BACKGROUND:EQUIPPED (Enhancing Quality of Prescribing Practices for Older Veterans Discharged from the Emergency Department) is a program developed within the Veterans Affairs (VA) health system that aims to reduce the prescription of potentially inappropriate medications (PIMs) for people aged 65 and over. A recent trial evaluated implementation of EQUIPPED via (1) academic detailing, which involves one-on-one provider guidance and coaching, or (2) dashboards that monitor providers' PIM prescribing rates. Evidence suggests better implementation among academic detailing sites, but qualitative evidence is lacking. OBJECTIVE:Our objective is to identify individual and organizational factors that affect EQUIPPED implementation and to compare these factors across the program's two audit and feedback arms. METHODS:Four academic detailing sites and three dashboard sites (comprising a total of 28 interviewees) were included in this qualitative analysis between May 2019 and June 2022; each site submitted regular site adaptation reports and participated in a series of interviews (1) at baseline, (2) after 6-8 months of implementation, and (3) a year after the first interview. Thematic analysis was done using constructs from the Organizational Theory of Implementation Effectiveness; reports from participating sites were also compared and analyzed using a categorization matrix. RESULTS:Respondents from both arms underlined the importance of change valence, innovation-values fit, and situational factors, such as ongoing accreditation, in fostering a favorable implementation climate for EQUIPPED. A unique challenge for academic detailing sites was the lack of resources and time to implement the mentoring intervention; dashboard sites encountered difficulties in sustaining momentum and motivation among providers. Common challenges included the prompt development and approval of medication order sets. CONCLUSION AND RECOMMENDATIONS:Results suggest the importance of implementation climate, alignment with shared individual and organizational values, and seamless integration of EQUIPPED implementation within existing workflows. TRIAL REGISTRATION:ClinicalTrials.gov identifier: NCT04004936.

BACKGROUND:The EQUIPPED (Enhancing Quality of Prescribing Practices for Older Adults Discharged from the Emergency Department) medication safety program is an evidence-informed quality improvement initiative to reduce potentially inappropriate medications (PIMs) prescribed by Emergency Department (ED) providers to adults aged 65 and older at discharge. We aimed to scale-up this successful program using (1) a traditional implementation model at an ED with a novel electronic medical record and (2) a new hub-and-spoke implementation model at three new EDs within a health system that had previously implemented EQUIPPED (hub). We hypothesized that implementation speed would increase under the hub-and-spoke model without cost to PIM reduction or site engagement. METHODS:We evaluated the effect of the EQUIPPED program on PIMs for each ED, comparing their 12-month baseline to 12-month post-implementation period prescribing data, number of months to implement EQUIPPED, and facilitators and barriers to implementation. RESULTS:The proportion of PIMs at all four sites declined significantly from pre- to post-EQUIPPED: at traditional site 1 from 8.9% (8.1-9.6) to 3.6% (3.6-9.6) (p < 0.001); at spread site 1 from 12.2% (11.2-13.2) to 7.1% (6.1-8.1) (p < 0.001); at spread site 2 from 11.3% (10.1-12.6) to 7.9% (6.4-8.8) (p = 0.045); and at spread site 3 from 16.2% (14.9-17.4) to 11.7% (10.3-13.0) (p < 0.001). Time to implement was equivalent at all sites across both models. Interview data, reflecting a wide scope of responsibilities for the champion at the traditional site and a narrow scope at the spoke sites, indicated disproportionate barriers to engagement at the spoke sites. CONCLUSIONS:EQUIPPED was successfully implemented under both implementation models at four new sites during the COVID-19 pandemic, indicating the feasibility of adapting EQUIPPED to complex, real-world conditions. The hub-and-spoke model offers an effective way to scale-up EQUIPPED though a speed or quality advantage could not be shown.

