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Ulintz AJ, Podolsky SR, Lapin B, Wyllie RR. Addition of community paramedics to a physician home-visit program: A prospective cohort study. J Am Geriatr Soc 2023; 71:3896-3905. [PMID: 37800363 DOI: 10.1111/jgs.18625] [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: 05/01/2023] [Revised: 08/17/2023] [Accepted: 09/11/2023] [Indexed: 10/07/2023]
Abstract
BACKGROUND Home-based primary care promotes aging in place but is not immediately responsive to urgent needs. Community paramedicine leverages emergency medical services clinicians to expedite in-home care, though limited evidence supports this model. We evaluated the primary care and acute care use of older adults evaluated urgently by a community paramedic with telemedicine physician compared to a physician home visit model. METHODS This prospective cohort study enrolled older adults in home-based primary care who requested an urgent evaluation. We allocated participants to the physician home visit model or physician home visit plus community paramedic model by ZIP code. We observed primary care and acute care use for 6 months following enrollment. The primary outcome was the median number of primary care and acute care visits per participant. Secondary outcomes included 30-day readmission rates, median wait times, and physician productivity. Data analysis included descriptive statistics, comparison of means and proportions, and negative binomial regression modeling reported as incidence rate ratios (IRR). RESULTS We screened 255 participants, determined 203 eligible, allocated 199, and completed observation for 167 (84 community paramedicine, 83 physician home visit). Participants were mostly female, age 76-86 years, with 3-5 comorbidities, living in a home/apartment. Community paramedic participants had 29% more primary care visits (IRR 1.29, 95% confidence interval [CI] 1.06-1.57) and shorter wait times for urgent evaluations (1 vs. 5 days, p < 0.001) without increasing acute care use (IRR 0.75, 95% CI 0.48-1.18) or 30-day readmissions (IRR 1.32, 95% CI 0.49-3.55). Physician productivity increased 81% (40 vs. 22 visits/week, p < 0.001). CONCLUSION Older adults evaluated by a community paramedic for urgent needs were seen sooner, used acute care similarly to patients evaluated by a physician home visit, and nearly doubled physician efficiency. This suggests that older adults may benefit from combining emergency medical services and primary care resources for urgent evaluations.
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Affiliation(s)
- Alexander J Ulintz
- Department of Emergency Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Seth R Podolsky
- Medical Operations, Legacy Health, Portland, Oregon, USA
- Elson S. Floyd College of Medicine, Washington State University, Spokane, Washington, USA
| | - Brittany Lapin
- Department of Medicine, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA
- Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Robert R Wyllie
- Medical Operations, Cleveland Clinic Foundation, Cleveland, Ohio, USA
- Department of Pediatrics, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA
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Fields B, Fitzpatrick M, Kinney L, Lee J, Sprecher B, Tredinnick R, Ponto K, Shin JH. Evaluating the Acceptability and Appropriateness of the Augmented Reality Home Assessment Tool (ARHAT): Qualitative Descriptive Study. JMIR Aging 2023; 6:e44525. [PMID: 37787657 PMCID: PMC10547935 DOI: 10.2196/44525] [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: 11/22/2022] [Revised: 06/28/2023] [Accepted: 07/13/2023] [Indexed: 10/04/2023] Open
Abstract
Background The Augmented Reality Home Assessment Tool (ARHAT) is a mobile app developed to provide rapid, highly accurate assessments of the home environment. It uses 3D-capture technologies to help people identify and address functional limitations and environmental barriers. Objective This study was conducted to gain stakeholder feedback on the acceptability and appropriateness of the ARHAT for identifying and addressing barriers within home environments. Methods A qualitative descriptive study was conducted because it allows for variability when obtaining data and seeks to understand stakeholders' insights on an understudied phenomenon. Each stakeholder group (occupational therapists, housing professionals, and aging adult and caregiver "dyads") participated in a 60-minute, web-based focus group via a secure Zoom platform. Focus group data were analyzed by 2 trained qualitative research team members using a framework method for analysis. Results A total of 19 stakeholders, aged from 18 to 85+ years, were included in the study. Of the occupational therapists (n=5, 26%), housing professionals (n=3, 16%), and dyads (n=11, 58%), a total of 32% (n=6) were male and 68% (n=13) were female, with most living in the Midwestern United States (n=10, 53%). The focus group data demonstrate the acceptability and appropriateness of the workflow, style, measurement tools, and impact of the ARHAT. All stakeholders stated that they could see the ARHAT being used at many different levels and by any population. Dyads specifically mentioned that the ARHAT would allow them to do forward planning and made them think of home modifications in a new light. Conclusions Stakeholders found the ARHAT to be acceptable and appropriate for identifying and addressing functional limitations and barriers in the home environment. This study highlights the importance of considering the workflow, style, measurement tools, and potential impact of home assessment technology early in the developmental process.
