Cherie Rosemond

Effect of the Goals of Care Intervention for Advanced Dementia: A Randomized Clinical Trial.

Importance In advanced dementia, goals of care decisions are challenging and medical care is often more intensive than desired. Objective To test a goals of care (GOC) decision aid intervention to improve quality of communication and palliative care for nursing home residents with advanced dementia. Design, Setting, and Participants A single-blind cluster randomized clinical trial, including 302 residents with advanced dementia and their family decision makers in 22 nursing homes. Interventions A GOC video decision aid plus a structured discussion with nursing home health care providers; attention control with an informational video and usual care planning. Main Outcomes and Measures Primary outcomes at 3 months were quality of communication (QOC, questionnaire scored 0-10 with higher ratings indicating better quality), family report of concordance with clinicians on the primary goal of care (endorsing same goal as the “best goal to guide care and medical treatment,” and clinicians’ “top priority for care and medical treatment”), and treatment consistent with preferences (Advance Care Planning Problem score). Secondary outcomes at 9 months were family ratings of symptom management and care, palliative care domains in care plans, Medical Orders for Scope of Treatment (MOST) completion, and hospital transfers. Resident-family dyads were the primary unit of analysis, and all analyses used intention-to-treat assignment. Results Residents’ mean age was 86.5 years, 39 (12.9%) were African American, and 246 (81.5%) were women. With the GOC intervention, family decision makers reported better quality of communication (QOC, 6.0 vs 5.6; P = .05) and better end-of-life communication (QOC end-of-life subscale, 3.7 vs 3.0; P = .02). Goal concordance did not differ at 3 months, but family decision makers with the intervention reported greater concordance by 9 months or death (133 [88.4%] vs 108 [71.2%], P = .001). Family ratings of treatment consistent with preferences, symptom management, and quality of care did not differ. Residents in the intervention group had more palliative care content in treatment plans (5.6 vs 4.7, P = .02), MOST order sets (35% vs 16%, P = .05), and half as many hospital transfers (0.078 vs 0.163 per 90 person-days; RR, 0.47; 95% CI, 0.26-0.88). Survival at 9 months was unaffected (adjusted hazard ratio [aHR], 0.76; 95% CI, 0.54-1.08; P = .13). Conclusions and Relevance The GOC decision aid intervention is effective to improve end-of-life communication for nursing home residents with advanced dementia and enhance palliative care plans while reducing hospital transfers. Trial Registration clinicaltrials.gov Identifier: NCT01565642

An innovative home-based interdisciplinary service-learning experience.

Abstract The University of North Carolina Mobile Student Health Action Coalition (UNC MSHAC) at Chapel Hill, North Carolina is a voluntary service-learning program in which interdisciplinary teams of graduate level health professional students provide monthly home visits to isolated, community-dwelling elders with complex medical and social issues. Students are mentored by UNC clinical faculty and retirees from the local community. Together, mentors and students generate action plans to improve the health and well-being of the participating elders. We report here the qualitative and quantitative results from our program evaluation demonstrating UNC MSHAC as an effective, service-learning model that compliments curricula, is satisfactory to students, and is a vehicle for academic institutions to serve elders in the local community.

Fidelity to a behavioral intervention to improve goals of care decisions for nursing home residents with advanced dementia.

Background/aims: Ensuring fidelity to a behavioral intervention implemented in nursing homes requires awareness of the unique considerations of this setting for research. The purpose of this article is to describe the goals of care cluster-randomized trial and the methods used to monitor and promote fidelity to a goals of care decision aid intervention delivered in nursing homes. Methods: The cluster randomized trial tested whether a decision aid for goals of care in advanced dementia could improve (1) the quality of communication and decision-making, (2) the quality of palliative care, and (3) the quality of dying for nursing home residents with advanced dementia. In 11 intervention nursing homes, family decision-makers for residents with advanced dementia received a two-component intervention: viewing a video decision aid about goals of care choices and then participating in a structured decision-making discussion with the nursing home care plan team, ideally within 3 months after the decision aid was viewed. Following guidelines from the National Institutes of Health Behavior Change Consortium, fidelity was assessed in study design, in nursing home staff training for intervention implementation, and in monitoring and receipt of the intervention. We also monitored the content and timing of goals of care discussions. Results: Investigators enrolled 151 family decision-maker/resident dyads in intervention sites; of those, 136 (90%) received both components of the intervention, and 92%–99% of discussions addressed each of four recommended content areas—health status, goals of care, choice of a goal, and treatment planning. A total of 94 (69%) of the discussions between family decision-makers and the nursing home care team were completed within 3 months. Conclusion: The methods we used for intervention fidelity allowed nursing home staff to implement a goals of care decision aid intervention for advanced dementia. Key supports for implementation included design features that aligned with nursing home practice, efficient staff training, and a structured guide for goals of care discussions between family decision-makers and staff. These approaches may be used to promote fidelity to behavioral interventions in future clinical trials.