BACKGROUND:In the U.S., assisted living (AL) is increasingly a site of death, and anxiety about dying has been identified in long-term care residents and their caregivers. Communication about death and dying is associated with better quality of life and care at end of life (EOL). OBJECTIVE:To understand communication behaviors used by AL residents and their informal caregivers (i.e., family members or friends) related to death and dying, and address communication needs or opportunities applicable to EOL care in AL. DESIGN:A thematic analysis of in-depth interviews and fieldnotes from a subsample of data from a 5-year NIA-funded study. SETTING/SUBJECTS:Participants included 15 resident-caregiver dyads from three diverse AL communities in Atlanta, Georgia in the U.S. MEASUREMENTS:Interview transcripts were coded for communication behavior. Concordances and discordances within dyads were examined. RESULTS:We identified a typology of four dyadic communication behaviors: Talking (i.e., both partners were talking with each other about death), Blocking (i.e., one partner wanted to talk about death but the other did not), Avoiding (i.e., each partner perceived that the other did not want to communicate about death), and Unable (i.e., dyads could not communicate about death because of interpersonal barriers). CONCLUSIONS:Older residents in AL often want to talk about death but are blocked from doing so by an informal caregiver. Caregivers and AL residents may benefit from training in death communication. Recommendations for improving advance care planning and promoting better EOL communication includes timing these conversations before the opportunity is lost.

Journal Article Art of pain: a multidisciplinary pain fellowship museum-based education pilot study Get access Boris Spektor, MD, Boris Spektor, MD Division of Pain Medicine, Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA 30322, United States Corresponding author: Boris Spektor, MD, Division of Pain Medicine, Department of Anesthesiology, Emory University School of Medicine, 1364 Clifton Road NE, 5th Floor Tower, c/o Karen Woods, Atlanta, GA 30322, USA. Email: bspekto@emory.edu https://orcid.org/0000-0001-6347-2257 Search for other works by this author on: Oxford Academic PubMed Google Scholar Shawn Banon, MD, Shawn Banon, MD Summit Spine and Joint Centers, Atlanta, GA, United States Search for other works by this author on: Oxford Academic PubMed Google Scholar Ann E Vandenberg, PhD, MPH, Ann E Vandenberg, PhD, MPH Division of General Medicine and Geriatrics, Department of Medicine, Emory University School of Medicine, Atlanta, GA 30322, United States Search for other works by this author on: Oxford Academic PubMed Google Scholar Ali John Zarrabi, MD Ali John Zarrabi, MD Division of Palliative Medicine, Department of Family and Preventive Medicine, Emory University School of Medicine, Atlanta, GA 30322, United States Search for other works by this author on: Oxford Academic PubMed Google Scholar Pain Medicine, Volume 24, Issue 8, August 2023, Pages 1008–1010, https://doi.org/10.1093/pm/pnad024 Published: 27 February 2023 Article history Received: 24 November 2022 Revision received: 11 February 2023 Accepted: 17 February 2023 Published: 27 February 2023 Corrected and typeset: 05 July 2023

Given an observed tension between perceived privacy restrictions and meaningful social connection in assisted living (AL) and using a relational perspective, we conducted a secondary thematic analysis of health information sharing practices among residents and their care partners in one large urban AL community in metropolitan Atlanta. Data included in-depth interviews with residents (n = 26), family members (n = 20), AL staff (n = 11), and external care workers (n = 4) as well as ethnographic data from observations and informal conversations conducted with these participants and others. Findings showed that health information sharing among residents was helpful in building social relationships; barriers to this communication contributed to isolation. Inappropriate public exchange of residents' healthcare information hindered building these relationships. Negotiating privacy boundaries for health information sharing was an ongoing confusing process across the community. Based on the findings, we propose new guidelines for health information sharing and additional privacy training for residents and care partners.

Assisted living (AL) is increasingly a site of end-of-life care and a long-term care location where growing numbers of people are aging in place and dying. Despite these trends, limited research focuses on how death and grief impact the work environment in AL. This grounded theory analysis examined qualitative data collected from 27 administrators and 38 direct care workers (DCWs) in 7 diverse settings. As assisted living administrators and DCWs experienced resident death, they engaged in a dynamic and individualized process of "managing the normalization of death," which refers to the balance of self-identity and workplace identity. The process of reconciling these opposing contexts in AL involved several individual- and community-level conditions. Administrators and DCWs would benefit from additional resources and training around death. Increasing collaboration with hospice and clarifying policies about death communication would better prepare the workforce to acknowledge the end of life in assisted living.

