Complex Comorbidities Research Articles

Abstract P292: Lessons Learned From the Implementation of a Peer-to-Peer Cardiology Consultation Program in Federally Qualified Health Centers

Introduction: Conventional access to specialist care for cardiovascular disease can be expensive, geographically limited, and unavailable to communities that need it most. Health consultations that include cardiovascular considerations can improve life expectancy without extra costs. The Doctors With Heart (DWH) is an initiative from the American Heart Association (AHA) initially developed to decrease gaps in care by using telemedicine as a vehicle for cardiovascular consultations between volunteer cardiologists and primary care providers at Federally Qualified Health Centers (Health Centers). Despite efforts to on-board and train Health Centers on the consultation process and benefits to patient care, consultation utilization remained low. Objective: Identify opportunities to enhance DWH to increase consultation utilization by understanding the need for and barriers to conducting consultations among Health Centers already participating in DWH. Methods: An AHA Program Evaluator and the DWH Program Director co-conducted interviews and focus groups with 31 health care professionals from five Health Centers in the Midwest participating in DWH. Thematic analysis revealed key themes across evaluation objectives. Results: Interviewees had mixed feelings about the need for consultations which was largely driven by the barriers they perceived to conducting them. Many interviewees felt consultations could be an effective way to expedite care for patients who need specialty cardiovascular care. They could also help patients with complex but manageable co-morbidities since the patient can receive cardiovascular care within the primary care setting. However, a few providers felt they already had sufficient access to cardiovascular care for their patients. Interviewees identified three key barriers to conducting consultations: time and administrative burden for providers and staff, providers forgetting the consultations exist, and provider hesitations and concerns. During Health Center on-boarding, DWH should work with Health Centers to integrate consultations into existing clinic workflows, identify a program champion at each site, train multiple clinic staff about the program, and secure buy-in from providers. After Health Center on-boarding, DWH and Health Center program champions should find ways to regularly remind providers about the program and determine whether non-provider staff can help providers identify potential consultation cases. Conclusion: While there was an identified need for cardiology consultations among many Health Centers, more support from DWH and Health Center staff and leadership is needed to establish the program within the clinic setting and ensure on-going consultation utilization. DWH can implement strategies to facilitate consultations during Health Center on-boarding and program implementation.

Developing an integrated clinical decision support system for the early identification and management of kidney disease—building cross-sectoral partnerships

BackgroundThe burden of chronic conditions is growing in Australia with people in remote areas experiencing high rates of disease, especially kidney disease. Health care in remote areas of the Northern Territory (NT) is complicated by a mobile population, high staff turnover, poor communication between health services and complex comorbid health conditions requiring multidisciplinary care.AimThis paper aims to describe the collaborative process between research, government and non-government health services to develop an integrated clinical decision support system to improve patient care.MethodsBuilding on established partnerships in the government and Aboriginal Community-Controlled Health Service (ACCHS) sectors, we developed a novel digital clinical decision support system for people at risk of developing kidney disease (due to hypertension, diabetes, cardiovascular disease) or with kidney disease. A cross-organisational and multidisciplinary Steering Committee has overseen the design, development and implementation stages. Further, the system’s design and functionality were strongly informed by experts (Clinical Reference Group and Technical Working Group), health service providers, and end-user feedback through a formative evaluation.ResultsWe established data sharing agreements with 11 ACCHS to link patient level data with 56 government primary health services and six hospitals. Electronic Health Record (EHR) data, based on agreed criteria, is automatically and securely transferred from 15 existing EHR platforms. Through clinician-determined algorithms, the system assists clinicians to diagnose, monitor and provide guideline-based care for individuals, as well as service-level risk stratification and alerts for clinically significant events.ConclusionDisconnected health services and separate EHRs result in information gaps and a health and safety risk, particularly for patients who access multiple health services. However, barriers to clinical data sharing between health services still exist. In this first phase, we report how robust partnerships and effective governance processes can overcome these barriers to support clinical decision making and contribute to holistic care.

Challenges Addressing Lung Cancer Screening for Patients With Multimorbidity in Primary Care: A Qualitative Study.

