Assessing Care Of Vulnerable Elders Research Articles

Assessing equity and quality indicators for older people – Adaptation and validation of the Assessing Care of Vulnerable Elders (ACOVE) checklist for the Portuguese care context

BackgroundDevelopment has promoted longer and healthier lives, but the rise in the proportion of older adults poses new challenges to health systems. Susceptibilities of older persons resulting from lower knowledge about services availability, health illiteracy, lower income, higher mental decline, or physical limitations need to be identified and monitored to assure the equity and quality of health care. The aim of this study was to develop equity indicators for the Assessing Care of Vulnerable Elders (ACOVE)-3 checklist and perform the first cross-cultural adaptation and validation of this checklist into Portuguese.MethodsA scoping literature review of determinants or indicators of health (in)equity in the care of older people was performed. A total of 5 language experts and 18 health professionals were involved in the development and validation of the equity and quality indicators through expert opinion and focus groups. Data collected from focus groups was analyzed through directed or conventional content analysis. The usefulness of the indicators was assessed by analyzing the clinical records of 30 patients.ResultsThe literature review revealed that there was a worldwide gap concerning equity indicators for older people primary health care. A structured and complete checklist composed of equity and quality indicators was obtained, validated and assessed. A significant number of non-screened quality or equity related potential occurrences that could have been avoided if the proposed indicators were implemented were detected. The percentage of non-registered indicators was 76.6% for quality and 96.7% for equity.ConclusionsApplying the proposed checklist will contribute to improve the monitoring of the clinical situation of vulnerable older people and the planning of medical and social actions directed at this group.

UCLA Partners with GAPNA To Improve Alzheimer’s and Dementia Care

UCLA Partners with GAPNA To Improve Alzheimer’s and Dementia Care

Quality Measures in Surgical Palliative Care: Adapting Existing Palliative Care Measures to Improve Care for Seriously Ill Surgical Patients.

Quality Measures in Surgical Palliative Care: Adapting Existing Palliative Care Measures to Improve Care for Seriously Ill Surgical Patients.

Documentation of Code Status for Elderly Patients Admitted to a Hospital

Introduction: Determining resuscitation preferences (code status) for hospitalized older adults has been identified as an indicator of quality of care by the Assessing Care of Vulnerable Elders (ACOVE) Project. Objectives: The primary objective of this study is to determine the rate of Advance Care Directives (code status) documentation among older patients hospitalized on the medical and cardiology units of the Hamilton General Hospital between July 1st 2009 to the end of June 2010. The secondary objective is to determine factors associated with the documentation rate of Code Status in the study group. Methods: This was a retrospective cross-sectional study (chart review) conducted at the Inpatient Medical and Cardiology Units of Hamilton General Hospital, among all patients aged of 65 years or older admitted between July 1st 2009 and June 30 2010, and with complete charts. Data of 100 patients randomly chosen through computer program were collected and analyzed. Results: This study shows that 39% of the sample only had there code status documented, the strongest indicator of being documented were heart failure, dementia, admit time (during regular hours) and admit location (ICU/CCU). Conclusion: Documentation of code status was low although is known to be one of the quality indicators in care of the elderly. It needs to be discussed and addressed more with residents and clinical clerks, study shows that some factors may increase or decrease the documentations.

Implementing ACOVE Quality Indicators as an Intervention Checklist to Improve Care for Hospitalized Older Adults.

Medicare patients account for approximately 50% of hospital days. Hospitalization in older adults often results in poor outcomes. To test the feasibility and impact of using Assessing Care of Vulnerable Elders (ACOVE) quality indicators (QIs) as a therapeutic intervention to improve care of hospitalized older adults. >Post-test only prospective intervention with a nonequivalent retrospective control group. Large tertiary hospital in the greater New York Metropolitan area. Hospitalized patients, 75 years and over, admitted to medical units. A checklist, comprised of four ACOVE QIs, administered during daily interdisciplinary rounds: venous thrombosis prophylaxis (VTE) (QI 1), indwelling bladder catheters (QI 2), mobilization (QI 3), and delirium evaluation (QI 4). Variables were extracted from electronic medical records with QI compliance as primary outcome, and length of stay (LOS), discharge disposition, and readmissions as secondary outcomes. Generalized linear mixed models for binary clustered data were used to estimate compliance rates for each group (intervention group or control group) in the postintervention period, along with their corresponding 95% confidence intervals. Of the 2,396 patients, 530 were on an intervention unit. In those patients not already compliant with VTE, compliance rate was 57% in intervention vs 39% in control (𝑃 < .0056). For indwelling catheters, mobilization, and delirium evaluation, overall compliance was significantly higher in the intervention group 72.2% vs 54.4% (𝑃 = .1061), 62.9% vs 48.2% (𝑃 < .0001), and 27.9% vs 21.7% (𝑃 = .0027), respectively. The study demonstrates the feasibility and effectiveness of integrating ACOVE QIs to improve the quality of care in hospitalized older adults.