OBJECTIVE:Systemic lupus erythematosus (SLE) is a complex chronic disease associated with reduced cognitive functioning. Patients with SLE report cognitive symptoms, but cognitive assessment is not routine in SLE and little is known about day-to-day cognitive problems and their effect on disease management. As part of a pilot exploring the use of a cognitive functioning report prototype for shared decision-making in clinical encounters (the Approaches to Positive Patient-Centered Experiences of Aging in Lupus [APPEAL] Study), we investigated the relevance of cognitive assessments performed using the National Institutes of Health (NIH) Toolbox among patients with SLE.METHODS:We conducted 4 focus groups, 2 with SLE patients (n = 18) and 2 with lupus providers (physicians and nurses; n = 9), addressing cognitive issues and interest in communicating about cognition. We compared how NIH Toolbox cognitive domains (episodic memory, working memory, processing speed, attention and inhibitory control, cognitive flexibility) matched with patient- and provider-identified cognitive problems and needs.RESULTS:Patients identified all NIH domains with rich experiential examples; providers identified fewer domains and offered less detail. An unanticipated additional domain was prospective memory (i.e., problems with remembering future actions). Use of technologic aids (e.g., smart phone alerts) was mentioned by some patients, but not providers, and represent a potential opportunity for medical care. All participants expressed interest in discussing cognition in clinic.CONCLUSION:Cognitive assessment using the NIH Cognitive Toolbox is relevant to this population, with the possible addition of a prospective memory assessment. Cognitive problems and indications of communication gaps suggest the appropriateness of more clinical communication about cognition in the SLE population.

BackgroundEnhancing Quality of Prescribing Practices for Older Adults Discharged from the Emergency Department (EQUIPPED) is an effective quality improvement program initially designed in the Veterans Administration (VA) health care system to reduce potentially inappropriate medication prescribing for adults aged 65 years and older. This study examined factors that influence implementation of EQUIPPED in EDs from four distinct, non-VA academic health systems using a convergent mixed methods design that operationalized the Consolidated Framework for Implementation Research (CFIR). Fidelity of delivery served as the primary implementation outcome.Materials and methodsFour EDs implemented EQUIPPED sequentially from 2017 to 2021. Using program records, we scored each ED on a 12-point fidelity index calculated by adding the scores (1–3) for each of four components of the EQUIPPED program: provider receipt of didactic education, one-on-one academic detailing, monthly provider feedback reports, and use of order sets. We comparatively analyzed qualitative data from focus groups with each of the four implementation teams (n = 22) and data from CFIR-based surveys of ED providers (108/234, response rate of 46.2%) to identify CFIR constructs that distinguished EDs with higher vs. lower levels of implementation.ResultsOverall, three sites demonstrated higher levels of implementation (scoring 8–9 of 12) and one ED exhibited a lower level (scoring 5 of 12). Two constructs distinguished between levels of implementation as measured through both quantitative and qualitative approaches: patient needs and resources, and organizational culture. Implementation climate distinguished level of implementation in the qualitative analysis only. Networks and communication, and leadership engagement distinguished level of implementation in the quantitative analysis only.DiscussionUsing CFIR, we demonstrate how a range of factors influence a critical implementation outcome and build an evidence-based approach on how to prime an organizational setting, such as an academic health system ED, for successful implementation.ConclusionThis study provides insights into implementation of evidence-informed programs targeting medication safety in ED settings and serves as a potential model for how to integrate theory-based qualitative and quantitative methods in implementation studies.

