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Zhou Y, Thakkar N, Phelan EA, Ishado E, Li CY, Borson S, Sadak T. How do care partners overcome the challenges associated with falls of community-dwelling older people with dementia? A qualitative study. DEMENTIA 2024:14713012241267137. [PMID: 39033360 DOI: 10.1177/14713012241267137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2024]
Abstract
BACKGROUND AND OBJECTIVES Previous studies have found that falls among community-dwelling older people with dementia negatively impact the health and well-being of their relative/friend care partners. Limited studies have explored the challenges care partners experience because of older people's falls (including fall incidents and fall risks). We sought to investigate care partners' experiences of these challenges and how care partners responded. METHODS We conducted an inductive thematic analysis of 48 dementia care partner interviews (age range: 33-86, mean: 61, 70.8% women; 58.3% adult children; 29.2% spouse; 62.5% completed college; 25% people of color), conducted after a health crisis of older people with dementia from three local university-affiliated hospitals in the United States. FINDINGS Care partners reported that falls in older people with dementia can intensify overall care demands and lead to self-sacrificing behaviors, dissatisfaction with healthcare providers, conflicts with care recipients, and intense emotions. Care partners described several adaptations to mitigate these impacts, including practicing acceptance, approaching falls as an opportunity for learning, facilitating collaborations within formal/informal care networks, collaborating with older people with dementia to balance autonomy and safety, and modifying the physical environment. DISCUSSIONS AND IMPLICATIONS Falls among older people with dementia are a significant stressor and an important activation stimulus for their care partners. Our findings suggest that care partners are "second clients" and "competent collaborators." As they provide important insights about fall prevention, care partners should be engaged to co-design new multi-level interventions to facilitate collaborations among care networks, older people with dementia, and service providers.
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Affiliation(s)
- Yuanjin Zhou
- Steve Hicks School of Social Work, University of Texas at Austin, USA
| | - Nirali Thakkar
- Steve Hicks School of Social Work, University of Texas at Austin, USA
| | - Elizabeth A Phelan
- Department of Health Systems and Population Health, University of Washington, USA
| | - Emily Ishado
- School of Nursing, University of Washington, USA
| | - Chih-Ying Li
- Department of Occupational Therapy, and School of Public and Population Health, University of Texas Medical Branch, USA
- Department of Population Health and Health Disparities, University of Texas Medical Branch, USA
| | - Soo Borson
- Department of Family Medicine, University of Southern California Keck School of Medicine, USA
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Hoffman GJ, Ha J, Li J. Association of Medicare Home Health Ratings With Older Adult Fall Injuries: An Instrumental Variables Analysis. J Am Med Dir Assoc 2024; 25:105013. [PMID: 38729215 DOI: 10.1016/j.jamda.2024.03.123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 03/29/2024] [Accepted: 03/29/2024] [Indexed: 05/12/2024]
Abstract
OBJECTIVES To understand the role of high-quality home health care for fall prevention. DESIGN A 100% sample of national Medicare claims and home health survey data (2015-2017) were used to assess fall injuries and receipt of a fall risk assessment among recently hospitalized Medicare fee-for-service home health users aged ≥66 years. Subanalyses examined patients by prior fall history status and hospital admission diagnosis type (eg, neurologic, respiratory, cardiovascular, infection, and orthopedic diagnoses). An instrumental variables design addressed potential endogeneity in home health care use by patient fall risk. SETTING AND PARTICIPANTS Home health agencies and Medicare fee-for-service beneficiaries. METHODS Multivariate regression and instrumental variables. RESULTS Among 962,610 patients with hospital discharges to home health, being treated by home health agencies with the highest star ratings in a person's zip code was associated with a 1.8-percentage point (ppt) (95% CI: 0.1, 3.5; P = .03) higher likelihood of receipt of fall risk assessment. There was no overall change in 30-day (-0.6 ppt, 95% CI: -1.3, 0.1; P = .09), 15-day (-0.3 ppt, 95% CI: -0.0.8, 0.2; P = .35), or 7-day fall injury risk (-0.2 ppt, 95% CI: -0.5, 0.1; P = .22), but a 1.9-ppt (95% CI: -3.9, -0.02; P = .048) lower 30-day fall injury risk for individuals with a history of falls. Effects were directionally similar by diagnosis type. CONCLUSIONS AND IMPLICATIONS Fall injury risk is reduced at higher-rated home health agencies. Star ratings may be adequate indicators of quality for key outcomes not explicitly measured in the ratings.
