Michael K. Paasche-Orlow

Project ReEngineered Discharge (RED) Lowers Hospital Readmissions of Patients Discharged From a Skilled Nursing Facility

CONTEXTnPatients admitted to skilled nursing facilities (SNFs) have a high risk for rehospitalization.nnnOBJECTIVEnThe goal of this project was to implement Project RED in an SNF to increase patient preparedness for care transitions and lower rehospitalization rates in the 30 days after discharge from the SNF facility.nnnDESIGNnIntervention study with historical control; phone survey 30 days after discharge from the SNF for data collection.nnnSETTINGnThe study was conducted in an SNF admitting patients from acute care hospitals in Boston, MA.nnnPATIENTS OR OTHER PARTICIPANTSnA consecutive sample of patients in the SNF before (n = 524) and after initiation (n = 100) of the intervention. Participants had an average age of 80 (SD = 10), 67% were female, and 84% were non-Hispanic white. Phone surveys were completed with 88% of participants in each group.nnnINTERVENTION(S)nWe adapted Project RED for use in an SNF. This includes a comprehensive approach to transitions of care that includes creating and teaching a personalized care plan to patients and their families. Software facilitating these activities was integrated into the electronic medical record of the SNF; intervention activities were delivered by existing staff.nnnMAIN OUTCOME MEASURE(S)nThe main outcome was hospital readmission within 30 days of discharge from the SNF. Secondary outcomes included attendance to a medical appointment within 30 days of discharge from the SNF and preparedness for care transitions as measured by a 6-item survey.nnnRESULTSnThe rate of hospitalization 30 days after discharge from the SNF for participants prior to the intervention was 18.9% and for participants during the intervention was 10.2%, P < .05. This remained significant adjusting for multiple potential confounders (P = .045). More patients in the intervention group had attended an outpatient appointment within 30 days of discharge (70.5% versus 52.0%, P < .003). In addition, intervention participants reported a higher level of preparedness for care transitions.nnnCONCLUSIONSnPatients in the intervention had a lower rate of returning to the hospital within 30 days of discharge from the SNF, were more likely to attend medical appointments, and were better prepared for their care transition.

Hospital buddy: a persistent emotional support companion agent for hospital patients

The hospital experience can be disempowering and disorientating. Patients are deprived of sleep deprivation and exposed to constant noise, frequent interruptions, an unfamiliar environment filled with changing health professionals and ancillary staff, as well as medications often fraught with physical or psychoactive side-effects. These conditions often lead to discomfort and anxiety, and commonly induce delirium (especially in older adults), a neuropsychiatric condition in patients that results in clinically significant cognitive and perceptional problems. Simultaneously, because patients are usually alone in their rooms until a medical intervention is required they often are bored and starved for personal attention.

Limited Health Literacy and Decline in Executive Function in Older Adults

Limited health literacy is associated with worse executive function, but the association between limited health literacy and decline in executive function has not been established because of a lack of longitudinal studies. The authors aimed to examine this association by studying a prospective cohort in the setting of a randomized controlled trial to promote walking in older adults. Participants were community-dwelling older adults (65 years of age or older) who scored 2 or more on the Mini-Cog, without depression (score of less than 15 on the 9-item Patient Health Questionnaire), and who completed baseline and 12-month evaluations (n = 226). Health literacy was measured using the Short Test of Functional Health Literacy in Adults. Executive function measured at baseline and 12 months using the Trail Making Test (TMT), Controlled Oral Word Association Test, and Category Fluency. The associations between health literacy and 12-month decline in each test of executive function were modeled using multivariate linear regression. Health literacy was found to be limited in 37% of participants. Limited health literacy was associated with reduced performance on all 3 executive function tests. In fully adjusted models, limited health literacy was associated with greater 12-month decline in performance on the TMT than higher health literacy (p = .01). In conclusion, older adults with limited health literacy are at risk for more rapid decline in scores on the TMT, a measure of executive function.

