Abstract Background/Objectives The number of older adults with complex health needs is growing, and this population experiences disproportionate morbidity and mortality. Interventions led by community health workers (CHWs) can improve clinical outcomes in the general adult population with multimorbidity, but few studies have investigated CHW‐delivered interventions in older adults. Design We systematically reviewed the impact of CHW interventions on health outcomes among older adults with complex health needs. We searched for English‐language articles from database inception through April 2020 using seven databases. PROSPERO protocol registration CRD42019118761. Setting Any U.S. or international setting, including clinical and community‐based settings. Participants Adults aged 60 years or older with complex health needs, defined in this review as multimorbidity, frailty, disability, or high‐utilization. Interventions Interventions led by a CHW or similar role consistent with the American Public Health Association's definition of CHWs. Measurements Pre‐defined health outcomes (chronic disease measures, general health measures, treatment adherence, quality of life, or functional measures) as well as qualitative findings. Results Of 5671 unique records, nine studies met eligibility criteria, including four randomized controlled trials, three quasi‐experimental studies, and two qualitative studies. Target population and intervention characteristics were variable, and studies were generally of low‐to‐moderate methodological quality. Outcomes included mood, functional status and disability, social support, well‐being and quality of life, medication knowledge, and certain health conditions (e.g., falls, cognition). Results were mixed with several studies demonstrating significant effects on mood and function, including one high‐quality RCT, while others noted no significant intervention effects on outcomes. Conclusion CHW‐led interventions may have benefit for older adults with complex health needs, but additional high‐quality studies are needed to definitively determine the effectiveness of CHW interventions in this population. Integration of CHWs into geriatric clinical settings may be a strategy to deliver evidence‐based interventions and improve clinical outcomes in complex older adults.
Abstract Background The Department of Veterans Affairs (VA) healthcare system routinely screens Veterans for food insecurity, housing instability, and intimate partner violence, but does not systematically screen for other health-related social needs (HRSNs). Objectives To (1) develop a process for systematically identifying and addressing Veterans’ HRSNs, (2) determine reported prevalence of HRSNs, and (3) assess the acceptability of HRSN screening among Veterans. Design “Assessing Circumstances and Offering Resources for Needs” (ACORN) is a Veteran-tailored HRSN screening and referral quality improvement initiative. Veterans were screened via electronic tablet for nine HRSNs (food, housing, utilities, transportation, legal needs, social isolation, interpersonal violence, employment, and education) and provided geographically tailored resource guides for identified needs. Two-week follow-up interviews with a purposive sample of Veterans explored screening experiences. Participants Convenience sample of Veterans presenting for primary care at a VA urban women’s health clinic and suburban community-based outpatient clinic (October 2019–May 2020). Main Measures Primary outcomes included prevalence of HRSNs, Veteran-reported acceptability of screening, and use of resources guides. Data were analyzed using descriptive statistics, chi-square tests, and rapid qualitative analysis. Key Results Of 268 Veterans screened, 50% reported one or more HRSNs. Social isolation was endorsed most frequently (29%), followed by educational needs (19%), interpersonal violence (12%), housing instability (9%), and utility concerns (7%). One in five Veterans reported at least one form of material hardship. In follow-up interviews ( n = 15), Veterans found screening acceptable and felt VA should continue screening. No Veterans interviewed had contacted recommended resources at two-week follow-up, although several planned to use resource guides in the future. Conclusion In a VA HRSN screening and referral program, Veterans frequently reported HRSNs, felt screening was important, and thought VA should continue to screen for these needs. Screening for HRSNs is a critical step towards connecting patients with services, identifying gaps in service delivery, and informing future resource allocation.
GRECC Connect, a national program with interprofessional teams at urban-based VA medical facilities, partner with VA community-based outpatient clinics (CBOCs) to provide geriatric specialty care via telemedicine to rural, older Veterans. Our QI project explored factors affecting program uptake. February-May 2020 we conducted 50 interviews with CBOC staff across the US; 60–80% of patients were rural/highly rural older Veterans. CBOC staff described social determinants of health negatively impacting telemedicine access. Patients on the edge of the digital divide were at risk of diminished access due to changes in physical, cognitive or emotional health and/or socio-economic status. CBOC staff also described highly rural Veterans caught in the digital divide, without access to reliable internet, devices or computer knowledge/skills; included in this subgroup were Veterans staff described as 'off the grid' due to histories of trauma resulting in mental/physical health challenges, distrust of institutions and technology, and desire for geographic/social isolation. This work differentiated rural, older Veterans GRECC Connect served through telemedicine, from those CBOC partners struggled to reach, even by phone. This digital divide may grow given the aging population. Unique contextual factors influencing telemedicine use among older adult populations are important to elucidate to inform structural supports for enhanced access.
Food insecurity during pregnancy has important implications for maternal and newborn health. There is increasing commitment to screening for social needs within health care settings. However, little is known about current screening processes or the capacity for prenatal care clinics to address food insecurity among their patients. We aimed to assess barriers and facilitators prenatal care clinics face in addressing food insecurity among pregnant people and to identify opportunities to improve food security among this population.We conducted a qualitative study among prenatal care clinics in New Hampshire and Vermont. Staff and clinicians engaged in food security screening and intervention processes at clinics affiliated with the Northern New England Perinatal Quality Improvement Network (NNEPQIN) were recruited to participate in key informant interviews. Thematic analysis was used to identify prominent themes in the interview data.Nine staff members or clinicians were enrolled and participated in key informant interviews. Key barriers to food security screening and interventions included lack of protocols and dedicated staff at the clinic as well as community factors such as availability of food distribution services and transportation. Facilitators of screening and intervention included a supportive culture at the clinic, trusting relationships between patients and clinicians, and availability of clinic-based and community resources.Prenatal care settings present an important opportunity to identify and address food insecurity among pregnant people, yet most practices lack specific protocols for screening. Our findings indicate that more systematic processes for screening and referrals, dedicated staff, and onsite food programs that address transportation and other access barriers could improve the capacity of prenatal care clinics to improve food security during pregnancy.