ObjectivePatient‐provider discussions about functioning are often outside the scope of usual care for systemic lupus erythematosus (SLE), and tools to facilitate such discussions are lacking. The present study was undertaken to assess the comprehension, utility, and acceptability of a novel, individualized functioning report, the purpose of which is to facilitate patient–provider communication about functioning, in a predominantly Black SLE patient population.MethodsIndividualized reports (including sections with pictorial representations of participants' measured activities of daily living, falls, physical performance, perceived physical functioning, and community mobility from a previous pilot study visit) and surveys were emailed or mailed to 59 SLE patients. Ease of interpretation was dichotomized (“very easy” versus all other responses). Utility and acceptability were assessed by items relating to usefulness for care planning and comfort with discussing the report.ResultsAmong 47 (79.7%) SLE patients who completed the survey (78.7% Black, 91.5% female, mean age 49.6 years), the reported ease of interpretation ranged from 70.2% to 85.1% across the report sections. Ease of interpretation was lower among those who were older, Black, and female and who had lower cognitive scores (P > 0.05 for all). Most reported that physical functioning domains of the report were useful for treatment or other care planning (70.2–80.5%) and that they felt comfortable discussing the report with a health care provider (93.2–100%).ConclusionWe found that a novel functioning report for SLE patients was associated with high comprehension, utility, and acceptability. Future studies can help determine how an individualized functioning report could improve patient–provider communication in the clinic setting.

Background We piloted a web-based, provider-driven mobile app (DialysisConnect) to fill the communication and care coordination gap between hospitals and dialysis facilities. Objective This study aimed to describe the development and pilot implementation of DialysisConnect. Methods DialysisConnect was developed iteratively with focus group and user testing feedback and was made available to 120 potential users at 1 hospital (hospitalists, advanced practice providers [APPs], and care coordinators) and 4 affiliated dialysis facilities (nephrologists, APPs, nurses and nurse managers, social workers, and administrative personnel) before the start of the pilot (November 1, 2020, to May 31, 2021). Midpilot and end-of-pilot web-based surveys of potential users were also conducted. Descriptive statistics were used to describe system use patterns, ratings of multiple satisfaction items (1=not at all; 3=to a great extent), and provider-selected motivators of and barriers to using DialysisConnect. Results The pilot version of DialysisConnect included clinical information that was automatically uploaded from dialysis facilities, forms for entering critical admission and discharge information, and a direct communication channel. Although physicians comprised most of the potential users of DialysisConnect, APPs and dialysis nurses were the most active users. Activities were unevenly distributed; for example, 1 hospital-based APP recorded most of the admissions (280/309, 90.6%) among patients treated at the pilot dialysis facilities. End-of-pilot ratings of DialysisConnect were generally higher for users versus nonusers (eg, “I can see the potential value of DialysisConnect for my work with dialysis patients”: mean 2.8, SD 0.4, vs mean 2.3, SD 0.6; P=.02). Providers most commonly selected reduced time and energy spent gathering information as a motivator (11/26, 42%) and a lack of time to use the system as a barrier (8/26, 31%) at the end of the pilot. Conclusions This pilot study found that APPs and nurses were most likely to engage with the system. Survey participants generally viewed the system favorably while identifying substantial barriers to its use. These results inform how best to motivate providers to use this system and similar systems and inform future pragmatic research in care coordination among this and other populations.

Rationale & Objective:Suboptimal care coordination between dialysis facilities and hospitals is an important driver of 30-day hospital readmissions among patients receiving dialysis. We examined whether the introduction of web-based communications platform ("DialysisConnect") was associated with reduced hospital readmissions. Study Design:Pilot pre-post study. Setting & Participants:A total of 4,994 index admissions at a single hospital (representing 2,419 patients receiving dialysis) during the study period (January 1, 2019-May 31, 2021). Intervention:DialysisConnect was available to providers at the hospital and 4 affiliated dialysis facilities (=intervention facilities) during the pilot period (November 1, 2020-May 31, 2021). Outcomes:The primary outcome was 30-day readmission; secondary outcomes included 30-day emergency department visits and observation stays. Interrupted time series and linear models with generalized estimating equations were used to assess pilot versus prepilot differences in outcomes; difference-in-difference analyses were performed to compare these differences between intervention versus control facilities. Sensitivity analyses included a third, prepilot/COVID-19 period (March 1, 2020-October 31, 2020). Results:There was no statistically significant difference in the monthly trends in the 30-day readmissions pilot versus prepilot periods (-0.60 vs -0.13, P = 0.85) for intervention facility admissions; the difference-in-difference estimate was also not statistically significant (0.54 percentage points, P = 0.83). Similar analyses including the prepilot/COVID-19 period showed that, despite a substantial drop in admissions at the start of the pandemic, there were no statistically significant differences across the 3 periods. The age-, sex-, race-, and comorbid condition-adjusted, absolute pilot versus prepilot difference in readmissions rate was 1.8% (-3.7% to 7.3%); similar results were found for other outcomes. Limitations:Potential loss to follow-up and pandemic effects. Conclusions:In this pilot, the introduction of DialysisConnect was not associated with reduced hospital readmissions. Tailored care coordination solutions should be further explored in future, multisite studies to improve the communications gap between dialysis facilities and hospitals.

