Dementia Care Staff and Family Carers: Their Relationships in the Context of Care

Objectives: This research examines relationships between care staff specifically employed to care for residents with dementia and family carers. Method: The study employed a qualitative approach involving multiple methods of data collection (in-depth interviews, participant observation, assessment of the physical and mental function of residents). A non-random sample consisting of fifteen care staff from seven residential care settings was used. Results: Care staff perceive that family carers are generally grateful and undemanding and that a significant number lack sufficient involvement in residents' care. Policy and organisational factors may produce positive understanding between care staff and family carers, while at a less visible level, may prevent both groups from voicing more difficult concerns related to care. Conclusions: Policy and organisational change is needed to enable staff and family carers to voice the tensions inherent in their relationship. Funding arrangements for residential care need to include time for staff to develop relationships with family carers.     

The Affordable Care Act and Diabetes Diagnosis and Care: Exploring the Potential Impacts

This article reviews available data on the implications of the Affordable Care Act (ACA) for the diagnosis and care of type 2 diabetes. We provide a general overview of the major issues for diabetes diagnosis and care, and describe the policies in the ACA that affect diabetes diagnosis and care. We also estimate that approximately 2.3 million of the 4.6 million people in the USA with undiagnosed diabetes aged 18–64 in 2009–2010 may have gained access to free preventive care under the ACA, which could increase diabetes detection. In addition, we note two factors that may limit the success of the ACA for improving access to diabetes care. First, many states with the highest diabetes prevalence have not expanded Medicaid eligibility, and second, primary care providers may not adequately meet the increase in Medicaid patients because federal funding to increase provider reimbursement for Medicaid visits recently expired. We close by discussing current gaps in the literature and future directions for research on the ACA’s impact on diabetes diagnosis, care, and health outcomes.     

Severe Asthma and the Primary Care Provider: Identifying Patients and Coordinating Multidisciplinary Care

Without proper care, patients with severe forms of asthma face substantial medical risks, marked reductions in quality of life, and other significant disease-related burdens. Therefore, it is essential that primary care clinicians and other healthcare providers are adept at identifying cases of severe asthma on the basis of symptom control, exacerbation risks, and the need for relatively aggressive treatment regimens (eg, high-dose inhaled corticosteroids with long-acting controller medications or frequent oral corticosteroid use). Engaging and educating affected individuals as part of ongoing treatment planning are best achieved with a good understanding of patients' own insights into their disease and management challenges that often arise in busy healthcare practices. This includes effectively communicating with patients about the implications of their diagnosis and potential treatment strategies that can be accessed via coordinated multidisciplinary care. Expert primary care and specialist faculty have highlighted strategies to identify cases of severe asthma, appropriate referral pathways for these individuals, and considerations on integrating patients' perspectives into clinical decision making across the continuum of care (access to an accredited educational program on these topics is available at http://courses.elseviercme.com/pcp/687). Additionally, this online program is a component of a larger platform of education activities and consolidated clinical resources designed to improve the care of patients with respiratory disorders (http://respiratorycme.elsevierresource.com/).     

Missing Care: the Initial Impact of the COVID-19 Pandemic on CKD Care Delivery

BackgroundChronic kidney disease (CKD) is a common condition with adverse health outcomes addressable by early disease management. The impact of the COVID-19 pandemic on care utilization for the CKD population is unknown.ObjectiveTo examine pandemic CKD care and identify factors associated with a high care deficit.DesignRetrospective observational studyParticipants248,898 insured individuals (95% Medicare Advantage, 5% commercial) with stage G3–G4 CKD in 2018Main MeasuresPredicted (based on the pre-pandemic period of January 1, 2019–February 28, 2020) to observed per-member monthly face-to-face and telehealth encounters, laboratory testing, and proportion of days covered (PDC) for medications, evaluated during the early (March 1, 2020–June 30, 2020), pre-vaccine (July 1, 2020–December 31, 2020), and late (January 2021–August 2021) periods and overall.Key ResultsIn-person encounters fell by 24.1% during the pandemic overall; this was mitigated by a 14.2% increase in telehealth encounters, resulting in a cumulative observed utilization deficit of 10% relative to predicted. These reductions were greatest in the early pandemic period, with a 19.8% cumulative deficit. PDC progressively decreased during the pandemic (range 9–20% overall reduction), with the greatest reductions in hypertension and diabetes medicines. CKD laboratory monitoring was also reduced (range 11.8–43.3%). Individuals of younger age (OR 1.63, 95% CI 1.16, 2.28), with commercial insurance (1.43, 95% CI 1.25, 1.63), residing in the Southern US (OR 1.17, 95% CI 1.14, 1.21), and with stage G4 CKD (OR 1.21, 95% CI 1.17, 1.26) had greater odds of a higher care deficit overall.ConclusionsThe early COVID-19 pandemic resulted in a marked decline of healthcare services for individuals with CKD, with an incomplete recovery during the later pandemic. Increased telehealth use partially compensated for this deficit. The downstream impact of CKD care reduction on health outcomes requires further study, as does evaluation of effective care delivery models for this population.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-022-07805-w.KEY WORDS: chronic kidney disease, COVID-19, epidemiology     

