Competing Risk Analysis of Time to Communal Residence for Elder Orphans.

Elder Orphans, socially/physically isolated older adults without caregiving support, are of interest in an aging population. Lack of caregivers for Elder Orphans may influence relocation to residential care facilities, including skilled nursing or assisted living facilities, compared to aging in place. Using the National Health and Aging Trends Study (NHATS), Competing Risk Survival Analyses were performed to determine if Elder Orphans or those At Risk for becoming elder orphans had increased risk for residential care relocation over nine NHATS waves (2011-2019). Elder Orphans had significantly higher risk for moving to residential care facilities in unadjusted (SHR = 1.780; p = 0.001) and adjusted (SHR = 1.571; p = 0.043) models. Those At Risk for becoming an elder orphan had significantly decreased risk for residential care residence in unadjusted (SHR = 0.517; p < 0.001) and adjusted (SHR = 0.726; p = 0.037) models. As aging in place becomes prioritized in the US healthcare system, understanding caregiving needs of older adults is vital to their health outcomes.

Respiratory Distress in Hospitalized Non-Mechanically Ventilated COVID-19 Adults: A Retrospective Multicenter Cohort Study.

BACKGROUND: COVID-19 typically presents with respiratory symptoms which may progress with severe disease. There are standard guidelines for managing respiratory distress (e.g. opioids, anxiolytics) and palliative care teams are well versed in managing these symptoms. AIM: Determine the extent to which hospitalized COVID-19 patients with moderate respiratory distress received medications or palliative consultation for symptom management and if these interventions had any association with outcomes. DESIGN: Retrospective chart review for hospitalized COVID-19+ patients from March 2-April 30, 2020. SETTING: Large integrated health system in the New York Metropolitan area. PATIENTS: 312 adult patients hospitalized with COVID-19 with an order for a non-rebreather mask and meeting criteria for moderate respiratory distress on the Respiratory Distress Observation Scale: concurrent respiratory rate ≥30 and heart rate ≥110 at any point during hospitalization. Patients receiving mechanical ventilation or intensive care were excluded. RESULTS: Most COVID-19 patients experiencing moderate respiratory distress did not receive medications or palliative consultation for symptom management. Patients who received medications were predominantly white, older, and had a Do-Not-Resuscitate order. Patients who received a palliative consultation were more likely to be older, female, and white, with a Do-Not-Resuscitate order. Mortality was similar between those receiving medication and those who did not. CONCLUSION: Medications and palliative expertise for symptom management were underused for patients with moderate respiratory distress due to COVID-19. Education and triggers may help providers to identify moderate respiratory distress and consider symptomatic treatment and palliative consultation when appropriate.

Remote Advance Care Planning in the Emergency Department During COVID-19 Disaster: Program Development and Initial Evaluation.

BACKGROUND: The coronavirus disease 2019 pandemic caused an unprecedented surge of patients presenting to emergency departments and forced hospitals to adapt to provide care to patients safely and effectively. The purpose here was to disseminate a novel program developed under disaster conditions to address advance care planning communications. METHODS: A program development and initial evaluation was conducted for the Remote Goals of Care program, which was created for families to communicate patient goals of care and reduce responsibilities of those in the emergency department. RESULTS: This program facilitated 64 remote goals of care conversation, with 72% of conversations taking place remotely with families of patients who were unable to participate. These conversations included discussions of patient preferences for care, including code status, presence of caregivers or surrogates, understanding of diagnosis and prognosis, and hospice care. Initially, this program was available 24 hours per day, 7 days per week, with gradual reduction in hours as needs shifted. Seven nurses who were unable to work in corona-positive environments but were able to continue working remotely were utilized. Lessons learned include the need for speed and agility of response and the benefit of established relationships between traditionally siloed specialties. Additional considerations include available technology for patients and families and expanding the documentation abilities for remote nurses. A logic model was developed to support potential program replication at other sites. DISCUSSION: Upon initial evaluation, Remote Goals of Care Program was well received and demonstrated promise in decanting the responsibility of goals of care discussions from the emergency department to a calmer, remote setting. In future iterations, additional services and technology adjustments can be made to make this program more accessible to more patients and families. Other facilities may wish to replicate our Remote Goals of Care Program described here.

