Care Coordination Program Research Articles

The Role of Community Health Workers in Developing Multidimensional Organizational Relationships.

Effective care coordination relies on organizations working collaboratively to meet medically and socially complex participants' needs. This study examines community health workers' (CHWs') roles in developing the organizational relationships on which care coordination efforts depend. Semistructured interviews (n = 13) were conducted with CHWs, CHWs' supervisors, and executive staff at organizations participating in a Washington State care coordination program. Interviewees described how CHWs developed and furthered multidimensional relationships in service of participants between and within participating organizations, as well as external organizations. Relationship-building challenges included COVID-19, geographic context, and staffing. The study concludes with considerations for care coordination efforts to support CHWs.

Care coordination for children with medical complexity and caregiver empowerment in the process: A literature review.

Advances in health care have led to an increase in infants and children being discharged home with increasingly complex conditions. Children with medical complexity require care from many physicians and specialties to thrive in their home environment. While some care coordination programs are in place, these programs are often dependent upon the child living within the geographic area of a major healthcare system. Additionally, children with medical complexity often need specialized care from providers outside the participating healthcare system, placing the onus of care coordination on the child's family. This literature review aimed to examine care coordination programs for children with medical complexity and what tools have been created to empower the child's family in the process. Qualitative and quantitative research studies published from 2015 to 2021 found in Academic Search Complete, Cumulative Index to Nursing and Allied Health Literature, and Medline that included a review of a care coordination program for children with medical complexity were included. Nonresearch articles, articles written about adults, or written in languages other than English were excluded. The Johns Hopkins Nursing Evidence-Based Practice grading scale was used to appraise the evidence. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist was utilized to structure this review to deter the risk of bias. A qualitative synthesis was used to analyze and present the results. There are varying strategies used to facilitate care coordination of children with medical complexity. Effects of care coordination on the child are inconsistent; however, the child's caregiver considers high-quality care coordination to improve quality of life. There are limited tools available for caregivers of children with medical complexity to coordinate their child's care across healthcare systems. Generalizability is a concern due to the small sample sizes of studies and underrepresentation of non-English speaking families in the research. Risk of bias is possible due to highly engaged families willing to participate in the selected research studies. There is an opportunity to develop further and study care coordination tools to empower the caregivers of children with medical complexity.

Patient reported function and symptom burden in breast cancer patients with CNS metastases.

e18635 Background: Central nervous system (CNS) metastases are associated with decreased quality of life for patients with metastatic breast cancer (MBC). Collecting patient-reported outcome (PRO) data can identify patient needs and inform patient-focused interventions. IMPACT the Brain is a care coordination program that aims to improve access to multidisciplinary care for patients with MBC and CNS metastases. The purpose of this study is to report baseline PRO data obtained as part of this program. Methods: Patients with MBC and CNS metastases are referred for enrollment in the program. PROs and caregiver assessments are collected on a voluntary basis at baseline and every 3 months. We performed a retrospective review of the baseline PRO data to determine: (1) type and severity of cancer-related symptoms reported by patients and (2) degree of burden reported by caregivers. The PROMIS Cancer Function Brief 3D Profile measures physical function (PF), fatigue (Fat), and social participation (Soc) in patients with cancer; 50.0 is the population mean and higher scores indicate a greater degree of a trait. The MD Anderson Symptom Inventory Brain Tumor (MDASI-BT) measures severity of cancer-related symptoms including interference with daily life. A score > 4 represents moderate symptoms and > 6 severe symptoms. The mean of the interference items represents overall symptom distress. The Short Form Zarit Burden Interview (ZBI-12) evaluates caregiver burden; a score ≥ 10 suggests mild burden while > 20 suggests high burden. PRO scores were summarized using descriptive statistics. Results: Sixty patients were referred and 54 (90%) enrolled; median age was 53 years (range 31-81). 47 questionnaires were collected at baseline from 32 participants. Average PROMIS T-scores were 37.0 for PF (31.9-51.2), 59.9 for Fat (48.9-66.8), and 42.3 for Soc (32.8-57.1). Participants reported greatest difficulty with performing heavy housework and completing usual work. The mean symptom severity score reported on the MDASI-BT (n = 20) was 2.82 (SD 1.56). Fatigue was the most severe symptom (mean 5.2, SD 2.7) and 25% of patients reported moderate symptoms. The mean interference score was 3.9 (SD 2.66), with 20% of patients reporting moderate and 30% reporting severe overall symptom distress. 65% of caregivers (n = 17) had at least mild caregiver burden on the ZBI-12. Of those, almost half (45.5%) had a score consistent with high burden. Conclusions: Collecting baseline PROs was feasible and provided valuable information about the patient experience. Symptoms experienced by patients with MBC and CNS metastases, particularly fatigue, interfere with ability to carry out usual activities. The distress caused by these symptoms may not correlate with the severity reported by the patient. Given the prevalence of burden experienced by caregivers, further work is needed to explore relationships among symptom distress, symptom severity, and caregiver burden.

