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Toles M, Ozier E, Briell L, Fender M, Hanson LC. Transitional Care of People With Dementia and Caregivers in the ADRD-PC Trial: A Mixed Methods Study. J Pain Symptom Manage 2024:S0885-3924(24)00907-2. [PMID: 39084411 DOI: 10.1016/j.jpainsymman.2024.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 06/28/2024] [Accepted: 07/23/2024] [Indexed: 08/02/2024]
Abstract
CONTEXT People with late-stage Alzheimer's diseases and related dementias (ADRD) have high risk for postacute complications and readmission; however, minimal research describes hospital transitional care. OBJECTIVE Within the context of the ongoing ADRD-PC clinical trial, the purpose of this study was to describe the content and quality of transitional care of people with ADRD. METHODS Descriptive mixed methods using data from a retrospective chart review and interviews with palliative care social workers and a nurse providing transitional care in the ADRD-PC clinical trial. RESULTS Of 40 dyads of people with late-stage ADRD and their caregivers, palliative care plans were documented for 29 patients (73%); completed postdischarge calls in 72 hours were made for 39 (98%) caregivers and calls in 2 weeks were made for 33 (78%). The content of postdischarge care was promoting continuity, identifying resources, helping caregivers feel heard, troubleshooting problems, and providing grief support. Challenges during transitional care were limited time to engage caregivers in hospital-based palliative care, educate caregivers about palliative care plans, coordinate care after transfers to long term care, and the scarcity of community ADRD resources. Facilitators of high quality transitional care were continuity of staff who saw the patient or caregiver across hospital and postacute contacts, caregiver understanding of goals of care, written palliative care plans, and resources for postdischarge care. CONCLUSION Findings indicate high quality dementia-specific transitional care occurs when staff have resources, such as ADRD training and care planning template, to pull the hospital palliative care plan forward into the postdischarge destination, help families fit the plan to new circumstances, and manage strain and grief related to changes in health and function.
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Affiliation(s)
- Mark Toles
- School of Nursing (M.T., M.F.), University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA.
| | - Ellen Ozier
- Duke University Medical Center (E.O.), Duke HomeCare and Hospice, Durham, North Carolina, USA
| | - Laura Briell
- Sheps Center for Health Services Research (L.B.), University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Moriah Fender
- School of Nursing (M.T., M.F.), University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Laura C Hanson
- School of Medicine (L.C.H.), University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Cornell PY, Hua CL, Buchalksi ZM, Chmelka GR, Cohen AJ, Daus MM, Halladay CW, Harmon A, Silva JW, Rudolph JL. Using social risks to predict unplanned hospital readmission and emergency care among hospitalized Veterans. Health Serv Res 2024. [PMID: 38972911 DOI: 10.1111/1475-6773.14353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/09/2024] Open
Abstract
OBJECTIVES (1) To estimate the association of social risk factors with unplanned readmission and emergency care after a hospital stay. (2) To create a social risk scoring index. DATA SOURCES AND SETTING We analyzed administrative data from the Department of Veterans Affairs (VA) Corporate Data Warehouse. Settings were VA medical centers that participated in a national social work staffing program. STUDY DESIGN We grouped socially relevant diagnoses, screenings, assessments, and procedure codes into nine social risk domains. We used logistic regression to examine the extent to which domains predicted unplanned hospital readmission and emergency department (ED) use in 30 days after hospital discharge. Covariates were age, sex, and medical readmission risk score. We used model estimates to create a percentile score signaling Veterans' health-related social risk. DATA EXTRACTION We included 156,690 Veterans' admissions to a VA hospital with discharged to home from 1 October, 2016 to 30 September, 2022. PRINCIPAL FINDINGS The 30-day rate of unplanned readmission was 0.074 and of ED use was 0.240. After adjustment, the social risks with greatest probability of readmission were food insecurity (adjusted probability = 0.091 [95% confidence interval: 0.082, 0.101]), legal need (0.090 [0.079, 0.102]), and neighborhood deprivation (0.081 [0.081, 0.108]); versus no social risk (0.052). The greatest adjusted probabilities of ED use were among those who had experienced food insecurity (adjusted probability 0.28 [0.26, 0.30]), legal problems (0.28 [0.26, 0.30]), and violence (0.27 [0.25, 0.29]), versus no social risk (0.21). Veterans with social risk scores in the 95th percentile had greater rates of unplanned care than those with 95th percentile Care Assessment Needs score, a clinical prediction tool used in the VA. CONCLUSIONS Veterans with social risks may need specialized interventions and targeted resources after a hospital stay. We propose a scoring method to rate social risk for use in clinical practice and future research.