Background: U.S. hospitals and dialysis centers are penalized for 30-day hospital readmissions of dialysis patients, despite little infrastructure to facilitate care transitions between these settings. We are developing a third-party web-based information exchange platform, DialysisConnect, to enable clinicians to view and exchange information about dialysis patients during admission, hospitalization, and discharge. This health information technology solution could serve as a flexible and relatively affordable solution for dialysis facilities and hospitals across the nation who are seeking to serve as true partners in the improved care of dialysis patients. The purpose of this study was to evaluate the perceived coherence of DialysisConnect to key clinical stakeholders, to prepare messaging for implementation. Methods: As part of a hybrid effectiveness-implementation study guided by Normalization Process Theory, we collected data on stakeholder perceptions of continuity of care for patients receiving maintenance dialysis and a DialysisConnect prototype before completing development and piloting the system. We conducted four focus groups with stakeholders from one academic hospital and associated dialysis centers [hospitalists (n = 5), hospital staff (social workers, nurses, pharmacists; n = 9), nephrologists (n = 7), and dialysis clinic staff (social workers, nurses; n = 10)]. Transcriptions were analyzed thematically within each component of the construct of coherence (differentiation, communal specification, individual specification, and internalization). Results: Participants differentiated DialysisConnect from usual care variously as an information dashboard, a quick-exchange communication channel, and improved discharge information delivery; some could not differentiate it in terms of workflow. The purpose of DialysisConnect (communal specification) was viewed as fully coherent only for communicating outside of the same healthcare system. Current system workarounds were acknowledged as deterrents for practice change. All groups delegated DialysisConnect tasks (individual specification) to personnel besides themselves. Partial internalization of DialysisConnect was achieved only by dialysis clinic staff, based on experience with similar technology. Conclusions: Implementing DialysisConnect for clinical users in both settings will require presenting a composite picture of current communication processes from all stakeholder groups to correct single-group misunderstandings, as well as providing data about care transitions communication beyond the local context to ease resistance to practice change.

Enhancing quality of prescribing practices for older adults discharged from the Emergency Department (EQUIPPED) aims to reduce the monthly proportion of potentially inappropriate medications (PIMs) prescribed to older adults discharged from the ED to 5% or less. We describe prescribing outcomes at three academic health systems adapting and sequentially implementing the EQUIPPED medication safety programme. EQUIPPED was adapted from a model developed in the Veterans Health Administration (VA) and sequentially implemented in one academic health system per year over a 3-year period. The monthly proportion of PIMs, as defined by the 2015 American Geriatrics Beers Criteria, of all medications prescribed to adults aged 65 years and older at discharge was assessed for 6 months preimplementation until 12 months postimplementation using a generalised linear time series model with a Poisson distribution. The EQUIPPED programme was translated from the VA health system and its electronic medical record into three health systems each using a version of the Epic electronic medical record. Adaptation occurred through local modification of order sets and in the generation and delivery of provider prescribing reports by local champions. Baseline monthly PIM proportions 6 months prior to implementation at the three sites were 5.6% (95% CI 5.0% to 6.3%), 5.8% (95% CI 5.0% to 6.6%) and 7.3% (95% CI 6.4% to 9.2%), respectively. Evaluation of monthly prescribing including the twelve months post-EQUIPPED implementation demonstrated significant reduction in PIMs at one of the three sites. In exploratory analyses, the proportion of benzodiazepine prescriptions decreased across all sites from approximately 17% of PIMs at baseline to 9.5%–12% postimplementation, although not all reached statistical significance. EQUIPPED is feasible to implement outside the VA system. While the impact of the EQUIPPED model may vary across different health systems, results from this initial translation suggest significant reduction in specific high-risk drug classes may be an appropriate target for improvement at sites with relatively low baseline PIM prescribing rates.

