Redesigning acute care for cognitively impaired older adults: Optimizing health care services.

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Redesigning acute care for cognitively impaired older adults: Optimizing health care services Michael A. LaMantia, Malaz A. Boustani, Shola Jhanji, Mungai Maina, Arif Nazir, Frank C. Messina, Amie Frame, Catherine Alder and Joshua Chodosh Dementia published online 15 August 2014 DOI: 10.1177/1471301214547089 The online version of this article can be found at: http://dem.sagepub.com/content/early/2014/08/12/1471301214547089

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Article

Redesigning acute care for cognitively impaired older adults: Optimizing health care services

Dementia 0(0) 1–18 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1471301214547089 dem.sagepub.com

Michael A. LaMantia and Malaz A. Boustani Indiana University Center for Aging Research, Indianapolis, IN, USA; Regenstrief Institute, Inc., Indianapolis, IN, USA; Indiana University School of Medicine, Indianapolis, IN, USA

Shola Jhanji Indiana University-Purdue University Indianapolis, Indianapolis, IN, USA

Mungai Maina Indiana University Center for Aging Research, Indianapolis, IN, USA; Regenstrief Institute, Inc., Indianapolis, IN, USA

Arif Nazir and Frank C. Messina Indiana University School of Medicine, Indianapolis, IN, USA

Amie Frame Indiana University Center for Aging Research, Indianapolis, IN, USA; Regenstrief Institute, Inc., Indianapolis, IN, USA

Catherine Alder Eskenazi Health, Indianapolis, IN, USA

Joshua Chodosh Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA, USA; David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA

Abstract Purpose of the study: Cognitive impairment (CI) is one of several factors known to influence hospitalization, hospital length of stay, and rehospitalization among older adults. Redesigning care delivery systems sensitive to the influence of CI may reduce acute care utilization while improving care quality. To develop a foundation of fundamental needs for health care redesign, we conducted focus groups with inpatient and outpatient providers to identify barriers, facilitators, and suggestions for improvements in care delivery for patients with CI. Corresponding author: Michael A. LaMantia, 410 West 10th Street, Suite 2000, Indianapolis, IN 46032, USA. Email: [email protected]



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Design and methods: Focus group sessions were conducted with providers to identify their approach to caring for cognitively impaired hospitalized adults; obstacles and facilitators to providing this care; and suggestions for improving the care process. Using a thematic analysis, two reviewers analyzed these transcripts to develop codes and themes. Results: Seven themes emerged from the focus group transcripts. These were: (1) reflections on serving the cognitively impaired population; (2) descriptions of perceived barriers to care; (3) strategies that improve or facilitate caring for hospitalized older adults; (4) the importance of fostering a hospital friendly to the needs of older adults; (5) the need for educating staff, patients, and caregivers; (6) the central role of good communication; and (7) steps needed to provide more effective care. Implications: Providing effective acute care services to older adults with CI is an important challenge in health care reform. An understanding derived from the perspective of multiple professional disciplines is an important first step. Future research will build on this preliminary study in developing new acute care models for patients with CI. Keywords dementia, focus groups, hospital/ambulatory care

Introduction Cognitive impairment (CI) impacts a growing number of older adults. For Alzheimer’s disease alone, there are 4.7 million affected individuals today and a projected 13.8 million individuals who will be affected by the condition in 2050 (Hebert, Weuve, Scherr, & Evans, 2013). The medical costs of providing care to this population are extremely high—approximately $11 billion to Medicare annually (Hurd, Martorell, Delavande, Mullen, & Langa, 2013)—and are driven in large part by this group’s high rate of hospitalizations (Bynum et al., 2004). Hospitalizations result not only in excess cost but also place older adults at risk of iatrogenic events and complications which may hasten functional decline, as identified in several seminal studies as well as more recent investigations (Covinsky et al., 2003; Hoogerduijn, Schuurmans, Korevaar, Buurman, & De Rooij, 2010; Inouye, 2006; Lefevre et al., 1992; Pedone et al., 2005; Sager et al., 1996). Care delivery systems that attend to the influence of CI may reduce acute care utilization and costs while improving care quality. Designing an improved model of acute care to serve older adults affected by CI is challenging. In the ambulatory care environment, dementia care programs and tools have been developed that successfully assist providers in both diagnosing dementia and delivering recommended protocols of care to patients and their caregivers (Boustani et al., 2011; Callahan et al., 2011; Frame, LaMantia, Bynagari, Dexter, & Boustani, 2013; Monahan et al., 2012; Vickrey et al., 2006). However, to our knowledge, no such programs exist in our country in the inpatient setting specifically designed for those with CI. During a hospitalization, older adults frequently interact with a range of providers, including the emergency department team, the primary medical team, and consultants, yet patients’ CI frequently goes unrecognized, as seen in the literature over the last 20 years (Fick, Agostini, & Inouye, 2002; Hwang et al., 2013; Inouye, Foreman, Mion, Katz, & Cooney, 2001; Inouye, Schlesinger, & Lydon, 1999; Lewis, Miller, Morley, Nork, & Lasater, 1995;



