Lisa B. Caruso

'It's just like you talk to a friend' relational agents for older adults

Relational agents-computational artifacts designed to build and maintain long-term social-emotional relationships with users-may provide an effective interface modality for older adults. This is especially true when the agents use simulated face-to-face conversation as the primary communication medium, and for applications in which repeated interactions over long time periods are required, such as in health behavior change. In this article, we discuss the design of a relational agent for older adults that plays the role of an exercise advisor, and report on the results of a longitudinal study involving 21 adults aged 62-84, half of whom interacted with the agent daily for 2 months in their homes and half who served as a standard-of-care control. Results indicate the agent was accepted and liked, and was significantly more efficacious at increasing physical activity (daily steps walked) than the control.

Acceptance and usability of a relational agent interface by urban older adults

This study examines the acceptance and usability of an animated conversational agent designed to establish long-term relationships with older, mostly minority adult users living in urban neighborhoods. The agent plays the role of an exercise advisor who interacts with subjects daily for two months on a touch-screen computer installed in their homes for the study. Survey results indicate the eight subjects who completed the pilot study (aged 62-82) found the agent very easy to interact with, even though most of them had little or no previous experience using computers. Most subjects also indicated strong liking for and trust in the agent, felt that their relationship with the agent was more similar to a close friend than a stranger, and expressed a strong desire to continue working with the agent at the end of the study. These results were also confirmed through qualitative analysis of post-experiment debrief transcripts.

Improving Quality of Care for Urban Older People with Diabetes Mellitus and Cardiovascular Disease

The management of older patients with chronic medical conditions dominates medical practice. Cardiovascular disease (CVD) and diabetes mellitus type 2 (DM) in patients aged 65 and older have reached epidemic proportions. Using elements of the Chronic Care Model (CCM), a quality improvement project was undertaken to restructure the Geriatric Ambulatory Practice at Boston Medical Center, Bostons safety net hospital, to improve the quality of care for CVD and diabetes mellitus. Two hundred eighty‐three eligible patients who had CVD, DM, or both were identified. The 39‐month project period was divided into a 12‐month baseline period and three follow‐up periods. The multifaceted intervention consisted of development of a disease registry that centralized clinical information, implementation of an electronic medical record, patient education, physician education regarding evidence‐based guidelines, feedback of provider‐specific and practice data to physicians, and implementation of a foot examination protocol. Clinical measures included glycosylated hemoglobin, a diabetic foot examination, lipid profile, and blood pressure measurement. These were collected at baseline and at each patient visit for the entire project period. The average age of all patients was 76; 64% were female, 64% were African American, 72% had Medicare, and 22% had state subsidized medical insurance. Patients in all disease groups showed significant improvement in all clinical measures over time, independent of the frequency of visits. Using the CCM as a quality improvement framework can improve clinical measures for older urban minority populations with CVD and DM.

Chief Resident Immersion Training in the Care of Older Adults: An Innovative Interspecialty Education and Leadership Intervention

Chief residents (CRs) play a crucial role in training residents and students but may have limited geriatrics training or formal preparation for their CR role. A 2‐day off‐site chief resident immersion training (CRIT) addressed these challenges. Objectives were to foster collaboration between disciplines in the management of complex older patients, increase knowledge of geriatrics principles to incorporate into teaching, enhance leadership skills, and help CRs develop an achievable project for implementation in their CR year. Three cohorts totaling 47 trainees and 18 faculty mentors from 13 medical and surgical disciplines participated over 3 successive years. The curriculum, developed and taught by a multidisciplinary team, featured an interactive surgical case, mini‐lectures on geriatrics topics, seminars to enhance teaching and leadership skills, and one‐on‐one mentoring to develop a project in geriatric care or education. Evaluation included pre‐ and postprogram tests and self‐report surveys and two follow‐up surveys or interviews. In 2006 and 2007, scores on a 12‐item objective knowledge test increased significantly (P<.001) from before to immediately after CRIT. Self‐report knowledge and confidence in teaching geriatrics also increased significantly (P<.05) in all formally covered topics. Mean enhancement of CR skills was 4.3 (1=not at all, 5=very much). Eleven months after CRIT, all but five CRs had implemented at least part of their action projects. CRs reported improved care of older patients, better leadership skills, more and better geriatrics teaching, and more collaboration between disciplines. A 2‐day interactive program for CRs can increase institutional capacity regarding geriatrics teaching and care of elderly patients across medical specialties.

Minimizing Geriatric Rehospitalizations A Successful Model

Rehospitalizations may indicate care quality problems. The authors conducted a retrospective cohort study of adults aged 65 years and older, comparing 30-day rehospitalization rates. Rates were compared for comprehensive geriatrics practice patients and for patients receiving usual general medical care. The unadjusted 30-day rehospitalization rate was 18% overall, 21% for geriatrics patients cared for on the geriatrics inpatient service, 22% for geriatrics practice patients on general medical services (GMSs), and 17% for older patients on GMS. Compared with older adults discharged from a GMS, geriatrics patients on the geriatrics service had an adjusted odds ratio for readmission of 1.00 (95% confidence interval = 0.88-1.13). Despite greater frailty, patients cared for in an interdisciplinary geriatrics practice were no more likely to be rehospitalized than adults receiving “usual care,” when adjusted for age and disease burden. Incomplete adjustment may account for this finding, which did not confirm the hypothesis that comprehensive geriatrics care would yield fewer rehospitalizations.

Following Up on Clinical Recommendations in Transitions from Hospital to Nursing Home

Following up on recommendations made at the time of a hospital discharge is important to patient safety. While data is lacking, specifically around the transition of patient to nursing home, it has been postulated that missed items such as laboratory tests may result in adverse patient outcomes. To determine the extent of this problem, a retrospective cohort study of subjects discharged from an academic medical center and admitted to nursing homes (NH) was followed to determine the type of discharge recommendations and the rate of completion. In addition, for the purpose of generalizability, the 30-day hospital readmission rate was calculated. 152 recommendations were made on 51 subjects. Almost a quarter of the recommendations made by the hospital discharging team were not acted upon. Furthermore, for the majority of those recommendations that were not acted upon, a reason could not be determined. In concert with national data, 20% of the subjects returned to the hospital within 30 days. Further investigation is warranted to determine if an association exists between missed recommendations and hospital readmission from the nursing home setting.