Care Coordination: A Valuable Adjunct To Dental Practice — Lessons Learned in a Public Health Setting

Background: Children and youth with special health care needs (CYSHCN) face numerous barriers in accessing dental care including a lack of providers who are comfortable and competent in addressing their needs. Care coordination is an effective and financially viable tool to navigate the complexities of the health care system and match patients to providers with the appropriate training and facilities to treat their specific needs. Care coordinators have been shown to improve access, reduce barriers and decrease health care costs for CYSHCN.Objectives: To present results of a care coordination pilot in two federally qualified health centers that worked with community dental care coordinators (CDCCs) as part of the Healthy Teeth Healthy Communities (HTHC) project to determine if this model is financially sustainable and potentially beneficial to connecting CYSHCN to dental care.Methods: Several case studies were examined to determine the efficacy of the care coordination model with regard to improving oral health outcomes by decreasing barriers to care for CYSHCN. Data were analyzed from two federally qualified health centers that participated in the dental care coordination pilot.Results: The results illustrate a positive correlation between care coordination and patients’ ability to establish a dental home. The data also show a decrease in the number of no-shows for the patients supported by care coordinators.Conclusions: This pilot demonstrated that care coordination improves access and continuity of care for all patient populations. Additional research and funding should be afforded to further investigate care coordination programs as a bridge to better oral health care for CYSHN.

Transcending inequities in dementia care in Black communities: Lessons from the maximizing independence at home care coordination program

We examine care partners' experience of the Maximizing Independence at Home (MIND) intervention, a multicomponent, home-based dementia care coordination program designed to provide high quality, wholistic care coordination for people and families living with dementia. The goal of the study was to understand 1. the unique dementia-related needs of Black care partners and barriers and challenges to caregiving experienced within the Black community, 2. perceived benefits of the MIND program, and 3. ways to improve the program and make it more culturally responsive to the Black community. We conducted three focus groups totaling 20 care partners of people living with dementia; who participated in the MIND intervention (2014-2019); all Black/African American and English speaking. Verbatim transcriptions were independently analyzed line-by-line by two coders using inductive approaches. Participants noted three overarching themes related to dementia care needs and challenges in the Black community: difficulty finding and accessing dementia information and relevant services and supports; familial conflict/lack of sibling and familial support; and lack of effective communication about dementia within Black Communities. Regarding MIND at home program benefits, four themes emerged: 1. perceived to help locate resources (formal and informal); 2. provided care partners an opportunity for socialization and interaction; 3. included comprehensive assessments and helpful linked information; and 4. resulted in a "much needed break for care partners." Increased diversity of the MIND program personnel, greater clarity and consistency in MIND program promotion, and better communications were themes for how the program could be improved. Care partners participating in the MIND program perceived common benefits in aspects related to care for the persons living with dementia as well as benefits to themselves, believed the program addressed important challenges and gaps in education, services, and social support, and could be enhanced in its delivery and cultural responsiveness.

Individual-Level and Neighborhood-Level Factors Associated with Longitudinal Changes in Cardiometabolic Measures in Participants of a Clinic-Based Care Coordination Program: A Secondary Data Analysis.