Feasibility of automatic evaluation of clinical rules in general practice

PurposeTo assess the extent to which clinical rules (CRs) can be implemented for automatic evaluation of quality of care in general practice. MethodsWe assessed 81 clinical rules (CRs) adapted from a subset of Assessing Care of Vulnerable Elders (ACOVE) clinical rules, against Dutch College of General Practitioners (NHG) data model. Each CR was analyzed using the Logical Elements Rule Method(LERM). LERM is a stepwise method of assessing and formalizing clinical rules for decision support. Clinical rules that satisfied the criteria outlined in the LERM method were judged to be implementable in automatic evaluation in general practice. ResultsThirty-three out of 81 (40.7%) Dutch-translated ACOVE clinical rules can be automatically evaluated in electronic medical record systems. Seven out of 7 CRs (100%) in the domain of diabetes can be automatically evaluated, 9/17 (52.9%) in medication use, 5/10 (50%) in depression care, 3/6 (50%) in nutrition care, 6/13 (46.1%) in dementia care, 1/6 (16.6%) in end of life care, 2/13 (15.3%) in continuity of care, and 0/9 (0%) in the fall-related care. Lack of documentation of care activities between primary and secondary health facilities and ambiguous formulation of clinical rules were the main reasons for the inability to automate the clinical rules. ConclusionApproximately two-fifths of the primary care Dutch ACOVE-based clinical rules can be automatically evaluated. Clear definition of clinical rules, improved GP database design and electronic linkage of primary and secondary healthcare facilities can improve prospects of automatic assessment of quality of care. These findings are relevant especially because the Netherlands has very high automation of primary care.

Commentaries on health services research

Commentaries on health services research

Effect of Physician Delegation to Other Healthcare Providers on the Quality of Care for Geriatric Conditions.

The quality of care of older adults in the United States has been consistently shown to be inadequate. This gap between recommended and actual care provides an opportunity to improve the value of health care for older adults. Prior work from the Assessing Care of Vulnerable Elders (ACOVE) investigators first defined, and then sought to improve, clinical practice for common geriatric conditions. A critical component of the ACOVE intervention for practice improvement was an emphasis on the delegation of specific care processes, but the independent effect of delegation on the quality of care has not been evaluated. This study analyzed the pooled results of prior ACOVE projects from 1998 to 2010. Totaled, these studies included 4,776 individuals aged 65 and older of mixed demographic backgrounds and 16,204 ACOVE quality indicators (QIs) for three geriatric conditions: falls, urinary incontinence, and dementia. In unadjusted analyses, QI pass probabilities were 0.36 for physician-performed tasks, 0.55 for nurse practitioner (NP)-, physician assistant (PA)-, and registered nurse (RN)-performed tasks; and 0.61 for medical assistant- and licensed vocational nurse-performed tasks. In multiply adjusted models, the independent pass-probability effect of delegation to NPs, PAs, and RNs was 1.37 (P = .05). These findings suggest that delegation of selected tasks to nonphysician healthcare providers is associated with higher quality of care for these geriatric conditions in community practices and supports the value of interdisciplinary team management for common outpatient conditions in older adults.

Assessment of the quality of fall detection and management in primary care in the Netherlands based on the ACOVE quality indicators.

