Cari Levy

The rise of concurrent care for veterans with advanced cancer at the end of life.

Unlike Medicare, the Veterans Health Administration (VA) health care system does not require veterans with cancer to make the “terrible choice” between receipt of hospice services or disease‐modifying chemotherapy/radiation therapy. For this report, the authors characterized the VAs provision of concurrent care, defined as days in the last 6 months of life during which veterans simultaneously received hospice services and chemotherapy or radiation therapy.

Naloxone Administration in US Emergency Departments, 2000–2011

Rates of opioid overdose and opioid-related emergency department (ED) visits have increased dramatically. Naloxone is an effective antidote to potentially fatal opioid overdose, but little is known about naloxone administration in ED settings. We examined trends and correlates of naloxone administration in ED visits nationally from 2000 to 2011. Using data from the National Hospital Ambulatory Medical Care Survey, we examined ED visits involving (1) the administration of naloxone or (2) a diagnosis of opioid overdose, abuse, or dependence. We assessed patient characteristics in these visits, including concomitant administration of prescription opioid medications. We used logistic regression to identify correlates of naloxone administration. From 2000 to 2011, naloxone was administered in an estimated 1.7 million adult ED visits nationally; 19xa0% of these visits recorded a diagnosis of opioid overdose, abuse, or dependence. An estimated 2.9 million adult ED visits were related to opioid overdose, abuse, or dependence; 11xa0% of these visits involved naloxone administration. In multivariable logistic regression models, patient age, race, and insurance and non-rural facility location were independently associated with naloxone administration. An opioid medication was provided in 14xa0% of visits involving naloxone administration. Naloxone was administered in a minority of ED visits related to opioid overdose, abuse, or dependence. Among all ED visits involving naloxone administration, prescription opioids were also provided in one in seven visits. Further work should explore the provider decision-making in the management of opioid overdose in ED settings and examine patient outcomes following these visits.

Implementing goals of care conversations with veterans in VA long-term care setting: a mixed methods protocol

BackgroundThe program “Implementing Goals of Care Conversations with Veterans in VA LTC Settings” is proposed in partnership with the US Veterans Health Administration (VA) National Center for Ethics in Health Care and the Geriatrics and Extended Care Program Offices, together with the VA Office of Nursing Services. The three projects in this program are designed to support a new system-wide mandate requiring providers to conduct and systematically record conversations with veterans about their preferences for care, particularly life-sustaining treatments. These treatments include cardiac resuscitation, mechanical ventilation, and other forms of life support. However, veteran preferences for care go beyond whether or not they receive life-sustaining treatments to include issues such as whether or not they want to be hospitalized if they are acutely ill, and what kinds of comfort care they would like to receive.MethodsThree projects, all focused on improving the provision of veteran-centered care, are proposed. The projects will be conducted in Community Living Centers (VA-owned nursing homes) and VA Home-Based Primary Care programs in five regional networks in the Veterans Health Administration. In all the projects, we will use data from context and barrier and facilitator assessments to design feedback reports for staff to help them understand how well they are meeting the requirement to have conversations with veterans about their preferences and to document them appropriately. We will also use learning collaboratives—meetings in which staff teams come together and problem-solve issues they encounter in how to get veterans’ preferences expressed and documented, and acted on—to support action planning to improve performance.DiscussionWe will use data over time to track implementation success, measured as the proportions of veterans in Community Living Centers (CLCs) and Home-Based Primary Care (HBPC) who have a documented goals of care conversation soon after admission. We will work with our operational partners to spread approaches that work throughout the Veterans Health Administration.

Dementia and co‐occurring chronic conditions: a systematic literature review to identify what is known and where are the gaps in the evidence?

The challenges posed by people living with multiple chronic conditions are unique for people with dementia and other significant cognitive impairment. There have been recent calls to action to review the existing literature on co‐occurring chronic conditions and dementia in order to better understand the effect of cognitive impairment on disease management, mobility, and mortality.

Association between aggressive care and bereaved families’ evaluation of end-of-life care for veterans with non-small cell lung cancer who died in Veterans Affairs facilities

To the authors’ knowledge, little is known regarding the relationship between patients’ and families’ satisfaction with aggressive end‐of‐life care. Herein, the authors examined the associations between episodes of aggressive care (ie, chemotherapy, mechanical ventilation, acute hospitalizations, and intensive care unit admissions) within the last 30 days of life and families’ evaluations of end‐of‐life care among patients with non‐small cell lung cancer (NSCLC).

Medical Foster Homes: Can the Adult Foster Care Model Substitute for Nursing Home Care?

To compare characteristics, healthcare use, and costs of care of veterans in the rapidly expanding Veterans Health Administration (VHA) medical foster home (MFH) with those of three other VHA long‐term care (LTC) programs.

Electronic communication capabilities of residential care facilities at times of transition.

Older adults are more frequently discharged from the hospital to post-acute care facilities for recovery.1 Readmissions from these facilities are also increasing: 30-day readmission rates rose from 18 to 24% between 2000 and 2006.2Improved communication betweenresidential care facilities (RCFs) and hospitals may facilitate safer care transitions and reduce harm to older adults.3-4However, little is known about the communication capabilities of RCFs with hospitals; thus, we sought to describe these capabilities in a national sample of RCFs.

Predicting Potential Adverse Events During a Skilled Nursing Facility Stay: A Skilled Nursing Facility Prognosis Score: Predicting adverse events in post-acute care

To derive a risk prediction score for potential adverse outcomes in older adults transitioning to a skilled nursing facility (SNF) from the hospital.

Correction to: Implementing goals of care conversations with veterans in VA long-term care setting: a mixed methods protocol

CorrectionThe authors would like to correct errors in the original article [1] that may have lead readers to misinterpret the scope, evidence base and target population of VHA Handbook 1004.03 “Life-Sustaining Treatment (LST) Decisions: Eliciting, Documenting, and Honoring Patients’ Values, Goals, and Preferences”.

Pandemic Influenza Plans in Residential Care Facilities

To identify characteristics of residential care facilities (RCFs) associated with having a pandemic influenza plan.