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Pisani, Redlich, McNicoll, Ely, & Inouye, 2003). As a result, cognitively impaired patients and their caregivers have an even more difficult time navigating the acute care environment warranting the development of new models of care for this vulnerable population (LaMantia, Scheunemann, Viera, Busby-Whitehead, & Hanson, 2010; Naylor et al., 2007). As a first step in health care redesign, we conducted focus groups with inpatient and outpatient providers to identify barriers, facilitators, and suggestions for improvements in care delivery for patients with CI. In particular, we interviewed providers who work in a local environment rich in services for older adults to understand not just which services should be provided but also how these existing services might be optimized to provide excellent care to these vulnerable adults. The purpose of this study was to develop an understanding of the problems with, strategies for, and possible solutions to providing excellent care to cognitively impaired older adults who require care in an acute care hospital.

Design and methods Study design We collected data from a series of focus group interviews with study participants. We audio taped, transcribed, and coded each interview consistent with a focus group methodology. The Indiana University Institutional Review Board approved this study including methods employed to recruit study subjects; all participants provided signed informed consent.

Study setting and population This study was conducted with medical professionals who provide care to older adults at Wishard Hospital, a 340 bed university-affiliated, public, safety-net hospital. Among older adults admitted to Wishard Hospital’s medical wards, the rate of CI has been estimated to be as high as 42% (Nazir et al., 2013). Potential study subjects were eligible to participate in the investigation if they worked with older adults at Wishard Hospital. Study participants included four groups engaged in the care of cognitively impaired older adults: (1) nurses; (2) social workers; (3) medical assistants; and (4) physicians. Focus groups were heterogeneous with respect to these disciplines, to ensure opportunities for perspectives that might arise from cross-discipline discussions. All of the participants are members of interdisciplinary teams providing care to older adults within the Indiana University (IU) Geriatrics programs. This group serves vulnerable older adults via a wide array of programs including an inpatient consultative ‘‘Acute Care of the Elderly’’ service (Counsell et al., 2000), outpatient geriatric medicine consultation and primary care clinics, a house calls program (Beck, Arizmendi, Purnell, Fultz, & Callahan, 2009), a ‘‘Geriatric Resources for Assessment and Care of Elders’’ (GRACE) service (Counsell, Callahan, Buttar, Clark, & Frank, 2006), the Healthy Aging Brain Center (Boustani et al., 2011), and the Aging Brain Care Medical Home program (Callahan et al., 2011). Participants were recruited via face-to-face inquiries, e-mail solicitations, and announcements made at staff meetings.

Focus group process Our outcomes of interest in this study were the statements, impressions, and opinions of the participants regarding caring for older adults affected by CI. Before the focus groups were



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Table 1. Focus group discussion questions.a What are the major obstacles you encounter in trying to provide care for these patients? What are your current treatment strategies? Which are successful and which are not? What changes in the treatment process do you think would help to improve quality of care? a

Additional questions were not excluded, if they arose during the course of the interviews.

conducted, the research team identified the following topics to be discussed during the course of the interviews: (1) barriers to providing care to cognitively impaired older adults in the acute care environment; (2) facilitators to providing this care; and (3) suggestions for improvements in acute care delivery for patients with CI. We decided on these topics a priori; however, these questions were not derived from an existing model. Focus group participants were encouraged to discuss other pertinent topics of interest if they arose during the course of the interview sessions. Prior to the focus group sessions, the research team developed an interview guide containing questions meant to spur discussion around key topics for exploration. Table 1 shows a list of the questions used in the focus group sessions. Each of the three focus group sessions was led by an experienced focus group moderator (JC). Each session lasted 90 to 120 min. Participants were provided a complimentary meal but were not otherwise incentivized to participate in this study.