SummaryWe determined adherence to nine fall-related ACOVE quality indicators to investigate the quality of management of falls in the elderly population by general practitioners in the Netherlands. Our findings demonstrate overall low adherence to these indicators, possibly indicating insufficiency in the quality of fall management. Most indicators showed a positive association between increased risk for functional decline and adherence, four of which with statistical significance.IntroductionThis study aims to investigate the quality of detection and management of falls in the elderly population by general practitioners in the Netherlands, using the Assessing Care of Vulnerable Elders (ACOVE) quality indicators.MethodsCommunity-dwelling persons aged 70 years or above, registered in participating general practices, were asked to fill in a questionnaire designed to determine general practitioner (GP) adherence to fall-related indicators. We used logistic regression to estimate the association between increased risk for functional decline—quantified by the Identification of Seniors At Risk for Primary Care score—and adherence. We then cross-validated the self-reported falls with medical records.ResultsOf the 950 elders responding to our questionnaire, only 10.6 % reported that their GP proactively asked them about falls. Of the 160 patients who reported two or more falls, or one fall for which they visited the GP, only 23.1 % had fall documentation in their records. Adherence ranged between 13.6 and 48.6 %. There was a significant positive association between the ISAR-PC scores and adherence in four QIs. Documentation of falls was highest (36.7 %) in patients whom the GP had proactively asked about falls.ConclusionBased on patient self-reports, adherence to the ACOVE fall-related indicators was poor, suggesting that the quality of evaluation and management of falls in community-dwelling older persons in the Netherlands is poor. The documentation of falls and fall-related risk factors was also poor. However, for most QIs, adherence to them increased with the increase in the risk of functional decline.

Longitudinal prevalence of potentially inappropriate medicines and potential prescribing omissions in a cohort of community-dwelling older people.

PurposeThis study aims to compare the prevalence of potentially inappropriate medicines (PIMs) and potential prescribing omissions (PPOs) using several screening tools in an Irish community-dwelling older cohort, to assess if the prevalence changes over time and to determine factors associated with any change.MethodsThis is a prospective cohort study of participants aged ≥65 years in The Irish Longitudinal Study on Ageing (TILDA) with linked pharmacy claims data (n = 2051). PIM and PPO prevalence was measured in the year preceding participants’ TILDA baseline interviews and in the year preceding their follow-up interviews using the Screening Tool for Older Persons’ Prescriptions (STOPP), Beers criteria (2012), Assessing Care of Vulnerable Elders (ACOVE) indicators and the Screening Tool to Alert doctors to Right Treatment (START). Generalised estimating equations were used to determine factors associated with change in prevalence over time.ResultsDepending on the screening tool used, between 19.8 % (ACOVE indicators) and 52.7 % (STOPP) of participants received a PIM at baseline, and PPO prevalence ranged from 38.2 % (START) to 44.8 % (ACOVE indicators), while 36.7 % of participants had both a PIM and PPO. Common criteria were aspirin for primary prevention (19.6 %) and omission of calcium/vitamin D in osteoporosis (14.7 %). Prevalence of PIMs and PPOs increased at follow-up (PIMs range 22–56.1 %, PPOs range 40.5–49.3 %), and this was associated with patient age, female sex, and numbers of medicines and chronic conditions.ConclusionsSub-optimal prescribing is common in older patients. Ongoing prescribing review to optimise care is important, particularly as patients get older, receive more medicines or develop more illnesses.Electronic supplementary materialThe online version of this article (doi:10.1007/s00228-015-1815-1) contains supplementary material, which is available to authorized users.

Abbreviated Care‐Process Quality Indicator Sets Linked with Survival and Functional Status Benefit in Older Adults Under Ambulatory Care

