Accuracy of self-reported health services use and patterns of care among urban older adults.

BACKGROUND: Understanding older adults' volume and patterns of health service use is fundamental to efforts to improve the quality and efficiency of services. OBJECTIVE: To analyze the accuracy of older adults' self report of health services use and to determine the proportion of care obtained outside a defined urban academic health care system. RESEARCH DESIGN: Telephone survey of self-reports validated against data routinely archived in an electronic medical record system. SUBJECTS: Stratified random sample of 422 patients (> or = 60 years) who had contact with the health care system at least once in the previous 3 months. MEASURES: Self reports of hospitalizations, emergency room visits, physicians visits, extended care visits, and home care visits over the past 12 months, health status, physical activity, and sociodemographics factors. RESULTS: The sample population was more likely to report health services use and functional disability than was a community-based sample of older adults; 67% of the sample were women, 53.9% were African American, 71% were age 65 and over, 38.7% lived alone, and 24.6% reported poor financial resources. Based on data from the electronic medical record, 27.9% of the sample were hospitalized at least once in the prior 12 months, 54.6% had at least one emergency room visit, and the mean number of ambulatory visits was 8.1. Comparing self-report data to the electronic record data, 24.1% of older adults with a hospitalization in the prior 12 months failed to report the episode; 28.1% of those with an emergency room visit failed to report the episode as did 5.2% of those with an ambulatory care visit. The accuracy of the self reports of volume of these services were also substantially under reported. We were unable to identify any patient characteristics that were highly correlated with inaccuracy. We estimate that approximately 9.5% of health care costs are accrued outside this urban health care system. CONCLUSIONS: These older adults substantially under-report health services use, including hospital episodes over a 12-month period. Reliance on self-reported use data over the prior year to model patterns of health care use among older adults is not supported by these data.     

Integrating emergency services in an urban health system

When planning for growth and management efficiency across urban health systems, economic and market factors present significant service line challenges and opportunities. This article describes the evolutionary integration of emergency services in St John Health System, a large, religious-sponsored health care system located in Detroit, Michigan. Critical business elements, including the System's vision, mission, and economic context, are defined as the framework for site-specific and System-wide planning. The impact of managed care and market changes prompted St John's clinicians and executives to explore how integrating emergency services could create a competitive market advantage.     

Lack of ethnic disparities in adult immunization rates among underserved older patients in an urban public health system

BACKGROUND: In some settings, immunization rates for ethnic minorities are less than those of non-Hispanic white populations. This study examines demographic differences in the rate of pneumococcal and influenza immunization in an ethnically diverse older patient population seeking care at an urban primary care clinic system. METHODS: The setting is an integrated system of 11 federally qualified community health centers serving approximately 100,000 unduplicated patients annually. We linked data from chart audits performed in 2001-2003 for quality assurance purposes with patient registration data to evaluate vaccination rates in 740 patients age 66 years and older who had at least 3 primary care visits in the previous 2 years. RESULTS: Factors significantly associated with receipt of pneumococcal vaccination in multivariable analysis were Hispanic ethnicity (odds ratio [OR] 1.66-1.77, P = 0.01), medical comorbidities (OR 1.48, P = 0.03), psychiatric comorbidities (OR 2.0, P = 0.001), use of a family medicine versus internal medicine clinic (OR 2.3, P < 0.001), and age (OR 1.04 for 1 year increase, P = 0.004). Factors significantly associated with influenza vaccination were having insurance (OR 2.25, P = 0.014), medical comorbidities (OR 1.71, P = 0.036), age (OR 1.03 for 1 year increase, P = 0.045), later year of audit (OR 1.68-1.73, P = 0.015), and a greater number of clinic visits (OR 1.69, P = 0.006). CONCLUSIONS: Among older regular users of our public community health centers, minority populations have equal or higher immunization rates compared with non-Hispanic whites.     

Falling, health status, and the use of health services by older adults. A prospective study.

In this study, data from the Longitudinal Study on Aging were used to prospectively assess the relationship between repetitive falling or falling only once in the year before baseline and changes in health status and the use of health services. Multiple and logistic regression were used to control for a variety of known covariates, in addition to the baseline values of the target outcomes. Repetitive falling was associated with decreased health status, measured by various activities of daily living and disability indices, at both 2- and 4-year follow-ups. One fall, however, was never associated with deteriorating health status. Similarly, repetitive falling was related to a decreased likelihood of visiting a physician (at the first follow-up, only), but to an increased likelihood of hospitalization, nursing home placement, and death (at both follow-ups). Falling just one time, however, was only associated with an increased likelihood of nursing home placement. Based on outcome trajectories, two subpopulations of repetitive fallers were identified. One subpopulation was consistent with the rapid deterioration hypothesized by the "spiral" response to falling, and includes about 35% of the repetitive fallers (i.e., those who die within 4 years of baseline). The other subpopulation was consistent with the initial decline and subsequent stabilization hypothesized by the "drop-stabilization" response.     