Data analysis Study data were analyzed using a general thematic analysis. Two reviewers analyzed each of the interviews, while a third reviewer oversaw coding and theme development to ascertain its validity. Each focus group interview was transcribed verbatim. Transcripts were coded line by line to ensure that all potential codes were identified. Codes were examined to detect emerging themes and to identify important quotes. A highlighting system was used to track quotes with their assigned codes; this system was used to confirm accuracy of codes, identify missing codes, and ensure reviewers selected and applied codes consistently. After all interviews were transcribed and coded, memos were constructed to assist in the development of themes and allow the research team to group together commonalities that arose as the data were sorted.

Results Twenty-two participants attended one of three focus group sessions. The professions of study participants and their relative representation in each session are included in Table 2. The majority of participants were social workers (n ¼ 7, 30%). Five nurses, three nurse practitioners, two physicians, and four medical assistants also participated in the focus group sessions. In Senior Care at Wishard, we employed 12 social workers, 10 nurses, 11 nurse practitioners, 12 physicians, and six medical assistants at the time of our focus group sessions. Seven distinct themes emerged from the coding and analysis of interview data. These themes and representative quotes are detailed below.



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Table 2. Characteristics of focus group participants. Participant category

Focus group 1

Focus group 2

Focus group 3

Physician Nurse practitioner Nurse (RN, LPN) Social worker Medical assistant Other Total (n)

1 3 1 1 1 0 7

1 0 0 4 0 1 6

0 0 4 2 3 0 9

RN: registered nurse; LPN: licensed practical nurse.

Reflections on serving this population Respondents had many positive things to say about their experiences in caring for patients affected by CI, including stories of the resilience and resourcefulness of their patients. One nurse practitioner said, ‘‘I’m impressed by how people adapt to their impairments, so much so that sometimes I don’t detect them.’’ Another nurse practitioner said, ‘‘People are very good at working around their cognitive limitations.’’ Referring to differences in the educational attainment in this population, one medical assistant reflected, We have illiterate people . . . and you wouldn’t really know it, because you say, ‘You know, can you see this form? Do you want me to read it?’ And they say, ‘Could you just read it to me? I can’t see it very well.’

This adaptability impressed participants. Still, some focus group participants recognized that while some patients may adapt to changes in their level of function, these adaptations may be tenuous at best. One nurse explained, ‘‘On the negative side, from the inpatient setting, I’m amazed at how some people are functioning. How when we see them in the hospital, they’re living alone, and you’re thinking, ‘Oh, my God.’’’ A physician added, ‘‘And you’re thinking, ‘How are you getting the groceries? . . . What about the dead of winter?’’’ A nurse practitioner stated, ‘‘Well, I think sometimes the cognitive impairment helps them not worry about those things.’’ But, while some providers are shocked by the debility of their patients during hospitalizations, others recognize that cognitively impaired patients with an acute illness may not be at their baseline level of functioning and may in fact improve greatly during the recovery period. One nurse noted, ‘‘It’s amazing how people will really, really improve . . . to the, you know, point where it’s almost, you read the hospital discharge note, and this isn’t even the same person.’’ Indeed, these providers are inspired by the resilience of their patients and find the act of supporting patients and families through the disease process very rewarding and a motivation for doing this work. One social worker stated, I would say that one of the aspects of being positive in terms of caring for older adults with dementia is the impact that you can have on their quality of life . . . by helping their caregiver make connections with other folks in the community.



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A physician reflected: My experience has been that older adults when they’re facing the dementia diagnosis are oftentimes very scared . . . . And I’ve found that it’s very rewarding to take people through that sort of journey from where they don’t even know what they’re dealing with, they just know that something’s wrong, to actually understanding it [the disease] and then empowering them to be able to make choices about what treatments they want to pursue, what types of care they’re going to need or want for their loved ones going forward.

These providers overall presented positive assessments of their experiences in working with these vulnerable older adults.

Descriptions of perceived barriers to care Each of the focus groups mentioned that there are multiple significant barriers to providing effective care to cognitively impaired individuals. Socioeconomic status plays a very important role in determining what kind of care a patient might receive, especially when faced with tough decisions regarding finances. Providers try to find ways to overcome the environmental, financial, and educational barriers that confront their cognitively impaired patients. One medical assistant commented on the effect of income on patients’ access to prescribed medicines, Patients’ income seems to really be a hindrance . . . they can’t afford a new medicine they may be prescribed and hopefully there’s a cheaper generic their insurance will cover. Or . . . they can just kind of try to figure out a different option.