Background: Identifying individual and neighborhood-level factors associated with worsening cardiometabolic risks despite clinic-based care coordination may help identify candidates for supplementary team-based care. Methods: Secondary data analysis of data from a two-year nurse-led care coordination program cohort of Medicare, Medicaid, dual-eligible adults, Leveraging Information Technology to Guide High Tech, High Touch Care (LIGHT2), from ten Midwestern primary care clinics in the U.S. Outcome Measures: Hemoglobin A1C, low-density-lipoprotein (LDL) cholesterol, and blood pressure. Multivariable generalized linear regression models assessed individual and neighborhood-level factors associated with changes in outcome measures from before to after completion of the LIGHT2 program. Results: 6378 participants had pre-and post-intervention levels reported for at least one outcome measure. In adjusted models, higher pre-intervention cardiometabolic measures were associated with worsening of all cardiometabolic measures. Women had worsening LDL-cholesterol compared with men. Women with pre-intervention HbA1c > 6.8% and systolic blood pressure > 131 mm of Hg had worse post-intervention HbA1c and systolic blood pressure compared with men. Adding individual’s neighborhood-level risks did not change effect sizes significantly. Conclusions: Increased cardiometabolic risks and gender were associated with worsening cardiometabolic outcomes. Understanding unresolved gender-specific needs and preferences of patients with increased cardiometabolic risks may aid in tailoring clinic-community-linked care planning.

Applying Implementation Mapping to Expand a Care Coordination Program at a Federally Qualified Health Center.

BackgroundA large and growing percentage of medically underserved groups receive care at federally qualified health centers (FQHCs). Care coordination is an evidence-based approach to address disparities in healthcare services. A partnered FQHC established a care coordination model to improve receipt and quality of healthcare for patients most at risk for poor health outcomes. This care coordination model emphasizes identification and support of behavioral health needs (e.g., depression, anxiety) and two evidence-based behavioral health programs needs were selected for implementation within the context of this care coordination model. Implementation Mapping is a systematic process for specifying the implementation strategies and outcomes. The current case study describes the application of Implementation Mapping to inform the selection and testing of implementation strategies to improve implementation of two behavioral health programs in a Care Coordination Program at a partnered FQHC.MethodsWe applied Implementation Mapping to inform the development, selection and testing of implementation strategies to improve the implementation of two evidence-based behavioral health programs within a care coordination program at a partnered FQHC.ResultsResults are presented by Implementation Mapping task, from Task 1 through Task 5. We also describe the integration of additional implementation frameworks (The Consolidated Framework for Implementation Research, Health Equity Implementation Framework) within the Implementation Mapping process to inform determinant identification, performance and change objectives development, design and tailoring of implementation strategies and protocols, and resulting evaluation of implementation outcomes.ConclusionsThe current project is an example of real-world application of Implementation Mapping methodology to improve care outcomes for a high priority population that is generalizable to other settings utilizing similar care models and health equity endeavors. Such case studies are critical to advance our understanding and application of innovative implementation science methods such as Implementation Mapping.

Improving patient well-being in the United States through care coordination interventions informed by social determinants of health.

Health and well-being are promoted when primary care teams partner with patients and provide care coordination to mitigate risks and promote optimal health. Identification of patients for care coordination is typically based on claim-driven risk assessments. Evidence shows that social determinants of health (SDOH) drive risk for adverse health outcomes but are omitted from existing risk tools. Missed opportunities for care coordination contribute to increased healthcare costs, poorer health outcomes and reduced patient well-being. To address the gap of risk-informed care coordination that includes SDOH, the aim of this project was to implement process improvement of a system's care coordination program through refined patient selection and customised engagement in intensive care coordination. A non-randomised care coordination quality improvement project was conducted at a community health centre in 2020. Inclusion criteria (i.e. presence of risk attribution score, SDOH questionnaire completed) resulted in 540 patients being offered care coordination services; Patients having at least one month of care coordination were included in the analysis (N=216). Analysis included the 216 patients that chose participation and the 324 patients that maintained usual care. Descriptive statistics were generated to distinguish patient demographics, frequency of care coordination contact, and specific SDOH insecurities for both the study and comparison groups. Paired t-tests were incorporated to evaluate statistical significance of the intervention group. Impact on well-being, SDOH barriers, appointment adherence and health outcomes were assessed in both conditions. Intervention condition patients reported improvement in well-being [feeling anxious (t=4.051; p<0.000)] and reduced SDOH barriers [food access (t=4.662; p<0.000); housing (t=2.203; p=0.008)] that were significantly different from the usual care condition in the expected directions. Care coordination based on factors including SDOH risks shows promise in improving patient well-being. Future research should refine this approach for comprehensive risk assessment to intervene and support patient health and well-being.

Use of Telephone- and Internet-Based Support to Elicit and Address Financial Abuse and Mismanagement in Dementia: Experiences from the Care Ecosystem Study.

