Author: Erin Luers

Jennifer Gabbard, MD

Posted on by Erin Luers

Wake Forest School of Medicine

Using Telemedicine to Improve Engagement in Advance Care Planning in Patients with Cognitive Impairment or Unrecognized Dementia

Health Care Systems

Wake Forest Baptist Health

Pilot Study Snapshot

Dr. Gabbard is an assistant professor in the Department of Internal Medicine. She is triple boarded in Internal Medicine, Geriatrics, and Hospice and Palliative Medicine. She trained at the University of Arizona and then completed a clinician-educator fellowship at Johns Hopkins University. Her clinical interests include integration of early palliative care in patients with serious illnesses, clinical care of comorbid chronically ill and frail older adults, and promotion of healthy aging. These interests translate into both educational and research settings. Dr. Gabbard serves as the Palliative Care Research Director and Associate Program Director of the Hospice and Palliative Medicine Fellowship Program at Wake Forest School of Medicine. She is a physician-scholar and educator seeking to develop her strong interests in implementation science, clinical informatics, and pragmatic clinical trial design.

RATIONALE: There is a growing need to provide high quality of care for people living with cognitive impairment or dementia that aligns with their overall goals, values, and health care preferences. Advance Care Planning (ACP) can help improve patient-centered care, however it is vastly underutilized as part of primary care. Telemedicine may provide a means to improve the outreach of ACP as part of outpatient primary care.

OBJECTIVE: The purpose of this pilot project is to test and evaluate the reach and adoption of a pragmatic telemedicine ACP intervention.

SETTING: Primary care practices in the Wake Forest Baptist Health Network’s affiliated Accountable Care Organization in North Carolina.

POPULATION: Community-dwelling patients, ≥65 years, with a diagnosis of mild cognitive impairment or unrecognized dementia, determined by the EHR Risk of Alzheimer's and Dementia Assessment Rule prediction model.

DESIGN: The intervention will be embedded into the clinical workflow and will consist of primary care providers participating in telemedicine dyad video visits with patients and their caregivers to discuss ACP.

OUTCOMES: This pilot study will assess the reach and adoption of the telemedicine ACP intervention among patients with mild cognitive impairment or unrecognized dementia.  Secondary outcomes will assess quality of ACP documentation within the electronic health record and usage of ACP billing codes.

IMPACT: This pilot study will inform and strengthen the design of a large-scale, multicenter embedded pragmatic trial. Telemedicine has the potential to overcome ACP barriers related to timing and travel restraints. It also provides patients and their caregivers with an opportunity to discuss their goals, values and priorities for healthcare within their home setting, thereby prioritizing “aging in place”. Engaging patients in ACP and obtaining appropriate reimbursement allows primary care providers to sustainably deliver high-quality, patient-centered care.

Ariel Green, MD, MPH, PhD

Posted on by Erin Luers

Johns Hopkins University School of Medicine

ALIGN: Aligning Medications with What Matters Most

Health Care Systems

Johns Hopkins University School of Medicine
Kaiser Permanente Institute for Health Research

Pilot Study Snapshot

Dr. Green is an assistant professor of medicine in the Division of Geriatric Medicine and Gerontology at the Johns Hopkins University School of Medicine. Her research focuses on improving communication between older adults, care partners and health care professionals about unnecessary and potentially harmful interventions, including medication use. As a member of the American Geriatrics Society (AGS) Clinical Practice Committee, Dr. Green co-wrote the Society’s recommendations for Choosing Wisely, a national initiative that promotes patient-physician conversations about unnecessary medical tests and procedures. Dr. Green received the AGS Choosing Wisely Champion Award for leading efforts to reduce overuse in medicine. Her research, supported by the NIA, is evaluating the impact on patient and care partner outcomes of pragmatic interventions to optimize prescribing for older adults with dementia in primary care. A former award-winning health journalist, Dr. Green has published personal essays and op-eds in Annals of Internal Medicine, The Washington Post and The New York Times, among other publications.

RATIONALE: Few deprescribing studies have targeted care partners of people living with dementia (PLWD), despite the enormous strain they face due to medication-related tasks. ALIGN builds on existing pharmacist-led comprehensive medication management programs by incorporating explicit focus on deprescribing to reduce medication regimen complexity and burden for care partners.

