Pilot Projects

Our Center is proud to support its members with pilot funding and other resources to facilitate their scholarly inquiry.

Mapping Care Transitions Among Long Term Services and Supports Recipients

Team: Mary Naylor (PI), Mark Toles, Karen Hirschman, Alexandra Hanlon

For many adults, older age is accompanied by significant changes in health and function. As these changes occur, health care providers and families often enroll older adults in programs to support their health and preserve their independence. Approximately 6 million older adults in the U.S. receive these services each year in a range of settings, including home and community based services, assisted living facilities and nursing homes. In this study, the team will examine the care transitions of approximately 470 LTSS recipients, describing their care transitions and create “transition maps” for each patient over 2 years. Describing and mapping care transitions among newly enrolled LTSS recipients over time will allow for identification of potentially modifiable risk factors which can be leveraged to improve care for LTSS recipients. With this new knowledge, the team is positioned to help develop tailored health services for older adults.

Incorporating Neighborhood Assessments in Transitional Care

Team: Karen Hirschman (PI), William Satariano, Irene Yen, Marlon Maus, Katy Abbott, Mary Naylor

The goal of this project is to assess the feasibility of generating and incorporating a neighborhood assessment module into an evidence based transitional care intervention for at-risk older adults and family caregivers—the Transitional Care Model. Most environmental assessments following transition from hospital to home focuses on the immediate home environment only. This presents an opportunity to strengthen the community construct for older adults retaining independence in their home and potentially reduce 30-day hospital readmissions. In partnership with UC Berkeley, the study team will examine, identify and define the application of these assessments for older adults served in the community.

Acceptability of Technology by Caregivers of Adults with Heart Failure

PI: Barbara Riegel

Surprisingly, there is little research on informal caregivers of adults with heart failure. However, recent studies have identified high stress as a cause for disrupted sleep, depression, poor health-related quality of life (HRQL) and low self-care in these caregivers. Interventions that improve the ability to deal with the stress of caregiving have been shown to improve sleep, depression, HRQL, and self-care. One challenge of intervening with caregivers is that most are confined to the home because of their caregiving duties.

Quality of Life in Long-Term Care Feasibility Study

Co-PIs: Katherine Abbott and Marylou Guihan

The project focused on identifying post-discharge transitions of care for Veterans, who were discharged home with supportive services or sent to other long-term (LTC) care settings. The goal of obtaining this information was to aid future exploration of LTC patient identification, and to identify the most efficient methods of recruitment, as well as effective means for locating Veterans in the community post-discharge.

Co-Morbidity Patterns of Elders with Cancer Receiving Long Term Services and Supports

PI: Janet Can Cleave

The study team conducted a secondary analysis of data from the “Health Related Quality of Life: Elders in Long Term Care” {R01AG025524, National Institutes of Health} study, a longitudinal, self-report/observational study of elders newly enrolled in long term care. A preliminary analysis of the relationship between health care utilization and number of chronic conditions in the three months prior to enrollment from a subset of 263 study participants living in nursing homes and assisted living facilities demonstrated the complexity of this population as well as the impact of comorbidities on healthcare utilization. This study represents a unique opportunity to generate new knowledge regarding healthcare utilization of older adults with multiple chronic conditions and to identify new strategies to optimize care for this growing population.

Diuretics, Diet and Fluid Adherence in Relation to Hospital Readmission in Heart Failure Patients

PI: Barbara Riegel

The ultimate goal of this study is to describe how patterns of diuretic usage and sodium/fluid intake interact to predict readmission in recently discharged heart failure (HF) patients. Sorting out how diuretic adherence and sodium/fluid intake interact (in the early days following transition from hospital to home) and identifying the characteristics of patients in each of the identified patterns, will clarify a primary mechanism for early readmission and provide direction for future intervention research.

Let Us Join Our Voices: A Qualitative Exploration of Singing in Frail, Urban, Community-Dwelling Older Adults

Team: Darina Petrovsky (PI), Justine Sefcik, Pamela Cacchione

Little is known about the perceived benefits of group singing or what facilitates prolonged group signing participation in frail older adults in the community. The study team will explore the perceived benefits of group singing in frail, urban, community-dwelling older adults. Ultimately, the results from this study will inform the public about the benefits of group singing in older adults with comorbidities, add to our understanding of how older adults with complex health needs perceive music participation as well as contribute to future studies investigating group singing as a potential health maintenance strategy as older adults experience transitions in health status.

Older Adults and Their Perspective on Chronic Conditions

Co-PIs: Gail Towsley and Salimah Meghani

Unfortunately, knowledge in the conceptualization, measurement and research domains of co-morbidity are underdeveloped, confusing, and inefficient in creating informative models for policy and practice. The first purpose of this qualitative descriptive study was to describe how patients talk about, understand, and function based on their health status. Thirty semi-structured interviews will be conducted with community based older adults from Penn Nursing’s LIFE program. Findings from this study will inform future research and guide the development of better measurement of chronic conditions. Lastly, it will help inform the policy makers and clinicians, who make decisions for patients on their behalf.

Exploring perceptions of dementia and the culturally appropriate services in Asian communities

PI: Dexia Kong

Certain cultural beliefs in Asian communities prevent older Asian immigrants with dementia and their family caregivers from seeking care. In addition, the strong stigma associated with dementia in the Asian community results in delayed diagnosis and treatment. Since early diagnosis and timely interventions are significant in treatment of dementia, elimination of stigma represents an urgent issue to improve accessing/providing care for persons with dementia in the Asian community. Ultimately, findings of the study will facilitate improved clinical communication and health outcomes for older Asian immigrants with dementia.

NewCourtland Center for Transitions and Health

Exploring Mortality and Medical Service Utilization for Older Adults After Discharge From Short Stays (<90d) in Skilled Nursing Facilities

PI: Mark Toles and Mary Naylor

Each year in the US, approximately 1.7 million hospitalized older adults transfer to skilled nursing facility (SNFs) for post-acute care. Recently hospitalized patients who have short stays in SNFs are thought to be at-risk for complications in care after they transfer from SNFs to home. However, studies have not described the incidence or predictors of mortality and use of acute hospital medical services among SNF patients after their transition home. Using Medicare Claims Data and Online Survey, Certification and Reporting (OSCAR) data, the study team will examine the characteristics and predictors of mortality and re-utilization of acute hospital services among recently hospitalized older adults who receive short-term care in SNFs and transfer to home.

Feasibility Testing of the Early Screen for Discharge Planning (EDSP) and the Discharge Decision Support System (D2S2) on Discharge Planning and Patient Outcomes

Co-PIs: Katherine Bowles and Diane Holland

This feasibility study examined how two decision support tools impact discharge planning and patient outcomes; thereby, allowing the investigators to demonstrate feasibility and calculate intra- class correlation for a larger study application. There, they will test the tools’ comparative and combined effectiveness for discharge planning and patient outcomes in a national, cluster-randomized sample. The research team was able to leverage these pilot funds to obtain further support for the addition of two sites in Pennsylvania and New York, which brings their total enrollment to 734 patients.