Financial mismanagement and abuse in dementia have serious consequences for patients and their families. Vulnerability to these outcomes reflects both patient and contextual factors. Our study aimed to assess how multidisciplinary care coordination programs assist families in addressing psychosocial vulnerabilities and accessing needed resources. Our study was embedded in a clinical trial of the Care Ecosystem, a telephone- and internet-based supportive care intervention for patients with dementia and caregivers. This program is built around the role of the Care Team Navigator (CTN), an unlicensed dementia care guide who serves as the patient and caregiver's primary point of contact, screening for common problems and providing support. We conducted a qualitative analysis of case summaries from a subset of 19 patient/caregiver dyads identified as having increased risk for financial mismanagement and abuse, to examine how Care Ecosystem staff identified vulnerabilities and provided support to patients and families. CTNs elicited patient and caregiver needs using templated conversations to address common financial and legal planning issues in dementia. Sources of financial vulnerability included changes in patients' behavior, caregiver burden, intrafamily tension, and confusion about resources to facilitate end-of-life planning. The Care Ecosystem staff's rapport with their dyads helped them address these issues by providing emotional support, information on how to access financial, medical, and legal resources, and improving intra-familial communication. The Care Ecosystem offers a scalable way to address vulnerabilities to financial mismanagement and abuse in patients and caregivers through coordinated care by unlicensed care guides supported by a multidisciplinary team.

Provider preferences for delivery of HIV care coordination services: results from a discrete choice experiment.

IntroductionThe PROMISE study was launched in 2018 to assess and document the implementation of changes to an existing HIV Care Coordination Programme (CCP) designed to address persistent disparities in care and treatment engagement among persons with HIV in New York City. We evaluated provider endorsement of features of the CCP to understand drivers of engagement with the programme.MethodsWe used a discrete choice experiment to measure provider endorsement of four CCP attributes, including: (1) how CCP helps with medication adherence, (2) how CCP helps with primary care appointments, (3) how CCP helps with issues other than primary care and (4) where CCP visits take place (visit location). Each attribute had three to four levels. Our primary outcomes were relative importance and part‐worth utilities, measures of preference for the levels of the four CCP program attributes, estimated using a hierarchical‐Bayesian multinomial logit model. All non‐medical providers in the core CCP positions of patient navigator, care coordinator and programme director or other administrator from each of the 25 revised CCP‐implementing agencies were eligible to participate.ResultsWe received responses from 152 providers, 68% of whom identified as women, 49% identified as Latino/a, 34% identified as Black and 60% were 30–49 years old. Visit location (28.6%, 95% confidence interval [CI] 27.0–30.3%) had the highest relative importance, followed by how staff help with ART adherence (24.3%, 95% CI 22.4–26.1%), how staff help with issues other than primary care (24.2%, 95% CI 22.7–25.7%) and how staff help with primary care appointments (22.9%, 95% CI 21.7–24.1%). Within each of the above attributes, respectively, the levels with the highest part‐worth utilities were home visits 60 minutes from the program or agency (utility 19.9, 95% CI 10.7–29.0), directly observed therapy (utility 26.1, 95% CI 19.1–33.1), help with non‐HIV specialty medical care (utility 26.5, 95% CI 21.5–31.6) and reminding clients about and accompanying them to primary care appointments (utility 20.8, 95% CI 15.6–26.0).ConclusionsOngoing CCP refinements should account for how best to support and evaluate the intensive CCP components endorsed by providers in this study.

Payer-Level Care Coordination and Re-admission to Acute Mental Health Care for Uninsured Individuals.

This study determined the short- and long-term outcomes associated with payer-level care coordination, compared with care-as-usual in "high-utilizers" of acute care services in a large, publicly funded safety net system. Administrative claims data (2016-2020) were analyzed. All patients were "high-utilizers," defined by the State of Florida as either (a) 3 + more acute care episodes in a 6-month period or (b) 1 + acute care episodes in the past 6months lasting 16 + days. Patients enrolled in care coordination (n = 178) were compared to usual care (n = 1,127) on rates of re-admission and post-discharge engagement in outpatient/residential services. Care coordination was associated with reduced rates of re-admission, significant cost savings, and enhanced engagement in post-discharge non-crisis services. In light of the observed clinical and economic benefits associated with care coordination, payers, policymakers, and administrators of acute care settings should consider potential return on investment for allocation of resources to support specialty care coordination programs.