OBJECTIVE: To refine and pilot a workflow in which an embedded clinical pharmacist makes deprescribing recommendations to the primary care provider (PCP) to reduce medication regimen complexity for PLWD and their care partners.

SETTING: Primary care practices in two health care systems in Maryland and Colorado.

POPULATION: People living with dementia and multiple medications and their care partners.

DESIGN: The intervention will be embedded into the clinical flow of the primary care practices and delivered by clinical pharmacists who are already integrated throughout both health care systems. The intervention consists of: 1) direct-to-consumer deprescribing educational materials designed to activate the care partner and PLWD; 2) a telehealth visit in which a clinical pharmacist discusses benefits and harms of the patient’s medications with the patient and care partner in the context of their goals and preferences; and 3) pharmacist-PCP communication in which the pharmacist provides tailored deprescribing recommendations designed to be useful and actionable for the PCP.

OUTCOMES: The pilot study will establish the feasibility and acceptability of ALIGN in two health care systems, and will determine the feasibility of measuring two primary clinical outcomes: 1) the patient-level Medication Regimen Complexity Index and 2) the Family Caregiver Medication Administration Hassles Scale.

IMPACT: Findings from this pilot study will guide the design, implementation, and subsequent evaluation of ALIGN in a multicenter embedded pragmatic trial, laying the groundwork to optimize prescribing and improve outcomes for people living with dementia and their caregivers in a variety of primary care settings.

IMPACT Collaboratory featured in New York Times opinion piece on effects of COVID-19 on people living with dementia with quotes from Harrison, Karlawish, and Berry

Posted on by Erin Luers

The NIA IMPACT Collaboratory has been featured in a New York Times opinion piece about the effects of COVID-19 restrictions on people living with dementia and their caregivers. Jill Harrison, PhD, Executive Director of the IMPACT Collaboratory, and Jason Karlawish, MD, the leader of the Ethics & Regulation Core are quoted, as is Sarah Berry, MD, MPH, the multiple PI of IMPACT-C, a COVID-19 supplement to the IMPACT Collaboratory. Dr. Harrison’s quote “We are Going to Keep you Safe, Even if It Kills Your Spirit” serves as the title.

“Dr. Karlawish thinks that blanket bans on dementia caregivers are akin to taking away a wheelchair from a person with physical disabilities. ‘And that’s a brutal metaphor,’ he said. ‘But all of a sudden, the people who would come there and help their minds function were taken away.’ Some geriatricians describe this separation as unfortunate and damaging, but necessary. Others believe that we should have allowed for a gentler nursing home quarantine, one that recognizes caregivers as ‘essential’ parts of dementia health care.

Jill Harrison, an executive director of the National Institute on Aging’s IMPACT Collaboratory, thinks the instinct to lock everything down reflects a broader tendency in dementia care to prioritize physical safety above all else… ‘I always call it surplus safety,’ Dr. Harrison told me. ‘It’s essentially like, we are going to keep you safe, even if it kills your spirit.’”

Read the full piece here.

New IMPACT Funding Opportunity: 2021 Career Development Award

Posted on by Erin Luers

For scientists pursuing careers in embedded pragmatic clinical trials for people living with Alzheimer’s disease and Alzheimer’s disease-related dementias (AD/ADRD) and their care partners.

Informational Webinars
Tuesday, January 19, 2021 at 2:00 pm ET: Registration closed.
Wednesday, February 3, 2021 at 3:00 pm ET: Registration closed.

Application Period Opens
January 18, 2021

Proposals Due
April 2, 2021 @ 5pm ET

Read full Request for Applications (RFA)

The NIA IMPACT Collaboratory (U54AG063546) is pleased to announce the request for applications for the 2021 IMPACT Career Development Award. We encourage applications from early-stage investigators interested in a research career that includes conducting embedded pragmatic clinical trials (ePCTs) of non-pharmacologic interventions within healthcare systems (HCS) for people living with Alzheimer’s disease (AD) and AD-related dementias (ADRD) and their care partners. The recent $300 million increase in National Institutes of Health funding for AD/ADRD research, reflects the urgency and opportunities for investigators focused in this area.

