Rural-dwelling older adults experience unique issues related to accessing medical and social services. We describe the development, implementation, and experience of a novel, community-based program to identify rural-dwelling older adults with unmet medical and social needs. The program leveraged the existing emergency medical services (EMS) system. The program specifically included: 1) geriatrics training for EMS providers; 2) screening of older adult EMS patients for falls, depression, and medication management strategies by EMS providers; 3) communication of EMS findings to community-based case managers; 4) in-home evaluation by case managers; 5) referral to community resources for medical and social interventions. Measures used to evaluate the program included patient needs identified by EMS or the in-home assessment, referrals provided to patients, and patient satisfaction. 1231 of 1444 visits to older patients (85%) were screened by EMS. Of those receiving specific screens, 45% had fall-related, 69% had medication management-related, and 20% had depression-related needs identified. 171 of eligible EMS patients who could be contacted accepted the in-home assessment. For the 153 individuals completing the assessment, 91% of patients had identified needs and received referrals or interventions. This project demonstrated that screening by EMS during emergency care for common geriatric syndromes and linkage to case managers is feasible in this rural community, although many will refuse the services. Further patient evaluations by case managers, with subsequent interventions by existing service providers as required, can facilitate the needed linkages between vulnerable rural-dwelling older adults and needed community-based social and medical services.

Background: Long-stay nursing home (NH) residents are at high risk of having emergency department (ED) visits, but current knowledge regarding risk-adjusted ED rates is limited. Objectives: To construct and validate 3 quarterly risk-adjusted rates of long-stay residents’ ED use: any ED visit, ED visits without hospitalization or observation stay (outpatient ED), and potentially avoidable ED visits (PAED). Research Design: The authors calculated quarterly NH risk-adjusted ED rates from 2011 Q2 to 2013 Q3 national Medicare claims and Minimum Data Set data. Using random-effect linear regressions, the authors validated these rates against Nursing Home Compare overall 5-star quality ratings and examined their associations with hospitalization rates to provide a quality context. Subjects: Resident-quarter observations (7.3 million) from 15,235 unique NHs. Results: Risk-adjusted rates of any ED, outpatient ED, and PAED averaged 9.7%, 3.4%, and 3.2%, respectively. Compared with NHs with 1 or 2 stars overall rating, NHs with ≥3 stars were significantly associated with lower rates of any ED visit, outpatient ED, and PAED (β, −0.23%, −0.16%, and −0.11%, respectively; all P<0.01). Pearson Correlation coefficients between hospitalization rates and rates of any ED visit, outpatient ED, and PAED were 0.74, 0.31, and 0.46, respectively. Conclusions: The moderately negative associations of 5-star ratings with ED rates provide supportive evidence to their validity. Outpatient ED and PAED were moderately correlated to hospitalizations suggesting they provided more information about quality than any ED.

Alzheimer's disease and related disorders (ADRD) are among the age‐associated chronic conditions that are most challenging to health care systems around the globe, as patients with dementia require full‐time, intensive care for multiple years. Oral health care is negatively impacted by cognitive decline, and consequently poor oral health is common among people with ADRD. Poor oral health status is linked with many undesirable consequences for the well‐being of people with ADRD, from excruciating local pain to life‐threatening conditions, as aspiration pneumonia. In this paper, the authors provide an update on the most current concepts about Alzheimer's disease epidemiology, etiology, and management, current oral health care for patients with Alzheimer's disease, oral health promotion strategies for this population, as well as current research and future direction for improving oral health care for patients with Alzheimer's disease. It concludes that oral health care should be included in the patient's routine health care as early as possible in the progression of Alzheimer's disease for preventing rapid oral health deterioration. Establishing oral hygiene routines and providing dental treatment that is customized to the patients’ individual needs and disease stage are important to achieve good oral health outcomes and prevent quality of life decline.

Background Significant racial disparities have been reported regarding nursing home residents’ use of hospital and hospice care at the end-of-life. Objective To examine whether the observed racial disparities in end-of-life care are due to within- or across-facility variations. Research Design and Subjects Cross-sectional study of 49,048 long-term-care residents (9.23% Black and 90.77% White) in 555 New York State nursing homes who died during 2005–2007. Minimum Data Set was linked with Medicare inpatient and hospice claims. Measures In-hospital death determined by inpatient claims and hospice use determined by hospice claims. For each outcome, risk factors were added sequentially to examine their partial effects on the racial differences. Hierarchical models were fit to test whether racial disparities are due to within- or across-facility variations. Results 40.33% of Blacks and 24.07% of Whites died in hospitals; 11.55% of Blacks and 17.39% of Whites used hospice. These differences are partially due to disparate use of feeding tubes, Do-Not-Resuscitate (DNR) and Do-Not-Hospitalize (DNH) orders. We find no racial disparities in in-hospital death (OR of race=0.95, CI:0.87–1.04) or hospice use (OR of race=0.90, CI:0.79–1.02) within same facilities. Living in facilities with 10% more Blacks increases the odds of in-hospital death by 22% (OR=1.22, CI:1.17–1.26) and decreases the odds of hospice use by 15% (OR=0.85, CI:0.78–0.94). Conclusions Differential use of feeding tubes, DNR and DNH orders lead to racial differences in in-hospital death and hospice use. The remaining disparities are primarily due to overall end-of-life care practices in predominately-Black facilities, not to differential hospitalization and hospice-referral patterns within facilities.