Optimizing care coordination to address social determinants of health needs for dual-use veterans

BackgroundVeterans increasingly utilize both the Veteran’s Health Administration (VA) and non-VA hospitals (dual-users). Dual-users are at increased risk of fragmented care and adverse outcomes and often do not receive necessary follow-up care addressing social determinants of health (SDOH). We developed a Veteran-informed social worker-led Advanced Care Coordination (ACC) program to decrease fragmented care and provide longitudinal care coordination addressing SDOH for dual-users accessing non-VA emergency departments (EDs) in two communities.Methods ACC had four core components: 1. Notification from non-VA ED providers of Veterans’ ED visit; 2. ACC social worker completed a comprehensive assessment with the Veteran to identify SDOH needs; 3. Clinical intervention addressing SDOH up to 90 days post-ED discharge; and 4. Warm hand-off to Veteran’s VA primary care team. Data was documented in our program database. We performed propensity matching between a control group and ACC participants between 4/10/2018 – 4/1/2020 (N- = 161). A joint survival model using Markov Chain Monte Carlo technique was employed for 30-day outcomes. We performed Difference-In-Difference analyses on number of ED visits, admissions, and primary care physician (PCP) visits 120-day pre/post discharge.ResultsWhen compared to a matched control group ACC had significantly lower risk of 30-day ED visits (Hazard Ratio (HR) = 0.61, 95% Confidence Interval (CI) = (0.42, 0.92)) and a higher probability of PCP visits at 13–30 days post-ED visit (HR = 1.5, 95% CI = (1.01, 2.22)). Veterans enrolled in ACC were connected to VA PCP visits (50%), VA benefits (19%), home health care (10%), mental health and substance use treatment (7%), transportation (7%), financial assistance (5%), and homeless resources (2%).ConclusionWe developed and implemented a program addressing dual-users’ SDOH needs post non-VA ED discharge.Social workers connected dual-users to needed follow-up care and resources which reduced fragmentation and adverse outcomes.

Can eHealth Support Managing an Integrated Health Service Delivery? A Case Study of an Integrated Care Program in Poland

There is a growing evidence that eHealth offers support for healthcare management, but the value of existing solutions for integrated healthcare delivery is still underestimated. The aim of this work is to explore the potential benefits for ICT-based tools for managing an integrated care program. The case study approach has been applied to map ICT-based services to assist the management of the selected coordinated care program and decision support systems (DSS) in health. The cross-case analysis followed a variables-oriented strategy of eHealth impact on seven eCCM components, assessed from the perspective of three segments of health stakeholders. The research results provide a fresh look at the range of eHealth solutions and their impact on managing integrated healthcare programs in Poland. Nevertheless, more research is needed to demonstrate the benefits of ICT-based solutions from perspectives of all health system's stakeholders.

Systemic barriers to care coordination for marginalized and vulnerable populations

ABSTRACT Care coordination can improve patient outcomes, increase continuity of care, and reduce healthcare utilization. This study explores the effectiveness and limitations of care coordination as a strategy for meeting vulnerable patients’ needs. The study team conducted a qualitative, multi-site, collective case study of four sites providing care coordination for vulnerable and marginalized populations. Data were gathered via individual patient interviews (n = 69) and staff focus groups (82 participants) and analyzed using a matrix template to code data and identify common themes. Addressing patients’ needs required coordination across behavioral, medical, and social service providers. This was most effective when it included social needs and built on trusting relationships between patients and staff. However, sites faced shared challenges from systemic barriers that limited their effectiveness. For vulnerable and marginalized populations, evidence-based care coordination can only address some needs, and benefits are often undermined by deeply entrenched structural deficits. Future care coordination programs must include an assessment of structural barriers and incorporate concurrent efforts to address them.

Staff Perspectives on Lessons Learned From an Interdisciplinary Memory Care Coordination Program