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Affiliation(s)
- Geoffrey J Hoffman
- Department of Systems, Population and Leadership, University of Michigan School of Nursing, Ann Arbor, MI, USA; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA.
| | - Jinkyung Ha
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Jun Li
- Public Administration and International Affairs Department, Maxwell School of Citizenship & Public Affairs, Syracuse University, Syracuse, NY, USA; Aging Studies Institute, Syracuse University, Syracuse, NY, USA
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Allen J, Woolford M, Livingston PM, Lobchuk M, Muldowney A, Hutchinson AM. Informal carer support needs, facilitators and barriers in transitional care for older adults from hospital to home: A scoping review. J Clin Nurs 2023; 32:6773-6795. [PMID: 37272211 DOI: 10.1111/jocn.16767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 04/06/2023] [Accepted: 05/12/2023] [Indexed: 06/06/2023]
Abstract
AIM To synthesise evidence about informal carers' (carers) experience of their support needs, facilitators and barriers regarding transitional care of older adults with multimorbidity. BACKGROUND Carers provide crucial support for older adults during care transitions. Although health practitioners are well positioned to support carers, system factors including limited healthcare resources can compromise the quality of care transitions. DESIGN Scoping review. METHODS Searches were undertaken of the published literature. Five databases were searched including MEDLINE, CINAHL, EMBASE, PsycINFO and the Cochrane Library. Two reviewers independently screened articles to identify relevant studies. Studies were retrieved from January 2000 to July 2022. Data were extracted and tabulated for study characteristics, support needs, facilitators and barriers. Key themes and patterns were synthesised across the studies. RESULTS Eighteen studies including N = 3174 participants were retrieved. Most studies (n = 13) employed qualitative designs. Five studies used surveys. Carers reported their need to: be involved in coordinated discharge planning; advocate and be involved in decision-making; and receive community-based follow-up. Carers described facilitators and barriers in four themes: (1) relationships with the older adult and health practitioners, (2) being involved in coordinated discharge planning; (3) communication and information strategies; and (4) community-based follow-up. Synthesis of themes across all studies resulted in the identification of five areas of research: carers' health literacy; community-based care; carers' involvement in transitional care planning; inpatient and community health practitioners' communication skills; and culturally diverse carers' experiences. CONCLUSION AND RELEVANCE TO CLINICAL PRACTICE The review highlights the importance of quality communication and relationships between carers, older adults, health practitioners and health organisations. Although information and education are important there is a need for further research to examine systems that support communication between carers, older adults and health practitioners and health literacy for all carers including culturally diverse carers.
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Affiliation(s)
- Jacqueline Allen
- School of Nursing and Midwifery, Monash University, Clayton, Victoria, Australia
| | - Marta Woolford
- Health and Social Care Unit, Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia
| | | | - Michelle Lobchuk
- Rady Faculty of Health Sciences, College of Nursing, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Anne Muldowney
- Older Person's Advocacy Network, Surry Hills, NSW, Australia
| | - Alison M Hutchinson
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia
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Crick JP, Juckett L, Salsberry M, Quatman C, Quatman-Yates CC. Experience and Hospital Context Influence Fall Prevention Practice by Physical Therapists: A Survey Study. J Healthc Qual 2023; 45:191-199. [PMID: 37010318 DOI: 10.1097/jhq.0000000000000382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2023]
Abstract
BACKGROUND Falls in and following hospitalization are common and problematic. Little is understood about the factors that impede or promote effective implementation of fall prevention practices. PURPOSE AND RELEVANCE Physical therapists are commonly consulted for acute care patients at risk for falling. The purpose of this study is to understand therapist perceptions of their effectiveness in fall prevention and to explore the impact of contextual factors on practice patterns to prevent falls surrounding hospitalization. METHODS Survey questions were tailored to the constructs of hospital culture, structural characteristics, networks and communications, and implementation climate, in addition to inquiries regarding practice patterns and attitudes/beliefs. RESULTS Overall, 179 surveys were analyzed. Most therapists (n = 135, 75.4%) affirmed their hospital prioritizes best practices for fall prevention, although fewer agreed that therapists other than themselves provide optimal fall prevention intervention (n = 105, 58.7%). Less practice experience was associated with greater odds of affirming that contextual factors influence fall prevention practice (odds ratio 3.90, p < .001). Respondents who agreed that their hospital system prioritizes best practices for fall prevention had 14 times the odds of believing that their system prioritizes making improvements ( p = .002). CONCLUSIONS/IMPLICATIONS As experience influences fall prevention practice, quality assurance and improvement initiatives should be used to ensure minimum specifications of practice.
