Challenges and Strategies to Maintain Fidelity to the MIRROR-TCM Intervention During the COVID-19 Pandemic

Abstract Randomized clinical trials (RCTs) have demonstrated that the multicomponent Transitional Care Model (TCM), an advanced practice registered nurse-led, team-based, care management strategy improves outcomes for older adults transitioning from hospital to home. However, healthcare systems’ adoption of the model has been limited. A multi-system, replication RCT (MIRROR-TCM) enrolling older adults hospitalized with heart failure, chronic obstructive pulmonary disease or pneumonia began in February 2020 just as the outbreak of COVID-19 in the U.S. dramatically changed the healthcare and research landscape. The goal of this qualitative descriptive study is to explore the impact of COVID-19 on fidelity to the TCM intervention during this clinical trial. Using directed content analysis, recorded monthly meetings with health system leaders and staff were coded to identify challenges and strategies to maintaining fidelity to the intervention in the context of the pandemic. Analyses showed that COVID-19 impacted all 10 TCM components. The components with the most challenges were delivering services from hospital-to-home due to quarantining, restrictive facility policies, lack of personal protective equipment and limited telehealth availability; coordinating care due reduced availability of services, and screening at risk individuals because of fewer eligible patients. Strategies for addressing challenges included: exploring alternatives (e.g., increasing reliance on telehealth, expanding study eligibility), building and engaging networks (e.g., direct outreach to skilled nursing facility staff) and anticipating needs (e.g., preparing for shorter hospital stays). Findings highlight the importance of monitoring the contextual challenges to implementing an evidence-based intervention and actively engaging partners in identifying strategies to achieve fidelity.

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Pharmacist-Led Transition of Care Pilot Targeting Older People After Emergency Department Discharge

The Senior Care Pharmacist ◽

10.4140/tcp.n.2020.273. ◽

2020 ◽

Vol 35 (6) ◽

pp. 273-282

Author(s):

Scott M. Pearson ◽

Anushka Tandon ◽

Danielle R. Fixen ◽

Sunny A. Linnebur ◽

Gretchen M. Orosz ◽

...

Keyword(s):

Emergency Department ◽

Older People ◽

Primary Outcome ◽

Transitional Care ◽

Intervention Group ◽

Chronic Obstructive ◽

P Value ◽

Historical Cohort ◽

Obstructive Pulmonary Disease ◽

The Impact

OBJECTIVE: To evaluate the impact of a pharmacist-led transitional care intervention targeting high-risk older people after an emergency department (ED) visit. DESIGN: Retrospective cohort study of older people with ED visits prior to and during a pharmacist-led intervention. SETTING: Patients receiving primary care from the University of Colorado Health Seniors Clinic. PARTICIPANTS: The intervention cohort comprised 170 patients with an ED visit between August 18, 2018, and February 19, 2019, and the historical cohort included 166 patients with an ED visit between August 18, 2017, and February 19, 2018. All included patients either had a historical diagnosis of heart failure or chronic obstructive pulmonary disease, or they had an additional ED visit in the previous six months. INTERVENTIONS: The pilot intervention involved postED discharge telephonic outreach and assessment by a clinical pharmacist, with triaging to other staff if necessary. MAIN OUTCOME MEASURE: The primary outcome was the proportion of patients with at least one repeat ED visit, hospitalization, or death within 30 days of ED discharge. Outcome rates were also assessed at 90 days postdischarge. RESULTS: The primary outcome occurred in 21% of the historical cohort and 25% of the intervention cohort (adjusted P-value = 0.48). The incidence of the composite outcome within 90 days of ED discharge was 43% in the historical group compared with 38% in the intervention group (adjusted P-value = 0.29). CONCLUSION: A pharmacist-led telephonic intervention pilot targeting older people did not appear to have a significant effect on the composite of repeat ED visit, hospitalization, or death within 30 or 90 days of ED discharge. A limited sample size may hinder the ability to make definitive conclusions based on these findings.

