Browsing by Author "Schubert, Cathy C."
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Item The Challenge of Reducing Patient Falls in Hospitals(ACP, 2020) Schubert, Cathy C.; Medicine, School of MedicineItem Effectiveness of the VA-Geriatric Resources for Assessment and Care of Elders (VA-GRACE) program: An observational cohort study(Wiley, 2022) Schubert, Cathy C.; Perkins, Anthony J.; Myers, Laura J.; Damush, Teresa M.; Penney, Lauren S.; Zhang, Ying; Schwartzkopf, Ashley L.; Preddie, Alaina K.; Riley, Sam; Menen, Tetla; Bravata, Dawn M.; Medicine, School of MedicineBackground: As the Department of Veterans Affairs (VA) healthcare system seeks to expand access to comprehensive geriatric assessments, evidence-based models of care are needed to support community-dwelling older persons. We evaluated the VA Geriatric Resources for Assessment and Care of Elders (VA-GRACE) program's effect on mortality and readmissions, as well as patient, caregiver, and staff satisfaction. Methods: This retrospective cohort included patients admitted to the Richard L. Roudebush VA hospital (2010-2019) who received VA-GRACE services post-discharge and usual care controls who were potentially eligible for VA-GRACE but did not receive services. The VA-GRACE program provided home-based comprehensive, multi-disciplinary geriatrics assessment, and ongoing care. Primary outcomes included 90-day and 1-year all-cause readmissions and mortality, and patient, caregiver, and staff satisfaction. We used propensity score modeling with overlapping weighting to adjust for differences in characteristics between groups. Results: VA-GRACE patients (N = 683) were older than controls (N = 4313) (mean age 78.3 ± 8.2 standard deviation vs. 72.2 ± 6.9 years; p < 0.001) and had greater comorbidity (median Charlson Comorbidity Index 3 vs. 0; p < 0.001). VA-GRACE patients had higher 90-day readmissions (adjusted odds ratio [aOR] 1.55 [95%CI 1.01-2.38]) and higher 1-year readmissions (aOR 1.74 [95%CI 1.22-2.48]). However, VA-GRACE patients had lower 90-day mortality (aOR 0.31 [95%CI 0.11-0.92]), but no statistically significant difference in 1-year mortality was observed (aOR 0.88 [95%CI 0.55-1.41]). Patients and caregivers reported that VA-GRACE home visits reduced travel burden and the program linked Veterans and caregivers to needed resources. Primary care providers reported that the VA-GRACE team helped to reduce their workload, improved medication management for their patients, and provided a view into patients' daily living situation. Conclusions: The VA-GRACE program provides comprehensive geriatric assessments and care to high-risk, community-dwelling older persons with high rates of satisfaction from patients, caregivers, and providers. Widespread deployment of programs like VA-GRACE will be required to support Veterans aging in place.Item Expanding Access to Comprehensive Geriatric Evaluation via Telehealth: Development of Hybrid-Virtual Home Visits(Springer, 2024) Schubert, Cathy C.; Penney, Lauren S.; Schwartzkopf, Ashley L.; Damush, Teresa M.; Preddie, Alaina; Flemming, Soyna; Myers, Jennifer; Myers, Laura J.; Perkins, Anthony J.; Zhang, Ying; Bravata, Dawn M.; Medicine, School of MedicineBackground: In response to the aging population, the Department of Veterans Affairs (VA) seeks to expand access to evidence-based practices which support community-dwelling older persons such as the Geriatric Resources for Assessment and Care of Elders (GRACE) program. GRACE is a multidisciplinary care model which provides home-based geriatric evaluation and management for older Veterans residing within a 20-mile drive radius from the hospital. We sought to expand the geographic reach of VA-GRACE by developing a hybrid-virtual home visit (TeleGRACE). Objectives: The objectives were to: (1) describe challenges encountered and solutions implemented during the iterative, pre-implementation program development process; and (2) illustrate potential successes of the program with two case examples. Design: Quality improvement project with longitudinal qualitative data collection. Program description: The hybrid-virtual home visit involved a telehealth technician travelling to patients' homes and connecting virtually to VA-GRACE team members who participated remotely. Approach & participants: We collected multiple data streams throughout program development: TeleGRACE staff periodic reflections, fieldnotes, and team meeting notes; and VA-GRACE team member interviews. Key results: The five program domains that required attention and problem-solving were: telehealth connectivity and equipment, virtual physical examination, protocols and procedures, staff training, and team integration. For each domain, we describe several challenges and solutions. An example from the virtual physical examination domain: several iterations were required to identify the combination of telehealth stethoscope with dedicated headphones that allowed remote nurse practitioners to hear heart and lung sounds. The two cases illustrate how this hybrid-virtual home visit model provided care for patients who would not otherwise have received timely healthcare services. Conclusions: These results provide a blueprint to translate an in-person home-based geriatrics program into a hybrid-virtual model and support the feasibility of using hybrid-virtual home visits to expand access to comprehensive