FlourishCare Model of Integrated Care: The Validation of the Flourish Index-Revised.

BACKGROUND AND OBJECTIVES: This study validates the Flourish Index-Revised (FI-R), a tool evaluating integrated healthcare models. The original Flourish Index (FI) was developed in 2018 and has been refined to align with the FlourishCare (FC) Model (Model) for geriatric primary care. RESEARCH DESIGN AND METHODS: The Model provides integrated biopsychosocial healthcare to older adults. The FI-R uses 25 quality-of-care indicators and 7 contextual community indicators. The FI-R was validated with Categorial Principal Components Analysis (CATPCA) using a sample of 949 patients 50+ who were mostly female (73%), non-Hispanic White (70%), living in urban areas (90%), and married (29%), single (22%), or divorced (19%). The mean age was 73.46 (standard deviation [SD] = 10.86) and mean years of education was 14.30 (SD = 2.14). RESULTS: CATPCA showed a 4-dimensional structure of biological, psychological, and 2 social determinants of health (SDOH) subdomains: health behaviors and community. Final selection of indicators was based on total variance accounted for >0.30, absolute values of item loadings >0.45, and not having cross-loadings >0.45 on 2 factors. Internal consistency (Cronbach's alpha) for the determinants were biological = 0.75, psychological = 0.76, SDOH:community = 0.70, SDOH:health behaviors = 0.50, and total FI-R = 0.95. Sensitivity to change was shown for the total FI-R, psychological determinants, and SDOH:health behaviors, but not for biological determinants. DISCUSSION AND IMPLICATIONS: The validation of the FI-R shows promise for its usability to evaluate integrated healthcare models using existing measures in electronic health systems. More work is needed to improve the incorporation of SDOH:sociodemographics into the FI-R.

Exploring the intersection of structural racism and ageism in healthcare.

The American Geriatrics Society (AGS) has consistently advocated for a healthcare system that meets the needs of older adults, including addressing impacts of ageism in healthcare. The intersection of structural racism and ageism compounds the disadvantage experienced by historically marginalized communities. Structural racism and ageism have long been ingrained in all aspects of US society, including healthcare. This intersection exacerbates disparities in social determinants of health, including poor access to healthcare and poor outcomes. These deeply rooted societal injustices have been brought to the forefront of the collective public consciousness at different points throughout history. The COVID-19 pandemic laid bare and exacerbated existing inequities inflicted on historically marginalized communities. Ageist rhetoric and policies during the COVID-19 pandemic further marginalized older adults. Although the detrimental impact of structural racism on health has been well-documented in the literature, generative research on the intersection of structural racism and ageism is limited. The AGS is working to identify and dismantle the healthcare structures that create and perpetuate these combined injustices and, in so doing, create a more just US healthcare system. This paper is intended to provide an overview of important frameworks and guide future efforts to both identify and eliminate bias within healthcare delivery systems and health professions training with a particular focus on the intersection of structural racism and ageism.

The Interprofessional Education Exchange: The Impact of a Faculty Development Program in Interprofessional Palliative Oncology Education on Trainee Competencies, Skills, and Satisfaction.

Background: The interprofessional education exchange (iPEX) provides education, training, and mentoring to select interprofessional faculty trainee teams for development and implementation of interprofessional education (IPE) in palliative oncology. Objective: To evaluate the impact of the iPEX project on trainees' self-efficacy in IPE skills and IPE competencies. Design: A pre-/post-test design was used to evaluate trainees' progress. Trainees rated project components and developed IPE curricula in palliative oncology. Setting/Subjects: Sixteen United States-based faculty teams consisting of four to five members representing three or more disciplines completed the one-year faculty development project consisting of webinars, online interactive modules, a face-to-face workshop, mentoring, and assistance. The exchange of ideas, means for overcoming obstacles, collaborative teaching techniques, and curriculum development guidelines were integrated into the program. Measurements: Standardized measures of self-efficacy in IPE skills (Interprofessional Facilitation Skills Checklist) and IPE competencies (Core Competencies for Interprofessional Practice Individual Competency Assessment Tool) were used. Trainees rated the effectiveness of the project components on a scale of 1-5 (1 = not at all effective, 5 = extremely effective) and reported their plan for IPE palliative care curricula at their home institution. Results: Pre and post-paired samples t-test scores (n = 78) on both standardized instruments for IPE skills and competencies were significantly different (p < 0.001). Ratings of project components ranged from 3.97 to 4.90. Each team successfully developed a unique plan for IPE in palliative oncology. Conclusions: Multimodal faculty development and mentoring are successful means for improving self-assessed IPE skills and competencies.

The Relationship Between Culture of Safety and Rate of Adverse Events in Long-Term Care Facilities.

OBJECTIVE: The aim of the study was to assess the relationship of culture of safety dimensions and the rate of unanticipated care outcomes in long-term care facilities (LTCFs) using the Agency for Healthcare Research and Quality framework of resident safety culture. METHODS: Cross-sectional survey data were collected on 13 dimensions of culture of safety in five LTCFs from registered nurses, licensed practical nurses (LPNs), nursing assistants, administrators/managers, administrative support, and rehabilitation staff. Secondary data on falls in the five LTCFs from quarters 1 to 3 of 2014 were obtained from the Centers for Medicare and Medicaid Services in February 2015. Spearman's ρ and the Generalized Estimating Equations using a log link (Poisson distribution) were used. RESULTS: Communication and feedback about incidences reported the highest mean scores (M = 4.35, SD =0.71). Higher rate of falls was associated with a lower level of team work, lower degree of handoffs, and lower levels of organizational learning. The risk for falls increased as the number of residents per facility increased (rate ratio [RR] = 1.02; 95% confidence interval [CI] = 1.01-1.02) and as the number of LPN hours per resident increased (RR = 37.7, 95% CI = 18.5-76.50). Risk for long stay urinary tract infections increased as number of residents increased (RR =1.01, 95% CI =1.01-1.01). Increase in culture of safety score was associated with decrease in risk of falls, long stay urinary tract infections, and short stay ulcers. CONCLUSIONS: With the shortage of registered nurses in LTCFs and new reimbursement regulations, many LTCFs are hiring LPNs to have full staffing and save money. Licensed practical nurses may lack essential knowledge to decrease the rate of falls.