Many individuals who are eligible for lung cancer screening have comorbid conditions complicating their shared decision-making conversations with physicians. The goal of our study was to better understand how primary care physicians (PCPs) factor comorbidities into their evaluation of the risks and benefits of lung cancer screening and into their shared decision-making conversations with patients. We conducted semistructured interviews by videoconference with 15 PCPs to assess the extent of shared decision-making practices and explore their understanding of the intersection of comorbidities and lung cancer screening, and how that understanding informed their clinical approach to this population. We identified 3 themes. The first theme was whether to discuss or not to discuss lung cancer screening. PCPs described taking additional steps for individuals with complex comorbidities to decide whether to initiate this discussion and used subjective clinical judgment to decide whether the conversation would be productive and beneficial. PCPs made mental assessments that factored in the patient's health, life expectancy, quality of life, and access to support systems. The second theme was that shared decision making is not a simple discussion. When PCPs did initiate discussions about lung cancer screening, although some believed they could provide objective information, others struggled with personal biases. The third theme was that ultimately, the decision to be screened was up to the patient. Patients had the final say, even if their decision was discordant with the PCP's advice. Shared decision-making conversations about lung cancer screening differed substantially from the standard for patients with complex comorbidities. Future research should include efforts to characterize the risks and benefits of LCS in patients with comorbidities to inform guidelines and clinical application.

Physicians, know thy patient.

Person-centered care is presently the standard healthcare model, which emphases shared clinical decision-making, patient autonomy and empowerment. However, many aspects of the modern-day clinical practice such as the increased reliance on medical technologies, artificial intelligence, and teleconsultation have significantly altered the quality of patient-physician communications. Moreover, many countries are facing an aging population with longer life expectancies but increasingly complex medical comorbidities, which, coupled with medical subspecialization and competing health systems, often lead to fragmentation of clinical care. In this article, I discuss what it truly means for a clinician to know a patient, which is, in fact, a highly intricate skill that is necessary to meet the high bar of person-centered care. I suggest that this can be achieved through the implementation of a holistic biopsychosocial model of clinical consultation at the physician level and fostering coordinated and continuity of care at the health systems level.

Introduction to the novel model of preoperative Multi - Domain Risk Stratification (pMDRS).

Preoperative risk stratification is an important step in surgical procedures. The current scoring systems do not predict accurate overall surgical outcomes in complex comorbid patients. The novel model of preoperative multi-domain risk stratification is described in this article, which categorises patients in to three risk groups, aiming to modify the risk for optimal surgical outcomes.

Modulation of Vitamin D- Fibroblast Growth Factor 23/Fibroblast Growth Factor Receptor 1-Klotho Axis by Astragalus in Elderly Heart Failure Patients

Heart failure is a geriatric syndrome, often accompanied by a high disability rate, complex comorbidities, and a poor prognosis. This study aimed to assess the effect of Astragalus on the vitamin D- fibroblast growth factor 23/fibroblast growth factor receptor 1-KLOTHO axis in elderly heart failure patients using a bioinformatics approach. Thirteen active ingredients and 159 targets were identified based on network pharmacology, and 500 HF targets were obtained using GeneCards database. A predicted target set was established using 22 core targets, and a diagram of the active component-target network was constructed using Cytoscape software (version 3.7.2); a protein-protein interaction network was constructed for analysis, and the Gene Ontology and Kyoto Encyclopedia of Genes and Genomes pathway enrichment were analyzed using DAVID software. Bioinformatics analyses revealed that 22 targets were mainly involved in the Ras and PI3K-Akt signaling pathways. Molecular docking for fibroblast growth factor receptor 1 revealed that the active components HMM7 and HMM13 demonstrated better binding stability with the target gene. This study may help explain the molecular mechanism of effects on vitamin D- fibroblast growth factor 23/fibroblast growth factor receptor 1-KLOTHO axis and promote clinical application.

Comprehensive Review of Urinary Tract Infections in Renal Transplant Recipients: Clinical Insights and Management Strategies.