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Transitional care quality indicators to assess quality of care following hospitalisation for chronic obstructive pulmonary disease and heart failure: a systematic review protocol

BMJ Open ◽

10.1136/bmjopen-2019-032764 ◽

2019 ◽

Vol 9 (12) ◽

pp. e032764

Author(s):

Faith Michael ◽

Sera Whitelaw ◽

Harriette GC Van Spall

Keyword(s):

Heart Failure ◽

Systematic Review ◽

Quality Indicators ◽

Transitional Care ◽

Care Quality ◽

Chronic Obstructive ◽

Obstructive Pulmonary Disease ◽

Patient Reported ◽

Hospital To Home

IntroductionThe period following hospitalisation for chronic obstructive pulmonary disease (COPD) or heart failure (HF)—when patients transition between settings and clinicians—is one of high risk. Transitional care services that bridge the gap from hospital to home can improve outcomes, but there are no widely accepted indicators to assess their quality.Methods and analysisIn this systematic review, we will summarise transitional care quality indicators, and describe their associations with clinical, patient-reported and cost outcomes. We will search MEDLINE, Embase, CINAHL and HealthSTAR, as well as grey literature and reference lists of included articles. We will screen all studies published between January 1990 and October 2019 that test an intervention that aims to improve the hospital-to-home transition for patients with COPD and/or HF; and measure at least one process (eg, medication errors), clinical (eg, hospital readmissions) or patient-reported (eg, health-related quality of life) outcome which will serve as a transitional care quality indicator . We will include randomised controlled trials, cohort studies, cross-sectional studies, interrupted time series studies and before–after studies. We will extract data in duplicate and classify transitional care quality indicators as structural, process-related or outcome-related. When possible, we will assess associations between transitional care quality indicators and clinical outcomes. In anticipation of conceptual and statistical heterogeneity, we will provide a qualitative synthesis and narrative review of the results.Ethics and disseminationThis review will provide a list of transitional care quality indicators and their associations with clinical outcomes. These results can be used by hospitals, administrators and clinicians for assessing the quality of transitional care provided to patients with COPD and HF. The findings can also be used by policy-makers to assess and incentivise transitional care quality. We will disseminate results through publications, social media releases and presentations.PROSPERO registration numberThis study is registered on PROSPERO.

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Pneumonia Hospitalization Coding Changes Associated With Transition From the 9th to 10th Revision of International Classification of Diseases

Health Services Research and Managerial Epidemiology ◽

10.1177/2333392820939801 ◽

2020 ◽

Vol 7 ◽

pp. 233339282093980

Author(s):

Ryan B. Smithee ◽

Tiffanie M. Markus ◽

Elizabeth Soda ◽

Carlos G. Grijalva ◽

Wei Xing ◽

...

Keyword(s):

Older Adults ◽

International Classification Of Diseases ◽

International Classification ◽

Chronic Obstructive ◽

Adjustment Factor ◽

Obstructive Pulmonary Disease ◽

Vaccine Introduction ◽

Icd 10 ◽

The Impact

Objectives: To evaluate the impact of International Classification of Disease, 10th revision, Clinical Modification ( ICD-10-CM) implementation on pneumonia hospitalizations rates, which had declined following pneumococcal conjugate vaccine introduction for infants in 2000. Methods: We randomly selected records from a single hospital 1 year before (n = 500) and after (n = 500) October 2015 implementation of ICD-10-CM coding. We used a validated ICD-9-CM algorithm and translation of that algorithm to ICD-10-CM to identify pneumonia hospitalizations pre- and post-implementation, respectively. We recoded ICD-10-CM records to ICD-9-CM and vice versa. We calculated sensitivity and positive predictive value (PPV) of the ICD-10-CM algorithm using ICD-9-CM coding as the reference. We used sensitivity and PPV values to calculate an adjustment factor to apply to ICD-10 era rates to enable comparison with ICD-9-CM rates. We reviewed primary diagnoses of charts not meeting the pneumonia definition when recoded. Results: Sensitivity and PPV of the ICD-10-CM algorithm were 94% and 92%, respectively, for young children and 74% and 79% for older adults. The estimated adjustment factor for ICD-10-CM period rates was −2.09% (95% credible region [CR], −7.71% to +3.0%) for children and +6.76% (95% CR, −3.06% to +16.7%) for older adults. We identified a change in coding adult charts that met the ICD-9-CM pneumonia definition that led to recoding in ICD-10-CM as chronic obstructive pulmonary disease (COPD) exacerbation. Conclusions: The ICD-10-CM algorithm derived from a validated ICD-9-CM algorithm should not introduce substantial bias for evaluating pneumonia trends in children. However, changes in coding of pneumonia associated with COPD in adults warrant further study.

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Pharmacist-Led Transition of Care Pilot Targeting Older People After Emergency Department Discharge

The Senior Care Pharmacist ◽

10.4140/tcp.n.2020.273 ◽

2020 ◽

Vol 35 (6) ◽

pp. 273-282

Author(s):

Scott M. Pearson ◽

Anushka Tandon ◽

Danielle R. Fixen ◽

Sunny A. Linnebur ◽

Gretchen M. Orosz ◽

...

