Nurse-led supportive Coordinated Transitional Care (CTraC) program improves care for veterans with serious illness

BACKGROUND

The Coordinated Transitional Care (CTraC) program is a telephone-based, nurse-driven program shown to decrease readmissions. The aim of this project was to implement and evaluate an adapted version of CTraC, Supportive CTraC, to improve the quality of transitional and end-of-life care for veterans with serious illness.

METHODS

We used the Replicating Effective Programs framework to guide adaptation and implementation. An RN nurse case manager (NCM) with experience in geriatrics and palliative care worked closely with inpatient and outpatient care teams to coordinate care. Eligible patients had a life-limiting diagnosis with substantial functional impairment and were not enrolled in hospice. The NCM identified veterans at VA Boston Healthcare System during an acute admission and delivered a protocolized intervention to define care needs and preferences, align care with patient values, optimize discharge plans, and provide ongoing, intensive phone-based case management. To evaluate efficacy, we matched each Supportive CTraC enrollee 1:1 to a contemporary comparison subject by age, risk of death or hospitalization, and discharge diagnosis. We used Kaplan-Meier plots and Cox-Proportional Hazards models to evaluate outcomes. Outcomes included palliative and hospice care use, acute care use, Massachusetts Medical Orders for Life Sustaining Treatment documentation, and survival.

RESULTS

The NCM enrolled 104 veterans with high protocol fidelity. Over 1.5 years of follow-up, Supportive CTraC enrollees were 61% more likely to enroll in hospice than the comparison group (n = 57 vs. 39; HR = 1.61; 95% CI = 1.07-2.43). While overall acute care use was similar between groups, Supportive CTraC patients had fewer ICU admissions (n = 36 vs. 53; p = 0.005), were more likely to die in hospice (53 vs. 34; p = 0.008), and twice as likely to die at home with hospice (32.0 vs. 15.5; p = 0.02). There was no difference in survival between groups.

CONCLUSIONS

A nurse-driven transitional care program for veterans with serious illness is feasible and effective at improving end-of-life outcomes.

Challenges for Patients Dying of Heart Failure and Cancer

BACKGROUND

Hospice and palliative care were originally implemented for patients dying of cancer, both of which continue to be underused in patients with heart failure (HF). The objective of this study was to understand the unique challenges faced by patients dying of HF compared with cancer.

METHODS

We assessed differences in demographics, health status, and financial burden between patients dying of HF and cancer from the Health and Retirement Study.

RESULTS

The analysis included 3203 individuals who died of cancer and 3555 individuals who died of HF between 1994 and 2014. Compared with patients dying of cancer, patients dying of HF were older (80 years versus 76 years), had poorer self-reported health, and had greater difficulty with all activities of daily living while receiving less informal help. Their death was far more likely to be considered unexpected (39% versus 70%) and they were much more likely to have died without warning or within 1 to 2 hours (20% versus 1%). They were more likely to die in a hospital or nursing home than at home or in hospice. Both groups faced similarly high total healthcare out-of-pockets costs ($9988 versus $9595, P=0.6) though patients dying of HF had less wealth ($29 895 versus $39 008), thereby experiencing greater financial burden.

CONCLUSIONS

Compared with patients dying of cancer, those dying from HF are older, have greater difficulty with activities of daily living, are more likely to die suddenly, in a hospital or nursing home rather than home or hospice, and had worse financial burden.

Top Ten Tips Palliative Care Clinicians Should Know About Caring for Jewish Patients

Judaism, one of the world's oldest religions, claims an estimated 14.3 million members worldwide. There is great diversity in terms of identity, practice, and belief among people who identify as Jewish. As of 2017, 40% of the global Jewish community resided in the United States, making it essential for palliative care clinicians to understand religious and cultural issues related to their serious illness care. In this article, we will discuss 10 important concepts relevant to the inpatient care, advance care planning, and bereavement needs of Jewish patients and families.

Top Ten Tips Palliative Care Clinicians Should Know About Opioid Use Disorder

Since the prevalence of substance use disorders, and opioid use disorder (OUD) specifically, remains high and represents a public health crisis, it is critical that palliative care (PC) providers have a broad understanding of this class of chronic, yet treatable, diseases. Conceptualizing stigma associated with OUD, treatment modalities available, and educational opportunities are key factors in providing patient-centered care. A solid foundation of knowledge about OUD in the setting of serious illness is also crucial as PC providers often recommend or prescribe opioids for symptom management in patients who also have OUD. Furthermore, the PC interdisciplinary team is particularly well poised to care for patients suffering from OUD due to the inherently holistic approach already present in the specialty of PC. This article offers PC teams a framework for understanding the diagnosis and treatment of OUD, methods for performing risk stratification and monitoring, and an overview of opportunities to enhance our care of PC patients with OUD.

