Janet H Van Cleave

Abstract

Providing affordable, high-quality care for the 10 million persons who are dual-eligible beneficiaries of Medicare and Medicaid is an ongoing health-care policy challenge in the United States. However, the workforce and the care provided to dual-eligible beneficiaries are understudied. The purpose of this article is to provide a narrative of the challenges and lessons learned from an exploratory study in the use of clinical and administrative data to compare the workforce of two care models that deliver home- and community-based services to dual-eligible beneficiaries. The research challenges that the study team encountered were as follows: (a) comparing different care models, (b) standardizing data across care models, and (c) comparing patterns of health-care utilization. The methods used to meet these challenges included expert opinion to classify data and summative content analysis to compare and count data. Using descriptive statistics, a summary comparison of the two care models suggested that the coordinated care model workforce provided significantly greater hours of care per recipient than the integrated care model workforce. This likely represented the coordinated care model's focus on providing in-home services for one recipient, whereas the integrated care model focused on providing services in a day center with group activities. The lesson learned from this exploratory study is the need for standardized quality measures across home- and community-based services agencies to determine the workforce that best meets the needs of dual-eligible beneficiaries.

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Objectives: To examine innovative models and other research-based interventions that hold potential to assure high-quality care for the growing older adult population living with cancer as one of multiple chronic conditions. Evidence from these care delivery approaches provides a roadmap for the development of future care models. Data Sources: Published peer-reviewed literature, policy analyses, and web-based resources. Conclusion: Available evidence suggests the need for models that engage patients and their family caregivers, focus on patient's functional capacities, emphasize palliative care, and maximize the contributions of all team members. Implications for Nursing Practice: Nurses are uniquely positioned to lead or play a major role in the evolution and implementation of care models targeting older adults with cancer, but must increase their knowledge and skills related to both oncology and geriatrics to maximize their contributions.

Abstract

In 2000, the John A. Hartford Foundation established the Building Academic Geriatric Nursing Capacity Program initiative, acknowledging nursing's key role in the care of the growing population of older adults. This program has supported 249 nurse scientists with pre- and postdoctoral awards. As a result of the program's success, several Building Academic Geriatric Nursing Capacity Program awardees formed an alumni organization to continue to advance the quality care of older adults. This group of Building Academic Geriatric Nursing Capacity Program awardees joined others receiving support from the John A. Hartford Foundation nursing initiatives to grow a formal organization, the Hartford Gerontological Nursing Leaders (HGNL). The purpose of this article is to present the development, accomplishments, and challenges of the HGNL, informing other professional nursing organizations that are experiencing similar accomplishments and challenges. This article also demonstrates the power of a funding initiative to grow an organization dedicated to impact gerontological health and health care through research, practice, education, and policy.

Abstract

Background Among older adults receiving long-term services and supports (LTSS), debilitating hospitalizations is a pervasive clinical and research problem. Multiple chronic conditions (MCCs) are prevalent in LTSS recipients. However, the combination of MCCs and diseases associated with hospitalizations of LTSS recipients is unclear. Objective The purpose of this analysis was to determine the association between classes of MCCs in newly enrolled LTSS recipients and the number of hospitalizations over a 1-year period following enrollment. Methods This report is based on secondary analysis of extant data from a longitudinal cohort study of 470 new recipients of LTSS, 60 years and older, receiving services in assisted living facilities, nursing homes, or through home- and community-based services. Using baseline chronic conditions reported in medical records, latent class analysis was used to identify classes of MCCs and posterior probabilities of membership in each class. Poisson regressions were used to estimate the relative ratio between posterior probabilities of class membership and number of hospitalizations during the 3-month period prior to the start of LTSS (baseline) and then every 3 months forward through 12 months. Results Three latent MCC-based classes named Cardiopulmonary, Cerebrovascular/Paralysis, and All Other Conditions were identified. The Cardiopulmonary class was associated with elevated numbers of hospitalizations compared to the All Other Conditions class (relative ratio [RR] = 1.88, 95% CI [1.33, 2.65], p