Keyword(s):

Emergency Department ◽

Older People ◽

Primary Outcome ◽

Transitional Care ◽

Intervention Group ◽

Chronic Obstructive ◽

P Value ◽

Historical Cohort ◽

Obstructive Pulmonary Disease ◽

The Impact

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Perceptions of a Transitional Care Model for Older Adults With Multimorbidity and Depressive Symptoms

Innovation in Aging ◽

10.1093/geroni/igaa057.828 ◽

2020 ◽

Vol 4 (Supplement_1) ◽

pp. 258-258

Author(s):

Maureen Markle-Reid ◽

Carrie McAiney ◽

Rebecca Ganann ◽

Carly Whitmore

Keyword(s):

Older Adults ◽

Depressive Symptoms ◽

Transitional Care ◽

Intervention Group ◽

Structured Interviews ◽

Community Assets ◽

Provider Perceptions ◽

Care Intervention ◽

Hospital To Home ◽

The Impact

Abstract Transitioning from hospital to home is an important healthcare system priority. This paper reports on the qualitative findings from a larger mixed methods study designed to examine the implementation and effectiveness of a new transitional care intervention (Community Assets Supporting Transitions [CAST]). The goal of the CAST intervention is to improve the quality and experience of hospital-to-home transitions for older adults (≥ 65 years) with depressive symptoms and multimorbidity. Semi-structured interviews were completed with a sub-set of intervention group trial participants including 11 older adult participants and 1 caregiver, as well as 4 intervention nurses. A qualitative descriptive design was used to explore the perceived impacts of the CAST intervention on participants and their caregivers. Audio-recorded interviews were transcribed verbatim, with descriptive codes and themes generated using conventional content analysis. Patient participants indicated that the intervention resulted in improved access to information (e.g., medication review) and services (e.g., care coordination) that enhanced their self-management. Participants felt that the home visits and phone visits were valuable and helped to improve their mental health. Intervention nurses described advocating for patients to help achieve their needs. For example, nurses advocated for physiotherapy services to provide additional education to support patient mobility. Understanding patient, caregiver, and provider perceptions of the impact of the CAST intervention will help to identify how to improve the delivery of this transitional care intervention, to bridge the gap between hospital and community care, and to positively impact patient health outcomes.

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Hazards for Construction Workers

10.1093/oso/9780190662677.003.0036 ◽

2017 ◽

Author(s):

Gavin H. West ◽

Laura S. Welch

Keyword(s):

Heavy Metals ◽

Prevention And Control ◽

Respiratory Diseases ◽

Noise Exposure ◽

Engineered Nanomaterials ◽

Construction Workers ◽

Chronic Obstructive ◽

Obstructive Pulmonary Disease ◽

And Control ◽

The Impact

This chapter describes the hazards for construction workers, with a particular focus on injuries as well as exposures to hazardous chemicals and dusts. A section describes hazardous exposures to lead and other heavy metals. Another section describes noise exposure. The impact of musculoskeletal disorders among construction workers is then discussed. A section on respiratory diseases focuses on asbestosis, silicosis, chronic obstructive pulmonary disease, and asthma. Exposures known to cause dermatitis and cancer are reviewed. There is a discussion of engineered nanomaterials as a potential emerging hazard. Various approaches to prevention and control, including regulations and health services, are described.

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The Impact of the COVID-19 Pandemic on Self-Reported Management of Chronic Conditions

Journal of Patient Experience ◽

10.1177/23743735211007693 ◽

2021 ◽

Vol 8 ◽

pp. 237437352110076

Author(s):

Hyllore Imeri ◽

Erin Holmes ◽

Shane Desselle ◽

Meagen Rosenthal ◽

Marie Barnard

Keyword(s):