Characterizing medication discrepancies among older adults during transitions of care: a systematic review focusing on discrepancy synonyms, data sources and classification terms

Medication reconciliation is a Joint Commission National Patient Safety Goal prioritized at transitions of care. Medication discrepancies are the reason for, and result of, medication reconciliation. However, their characterization in the literature has not been systematically studied. Older adults are at particularly high risk for medication discrepancies given the prevalence of polypharmacy in this population. The aim was to determine how medication discrepancies among older adults are defined during transitions of care by analyzing synonyms, medication data sources and classification terms. A systematic search of PubMed and EMBASE for primary literature involving medication discrepancies among adults aged ≥50 years during hospital care transitions was carried out. Reviewers consolidated data into like categories and used descriptive statistics to summarize findings. Out of 746 records retrieved, 35 studies were included in this review. In total, 19 studies (54%) were exclusive to adults over 65 years of age. Study settings included hospital discharge (n = 16; 46%), admission (n = 13; 37%) and mixed or multiple transitions (n = 6; 17%). Synonyms for discrepancies included inconsistencies, incongruences, inaccuracies and disagreements, among others. Common data sources included inpatient medication records and medication histories. A comprehensive, best possible medication history utilizing all available medication data sources was recorded in 51% of studies (n = 18), most consistently at admission. Most studies (n = 32; 91%) classified discrepancies; common classification terms included drug dose (n = 28; 88%), omission (n = 26; 80%) and commission (n = 16; 50%). In this first systematic review of medication discrepancy definitions, we found inconsistency across studies. Standardization and common discrepancy nomenclature is necessary for medication reconciliation outcomes to be compared, and to identify best practices to enhance safety. Safety implications are most salient in older adults given the number of medications and transitions of care to which they are exposed, as well as their sensitivity to adverse consequences of medication discrepancies.

Complexity perplexity: a systematic review to describe the measurement of medication regimen complexity

INTRODUCTION

Complex medication regimens are error prone and challenging for patients, which may impact medication adherence and safety. No universal method to assess the complexity of medication regimens (CMRx) exists. The authors aim to review literature for CMRx measurements to establish consistencies and, secondarily, describe CMRx impact on healthcare outcomes.

AREAS COVERED

A search of EMBASE and PubMed for studies analyzing at least two medications and complexity components, among those self-managing medications, was conducted. Out of 1204 abstracts, 38 studies were included in the final sample. The majority (74%) of studies used one of five validated CMRx scales; their components and scoring were compared.

EXPERT OPINION

Universal CMRx assessment is needed to identify and reduce complex regimens, and, thus, improve safety. The authors highlight commonalities among five scales to help build consensus. Common components (i.e., regimen factors) included dosing frequency, units per dose, and non-oral routes. Elements (e.g., twice daily) of these components (e.g., dosing frequency) and scoring varied. Patient-specific factors (e.g., dexterity, cognition) were not addressed, which is a shortcoming of current scales and a challenge for future scales. As CMRx has important outcomes, notably adherence and healthcare utilization, a standardized tool has potential for far-reaching clinical, research, and patient-safety impact.

Spiritual needs and spiritual care for veterans at end of life and their families

Spiritual care is an important domain of palliative care programs across the country and in the Veterans Affairs (VA) Healthcare System specifically. This qualitative study assessed the spiritual needs, spiritual care received, and satisfaction with spiritual care of both Veterans at the end of life and their families. Seventeen Veterans and 9 family members participated. They expressed a wide range of spiritual needs, including a wish of Veterans to have a better understanding of traumatic events that occurred during their combat experience. Some Veterans reported military experience enhanced their spirituality. Generally, respondents reported satisfaction with VA spiritual care, but indicated that Veterans may benefit from greater access to VA chaplains and explicit discussion of the impact of their military experience on their spirituality.

Ovarian carcinoma with thyroid metastases causing clinical hypothyroidism: A case report

BACKGROUND

Ovarian cancer is known to metastasize to the thyroid gland. Despite an incidence of ovarian metastasis to the thyroid of 3-15%, clinical hypothyroidism resulting from such metastasis has not yet been reported. We present a case of metastatic ovarian cancer to the thyroid resulting in clinical hypothyroidism.

CASE

A 55-year-old woman with recurrent papillary adenocarcinoma of the ovary presented with fatigue, abdominal distention, lymphedema, and depression. Thyroid stimulating hormone was markedly elevated, and thyroid biopsy demonstrated bilateral metastatic ovarian carcinoma.

CONCLUSION

Although uncommon, metastatic disease to the thyroid should be considered when evaluating a patient with advanced ovarian cancer and clinical hypothyroidism.