• Adult Patients’ Experience Using Patient Portal: The Impact of Perceived Usability on Portal Use Behavior

      Son, Hyojin; Nahm, Eun-Shim (2020)
      Background: Patient portals (PPs) are a robust tool that can engage patients into their care. PPs can be especially helpful for older adults who have complex healthcare conditions. Usability of PPs is a major influencing factor for PP use. PP usability is more important for older adults who tend to be less familiar with technologies and may need additional support for using PPs. Currently, there has been a lack of studies that examined PP usability perceived by patients after PP implementation in healthcare settings. Objectives: The primary aim of the study was to test a modified PP Acceptance Model that explains factors affecting patients’ PP use. The secondary aim was to compare the difference in PP usability, PP self-efficacy, and PP use between older adults recruited from community settings and older adults recruited from hospital settings. Methods: To test the primary aim, an anonymous cross-sectional online survey was conducted with adult patients in an integrated healthcare system. Data from 743 patients who used PPs in the past 12 months were subject to structural equation modeling (SEM). For the secondary aim, a secondary data analysis was performed using descriptive statistics and content analysis (272 community-residing older adults). From this sample, those who used PPs (n=126) were compared with hospital/clinic-based older adults (n=174) by conducting regression analyses. Results: Among 743, about two-thirds were White and female (mean age, 53.1; range, 18-92). Mean PP usability was 36.6 (range, 6-42). The SEM revealed that the final model fit the data: CFI=.983, RMSEA=.059. PP self-efficacy and privacy/security concerns had a direct impact on PP use. PP use was indirectly influenced by PP usefulness, PP ease of use, eHealth literacy, education, and age. The secondary data analysis indicated that older adults recognized PP benefits and were willing to use PPs. However, their PP use was limited due to several challenges. The relationship between PP usability and PP use was stronger in the community sample. Conclusion: Findings suggest a strong potential for using PPs to engage patients in healthcare and strategies to improve patients’ PP use. Further studies need to include more diverse populations in various settings.
    • Exploration of Coping Strategies in Older, Community Dwelling, HIV Positive Individuals in Baltimore

      DeGrezia, Mary G.; Kauffman, Karen (2012)
      Background: The CDC reports that by 2015 50% of HIV-positive individuals in the U.S. will be at least 50 years old. Individuals with HIV develop more comorbid health conditions at an earlier age than those without HIV. Older adults with HIV are a sizeable, growing population. However, published qualitative data on how older adults cope with HIV, comorbid conditions, and related stressors are extremely limited. Objectives: The purpose of this exploratory study was to identify comorbid conditions and other related stressors experienced by HIV-positive community-dwelling older adults in Baltimore and to understand how they cope. Methods: Forty HIV-positive individuals aged 50 and older (range 50-69 years; male, N=17, mean age 55; female, N=23, mean age 56) affiliated with at least one of two Baltimore-based HIV support groups with older adult members were recruited via purposeful sampling and interviewed to the point of data saturation. Data were analyzed using an interpretive hermeneutic methodology and qualitative content analysis. Results: Participants experienced one or more comorbid condition (range 1-18; male mean = 7; female mean = 6). The most frequently reported comorbid conditions for both genders were hypertension 48%, depression 43%, hypercholesterolemia 38%, memory difficulties 35%, Hepatitis C 34%, and anxiety 33%. Related stressors included HIV-related fear, perceived and actual stigma, multiple medications to treat comorbid conditions, and financial concerns. Participants learned to cope with stressors by accessing support, helping selves and helping others, and tapping into one's own spirituality. Employing these strategies helped participants cope, develop hope, and work toward psychological well-being. Conclusions: Participants employed active and meaning-based coping strategies to engage in life despite HIV, comorbid conditions, and related stressors. Findings are significant because this study is among the first to give voice to older HIV-positive community dwelling individuals in Baltimore about how they cope with HIV, comorbidities, and related stressors. Nurses' increased understanding of the impact of HIV, comorbidities, and related stressors in HIV-positive older adults along with knowledge of their active and meaning-based coping strategies can lead to holistic patient care with interventions encouraging hope and psychological well-being.
    • Factors Associated with Length of Stay and Discharge Disposition in Older Trauma Patients