To identify subsets of ambulatory care (outpatient only) quality indicators (QIs) associated with better survival and physical function outcomes. Observational cohort study. Pooled data from the Assessing Care of Vulnerable Elders (ACOVE)-1 study, which measured quality of care using 140 care-process QIs, and the subsequent ACOVE-2 study, which reduced the QIs to 69 ambulatory care QIs. Older adults receiving ambulatory care (N=1,015). To prioritize and reduce the QIs into subsets, an expert panel rated each of 69 ambulatory care QIs for the strength of the link between process and benefit, defined as direct trial evidence on older adults or high expectation of benefit if a trial were conducted in older adults. This resulted in three reduced QI sets, reflecting their intended benefit: 17 QIs for survival (ACOVE Quality for Survival (AQS)-17), five QIs to preserve function (AQF-5), and 16 QIs to improve quality-of-life related to physical health and symptoms (AQQ-16). Whether AQS-17 would predict 3-year survival was first tested in 1,015 pooled ACOVE-1 and ACOVE-2 participants. Second, whether AQF-5 (n=74) and AQQ-16 (n=359) would predict change in the Physical Component Summary (PCS) score of the Medical Outcomes Study 12-item Short-Form Survey at 1 year was tested in the ACOVE-2 cohort. Control variables were age, function-based vulnerability, and comorbidity. Each 20-percentage-point increment in AQS-17 was associated with survival (hazard ratio (HR)=0.83, P=.01) up to 500 days but not thereafter. AQF-5, but not AQQ-16, predicted 1-year improvement in PCS score (1.13-points per 20%-point increment in AQF-5, P=.02). Subsets of care processes can be linked with outcomes important to older adults. The AQS-17 and AQF-5 are potential tools for improving ambulatory care of older adults.

From assessment to improvement of elderly care in general practice using decision support to increase adherence to ACOVE quality indicators: study protocol for randomized control trial

BackgroundPrevious efforts such as Assessing Care of Vulnerable Elders (ACOVE) provide quality indicators for assessing the care of elderly patients, but thus far little has been done to leverage this knowledge to improve care for these patients. We describe a clinical decision support system to improve general practitioner (GP) adherence to ACOVE quality indicators and a protocol for investigating impact on GPs’ adherence to the rules.DesignWe propose two randomized controlled trials among a group of Dutch GP teams on adherence to ACOVE quality indicators. In both trials a clinical decision support system provides un-intrusive feedback appearing as a color-coded, dynamically updated, list of items needing attention. The first trial pertains to real-time automatically verifiable rules. The second trial concerns non-automatically verifiable rules (adherence cannot be established by the clinical decision support system itself, but the GPs report whether they will adhere to the rules). In both trials we will randomize teams of GPs caring for the same patients into two groups, A and B. For the automatically verifiable rules, group A GPs receive support only for a specific inter-related subset of rules, and group B GPs receive support only for the remainder of the rules. For non-automatically verifiable rules, group A GPs receive feedback framed as actions with positive consequences, and group B GPs receive feedback framed as inaction with negative consequences. GPs indicate whether they adhere to non-automatically verifiable rules. In both trials, the main outcome measure is mean adherence, automatically derived or self-reported, to the rules.DiscussionWe relied on active end-user involvement in selecting the rules to support, and on a model for providing feedback displayed as color-coded real-time messages concerning the patient visiting the GP at that time, without interrupting the GP’s workflow with pop-ups. While these aspects are believed to increase clinical decision support system acceptance and its impact on adherence to the selected clinical rules, systems with these properties have not yet been evaluated.Trial registrationControlled Trials NTR3566

Quality Improvement in Neurology: Dementia Management Quality Measures

Professional and advocacy organizations have long urged that dementia should be recognized and properly diagnosed. With the passage of the National Alzheimer's Project Act in 2011, an Advisory Council for Alzheimer's Research, Care, and Services was convened to advise the Department of Health and Human Services. In May 2012, the Council produced the first National Plan to address Alzheimer's disease, and prominent in its recommendations is a call for quality measures suitable for evaluating and tracking dementia care in clinical settings. Although other efforts have been made to set dementia care quality standards, such as those pioneered by RAND in its series Assessing Care of Vulnerable Elders (ACOVE), practitioners, healthcare systems, and insurers have not widely embraced implementation. This executive summary (full manuscript available at www.neurology.org) reports on a new measurement set for dementia management developed by an interdisciplinary Dementia Measures Work Group (DWG) representing the major national organizations and advocacy organizations concerned with the care of individuals with dementia. The American Academy of Neurology (AAN), the American Geriatrics Society, the American Medical Directors Association, the American Psychiatric Association, and the American Medical Association-convened Physician Consortium for Performance Improvement led this effort. The ACOVE measures and the measurement set described here apply to individuals whose dementia has already been identified and properly diagnosed. Although similar in concept to ACOVE, the DWG measurement set differs in several important ways; it includes all stages of dementia in a single measure set, calls for the use of functional staging in planning care, prompts the use of validated instruments in patient and caregiver assessment and intervention, highlights the relevance of using palliative care concepts to guide care before the advanced stages of illness, and provides evidence-based support for its recommendations and guidance on the selection of instruments useful in tracking patient-centered outcomes. It also specifies annual reassessment and updating of interventions and care plans for dementia-related problems that affect families and other caregivers as well as individuals with dementia. Here, a brief synopsis of why major reforms in healthcare design and delivery are needed to achieve substantive improvements in the quality of care is first provided, and then the final measures approved for publication, dissemination, and implementation are listed.