geriatric evaluation and ongoing care for high-risk, community-dwelling older persons who reside geographically distant from the primary VA facility.Item Impact of event notification services on timely follow-up and rehospitalization among primary care patients at two Veterans Affairs Medical Centers(Oxford University Press, 2021-11-25) Dixon, Brian E.; Judon, Kimberly M.; Schwartzkopf, Ashley L.; Guerrero, Vivian M.; Koufacos, Nicholas S.; May, Justine; Schubert, Cathy C.; Boockvar, Kenneth S.; Medicine, School of MedicineObjective: To examine the effectiveness of event notification service (ENS) alerts on health care delivery processes and outcomes for older adults. Materials and methods: We deployed ENS alerts in 2 Veterans Affairs (VA) medical centers using regional health information exchange (HIE) networks from March 2016 to December 2019. Alerts targeted VA-based primary care teams when older patients (aged 65+ years) were hospitalized or attended emergency departments (ED) outside the VA system. We employed a concurrent cohort study to compare postdischarge outcomes between patients whose providers received ENS alerts and those that did not (usual care). Outcome measures included: timely follow-up postdischarge (actual phone call within 7 days or an in-person primary care visit within 30 days) and all-cause inpatient or ED readmission within 30 days. Generalized linear mixed models, accounting for clustering by primary care team, were used to compare outcomes between groups. Results: Compared to usual care, veterans whose primary care team received notification of non-VA acute care encounters were 4 times more likely to have phone contact within 7 days (AOR = 4.10, P < .001) and 2 times more likely to have an in-person visit within 30 days (AOR = 1.98, P = .007). There were no significant differences between groups in hospital or ED utilization within 30 days of index discharge (P = .057). Discussion: ENS was associated with increased timely follow-up following non-VA acute care events, but there was no associated change in 30-day readmission rates. Optimization of ENS processes may be required to scale use and impact across health systems. Conclusion: Given the importance of ENS to the VA and other health systems, this study provides guidance for future research on ENS for improving care coordination and population outcomes.Item Implementing GRACE Team Care in a Veterans Affairs Medical Center: Lessons Learned and Impacts Observed(Wiley, 2016-07) Schubert, Cathy C.; Myers, Laura J.; Allen, Katie; Counsell, Steven R.; Department of Medicine, IU School of MedicineIn a randomized clinical trial, Geriatric Resources for Assessment and Care of Elders (GRACE), a model of care that works in collaboration with primary care providers (PCPs) and patient-centered medical homes to provide home-based geriatric care management focusing on geriatric syndromes and psychosocial problems commonly found in older adults, improved care quality and reduced acute care use for high-risk, low-income older adults. To assess the effect of GRACE at a Veterans Affairs (VA) Medical Center (VAMC), veterans aged 65 and older from Marion County, Indiana, with PCPs from four of five VAMC clinics who were not on hospice or dialysis were enrolled in GRACE after discharge home from an acute hospitalization. After an initial home-based transition visit to GRACE enrollees, the GRACE team returned to conduct a geriatric assessment. Guided by 12 protocols and input from an interdisciplinary panel and the PCP, the GRACE team developed and implemented a veteran-centric care plan. Hospitalized veterans from the fifth clinic, who otherwise met enrollment criteria, served as a usual-care comparison group. Demographic, comorbidity, and usage data were drawn from VA databases. The GRACE and comparison groups were similar in age, sex, and burden of comorbidity, although predicted risk of 1-year mortality in GRACE veterans was higher. Even so, GRACE enrollment was associated with 7.1% fewer emergency department visits, 14.8% fewer 30-day readmissions, 37.9% fewer hospital admissions, and 28.5% fewer total bed days of care, saving the VAMC an estimated $200,000 per year after program costs during the study for the 179 veterans enrolled in GRACE. Having engaged, enthusiastic VA leadership and GRACE staff; aligning closely with the medical home; and accommodating patient acuity were among the important lessons learned during implementation.Item Improving Patient Activation among Older Veterans: Results from a Social Worker-Led Care Transitions Intervention(Taylor & Francis, 2022) Koufacos, Nicholas S.; May, Justine; Judon, Kimberly; Franzosa, Emily; Dixon, Brian E.; Schubert, Cathy C.; Schwartzkopf, Ashley L.; Guerrero, Vivian M.; Traylor, Morgan; Boockvar, Kenneth S.; Medicine, School of MedicineOlder veterans enrolled in the Veterans Health Administration (VHA) often use both VHA and non-VHA providers for their care. This dual use, especially around an inpatient visit, can lead to fragmented care during the time of transition post-discharge. Interventions that target patient activation may be valuable ways to help veterans manage complex medication regimens and care plans from multiple providers. The Care Transitions Intervention (CTI) is an evidence-based model that helps older adults gain confidence and skills to achieve their health goals