Objective To determine whether and how cognitive assessment data should be included in a report for patients with SLE and their providers. Methods Leveraging experiences from prior studies, we created a cognitive report that included a hypothetical patient’s results on tests of multiple domains based on the NIH Toolbox Fluid Cognition Battery. In focus groups that comprised patients with SLE (two groups) and their providers (two groups), feedback was sought on the presentation of results as well as the potential value of the report in the clinical setting. Results Feedback regarding the presentation of the report was generally positive. Both patients with SLE and their providers liked its simple graphics and use of a colour-gradated scale to indicate performance. However, both groups stressed the importance of using non-stigmatising language in describing results. Several potential purposes of the report, including distinguishing cognitive versus other issues, explaining cognitive challenges, improving patient–provider interactions, guiding decision-making, improving functioning or preventing impairment and tracking cognitive function over time, were noted by the participants. Potential barriers, such as inadequate clinical staffing or time and lack of potential treatments for identified issues, were also discussed. Conclusion In this exploratory study, we found that both patients with SLE and their providers were receptive to the idea of a patient-friendly report of cognitive test results. This study provides important information to guide future pragmatic research to optimise the delivery of cognitive information to patients with SLE.

In the United States, 34% of hospital discharges among patients receiving dialysis are followed by a 30-day readmission,1US Renal Data SystemUSRDS 2020 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, 2020Google Scholar and both dialysis clinics2Centers for Medicare & Medicaid ServicesEnd-stage renal disease prospective payment system, quality incentive program, and durable medical equipment, prosthetics, orthotics, and supplies: final rule.Fed Regist. 2014; 79: 37808-37860Google Scholar and hospitals3Centers for Medicare & Medicaid ServicesHospital Readmissions Reduction Program. 42 CFR part 412 (§412.150 through §412.154).2012Google Scholar are held accountable for readmissions (through potential payment reductions). Although improved care coordination between hospitals and dialysis clinics may play an important role in reducing hospital readmissions and improving other patient outcomes, the fragmented US health care system does not facilitate this coordination. Particularly the lack of interoperability of electronic health records remains a key barrier for most dialysis clinic–hospital dyads.4Kelly Y.P. Kuperman G.J. Steele D.J.R. Mendu M.L. Interoperability and patient electronic health record accessibility: opportunities to improve care delivery for dialysis patients.Am J Kidney Dis. 2020; 76: 427-430Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar In an ongoing pilot study, we are testing the feasibility and effectiveness of a web-based communications platform for hospital and dialysis clinic providers (DialysisConnect5Vandenberg A.E. Jaar B.G. James K.P. et al.Making sense of DialysisConnect: a qualitative analysis of stakeholder viewpoints on a web-based information exchange platform to improve care transitions between dialysis clinics and hospitals.BMC Med Inform Decis Mak. 2021; 21: 47Crossref PubMed Scopus (1) Google Scholar) to circumvent these issues and improve care coordination between patients hospitalized at Emory University Hospital Midtown and treated at 4 independently managed Emory Dialysis clinics. The purpose of this study was to examine the perspectives of recently hospitalized patients regarding their perceptions of usual (pre-intervention) care coordination between hospital and dialysis clinic providers during and after hospitalization. Our study targeted 113 hemodialysis patients who were being treated at 4 Emory Dialysis clinics and had been hospitalized at Emory University Hospital Midtown in the 6 months before approach. We administered a 1-time survey (Item S1) about their care coordination during their hospitalization episode, online or by telephone (11/27/20-1/04/21). Data were collected and managed through REDCap,6Harris P.A. Taylor R. Thielke R. Payne J. Gonzalez N. Conde J.G. Research electronic data capture (REDCap)--a metadata-driven methodology and workflow process for providing translational research informatics support.J Biomed Inform. 2009; 42: 377-381Crossref PubMed Scopus (17221) Google Scholar and descriptive statistics were calculated using Stata (StataCorp), version 16.1. The survey was approved by the Emory University Institutional Review Board (IRB00102971). Detailed methods are provided in Item S1. Respondents (n=24; 21% response rate) had an average age of 62 years and had been receiving dialysis for a median of 4 (interquartile range, 1.4-6.2) years; 24 (100%) were Black and 11 (46%) were men (Table S1). Nonrespondents were generally similar to respondents (Table S2). For 21 respondents (91%), the time between onset of presenting symptom(s) (including shortness of breath, fever, syncope, pain, cough, and weakness; Table S1) and hospital admission was less than 1 week. The percentages of patients who reported that their hospital and dialysis providers knew key information or performed care coordination tasks during and after hospitalization, as