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Allen J, Lobchuk M, Livingston PM, Layton N, Hutchinson AM. Informal carers' support needs, facilitators and barriers in the transitional care of older adults: A qualitative study. Health Expect 2022; 25:2876-2892. [PMID: 36069335 DOI: 10.1111/hex.13596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 08/08/2022] [Accepted: 08/24/2022] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION Inclusion of informal carers in transitional care is challenging because of fast throughput and service fragmentation. This study aimed to understand informal carers' needs during the care transitions of older adults from inpatient care to the community. METHODS A qualitative exploratory design was used with mixed-methods data collection. Seventeen semi-structured telephone interviews were conducted with family carers; one focus group was conducted by videoconference with two family carers and three community-based advocacy and aged care providers; and eight semi-structured telephone interviews were undertaken with healthcare practitioners from rehabilitation services. Data were thematically analysed. FINDINGS All carers described the main social challenge that they needed to address in transitional care as 'Needing to sustain family'. Carers reported their social needs across five solutions: 'Partnering with carers', 'Advocating for discharge', 'Accessing streamlined multidisciplinary care', 'Knowing how to care' and 'Accessing follow-up care in the community'. Focus group participants endorsed the findings from the carer interviews and added the theme 'Putting responsibility back onto carers'. All healthcare practitioners described the main social challenge that they needed to address as 'Needing to engage carers'. They reported their social solutions in three themes: 'Communicating with carers', 'Planning with carers' and 'Educating carers'. DISCUSSION Findings highlight the importance of reconstructing the meaning of transitional care and relevant outcomes to be inclusive of carers' experiences and their focus on sustaining family. Transitional care that includes carers should commence at the time of hospital admission of the older adult. CONCLUSIONS Future sustainable and high-quality health services for older adults will require transitional care that includes carers and older adults and efficient use of inpatient and community care resources. Healthcare professionals will require education and skills in the provision of transitional care that includes carers. To meet carers' support needs, models of transitional care inclusive of carers and older adults should be developed, implemented and evaluated. PUBLIC CONTRIBUTION This study was conducted with the guidance of a Carer Advisory Group comprising informal carers with experience of care transitions of older adults they support and community-based organizations providing care and advocacy support to informal carers.
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Affiliation(s)
- Jacqueline Allen
- School of Nursing and Midwifery, Monash University, Clayton, Victoria, Australia
| | - Michelle Lobchuk
- College of Nursing, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Patricia M Livingston
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia
| | - Natasha Layton
- Rehabilitation, Ageing and Independent Living Research Centre, Peninsula Campus, Monash University, Frankston, Victoria, Australia
| | - Alison M Hutchinson
- School of Nursing and Midwifery, Centre for Quality and Patient Safety Research, Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia
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Abstract
IMPORTANCE To date, measurement and treatment of older adult fall injury has been siloed within specific care settings, such as a hospital or within a nursing home or community. Little is known about changes in fall risk across care settings. Understanding the occurrence of falls across settings has implications for measuring and incentivizing high-value care across care settings. OBJECTIVE To estimate the risk of older adult fall injury within and across discrete periods during a 12-month care episode anchored by an acute hospitalization. DESIGN, SETTING, AND PARTICIPANTS This cohort study is a longitudinal analysis of 12-month periods that include an anchor hospital stay using national data from 2006 to 2014. Participants included older (aged ≥65 years) Medicare fee-for-service beneficiaries from the Health and Retirement Study. Weekly fall injury rates were computed for 4 periods compared with the anchor hospitalization: at baseline (1-6 months before hospitalization), just before (<1 month before hospitalization), just after (<1 month after hospitalization), and at follow-up (1-6 months after hospitalization). Piecewise logistic regression models estimated weekly marginal risk of fall injury within each period, adjusting for sociodemographic and health characteristics. Fall injury risks for high-risk beneficiaries with a fall injury during the anchor hospitalization were also estimated. Data analysis was performed from November 2019 to April 2020. MAIN OUTCOMES AND MEASURES Fall injuries. RESULTS In total, 10 106 anchor hospitalizations for 4101 beneficiaries (mean [SD] age, 77.1 [7.6] years; 5912 hospitalizations among women [58.5%]) were identified. The overall fall injury risk was 0.77%. In adjusted models, marginal increases in weekly fall injury risk just before hospitalization (0.27 percentage points [95% CI, 0.22 to 0.33 percentage points], or 30.0%; P < .001) were 4 times greater than decreases just after hospitalization (-0.18 percentage points [95% CI, -0.23 to -0.13 percentage points], or -9.2%; P < .001)]. A greater risk differential before and after hospitalization was observed for patients with an inpatient fall injury (1.89 percentage points [95% CI, 1.37 to 2.40], or 309.8%; P < .001; vs -0.39 percentage points [95% CI, -0.73 to -0.04], or -11.6%; P = .03). CONCLUSIONS AND RELEVANCE An episode-based assessment of fall injury illustrates substantial variability in period-specific risks over an extended period including an anchor hospitalization. Risk transitions between periods include sizable increases just before hospitalization that do not fully subside after hospital discharge. Financial incentives to coordinate hospital and posthospital care for patients at risk for fall injury are needed. These could include bundled payments for fall injury episodes that incentivize coordination across settings.