The three D's of Geriatric Psychiatry-delirium, dementia, and depression-represent some of the most common and challenging diagnoses for older adults. Delirium is often difficult to diagnose and treatment is sometimes controversial with the use of antipsychotic medications, but it is common in a variety of patient care settings and remains an independent risk factor for morbidity and mortality in older adults. Dementia may affect a significant number of older adults and is associated with delirium, depression, frailty, and failure to thrive. Treatment of dementia is challenging and while medication interventions are common, environmental and problem solving therapies may have some of the greatest benefits. Finally, depression increases with age and is more likely to present with somatic complaints or insomnia and is more likely to be reported to a primary care physician than any other healthcare provider by older adults. Depression carries an increased risk for suicide in older adults and proven therapies should be initiated immediately. These three syndromes have great overlap, can exist simultaneously in the same patient, and often confer increased risk for each other. The primary care provider will undoubtedly benefit from a solid foundation in the identification, classification, and treatment of these common problems of older adulthood.

Although final conclusions about program effectiveness must await the results of the randomized controlled trial, the findings reported here are promising and provide preliminary support for an ED-to-home CTI Program's ability to improve outcomes. The coaches' identity as community paramedics is particularly noteworthy, because this is a unique role for this provider type. J Am Geriatr Soc 66:2213-2220, 2018.

Objectives Hospice enrollment is known to reduce risk of hospitalizations for nursing home residents who use it. We examined whether residing in facilities with a higher hospice penetration: 1) reduces hospitalization risk for non-hospice residents; and 2) decreases hospice-enrolled residents’ hospitalization risk relative to hospice-enrolled residents in facilities with a lower hospice penetration. Method Medicare Beneficiary File, Inpatient and Hospice Claims, Minimum Data Set Version 2.0, Provider of Services File and Area Resource File. Retrospective analysis of long-stay nursing home residents who died during 2005-2007. Overall, 505,851 non-hospice (67.66%) and 241,790 hospice-enrolled (32.34%) residents in 14,030 facilities nationwide were included. We fit models predicting the probability of hospitalization conditional on hospice penetration and resident and facility characteristics. We used instrumental variable method to address the potential endogeneity between hospice penetration and hospitalization. Distance between each nursing home and the closest hospice was the instrumental variable. Main Findings In the last 30 days of life, 37.63% of non-hospice and 23.18% of hospice residents were hospitalized. Every 10% increase in hospice penetration leads to a reduction in hospitalization risk of 5.1% for non-hospice residents and 4.8% for hospice-enrolled residents. Principal Conclusions Higher facility-level hospice penetration reduces hospitalization risk for both non-hospice and hospice-enrolled residents. The findings shed light on nursing home end-of-life care delivery, collaboration among providers and cost benefit analysis of hospice care.

ObjectivesEvaluate the independent and interactive effects of dementia and racial/ethnic minority status on functional outcomes during a home health (HH) admission among Medicare beneficiaries. MethodsSecondary analysis of data from the Outcome and Assessment Information Set [OASIS] and billing records in a non-profit HH agency in New York. Participants were adults � 65 years old who received HH in CY 2017 with OASIS records at HH admission and HH discharge. Dementia was identified by diagnosis (ICD-10 codes) and cognitive impairment (OASIS: M1700, M1710, M1740). We used OASIS records to assess race/ethnicity (M0140) and functional status (M1800-M1870 on activities of daily living [ADL]). Functional outcome was measured as change in the composite ADL score from HH admission to HH discharge, where a negative score means improvement and a positive score means decline. ResultsThe sample included 4,783 patients, among whom 93.9% improved in ADLs at HH discharge. In multivariable linear regression that adjusted for HH service use and covariates (R 2 = 0.23), being African American (β = 0.21, 95% confidence interval [CI]: 0.06, 0.35, p = 0.005) and having dementia (β = 0.51, 95% CI: 0.41, 0.62, p<0.001) were independently related to less ADL improvement at HH discharge, with significant interaction related to further decrease in ADL improvement. Relative to white patients without dementia, African American patients with dementia (β = 1.08, 95% CI: 0.81, 1.35, p<0.001), Hispanics with