Surgical interventions are common among seriously ill older patients, with nearly one-third of older Americans facing surgery in their last year of life. Despite the potential benefits of palliative care among older surgical patients undergoing high-risk surgical procedures, palliative care in this population is underutilized and little is known about potential disparities by race/ethnicity and how frailty my affect such disparities. The aim of this study was to examine disparities in palliative care consultations by race/ethnicity and assess whether patients\' frailty moderated this association. Drawing on a retrospective cross-sectional study of inpatient surgical episodes using the National Inpatient Sample of the Healthcare Cost and Utilization Project from 2005 to 2019, we found that frail Black patients received palliative care consultations least often, with the largest between-group adjusted difference represented by Black-Asian/Pacific Islander frail patients of 1.6 percentage points, controlling for sociodemographic, comorbidities, hospital characteristics, procedure type, and year. No racial/ethnic difference in the receipt of palliative care consultations was observed among nonfrail patients. These findings suggest that, in order to improve racial/ethnic disparities in frail older patients undergoing high-risk surgical procedures, palliative care consultations should be included as the standard of care in clinical care guidelines.

UNASSIGNED: Inter-organisational collaboration is challenging but essential in managing the complex and comprehensive needs of frail older people. Therefore, there is a need to investigate the influence of different barriers to inter-organisational collaboration when implementing an integrated care programme. The aim of this study was to investigate both inpatient and outpatient staff views on the factors they deemed to be influential to inter-organisational collaboration for an integrated care programme.
UNASSIGNED: The study was a cross-sectional study and included staff from hospitals, primary care and municipal health and social care.
UNASSIGNED: There were no significant differences between staff from inpatient and outpatient care in measuring factors that may cause difficulties for inter-organisational collaboration. Staff views diverged significantly on all factors, such as educational level at long physical distances, laws and regulations, knowledge of each others work settings, experience from inter-organisational collaboration, different professions, variations in professional status and power, psychosocial factors such as positive work environment and interpersonal chemistry.
UNASSIGNED: A multidisciplinary team culture and avenues for inter-organisational collaboration need to be developed for improved care continuity.
UNASSIGNED: The staffs\' educational level influenced what was perceived as barriers to inter-organisational collaboration, and may guide future development of integrated care programmes.

UNASSIGNED: Home-based cardiac rehabilitation (CR) is an attractive alternative for frail older patients who are unable to participate in hospital-based CR. Yet, the feasibility of home-based CR provided by primary care physiotherapists (PTs) to these patients remains uncertain.
UNASSIGNED: To investigate physiotherapists\' (PTs) clinical experience with a guideline-centered, home-based CR protocol for frail older patients.
UNASSIGNED: A qualitative study examined the home-based CR protocol of a randomized controlled trial. Observations and interviews of the CR-trained primary care PTs providing home-based CR were conducted until data saturation. Two researchers separately coded the findings according to the theoretical framework of Gurses.
UNASSIGNED: The enrolled PTs (n = 8) had a median age of 45 years (IQR 27-57), and a median work experience of 20 years (IQR 5-33). Three principal themes were identified that influence protocol-adherence by PTs and the feasibility of protocol-implementation: 1) feasibility of exercise testing and the exercise program; 2) patients\' motivation and PTs\' motivational techniques; and 3) interdisciplinary collaboration with other healthcare providers in monitoring patients\' risks.
UNASSIGNED: Home-based CR for frail patients seems feasible for PTs. Recommendations on the optimal intensity, use of home-based exercise tests and measurement tools, and interventions to optimize self-regulation are needed to facilitate home-based CR.

OBJECTIVE: To develop knowledge about homecare professionals\' observational competence in early recognition of deterioration in frail older patients.
BACKGROUND: The number of frail older patients in homecare has been rising, and these patients are at higher risk of deterioration and mortality. However, studies are scarce on homecare professionals\' recognition and response to clinical deterioration in homecare.
METHODS: This study applies an explorative, qualitative, mixed-methods design.
METHODS: The data were collected in two homecare districts in 2018 during 62 hr of participant observation, as well as from six focus group interviews. The data were subjected to qualitative content analyses. The Standards for Reporting Qualitative Research (SRQR) checklist was used to report the results.
RESULTS: The data analyses revealed two main themes and five sub-themes related to homecare professionals\' observational practices. The first main theme entailed patient-situated assessment of changes in patients\' clinical condition, that is, the homecare professionals\' recognised changes in patients\' physical and mental conditions. The second theme was the organisational environment, in which planned, practical tasks and collaboration and collegial support were emphasised.
CONCLUSIONS: The homecare professionals in the two districts varied in their ability to recognise signs of patient deterioration. Their routines are described in detailed work plans, which seemed to affect assessment of their patients\' decline.
CONCLUSIONS: The results can inform homecare services on how homecare professionals\' observational competence and an appropriate organisational system are essential in ensuring early detection of deterioration in frail older patients.

Managing patients with frailty is an increasing element of acute hospital care, constituting around 40% of acute hospital inpatients. Up to half of these patients may be approaching the end of their life, and many also have repeated hospital admissions. We therefore undertook a quality improvement project to help us identify the prevalence of frail older inpatients approaching end of life and to better identify these patients in advance. We also developed and evaluated a pro forma to assist in initiating an advance care planning conversation with the patient and/or family. Fifty percent of our frail older inpatients were assessed as approaching end of life. Factors identifying older inpatients as more likely to die during the hospital admission included residence in a care home, two or more hospital admissions over the preceding 12 months, and a diagnosis of some form of dementia for more than 3 years. A novel goals and priorities of care (GPOC) document was found to support and guide palliative care conversations. Acute hospital care could be organised more effectively to recognise the potential need for palliative care in frail older patients. Identifying those at higher risk and using structured interviews and documentation is helpful, ultimately resulting in more appropriate care. Well-developed communication skills are needed for these complex care planning conversations.