Patients with CI, however, have a limited ability to manage these issues and often present to their providers’ office several weeks later not having followed a prescribed plan of care. As one social worker stated, . . . a lot of times they just don’t take it and then they show up at their primary care doctor, two or three weeks later and say, ‘I was supposed to be taking this, but was too expensive, so I didn’t get it.’

Insurance language can also be difficult for patients to understand and access to the correct insurance plan can affect patients’ ability to obtain their medications. A social worker remarked: Some people just don’t do anything for fear, because they don’t know, will this be covered? Is this covered? . . . They have one bad experience where they get a medicine outside their formulary and then they don’t trust it, anymore. And they want out of it, and they want to change. Or they get a phone call from somebody selling a new kind of HMO insurance and sign up for it. Then they’ve got the premium.

As this social worked concluded, ‘‘It’s just a headache all around . . . . especially people with cognitive impairments who are living at home and will talk to anybody on the phone.’’ Another significant barrier to providing high-quality care to cognitively impaired adults is insufficient time. Geriatric medicine-based providers and staff frequently find that they do not have the time to give cognitively impaired patients all the care they need and are frequently frustrated by other parts of the hospital system that either do not recognize CI



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among patients or rely on geriatric medicine providers to coordinate all of these patients’ needs. As one nurse stated, We do intensive care, whether it’s inpatient, in-home, or in clinic, for our patients because of the kind of patients we see. And that takes a lot of time . . . . It takes a lot of energy. It takes a lot of resources.

As one social worked observed, ‘‘We are providing a lot of innovative services and we have the team to be able . . . to address a lot of different needs. We’re also getting stretched, as far as our resources and being able to respond to problems.’’ One physician remarked: The part that I find the most frustrating is when I encounter other parts of the medical system that are not set up to care for these folks at all. They don’t have the faintest idea . . . .and they don’t seem to care that the patient’s cognitively impaired, that they [the patients] can’t understand all the information that’s being thrown at them . . . . . . if they’re [other providers are] aware of us . . . they sometime will look at us to be the savior for all of these folks.

Clearly, some providers feel the strain and the pressure associated with providing care for vulnerable older adults in a system that is not optimally configured to care for an everincreasing number of cognitively impaired patients. Finally, one other frequently mentioned barrier to care is the denial of CI, expressed not only by patients but also by caregivers. This denial can affect not only providers’ efforts to make a diagnosis of CI but also efforts to coordinate care for these older adults. One nurse practitioner noted, One of the challenges is identifying cognitive impairment . . . And the families oftentimes will deny that there’s anything wrong with the person, and even though you get the sense that something’s wrong, they do a good job of covering it up and . . . it takes a while to tease out, you know, fact and fiction.

Another medical assistant added: I’ve literally begged this one son-in-law to just once a week, please, set this guy’s Warfarin up for the week . . . so then you don’t have to bring him every week, ‘cause he [the patient] can’t figure it out himself . . . So families can be a barrier, as well as a great helping factor.

As a result of these issues, providers find that it can be very difficult to provide effective and coordinated care to patients within and across settings.

Strategies that improve or facilitate caring for hospitalized older adults Despite these difficulties in providing care to cognitively impaired individuals, the focus group participants identified strategies that facilitate providing improved care to these adults. The first of these was having a dedicated inpatient service involved in coordinating care for the patient, particularly around the time of their discharge. As one inpatient physician speaking about the ‘‘Acute Care for the Elderly’’ (ACE) service remarked, ‘‘Having that service [ACE] does a lot of good . . . for coordinating care . . . because we have our social worker and one of our nurses take over the discharge planning process for those patients.’’ These teams of providers are familiar with services that exist in the community and surrounding health care environment and



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are able to connect vulnerable seniors with these services. As one social worker stated, ‘‘I think we provide good Band-Aids and . . . wrap-around services while our patients are waiting for other services . . . ’’ Indeed, a hallmark of our local geriatric medicine program has been a rich variety of services designed to meet the unique needs of older adults. Perhaps not surprisingly, our focus group participants remarked that the collaboration among and continuity of care provided by these programs is very helpful when caring for this population. Remarking on this phenomenon, one nurse practitioner stated, ‘‘I’m with the GRACE program and . . . a lot of our referrals do come straight from the ACE. I go out in the home. So I often get a packet with their full evaluation in it, which is very helpful.’’ In fact, this sharing of information is seen as essential for providing excellent care and is facilitated by an electronic medical record that notifies other providers when patients are hospitalized. As one social worker stated: I get updates when our patients go inpatient automatically on the computer and that will tell me that I need to look in their history and see what’s going on . . . and then if they’ve had an ACE consult, I can read it in the computer and all of our primary care physicians get a report when one of their patients goes onto ACE. So they’re aware . . . that they were seen and what the recommendations were.