Urinary tract infections (UTIs) pose a significant challenge in the care of renal transplant recipients. This comprehensive review explores this population's multifaceted landscape of UTIs, emphasizing the importance of early diagnosis and tailored management strategies. Renal transplant recipients face an elevated risk of UTIs due to immunosuppression, altered urinary tract anatomy, and complex comorbidities. Complications of UTIs can lead to graft dysfunction and systemic illness, underscoring the need for effective management. The emergence of multidrug-resistant uropathogens adds complexity to treatment, highlighting the importance of targeted antibiotic therapy. Antibiotics are the most commonly prescribed drugs for UTIs, with nitrofurantoin, fosfomycin, amoxicillin, and amoxicillin-clavulanate potassium being some of the commonly used antibiotics. However, the emergence of multidrug-resistant uropathogens has led to the exploration of alternative treatments, such as bacteriophage therapy, as a potential alternative against multidrug-resistant uropathogenic bacteria. Analgesics such as phenazopyridine can be prescribed to relieve discomfort associated with UTIs. Estrogen therapy has also been suggested as a potential treatment option for UTIs, particularly in postmenopausal women. Trimethoprim-sulfamethoxazole or trimethoprim is recommended as first-line therapy for uncomplicated UTIs. The choice of drug and therapy for UTIs depends on the severity of the infection, the causative organism, and the presence of antibiotic resistance.Preventive measures encompass pre-transplant evaluation, perioperative strategies, post-transplant follow-up, and vaccination. A multidisciplinary approach involving transplant specialists, infectious disease experts, pharmacists, and patient engagement is vital for successful care. The future of UTI management lies in ongoing research, exploring personalized medicine, novel therapies, and innovative prevention strategies. By implementing these strategies and advancing research, healthcare providers can improve graft and patient survival, enhancing the quality of care for renal transplant recipients.

Long-term medication for ADHD (LMA) trial: 2-year prospective observational study in children and adolescents. Core symptoms, daily functioning, and comorbidity outcomes

More knowledge is needed about long-term ADHD medication and symptom, daily functioning, comorbidity, and tolerability outcomes. This “Long-term Medication for ADHD (LMA) trial” was a prospective observational 2-year trial in children and adolescents aged 6–18 years (extension of 1-year trial). Participants met criteria for DSM-5 ADHD (inattentive or combined), with complex comorbidities; autism spectrum disorder (31%), autistic traits (24%), oppositional symptoms (59%), anxiety (32%), dyslexia/language disorder (16%), borderline intellectual functioning (17%). Medication was individually tailored and followed-up at clinical visits (1, 2, 3, 6, 12, 18, 24 months). Primary outcome: Clinical Global Impression-Severity and Improvement scales (CGI-S, CGI-I). Secondary outcomes: Investigator-rated ADHD-Rating Scale, Weiss Functional Impairment Rating Scale-Parent report (WFIRS-P; Family, School Learning and Behavior, Life Skills, Self-Concept, Social Activities, and Risky Activities domains), comorbidity symptoms and adverse events (AEs). One hundred twenty-eight participants were enrolled (1-year trial only n = 27, LMA trial n = 101). Of these 29 (23%) discontinued, mainly due to AEs (n = 7), moving (n = 7), or no longer needing medication (n = 6). Main AEs were poor appetite, low mood, anxiety, irritability, fatigue. Improvements from baseline to 2 years were large in CGI-S (effect size (ES) 2.28), ADHD-RS (ES 2.06), and moderate to large in WFIRS-P (ES total 0.73, learning 0.4, family 0.67). Overall, the trial showed robust and sustained improvements in ADHD symptom severity and daily functioning over a period of 2 years of ADHD medication in children and adolescents with ADHD and complex comorbidities. Most AEs were mild. Comorbidity symptoms were improved after 1 year, particularly oppositional symptoms, depression, and anxiety.

Nutritional considerations for people living with a Fontan circulation: a narrative review.

The population of people living with a Fontan circulation are highly heterogenous, including both children and adults, who have complex health issues and comorbidities associated with their unique physiology throughout life. Research focused on nutritional considerations and interventions in the Fontan population is extremely limited beyond childhood. This review article discusses the current literature examining nutritional considerations in the setting of Fontan physiology and provides an overview of the available evidence to support nutritional management strategies and future research directions. Protein-losing enteropathy, growth deficits, bone mineral loss, and malabsorption are well-recognised nutritional concerns within this population, but increased adiposity, altered glucose metabolism, and skeletal muscle deficiency are also more recently identified issues. Emergencing evidence suggets that abnormal body composition is associated with poor circulatory function and health outcomes. Many nutrition-related issues, including the impact of congenital heart disease on nutritional status, factors contributing to altered body composition and comorbidities, as well as the role of the microbiome and metabolomics, remain poodly understood.