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Affiliation(s)
- Beth Fields
- Department of Kinesiology, University of Wisconsin Madison, MadisonWI, United States
| | - McKenzie Fitzpatrick
- Department of Kinesiology, University of Wisconsin Madison, MadisonWI, United States
| | - Lauryn Kinney
- Department of Kinesiology, University of Wisconsin Madison, MadisonWI, United States
| | - Jenny Lee
- Department of Design Studies, University of Wisconsin Madison, MadisonWI, United States
| | - Bryce Sprecher
- Wisconsin Institute for Discovery, University of Wisconsin Madison, MadisonWI, United States
| | - Ross Tredinnick
- Wisconsin Institute for Discovery, University of Wisconsin Madison, MadisonWI, United States
| | - Kevin Ponto
- Department of Design Studies, University of Wisconsin Madison, MadisonWI, United States
| | - Jung-hye Shin
- Department of Design Studies, University of Wisconsin Madison, MadisonWI, United States
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Spoelstra SL, Schueller M, Basso V, Sikorskii A. Results of a multi-site pragmatic hybrid type 3 cluster randomized trial comparing level of facilitation while implementing an intervention in community-dwelling disabled and older adults in a Medicaid waiver. Implement Sci 2022; 17:57. [PMID: 36028873 PMCID: PMC9419328 DOI: 10.1186/s13012-022-01232-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 08/14/2022] [Indexed: 01/28/2023] Open
Abstract
Background Evidence-based interventions that optimize physical function for disabled and older adults living in the community who have difficulty with daily living tasks are available. However, uptake has been limited, particularly in resource-constrained (Medicaid) settings. Facilitation may be an effective implementation strategy. This study’s aim was to compare internal facilitation (IF) versus IF and external facilitation (EF) on adoption and sustainability of an intervention in a Medicaid home and community-based waiver. Methods In a hybrid type 3 trial, waiver sites (N = 18) were randomly assigned to implement the intervention using a bundle of strategies with either IF or IF and EF. Adoption and sustainability were assessed via Stages of Implementation Completion (SIC) for each site. Clinician attitudes toward evidence-based practice and self-efficacy were evaluated among 539 registered nurses, social workers, and occupational therapists. Medicaid beneficiary outcomes of activities of daily living, depression, pain, falls, emergency department visits, and hospitalizations were evaluated in a sample of N = 7030 as reflected by electronic health records data of the Medicaid waiver program. Linear mixed-effects models were used to compare outcomes between trial arms while accounting for cluster-randomized design. Results The mean SIC scores were 72.22 (standard deviation [SD] = 16.98) in the IF arm (9 sites) and 61.33 (SD = 19.29) in the IF + EF arm (9 sites). The difference was not statistically significant but corresponded to the medium clinically important effect size Cohen’s d = 0.60. Clinician implementation outcomes of attitudes and self-efficacy did not differ by trial arm. Beneficiary depression was reduced significantly in the IF + EF arm compared to the IF arm (p = .04, 95% confidence interval for the difference [0.01, 0.24]). No differences between trial arms were found for other beneficiary outcomes. Conclusions Level of facilitation did not enhance capacity for adoption and sustainability of an evidence-based intervention in a Medicaid setting that cares for disabled and older adults. Improved beneficiary depression favored use of IF and EF compared to IF alone, and no differences were found for other outcomes. These findings also suggest level of facilitation may not have impacted beneficiary outcomes. Trial registration ClinicalTrials.gov, NCT03634033; date registered August 16, 2018. Supplementary Information The online version contains supplementary material available at 10.1186/s13012-022-01232-5.