listed in Fig 1A and B, respectively, were generally high. Most patients additionally reported that hospital providers asked them about their reason for the hospital stay (n = 19 [79%]), dialysis schedule (n = 18 [75%]), symptoms (n = 18 [75%]), current medications (n = 17 [71%]), vascular access (n = 16 [67%]), nephrologist name (n = 16 [67%]), dialysis facility name (n = 13 [54%]), and/or dry weight (n = 12 [50%]) (Table S3). Eleven patients (47%) reported bringing their discharge instructions to their next dialysis session. Only 16 (67%) reported that they were likely to log into a hypothetical patient version of our web-based platform for hospital care coordination, although 21 (88%) reported they would like a health care surrogate to see this information (Table S3). We found that patients’ perceptions of care coordination between the hospital and dialysis clinic were high: most reported that both hospital and dialysis providers were aware of the patient’s clinical situation and had exchanged necessary information despite also reporting that providers had asked the patient for much of the same information. Fewer reported that care coordination tasks, such as dry weight reassessment and medication reconciliation, occurred soon after discharge. Although most care coordination programs7Coleman E.A. Parry C. Chalmers S. Min S.J. The care transitions intervention: results of a randomized controlled trial.Arch Intern Med. 2006; 166: 1822-1828Crossref PubMed Scopus (1361) Google Scholar target the patient as an active and primary partner in care coordination, fewer than half noted that they brought hospital discharge instructions to the dialysis clinic after discharge, and one-third were not interested in a portal to view the communication between hospital and dialysis providers about their care. This suggests that patients had identified the providers and not themselves as primary coordinators of care. Efforts to understand, measure, and increase patient/surrogate engagement during and after hospitalization, including making hospitalization information directly available to patients/surrogates, should be considered in future studies. It is important to note that our patients may have higher perceptions of care coordination than patients in more typical dialysis clinics due to the academic setting (in which the nephrologists at the dialysis clinic and hospital often overlap) and university affiliation of the dialysis clinics (despite their independent management and separate electronic health record and care teams). However, patients in other settings may also have misconceptions about the ease and frequency of communication between the hospital and dialysis clinic settings, despite this communication being suboptimal.5Vandenberg A.E. Jaar B.G. James K.P. et al.Making sense of DialysisConnect: a qualitative analysis of stakeholder viewpoints on a web-based information exchange platform to improve care transitions between dialysis clinics and hospitals.BMC Med Inform Decis Mak. 2021; 21: 47Crossref PubMed Scopus (1) Google Scholar,8Reilly J.B. Marcotte L.M. Berns J.S. Shea J.A. Handoff communication between hospital and outpatient dialysis units at patient discharge: a qualitative study.Jt Comm J Qual Patient Saf. 2013; 39: 70-76Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar Additionally, small sample size limits our power to compare perceptions across subgroups; our response rate was low, although responders and nonresponders were similar; and patients may misremember events, particularly dry weight reassessment or medication reconciliation, or confuse multiple hospitalizations. Future studies could further explore objective measures of care coordination using validated instruments and reasons for patient perceptions of high levels of hospital care coordination in larger more representative populations of patients and surrogates. Such studies will be key to targeting interventions to improve coordination of care between hospitals and dialysis clinics. Research idea and study design: CH, AV, LCP; data acquisition: CP, CH; data analysis/interpretation: CP, LCP; supervision or mentorship: BGJ, JPL, LCP. Each author contributed important intellectual content during manuscript drafting or revision and accepts accountability for the overall work by ensuring that questions pertaining to the accuracy or integrity of any portion of the work are appropriately investigated and resolved. Research reported in this publication was supported by the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health (NIH) under award no. R18DK118467. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. The funders had no role in study design; collection, analysis, and interpretation of data; writing the report; or the decision to submit the report for publication. Emory University REDCap is supported by National Center for Advancing Translational Sciences award no. UL1 TR000424. The authors declare that they have no relevant financial interests. We thank the patients who participated in our survey; Linda Turberville-Trujillo, NP, and Michelle Young, NP, for distributing recruitment letters to dialysis patients; and Queen Nguyen, MPH, for assisting with piloting of the survey. Received May 6, 2021. Evaluated by 2 external peer reviewers, with direct editorial input by the Statistical Editor and the Editor-in-Chief. Accepted in revised form July 11, 2021. Download .pdf (.24 MB) Help with pdf files Supplementary File (PDF)Item S1, Tables S1-S3.

