Background: Before the Affordable Care Act (ACA), the financing landscape for fee-for-service health care lacked broad structure and incentives to provide palliative care outside hospitals. Since the ACA, several payers have taken the opportunity to offer home-based palliative care (HBPC) to their members. Objective: To evaluate the impact of outreach efforts by a physician champion among a cohort of primary care physicians (PCPs) to introduce a new HBPC program and benefit, obtain buy-in, and motivate referrals for Blue Shield patients. Design: Secondary qualitative analysis of detailed field notes from a HBPC physician champion from in-person meetings with a cohort of PCPs and their office staff. Subjects: PCPs were from a physicians group in northern California that met with the physician champion during a 12-month study period. Results: During the 12-month study period, the physician champion met with clinicians at 27 distinct primary care offices. Qualitative analyses revealed three independent themes relating to receptivity and perception of the new HBPC program: (1) physician-level factors (overburdened, lack of palliative care knowledge, misconceptions around palliative care, and patient control), (2) practice-level factors (practice structure and role/integration of advance practice providers), and (3) first impression of the HBPC program (receptivity, ''dirty data,'' and communication). Conclusion: Results hold important implications for practice and new approaches to engaging PCPs in HBPC, obtaining buy-in, and generating patient referrals. PCPs need better support in caring for patients with serious illness and HBPC can likely fill that role if PCPs are willing to refer and HBPC programs adapt.

Throughout the country, access to professional capacity assessments is inconsistent. Capacity assessments are often a critical factor in case management of elder abuse investigations. This unmet need for many Adult Protective Services (APS) programs hampers their ability to protect older adults from mistreatment and preserve self-determination when appropriate. In June 2019, electronic surveys regarding access to capacity assessments were sent to APS leadership in all 58 California counties. A similar survey is planned for each US state in June 2020. In California, with 100% response rate, 53% of counties had no access to assessments and 56.1% had no funding for assessments. Most assessments were completed by physicians or psychologists. Seventy-three percent of counties reported that primary care physicians complete requests for capacity declarations less than half the time. Physicians decline to complete capacity declarations because they don’t know how to do the assessments (22.4%) and are concerned about being called into court (28.5%). Findings from the national survey will be presented along with maps illustrating capacity assessment accessibility. Factors that appear to influence accessibility positively (forensic centers) and negatively (lack of funding and lack of trained evaluators) will be discussed along with policy implications.

As our country increases our capacity to provide quality interprofessional geriatric medical care to older adults, we find challenges that are unique to the setting. Many older adults receive care in Federally Qualified Healthcare Centers where implementing Age-Friendly Care is critical. Implementing the 4M’s in this setting has specific challenges including lack of geriatric trained staff, staff turnover, leadership engagement and financial sustainability. When implementing Age-Friendly Care within a large-scale complex academic health system, equally difficult challenges surface. With less nimble infrastructures, changes in one service area can have a domino effect and create larger barriers in other parts of the system. Instituting the 4M’s in an academic health system environment requires a careful strategic approach and support from many areas of organizational leadership. This talk will focus on strategies to anticipate and adapt implementation plans to best address barriers that are unique to the setting.

Adult Protective Services (APS) workers assess clients for abuse and neglect and are asked to determine the client’s understanding of risks they face. Yet, APS workers have little structured training in how to make such judgements. The Interview for Decisional Abilities (IDA 3.0-CA) is a tool designed for use by APS workers to assess the ability of suspected victims of elder mistreatment to make decisions about the risks they face. This study evaluates the impact of training and use of this tool on the knowledge, experiences and ability of APS workers to determine decisional ability. APS workers and supervisors were recruited from central and northern California APS programs and randomized into either control (n=94) or IDA 3.0-CA training groups (n= 95). Baseline surveys measure knowledge of, and experiences with, assessing decisional ability and determining next steps for case management. Additionally, respondents determine the decisional ability of three case scenarios. Three months post-training, controls and trained subjects complete the same survey with a new set of cases. Preliminary results at baseline indicate there were no statistically-significant differences between trained subjects (n=42) and controls (n=50) in their knowledge scores (78.6% correct vs. 81.0%, p=0.6641) or performance assessing decisional ability in the case scenarios (60.1% correct vs. 63.3%, p=0.3497). Reported experiences assessing decisional ability and determining next steps in case management were also similar for trained subjects and controls. Complete results will be presented regarding change in knowledge scores, experiences, and assessing decisional ability in case scenarios compared across trained subjects and controls.

There are few structured methods to assess a client's decisional ability, and none have been evaluated for use by Adult Protective Services (APS) workers. As part of a larger randomized-controlled trial to test the California APS Interview for Decisional Ability (IDA 3.0-CA), we sought to determine the reliability of the instrument. We assessed the extent to which trained APS personnel reached similar conclusions about a client’s decisional ability (i.e., inter-rater reliability) when presented with a client vignette and a completed IDA 3.0-CA form. First, we developed 12 client vignettes based on common client risks. Consideration was given to diversity in gender, race/ethnicity, socioeconomic status, and geography. Second, five content experts familiar with development of the tool reviewed completed IDA 3.0-CA forms for each case. Based on reported case difficulty and level of agreement between experts, eight cases were selected to formally test the instrument’s reliability. Third, 39 APS personnel, who had trained to use the IDA 3.0-CA, reviewed completed IDA 3.0-CA forms and answered questions about the clients’ decisional ability for two randomly-assigned cases. For each case, we calculated the percent correct and inter-rater reliability (Cohen’s Kappa). The percent correct ranged from 67% to 100%, with an average of 87%. The inter-rater reliability for cases ranged from -0.01 to 1.00, with the average across cases of 0.66 (i.e., substantial inter-rater reliability). The results suggest that APS personnel using the IDA 3.0-CA have a high likelihood of reaching similar conclusions about a client’s decisional ability when provided the same client responses.