Background Community health workers (CHWs) can engage elderly persons in advance care planning (ACP) conversations. Objective We report how trained CHWs used Go Wish cards (GWR cards) to identify patients’ highest priority preferences and evaluated whether engaging in ACP conversations was associated with subsequent health care utilization. Design A one-year long, pre-post longitudinal design was used to evaluate our educational intervention using mixed-methods. Patients 392 patients (mean of 73.3 years, 82% women, 48% African American, 43% Caucasian) enrolled in the Aging Brain Care (ABC) program and participated in ACP discussions with CHWs. Intervention We expanded the role of the ABC’s CHW, who work directly with individuals and caregivers during home visits to monitor bio-psycho-social needs, to include ACP conversations. Main Measures The CHWs received ACP training, practice with tools such as GW R cards, and support from an electronic health record (EHR) clinical decision support tool. Quantitative measures of patients’ ACP preferences and health care utilization were abstracted from the EHR. Qualitative data about patients’ perceptions of CHWs in facilitating ACP discussions was obtained through semi-structured interviews. Results Eighty-six patients’ data indicated that they had engaged in a preferences-for-care process using GWR cards. The top-three card choices by patients was attending to spirituality and religious concerns, preparing for end of life, and maintaining personal wholeness. Conclusion CHWs were able to effectively engage in ACP conversations with patients and GWR cards were a positive way to stimulate discussion of issues previously undiscussed.

Background Advance care planning (ACP) is recommended for all persons to ensure that the care they receive aligns with their values and preferences. Objective Evaluate an ACP intervention developed to better meet the needs and priorities of persons with chronic diseases, including mild cognitive impairment. Research Design A year-long, pre-post intervention employing lay community health workers (care coordinator assistants [CCAs]) trained to conduct and document ACP conversations with patients during home health visits with pre/post evaluation. Subjects The 818 patients were 74.2 years old (mean); 78% women; 51% African American; 43% Caucasian. Measures Documentation of ACP conversation in EHR fields and health care utilization outcomes. Results In this target population ACP documentation rose from 3.4% (pre-CCA training) to 47.9% (post) of patients who had at least one discussion about ACP in the EHR. In the one-year pre-intervention period, there were no differences in admissions, emergency department (ED) visits, and outpatient visits between patients who did and did not have ACP discussion. After adjusting for prior hospitalization and ED use histories, ACP discussions were associated with a 34% less probability of hospitalization (HR = 0.66, 95% CI 0.45–0.97), and similar effects are apparent on ED use independent of age and prior ED use effects. Conclusions Patients with chronic diseases including mild cognitive impairment can engage in ACP conversations with trusted home health care providers. Having ACP conversation is associated with significant reduction in seeking urgent health care and in hospitalizations.

Background Globalization has increased the demand for international experiences in medical education. International experiences improve medical knowledge, clinical skills, self-development, influence career objectives, and provide insights on ethical and societal issues. However, global health rotations can end up being no more than tourism if not structured to foster personal transformation and global citizenship. Objective We conducted a qualitative assessment of trainee-reported critical incidents to more deeply understand the impact of our global health experience on trainees. Method A cross-sectional survey was administered to trainees who had participated in a two-month elective in Kenya from January 1989 to May 2013. We report the results of a qualitative assessment of the critical incident reflections participants (n=137) entered in response to the prompt: “Write about one of their most memorable experiences and explain why you chose to describe this particular one.” Approach Qualitative analyses were conducted using thematic analysis and crystallization immersion analytic methods based on the principles of grounded theory, employing a constructivists’ research paradigm. Results Four major themes emerged. These themes included: Opening Oneself to a Broader World View; Impact of Suffering and Death; and Life Changing Experiences; and Commitment to Care for the Medically Underserved. Conclusions Circumstances that learners encounter in the resource-scarce environment in Kenya are eye-opening and life-changing. When exposed to these frame-shifting circumstances, students elaborate upon or transform existing points of view. These emotionally disruptive experiences in an international health setting allowed students to enter a transformational learning process with a global mind. Students can see the world as an interdependent society and develop the capacity to advance both their enlightened self-interest and the interest of people elsewhere in the world as they mature as global citizens. Medical schools are encouraged to foster these experiences by finding ways to integrate them into curriculum.

Authorship Correction: (On Becoming a Global Citizen: Transformative Learning through Global Health Experiences). Ms. Ann Cottingham came forward after the paper was published requesting authorship for her contribution to the qualitative analyses and after review it was determined that her contributions were sufficient to qualify for authorship. Ms. Cottingham contributed to the qualitative analyses and reviewed and contributed to drafts of the manuscript. All authors have agreed in writing to the requested change.