Conducting ePCTs in AD/ADRD within HCS requires unique research skills, yet the field is relatively nascent. The number of investigators capable of rigorously designing and executing ePCTs in partnership with HCS and other key stakeholders remains limited, and those that have intersecting expertise in AD/ADRD populations are even fewer. Thus, a critical objective of the IMPACT Collaboratory is to build the nation’s capacity to conduct impactful ePCTs in AD/ADRD by training a workforce of investigators prepared to carry on this work well into the future.

The IMPACT Collaboratory funds up to four career development awards (CDAs) annually. These CDAs seek to support the development of early-stage MD, PhD, or equivalent researchers who seek careers conducting ePCTs for people living with AD/ADRD and their care partners. The IMPACT Collaboratory prioritizes applications that address dementia care for people of all backgrounds and promote health equity. CDAs are funded for two years. Each award will provide $100,000 annually in direct costs with an indirect cost rate capped at 8%. Awardees are required to devote a minimum of 75% effort toward the goals of the award.

A set of frequently asked questions (FAQ) regarding this award is available at https://impactcollaboratory.org/CDA-grant-faq/. Additionally, please email IMPACTcollaboratory@hsl.harvard.edu with any questions.

Request for Applications to Attend the Annual IMPACT Training Workshop & Retreat (April 7-8, 2021)

Posted on by Erin Luers

The IMPACT Collaboratory will hold its first annual Training Workshop and Retreat, “Building Skills to Conduct Embedded Pragmatic Clinical Trials for People Living with Dementia (PLWD) and their Care Partners,” on April 7-8, 2021.

We are inviting applications from early to mid-career researchers who seek to develop competence in designing and conducting ePCTs of interventions to improve care for PWLD and their care partners. We anticipate accepting up to 25 participants to attend the workshop.

This virtual 1.5-day workshop and retreat will provide a foundation in practical aspects of designing and conducting ePCTs in AD/ADRD through a combination of panel discussions, small group sessions, and networking opportunities with experts in the field. Workshop modules will focus on healthcare systems, implementation science, and study design.

Participants will gain knowledge in ePCT design and method, problem-solve challenges faced in current or planned projects, and network and engage with the larger community of IMPACT investigators. Throughout the program, special attention will be paid to key considerations in design, implementation, and monitoring ePCTs of PLWD and care partners to ensure health equity.

Successful applicants will be expected to complete selected readings and online training prior to the workshop. Please note that all participants will be expected to attend and participate in the entire 1.5-day IMPACT Collaboratory Training Workshop and Retreat.

Please help to publicize this training program and encourage your investigators and colleagues to apply.

EVENT DETAILS (virtual):
Wednesday, April 7, 2021 from 1:30pm – 4:30pm ET
Thursday, April 8, 2021 from 10:00am – 4:30pm ET

TO APPLY:
For more information and to apply please visit:  https://impactcollaboratory.org/training-workshop

  • Deadline: Friday, January 15, 2021
  • Application: Please submit your online application and your NIH biosketch by January 15, 2021 through our application portal.

ELIGIBILITY CRITERIA: Applicants should have an MD, PhD, or equivalent research degree and hold a full-time position at an academic or research organization in the United States.  Although the primary audience is early-career investigators, mid-career applicants who are seeking to change their career path to pursue research on ePCTs in AD/ADRD will be considered. Individuals from underrepresented racial and ethnic groups as well as individuals with disabilities are encouraged to apply.

SELECTION CRITERIA: Applicants will be selected based on their demonstrated commitment to improving the care of people living with dementia and/or their caregivers through the conduct of ePCTs in health care systems and the potential impact of the workshop on promoting the applicant’s career in this area.

If you have any questions regarding this opportunity, please email IMPACTcollaboratory@hsl.harvard.edu

External Funding Opportunities: US Deprescribing Research Network Pilot and Grant Opportunity and Junior Investigator Intensive Program; Hopkins’ Economics of Alzheimer’s Disease & Services (HEADS) Center Pilot Grant

Posted on by Erin Luers

US Deprescribing Research Network Pilot and Grant Opportunity

Application Deadlines: 1/22/21

The US Deprescribing Research Network funds pilot and exploratory studies, grant planning activities, and small collaboration grants. The goals of these grant programs are to support early-stage research in deprescribing that has high potential to develop into future large projects, to catalyze research in areas that are of particular importance to the field, to support junior investigator development, and to promote collaborations that will lead to future research projects.