Mental health for older adults and benzodiazpine use

Benzodiazepine (BZD) drug use among community-dwelling seniors is a significant health issue. Although long-term use of BZDs by seniors is a recognized problem, little is known about the mental health of the consumers. Better knowledge of their mental health would help nurses in identifying the psychological needs of this population. The goals of this longitudinal study1 (n = 138) were to describe the mental health status of long-term users of BZDs and to compare it with the mental health of seniors who have either begun or stopped consuming BZDs over a 1-year period (from Phase 1 to Phase 2). Results showed that one third of long-term users of BZDs do not present any mental health problem. Furthermore, no differences were observed between the mental health statuses of new users of BZDs, individuals who stopped using BZDs, and long-term users of BZDs. In conclusion, at least one third of long-term users of BZDs should stop using these drugs, and nurses should play a leading role in helping these seniors withdraw from BZD consumption.     

Health literacy and functional health status in Korean older adults

Aims and objectives. The aim of the study was to investigate the relationships of health literacy to chronic medical conditions and the functional health status among community‐dwelling Korean older adults. Background. In the literature, limited health literacy has been reported to have adverse effect on health outcomes. However, the link between health literacy to health status among Korean older adults needs to be clarified. Design. A cross‐sectional survey. Methods. A cross‐sectional survey of 103 community‐dwelling Korean older adults was conducted from June 2007–September 2007. Health literacy was measured using the Korean Functional Health Literacy test and functional health status was measured using the subscales of the Medical Outcomes Study 12‐item Short‐Form Health Survey. Results. Individuals with a low health literacy had significantly higher rates of arthritis and hypertension. After adjusting for age, education and income, older individuals with low health literacy had higher limitations in activity and lower subjective health. In a model adjusting for age and income only, older individuals with low health literacy were more likely to report lower levels of physical function and subjective health and higher levels of limitations in activity and pain. Conclusions. Among community‐dwelling Korean older adults, limited health literacy is associated independently with higher rates of chronic medical conditions and lower subjective health status. Relevance to clinical practice. Nurses are key to providing health education to older adults. The understanding of the relationship of health literacy to health status is essential to develop communication and health education efforts for older adults in nursing practice.     

Engaging black older adults and caregivers in urban communities in health research

The under-representation of the Black population in research may lead to poor health outcomes for them and a decreased capacity to generalize results to Black populations. This article describes ways in which sensitivity to cultural distinctions of Black older adults and their current or future caregivers can enhance their recruitment and retention in research. Cultural mores play an important role in the shaping of one's perceptions, definitions, responses to disease, and participation in health regimens. Similarly, one's cultural orientation plays a role in how a person is effectively recruited and retained in resear Wenger's translation process model uses cultural meaning to inform research decisions. This model was used in a recent study of Black older adults and their caregivers and will be described in this article. Effectively engaging Black individuals in health research is essential for improving their health.     

Health care use and costs associated with use of a health club membership benefit in older adults with diabetes