2026 Development of a novel 2-week wait oncogeriatric service: A GI Frailty Clinic

Abstract Introduction Over the last 12 months, a novel oncogeriatric clinic was successfully established to assess frail 2-week wait (2WW) patients referred with gastrointestinal (GI) symptoms. The clinic was initially funded by the West Yorkshire Cancer Alliance, enabling a weekly clinic, run by a geriatrician, clinical specialist nurse and an advance clinical practitioner. Methods A total of 350 patients were assessed (those with a clinical frailty score of ≥ 6 were eligible for referral); due to demand exceeding capacity, remaining patients were referred on through the default surgical or GI pathways. Patients were triaged by endoscopy nurses from ‘straight to test’ referrals after training provided to assess frailty scores using routinely available data. Results Only a third of patients referred remained on the 2WW pathway compared to surgical patients; this was due to patients being too frail or an alternative diagnosis being made through comprehensive geriatric assessment, and a shared decision-making process. The patient level information and costing system (PLICS) demonstrated that the oncogeriatric clinic was cost effective, costing approximately £190 less per patient than the default pathways of care. Feedback from patients demonstrated extremely high satisfaction rates with the service provided. One of the most significant interventions was medicines management, which has led to a pharmacist supporting the clinic through further innovation funding. Conclusion Lessons learned included developing a better understanding of cancer diagnosis and frailty, providing a ‘one stop centre’ for cancer care, and managing complex comorbid conditions in frail older people suspected of having cancer. As a result of this QI service development project, a Frailty Cancer Strategy for the Trust is currently being developed and will be presented to the executive team with the aim of developing a comprehensive oncogeriatric service for frail patients in Leeds, providing the right care, the right treatment, first time.

Host-directed therapy against mycobacterium tuberculosis infections with diabetes mellitus.

Tuberculosis (TB) is caused by the bacterial pathogen Mycobacterium tuberculosis (MTB) and is one of the principal reasons for mortality and morbidity worldwide. Currently, recommended anti-tuberculosis drugs include isoniazid, rifampicin, ethambutol, and pyrazinamide. TB treatment is lengthy and inflicted with severe side-effects, including reduced patient compliance with treatment and promotion of drug-resistant strains. TB is also prone to other concomitant diseases such as diabetes and HIV. These drug-resistant and complex co-morbid characteristics increase the complexity of treating MTB. Host-directed therapy (HDT), which effectively eliminates MTB and minimizes inflammatory tissue damage, primarily by targeting the immune system, is currently an attractive complementary approach. The drugs used for HDT are repositioned drugs in actual clinical practice with relative safety and efficacy assurance. HDT is a potentially effective therapeutic intervention for the treatment of MTB and diabetic MTB, and can compensate for the shortcomings of current TB therapies, including the reduction of drug resistance and modulation of immune response. Here, we summarize the state-of-the-art roles and mechanisms of HDT in immune modulation and treatment of MTB, with a special focus on the role of HDT in diabetic MTB, to emphasize the potential of HDT in controlling MTB infection.

Exploring the Role of Nurses in Advance Care Planning Within Long-Term Care Homes: A Qualitative Study.

Residents in long-term care homes (LTCHs) are often diagnosed with chronic, life-limiting illnesses, and it is now a common site to provide high levels of care and eventual death. There is an urgent need to address communication gaps and uncertainties surrounding resident's end of life preferences. Nurses are well situated to be key facilitators of necessary advance care planning (ACP), ensuring residents have discussions with family, substitute decision-makers and healthcare providers regarding future health and personal care preferences. However, LTCHs present unique challenges for nurses due to not only complex comorbidities but also staffing dynamics. This study explored the experiences and perceptions of Registered Nurses (RNs) and Registered Practical Nurse (RPNs) in LTCHs regarding their role in engaging residents and families in ACP discussions. Qualitative interpretive descriptive methodology was used. Data were collected from two LTCHs in Southern Ontario with a sample of 15 nurses (7 RNs and 8 RPNs). Analysis involved review of semistructured interviews, field notes, and utilizing constant comparison within an inductive approach. Power and authority dynamics in LTCH's was an overarching theme in the data, with four subthemes: (1) Nurses lacking clarity about ACP, (2) nurses' uncertainty regarding their role in ACP, (3) nurses feeling uncomfortable engaging in ACP discussions, and (4) nurses struggling to support families in ACP discussions. Recommendations for nurses, healthcare providers, LTCH administrators, and policy makers include: (1) development of policies which support, from a systemic level, nurses to feel safe while engaging in ACP; (2) reassessing LTCH's hierarchical structure, and clarifying RN, RPN, and interdisciplinary team members roles in ACP; (3) developing culture change that allows a team and person-centered approach to ACP; and (4) providing ongoing education and mentorship for nurses to manage family dynamics and expand their understanding of ACP beyond a biomedical lens.