Disparities in Age‐Associated Cognitive Decline Between African‐American and Caucasian Populations: The Roles of Health Literacy and Education

To examine health literacy as a mediator of racial disparities in cognitive decline as measured by executive function in elderly adults.

Automated conversation system before pediatric primary care visits: a randomized trial.

BACKGROUND AND OBJECTIVES: Interactive voice response systems integrated with electronic health records have the potential to improve primary care by engaging parents outside clinical settings via spoken language. The objective of this study was to determine whether use of an interactive voice response system, the Personal Health Partner (PHP), before routine health care maintenance visits could improve the quality of primary care visits and be well accepted by parents and clinicians. METHODS: English-speaking parents of children aged 4 months to 11 years called PHP before routine visits and were randomly assigned to groups by the system at the time of the call. Parents’ spoken responses were used to provide tailored counseling and support goal setting for the upcoming visit. Data were transferred to the electronic health records for review during visits. The study occurred in an urban hospital-based pediatric primary care center. Participants were called after the visit to assess (1) comprehensiveness of screening and counseling, (2) assessment of medications and their management, and (3) parent and clinician satisfaction. RESULTS: PHP was able to identify and counsel in multiple areas. A total of 9.7% of parents responded to the mailed invitation. Intervention parents were more likely to report discussing important issues such as depression (42.6% vs 25.4%; P < .01) and prescription medication use (85.7% vs 72.6%; P = .04) and to report being better prepared for visits. One hundred percent of clinicians reported that PHP improved the quality of their care. CONCLUSIONS: Systems like PHP have the potential to improve clinical screening, counseling, and medication management.

Sociodemographic Factors Mediate Race and Ethnicity-associated Childhood Asthma Health Disparities: a Longitudinal Analysis

BackgroundRace and ethnicity-based disparities in childhood asthma are well established. We characterized the longitudinal effects associated with being African-American/Black or Hispanic/Latino on a range of asthma outcomes, and the extent to which sociodemographic factors, caregiver health literacy, education level, and asthma knowledge mediate these associations.MethodsChildren ages 8–15 and their caregivers (nxa0=xa0544) in the Chicago Initiative to Raise Asthma Health Equity (CHIRAH) cohort completed interviews every 3xa0months for 1.5xa0years. Health literacy was measured with the Rapid Estimate of Adult Literacy in Medicine (REALM). Other covariates include sex, age, education level, income, smoke exposure, asthma duration, employment status, and insurance status. We conducted a series of models to evaluate these factors as mediators of the relationship between race/ethnicity and (1) asthma knowledge, (2) asthma-related quality of life, (3) asthma severity, and (4) asthma control based on NAEPP/EPR-3 2007 guidelines.ResultsAfrican-American race and Hispanic/Latino ethnicity were significantly associated with all outcomes when compared to Whites. Adjusting for sociodemographic factors resulted in the most significant mediation of racial/ethnic disparities in all outcomes. Health literacy was a partial mediator of race/ethnic disparities in asthma knowledge and asthma-related quality of life. Asthma knowledge remained significantly associated with race and ethnicity, and race remained associated with asthma-related quality of life.ConclusionsAfrican-American race and Hispanic/Latino ethnicity are significantly associated with worse asthma compared to Whites in longitudinal analyses. Sociodemographic factors are potent mediators of these disparities, and should be considered when designing interventions to reduce asthma disparities. Health literacy and education level are partial mediators.

Acculturation and a Potential Relationship with Oral Health Outcomes Among Somali Refugees in Massachusetts

This paper explores the relationship between acculturation and oral health in a study of Somali refugees. This cross-sectional survey included structured surveys and dental examinations of a convenience sample of 439 Somali adults living in Massachusetts. Associations between an acculturation scale and: (1) lifetime history of caries and (2) access to oral health services were calculated. In bivariate analyses, many individual questions in the scale were associated with outcomes. In multivariate analysis, speaking English (OR 0.5, CI 0.28–0.84) was associated with better access to, and utilization of, dental health services while reading American books and newspapers in English was associated with increased lifetime history of dental disease (OR 2.6, CIu20091.1–6.0). As specific elements of acculturation have different relationships with oral health among Somali refugees, a summary acculturation scale may have limited utility. Ongoing efforts to remove language barriers may improve oral health.