MIND at Home is a home-based care coordination program for persons living with dementia (PLWD) and their informal care partners (CP). Assessments, care planning and coordination is delivered by trained non-clinical Memory Care Coordinators (MCCs), working together on an interdisciplinary team with nurses and geriatric psychiatrists. We report qualitative results from program staff (two nurses and eight MCCs) who implemented the program in the context of two clinical trials. Care team respondents answered open-ended questions covering 5 domains pertaining to: helpful skillsets; positive and challenging factors aspects of care coordination; barriers to care coordination for clients; and improvements suggestions/resources to strengthen the program. Compassion, finding common ground, listening, organization, and time management were reported as critical skills. Staff enjoyed team collaboration, being in and learning about the community, increasing CP confidence and mastery when caring for a PLWD. Reported challenges included documentation in EHR, accessing/navigating resources, driving long distances, unsafe neighborhoods, ambiguous assessment tools, and working with low engagement clients. Common barriers faced by clients (as reported by staff) were financial struggles/poverty, and lack of insurance coverage for needed services. Staff suggested several improvements: better communication strategies, integration with LTSS services and medical providers, 24-hour program hotline, continuous education for staff, simplified data collection and care delivery tracking process. This presentation on the experience of MIND at Home trained nurses and MCCs provides deep insight on how this and similar care coordination programs might be successfully implemented or strengthened.

Virtual Interdisciplinary Collaboration in Statewide Implementation of the MIND at Home Dementia Care Program

MIND at Home, a well-researched holistic, family-centered dementia care coordination program, provides collaborative support to community-dwelling persons living with dementia (PLWD) and their informal care partners (CP). Through comprehensive home-based assessment of 13 memory-care domains covering PLWD and CPs, individualized care plans are created, implemented, monitored, and revised over the course of the illness. Non-clinical Memory Care Coordinators (MCCs) working with an interdisciplinary team provide education and coaching to PLWD and their identified CP, and serve as a critical liaison and resource and between families, medical professional, and formal and informal community resources. This paper will describe a statewide pilot implementation of the program within a health plan across diverse sites in Texas and will present qualitative and quantitative descriptions of a key component of the program's effective translation to practice, the virtual collaborative case-based learning sessions. Health plan teams completed online interactive training modules and an intensive in-person case-based training with the Johns Hopkins team prior to program launch, and then engaged in weekly, hour-long virtual collaborative sessions that included health plan teams (site-based field teams, health plan clinical supervisory and specialty personnel [RNs, pharmacists, a geriatric psychiatrist, behavioral health specialists] and Johns Hopkins MIND program experts and geriatric psychiatrists. To date, the program has enrolled 350 health plan members, conducted 65 virtual collaborative sessions, and provided 423 CME/CEU units to team members. We will provide an overview of virtual collaborative session structure, participant contributions and discussion topics, case complexity, as well as didactic learning topics covered.

Socially Relevant Approaches to the Detection of Dementia in Minority Older Adults

Substantial gaps remain in the scientific literature regarding low-income minority older adult populations with Alzheimer’s disease and related dementias (ADRDs). Access to care and early cognitive screening are often barriers to advancing ADRD detection in low socioeconomic status (SES) minority older adults. Additionally, there is the need for demographically (age, education, sex, race, ethnicity, and income) corrected normative scores in cognitive measures. Our cross-sectional study evaluated the psychometrics of the Mini-Mental State Exam-2 (MMSE-2) and the NIH Toolbox Cognition Battery (NIHTB-CB). The sample consisted of n=80 community-based older adults without a diagnosis of dementia living in low-income high-rise housing units. Acceptability is assessed with a brief 6-item acceptability survey, multiple linear regression is used to get predicted cognitive scores adjusted for age, education, income, ethnicity, race, and sex, and t-test comparison of the adjusted scores found in this study to established norms. Results found a mean age of 73, 70% black, 48% with < 12th-grade education, 51% have a monthly income of < $1,000, and 49% with undiagnosed cognitive impairment (CI) by both measures. When applying demographic adjustments in the NIHTB-CB 1) standard scores; 2) age-corrected scores, and 3) demographically correct scores all remained significant (p > 0.0001). Participants reported high (80-95%) acceptability for the community-based cognitive screening, 18% reported concerns with cultural appropriateness of the questions in the NIHTB-CB as compared to 5% with the MMSE-2. This research lays the foundation for a community-based cognitive screening and care coordination program for the low SES minority older adult population.

