Care manager, older adult, and caregiver perspectives on co-occurring care management among high-need older adults

BACKGROUND

Care management programs are widely used to improve care coordination and management of chronic conditions for high-need older adults. With many care management programs targeting a small number of people, high-need older adults may receive services from more than one care management program (co-occurring care management), the implications of which are unknown.

METHODS

We conducted semi-structured interviews with 37 care managers, 15 older adults, and 13 caregivers, who were recruited through an urban academic medical center and a large rural health system in Maryland. We analyzed interview transcripts using qualitative content analysis with the aim of understanding contributors to, implications of, and strategies to manage co-occurring care management among high-need older adults.

RESULTS

Contributors to co-occurring care management included siloed programs due to program-specific financial incentives and inability to easily identify other involved care managers, and the complex needs of the enrolled older adult population, which motivated involvement of more than one program. Implications of co-occurring care management included older adults and caregivers feeling cared for and safe when they had multiple care management programs involved and reporting value in their relationships with care managers. Older adults were identified as having greater access to resources and improved care when care manager roles were aligned in a complementary way; however, misaligned roles posed the potential for confusion about care manager accountability for tasks and resulted in frustration and lack of follow-through. Strategies for managing co-occurring care management included alignment of care manager roles through communication and negotiation and older adults and caregivers identifying and relying on a single care manager with whom they had the strongest relationship.

CONCLUSIONS

Initiatives that clarify strengthen the relationship between care managers and older adults, increase care manager visibility, and facilitate communication across care managers may help foster collaboration.

"It's Tricky": Care Managers' Perspectives on Interacting with Primary Care Clinicians

Care management programs that facilitate collaboration between care managers and primary care clinicians are more likely to be successful in improving chronic disease metrics than programs that do not facilitate such collaboration. The authors sought to understand care managers' perspectives on interacting with primary care clinicians. Semi-structured qualitative interviews were conducted with care managers (n = 29) from 3 health systems in and around a large, urban academic center. Interviews were audio recorded, transcribed verbatim, and iteratively analyzed using a grounded theory approach. Care managers worked for health plans (14%), outpatient specialty clinics (31%), hospitals and emergency departments (24%), and primary care offices (14%). Care managers identified the primary care clinician as leading patients' care and as essential to avoiding unnecessary utilization. Care managers described variability in and barriers to interacting with primary care clinicians. When possible, care managers use the electronic medical record to facilitate interaction rather than communicating directly (eg, phone call) with primary care clinicians. The role of the care manager varied across programs, contributing to primary care clinicians' poor understanding of what the care manager could provide. Consequently, primary care clinicians asked the care manager for help with tasks beyond his/her role. Care managers felt inferior to primary care clinicians, a potential result of the traditional medical hierarchy, which also hindered interactions. Although care managers view interactions with the primary care clinician as essential to the health of the patient, communication challenges, variability of the care manager's role, and medical hierarchy limit collaboration.

A DNA barcode reference library for Swiss butterflies and forester moths as a tool for species identification, systematics and conservation

Butterfly monitoring and Red List programs in Switzerland rely on a combination of observations and collection records to document changes in species distributions through time. While most butterflies can be identified using morphology, some taxa remain challenging, making it difficult to accurately map their distributions and develop appropriate conservation measures. In this paper, we explore the use of the DNA barcode (a fragment of the mitochondrial gene COI) as a tool for the identification of Swiss butterflies and forester moths (Rhopalocera and Zygaenidae). We present a national DNA barcode reference library including 868 sequences representing 217 out of 224 resident species, or 96.9% of Swiss fauna. DNA barcodes were diagnostic for nearly 90% of Swiss species. The remaining 10% represent cases of para- and polyphyly likely involving introgression or incomplete lineage sorting among closely related taxa. We demonstrate that integrative taxonomic methods incorporating a combination of morphological and genetic techniques result in a rate of species identification of over 96% in females and over 98% in males, higher than either morphology or DNA barcodes alone. We explore the use of the DNA barcode for exploring boundaries among taxa, understanding the geographical distribution of cryptic diversity and evaluating the status of purportedly endemic taxa. Finally, we discuss how DNA barcodes may be used to improve field practices and ultimately enhance conservation strategies.