The Conversation: A Vital Element of Nephrology Care for Older Americans Who Are Medically Complex.

The U.S. population is aging, supported in part by continued development of life-prolonging medical therapies and technologies. These innovations, including kidney replacement therapies, have been effective in providing additional options to patients facing serious illness, but they have also introduced a new level of complexity in the provider assessment of treatment for these patients. Health care providers are being tasked to decide if medical care is appropriate for an aging and medically complex population, a decision complicated by a variety of factors. Patient-focused conversations surrounding goals of care, prognosis, medical futility, and quality of life need to become part of the routine practice pattern for nephrology care in the United States.

"Palliative Pandemic Plan," Triage and Symptoms Algorithm as a Strategy to Decrease Providers' Exposure, While Trying to Increase Teams Availability and Guidance for Goals of Care (GOC) and Symptoms Control.

As the spread of the novel coronavirus disease 2019 (COVID-19) continues worldwide, health care systems are facing increased demand with concurrent health care provider shortages. This increase in patient demand and potential for provider shortages is particularly apparent for palliative medicine, where there are already shortages in the provision of this care. In response to the developing pandemic, our Geriatrics and Palliative (GAP) Medicine team formulated a 2-team approach which includes triage algorithms for palliative consults as well as acute symptomatic management for both patients diagnosed with or under investigation (PUI) for COVID-19. These algorithms provided a delineated set of guidelines to triage patients in need of palliative services and included provisions for acute symptoms management and the protection of both the patient care team and the families of patients with COVID-19. These guidelines helped with streamlining care in times of crisis, providing care to those in need, supporting frontline staff with primary-level palliative care, and minimizing the GAP team's risk of infection and burnout during the rapidly changing pandemic response.

Estimated Prevalence of Elder Orphans Using National Health and Aging Trends Study.

Objectives: By 2050, individuals aged 65 years and older will comprise over 20% of the American population. A portion is at risk for becoming elder orphans: older adults living in the community who lack caregivers or surrogates. Methods: Using the first wave of the National Health and Aging Trends Survey, we estimated the prevalence of older adults who reside in the community, who are socially or physically isolated, and who lack caregivers. Individuals who are "at risk" meet all of these criteria, with the exception that they live with and receive caregiving from their spouse. Results: We estimated the elder orphan prevalence for this population to be 2.62% (2.24-3.00), with an additional 21.29% determined to be at risk. Discussion: As the population of the United States ages, an understanding of the prevalence and demographics of elder orphans will be useful to guide policies and services to assist this population.

Implementation of Hip Fracture Co-Management Program (AGS CoCare: Ortho®) in a Large Health System.

OBJECTIVES: Acute hip fracture is common and leads to significant morbidity and mortality. Co-management programs, such as American Geriatric Society (AGS) CoCare: Ortho®, that optimize perioperative care of older adults, have demonstrated improved outcomes. Yet there is substantial variation in hip fracture care nationally. Our objective was to describe the implementation of AGS CoCare: Ortho® across a large integrated health system. DESIGN: Program implementation of four phases. SETTING: Large integrated health system. PARTICIPANTS: One tertiary and three community hospitals. MEASUREMENTS: The first two phases were communication and system-level planning. The communication phase consisted of getting health system leadership buy-in, creating an interdisciplinary steering committee, and building a business model. The planning phase consisted of choosing process and outcome measures, ensuring accurate and timely data collection, and creating standardized order sets and physician documentation. RESULTS: The second two phases were hospital-level planning and implementation. The planning phase consisted of identifying sites and developing the co-management structure. The implementation phase consisted of identifying and engaging frontline staff, rolling out the program, optimizing workflow, and educating providers. CONCLUSION: The program was implemented at four diverse sites. Major lessons learned included the need for an engaged steering committee to oversee the program; the importance of standardizing order sets and documentation; the utilization of hospitalists as co-managers; the benefit of developing and actively using a data dashboard; the challenge of ensuring wide uptake of education modules; and the need to take proactive steps to improve multidisciplinary communication. J Am Geriatr Soc 68:1706-1713, 2020.