      Brotemarkle, Rebecca Ann; Resnick, Barbara (2013)
      Factors Associated with Length of Stay and Discharge Disposition in Older Trauma Patients Abstract Background: Trauma patients over the age of 65 are living longer and staying active at older ages. Older trauma patients tend to have longer lengths of stay (LOS) and to be discharged more often to rehabilitation and skilled nursing facilities. Understanding the factors that influence LOS and discharge disposition is needed to guide interventions focused on decreasing LOS and assuring that patients are discharged to the least restrictive setting. Purpose: The purpose of this study was to explore the impact of patient and system related factors on LOS and discharge disposition for older adults hospitalized for traumatic injury. Methods: This was a secondary data analysis using descriptive data from rehabilitation notes during inpatient encounters. Data analysis was done using structural equation modeling and logistic regression. Results: 132 patients were randomly selected from 1387 patients admitted to a level 1 trauma center. The majority were Caucasian (83.9%, n = 111), 46.9% (n = 62) were males with an average age of 78.3 (S.D. = 9.7) years. On average participants had 2.29 (S.D. = 1.96) comorbidities and approximately two thirds (65.9%, n = 87) were rated as having severe injuries. The average length of stay was 4.3 (S.D. = 4.0) days with 57.6% (n = 76) of patients discharged to a facility. The model had a fair fit to the data and demonstrated that younger patients who had more comorbidities, were likely to have more pain. Older patients with more comorbidities, higher injury severity, more days from admission to evaluation, and lower pain were more likely to have a longer LOS which explained 37% of the variance in LOS. Based on logistic regression analysis, having longer LOS (O.R. = .049, 95% CI .008 - .301, p=.001) and more pain (O.R. = .531, 95% CI .310 - .908, p=.021) were associated with decreased likelihood of returning home versus being discharged to a facility. Conclusion: Increased focus on pain and pain management, consideration of comorbidities, and decreasing time from admission to initial evaluation by rehabilitation therapists among older trauma patients may help to decrease LOS and facilitate discharge to the least restrictive setting.
    • Implementation of a Pneumococcal Immunization Standing Order Protocol in Long-Term Care

      Shittu, Alyson P.; Alessandrini, Erica (2020-05)
      Problem & Purpose Streptococcus pneumonia is a significant cause of morbidity and mortality of adults who are immunocompromised and of advanced age. It is the standard of care to vaccinate all high-risk adults (18-64 years) and adults 65 years and older with two pneumococcal vaccines (Centers for Disease Control and Prevention [CDC], 2015). However, pneumococcal immunization rates remain below the HeathyPeople2020 target goal of 90% nationally and locally (Office of Disease Prevention and Health Promotion [ODPHP], 2019). The objective of this quality improvement (QI) project was to implement the Immunization Action Coalition (2017) pneumococcal standing order protocol to increase the percentage of adult patients screened for vaccine need by 90%, and percentage of total residents vaccinated according to CDC recommendations by 10%. Methods The strategy of this QI project was to educate registered nurses to implement a pneumococcal standing order protocol, in a privately owned, 120-bed, long-term care (LTC) center in suburban Maryland. The design of this QI project was based on the diffusion of innovation theory, the 4 pillars practice transformation program (4 Pillars), and the Mobilize-Assess-Plan-Implement-Track (MAP-IT) process model. Weekly frequency distributions were used to examine the screening and vaccination rates, and a chi squared (X2) test was performed post intervention to examine the significance of intervention on vaccination rates. Results The total number of LTC residents (n=100) were White (66%), Black (32%), other (2%), with an average age of 83 years. Pneumococcal immunization rates increased from 56% pre-intervention to 82% post-intervention, and screening rates for vaccination need increased from 0% to 100%. A chi-squared test for independence indicated a significant relationship between vaccination status and implantation of the SOP intervention (p = 0.046, df = 1, n = 100). Conclusions This QI initiative showed that a systematic process change is feasible and can improve pneumococcal vaccination rates in a single institution. The findings may not be applicable to centers without an electronic medical record software to document immunizations or dedicated QI team. Ongoing work should focus on the perceived self-efficacy of LTC nursing staff to effectively implement a behavior change, and skills to provide strong recommendations for immunizations.
    • The relationship between stress appraisal, coping behavior, and subjective well-being in Chinese elderly with a diagnosis of congestive heart failure

      Lee, Wen-Lin; Spellbring, Ann Marie (1999)
      The purpose of this study was to examine the relationships between stress appraisal, coping behavior, and subjective well-being. The theoretical framework for the investigation was based on a process theory of stress and coping developed by Lazarus and Folkman (1984). A descriptive correlational research design was used to examine the relationships among the variables. Convenience sampling was used to select the subjects from three hospitals in Northern Taiwan. A convenience sample of 133 Chinese elderly aged 60 and over had a diagnosis of Congestive Heart Failure. Subjects were interviewed with structured questionnaires. Stress appraisal was measured by the Appraisal Scale. Coping was measured by the revised Ways of Coping Checklist. Subjective well-being was measured by the Philadelphia Geriatric Center Morale Scale. Descriptive statistics were reported for several demographic variables. Several multiple regressions were performed to determine the significance of the independent variables. Those Chinese elderly patients who perceived Congestive Heart Failure as a challenge, used more problem-focused coping and less emotional-focused coping. When Congestive Heart Failure is viewed as a threat or harm, they used more emotional-focused coping. There were no significant relationships between benefit appraisal and coping behaviors. The seven significant predictors of subjective well-being were identified as higher income, less threat and harm appraisals, less avoidance coping behavior, and higher health perception. Demographics (age, gender, education and income), severity of illness, and comorbidity variables together explained a significant amount of the variance (11%) in subjective well-being, but only income was an individually significant predictor. Stress appraisal, coping behaviors, physical functioning, and health perception contributed an additional statistically significant amount variance (46%) of subjective well-being after controlling for demographic variables, severity of illness, and comorbidity. Additional findings indicated that men had significantly higher physical functioning and subjective well-being than women. In addition, men used more problem-focused coping. Findings provide more information for health care providers to recognize the variables that influence subjective well-being, identify patients at greater risk for lower subjective well-being, and assist patients to achieve the highest subjective well-being possible within the constraints of their heart disease.
    • Sarcopenia and PRAISEDD-2 Intervention's Impact on Diet, Physical Activity, and Body Composition