Care of Older Adults: Role of Primary Care Physicians in the Treatment of Cataracts and Macular Degeneration

This article aims to facilitate optimal management of cataracts and age‐related macular degeneration (AMD) by providing information on indications, risk factors, referral guidelines, and treatments and to describe techniques to maximize quality of life (QOL) for people with irreversible vision loss. A review of PubMed and other online databases was performed for peer‐reviewed English‐language articles from 1980 through August 2012 on visual impairment in elderly adults. Search terms included vision loss, visual impairment, blind, low vision, QOL combined with age‐related, elderly, and aging. Articles were selected that discussed vision loss in elderly adults, effects of vision impairment on QOL, and care strategies to manage vision loss in older adults. The ability of primary care physicians (PCPs) to identify early signs of cataracts and AMD in individuals at risk of vision loss is critical to early diagnosis and management of these common age‐related eye diseases. PCPs can help preserve vision by issuing aptly timed referrals and encouraging behavioral modifications that reduce risk factors. With knowledge of referral guidelines for soliciting low‐vision rehabilitation services, visual aids, and community support resources, PCPs can considerably increase the QOL of individuals with uncorrectable vision loss. By offering appropriately timed referrals, promoting behavioral modifications, and allocating low‐vision care resources, PCPs may play a critical role in preserving visual health and enhancing the QOL for the elderly population.     

Innovation and Consumer Directed Care: Identifying the challenges

Our aim was to report clinician and researcher observations about the practical difficulties with achieving the articulated objectives of Consumer Directed Care (CDC). The methods used were as follows: identification of key client community services issues through analysis of qualitative data related to a PhD project; review of the summary of these issues by the supervising academic; presentation of the issues to five clinicians involved with a community service clinical trial; verification of the findings through discussions with a senior community service provider. There is anecdotal evidence that the current overlay of CDC in the existing community‐based home services sector for people who are older will continue to prevent its effective implementation. The existing culture and underlying philosophies related to this sector maybe unable to support the level of innovative change required. Research is needed into how the stated objectives of CDC can be achieved in Australia and how this can best be managed.     

Health Care Reform and the Primary Care Workforce Bottleneck

To establish and sustain the high-performing health care system envisioned in the Affordable Care Act (ACA), current provisions in the law to strengthen the primary care workforce must be funded, implemented, and tested. However, the United States is heading towards a severe primary care workforce bottleneck due to ballooning demand and vanishing supply. Demand will be fueled by the “silver tsunami” of 80 million Americans retiring over the next 20 years and the expanded insurance coverage for 32 million Americans in the ACA. The primary care workforce is declining because of decreased production and accelerated attrition. To mitigate the looming primary care bottleneck, even bolder policies will be needed to attract, train, and sustain a sufficient number of primary care professionals. General internists must continue their vital leadership in this effort.     

Academia,Chronic Care,and the Future of Primary Care

Most proposals to reform health care delivery center on a robust, well-designed primary care sector capable of reducing the health and cost consequences of major chronic illnesses. Ironically, the intensified policy interest in primary care coincides with a steep decline in the proportion of medical students choosing primary care careers. Negativity stemming from the experience of trying to care for chronically ill patients with complex conditions in poorly designed, chaotic primary care teaching settings may be influencing trainees to choose other career paths. Redesigning teaching clinics so that they routinely provide high quality, well-organized chronic care would appear to be a critical early step in addressing the looming primary care workforce crisis. The Chronic Care Model provides a proven framework for such a redesign, and has been, with organizational support and effort, successfully implemented in academic settings.