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Affiliation(s)
- Geoffrey J. Hoffman
- Department of Systems, Populations and Leadership, University of Michigan School of Nursing, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Mary E. Tinetti
- Department of Medicine (Geriatrics), Yale University, New Haven, Connecticut
- School of Public Health, Yale University, New Haven, Connecticut
| | - Jinkyung Ha
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Neil B. Alexander
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
- Geriatric Research Education Clinical Center, VA Medical Center, Ann Arbor, Michigan
| | - Lillian C. Min
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Division of Geriatric and Palliative Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
- Geriatric Research Education Clinical Center, VA Medical Center, Ann Arbor, Michigan
- Veterans Affairs Center for Clinical Management and Research, VA Medical Center, Ann Arbor, Michigan
- Institute for Social Research, University of Michigan, Ann Arbor
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Validation of the Hendrich II Fall Risk Model: The imperative to reduce modifiable risk factors. Appl Nurs Res 2020; 53:151243. [PMID: 32451003 DOI: 10.1016/j.apnr.2020.151243] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 02/06/2020] [Accepted: 02/15/2020] [Indexed: 11/24/2022]
Abstract
AIM To validate the psychometrics of the Hendrich II Fall Risk Model (HIIFRM) and identify the prevalence of intrinsic fall risk factors in a diverse, multisite population. BACKGROUND Injurious inpatient falls are common events, and hospitals have implemented programs to achieve "zero" inpatient falls. METHODS Retrospective analysis of patient data from electronic health records at nine hospitals that are part of Ascension. Participants were adult inpatients (N = 214,358) consecutively admitted to the study hospitals from January 2016 through December 2018. Fall risk was assessed using the HIIFRM on admission and one time or more per nursing shift. RESULTS Overall fall rate was 0.29%. At the standard threshold of HIIFRM score ≥ 5, 492 falls and 76,800 non-falls were identified (fall rate 0.36%; HIIFRM specificity 64.07%, sensitivity 78.72%). Area under the receiver operating characteristic curve was 0.765 (standard error 0.008; 95% confidence interval 0.748, 0.781; p < 0.001), indicating moderate accuracy of the HIIFRM to predict falls. At a lower cut-off score of ≥4, an additional 74 falls could have been identified, with an improvement in sensitivity (90.56%) and reduction in specificity (44.43%). CONCLUSION Analysis of this very large inpatient sample confirmed the strong psychometric characteristics of the HIIFRM. The study also identified a large number of inpatients with multiple fall risk factors (n = 77,292), which are typically not actively managed during hospitalization, leaving patients at risk in the hospital and after discharge. This finding represents an opportunity to reduce injurious falls through the active management of modifiable risk factors.
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Anderson LK, Lane K. Characteristics of falls and recurrent falls in residents of an aging in place community: A case-control study. Appl Nurs Res 2019; 51:151190. [PMID: 31734004 DOI: 10.1016/j.apnr.2019.151190] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 08/20/2019] [Accepted: 09/02/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Falls and fall-related injuries remain an ongoing and serious health problem in older adults. Many clinical and environmental factors have been implicated in falls and recurrent falls, including sleep disturbances, sensory deficits, balance problems, incontinence, comorbid conditions, and certain categories of medications. We undertook this study to determine if there was an association between these factors and falls or recurrent falls in older adult residents of an aging in place community. METHODS Our retrospective case-control study compared residents who did and did not fall in an aging in place community, as well as those who experienced recurrent versus single falls in a single year. RESULTS A total of 50 residents met the criteria for inclusion in this study, with 30 participants (60%) having experienced one or more falls during the observation period. Of the 30 participants who fell, 21 (70%) experienced more than one fall in a single year. Variables associated with falls included marital status and bowel incontinence; variables associated with recurrent falls included self-reported sleep difficulty, balance with sitting to standing and surface-to-surface transfer, use of a walker, and use of antidepressant medications. DISCUSSION Our study supports the existing nursing research that falls, and recurrent falls are the result of multiple, interrelated factors. Further research is needed into preventative measures for both falls and recurrent falls, particularly in the context of aging in place.