Developing an evidence-based fall prevention curriculum for community health workers.

This perspective paper describes processes in the development of an evidence-based fall prevention curriculum for community health workers/promotores (CHW/P) that highlights the development of the curriculum and addresses: (1) the need and rationale for involving CHW/P in fall prevention; (2) involvement of CHW/P and content experts in the curriculum development; (3) best practices utilized in the curriculum development and training implementation; and (4) next steps for dissemination and utilization of the CHW/P fall prevention curriculum. The project team of CHW/P and content experts developed, pilot tested, and revised bilingual in-person training modules about fall prevention among older adults. The curriculum incorporated the following major themes: (1) fall risk factors and strategies to reduce/prevent falls; (2) communication strategies to reduce risk of falling and strategies for developing fall prevention plans; and (3) health behavior change theories utilized to prevent and reduce falls. Three separate fall prevention modules were developed for CHW/P and CHW/P Instructors to be used during in-person trainings. Module development incorporated a five-step process: (1) conduct informal focus groups with CHW/P to inform content development; (2) develop three in-person modules in English and Spanish with input from content experts; (3) pilot-test the modules with CHW/P; (4) refine and finalize modules based on pilot-test feedback; and (5) submit modules for approval of continuing education units. This project contributes to the existing evidence-based literature by examining the role of CHW/P in fall prevention among older adults. By including evidence-based communication strategies such as message tailoring, the curriculum design allows CHW/P to personalize the information for individuals, which can result in an effective dissemination of a curriculum that is evidence-based and culturally appropriate.

Falling for a Balance Partner

The growing accumulation of knowledge about fall prevention strategies primarily reflects a research perspective where intervention data are rigorously collected and analyzed. However, the voices of program deliverers or participants who are part of these interventions are often aggregated and thus muted. With recognition of the growing importance of patient-centered care, we wanted to provide a personal reflection on the Balance Partner program, a CDC funded project to train peer leaders in fall prevention. In the story below, Sara was trained as a Balance Partner using a curriculum developed at The University of North Carolina’s Center for Health Promotion and Disease Prevention. The Balance Partner Program provides training and support to community volunteers who are paired with a peer who is at risk for falls. Together, Balance Partners plan strategies to decrease the likelihood of a fall – strategies that could include joining a balance exercise program, improving home safety, or getting a vision check-up. By addressing social and emotional factors alongside knowledge about falls, the Balance Partner Program aims to increase older adults’ overall adherence to fall prevention activities above the 50% rate reported in literature (1). Sara, a 69-year-old volunteer, was paired with Georgia, who screened at high risk for falls during a Building Better Balance Screening in Asheville, NC, USA. As of this writing, Sara and Georgia had worked together for almost 6 months to implement strategies to reduce their falls risk.

Nursing home staff perspectives on adoption of an innovation in goals of care communication

ABSTRACT Nursing homes (NH) are important settings for end‐of‐life care, but limited implementation may impede goals of care discussions. The purpose of this study was to understand NH staff perceptions of adoption and sustainability of the Goals of Care video decision aid for families of residents with advanced dementia. Study design was a cross‐sectional survey of staff at 11 NHs in North Carolina who participated in the Goals of Care (GOC) cluster randomized clinical trial. Staff perceived the GOC decision aid intervention as a positive innovation; it was perceived as more compatible with current practices by male staff, nurses, and more experienced NH staff. Perceptions were correlated with experience, implying that experience with an innovative approach may help to promote improved GOC communication in nursing homes. Nurses and social work staff could be effective champions for implementing a communication technique, like the GOC intervention.