Karen L. Fortuna

Feasibility, Acceptability, and Preliminary Effectiveness of a Peer-Delivered and Technology Supported Self-Management Intervention for Older Adults with Serious Mental Illness

To assess the feasibility, acceptability, and preliminary effectiveness of a peer-delivered and technology supported integrated medical and psychiatric self-management intervention for older adults with serious mental illness. Ten older adults with serious mental illness (i.e., schizophrenia, schizoaffective disorder, bipolar disorder, or major depressive disorder) and medical comorbidity (i.e., cardiovascular disease, obesity, diabetes, chronic obstructive pulmonary disease, hypertension, and/or high cholesterol) aged 60xa0years and older received the PeerTECH intervention in their homes. Three certified peer specialists were trained to deliver PeerTECH. Data were collected at baseline, one-month, and three-month. The pilot study demonstrated that a three-month, peer-delivered and technology-supported integrated medical and psychiatric self-management intervention (“PeerTECH”) was experienced by peer specialists and participants as feasible and acceptable. PeerTECH was associated with statistically significant improvements in psychiatric self-management. In addition, pre/post, non-statistically significant improvements were observed in self-efficacy for managing chronic health conditions, hope, quality of life, medical self-management skills, and empowerment. This pre/post pilot study demonstrated it is possible to train peers to use technology to deliver an integrated psychiatric and medical self-management intervention in a home-based setting to older adults with serious mental illness with fidelity. These findings provide preliminary evidence that a peer-delivered and technology-supported intervention designed to improve medical and psychiatric self-management is feasible, acceptable, and is potentially associated with improvements in psychiatric self-management, self-efficacy for managing chronic health conditions, hope, quality of life, medical self-management skills, and empowerment with older adults with serious mental illness and chronic health conditions.

Text message exchanges between older adults with serious mental illness and older certified peer specialists in a smartphone-supported self-management intervention.

Objective: To identify the strategies peer specialists use to provide illness self-management support for older adults with serious mental illness (SMI) through text messaging. Method: Transcripts of text message exchanges between 8 older adult participants with SMI who completed the PeerTECH intervention and 3 older adult certified peer specialists who delivered the 12-week program were analyzed. Text message analyses explored themes relevant to peer support and health behavior change. Quantitative data comprised frequency of text messages by either the peer or consumer. Results: Consumers (N = 8) had a mean age of 68.8 years (SD = 4.9) and were mainly women (88%), White (100%), and married (75%). Certified peer specialists (N = 3) were all 55 or older; 100% were female, 66% identified as White, and 33% identified as African American. Overall, peers sent 215 text messages whereas consumers sent 141 text messages. In the peer specialist−consumer text message exchanges, we identified 4 themes on different aspects of illness self-management, including health behavior change, self-management therapeutic techniques, engagement in health technology, and peer support. Conclusions and Implications for Practice: This exploratory qualitative study offers preliminary support that peers are able to use text messages to support the delivery of a peer-delivered home-based medical and psychiatric self-management intervention. Certified peer specialists can potentially provide a range of illness self-management support to older adults with SMI via text messaging. These findings will inform the development of standardized peer text-messaging services to augment evidence-based illness self-management interventions for older adults with SMI.

Integration of Peer Philosophy into a Standardized Self-Management Mobile Health Intervention

Description of certified peer specialists integration of peer philosophy into the delivery of a self-management intervention enhanced with mobile health. Qualitative examination of peer case notes that were routinely entered on a peer care management electronic dashboard. This study included consumers with serious mental illness (Nxa0=u20098) with a mean age of 68.8xa0years (SDxa0=u20094.9). Certified peer specialists (Nxa0=u20093) were all female and aged 55xa0years or older. Peers entered 146 case notes on the peer care management notes dashboard. Five themes emerged including encouragement of self-determination, bio-psychosocial-spiritual framework guides practice, sharing lived experience to teach self-management skills, personalized text messages to reinforce self-management skill development, and identifying unmet needs and advocating for human rights. Peers unique perspectives and expertise was complemented with the standardized delivery of evidence-based intervention enhanced with mobile health.