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Affiliation(s)
- Portia Y Cornell
- Center of Innovation for Long Term Services and Supports, Providence VA Medical Center, Providence, Rhode Island, USA
- Centre for the Digital Transformation of Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Cassandra L Hua
- Department of Public Health, Zuckerberg College of Health Sciences, University of Massachusetts, Lowell, Massachusetts, USA
| | - Zachary M Buchalksi
- Center of Innovation for Long Term Services and Supports, Providence VA Medical Center, Providence, Rhode Island, USA
| | - Gina R Chmelka
- National Social Work Program, Care Management and Social Work, Patient Care Services, Department of Veterans Affairs, Washington, DC, USA
- Tomah VA Medical Center, Tomah, Wisconsin, USA
| | - Alicia J Cohen
- Department of Health Services, Policy and Practice, Brown University, Providence, Rhode Island, USA
- Department of Family Medicine, Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | | | - Christopher W Halladay
- Center of Innovation for Long Term Services and Supports, Providence VA Medical Center, Providence, Rhode Island, USA
| | - Alita Harmon
- National Social Work Program, Care Management and Social Work, Patient Care Services, Department of Veterans Affairs, Washington, DC, USA
- Gulf Coast Veterans Health Care System, Biloxi, Mississippi, USA
| | - Jennifer W Silva
- National Social Work Program, Care Management and Social Work, Patient Care Services, Department of Veterans Affairs, Washington, DC, USA
| | - James L Rudolph
- Center of Innovation for Long Term Services and Supports, Providence VA Medical Center, Providence, Rhode Island, USA
- Department of Health Services, Policy and Practice, Brown University, Providence, Rhode Island, USA
- Department of Family Medicine, Alpert Medical School of Brown University, Providence, Rhode Island, USA
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Kennedy KA, Corneau E, Rickard T, Mills WL, Thomas KS. VA social workers identify factors predictive of enrollment and variability in Veterans' access to aid and attendance benefits. JOURNAL OF GERONTOLOGICAL SOCIAL WORK 2024; 67:157-177. [PMID: 37483074 DOI: 10.1080/01634372.2023.2237086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 07/12/2023] [Indexed: 07/25/2023]
Abstract
The Aid and Attendance (A&A) benefit is a cash entitlement for Veterans who served in the U.S. military to obtain personal care services. Our objective was to identify factors contributing to variation in A&A enrollment across VA Medical Centers (VAMCs). We used VA data to calculate the enrollment rate among older Veterans receiving a VA pension or compensation in 2015, then purposefully sampled social work leaders at 15 VAMCs with the highest (n = 7) and lowest (n = 8) enrollment rates for interviews. All respondents viewed A&A as an important benefit. Participants at high-enrollment sites indicated strong working relationships with Veterans Benefits Administration (VBA) and Veterans Service Organizations (VSOs) with onsite presence and education about A&A facilitate access. Participants at low-enrollment sites indicated they desired education around A&A eligibility criteria and collaboration with VBA/VSOs. VA and non-VA social workers would benefit from education about VBA's benefits, and this requires collaboration with VBA representatives.