post-discharge. Our study examined the impact of CTI upon patient activation for veterans discharged from non-VHA hospitals. In total, 158 interventions were conducted for 87 veterans. From baseline to follow-up there was a significant 1.7-point increase in patient activation scores, from 5.4 to 7.1. This association was only found among those who completed the intervention. The most common barriers to completion were difficulty reaching the veteran by phone, patient declining the intervention, and rehospitalization during the 30 days post-discharge. Care transitions guided by social workers may be a promising way to improve patient activation. However, future research and practice should address barriers to completion and examine the impact of increased patient activation on health outcomes.Item Lessons and Outcomes of Mobile Acute Care for Elders Consultation in a Veterans Affairs Medical Center(Wiley, 2019-04) Schubert, Cathy C.; Parks, Rebecca; Coffing, Jessica M.; Daggy, Joanne; Slaven, James E.; Weiner, Michael; Medicine, School of MedicineOBJECTIVE Describe the implementation and effects of Mobile Acute Care for Elders (MACE) consultation at a Veterans Affairs Medical Center (VAMC). DESIGN Retrospective cohort analysis. INTERVENTION Veterans aged 65 or older who were admitted to the medicine service between October 1, 2012, and September 30, 2014, were screened for geriatric syndromes via review of medical records within 48 hours of admission. If the screen was positive, the MACE team offered the admitting team a same‐day consultation involving comprehensive geriatric assessment and ongoing collaboration with the admitting team and supportive services to implement patient‐centric recommendations for geriatric syndromes. RESULTS Veterans seen by MACE (n = 421) were compared with those with positive screens but without consultation (n = 372). The two groups did not significantly differ in age, comorbidity, sex, or race. All outcomes (30‐day readmission, 30‐day mortality, readmission costs) were in the expected direction for patients receiving MACE but did not reach statistical significance. Patients receiving MACE had lower odds of 30‐day readmission (11.9% vs 14.8%; odds ratio [OR] = 0.82; 95% confidence interval [CI] = 0.54‐1.25; p = .360) and 30‐day mortality (5.5% vs 8.6%; OR = 0.64; CI = 0.36‐1.12; p = .115), and they had lower 30‐day readmission costs (MACE $15,502; CI = $12,242‐$19,631; comparison = $18,335; CI = $14,641‐$22,962; p = .316) than those who did not receive MACE after adjusting for age and Charlson Comorbidity Index. CONCLUSION Our MACE consultation model for older veterans with geriatric syndromes leverages the limited supply of clinicians with expertise in geriatrics. Although not statistically significant in this study of 793 subjects, MACE patients had lower odds of 30‐day readmission and mortality, and lower readmission costs.Item Regional data exchange to improve care for veterans after non-VA hospitalization: a randomized controlled trial(Biomed Central, 2019-07-04) Dixon, Brian E.; Schwartzkopf, Ashley L.; Guerrero, Vivian M.; May, Justine; Koufacos, Nicholas S.; Bean, Andrew M.; Penrod, Joan D.; Schubert, Cathy C.; Boockvar, Kenneth S.; Epidemiology, Richard M. Fairbanks School of Public HealthBACKGROUND: Coordination of care, especially after a patient experiences an acute care event, is a challenge for many health systems. Event notification is a form of health information exchange (HIE) which has the potential to support care coordination by alerting primary care providers when a patient experiences an acute care event. While promising, there exists little evidence on the impact of event notification in support of reengagement into primary care. The objectives of this study are to 1) examine the effectiveness of event notification on health outcomes for older adults who experience acute care events, and 2) compare approaches to how providers respond to event notifications. METHODS: In a cluster randomized trial conducted across two medical centers within the U.S. Veterans Health Administration (VHA) system, we plan to enroll older patients (≥ 65 years of age) who utilize both VHA and non-VHA providers. Patients will be enrolled into one of three arms: 1) usual care; 2) event notifications only; or 3) event notifications plus a care transitions intervention. In the event notification arms, following a non-VHA acute care encounter, an HIE-based intervention will send an event notification to VHA providers. Patients in the event notification plus care transitions arm will also receive 30 days of care transition support from a social worker. The primary outcome measure is 90-day readmission rate. Secondary outcomes will be high risk medication discrepancies as well as care transitions processes within the VHA health system. Qualitative assessments of the intervention will inform VHA system-wide implementation. DISCUSSION: While HIE has been evaluated in other contexts, little evidence exists on HIE-enabled event notification interventions. Furthermore, this trial offers the opportunity to examine the use of event notifications that trigger a care transitions intervention to further support coordination of care. TRIAL REGISTRATION: ClinicalTrials.gov NCT02689076. "Regional Data Exchange to Improve Care for Veterans After Non-VA Hospitalization." Registered 23 February 2016.