The Letter of Intent deadline has passed, but it is not required. Application deadline is January 22. See details here

Junior Investigator Intensive Program in Deprescribing Research

The US Deprescribing Research Network (USDeN) seeks applicants for its Junior Investigator Intensive Program in Deprescribing Research.  The program will create a cohort of emerging leaders who are committed to pursuing research training and collaborative opportunities related to deprescribing.

Applications Due:  February 1, 2021

Selected Investigators Notified:  Mid-March, 2021

What is deprescribing research and why is it important?
There is increasing recognition that use of some medication, especially as people get older or more ill, can cause more harm than good. Optimizing medication through targeted deprescribing is a vital part of managing chronic conditions, avoiding adverse effects and improving outcomes. The goals of deprescribing include reducing medication burden and maintaining or improving quality of life. Yet, there is a dearth of strong research evidence to guide clinical practice and inform shared clinical decision-making relevant to deprescribing.

What is the Junior Investigator Intensive Program?
The program has 3 main components.

  1. Scholars will attend a special session at the 2021 US Deprescribing Research Network Annual Meeting (date to be determined) that is focused on career development, networking, and collaborative research opportunities for early-stage investigators interested in deprescribing. *Due to the COVID-19 pandemic this meeting may be held virtually.*
  2. Scholars will attend monthly virtual “works in progress” meetings and other activities over the year that offer a mix of opportunities to get feedback on your research from colleagues and senior researchers and discussion of collaborative research projects in which scholars can participate (and help lead).
  3. Scholars will have access to other aspects of the US Deprescribing Research Network such as attendance at webinars, consultations, and a variety of other resources. Scholars will be expected to attend the virtual USDeN Annual Meeting and most of the monthly web-based meetings during the year.

See full details here.

Application Deadline 2/1/21: Hopkins’ Economics of Alzheimer’s Disease & Services (HEADS) Center Pilot Grant

Pilot Proposal Guidelines (Pilot 2021-2022)
Application Deadline: February 1, 2021 11:59 PM (EST)

The HEADS Center stimulates and coalesces population-based research that identifies, quantifies, and addresses economic and care systems challenges posed by Alzheimer’s Disease and Related Dementias (ADRD).

We invite applications for pilot grants related to our two themes:
(1) To identify and quantify the range of care needs of persons with ADRD and the economic consequences of ADRD for patients and families.
(2) To examine how the organization, financing, and delivery of services affects accessibility, affordability, quality, and equity of ADRD care.

We expect to award 4 one-year pilot grants of up to $25,000 per award in the coming 2021-2022 cycle. We are particularly interested in supporting promising post-doctoral fellows and junior faculty, but applicants may be of any rank from Johns Hopkins University and external institutions.

Please see the attached RFA and click on the link to our website below for full details and application instructions.
Applicants will be notified of funding decisions on or around April 1, 2021.

More details here:
https://www.jhsph.edu/departments/health-policy-and-management/research-centers-and-institutes/hopkins-economics-of-alzheimers-disease-and-services-center/research-projects/Request%20for%20Applications.html

COVID-19 Serology Strategies in Skilled Nursing Facilities (CERO)

Posted on by Erin Luers
Principal Investigator
NYU Langone Health

 

Study Snapshot

 

“This is a unique opportunity to collaboratively engage with skilled nursing facility leadership, staff, residents, and families to immediately address this devastating pandemic in preventing new infections and in using these strategies for other infectious challenges that may come in the future.”

Joshua Chodosh, MD, MSHS, holds the inaugural endowed Michael L. Freedman professor of Geriatric Research in the Division of Geriatric Medicine and Palliative Care in the Department of Medicine at NYU School of Medicine. He is a clinical geriatrician, seeing patients in the VA NY Harbor Healthcare System and is founding Director of the Freedman Center on Aging, Technology, and Cognitive Health (CATCH) and co-Director of the NYU Aging Incubator. Dr. Chodosh conducts multiple AD/ADRD NIH and VA pragmatic clinical trials and leads the Outreach and Recruitment Core of the NYU Alzheimer’s Disease Center. He has held a number of leadership roles focused on healthcare policy impacting the quality of care for patients with chronic disease, particularly those living with dementia. Dr. Chodosh served as chair of the State of California Alzheimer’s and Related Dementias Advisory Committee and co-chaired a statewide effort leading to the California State Plan for Alzheimer’s disease.