Our focus group participants suggested that excellent care can only be provided to cognitively impaired older adults when inpatient services are attuned to patients’ needs and all of the older adult services are effectively communicating with each other.

The central role that good communication plays In fact, throughout the focus group sessions, the quality of communication between teams was mentioned as a central determinant of the quality of patient care. Good communication was recognized as facilitating excellent care while poor communication was seen as one of the greatest barriers to care. Participants commented that within a large hospital system, inpatient providers’ actions may not be well coordinated with outpatient providers’ work. As one physician summarized, ‘‘There’s a disconnect, a complete disconnect between outpatient and inpatient care. And in many places . . . in many ways, I think . . . that disconnect starts the moment you walk in the front door of the hospital.’’ Participants noted that this lack of alignment between inpatient and outpatient care was exacerbated by the lack of a personal relationship between these teams. Providers lamented not having personal relationships with the inpatient providers responsible for their patients’ inpatient care. A social worker noted, ‘‘Here, I don’t even know who the attendings are’’ and ‘‘I don’t even really know who the house staff is here or who staffs those teams.’’ A physician noted, ‘‘There seems to be very little culture of connecting with primary care [physicians].’’ According to our study participants, these communication barriers can result in patient confusion, medication mismanagement, and inefficient use of providers’ time, among other things. One social worker stated, ‘‘We don’t always have the best communication, but even if we do have the best of intentions, we might be giving the family mixed messages between our teams.’’ Speaking to the issue of medication management, a nurse practitioner noted, ‘‘Somebody in the hospital told them to go home and throw all their medicines away. And you get there, and they actually need some of them . . . not everything was changed.’’



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This miscommunication can result not only in a waste of potentially needed medications but also a waste of provider time. There are also times when outpatient providers are not aware that services are being duplicated. As one social worker stated, Like a CICOA [Central Indiana Council on Aging] referral: maybe it was already done, and I didn’t know it and now I’m repeating everything again . . . sometimes we have really good intentions with all of our different programs, but we get so specialized and split up that we’re really not on the same page.

This type of disjunction between inpatient and outpatient care can result in a clear gap in the patient’s health care.

The importance of fostering a hospital friendly to the needs of older adults Good communication, however, was not the only prerequisite for improving care to cognitively impaired older adults. Our focus group participants reported that it was also important to have a hospital system that was friendly to the needs of older adults—both on the inpatient and outpatient sides. A hospital system that provides resources to accommodate the needs of vulnerable older adults can go a long way toward ensuring they get indicated care. As one social worker noted: That’s just one thing that’s special about Wishard, that they understand the importance of social work in the team environment and you know, that we help with transportation and get people here, and we help figure out their insurance so they’re not afraid to come to their appointments. You know, we’ve had a lady show up and say, well, I’m here, but I can’t be seen because there’s something wrong with my insurance. So, you know, we help her fix that and get her a return appointment when it will be covered. So that’s someone that could have been lost to primary care in another system.

Remarking on geriatric medicine’s influence on the quality of inpatient care, one physician noted: I think, first of all, the medicine teams here get a lot more geriatric education [than] I think medicine teams do in most settings, and so I think they’re particularly well educated. Geriatrics has such a strong presence here, particularly at Wishard, that I think the medicine teams are . . . well, they’re much more knowledgeable . . .

As one social worker succinctly concluded regarding caring for cognitively impaired older adults, ‘‘And for any system that’s going to work, everyone has to buy into the importance of geriatrics and what we’re doing . . . ’’

The need for educating staff, patients, and caregivers Respondents felt that providing education—for staff as well as for patients and caregivers—is one way to improve care for older patients with CI. When asked about strategies to improve care, one social worker replied: What about more education for the folks that are seeing the patients? You know, obviously not that they could become a geriatrician but just very basic things. You know, we hear so much about the medications that make their [the patients’] experience worse . . .