Abstract Background Older rural Veterans often have less access to specialty care services, including geriatrics. The Veterans Health Administration’s (VHA) GRECC Connect is a national program that provides virtual geriatric services for patients and geriatric education for rural clinicians through a case conference series focused on the 5Ms (Mind, Mobility, Medications, Multicomplexity, and Matters Most), a hallmark of high-quality geriatric care. We aimed to measure rural frontline clinicians’ confidence in managing common geriatric problems to inform future education efforts. Methods We conducted an electronic survey-based needs assessment during three case conferences in Spring, 2024. The survey included a brief demographic section and 16 questions on respondents’ confidence addressing clinical issues within the 5Ms (e.g., polypharmacy, falls prevention, goals of care). Results Forty nine percent (211/430) of conference participants completed the survey, including social workers, pharmacists, nurses, and physicians. On average, 69% of respondents reported being ‘confident’ or ‘very confident’ (range 53%-84%) across the 16 questions. Highest confidence levels were in the ‘Matters Most’ domain. Topics rated lower included managing depression, deprescribing, and managing behaviors in patients with dementia. Confidence varied according to health professions and the responsibilities associated with each role. Providers who serve a higher percentage of rural Veterans reported feeling more confident than their urban colleagues across all questions. Conclusion The high level of confidence aligns with findings in the literature that report high self-efficacy ratings in the 5Ms domains among other VA providers and may be related to the VHA’s focus on Age Friendly Health Systems.
Abstract Scalable, transdiagnostic interventions are needed to meet the needs of a growing population of older adults experiencing multimorbidity and functional decline. Behavioral activation (BA) is a pragmatic, empirically supported treatment for depression that focuses on increasing engagement in values-aligned activities. We propose BA is an ideal transdiagnostic intervention approach for older adults because it (a) specifically targets activity restriction, a shared characteristic of common conditions of aging; and (b) has strong potential for scalability through delivery by a broad range of clinician and nonclinician interventionists and via telehealth. We describe the history of BA and review recent literature demonstrating impacts beyond depression including on cognition, social isolation, and disability. We also describe the feasibility of delivering BA across interventionists, settings, and modalities. Our approach advances scholarship by proposing BA as a scalable, transdiagnostic behavioral intervention to address functional decline in older adults with common geriatric conditions.
Primary care practices can address food insecurity (FI) through routine screening, practice-based food programmes, and referrals to community resources. The COVID-19 pandemic had disproportionate impacts on health outcomes for food-insecure households.
Food insecurity (FI) is associated with adverse health outcomes across the lifespan. Primary care and prenatal practices can identify and address FI among patients through screening and interventions. It is unclear how practices and communities responded to FI during the COVID-19 pandemic, and how the pandemic may have impacted practices' FI strategies. We aimed to understand how practices providing primary care or prenatal care in northern New England experienced changes in FI during the COVID-19 pandemic.We conducted a web-based survey of clinicians and staff from 43 unique practices providing primary care or prenatal care in northern New England.Most practices (59.5%) reported at least 1 new food program in the practice or community since the pandemic began. Practices reporting new practice- or community-based food programs were more likely to be rural, federally qualified health centers, and have greater confidence in practice and community capacity to address FI (chi-square tests, P < .05).Results suggest that practices and surrounding communities in northern New England responded to FI during the pandemic by increasing food support programs. Future work is needed to examine the impact of food programs initiated during the pandemic and determine optimal strategies for practices to address FI among patients.
Abstract Background Half of the 4.7 M veterans who reside in rural communities and rely on U.S. Department of Veterans Affairs (VA) health care are older (≥65). Their rurality presents unique challenges, including a shortage of clinicians skilled in geriatric medicine. Community‐based outpatient clinics (CBOCs) help extend VA's geographic reach but are typically located in under‐resourced settings. Telemedicine may increase access to care, but little is known about CBOCs' capacity to leverage telemedicine to meet older patients' needs. We identified organizational barriers and facilitators to the use of geriatric telemedicine specialty care from the perspective of rural clinicians and staff. Methods From February–April 2020, we interviewed CBOC clinicians and staff ( N = 50) from 13 rural CBOCs affiliated with four VA Geriatric Research Education and Clinical Centers. Semi‐structured interviews addressed patient population characteristics; CBOC location, staffing, and in‐house resources; use of VA specialty care services; and telemedicine use. We developed a codebook using an iterative process and Gale's Framework Method thematically organize and analyze data. Results Respondents perceived that their CBOCs serve a predominantly older patient population. Four characteristics enabled CBOCs to offer geriatric telemedicine specialty care: partnerships with larger VA Medical Center teams; social worker/telehealth clinical technician knowledge of geriatrics and telehealth resources; periodic outreach/education from geriatric specialists; and routine use of other telehealth services. Barriers included: constraints on clinic space and unstable internet for telemedicine visits; staffing challenges leading to limited familiarity with telemedicine resources; and clinician and staff perceptions of older veterans' preference for in‐person visits. Conclusions Telemedicine is an important modality to enhance access to care for an increasingly older and medically complex patient population. Although rural CBOCs provide a large portion of care to VA's growing geriatric population, staff are insufficiently trained in geriatrics, work in resource‐poor settings, and are largely unaware of VA telemedicine programs designed to support them.
To assess the association between depression symptoms and physical functioning and participation in daily life over 2 years in older adults at risk of mobility decline.