Mental Health Conditions and Symptoms in Pediatric Hospitalizations: A Single-Center Point Prevalence Study

BACKGROUND

Children and adolescents necessitating hospitalization for physical health conditions are at high risk for mental health conditions; however, the prevalence of mental health conditions and symptoms among hospitalized children and adolescents is uncertain. The objective of this study was to determine the proportion of hospitalized children and adolescents who have diagnosed mental health disorders or undiagnosed mental health problems.

METHODS

In this single-center point prevalence study of hospitalized children between the ages of 4 and 21 years, patients or their parents reported known mental health diagnoses and use of services using the Services Assessment for Children and Adolescent, and they reported patient mental health symptoms using the Pediatric Symptom Checklist, 17-item form (PSC-17).

RESULTS

Of 229 eligible patients, 119 agreed to participate. Demographic characteristics of patients who enrolled were not statistically significantly different from those of patients who declined to participate. Among participants, 26% (95% confidence interval [CI], 18%-35%) reported a known mental health diagnosis. On the PSC-17, 29% (95% CI, 21%-38%) of participants had a positive screen for mental health symptoms. Of those with a positive screen, 38% (95% CI, 21%-55%) had no known mental health diagnosis, and 26% (95% CI, 12%-43%) had not received ambulatory mental health services in the 12 months before hospitalization.

CONCLUSIONS

Mental health conditions and symptoms are common among patients hospitalized in a tertiary children's hospital, and many affected patients are not receiving ambulatory mental health services.

Optical-feedback cavity ring-down spectroscopy measurements of extinction by aerosol particles

Optical feedback cavity ring-down spectroscopy (OF-CRDS) using a continuous wave distributed feedback diode laser at 1650 nm has been used to measure extinction of light by samples of monodisperse spherical aerosol particles <1 mum in diameter. The OF-CRDS method allows measurements of low levels of extinction of incident light to be made at repetition rates of 1 kHz or greater. A statistical model is proposed to describe the linear relationship between the extinction coefficient (alpha) and its variance (Var(alpha)). Application of this model to experimental measurements of Var(alpha) for a range of alpha values typically below approximately 1 x 10(-6) cm(-1) allows extinction cross-sections for the aerosol particles to be obtained without need for knowledge of the particle number density. Samples of polystyrene spheres with diameters of 400, 500, 600, and 700 nm were used to test the model by comparing extinction cross-sections determined from the experiment with the predictions of Mie theory calculations. Fitting of ring-down decay traces exhibiting amplitude noise to extract cavity ring-down times introduces additional quadratic and higher order polynomial dependencies of the variance that become significant for larger particle number densities and thus extinction coefficients (typically for alpha > 1 x 10(-6) cm(-1) under our experimental conditions). Aggregation of particles at larger number densities is suggested as a further source of variance in the measurements. Extinction cross-sections are severely underestimated if the measurements are made too rapidly to sample uncorrelated distributions of particle numbers and positions.

Porcine bladder acellular matrix (ACM): protein expression, mechanical properties

Experimentally, porcine bladder acellular matrix (ACM) that mimics extracellular matrix has excellent potential as a bladder substitute. Herein we investigated the spatial localization and expression of different key cellular and extracellular proteins in the ACM; furthermore, we evaluated the inherent mechanical properties of the resultant ACM prior to implantation. Using a proprietary decellularization method, the DNA contents in both ACM and normal bladder were measured; in addition we used immunohistochemistry and western blots to quantify and localize the different cellular and extracellular components, and finally the mechanical testing was performed using a uniaxial mechanical testing machine. The mean DNA content in the ACM was significantly lower in the ACM compared to the bladder. Furthermore, the immunohistochemical and western blot analyses showed that collagen I and IV were preserved in the ACM, but possibly denatured collagen III in the ACM. Furthermore, elastin, laminin and fibronectin were mildly reduced in the ACM. Although the ACM did not exhibit nucleated cells, residual cellular components (actin, myosin, vimentin and others) were still present. There was, on the other hand, no significant difference in the mean stiffness between the ACM and the bladder. Although our decellularization method is effective in removing nuclear material from the bladder while maintaining its inherent mechanical properties, further work is mandatory to determine whether these residual DNA and cellular remnants would lead to any immune reaction, or if the mechanical properties of the ACM are preserved upon implantation and cellularization.