Hospitalization Risk and Potentially Inappropriate Medications among Medicare Home Health Nursing Patients

BackgroundHospitalizations and potentially inappropriate medication (PIM) use are significant and costly issues among older home health patients, yet little is known about the prevalence of PIM use in home health or the relationship between PIM use and hospitalization risk in this population.ObjectiveTo describe the prevalence of PIM use and association with hospitalization among Medicare home health patients.DesignCross-sectional analysis using data from 132 home health agencies in the US.SubjectsMedicare beneficiaries starting home health nursing services between 2013 and 2014 (nxa0=xa087,780).Main MeasuresPrevalence of individual and aggregate PIM use at start of care, measured using the 2012 Beers criteria. Relative risk (RR) of 30-day hospitalization or re-hospitalization associated with individual and aggregate PIM use, compared to no PIM use.Key ResultsIn total, 30,168 (34.4%) patients were using at least one PIM, with 5969 (6.8%) taking at least two PIMs according to the Beers list. The most common types of PIMs were those affecting the brain or spinal cord, analgesics, and medications with anticholinergic properties. With the exception of nonsteroidal anti-inflammatory drugs (NSAIDs), PIM use across all classes was associated with elevated risk (10–33%) of hospitalization compared to non-use. Adjusting for demographic and clinical characteristics, patients using at least one PIM (excluding NSAIDs) had a 13% greater risk (RRxa0=xa01.13, 95% CI: 1.09, 1.17) of being hospitalized than patients using no PIMs, while patients using at least two PIMs had 21% greater risk (RRxa0=xa01.21, 95% CI: 1.12, 1.30). Similar associations were found between PIMs and re-hospitalization risk among patients referred to home health from a hospital.ConclusionsGiven the high prevalence of PIM use and the association between PIMs and hospitalization risk, home health episodes represent opportunities to substantially reduce PIM use among older adults and prevent adverse outcomes. Efforts to address medication use during home health episodes, hospitalizations, and care transitions are justified.

Effectiveness of a High End Users Program for Persons with Psychiatric Disorders

To evaluate the effectiveness of an intensive system of case management for high end users of inpatient care in reducing psychiatric inpatient utilization. A pre-post study design with a contemporaneous comparison group was employed to determine the effects of a State designed intervention to reduce inpatient care for adults with a mental health disorder who had high utilization of inpatient psychiatric care between 2004 and 2007. Logit and negative binomial regression models were used to determine the likelihood, frequency and total days of inpatient utilization in the post period as a function of the intervention. Data from administrative reporting forms and Medicaid claims were used to construct inpatient utilization histories and characteristics of 176 patients. Patients in both groups had a significant reduction in mean inpatient days. However, being in the intervention program did not result in lower odds of being re-hospitalized or in fewer episodes during the study period.

Sociodemographic characteristics, health conditions, and functional impairment among older adults with serious mental illness reporting moderate-to-severe pain.

Objective: To compare adults aged ≥50 years with serious mental illness reporting moderate-to-severe pain to older adults with serious mental illness without pain with respect to sociodemographic characteristics, health conditions, and functional impairment. Method: Secondary data analyses were conducted using baseline assessments of 183 participants recruited for the Helping Older People Experience Success (HOPES) study from three community mental health centers. The primary outcome was self-reported, nonexperimentally induced, moderate-to-severe pain (referent = no-to-mild pain). Predictor variables consisted of sociodemographic characteristics, health conditions, and functional impairment. We conducted univariable and multivariable logistic regression analyses to examine the associations between these variables. Results: Sixty-one participants (33.3%) from our sample reported pain. Pain was associated with all of the sociodemographic and health-related factors in univariable analyses. In the multivariable model, only older age, pain-related activity interference, and physical and emotional health-related social limitations were significantly associated with pain. Conclusions and Implications for Practice: The presence of moderate-to-severe pain in older adults with serious mental illness is associated with pain-attributable impairment of activities and social problems above and beyond the substantial functional limitations routinely experienced by this high-risk, high-need group. Given the high rates of preexisting conditions and persistent social impairment among these older adults, our findings suggest that pain may contribute to worse overall functional outcomes. Future research and clinical interventions focused on improving outcomes should include an evaluation of pain as a contributor to decreased functioning and assess the need for early intervention, nonpharmacological pain management, or other health promotion services in psychiatric rehabilitation.