Human Flourishing and Integrated Care Models: The Development of the Flourish Index.

BACKGROUND AND OBJECTIVES: In evaluating integrated care models, traditional quality measures do not account for functional and quality of life factors, affecting older adults with multiple chronic conditions. The objective of this study was the development and validation of the Flourish Index (FI), an instrument to evaluate integrated care, using a determinants of health model. RESEARCH DESIGN AND METHODS: The study took place within the evaluation study of the Flourish Model (FM). The FM provides care coordination services using an integrated primary care and community-based services model. Baseline data from 70 older adults were used in the validation study. Twenty-seven quality of care indicators within six determinants of health, namely biological, psychological, individual health behaviors, health services, environmental, and social, formed part of the FI. RESULTS: Categorical principal components analysis showed a 5-dimensional structure with psychological determinants loading on the biological determinants of health. Internal consistency (Cronbach's alpha) for the determinants was as follows: biological/psychological = 0.73, individual = 0.58, environmental = 0.62, health services = 0.65, social = 0.67, total score = 0.97. Sensitivity to change was shown for the total FI score (F1,22 = 8.82, p = .01) and social (F1,22 = 5.82, p = .02), with a trend toward sensitivity for individual health behaviors (F1,22 = 3.95, p = .06) and health services (F1,22 = 3.26, p = .09). DISCUSSION AND IMPLICATIONS: The preliminary analysis of the FI shows promise for the usability of the index to provide insight into the fundamental challenges of aging. It brings greater clarity in caring for older adults and supports quality evaluation of integrated care coordination models.

Overcoming barriers to interprofessional education in gerontology: the Interprofessional Curriculum for the Care of Older Adults.

A fragmented workforce consisting of multiple disciplines with varying levels of training and limited ability to work as a team often provides care to older adults. Interprofessional education (IPE) is essential for preparing practitioners for the effective teamwork required for community-based, holistic, person-centered care of the older adults. Despite numerous programs and offerings to advance education and interdisciplinary patient care, there is an unmet need for geriatric IPE, especially as it relates to community-dwelling older adults and caregivers in medically underserved areas. A core group of university faculty from multiple disciplines received funding from the Health Resources and Services Administration Geriatric Workforce Enhancement Program to collaborate with community-based providers from several Area Agencies on Aging in the creation and implementation of the Interprofessional Curriculum for the Care of Older Adults (iCCOA). This geriatric curriculum is interprofessional, comprehensive, and community-based. Learners include third-year nursing students, nurse practitioner students, third-year medical students, internal medicine and family medicine residents, master's level social work students, third-year pharmacy students, pharmacy residents, third-year dental students, dental hygiene students, community-based organization professionals, practicing community organizers, and community health navigators. This article describes the efforts, successes, and challenges experienced with this endeavor, including securing funding, ensuring equal representation of the disciplines, adding new components to already crowded curricula, building curriculum on best practices, improving faculty expertise in IPE, managing logistics, and ensuring comprehensive evaluation. The results summarize the iCCOA components, as well as the interprofessional domains, knowledge, and competencies.

A case of inappropriate apolipoprotein e testing in Alzheimer's disease due to lack of an informed consent discussion.

BACKGROUND/OBJECTIVE: Apolipoprotein E (APOE) genetic testing is used to assist in the diagnosis of Alzheimer's Disease (AD). Whenever genetic testing is performed, an informed consent process should occur. METHODS: In this case, a patient with memory loss presented to the neurologist. The neurologist ordered a lumbar puncture (LP). The LP was performed by a neuroradiologist who also ordered APOE genetic testing. The patient received no genetic counseling, nor was an informed consent document offered. RESULTS: After the testing was completed, the neurologist faced an ethical dilemma. His solution was to offer the genetic testing to the patient in order to have an informed consent process. It was clear that the patient and her adult children did not want the genetic testing and that they would have been burdened with the results. The neurologist opted not to disclose the results. CONCLUSION: Genetic counseling and a signed informed consent document are required prior to any genetic testing. In this case, neither occurred and it led to an ethical dilemma that was ultimately resolved by the neurologist. As the population ages and AD becomes more prevalent, there is a need to expand the workforce of genetic counselors and educate physicians who commonly treat AD about genetic testing.

Diagnostic challenges in Creutzfeldt-Jakob disease: case report.

Sporadic Creutzfeldt-Jakob disease (CJD) is the most common prion disease. The diagnosis can be confirmed only by histological examination of brain tissue obtained at biopsy or at autopsy. Because of the transmissible nature of the disease, autopsy or brain biopsy cannot be performed at many institutions, which poses numerous challenges in confirming the diagnosis. We report the case of a patient with CJD in which autopsy to confirm the diagnosis was performed after overcoming numerous obstacles and advocating with hospital leadership. This case illustrates the numerous challenges that exist in achieving a definitive diagnosis of CJD and in postmortem disposition of the body, and we provide recommendations to clinicians who face similar challenges.