A Multiple Case Study Exploring Person‐Centred Care in Care Homes

Background: There are 14,228 care homes in England with a population of approximately 372,035 residents, many of whom are living with frailty or multiple and complex comorbidities. Policy and international literature advocate that care homes provide high‐quality person‐centred care that meets each person’s specific needs. This study aims to provide an exploration of person‐centred care in care homes in the South West of England from the perspective of all those involved.Methods: A qualitative multiple case study design was used across seven care homes in a region of South West England. Semistructured interviews were conducted with 61 participants (residents, family and health and care professionals). Nonparticipant observations were undertaken in communal areas to understand the practices and cultures of the care homes. All data were analysed using reflexive thematic analysis.Findings: The findings are presented as six themes, they are adjusting to the transition into a care home; people at the centre of care; the place we call home with the people we call family; working across the boundaries of care; supporting, valuing and empowering care home teams; and managing complex and challenging moments of care.Conclusion: This study demonstrates a whole system understanding of person‐centred care across seven care homes. The main components of person‐centred care appear to be relational. These relationships take place in cultures and systems that are complex and challenging with care boundaries that need to be navigated. Navigating these care boundaries requires a people‐centred care approach built on partnerships and mutual respect.

Клинические особенности пограничного личностного расстройства у подростков

Aim. Identification of the features of primary and comorbid signs of borderline personality disorder (BPD) in teenagers. Design. Open-label cohort study. Materials and methods. A pilot clinical evaluation was performed for a full cohort of teenagers admitted to psychiatric in-patient clinic in 2021–2022, the condition of which corresponded to the International Classification of Diseases, revision 11, BPD criteria. The study included 74 teenagers aged 11–17 years old, of which 72 were females. The mean age was 16.6 years old. Results. All 74 patients had comorbid disorders; complex comorbidities were observed in 31 (41.9%) patients. Forty-seven (63.5%) patients had a history of bullying. Anxiety and post-stress disorders preceded clinical manifestations of the BPD symptoms in 64 (86.5%) cases. Self-harm and attempted suicide were recorded in 58 (78.4%) patients; problems with self-identification, including gender preferences, were observed in 56 (75.7%) patients, problems with interpersonal relationships — in 64 (86.5%) patients, and dissociative symptoms — in 41 (55.4%) patients. Multiple personality disorder identification as “we”, “multiple personalities”) was observed in 12 (16.2%) cases. Clinically significant signs of various eating disorders were diagnosed in 16 (21.6%) patients. After being treated in an in-patient clinic, 65 (87.8%) teenagers demonstrated significant improvement. Most challenging was the management of patients with substantial dissociative symptoms, persistent “gender identity disorder” and trends to use abnormal psychological defence mechanisms. Conclusion. Interim data show that manifestation of symptoms and comorbidities, as well as a short-term response to therapy in teenagers differ from those in adults with BPD, favouring BPD with adolescent onset as a relatively separate sub-type and justifying a dimensional approach for the search and optimisation of early therapeutic interventions in teenagers with BPD. Keywords: borderline personality disorder, teenagers, comorbidity, psychiatric disorders, International Classification of Diseases, revision 11 (ICD-11).

Australian healthcare professionals' beliefs and practice behaviours in management of chronic pelvic pain: a cross-sectional survey.