Dissemination of geriatric emergency department accreditation in a large health system.

The population of older adults in the United States is expanding rapidly. With this expansion, the healthcare system, and emergency departments (EDs) in particular, should provide geriatric-focused care tailored to the needs of this population. To this end, the American College of Emergency Physicians (ACEP) released a geriatric emergency department accreditation (GEDA) to certify EDs that have the staffing, training, and resources to provide high-quality, geriatric-focused, emergent care. Our healthcare system set out to achieve the GEDA at all system hospitals using a service-line approach and standardized policies. The implementation and application process was completed through strong partnerships between the Emergency Medicine Service Line and the Division of Geriatrics and Palliative Medicine. Further partnerships with ACEP were vital to completing the application process and using a standardized application. Through these partnerships, all 17 of our system hospitals achieved tier 3 accreditation. Through this process, we were able to identify opportunities to improve the care provided to older adults in the ED, particularly via staff education. We also gathered lessons learned for system-level accreditation, including fostering close partnerships, meeting the unique needs of each ED, and strategically planning when and where to increase tier levels. This practice of large-scale, system-wide standardization, rather than individual site implementation, is an effective measure to provide geriatric-focused care to the large and growing population of older adults.

The GAP-ED Project: Improving Care for Elderly Patients Presenting to the Emergency Department.

BACKGROUND: Older adults presenting to the emergency department (ED) represent a highly vulnerable patient population with complex conditions and multiple comorbidities. The introduction of a Geriatric and Palliative (GAP)-ED partnership may be an effective strategy to avoid unneeded admissions and improve outcomes for this population. OBJECTIVES: The primary objective was to decrease 30-day revisit and hospitalization rates in this population through identifying patients that could be safely sent home with connection to community resources. Secondary outcomes included achieving high patient and family satisfaction scores assessed through follow-up interviews. METHODS: The GAP-ED intervention included the placement of a Specialist in the ED to coordinate care for older adults presenting to the ED who were likely to be discharged home. Independent t-tests and chi-squared tests were used to assess for changes in outcomes between the intervention group and a blocked matched historical usual-care group. RESULTS: There was no significant difference in 30-day ED revisits between the two groups, but there was a statistically significant reduction in hospital admissions from these 30-day revisits. Patient and family satisfaction with the presence of the GAP-ED Specialist was high. CONCLUSION: The implementation of a GAP-ED partnership and use of a GAP-ED Specialist is an effective means of reducing hospitalization in older adults revisiting the ED.

Developing and Piloting a Tool to Identify Food Insecurity in Older Adults.

OBJECTIVE: The literature shows that food insecurity (FI) can negatively affect the trajectory of many chronic illnesses. FI can be acutely severe for older adults, but screening for FI is not regularly performed in the hospital setting. Our goal was to develop a tool to screen for FI upon hospital discharge to identify patients who may require community food resources. This is the first attempt to build such a tool for implementation in our health system. METHODS: In two university hospitals and one community hospital, patients 65 years old and older were admitted to the Internal Medicine service who would approach discharge within 2 days. We screened patients meeting our criteria using an FI tool (FIT), which addressed patterns associated with FI. All of the patients screened were offered a list of community resources. RESULTS: Of the patients recruited, 69 met the study criteria. The majority of patients screened displayed some FI, with 56% having ≥3 food insecurities. Statistically significant relationships were established for individual FIT questions with age, admission albumin level, body mass index, length of stay, and median household income based on ZIP code. CONCLUSIONS: Use of the FIT can help identify vulnerable patients and connect them to food resources. The FIT was easy to use, well tolerated, and time-efficient, leaving it poised for use in the busy environment of inpatient services.