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When asked about this same topic in another focus group, another participant agreed that education of staff about conditions affecting older adults was an important goal but provided a specific example where their team had achieved success. The medical assistant stated: Our nurse case manager on the ACE team . . . worked with our education department last year, and I think the year before, to kind of get delirium into the forefront so that the nursing staff will understand what we’re talking about when we discuss delirium.

As one medical assistant concluded, ‘‘Everything starts with education.’’ Participants also emphasized the importance of education for patients and family caregivers. Patients and caregivers need fundamental information about their medical conditions and how to navigate the medical system. One nurse stated, I think it kind of starts with us, to be able to tell patients and caregivers where to go, this is what you need to do . . . we should be the resources since we’re supposed to be the so-called experts in this area.

Addressing the challenge of motivating caregivers to ask for help, a nurse stated, ‘‘We need to educate them first, maybe before even a diagnosis has been made’’ in order to encourage caregivers to ask for help when they notice that cognition is diminishing in their loved ones. This nurse envisioned this type of education occurring not just during clinic visits but also via other media throughout the hospital settings: We could make up our own videos about our different programs or maybe about delirium, about Alzheimer’s, and have those just running . . . when the loved ones are here visiting at the hospital . . . they [patients and caregivers]would be automatically exposed to information that would enlighten them.

One focus group nurse participant hoped that education of caregivers might help some families understand when it is appropriate to use the emergency department, ‘‘It really is just making sure that the family and patient will remember . . . to use that ‘yell out’ rather than call 911 or throw them in the car and go. You know? Follow proper procedure.’’

Specific steps needed to provide more effective care to cognitively impaired individuals Throughout the course of the focus group interviews, participants offered a series of specific recommendations to improve care of cognitively impaired patients in the time around a hospitalization. These included having inpatient and outpatient computer systems that talk to each other, so that information can be freely shared; integrating nurse practitioners into systems of care so that they can follow patients into and out of the hospital; having a discharge nurse who coordinates everything for the patient including their new medicines; and achieving consistency in who is responsible for patients during a hospitalization (instead of constantly shifting teams).

Discussion Our focus group study indicated that there are several strategies that health care leaders might consider, beyond the simple addition of further resources, if our hospital systems are to better serve vulnerable seniors. In our interviews, our study participants identified factors



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that may facilitate improved care of cognitively impaired older adults (e.g. enhanced communication between teams and better education of staff about conditions affecting older adults); described barriers to delivering this care for which solutions must be devised (e.g. enrolling seniors in insurance programs and existing community support programs); and delineated those aspects of working with cognitively impaired older adults that they enjoy. Older adults, particularly those affected by CI, are at risk for poor care before, during, and after the time of their interactions with the acute care system (Coleman, 2003; Coleman & Berenson, 2004; LaMantia et al., 2010). Inpatient care is costly (Bynum et al., 2004; Hurd et al., 2013), may in some cases be avoidable (Ouslander et al., 2010; Saliba et al., 2000), and places these vulnerable patients at risk of further functional decline (Inouye, 2006; Lefevre et al., 1992; Pedone et al., 2005; Sager et al., 1996). Our results are consistent with and add to the findings of a previous systematic review that evaluated models of care that may improve the care of older adults in the acute care setting and identified four successful strategies that include: (1) a team-based, multidisciplinary approach to care using gerontological expertise; (2) targeted intervention techniques that assess risk factors for the development of complications; (3) attention to discharge planning; and (4) improved communication across care settings (Hickman, Newton, Halcomb, Chang, & Davidson, 2007). In line with the findings of Hickman et al. (2007), our focus group participants felt that specialized care services for the older adult were effective at improving the quality of care that our patients receive. Our respondents noted that good communication between the variety of programs that support older adults in both the inpatient and outpatient teams was central to providing efficient, effective, and sustainable care to this group of patients. Yet, even with these services in place, the focus group participants felt that there were further ways that care could be improved. The focus group participants thought it was important to foster an environment throughout the hospital system that is friendly to older adults and to establish a plan for educating staff, patients, and caregivers about conditions affecting elders, including CI. Indeed, both organization culture change and education of individuals have been identified previously as strategies to help improve the quality of care delivery within a health care system (Ferlie & Shortell, 2001). With the combined challenge posed by the aging of the Baby Boom generation and the dearth of additional geriatricians entering the physician workforce, it may be more important than ever that our hospital services as a whole become ‘‘geriatricized’’ and that incentives to coordinate care for vulnerable seniors across sites of care be developed. As others have noted (Walke & Tinetti, 2013), these adaptations may be further encouraged by the changes that occur with the implementation of health care reform. Indeed, the 2011 National Alzheimer’s Project Act in the United States has set the funding of programs to improve health outcomes of older adults with dementia as a national priority (Mitchell et al., 2012). Further, the Center for Medicare and Medicaid Innovation has supported the development of models of care that focus on people with Alzheimer’s disease (Callahan et al., 2014; Reuben et al., 2013). Our focus group participants identified several barriers in coordinating care for cognitively impaired older adults including difficulties addressing insurance issues (particularly around paying for medications), finding adequate time to provide the highintensity care across settings that these patients require, and denial on the part of patients and caregivers that the patient is affected significantly by their CI. These identified barriers match well with impediments to excellent care identified in previous work in vulnerable populations. In 2003, the President’s New Freedom Commission on Mental Health