Locus Of Control ◽

Chronic Conditions ◽

Online Survey ◽

Health Locus Of Control ◽

Patient Activation ◽

Survey Study ◽

Chronic Obstructive ◽

Cross Sectional ◽

Obstructive Pulmonary Disease ◽

The Impact

Chronic conditions (CCs) management during the COVID-19 pandemic and the impact of the pandemic on patient activation (PA) and health locus of control (HLOC) remain unknown. This cross-sectional online survey study examined the role of COVID-19 pandemic-related worry or fear in PA and HLOC among patients with CCs. Individuals with CCs (n = 300) were recruited through MTurk Amazon. The questionnaire included sociodemographic questions, the Patient Activation Measure, and the Multidimensional Health Locus of Control–Form B. Out of the 300 participants, 9.7% were diagnosed with COVID-19, and 7.3% were hospitalized. Patients with cancer, chronic kidney disease, chronic obstructive pulmonary disease, drug abuse/substance abuse, and stroke reported significant difficulties in managing their CCs due to worry or fear because of COVID-19. More than half of the sample (45.7%) reported COVID-19-related worry or fear about managing their CCs, and these patients had lower PA and lower external HLOC compared to patients not affected by COVID-19-related worry or fear. Health professionals should provide more support for patients facing difficulties in managing their CCs during the COVID-19 pandemic.

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Medically Treated Opioid Overdoses Among the U.S. Elderly: Trends and Correlates

Innovation in Aging ◽

10.1093/geroni/igaa057.176 ◽

2020 ◽

Vol 4 (Supplement_1) ◽

pp. 54-54

Author(s):

Peter Treitler ◽

Stephen Crystal ◽

Richard Hermida ◽

Jennifer Miles

Keyword(s):

Older Adults ◽

Pain Management ◽

The Elderly ◽

Opioid Use Disorder ◽

Chronic Obstructive ◽

Medicare Beneficiaries ◽

Older Individuals ◽

Opioid Use ◽

Policy And Practice ◽

Obstructive Pulmonary Disease

Abstract High rates of opioid prescribing and comorbid medical conditions increase risk of overdose among older adults. As the US population ages and the rates of opioid use disorder (OUD) increase in the elderly population, there is a need to characterize trends and correlates of overdose in order to more effectively target policy and practice. Using a ~40% random sample of 2015-2017 Medicare beneficiaries ages 65 and older with Part D pharmacy coverage, this study examined medically treated opioid overdoses among US older adults. The sample included 13-14 million beneficiaries per year. The rate of medically treated opioid overdoses among elderly Medicare beneficiaries increased by 15% from 6 per 10,000 in 2015 to 6.9 per 10,000 in 2017. Those with overdose were disproportionately female (63%), non-Hispanic white (83%), with diagnoses of pain conditions (96%), with diagnoses of major depression (63%), and with high rates of conditions that decrease respiratory reserve such as chronic obstructive pulmonary disease. 13% had co-occurring diagnosed alcohol use disorder, 36% were diagnosed with opioid dependence or abuse, and 12% were diagnosed with hepatitis C. Older individuals with overdose represent a complex mix of risk factors; identifying those most at risk (as well as those who have very low risk, whose pain management may be compromised by overly-rigid interpretation of opioid use guidelines) is key in order to address multiple risks, balancing risk reduction with appropriate pain management.

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‘I’m fine!’: Assertions of lack of support need among patients with chronic obstructive pulmonary disease: A mixed-methods study

Chronic Illness ◽

10.1177/17423953211000386 ◽

2021 ◽

pp. 174239532110003

Author(s):

A Carole Gardener ◽

Caroline Moore ◽

Morag Farquhar ◽

Gail Ewing ◽

Efthalia Massou ◽

...

Keyword(s):

Chronic Obstructive Pulmonary Disease ◽

Pulmonary Disease ◽

Mixed Method ◽

Self Report ◽

Design Stage ◽

Chronic Obstructive ◽

Support Needs ◽

Obstructive Pulmonary Disease ◽

Stage 1 ◽

The Impact

Objectives To understand how people with Chronic Obstructive Pulmonary Disease (COPD) disavow their support needs and the impact on care. Methods Two stage mixed-method design. Stage 1 involved sub-analyses of data from a mixed-method population-based longitudinal study exploring the needs of patients with advanced COPD. Using adapted criteria from mental health research, we identified 21 patients who disavowed their needs from the 235 patient cohort. Qualitative interview transcripts and self-report measures were analysed to compare these patients with the remaining cohort. In stage 2 focus groups (n = 2) with primary healthcare practitioners (n = 9) explored the implications of Stage 1 findings. Results Patients who disavowed their support needs described non-compliance with symptom management and avoidance of future care planning (qualitative data). Analysis of self-report measures of mental and physical health found this group reported fewer needs than the remaining sample yet wanted more GP contact. The link between risk factors and healthcare professional involvement present in the rest of the sample was missing for these patients. Focus group data suggested practitioners found these patients challenging. Discussion This study identified patients with COPD who disavow their support needs, but who also desire more GP contact. GPs report finding these patients challenging to engage.

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