OBJECTIVE—The purpose of this study was to determine whether elective use of a health plan–sponsored health club membership had an impact on health care use and costs among older adults with diabetes.RESEARCH DESIGN AND METHODS—Administrative claims for 2,031 older adults with diabetes enrolled in a Medicare Advantage plan were obtained for this retrospective cohort study. Participants (n = 618) in the plan-sponsored health club benefit (Silver Sneakers [SS]) and control subjects (n = 1,413) matched on SS enrollment index date were enrolled in the plan for at least 1 year before the index date. Two-year health care use and costs of SS participants and control subjects were estimated in regressions adjusting for baseline differences.RESULTS—SS participants were more likely to be male, had a lower chronic disease burden, used more preventive services, and had a lower prevalence of arthritis (P ≤ 05). SS participants had lower adjusted total health care costs than control subjects in the first year after enrollment (−$1,633 [95% CI −$2,620 to −$646], P = 0.001), and adjusted total costs in year 2 trended lower (−$1,230 [−$2,494 to $33], P = 0.06). Participants who made on average ≥2 SS visits/week in year 1 had lower total costs in year 2 ($2,141 [−$3,877 to −$405], P = 0.02) than participants who made <2 visits/week.CONCLUSIONS—Use of a health club benefit by older adults with diabetes was associated with slower growth in total health care costs over 2 years; greater use of the benefit was actually associated with declines in total costs.Health care costs associated with diabetes account for 32% of total Medicare spending (1). Clinical practice guidelines recommend physical activity as an important component of diabetes management (2) and for prevention of cardiovascular complications (3), but only 16% of individuals aged 65–74 years engage in at least 30 min of moderate activity ≥5 days/week (4). The benefits of physical activity for older adults include better health, improved functioning, increased quality of life, lower health care costs, and longer survival (5–8). There is growing recognition that environmental conditions and policies that promote physical activity can have an impact on modifiable behavioral risks and chronic conditions (9,10).Health plan promotion and direct support of physical activity via sponsored exercise programs have the potential to reach many people because 61% of younger Americans had employment-based health insurance in 2004 (11) and nearly 100% of older Americans have Medicare coverage. Two previous studies of a health plan–sponsored community-based group exercise program (EnhanceFitness) for Medicare Advantage plan enrollees showed that participants in a general population (12) and in a subgroup of members with diabetes (13) who made greater use of the exercise program had lower adjusted health care costs than less active participants and control subjects. A third study examined the cost impact of a health club membership (Silver Sneakers [SS]) sponsored by the same Medicare Advantage plan with older adult members and found that SS use was associated with slower growth in total health care costs, particularly for the most active SS participants (14).This study extends prior studies by examining whether the health care use and cost impacts of SS participation found in older adults also apply to the subset of older adults with diabetes who have the most to gain from regular physical activity. We compared dose effects of SS participation on health care use and costs, based on a dose threshold of <2 or ≥2 visits/week. This study may provide further evidence of whether health plan–sponsored health club memberships provide a return on investment for older adults with chronic conditions and the level of participation needed to reduce health care costs.     

One-year outcomes of older adults referred for aging and mental health services by community gatekeepers

One-year outcomes of older adults referred for community aging and mental health services through the Gatekeeper Model were examined in this study. Outcomes included level of social, physical, psychological, and economic isolation, physical health problems, service need, and service utilization. Findings indicate that individuals referred by gatekeepers were more likely to live alone and to be socially isolated but less likely to have physical health problems. They were also less likely to have a physician at referral, but at 1 year this difference was not found. Cognitive problems had a significant impact on the lives of clients referred by gatekeepers at referral but not after one year. At referral, those referred by gatekeepers had greater service needs, but after 1 year they did not use more services than those referred by other sources. Implications of these findings are discussed. The findings from this study indicate that the adoption of the Gatekeepers model does not result in high service utilization. The Gatekeeper model is inexpensive to implement and can benefit communities through increased collaboration among service providers.     

The use of Tai Chi to improve health in older adults

Tai Chi is a slow and gentle exercise that is suitable for older adults with chronic illness. This exercise offers the benefits of flexibility, muscle strengthening, and endurance training. Tai Chi has the capability of improving the health of elders without exacerbating existing impairments. Therefore, older adults may be more inclined to participate in and maintain an exercise program. The purpose of this article is to (1) compare Tai Chi to muscle-strengthening and aerobic exercise, (2) describe possible mechanisms for the effects of Tai Chi on factors that contribute to disability, and (3) identify nursing interventions to promote the use of Tai Chi.     

Cognitive health in older adults

This article addresses both the theoretical and practical issues associated with cognitive aging, including the implications of neurophysiological changes in the brain as well as practical ways of screening for changes that may be problematic or may actually enhance healthy cognitive adaptations.     

ED use by older adults attempting suicide

Objective

The objective of this study was to describe patterns of older adult patient visits to emergency departments (EDs) for self-harm and suicide-related injuries.

Methods

A retrospective, secondary data analysis of the Nationwide Emergency Department Sample was conducted. Nationally representative estimates of patient visits by older adults attempting suicide were calculated using available sampling weights. Population estimates were calculated using estimates from the US Census Bureau.

Results

Findings suggest that 22 444 ED patient visits were made by adults aged 65 years and older for suicide-related injuries, representing an estimated population rate of 63 ED patient visits per 100 000 adults aged 65 years and older, with nearly half of all visits involving substance use. Total ED and hospital charges exceeded $353.9 million.

Conclusions

Effort is needed to better integrate and deliver suicide screening and support services in the ED, while also connecting at-risk older adults with mental health services before and after the ED encounter.