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Affiliation(s)
- Linda K Anderson
- University of Missouri Sinclair School of Nursing, United States of America.
| | - Kari Lane
- University of Missouri Sinclair School of Nursing, United States of America
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Hoffman GJ, Liu H, Alexander NB, Tinetti M, Braun TM, Min LC. Posthospital Fall Injuries and 30-Day Readmissions in Adults 65 Years and Older. JAMA Netw Open 2019; 2:e194276. [PMID: 31125100 PMCID: PMC6632136 DOI: 10.1001/jamanetworkopen.2019.4276] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
IMPORTANCE Falls are common among older adults, particularly those with previous falls and cognitive impairment and in the postdischarge period. Hospitals have financial incentives to reduce both inpatient falls and hospital readmissions, yet little is known about whether fall-related injuries (FRIs) are common diagnoses for 30-day hospital readmissions. OBJECTIVE To compare fall-related readmissions with other leading rehospitalization diagnoses, including for patients at greatest risk of readmission. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of the Hospital Cost and Utilization Project's Nationwide Readmissions Database of nationally representative US hospital discharges among Medicare beneficiaries aged 65 years and older from January 1, 2013, to November 30, 2014. The prevalence and ranking of FRIs compared with other diagnostic factors for 30-day unplanned hospital-wide readmissions were determined, overall and for 2 acute geriatric cohorts, classified by fall injury or cognitive impairment diagnoses observed at the index admission. Analyses were also stratified by patient discharge disposition (home, home health care, skilled nursing facility). Analyses were conducted from February 1, 2018, to February 26, 2018. MAIN OUTCOMES AND MEASURES Unplanned hospital-wide readmission within 30 days of discharge. RESULTS From the database, 8 382 074 eligible index admissions were identified, including 746 397 (8.9%) in the FRI cohort and 1 367 759 (16.3%) in the cognitive impairment cohort. Among the entire 8 382 074-discharge cohort, mean (SD) age was 77.7 (7.8) years and 4 736 281 (56.5%) were female. Overall, 1 205 962 (14.4%) of index admissions resulted in readmission, with readmission rates of 12.9% for those with a previous fall and 16.0% for patients with cognitive impairment. Overall, FRIs ranked as the third-leading readmission diagnosis, accounting for 60 954 (5.1%) of all readmission diagnoses. Within the novel acute geriatric cohorts, FRIs were the second-leading diagnosis for readmission both for patients with an FRI at index admission (10.3% of all readmission diagnoses) and those with cognitive impairment (7.0% of all readmission diagnoses). For those with an FRI at index admission and discharged home or to home health care, FRIs were the leading readmission diagnosis. CONCLUSIONS AND RELEVANCE This study found that posthospital FRIs were a leading readmission diagnosis, particularly for patients originally admitted with a FRI or cognitive impairment. Targeting at-risk hospitalized older adults, particularly those discharged to home or home health care, is an underexplored, cost-effective mechanism with potential to reduce readmissions and improve patient care.
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Affiliation(s)
- Geoffrey J. Hoffman
- Department of Systems, Populations and Leadership, University of Michigan School of Nursing, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Haiyin Liu
- Department of Systems, Populations and Leadership, University of Michigan School of Nursing, Ann Arbor
| | - Neil B. Alexander
- Geriatric Research Education and Clinical Care Center (GRECC), VA Medical Center, Ann Arbor, Michigan
- Division of Geriatric and Palliative Medicine, Department of Medicine, University of Michigan, Ann Arbor
| | - Mary Tinetti
- Division of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- School of Public Health, Yale University, New Haven, Connecticut
| | - Thomas M. Braun
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor
| | - Lillian C. Min
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Division of Geriatric and Palliative Medicine, Department of Medicine, University of Michigan, Ann Arbor
- Veterans Affairs Center for Clinical Management and Research (CCMR), VA Medical Center, Ann Arbor, Michigan
- Institute for Social Research, University of Michigan, Ann Arbor
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