      Hammersla, Margaret; Resnick, Barbara (2017)
      Background: Older adults with a low socioeconomic status and African Americans are more sedentary than the general population. This contributes to the development of sarcopenia and has a negative impact on the health and function of these individuals. PRAISEDD-2 was a 24-month quasi-experimetnal study of low income adults living in senior housing. A focused 3-month intervention included education about stroke prevention and heart health through adherence to heart healthy diets, regular exercise, and prescribed medication combined with exercise classes that included verbal encouragement, blood pressure feedback, and role modeling. Classes continued to be offered in months 4-24 but only included a monthly motivational intervention. The impact of the PRAISEDD-2 intervention on diet (fat, sodium, and protein intake), time spent in physical activity, and body composition are examined in the study reported here. Design: Diet and body composition measures were collected at baseline, 3, 6, 12, and 24 months. Sample included 29 residents of a low-income senior housing complex in Baltimore, MD. Complete data was obtain from 13 participants. Generalized estimating equations (GEE) were used to examine change over the time periods. An intention-to-treat (ITT) paradigm was followed. Results: At 3 months, participants experienced a decrease in sodium (p<0.01) and fat intake (p<0.01), as well as in a decrease in percent body fat (p<.001). However, at 24 months, fat intake (p<0.001) and percent body fat (p<0.001) increased, although protein intake increased (p<.001). No significant change was noted in physical activity (p=.056) or sodium intake (p=0.69) at 24 months. Conclusions: The findings from this study provided some support for the feasibility and preliminary efficacy of the PRAISEDD-2 intervention. The changes that occurred in the early 3 month period were likely due to the intensive nature of the education and exercise classes. Future research should focus on building a stronger self-efficacy based motivational component into the exercise classes to strengthen long term adherence to the recommended dietary change and physical activity, essential to promote decrease in body fat and increases in muscle mass. Interventions may need to be sustained longer to achieve more permanent changes in diet and exercise.
    • Stopping Elderly Accidents, Deaths and Injuries: Fall Prevention for Community-Dwelling Older Adults

      Neser, Sarah B.; Rowe, Gina C. (2020-05)
      Problem & Purpose: Falls are the leading cause of death due to injury among older adults, yet most older adults who fall fail to report falling to their provider. Lack of routine fall screening and management among community-dwelling older adults places them at risk for future falls and injuries. The purpose of this 12-week quality improvement project was to implement the Centers for Disease Control and Prevention’s Stopping Elderly Accidents, Deaths, and Injuries protocol in a primary care office to screen older adults for falls and address modifiable risk factors for those at increased risk. Methods: A literature review supported the protocol in reducing falls among older adults. Publicly available resources were adapted into training presentations and case scenarios for providers and staff. Staff screened eligible older adults during their office visit. Providers assessed gait and balance for those with a positive screen and identified fall risk (low, moderate or high). Moderate- and high-risk patients received a risk assessment and fall plan of care. Protocol steps were recorded on checklists reviewed weekly by the project leader to evaluate protocol adherence. Ongoing chart reviews, case scenarios, and a mid-project training session reinforced the protocol. Data was analyzed in three four-week time intervals with a goal of 80% adherence to all protocol steps. Results: The majority of protocol steps remained above goal over all time intervals or improved with training. All moderate- and high-risk patients received a fall care plan, despite risk assessments dropping below goal in the final interval. Moderate-risk patients were difficult to correctly identify. Overall protocol adherence was highest for low-risk patients (97%) and lowest for high-risk patients (80%) compared to moderate-risk (81%). Conclusion: With continued staff education and protocol reinforcement, the Stopping Elderly Accidents Deaths and Injuries protocol can be successfully implemented in the primary care daily workflow. Protocol adherence may be complicated by fall risk level. This project’s results support the 2019 modified protocol in removing stratified risk levels. Barriers to implementation include lack of protocol reimbursement and time to complete the protocol. Future studies should assess effectiveness of the protocol in reducing falls at one-year follow-up.