Background Chronic pelvic pain (CPP) is a common and debilitating condition, and sufferers present to healthcare professionals with variable complex symptoms and co-morbidities. This study aimed to investigate the current beliefs and practice behaviours of healthcare professionals towards the management of CPP in Australian females. Methods We distributed an online survey to Australian healthcare professionals. Participants were questioned regarding their beliefs, the importance of various contributing factors and assessment variables, and their management preferences for two CPP vignettes. Demographic information and responses were analysed with descriptive statistics. Results Complete data were obtained and analysed from 446 respondents including gynaecologists (n =75), general practitioners (GPs) (n =184) and physiotherapists (n =187). Most of the respondents were female (88.1%), with male (11.7%) and other (0.2%) making up a smaller representation. Physiotherapists rated themselves higher in understanding mechanisms of CPP (64.7% very good to excellent) compared to gynaecologists (41.3%) and GPs (22.8%). Physiotherapists also reported higher levels of confidence in managing patients with CPP (57.8% quite or extremely confident) compared to 41.3% of gynaecologists and 22.3% of GPs who reported being quite or extremely confident. All three professions rated patient's beliefs (89.8%), nervous system sensitisation (85.7%), stress/anxiety/depression (91.9%), fear avoidance (83.3%), history of sexual/emotional/physical abuse (94.1%) and pelvic floor muscle function (85.0%) as very/extremely important factors in the development of chronic pelvic pain. Most gynaecologists (71.0%) and GPs (70.2%) always referred for pelvic ultrasound during assessment. Physiotherapists assessed goal setting (88.8%) and screened for patients' beliefs (80.9%) more often than gynaecologists (30.4% and 39.1% respectively) and GPs (46.5% and 29.0% respectively). Conclusions All three groups of healthcare professionals demonstrated a good understanding of pain mechanisms and incorporated a biopsychosocial and multidisciplinary approach to management of females with chronic pelvic pain. However, both gynaecologists and GPs were less confident in their understanding of and management of CPP, and less likely to consider patient beliefs and goals. The findings of this online survey may assist in the provision of more targeted education to further improve management of this condition.

CONNECTING AGING RURAL VETERANS WITH TELE-GERIATRIC MENTAL HEALTH: REFERRING PROVIDERS’ SURVEYED PERSPECTIVE

Abstract Providing comprehensive, individualized care to older Veterans with complex needs is particularly challenging in rural areas. Geriatric mental health specialists are scarce but needed for care including psychiatric medication and behavior management, consultation on complex comorbidities, cognition, and caregiver support and education. Tele-geriatric mental health services were initially developed in one VA regional telehealth hub and then expanded to three more regional telehealth hubs. Referring providers (N = 37) to tele-geriatric mental health services during a 1-year period were surveyed via REDCap. Providers came from varied settings in the 4 VA regions with 76% serving rural Veterans. Referring providers included prescribers (N = 26; pharmacists, physicians, physician assistants, nurse practitioners and advanced practice nurses) and non-prescribers (N = 11; psychologists, social workers). Most worked in Patient Aligned Care Teams, mental health clinics, or Community Living Centers and reported geriatric training and comfort with geriatric patients. When asked about their perception of the impact of the services, most providers believed that patients (91.9%) and care teams (94.6%) benefitted from the telehealth services and would recommend the services (94.6%). Most followed through on recommendations (83.7%) and believed the service increased access to geriatric mental health (89.2%). Open-ended feedback included gratefulness for providing care to aging rural Veterans lacking resources. These services are appreciated by providers and may facilitate access to specialized mental health care particularly in rural areas. Having access to specialists to assist with the care of patients with complex needs may ease the care coordination needed by referring providers.

ETHICAL CONSIDERATIONS UNDERLYING ACP FOR ACCOMPANIED OLDER ADULTS WITH COGNITIVE IMPAIRMENT

Abstract While clinicians understand the importance of ACP, it is difficult to overcome logistical and ethical challenges in the limited time providers have in primary clinic appointments with older adults with ADRD and other complex co-morbidities. Ethical/moral dilemmas faced by patients, families, and clinicians are reflected in the four principles of biomedical ethics including autonomy, beneficence, nonmaleficence, and justice. While ethical challenges are recognized there is a lack of real-world evidence to guide clinicians or family caregivers in ACP for older adults with ADRD based on the reality of complex patient and family dynamics. Throughout the SHARE trial, facilitated ACP conversations with trained ACP facilitators, older adult patients with cognitive impairment, and their family caregiver were audio recorded and transcribed. The purpose of this presentation is to expand our understanding of best practices for facilitating ACP conversations among persons with ADRD and their family caregivers, guided by medical ethics and the Learning Health Care System Ethics Framework. We draw on the unique dataset of recorded ACP conversations involving older adults with severe cognitive impairment (N=92, average age=88 years), family caregivers, and trained ACP facilitators. We qualitatively coded transcripts for ethical considerations of ACP conversations and conducted the thematic analysis. We will present major themes related to ethical considerations in facilitating ACP conversations among persons with moderate to severe ADRD and their family caregivers. We will provide a discussion framed in balancing patient, family, and provider needs within a Learning Health Care System.