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identified prescription and insurance coverage and stigma associated with diagnosis as significant barriers to improved access and continuity of care among older adults with mental illness (Bartels, 2003). In foundational work on transitional care, Coleman identified both insurance issues and confusion around medications as barriers to care, as well as the provision of care in siloes and fragmented communication between providers as additional obstacles to improved care (Coleman, 2003). The fact that these barriers to care still persist even in an environment where programs designed to care for older adults flourish, and in an era where most medications and services should be covered by Medicare-derived insurance programs for older adults, underlines that it is not merely sufficient to make geriatric services available to vulnerable older adults, rather these services must be offered and provided in a seamless and coordinated manner. Beyond these findings, our respondents identified factors related to providing care to cognitively impaired adults that they either enjoyed or found challenging. On the whole, our focus group participants not only enjoyed working with this cohort of patients but also found that the time and intensity of their work were at times stressful. Prior work comparing stress and burnout among staff working with older adults in nursing homes and acute geriatric medicine wards has found stress levels to be higher among hospital staff dedicated to the care of older adults and among staff working with cognitively impaired patients than for staff working with other patients (Cocco, Gatti, de Mendonca Lima, & Camus, 2003). Recognition of these factors and the development of plans by health care

Figure 1. Proposed inpatient model of care for patients with cognitive impairment.



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system leaders to mitigate staff burnout will be important if we are to develop effective and sustainable service models to provide care to this vulnerable segment of the population. Given these suggestions from our study participants, constructing a prototype of an improved system of hospital-based care for cognitively impaired individuals based upon existing outpatient-based models of care for similar patients is possible. In these outpatient collaborative care models (Boustani et al., 2011; Callahan et al., 2011; Vickrey et al., 2006), care coordinators serve as intermediaries who help link services that are provided by primary care providers and specialists; manage and ensure the delivery of harmonized plans of care across settings that respect patients’ goals; and provide caregivers with important education and support services. These models of care are effective at improving the quality of care for patients with Alzheimer’s disease and at reducing the behavioral and psychological symptoms of dementia in the outpatient setting (Callahan et al., 2006; Chodosh et al., 2012; Vickrey et al., 2006). In such a model (Figure 1), an inpatient brain care coordinator serves as a clinical liaison for the patient’s plan of care and addresses many of the recommendations of our study participants for how hospital-based care might be improved for cognitively impaired individuals (Figure 2).

Figure 2. Focus group participants’ suggestions of strategies to improve care of hospitalized older adults with cognitive impairment.



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Our conclusions are constrained by the usual limits of focus group methodologies. Our study group participants represent a convenience sample, and their responses represent only their opinions and not the opinions of other providers. We also did not interview patients or their caregivers; they will need to be interviewed in future work. Still, these results report the opinion of a wide array of professionals who are very familiar with the care of cognitively impaired older adults with a combined wealth of experience serving this population. Moreover, these individuals work in a health care system that enjoys a number of innovative geriatric programs, and this study provides the opportunity to highlight gaps in the system of care that might lead to greater improvement when specifically targeted to patients with CI. The findings of this study suggest multiple factors that either facilitate or serve as barriers to providing excellent care to cognitively impaired older adults as they interact with the acute care system. From our interviews, it is clear that having excellent and well-designed older adult service programs certainly makes caring for vulnerable seniors easier. However, is not simply sufficient to have these services available; rather what is also needed is a coordinated effort by a well-educated hospital staff and system friendly to older adults that aim to harmonize patients’ care. Improving the care of patients affected by CI is indeed an important challenge in health care reform, and it is our hope that health care reform may ultimately provide the incentive for health care systems to adequately design systems to coordinate care for patients across care settings. Focus group interviews with providers are an important first step in considering how we might redesign this system of care. Future work may additionally incorporate the perspective of affected patients and family caregivers in order to develop even more grounded innovations. Funding This work was supported by funding from the John A. Hartford Foundation.