“It’s like a mirror image of my illness”: Exploring Patient Perceptions About Illness Using Health Mind Mapping—a Qualitative Study

BackgroundA patient’s self-management of chronic disease is influenced in part by their explanatory model of illness (EMI) and daily lived experiences (DLE). Unfortunately, assessing patient’s EMI and using this information to engage patients in chronic illness self-management continues to be a challenge.Objective“Health mind mapping” (HMM) is a novel process that captures a patient’s EMI and DLE through the use of a graphic representation of ideas. We aimed to explore patient’s experiences using HMM.DesignQualitative study utilizing semi-structured interviews.ParticipantsAdult patients with uncontrolled type 2 diabetes from a primary care clinic.ApproachA facilitator guided 20 participants through the process of developing a health mind map. Subsequently, each participant completed a semi-structured interview about their experience with the process and perceptions about how their maps could be used. The process and interviews were video and audio recorded. We conducted a content analysis of the maps and a thematic analysis, using an inductive approach, of the interview data.ResultsParticipants explored a wide range of EMs and DLEs in their HMM process. Participants reported that the HMM process (1) helped to develop insight about self and illness; (2) was a catalyst for wanting to take actions to improve illness; and (3) represented an opportunity to actively share illness experiences. They reported potential uses of the map: (1) to communicate about their illness to others in their social network; (2) to communicate about their illness to providers; (3) to help others with diabetes manage their illness; and (4) to encourage ongoing engagement in diabetes self-care.ConclusionsParticipants reported that HMM helped them develop new insight about their illness and was a catalyst for encouraging them to take control of their illness. HMM has the potential to facilitate communication with providers and engage patients in collaborative goal setting to improve self-care in chronic illness.

Health Literacy and Cardiovascular Disease: Fundamental Relevance to Primary and Secondary Prevention: A Scientific Statement From the American Heart Association

Health literacy is the degree to which individuals are able to access and process basic health information and services and thereby participate in health-related decisions. Limited health literacy is highly prevalent in the United States and is strongly associated with patient morbidity, mortality, healthcare use, and costs. The objectives of this American Heart Association scientific statement are (1) to summarize the relevance of health literacy to cardiovascular health; (2) to present the adverse associations of health literacy with cardiovascular risk factors, conditions, and treatments; (3) to suggest strategies that address barriers imposed by limited health literacy on the management and prevention of cardiovascular disease; (4) to demonstrate the contributions of health literacy to health disparities, given its association with social determinants of health; and (5) to propose future directions for how health literacy can be integrated into the American Heart Associations mandate to advance cardiovascular treatment and research, thereby improving patient care and public health. Inadequate health literacy is a barrier to the American Heart Association meeting its 2020 Impact Goals, and this statement articulates the rationale to anticipate and address the adverse cardiovascular effects associated with health literacy.

Talk About Death: End of Life Planning with a Virtual Agent.

For those nearing the end of life, “wellness” must encompass reduction in suffering as well as the promotion of behaviors that mitigate stress and help people prepare for death. We discuss the design of a virtual conversational palliative care coach that works with individuals during their last year of life to help them manage symptoms, reduce stress, identify and address unmet spiritual needs, and support advance care planning. We present the results of an experiment that features the reactions of older adults in discussing these topics with a virtual agent, and note the importance of discussing spiritual needs in the context of end-of-life conversations. We find that all participants are comfortable discussing these topics with an agent, and that their discussion leads to reductions in state and death anxiety, as well as significant increase in intent to create a last will and testament.