PALLIATIVE AND END-OF-LIFE CARE FOR OLDER ADULTS WITH EXPERIENCES OF HOMELESSNESS

Abstract Although palliative and end-of-life (PEOL) care offers many benefits to those with life-limiting illness, unhoused older adults face significant barriers in accessing these types of care. This symposium examines disparities in PEOL care, emerging services for disadvantaged older adults, and recommendations for capacity-building within healthcare, housing, and aging services. The first paper is an exploratory study of programs serving the PEOL care needs of unhoused adults with serious illnesses. The second paper is a mixed methods study that explores provider perspectives on approaches and challenges to addressing the PEOL care needs among unhoused individuals. The third paper uses the CBPR method photovoice to highlight the experiences of terminally ill patients accessing social model hospice care, a free option to facilitate access to hospice for unhoused older adults. In addition to well-established disparities in the prevalence of serious illness and access to palliative care among people with experiences of homelessness, limits and barriers to holistic support remain once housed. The fourth paper uses secondary data analysis of the Research and Supportive Care at Later-life for Unhoused People (RASCAL-UP) study to describe current practices, perceived barriers, and recommendations in permanent supportive housing for older residents with complex comorbidities. The final paper, also using secondary data analysis of the RASCAL-UP study, addresses the role of skilled nursing for palliative care patients with histories of homelessness. Together, findings illuminate challenges to providing PEOL care for unhoused older adults and those with prior experiences of homelessness, as well as opportunities to improve access to care. This is a Hospice, Palliative and End-of-Life Care Interest Group Sponsored Symposium.

Psychodynamic Psychiatry and Psychoanalysis in Indonesia.

Indonesia, a country with a vast population of approximately 275 million people on over 17,000 islands, currently has 1,221 psychiatrists nationwide. Psychodynamic psychiatry and psychoanalysis are integral to the practice of psychiatry in Indonesia, primarily because of the charismatic influence of Bachtiar Lubis, who trained in Canada in the early 1960s. Upon his return to Indonesia, Bachtiar Lubis supervised a generation of psychiatrists, including two of this article's authors, who carried on his pedagogical work. The psychodynamic model and treatments have faced obstacles limiting their acceptance in Indonesia, including importing a Western model that has not been culturally adapted to treat patients in the East, the stigma of mental illness in local communities, and the complex comorbidities of persons who seek psychiatric care. Psychodynamic psychotherapy in Indonesia is presently taught in university-based residency programs for eight semesters. A psychodynamic psychotherapy competency-based curriculum was adopted nationwide. The dissemination of psychotherapy knowledge and skills is greatly assisted by an active psychiatric professional association-the Indonesian Psychiatric Association Psychotherapy Section, a member society of the World Federation for Psychotherapy. The authors propose international and regional academic collaborations to maintain enthusiasm among trainees and improve quality of care.

Brief conjoint visits between an embedded behavioral health provider and primary care team member: When are they used and what are the barriers and facilitators?

Conjoint visits utilize the expertise of primary care providers (PCPs) and behavioral health providers (BHPs) to address complex comorbidities in patients. The objectives were to describe the use and features of conjoint visits and identify barriers and facilitators as described by BHPs in integrated settings. Three hundred and forty-five BHPs who worked in integrated primary care, a majority identifying as female and white, completed an online survey between October 2018 and July 2019. Results indicated common reasons for conjoint visits were for mental or behavioral health concerns. Though they reported high comfort using conjoint visits (M = 4.3/5), 56.5% of BHPs participated in them less than monthly or never. Using a constant comparison approach, qualitative data were coded to reveal six categories of barriers and five categories of facilitators to conjoint visits. The most common barriers were a result of a lack of systemic support, such as 73.5% reporting lack of time, while the most common facilitators were coordination (60.7%) and interprofessional communication (39.3%). Although conjoint visits are used infrequently, findings suggest it is not because they are unhelpful as providers generally found this type of appointment favorable. Rather, they and their teams lack time, training, and support needed for implementation. This research provides an introduction for researchers or clinicians to better understand the use of conjoint visits for patients with high needs and complexities. Future work focused on addressing barriers cited by providers regarding conjoint visits would increase providers' ability to use this form of care when it is needed. (PsycInfo Database Record (c) 2024 APA, all rights reserved).