Care transitions and social needs: A Geriatric Emergency care Applied Research (GEAR) Network scoping review and consensus statement

OBJECTIVES

Individual-level social needs have been shown to substantially impact emergency department (ED) care transitions of older adults. The Geriatric Emergency care Applied Research (GEAR) Network aimed to identify care transition interventions, particularly addressing social needs, and prioritize future research questions.

METHODS

GEAR engaged 49 interdisciplinary stakeholders, derived clinical questions, and conducted searches of electronic databases to identify ED discharge care transition interventions in older adult populations. Informed by the Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE) framework, data extraction and synthesis of included studies included the degree that intervention components addressed social needs and their association with patient outcomes. GEAR convened a consensus conference to identify topics of highest priority for future care transitions research.

RESULTS

Our search identified 248 unique articles addressing care transition interventions in older adult populations. Of these, 17 individual care transition intervention studies were included in the current literature synthesis. Overall, common care transition interventions included coordination efforts, comprehensive geriatric assessments, discharge planning, and telephone or in-person follow-up. Fourteen of the 17 care transition intervention studies in older adults specifically addressed at least one social need within the PRAPARE framework, most commonly related to access to food, medicine, or health care. No care transition intervention addressing social needs in older adult populations consistently reduced subsequent health care utilization or other patient-centered outcomes. GEAR stakeholders identified that determining optimal outcome measures for ED-home transition interventions was the highest priority area for future care transitions research.

CONCLUSIONS

ED care transition intervention studies in older adults frequently address at least one social need component and exhibit variation in the degree of success on a wide array of health care utilization outcomes.

Organizational Readiness for Community Health Worker Workforce Integration Among Medicaid Contracted Health Plans and Provider Networks: An Arizona Case Study

Understanding and building organizational capacity for system change and the integration of the Community Health Worker (CHW) workforce within the health scare sector requires a supportive organizational culture among sector leaders and providers. The aim of this mixed-methods study was to assess organizational readiness for CHW workforce integration into Arizona Medicaid health systems and care teams. This collaborative effort was in direct response to emergent state and national CHW workforce policy opportunities, and the shifting health care landscape in Arizona – which merged behavior and physical health. Specifically, and in collaboration with a broad-based, statewide CHW workforce coalition, led by the CHW professional association, we assessed 245 licensed health care professionals with experience working with CHWs and 16 Medicaid-contracted health plan leadership. Our goal was to generate a baseline understanding of the knowledge, attitudes and beliefs these stakeholders held about the integration of CHWs into systems and teams. Our findings demonstrate a high level of organizational readiness and action toward integration of CHWs within the Arizona health care system and care teams. CHWs have emerged as a health care workforce able to enhance the patient experience of care, improve population health, reduce cost of care, and improve the experience of providing care among clinicians and staff.

Native mutant huntingtin in human brain: evidence for prevalence of full-length monomer

Huntington disease (HD) is caused by polyglutamine expansion in the N terminus of huntingtin (htt). Analysis of human postmortem brain lysates by SDS-PAGE and Western blot reveals htt as full-length and fragmented. Here we used Blue Native PAGE (BNP) and Western blots to study native htt in human postmortem brain. Antisera against htt detected a single band broadly migrating at 575-850 kDa in control brain and at 650-885 kDa in heterozygous and Venezuelan homozygous HD brains. Anti-polyglutamine antisera detected full-length mutant htt in HD brain. There was little htt cleavage even if lysates were pretreated with trypsin, indicating a property of native htt to resist protease cleavage. A soluble mutant htt fragment of about 180 kDa was detected with anti-htt antibody Ab1 (htt-(1-17)) and increased when lysates were treated with denaturants (SDS, 8 M urea, DTT, or trypsin) before BNP. Wild-type htt was more resistant to denaturants. Based on migration of in vitro translated htt fragments, the 180-kDa segment terminated ≈htt 670-880 amino acids. If second dimension SDS-PAGE followed BNP, the 180-kDa mutant htt was absent, and 43-50 kDa htt fragments appeared. Brain lysates from two HD mouse models expressed native full-length htt; a mutant fragment formed if lysates were pretreated with 8 M urea + DTT. Native full-length mutant htt in embryonic HD(140Q/140Q) mouse primary neurons was intact during cell death and when cell lysates were exposed to denaturants before BNP. Thus, native mutant htt occurs in brain and primary neurons as a soluble full-length monomer.

A roadmap for the prevention of dementia II: Leon Thal Symposium 2008

This document proposes an array of recommendations for a National Plan of Action to accelerate the discovery and development of therapies to delay or prevent the onset of disabling symptoms of Alzheimer's disease. A number of key scientific and public-policy needs identified in this document will be incorporated by the Alzheimer Study Group into a broader National Alzheimer's Strategic Plan, which will be presented to the 111th Congress and the Obama administration in March 2009. The Alzheimer's Strategic Plan is expected to include additional recommendations for governance, family support, healthcare, and delivery of social services.

Recombination events suggest potential sites for the Huntington's disease gene

The Huntington's disease gene (HD) maps distal to the D4S10 marker in the terminal 4p16.3 subband of chromosome 4. Directed cloning has provided several DNA segments that have been grouped into three clusters on a physical map of approximately 5 X 10(6) bp in 4p16.3. We have typed RFLPs in both reference and HD pedigrees to produce a fine-structure genetic map that establishes the relative order of the clusters and further narrows the target area containing the HD gene. Despite the large number of meiotic events examined, the HD gene cannot be positioned relative to the most distal cluster. One recombination event with HD suggests that the terminal-most markers flank the disease gene; two others favor a telomeric location for the defect. Efforts to isolate the HD gene must be divided between these two distinct intervals until additional genetic data resolve the apparent contradiction in localization.

Word association: variables affecting popular-response frequency

Normal Ss were given 54 Kent-Rosanoff word-association-test items in one of two different orders; antonym-eliciting items were concentrated either (a) near the beginning or (b) near the end of the list. For each order, testing was administered under three different test conditions: (a) standard free-association instructions, (b) instructions to give the response “most people” would give, and (c) “most people” instructions with a multiple-choice test format. The order starting with antonym-eliciting items elicited more popular antonym responses than did the other order. Popularity-set instructions, particularly with the multiple-choice format, elicited more non-antonym popular responses than did free-association test conditions. With repeated testing, popular antonyms became more frequent. For some sequences of test conditions, there was also an increase in non-antonym popular responses with repeated testing.