Smartphone Ownership, Use, and Willingness to Use Smartphones to Provide Peer-Delivered Services: Results from a National Online Survey

Assess certified peer specialists’ smartphone ownership, use, and willingness to use smartphones to provide peer-delivered services. Certified peer specialist from 38 states completed an online survey. The final sample of 267 certified peer specialists included respondents from 38 states. The majority of certified peer specialists were female (73%; nxa0=u2009195) and Caucasian (79.8%; nxa0=u2009213), with an average age of 50.9 (SDxa0=u200912) years, range from 21 to 77xa0years. More than half of the certified peer specialists (82.1%; nxa0=u2009184) were currently working in peer support positions. Of those who reported their mental health diagnoses, 11% reported their diagnosis as schizophrenia spectrum disorder, 22% of respondents reported bipolar disorder, and 23% reported persistent major depressive disorder. Nearly all respondents owned a smartphone (94.8%; nxa0=u2009253), and everyone indicated that smartphones and tablets could enhance the services they deliver. Certified peer specialists reported substantial ownership and use of smartphones, comparable to existing national data. They are willing to deliver smartphone interventions for mental health and physical health self-management, suggesting that smartphones may be an increasingly useful tool for offering evidence-based care. Without Medicaid mandate, certified peer specialists are naturally trying to enhance peer delivered services with technology. Peer support could act as a mechanism to promote consumer engagement in a smartphone-based intervention. Certified peer specialist own and utilize smartphones, and the majority are willing to deliver technology-based and technology-enhanced interventions using these devices to address medical and psychiatric self-management.

Association between obesity and patient-centered measures using the medical expenditure panel survey

Patient-centeredness is an important factor in patient health and engagement but its association in patients with obesity is not thoroughly understood. Of 28,854 participants aged ≥60 from the Medical Expenditure Panel Survey 2004-2013, we evaluated four patient-centered domains: patient/provider relationship, shared-decision making, access to care, overall medical care provider rating, and prescription care. Weighted logistic (OR [95% CI]) and linear (β±s.e.; p-value) regression models demonstrated that participants as having obesity reported a marginally higher delay in getting the necessary care than healthy BMI (OR 1.25 [1.01, 1.53]). Older adults with obesity report reduced perceived access to care.

The Role of Ethnic and Racial Disparities in Mobility and Physical Function in Older Adults

Objective: To compare estimates of the prevalence of mobility and physical function limitations by race and ethnicity using data from the Medical Expenditure Panel Survey (MEPS). Method: The sample comprised of 28,854 adults aged ≥60 from the MEPS (2004-2013). Physical function (limitations in basic and instrumental activities of daily living [ADL/IADL]) and mobility limitations were assessed by self-report. Results: Non-Hispanic Whites (NHWs) represented the majority of the sample followed by non-Hispanic Blacks (NHBs), Hispanic and non-Hispanic Other (Other). For mobility limitation, NHBs had the highest prevalence followed by NHWs and Hispanics (33.3%, 28.6%, and 26.2%, respectively). Multivariable logistic regression analyses were performed for the primary outcome of mobility limitation. In the adjusted model, Hispanics had lower odds of mobility limitations (prevalence odds ratio [POR]: 0.78; 95% confidence interval [CI] = [0.67,0.91]) compared with NHWs. For ADL limitations, NHBs had higher odds of having ADLs (POR: 1.87; 95% CI = [1.44, 2.44]) when compared with NHWs. Conclusion: This article evaluated the influence of race and ethnicity, on the prevalence of mobility and functional limitations that are not always consistent with expected racial and ethnic differences.

Utility of functioning measures in the prediction of independent living status in older adults with serious mental illness

The objective of the study was to compare the predictive utility of three commonly used functioning measures for people with serious mental illness in the prediction of independent living status.