Abstract

The current article addresses pharmacological treatment issues regarding the management of persistent pain in later life, which is a worldwide problem associated with substantial disability. Recommendations from guidelines were reviewed and data are presented regarding the benefits and risks of commonly prescribed analgesic medications. The evidence base supports a stepwise approach with acetaminophen as first-line therapy for mild-to-moderate pain. Oral nonsteroidal anti-inflammatory drugs are not recommended for long-term use. In properly selected older patients, opioid drugs should be considered if pain is not adequately controlled. Careful surveillance to monitor for benefits and harms of therapy is critical, given that advancing age increases risk for adverse effects. Key aspects of the pain care process that nurses routinely engage in are covered, including conducting pain assessments prior to initiating therapy, addressing barriers to effective pain care, educating patients and family members about the importance of reducing pain, discussing treatment-related risks and benefits, and formulating strategies to monitor for treatment outcomes. Finally, a case is presented to illustrate issues that arise in the care of affected patients.

Abstract

Objectives: The global challenge of accessible, affordable cancer care for all older adults requires a new research agenda for gero-oncology nursing to guide investigator skill development, identify priority areas for investigation, and direct resource distribution. Data Sources: Published peer-reviewed literature and web-based resources. Conclusion: A cross-cutting theme of the research agenda is the need to determine the gero-oncology nursing care that will preserve economic resources, promote function, provide symptom management, and incorporate patient preferences. Implications for Nursing Practice: In partnership with interprofessional colleagues, gero-oncology nurse scientists are poised to conduct global research that improves access to quality cancer care.

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The growing number of individuals with comorbidities experiencing care transitions represents a challenge to the current health care system. A qualitative study of empirical literature, using the Dimensional Analysis approach, was conducted to elucidate the theoretical underpinnings of the phenomenon of individuals with comorbidities undergoing care transitions. The findings were arranged in a novel schematic demonstrating that the relationship among individual attributes, comorbidities, and care processes informed the individual's risk for adverse outcomes. This schematic is useful for future nursing research studies evaluating innovative programs implemented to improve health outcomes among vulnerable populations undergoing care transitions.

Abstract

BACKGROUND:: Symptom distress remains a significant health problem among older adults with cancer following surgery. Understanding factors influencing older adults' symptom distress may lead to early identification and interventions, decreasing morbidity and improving outcomes. OBJECTIVE:: We conducted this study to identify factors associated with symptom distress following surgery among 326 community-residing patients 65 years or older with a diagnosis of thoracic, digestive, gynecologic, and genitourinary cancers. METHODS:: This secondary analysis used combined subsets of data from 5 nurse-directed intervention clinical trials targeting patients after surgery at academic cancer centers in northwest and northeastern United States. Symptom distress was assessed by the Symptom Distress Scale at baseline and at 3 and 6 months. RESULTS:: A multivariable analysis, using generalized estimating equations, showed that symptom distress was significantly less at 3 and 6 months (3 months: P < .001, 6 months: P = .002) than at baseline while controlling for demographic, biologic, psychological, treatment, and function covariates. Thoracic cancer, comorbidities, worse mental health, and decreased function were, on average, associated with increased symptom distress (all P < .05). Participants 75 years or older reported increased symptom distress over time compared with those aged 65 to 69 years (P < .05). CONCLUSIONS:: Age, type of cancer, comorbidities, mental health, and function may influence older adults' symptom distress following cancer surgery. IMPLICATIONS FOR PRACTICE:: Older adults generally experience decreasing symptom distress after thoracic, abdominal, or pelvic cancer surgery. Symptom management over time for those with thoracic cancer, comorbidities, those with worse mental health, those with decreased function, and those 75 years or older may prevent morbidity and improve outcomes of older adults following surgery.