RATIONALE: The COVID-19 pandemic has been particularly devastating for those with multimorbidity including Alzheimer’s disease (AD) and AD related dementia (AD/ADRD) and who are living in congregant environments such as skilled nursing facilities (SNF). ADRD SNF residents are at greatest risk of being unable to comply with prevention behaviors and subsequently impact the entire facility and staff. Not surprisingly, long-term care facility deaths have been among the largest proportion of state reported deaths. Asymptomatic spread may also be higher in these settings, further challenging our ability to achieve isolation practices without complete isolation of all residents – resulting in harmful social isolation, especially for those with ADRD.

OBJECTIVE: Design and pilot test an intervention that leverages the COVID-antibody and PCR status of residents and staff to inform staff-residents care assignments that will minimize COVID-19 transmission rates.

SETTING: Two New York City nursing facilities with high minority and ADRD representation.

POPULATION: People with ADRD and those who are living in congregant environments such as SNF.

DESIGN: We will develop facility-specific staff-resident assignment protocols based on COVID-19 serology and PCR testing, which are feasible, scientifically sound, safe, and acceptable to stakeholders: administrators, clinical leaders, front-line staff, residents and families. Methods will include: 1) obtaining stakeholder feedback for testing and cohorting protocol refinement; and 2) implementing SNF-unit staffing assignment strategies based on COVID-19 serology and PCR status to minimize viral transmission.

OUTCOMES: We will measure a) COVID-19 resident and staff incidence; and b) related hospital transfers. We will assess implementation by: 1) % intended pairings achieved; 2) reasons for success/failure; and 3) intervention acceptability using exit interviews with stakeholders.

IMPACT: We anticipate our findings will enable a larger trial to create evidence-based policy for nursing homes’ staff-resident assignments that minimize risk of acquiring COVID-19.

Effect of a COVID-Specific Advance Care Planning Intervention on Documentation of Advance Directives and Goals of Care

Posted on by Erin Luers
Principal Investigator
Ellen McCreedy, PhD, MPH Brown University School of Public Health

 

Study Snapshot

 

“The pandemic is highlighting some of the challenges to documenting and honoring care preferences for assisted living community residents with ADRD.”

Ellen McCreedy, PhD, MPH is interested in improving the quality of life for people living with advanced dementia. Her research goals are to reduce the amount of futile and burdensome care received at the end of life; and to provide comfort, meaning, and moments of joy to people living with dementia and their families. Professor McCreedy received her MPH in Global Health from the University of South Florida, her PhD in Health Services Research from the University of Minnesota, and recently completed a postdoctoral research fellowship at Brown University, Center for Gerontology and Healthcare Research. Dr. McCreedy is directing a pragmatic trial of a personalized music intervention to reduce agitation and isolation in nursing home residents living with dementia.

RATIONALE: Assisted living communities (ALCs) serve over 800,000 vulnerable older adults at high risk of developing complications and dying from COVID-19. Documenting care preferences in the form of an advance directive or medical order reduces receipt of unwanted care during and after the pandemic.

OBJECTIVE: The primary objective of this embedded, pragmatic, cluster-randomized trial (ePCT) is to test the effects of a COVID-specific, advance care planning (ACP) intervention on documentation of care preferences in a target cohort of assisted living community (ALC) residents with Alzheimer’s disease and related dementias (ADRD) from 150 ALCs in 3 states.

SETTING: 150 assisted living communities (ALCs) in Minnesota, Wisconsin, and Florida.

POPULATION: People living with ADRD and their family members.

DESIGN: ALCs will be randomly assigned to one of three groups: 1) Usual care; 2) ACP informational website and video sent electronically to family members; or 3) ACP informational website and video sent electronically to family members plus a follow-up ACP discussion with a Bluestone clinician.

OUTCOMES: The primary clinical outcome will be new documentation of a preference for comfort-focused care in the EHR over four months; secondary clinical outcomes will be new documentation DNR or DNI orders in the EHR over four months and the proportion of enrolled residents with any hospitalizations over four months. Implementation outcomes include counts of physician calls with family members and counts of website and video views.

IMPACT: Little is known about the ACP process for ALC residents with ADRD during COVID-19, and the barriers to honoring care preferences in this setting. This ePCT leverages the EHR of a large ALC physician group to identify eligible residents and family members, deliver the intervention, and assess resident outcomes.