Transcending Inequities in Dementia Care in Black Communities: Lessons From the MIND Care Coordination Program

Previous cognitive learning interventions have focused primarily on learning one or two novel real-world skills at a time, or utilizing computer-based programs to enhance specific cognitive skills (Ball et. al 2002; Park et. al, 2014). While these studies yielded immediate cognitive improvements in participants, the long-term benefits of continuing to learn several real-world skills in older adulthood is unclear. In the present two studies, the long-term (1-year post-intervention) benefits of a multi-skill learning intervention were investigated with older adult participants. Study 1 (a pilot sample) included 6 participants (67% female, M = 66.33 years, SD = 6.41, range = 58–74 years old) and Study 2 included 27 participants (67% female, M = 69.44 years, SD= 7.12, range = 58–86 years old). Following a three month intervention which entailed simultaneously learning at least three real-world skills, such as photography, drawing, and Spanish, participants’ cognitive abilities were assessed using four tasks (Flanker, Set-Shifting, Dot Counting, and N-Back), as well as RAVLT and Digit Span. Follow-up assessments were completed at three-, six-, and 12-month follow-ups after the interventions. Linear mixed-effects regression models revealed significant cognitive improvements across time points up to one year following the intervention compared to baseline assessments. These promising results support the idea that intense learning experiences may lead to considerable cognitive growth in older adulthood, as they do earlier in the lifespan.

Transcending Inequities in Dementia Care in Black Communities: Lessons From the MIND Care Coordination Program

Family caregivers (FCs) of persons institutionalized at geriatric facilities present significant unmet communication needs regarding receiving regular updates about their loved one’s condition and having available healthcare professionals (HPs) to approach when needed. We developed and tested a mobile-app for staff-family communication with both parties having active roles in app planning to tailor it to their needs and abilities. The app includes a daily-update module for FCs and a chat option for FCs and HPs. App use was piloted at one geriatric-medical-center for 15 months (unit-level randomization resulted in one complex-care and one assisted-ventilation unit in each group- intervention and control) and one single-unit nursing-home for three months. Personal interviews were conducted with 55 FCs (28 from intervention-group and 27 FCs from control-group) before-and-after app use (with mean duration of use 1.6[S.D.=.6] months. Most participants were women and the children of the patients; their mean age was 55.9 years (S.D.=12.4). Repeated-measures Analysis-of-Variance for the end-of-life communication sub-scale on the Quality-of-communication questionnaire yielded a main effect for time (F(1,53)=8.31, p=.006) with both groups’ ratings increasing over time and an interaction effect (F(1,53)=4.78, p=.033) with a greater increase for intervention-group compared to control-group. Intervention-group participants rated the app as convenient to use. Qualitative data revealed that FCs perceived app use as improving quality of communication with the HPs who used it and improving their own well-being. The app offers a feasible and an effective mode of communication that incorporates technology in daily communication between FCs and HPs while addressing FCs’ unmet needs.

A Digital Case-Finding Algorithm for Diagnosed but Untreated Hepatitis C: A Tool for Increasing Linkage to Treatment and Cure.

Background and AimsAlthough chronic HCV infection increases mortality, thousands of patients remain diagnosed‐but‐untreated (DBU). We aimed to (1) develop a DBU phenotyping algorithm, (2) use it to facilitate case finding and linkage to care, and (3) identify barriers to successful treatment.Approach and ResultsWe developed a phenotyping algorithm using Java and SQL and applied it to ~2.5 million EPIC electronic medical records (EMRs; data entered January 2003 to December 2017). Approximately 72,000 EMRs contained an HCV International Classification of Diseases code and/or diagnostic test. The algorithm classified 10,614 cases as DBU (HCV‐RNA positive and alive). Its positive and negative predictive values were 88% and 97%, respectively, as determined by manual review of 500 EMRs randomly selected from the ~72,000. Navigators reviewed the charts of 6,187 algorithm‐defined DBUs and they attempted to contact potential treatment candidates by phone. By June 2020, 30% (n = 1,862) had completed an HCV‐related appointment. Outcomes analysis revealed that DBU patients enrolled in our care coordination program were more likely to complete treatment (72% [n = 219] vs. 54% [n = 256]; P < 0.001) and to have a verified sustained virological response (67% vs. 46%; P < 0.001) than other patients. Forty‐eight percent (n = 2,992) of DBU patients could not be reached by phone, which was a major barrier to engagement. Nearly half of these patients had Fibrosis‐4 scores ≥ 2.67, indicating significant fibrosis. Multivariable logistic regression showed that DBUs who could not be contacted were less likely to have private insurance than those who could (18% vs. 50%; P < 0.001).ConclusionsThe digital DBU case‐finding algorithm efficiently identified potential HCV treatment candidates, freeing resources for navigation and coordination. The algorithm is portable and accelerated HCV elimination when incorporated in our comprehensive program.