An inter-rater reliability study of the prescribing indicated medications quality indicators of the Assessing Care Of Vulnerable Elders (ACOVE) 3 criteria as a potentially inappropriate prescribing tool

PurposeThere are limited tools to assess potential prescribing omissions (PPOs) or underprescribing in the elderly. The ACOVE project defines comprehensive quality care indicators for older people and some of these indicators focused on appropriate use of medicines. The aim of the present study was to assess the inter-rater reliability between observers using the ACOVE 3 prescribing indicated medications indicators and compare it with the inter-rater reliability obtained for the Screening Tool of Older Person's Prescriptions (STOPP)/Screening Tool to Alert Doctors to Right Treatment (START) criteria. MethodsIn the context of an observational and multicentric study of a cohort of 672 patients 75 years and older who were hospitalized in Internal Medicine services of seven Spanish hospitals, an inter-rater reliability study using the ACOVE selected indicators and the STOPP/START criteria was carried out between April 2011 and March 2012. Three patients were randomly selected in each participating hospital, one for each four months of study. ResultsA total of 21 patients (mean (SD) age of 84.3 (5.6) years, 57.1% female) were included in the inter-rater reliability study. For the STOPP, START and ACOVE criteria, the median kappa coefficient for the seven hospital analyses was 0.97, 0.92 and 0.95, respectively. Out of 123 total indicators in only 7 (5.7%) was the kappa coefficient value below 0.75. Only for 2 (5.6%) of the 37 studies selected ACOVE quality indicators was the kappa coefficient value less than 0.75. ConclusionsA high inter-rater reliability was obtained for the selected underprescribing quality indicators of ACOVE 3. These quality indicators may be considered a useful tool in detecting underprescribing to the elderly patients.

Effect of Nurse Practitioner Comanagement on the Care of Geriatric Conditions

To determine whether community-based primary care physician (PCP)-nurse practitioner (NP) comanagement implementing the Assessing Care of Vulnerable Elders (ACOVE)-2 model: (case finding, delegation of data collection, structured visit notes, physician and patient education, and linkage to community resources) can improve the quality of care for geriatric conditions. Case study. Two community-based primary care practices. Patients aged 75 and older who screened positive for at least one condition: falls, urinary incontinence (UI), dementia, and depression. The ACOVE-2 model augmented by NP comanagement of conditions. Quality of care according to medical record review using ACOVE-3 quality indicators (QIs). Individuals receiving comanagement were compared with those who received PCP care alone in the same practices. Of 1,084 screened individuals, 658 (61%) screened positive for more than one condition; 485 of these were randomly selected for chart review and triggered a mean of seven QIs. A NP saw 49% for comanagement. Overall, individuals received 57% of recommended care. Quality scores for all conditions (falls, 80% vs 34%; UI, 66% vs 19%; dementia, 59% vs 38%) except depression (63% vs 60%) were higher for individuals who saw a NP. In analyses adjusted for sex and age of patient, number of conditions, site, and a NP estimate of medical management style, NP comanagement remained significantly associated with receiving recommended care (P < .001), as did NP estimate of medical management style (P = .02). NP comanagement is associated with better quality of care for geriatric conditions in community-based primary care than usual care using the ACOVE-2 model.

Studies pertaining to the ACOVE quality criteria: a systematic review

To identify and uniformly describe studies employing the Assessing Care Of Vulnerable Elders (ACOVE) quality indicators within a comprehensive thematic model that reflects how the indicators were used. A systematic search of MEDLINE, EMBASE and CINAHL was conducted. English-language studies meeting our criteria published prior to January 2010. Data extraction Included studies were analyzed and described by two independent researchers. A total of 41 articles met our selection criteria. Studies were classified into the themes 'Application of indicators' (32 studies) and ' and development of indicators' (13 studies). 'Application' studies included assessing quality of care, influencing behavior of health professionals and examining the association of quality of care with other factors. 'Analysis and development' included studies developing new indicator sets, and those adapting and validating the original quality indicators to new settings. The indicators were used in a wide range of applications with two main foci: the assessment of quality of care for elderly patients, and investigating the feasibility of similar indicators and their adaptation to new settings. Very few of the studies published to date have addressed the goal of care improvement. We foresee an important role for application of indicators that proactively help health-care professionals to deliver the right care at the right time, for example by resorting to decision support systems.