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Affiliation(s)
- Katherine A Kennedy
- Center for Innovation in Long-Term Services & Supports, Providence VA Medical Center, Providence, Rhode Island, USA
- School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Emily Corneau
- Center for Innovation in Long-Term Services & Supports, Providence VA Medical Center, Providence, Rhode Island, USA
| | - Taylor Rickard
- Center for Innovation in Long-Term Services & Supports, Providence VA Medical Center, Providence, Rhode Island, USA
| | - Whitney L Mills
- Center for Innovation in Long-Term Services & Supports, Providence VA Medical Center, Providence, Rhode Island, USA
- School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Kali S Thomas
- Center for Innovation in Long-Term Services & Supports, Providence VA Medical Center, Providence, Rhode Island, USA
- School of Public Health, Brown University, Providence, Rhode Island, USA
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Cornell PY, Hua CL, Halladay CW, Halaszynski J, Harmon A, Koget J, Silva JW. Benefits and challenges in the use of RE-AIM for evaluation of a national social work staffing program in the veterans health administration. FRONTIERS IN HEALTH SERVICES 2023; 3:1225829. [PMID: 38034078 PMCID: PMC10687433 DOI: 10.3389/frhs.2023.1225829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 10/11/2023] [Indexed: 12/02/2023]
Abstract
Background In the Department of Veterans Affairs (VA) Veterans Health Administration (VHA), social workers embedded in primary care teams address social and emotional needs that are associated with health outcomes. The mission of the National Social Work PACT Staffing Program is to improve access to social work services for rural Veterans by supporting additional social work staffing in VA medical centers serving rural areas. Methods We obtained data from the VA corporate data warehouse on Veterans' characteristics and health care use from 2016 to 2022 for all Veterans who received primary care at a Veterans Affairs Medical Center (VAMC) or associated clinic that received funding from the program. We evaluated the program according to RE-AIM constructs as follows: Reach [total number of Veterans who engaged with PACT social work and representativeness with regard to race, rural residence, chronic conditions and health behaviors, and hospital and emergency department (ED) use in the previous 12 months]; Effectiveness (impact of the program on key health care use outcomes which include hospitalizations, emergency department visits, and palliative care); Adoption (number of VA medical centers and outpatient clinics serving rural Veterans that have participated in the program, and number and representativeness of sites eligible for program participation that have not yet received funding); Implementation (adherence to standardized note templates), and Maintenance (permanent social work positions created by the program and continued technical support). Results In 2022, the program engaged with 30,982 Veterans, 65% of whom lived in rural areas. The program increased social work encounters, reduce hospital and emergency department use, and increase use of palliative care services among Veterans. Key elements of implementation include proactive outreach to Veterans with high-risk indicators and assessment for social risk factors using standardized, national note templates. In terms of maintenance, the program continues to provide data and technical assistance to 23 sites and has created 171 permanent social work positions. Conclusions and implications The Social Work PACT Staffing Program demonstrates positive outcomes and program sustainment. The RE-AIM framework was a useful tool to evaluate the program, but additional adaption was needed to fit the program's needs.
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Affiliation(s)
- Portia Y. Cornell
- Providence Veterans Affairs (VA) Medical Center, Center of Innovation for Long Term Services and Supports, Providence, RI, United States
- Departmentof Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, United States
| | - Cassandra L. Hua
- Providence Veterans Affairs (VA) Medical Center, Center of Innovation for Long Term Services and Supports, Providence, RI, United States
- Departmentof Health Services, Policy, and Practice, Brown University School of Public Health, Providence, RI, United States
| | - Christopher W. Halladay
- Providence Veterans Affairs (VA) Medical Center, Center of Innovation for Long Term Services and Supports, Providence, RI, United States
| | | | - Alita Harmon
- Department of Veterans Affairs, Veterans Health Administration, Office of Care Management and Social Work Services, National Social Work Program, Washington, DC, United States
- Gulf Coast Veterans Health Care System, Biloxi, MS, United States
| | - Jennifer Koget
- Department of Veterans Affairs, Veterans Health Administration, Office of Care Management and Social Work Services, National Social Work Program, Washington, DC, United States
| | - Jennifer W. Silva
- Department of Veterans Affairs, Veterans Health Administration, Office of Care Management and Social Work Services, National Social Work Program, Washington, DC, United States
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