Abstract Limited empirical evidence suggests that caregiver burden is greater for informal care partners (family and friends) in assisted living (AL) compared with other long-term care settings, particularly within context of end of life. Using qualitative data from a larger 5-year, 7-site study of end-of-life care in AL funded by the National Institute on Aging (R01AG047408), we investigate informal care partners’ involvement in end-of-life care and identify challenges related to informal caregiving that might contribute to care burden. Grounded theory analysis of ethnographic data and in-depth interviews (average interview length = 97 minutes) with 59 racially and ethnically diverse informal care partners (mean age = 60) shows that informal care partner involvement in end-of-life care varies across participants and over time and is shaped by multiple intersecting social and structural determinants. At individual levels, these include many personal, situational, and relational factors. Personal factors include but are not limited to care partners’ own physical and mental health and material resources (e.g., ability to pay for supplementary care). Situational and relational factors include care partners’ awareness (or lack thereof) of residents’ impending death and the quality of the caregiving relationship. AL and wider community-level factors include understaffing, staff turnover, inadequate hospice support, and lack of access to these services. We find that informal care partners navigate these caregiving challenges through a basic social process we conceptualize as “negotiating risks.” Strategies for easing caregiver burden and improving informal care partner and resident quality of life at end of life are implicated.

OBJECTIVES To present the three-site EQUIPPED academic health system research collaborative, which engaged in sequential implementation of the EQUIPPED medication safety program, as a learning health system; to understand how the organizations worked together to build resources for program scale-up. DESIGN Following the Replicating Effective Programs framework, we analyzed content from implementation teams' focus groups, local and cross-site meeting minutes and sites' organizational profiles to develop an implementation package. SETTING Three academic emergency departments that each implemented EQUIPPED over three successive years. PARTICIPANTS Implementation team members at each site participating in focus groups (n = 18), local meetings during implementation years, and cross-site meetings during all years of the projects. INTERVENTION(S) EQUIPPED provides Emergency Department providers with clinical decision support (education, order sets, and feedback) to reduce prescribing of potentially inappropriate medications to adults aged 65 years and older who received a prescription at time of discharge. MAIN OUTCOME MEASURE(S) Implementation process components assembled through successive implementation. RESULTS Each site had clinical and environmental characteristics to be addressed in implementing the EQUIPPED program. We identified 10 process elements and describe lessons for each. Lessons guided the compilation of the EQUIPPED intervention package or toolkit, including the EQUIPPED logic model. CONCLUSIONS Our academic health system research collaborative addressing medication safety through sequential implementation is a learning health system that can serve as a model for other quality improvement projects with multiple sites. The network produced an implementation package that can be vetted, piloted, evaluated, and finalized for large-scale dissemination in community-based settings.