Association of Claims-based Quality of Care Measures With Outcomes Among Community-dwelling Vulnerable Elders

Few studies examine the link between measured process of care and outcome. To evaluate the relationship of claims-based assessment of process of care to subsequent function and survival. Retrospective cohort study using claims from 1999 to assess performance on 41 quality indicators (QIs) from the Assessing Care of Vulnerable Elders (ACOVE) measurement set on functional decline and death in 2000. Community-dwelling individuals. All persons ≥75 years enrolled in Medicare and Medicaid in 19 California counties in 1998 and 1999 who received In Home Supportive Services. Quality of care index, activities of daily living, and instrumental activities of daily living (IADL) need indices, mortality. Total 21,310 persons were eligible for a mean of 7.1 QIs; and received 46% of recommended care. The ADL index increased from 8.1 to 11.6 between baseline and follow-up. The IADL index increased from 13.6 to 14.1. Fifteen percent of the cohort died in 2000. After accounting for number of QIs triggered, baseline function and other covariates, better quality was associated with better function at follow-up. Ten percent better quality was associated at follow-up with 0.21 lower ADL need score [95% confidence interval (CI), 0.25-0.17], 0.022 lower IADL need score (95% CI, 0.032-0.013), and lower odds of death (0.91; 95% CI, 0.89 to 0.93). Routinely collected data implementing ACOVE measures for community vulnerable elders generate quality scores that are directly related to patient functional and survival outcomes. These findings suggest that population-based assessment of care is feasible for vulnerable older persons.

Quality Indicators for In-Hospital Pharmaceutical Care of Dutch Elderly Patients

In 2001, the ACOVE (Assessing Care Of Vulnerable Elders) quality indicators (QIs) were developed in the US to measure the quality of care of vulnerable elderly patients. However, the ACOVE QI set was developed mainly to assess the overall quality of care of community-dwelling vulnerable elders (as opposed to hospitalized elderly). Therefore, they need to be adapted when used in a non-US hospital setting. In addition, the ACOVE QIs depend on patient and caretaker interviews to assess the quality of care. The aim of this study was to develop and validate a set of explicitly phrased QIs to measure (without the need for interviews) the quality of pharmaceutical care of elderly hospitalized patients in the Netherlands. The QI set was developed based on the ACOVE QIs, Dutch national guidelines, evidence from the literature and expert opinion. The QI set focused on in-hospital pharmaceutical care and was evaluated in terms of whether the QIs were able to assess the quality of care using medical records and a hospital information system. In three review rounds, the QI set was adapted and judged on face and content validity. The feasibility of implementation of the QI set and inter-rater reliability were determined. The study was conducted between September 2007 and August 2008 in a tertiary 1002-bed university hospital. RESEARCH TEAM: Two pharmacists were responsible for the selection and adaptation of QIs. An internist-geriatrician, a physician with experience in quality assurance and internal medicine and a senior hospital pharmacist formed the expert panel responsible for reviewing the QIs. Fleiss' κ values and the intraclass correlation coefficient were calculated for inter-rater reliability. An 87-item QI set was accepted by the expert panel. Of this set, 49 QIs were based on ACOVE QIs and 38 QIs were newly added. The QI set demonstrated excellent inter-rater reliability and good feasibility. We developed a valid and reliable set of QIs to efficiently assess the quality of the in-hospital pharmaceutical care provided to elderly Dutch patients.