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Affiliation(s)
- Sandra L Spoelstra
- Kirkhof College of Nursing, Grand Valley State University, 301 Michigan St, Room C352, Grand Rapids, MI, 49504, USA.
| | - Monica Schueller
- Kirkhof College of Nursing, Grand Valley State University, 301 Michigan St, Room C352, Grand Rapids, MI, 49504, USA
| | - Viktoria Basso
- Statistics Department, Grand Valley State University, Grand Rapids, USA
| | - Alla Sikorskii
- Department of Psychiatry, Michigan State University, East Lansing, USA
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Mah J, Rockwood K, Stevens S, Keefe J, Andrew MK. Do Interventions Reducing Social Vulnerability Improve Health in Community Dwelling Older Adults? A Systematic Review. Clin Interv Aging 2022; 17:447-465. [PMID: 35431543 PMCID: PMC9012306 DOI: 10.2147/cia.s349836] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 03/10/2022] [Indexed: 11/23/2022] Open
Abstract
Background Social vulnerability occurs when individuals have been relatively disadvantaged by the social determinants of health. Complex interventions that reduce social vulnerability have the potential to improve health in older adults but robust evidence is lacking. Objective To identify, appraise and synthesize evidence on the effectiveness of complex interventions targeting reduction in social vulnerability for improving health related outcomes (mortality, function, cognition, subjective health and healthcare use) in older adults living in the community. Methods A mixed methods systematic review was conducted. Five databases and targeted grey literature were searched for primary studies of all study types according to predetermined criteria. Data were extracted from each distinct intervention and quality was assessed using the Mixed Methods Appraisal Tool. Effectiveness data were synthesized using vote counting by direction of effect, combining p values and Albatross plots. Results Across 38 included studies, there were 34 distinct interventions categorized as strengthening social supports and communities, helping older adults and their caregivers navigate health and social services, enhancing neighbourhood and built environments, promoting education and providing economic stability. There was evidence to support positive influences on function, cognition, subjective health, and reduced hospital utilization. The evidence was mixed for non-hospital healthcare utilization and insufficient to determine effect on mortality. Conclusion Despite high heterogeneity and varying quality of studies, attention to reducing an older adult's social vulnerability assists in improving older adults' health.
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Affiliation(s)
- Jasmine Mah
- Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Kenneth Rockwood
- Division of Geriatric Medicine, Dalhousie University, Halifax, NS, Canada
| | - Susan Stevens
- Department of Family Studies and Gerontology, Mount Saint Vincent University, Halifax, NS, Canada
| | - Janice Keefe
- Department of Family Studies and Gerontology, Mount Saint Vincent University, Halifax, NS, Canada
| | - Melissa K Andrew
- Division of Geriatric Medicine, Dalhousie University, Halifax, NS, Canada
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Gill TM. Setting realistic expectations for an innovative program of home-based care for vulnerable older persons. J Am Geriatr Soc 2021; 69:3413-3415. [PMID: 34498270 DOI: 10.1111/jgs.17440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 08/15/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Thomas M Gill
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
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Szanton SL, Leff B, Li Q, Breysse J, Spoelstra S, Kell J, Purvis J, Xue QL, Wilson J, Gitlin LN. CAPABLE program improves disability in multiple randomized trials. J Am Geriatr Soc 2021; 69:3631-3640. [PMID: 34314516 DOI: 10.1111/jgs.17383] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 06/23/2021] [Accepted: 07/07/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND Programs to reduce disability are crucial to the quality of life for older adults with disabilities. Reducing disability is also important to avert unnecessary and costly hospitalizations, relocation, or nursing home placements. Few programs reduce disability and few have been replicated and scaled beyond initial research settings. CAPABLE is one such program initially tested in a randomized control trial and has now been tested and replicated in multiple settings. CAPABLE, a 10-session, home-based interprofessional program, provides an occupational therapist, nurse, and handyworker to address older adults' self-identified functional goals by enhancing individual capacity and home environmental supports. We examine evidence for the CAPABLE program from clinical trials embedded in different health systems on outcomes that matter most to older adults with disability. METHODS Six trials with peer-reviewed publications or reports were identified and included in this review. Participants' outcomes included basic and instrumental activities of daily living (ADLs, IADLs), fall efficacy, depression, pain, and cost savings. RESULTS A total of 1144 low-income, community-dwelling older adults with disabilities and 4236 matched comparators were included in the six trials. Participants were on average ≥74-79 years old, cognitively intact, and with self-reported difficulty with ≥1 ADLs. All six studies demonstrated improvements in ADLs and IADLs, with small to strong effect sizes (0.41-1.47). Outcomes for other factors were mixed. Studies implementing the full-tested dose of CAPABLE showed more improvement in ADLS and cost savings than studies implementing a decreased dose. CONCLUSIONS The CAPABLE program resulted in substantial improvements in ADLs and IADLs in all six trials with other outcomes varying across studies. A dose lower than the original protocol tested resulted in less benefit. The four studies examining cost showed that CAPABLE saved more than it costs to implement.
