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Efforts to improve physician communication with families of LTC residents may be promoted using face-to-face meetings between the physician and family caregivers, explanation of the patient's prognosis, and timely conveyance of information about health status changes, especially when a patient is actively dying.

Purpose This study was designed to examine the end-of-life (EOL) experience in long-term care (LTC) based on input from key stakeholders. Design and Methods The study consisted of ten homogeneous focus groups drawn from a purposive sample of LTC residents (2 groups; total n = 11); family caregivers (2 groups; total n = 19); paraprofessional staff (3 groups; total n = 20); and licensed/registered staff (3 groups; total n = 15) from five nursing homes (NHs) and eight residential care/assisted living (RC/AL) communities in North Carolina. Data were analyzed using grounded theory techniques to elicit manifest and latent themes. Results Five overarching themes emerged: (1) components of a good death in LTC; (2) normalcy of dying in LTC; (3) the role of relationships in the provision and receipt of care; (4) Hospice contributions to care at the EOL in LTC; and (5) stakeholder recommendations for enhancing EOL care in these settings. Underlying these themes is one central category, “closeness,” based on physical proximity and frequency of contact. Implications Findings suggest that promoting collaborative relationships among the four stakeholder groups, increasing social worker involvement, and removing barriers to Hospice may enhance the EOL experience in LTC.

Background Patients with diabetes and poorly controlled hypertension are at increased risk for adverse renal and cardiovascular outcomes. Identifying these patients early and addressing modifiable risk factors is central to delaying renal complications such as diabetic kidney disease. Mobile health (mHealth), a relatively inexpensive and easily scalable technology, can facilitate patient-centered care and promote engagement in self-management, particularly for patients of lower socioeconomic status. Thus, mHealth may be a cost-effective way to deliver self-management education and support. Objective This feasibility study aimed to build a population management program by identifying patients with diabetes and poorly controlled hypertension who were at risk for adverse renal outcomes and evaluate a multifactorial intervention to address medication self-management. We recruited patients from a federally qualified health center (FQHC) in an underserved, diverse county in the southeastern United States. Methods Patients were identified via electronic health record. Inclusion criteria were age between 18 and 75 years, diagnosis of type 2 diabetes, poorly controlled hypertension over the last 12 months (mean clinic systolic blood pressure [SBP] ≥140 mm Hg and/or diastolic blood pressure [DBP] ≥90 mm Hg), access to a mobile phone, and ability to receive text messages and emails. The intervention consisted of monthly telephone calls for 6 months by a case manager and weekly, one-way informational text messages. Engagement was defined as the number of phone calls completed during the intervention; individuals who completed 4 or more calls were considered engaged. The primary outcome was change in SBP at the conclusion of the intervention. Results Of the 141 patients enrolled, 84.0% (118/141) of patients completed 1 or more phone calls and had follow-up SBP measurements for analysis. These patients were on average 56.9 years of age, predominately female (73/118, 61.9%), and nonwhite by self-report (103/118, 87.3%). The proportion of participants with poor baseline SBP control (50/118, 42.4%) did not change significantly at study completion (53/118, 44.9%) ( P =.64). Participants who completed 4 or more phone calls (98/118, 83.1%) did not experience a statistically significant decrease in SBP when compared to those who completed fewer calls. Conclusion We did not reduce uncontrolled hypertension even among the more highly engaged. However, 83% of a predominately minority and low-income population completed at least 67% of the multimodal mHealth intervention. Findings suggest that combining an automated electronic health record system to identify at-risk patients with a tailored mHealth protocol can provide education to this population. While this intervention was insufficient to effect behavioral change resulting in better hypertension control, it does suggest that t...

Purpose To determine the prevalence and correlates of decisions made about life-sustaining treatments among residents in long-term care settings, including how often decisions were honored and characteristics associated with decisions not being followed. Design and Methods Retrospective interviews with one family caregiver and one facility staff member for each of 327 decedents who received end-of-life care in 27 nursing homes (NHs) and 85 residential care/assisted living (RC/AL) settings in four states were analyzed with respect to decedent demographics, facility characteristics, prevalence of decisions made about medical interventions, proportion of residents whose decisions were heeded, and characteristics associated with decisions not being heeded. Results Most family caregivers reported making a decision with a physician about resuscitation (89.1%), inserting a feeding tube (82.1%), administering antibiotics (64.3%), and hospital transfer (83.7%). Reported care was inconsistent with decisions made in five of seven (71.4%) of resuscitations, one of seven feeding tube insertions (14.3%), 15 of 78 antibiotics courses (19.2%), and 26 of 87 hospital transfers (29.9%). Decedents who received antibiotics contrary to their wishes were older (mean age 92 versus 85, p= 0.014). More than half (53.8%) of decedents who had care discordant with their wishes about hospitalization lived in a NH compared to 32.8% of those whose decision were concordant (p=0.034). Implications Most respondents reported decision-making with a doctor about life-sustaining treatments, but those decisions were not consistently heeded. Being older and living in a NH were risk factors for decisions not being heeded.

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Objectives To determine the prevalence and characteristics of advance care planning (ACP) among persons dying in long-term care (LTC) facilities, and to examine the relationship between respondent, facility, decedent, and family characteristics and ACP. Design After-death interviews of family members of decedents and facility liaisons where decedents received care. Setting Stratified sample of 164 residential care/assisted living facilities and nursing homes in Florida, Maryland, New Jersey, and North Carolina. Subjects Family members and facility liaisons who gave 446 and 1014 reports, respectively, on 1015 decedent residents. Measurements Reports of death/dying discussions, known treatment preferences, and reports and records of signed living wills (LW), health care powers of attorney (HCPOA), do-not-resuscitate orders, and do-not-hospitalize orders. Results Family respondents reported a higher prevalence, compared with facility reports, of HCPOAs (92% vs 49%) and LWs (84% vs 43%). In family reports, non-white race and no private insurance were significantly associated with lower prevalence of LWs and HCPOAs; additionally, residing in nursing homes (vs assisted living facilities) and in North Carolina were associated with lower prevalence of reported LWs. In facility reports, non-white race, unexpected death and residing in North Carolina or Maryland were significantly associated with lower prevalence of LWs, whereas high Medicaid case mix, intact cognitive status and high family involvement were associated with lower prevalence of HCPOAs. Concordance of family and facility reporting of HCPOAs was significantly greater in facilities with fewer than 120 beds. Conclusions The prevalence of ACP in LTC is much higher than previously described, and there is marked variation in characteristics associated with ACP, despite moderately high concordance, when reported by the facility or family caregivers.

Objectives: This quality improvement initiative aimed to develop and implement a protocol for an alcohol and substance use disorder screening for primary care. Methods: The Two Item Conjoint Screen was selected and a process was piloted by care teams. Quality improvement tools were used to improve the protocol. Primary care providers (PCPs) were surveyed about their use of the screening protocol in the primary care setting. Data on total number of screenings were collected through the electronic health record. Results: Implementation resulted in more than 30,000 screenings completed in 2016. PCP survey results indicated that PCPs felt screening was helpful in identifying potential substance use problems (100%) and that most providers (76%) felt that overall patient care improved after screening was initiated. Conclusions: Brief alcohol and substance use disorder screenings can be easily implemented and well integrated into primary care settings. PCPs found screenings to be valuable in caring for patients.