The After Discharge Care Management of Low Income Frail Elderly (AD-LIFE) Randomized Trial: Theoretical Framework and Study Design

Interdisciplinary care management is advocated for optimal care of patients with many types of chronic illnesses; however, few models exist that have been tested using randomized trials. The purpose of this report is to describe the theoretical basis for the After Discharge Management of Low Income Frail Elderly (AD-LIFE) trial, which is an ongoing 2-group randomized trial (total n = 530) to test a chronic illness management and transitional care intervention. The intervention is based on Wagner's chronic illness care model and involves comprehensive posthospitalization nurse-led interdisciplinary care management for low income frail elders with chronic illnesses, employs evidence-based protocols that were developed using the Assessing Care of Vulnerable Elders (ACOVE) guidelines, emphasizes patient activation, and integrates with community-based long-term care and other community agencies. The primary aim of the AD-LIFE trial is to test a chronic illness management intervention in vulnerable patients who are eligible for Medicare and Medicaid. This model, with its standardized, evidence-based medical and psychosocial intervention protocols, will be easily transportable to other sites interested in optimizing outcomes for chronically ill older adults. If the results of the AD-LIFE trial demonstrate the superiority of the intervention, then this data will be important for health care policy makers.

Invictus: Increasing Patient Choice in Advanced Illness and End-of-Life Care

Humans' knowledge of our own mortality creates a conflict with our inborn desire to live. Cultures have grappled with this conflict throughout history. In The Epic of Gilgamesh, one of the earliest known works of literature, the title character wrestles with the concept. The Greek philosopher Epicurus tried to define death in context: Death does not concern us, because as long as we exist, death is not here. And when it does come, we no longer exist. Knowledge of our own demise should provide us with the means to influence some of its circumstances, and our choice might not be futile pursuit of the unattainable. Indeed, surveys have shown that when people are asked about such preferences, a majority indicate they would prefer death in hospice, with pain relief and with the support of loved ones, to death in hospital (Last Acts 2002). However, too frequently, these preferences are not honored. In many cases of critical illness, people are given the choice of where to die too late, or not at all. Few people would aspire to end their lives in intensive care units, on various forms of life support, in pain and isolated from loved ones. We are justifiably proud of our medical technology, skills, and capabilities and of the compassion our concern bespeaks; however, do we view knowledge of our mortality as a challenge to be defeated at all costs, despite the certainty that we will lose? Is there a better path? Is the laudable Talmudic precept to preserve life absolute, or is the realization and gracious acceptance of a point of inevitability a better way? Can we transcend the emotional and physical pain by dying with the emotional and physical support of our loved ones and trusted healthcare providers? Can we reconcile the goals of preserving life and accommodating a pain-free death that is supportive to all concerned? This reconciliation will require us to identify points at which decisions and transitions are appropriate; it will also require that the healthcare system and our culture come together and recognize supportive end-of-life care as a feature of the compassionate society we wish to be. There has been a considerable amount of progress in addressing the needs of advanced illness in the last few decades. Since my 1972 graduation from medical school, I have seen the hospice movement yield a large number of valuable and effective institutions in many countries, including our own (NHPCO 2010b). We have also seen hospice use increase considerably (MedPAC 2004). Since the ACOVE (Assessing Care of Vulnerable Elders) study demonstrated the lack of end-of-life care quality (Wenger et al. 2001), deaths in hospice have increased and deaths in acute care facilities have decreased (Hogan et al. 2000). Many segments of the healthcare system have contributed to increasing hospice use, including palliative care consultation and expertise at an increasing number of hospitals; the advent of palliative medicine as a specialty; specialized case management by health plans (Meier et al. 2009); and efforts by governments and other organizations to address these issues. COMPASSIONATE CARE At Aetna, we developed the Compassionate CareSM program to provide support to members with advanced illness and to their families and to help patients access optimal care. One element of this program is enhanced hospice benefits. Aetna allows members eligible for the program to access hospice care with an advanced illness diagnosis of 12 months or fewer, as opposed to the traditional standard of six months. Members can also continue to receive coverage for curative treatment while in hospice care under certain commercial group health plans. The second and most important element of the program is its specialized case management services. Our nurse case managers are specially trained and experienced in care management of terminal illness. These empathetic and dedicated nurse case managers help * engage members, family, and caregivers and physicians to help initiate discussions on options and advanced care planning and to present alternatives; * coordinate medical care, benefits, and community-based services; * identify resources to make members as comfortable as possible, addressing pain and other symptoms; and * provide and facilitate culturally sensitive emotional and psychosocial support. …