Acknowledgements An earlier version of this work has been presented previously in poster format at the Annual Scientific Meeting of the American Geriatrics Society in Grapevine, Texas in May 2013.

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Michael A. LaMantia is an Assistant Professor of Medicine in the Indiana University Center for Aging Research at the Indiana University School of Medicine and a Research Scientist with Regenstrief Institute. His research focuses on the care of vulnerable older adults, particularly those with cognitive impairment, in the acute care environment. Malaz A. Boustani is a Professor of Medicine in the Indiana University Center for Aging Research at the Indiana University School of Medicine and a Research Scientist with Regenstrief Institute. He is a physician and health services researcher who serves as Chief Operating Officer of Indiana University’s Center for Health Innovation and Implementation Science. Shola Jhanji is currently a Research Compliance Associate with the Indiana University Human Subjects Office. She has also been involved in research involving medication adherence in older adults with mild cognitive impairment and delirium evaluation in the emergency department. She has a particular interest in bioethics and the involvement of people with delirium and mild cognitive impairment in social research. Mungai Maina is a Research Coordinator at the Indiana University Center for Aging Research. He is currently working on projects involving delirium detection in the Emergency Department and interventions for older people with dementia and their caregivers. Arif Nazir is an Associate Professor of Clinical Medicine in the Indiana University School of Medicine. His research evaluates mechanisms to improve care provided to older adults in nursing home settings. Frank C. Messina is an Associate Professor of Clinical Emergency Medicine and Clinical Medicine in the Indiana University School of Medicine. He is also Medical Director of Transition of Care and Medical Director of Clinical Decision Unit at Eskenazi Health. Amie Frame is a Research Manager at the Indiana University Center for Aging Research. She is currently working on a project regarding screening for dementia in primary care settings.



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Catherine Alder is a Chief Administrator of the Aging Brain Care programs at Eskenazi Health. In addition to managing the day-to-day operations of the Aging Brain Care Medical Home, she is currently serving as project manager for the Center for Medicare and Medicaid Health Care Innovation Challenge Award project, Dissemination of the Aging Brain Care Program. Joshua Chodosh is an Assistant Chief of Staff for Patient Safety at the Veterans Affairs Greater Los Angeles Health System and Professor of Medicine at the David Geffen School of Medicine at University of California, Los Angeles. He is a physician and health services researcher and directs a dementia telehealth program.


Redesigning systems of care for older adults with Alzheimer's disease.

Outcomes of cognitively impaired older people in Transition Care.

Cost-effectiveness of optimizing acute stroke care services for thrombolysis.

Factors associated with family caregiver dissatisfaction with acute hospital care of older cognitively impaired relatives.

Evaluation of health care services provided for older adults in primary health care centers and its internal environments.

Filling the gaps in preventive care services for older adults.

Effects of alternative interventions among hospitalized, cognitively impaired older adults.

Studying nursing interventions in acutely ill, cognitively impaired older adults.

Older adults and the health care workforce.

Cross-cultural health care for older adults: strategies for pharmacists.

Cognitive Decline and Hearing Health Care for Older Adults.

Virtual visits in home health care for older adults.

Optimizing Eating Performance for Older Adults With Dementia Living in Long-term Care: A Systematic Review.

Care of older adults.

Outpatient health care utilization in a sample of cognitively impaired veterans receiving care in VHA geriatric evaluation and management clinics.

Integration and continuity of Care in health care network models for frail older adults.

Dental care utilization among caregivers who care for older adults.

Transforming emergency care for older adults.

Caring for older adults in critical care.

Medication transitions and polypharmacy in older adults following acute care.

Health care services for flood victims.

Redesigning the regulatory framework for ambulatory care services in New York.

Providing culturally congruent health care to older adults.

Mental Health Screening of Older Adults in Primary Care.