Evaluation of an initiative to improve advance care planning for a home-based primary care service

Abstract Background Advance care planning (ACP) is a process that enables individuals to describe, in advance, the kind of health care they would want in the future. There is evidence that ACP reduces hospital-based interventions, especially at the end of life. ACP for frail older adults is especially important as this population is more likely to use hospital services but less likely to benefit from resource intensive care. Our study goal was to evaluate whether an approach to ACP developed for frail older adults, known as the Palliative and Therapeutic Harmonization or PATH, demonstrated an improvement in ACP. Methods The PATH approach was adapted to a primary care service for homebound older adults in Vancouver, Canada. This retrospective chart review collected surrogate measures related to ACP from 200 randomly selected patients enrolled in the service at baseline (prior to June 22, 2017), and 114 consecutive patients admitted to the program after implementation of the PATH ACP initiative (October 1, 2017 to May 1, 2018). We compared the following surrogate markers of ACP before and after implementation of the PATH model, chart documentation of: frailty stage, substitute decision-maker, resuscitation decision, and hospitalization decision. A composite ACP documentation score that ascribed one point for each of the above four measures (range 0 to 4) was also compared. For those with documented resuscitation and hospitalization decisions, the study examined patient/ substitute decision-maker expressed preferences for do-not-resuscitate and do-not-hospitalize, before and after implementation. Results We found the following changes in ACP-related documentation before and after implementation: frailty stage (27.0% versus 74.6%, p < .0001); substitute decision-maker (63.5% versus 71.9%, p = 0.128); resuscitation decision documented (79.5% versus 67.5%, p = 0.018); and hospitalization decision documented (61.5% versus 100.0%, p < .0001); mean (standard deviation) composite ACP documentation score (2.32 (1.16) versus 3.14 (1.11), p < .0001). The adjusted odds ratios (95% confidence intervals) for an expressed preference of do-not-resuscitate and do-not-hospitalize after implementation were 0.87 (0.35, 2.15) and 3.14 (1.78, 5.55), respectively. Conclusions Results suggest partial success in implementing the PATH approach to ACP in home-based primary care. Key contextual enablers and barriers are important considerations for successful implementation.

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Advance Care Planning and Decision-Making in a Home-Based Primary Care Service in a Canadian Urban Centre

Canadian Geriatrics Journal ◽

10.5770/cgj.22.377 ◽

2019 ◽

Vol 22 (4) ◽

pp. 182-189 ◽

Cited By ~ 3

Author(s):

Madison Huggins ◽

Margaret J. McGregor ◽

Michelle B. Cox ◽

Katie Bauder ◽

Jay Slater ◽

...

Keyword(s):

Primary Care ◽

Decision Making ◽

Logistic Regression ◽

Decision Maker ◽

Older Age ◽

Care Planning ◽

Substitute Decision Maker ◽

Home Based Primary Care ◽

Home Based ◽

Essential Components

BackgroundAdvance care planning (ACP) is a process that enables individuals to describe, in advance, the kind of health care they would want in the future, and has been shown to reduce hospital-based interventions at the end of life. Our goal was to describe the current state of ACP in a home-based primary care program for frail homebound older people in Vancouver, Canada. We did this by identifying four key elements that should be essential to ACP in this program: frailty stage, documentation of substitute decision-makers, and decision-making with regard to both resuscitation (i.e., do not resuscitate (DNR)) and hospitalization (i.e., do not hospitalize (DNH)). While these elements are an important part of the ACP process, they are often excluded from common practice. MethodsThis was a cross-sectional, observational study of data abstracted from 200 randomly selected patient electronic medical records between July 1 and September 30, 2017. We describe the association between demographic characteristics, comorbidities, and four key elements of ACP documentation and decision-making as documented in the clinical record using bivariate comparison, a logistic regression model and multiple logistic regression analysis. ResultsIn 73% (n=146) of the patient records, there was no explicit documentation of frailty stage. Sixty-four percent had documentation of a substitute decision-maker. Of those who had their preferences documented, 90.6% (n=144/159) indicated a preference for DNR, and 23.6% (n=29/123) indicated a preference for DNH. In multiple regression modeling, a diagnosis of dementia and older age were associated with documentation of a DNR preference, adjusted odds ratio (AOR) = 4.79 (95% CI 1.37, 16.71) and AOR = 1.14 (95% CI 1.05, 1.24), respectively. Older age, male sex, and English identified as the main language spoken were associated with a DNH preference. AOR = 1.17 (95% CI 1.06, 1.28), AOR = 4.19 (95% CI 1.41, 12.42), and AOR = 3.42 (95% CI 1.14, 10.20), respectively. ConclusionsClinician documentation of some elements of ACP, such as identification of a substitute decision-maker and resuscitation status, have been widely adopted, while other elements that should be considered essential components of ACP, such as frailty staging and preferences around hospitalization, are infrequent and provide an opportunity for practice improvement initiatives. The significant association between language and ACP decisions suggests an important role for supporting cross-cultural fluency in the ACP process.

