomes. OBJECTIVE: This study evaluates the medical knowledge and clinical impact of a WLR intervention in a single institution. DESIGN & PARTICIPANTS: Nonrandomized intervention study with comparison to a historical control study among 58 PGY-1 internal medicine trainees in the 2 years after duty hour implementation [exposure cohort (EC), 7/1/2011-6/30/2013], compared to 2 years before implementation [comparison cohort (CC), 7/1/2009-6/30/2011]. MAIN MEASURES: Process outcomes were average inpatient encounters, average new inpatient admissions, and average scheduled outpatient encounters per PGY-1 year. Performance outcomes included trainee inpatient and outpatient days on service, In-Training Examination (ITE) scores as an objective surrogate of medical knowledge, Case-Mix Index (CMI), and quality of care measures (30-day readmission rate, 30-day mortality rate, and average length of stay). KEY RESULTS: Baseline characteristics and average numbers of inpatient encounters per PGY-1 class were similar between the EC and CC. However, the EC experienced fewer new inpatient admissions (157.47 ± 40.47 vs. 181.72 ± 25.45; p < 0.01), more outpatient encounters (64.80 ± 10.85 vs. 56.98 ± 6.59; p < 0.01), and had similar ITE percentiles (p = 0.58). Patients of similar complexity cared for by the EC also had a greater reduction in readmissions (21.21 % to 19.08 %; p < 0.01) than the hospital baseline (12.07 to 11.14 %; p < 0.01). CONCLUSIONS: Our WLR resulted in a small decrease in the average number of new inpatient admissions and an increase in outpatient encounters. ITE and care quality outcomes were maintained or improved. While there is theoretical concern that reducing PGY-1 inpatient admissions volumes may negatively impact education and clinical care measures, this study found no evidence of such a trade-off.

A four-phase approach for systematically collecting data and measuring medication discrepancies when patients transition between health care settings.

BACKGROUND: No methodological standards are available for researchers and clinicians to examine medication discrepancies between health care settings. Systematic methods of examining medication discrepancies will allow researchers and clinicians to better understand factors driving medication discrepancies, to better measure effects of medication reconciliation interventions, and to compare findings across studies. OBJECTIVE: This article proposes a four-phase approach for systematically collecting medication data and measuring medication discrepancies between a hospital and community pharmacies. Methodologic considerations related to studying medication discrepancies in health services research are also discussed. METHODS: A multi-disciplinary study team developed a four-phase systematic approach to improve quality of data and study rigor: 1) operationalization of a medication discrepancy, 2) acquiring medication data, 3) abstraction of medication data and creation of dataset, and 4) measuring and reporting medication discrepancies. RESULTS: Using this phase-based approach, the study team successfully identified and reported medication discrepancies between a hospital and community pharmacies at the patient, medication, and community pharmacy units of analyses. CONCLUSIONS: Systematically measuring medication discrepancies that occur in the care transitions process is a critical step as researchers, clinicians, and other stakeholders work to improve health care quality and patient outcomes. This article detailed how a phase-based approach can be used in research to examine medication discrepancies as well as address the complexity of collecting medication data and analyzing medication discrepancies. Such methods should be considered when developing, conducting, and reporting research on medication discrepancies.

Patterns of Feedback on the Bridge to Independence: A Qualitative Thematic Analysis of NIH Mentored Career Development Award Application Critiques.

BACKGROUND: NIH Mentored Career Development (K) Awards bridge investigators from mentored to independent research. A smaller proportion of women than men succeed in this transition. The aim of this qualitative study was to analyze reviewers' narrative critiques of K award applications and explore thematic content of feedback provided to male and female applicants. METHOD: We collected 88 critiques, 34 from 9 unfunded and 54 from 18 funded applications, from 70% (n = 26) of investigators at the University of Wisconsin-Madison with K awards funded between 2005 and 2009 on the first submission or after revision. We qualitatively analyzed text in the 5 critique sections: candidate, career development plan, research plan, mentors, and environment and institutional commitment. We explored thematic content within these sections for male and female applicants and for applicants who had received a subsequent independent research award by 2014. RESULTS: Themes revealed consistent areas of criticism for unfunded applications and praise for funded applications. Subtle variations in thematic content appeared for male and female applicants: For male applicants criticism was often followed by advice but for female applicants it was followed by questions about ability; praise recurrently characterized male but not female applicants' research as highly significant with optimism for future independence. Female K awardees that obtained subsequent independent awards stood out as having track records described as "outstanding." CONCLUSION: This exploratory study suggests that K award reviewer feedback, particularly for female applicants, should be investigated as a potential contributor to research persistence and success in crossing the bridge to independence.

Who participates in chronic disease self-management (CDSM) programs? Differences between participants and nonparticipants in a population of multimorbid older adults.

BACKGROUND: Self-care management is recognized as a key component of care for multimorbid older adults; however, the characteristics of those most likely to participate in Chronic Disease Self-Management (CDSM) programs and strategies to maximize participation in such programs are unknown. OBJECTIVES: To identify individual factors associated with attending CDSM programs in a sample of multimorbid older adults. RESEARCH DESIGN: Participants in the intervention arm of a matched-pair cluster-randomized controlled trial of the Guided Care model were invited to attend a 6-session CDSM course. Logistic regression was used to identify factors independently associated with attendance. SUBJECTS: All subjects (N = 241) were aged 65 years or older, were at high risk for health care utilization, and were not homebound. MEASURES: Baseline information on demographics, health status, health activities, and quality of care was available for CDSM participants and nonparticipants. Participation was defined as attendance at 5 or more CDSM sessions. RESULTS: A total of 22.8% of multimorbid older adults who were invited to CDSM courses participated in 5 or more sessions. Having better physical health (odds ratio [95% confidence interval] = 2.3 [1.1-4.8]) and rating one's physician poorly on support for patient activation (odds ratio [95% confidence interval] = 2.8 [1.3-6.0]) were independently associated with attendance. CONCLUSIONS: Multimorbid older adults who are in better physical health and who are dissatisfied with their physicians' support for patient activation are more likely to participate in CDSM courses.