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Affiliation(s)
- Sarah L Szanton
- Johns Hopkins School of Nursing, Baltimore, Maryland, USA.,Johns Hopkins School of Public Health, Baltimore, Maryland, USA
| | - Bruce Leff
- Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Qiwei Li
- Johns Hopkins School of Nursing, Baltimore, Maryland, USA
| | - Jill Breysse
- National Center for Healthy Housing, Columbia, Maryland, USA
| | | | | | | | - Qian-Li Xue
- Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Jonathan Wilson
- National Center for Healthy Housing, Columbia, Maryland, USA
| | - Laura N Gitlin
- Johns Hopkins School of Nursing, Baltimore, Maryland, USA.,Drexel College of Nursing and Health Professions, Philadelphia, Pennsylvania, USA
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Spoelstra SL, Schueller M, Sikorskii A. Testing an implementation strategy bundle on adoption and sustainability of evidence to optimize physical function in community-dwelling disabled and older adults in a Medicaid waiver: a multi-site pragmatic hybrid type III protocol. Implement Sci 2019; 14:60. [PMID: 31196137 PMCID: PMC6567613 DOI: 10.1186/s13012-019-0907-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 05/23/2019] [Indexed: 12/12/2022] Open
Abstract
Background In partnership with a state Medicaid home and community-based waiver program, this study tests implementation strategies for adoption and sustainability of an evidence-based intervention to support disabled and older adults who have difficulty with physical function and daily living tasks. A multi-level implementation strategy bundle will be directed at relationship, coalition, and team building; readiness to implement, leadership, and clinician attitude toward evidence assessments; intervention and facilitation training; interdisciplinary coordination; facilitation; and audit and feedback to support practice change. Methods Knowledge-to-Action model underpins this 2-arm, 3-year pragmatic mixed method randomized hybrid type III trial in 18 waiver program sites in Michigan. Data will be collected on sites, 775 clinicians (registered nurses, occupational therapists, social workers), and 15,000 disabled and older adults. Consolidated Framework for Implementation Research guides examination of site, clinician, and beneficiary characteristics; clinician attitude and self-efficacy; leadership and readiness to implement; and intervention impact on beneficiary outcomes. Sites will be randomized to either usual waiver care with internal facilitation of the bundle of implementation strategies or usual waiver care with both internal and external facilitation of the bundle. Primary outcomes are site-level adoption and sustainability over 12 months, and intervention effects on these outcomes are hypothesized to be mediated by clinicians’ attitude and self-efficacy. At the beneficiary level, by addressing the individual’s capabilities and home environment, the intervention is hypothesized to improve secondary outcomes of activities of daily living, pain, depression, falls, emergency department visits, and hospitalizations. Baseline site readiness and leadership and stages of implementation at 6 months will be explored as potential moderators. Linear mixed effects models will be used to test intervention effects on primary outcomes, with bias-correcting analytic strategy in mediation analyses. Generalized linear mixed effects modeling will be employed for the analysis of intervention effects on secondary outcomes. Discussion Synthesizing findings within and across the sites, we will specify how leadership, readiness for change, and level of facilitation enhance capacity for adoption and sustainability of an evidence-based intervention in an under-resourced Medicaid setting that cares for disabled and older adults. Trial registration ClinitalTrials.gov, NCT03634033. Registered 16 August 2018. Electronic supplementary material The online version of this article (10.1186/s13012-019-0907-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sandra L Spoelstra
- Kirkhof College of Nursing, Grand Valley State University, 301 Michigan St, Room C352, Grand Rapids, MI, 49504, USA.
| | - Monica Schueller
- Kirkhof College of Nursing, Grand Valley State University, 301 Michigan St, Room C352, Grand Rapids, MI, 49504, USA
| | - Alla Sikorskii
- Departments of Psychiatry and Statistics and Probability, Michigan State University, East Lansing, USA
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Bowling CB. Addressing the Need for New Models of Care for Older Adults Receiving Long-term Dialysis. Kidney Med 2019; 1:3-5. [PMID: 32734943 PMCID: PMC7380339 DOI: 10.1016/j.xkme.2019.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- C Barrett Bowling
- Durham VA Geriatrics Research, Education, and Clinical Center; and Division of Geriatrics, Department of Medicine, Duke University, Durham, NC
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