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Addressing COVID-19 Worry and Social Isolation in Home-Based Primary Care

10.31234/osf.io/483zv ◽

2020 ◽

Author(s):

Rachel Elizabeth Weiskittle ◽

Michelle Mlinac ◽

LICSW Nicole Downing

Keyword(s):

Mental Health ◽

Older Adults ◽

Primary Care ◽

Social Workers ◽

Social Isolation ◽

Mental Health Providers ◽

Health Providers ◽

Home Based Primary Care ◽

Home Based ◽

Socially Isolated

Social distancing measures following the outbreak of COVID-19 have led to a rapid shift to virtual and telephone care. Social workers and mental health providers in VA home-based primary care (HBPC) teams face challenges providing psychosocial support to their homebound, medically complex, socially isolated patient population who are high risk for poor health outcomes related to COVID-19. We developed and disseminated an 8-week telephone or virtual group intervention for front-line HBPC social workers and mental health providers to use with socially isolated, medically complex older adults. The intervention draws on skills from evidence-based psychotherapies for older adults including Acceptance and Commitment Therapy, Cognitive-Behavioral Therapy, and Problem-Solving Therapy. The manual was disseminated to VA HBPC clinicians and geriatrics providers across the United States in March 2020 for expeditious implementation. Eighteen HBPC teams and three VA Primary Care teams reported immediate delivery of a local virtual or telephone group using the manual. In this paper we describe the manual’s development and clinical recommendations for its application across geriatric care settings. Future evaluation will identify ways to meet longer-term social isolation and evolving mental health needs for this patient population as the pandemic continues.

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Oral health status and needs of homebound elderly in an urban home-based primary care service

Special Care in Dentistry ◽

10.1111/j.1754-4505.2012.00316.x ◽

2012 ◽

Vol 33 (5) ◽

pp. 218-226 ◽

Cited By ~ 8

Author(s):

R. Gluzman ◽

H. Meeker ◽

P. Agarwal ◽

S. Patel ◽

G. Gluck ◽

...

Keyword(s):

Primary Care ◽

Health Status ◽

Oral Health ◽

Care Service ◽

Oral Health Status ◽

Primary Care Service ◽

Home Based Primary Care ◽

Home Based

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Hospitalizations and Skilled Nursing Facility Admissions Before and After the Implementation of a Home-Based Primary Care Program

Journal of the American Geriatrics Society ◽

10.1111/j.1532-5415.2010.02859.x ◽

2010 ◽

Vol 58 (6) ◽

pp. 1144-1147 ◽

Cited By ~ 29

Author(s):

Ania Wajnberg ◽

Karen H. Wang ◽

Mohamed Aniff ◽

Hillary V. Kunins

Keyword(s):

Primary Care ◽

Skilled Nursing Facility ◽

Care Program ◽

Nursing Facility ◽

Skilled Nursing ◽

Home Based Primary Care ◽

Home Based ◽

Primary Care Program ◽

Before And After

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Home-Based Primary Care for Homebound Older Adults: Literature Review

Annals of Geriatric Medicine and Research ◽

10.4235/agmr.2018.22.2.62 ◽

2018 ◽

Vol 22 (2) ◽

pp. 62-72 ◽

Cited By ~ 1

Author(s):

Chang-O Kim ◽

Soong-Nang Jang

Keyword(s):

Older Adults ◽

Primary Care ◽

Literature Review ◽

Home Based Primary Care ◽

Home Based ◽

Homebound Older Adults

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Home and community-based services coordination for homebound older adults in home-based primary care

BMC Geriatrics ◽

10.1186/s12877-018-0931-z ◽

2018 ◽

Vol 18 (1) ◽

Cited By ~ 2

Author(s):

Gregory J. Norman ◽

Amy J. Wade ◽

Andrea M. Morris ◽

Jill C. Slaboda

Keyword(s):

Older Adults ◽

Primary Care ◽

Community Based ◽

Home Based Primary Care ◽

Home Based ◽

Homebound Older Adults ◽

Community Based Services

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Profiles of Frailty among Older People Users of a Home-Based Primary Care Service in an Urban Area of Barcelona (Spain): An Observational Study and Cluster Analysis

Journal of Clinical Medicine ◽

10.3390/jcm10102106 ◽

2021 ◽

Vol 10 (10) ◽

pp. 2106

Author(s):

Juan-José Zamora-Sánchez ◽

Edurne Zabaleta-del-Olmo ◽

Sergio Fernández-Bertolín ◽

Vicente Gea-Caballero ◽

Iván Julián-Rochina ◽

...

Keyword(s):

Primary Care ◽

Cluster Analysis ◽

Observational Study ◽

Older People ◽

Care Service ◽

Primary Care Service ◽

Moderate Degree ◽

Care Needs ◽

Home Based Primary Care ◽

Home Based

Background: The multidimensional assessment of frailty allows stratifying it into degrees; however, there is still heterogeneity in the characteristics of people in each stratum. The aim of this study was to identify frailty profiles of older people users of a home-based primary care service. Methods: We carried out an observational study from January 2018 to January 2021. Participants were all people cared for a home-based primary care service. We performed a cluster analysis by applying a k-means clustering technique. Cluster labeling was determined with the 22 variables of the Frail-VIG index, age, and sex. We computed multiple indexes to assess the optimal number of clusters, and this was selected based on a clinical assessment of the best options. Results: Four hundred and twelve participants were clustered into six profiles. Three of these profiles corresponded to a moderate frailty degree, two to a severe frailty degree and one to a mild frailty degree. In addition, almost 75% of the participants were clustered into three profiles which corresponded to mild and moderate degree of frailty. Conclusions: Different profiles were found within the same degree of frailty. Knowledge of these profiles can be useful in developing strategies tailored to these differentiated care needs.

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