Sage Journals: Discover world-class research

Abstract

Age-Friendly Health Systems (AFHS) emphasize aligning care with “What Matters” most to older adults. Hospitalization represents a critical period where value-based goals could shape key decisions about post-acute care transitions. However, few tools designed for eliciting such goals have been adapted for use in the inpatient setting, where the acute nature of care poses unique challenges. This mixed-methods study evaluates the usability of the Health Priorities Primer Tool (HPPT) in older hospitalized adults who anticipate needing post-acute care, aiming to identify necessary adaptations for the inpatient setting. We conducted interviews, observations, and surveys with older hospitalized patients to understand their experiences using the HPPT. We combined thematic analysis with descriptive statistics to analyze the data. Of the 26 participants, 73% expressed positive views toward completing a value-goal elicitation tool while hospitalized, with 53% supporting the HPPT. For open-ended questions, many participants shared broad goals like “getting better” without providing specific outcomes to achieve. For pre-determined checkbox-based questions, some participants found response options overwhelming or irrelevant. Most participants (85%) preferred facilitated administration of the tool over self-administration. Key Recommendations include simplifying the tool’s format, personalizing content, and improving framing about how and why values and goals would be used. Our findings highlight the potential usability of value-goal elicitation tools like HPPT to guide post-acute care planning for hospitalized adults. Key adaptations, including facilitated administration and clinician involvement, may enhance usability. Early user engagement and tailoring are essential for successful implementation in busy inpatient settings.

Keywords

age-friendly healthcare system discharge planning decisional-tool Veterans Health Administration geriatrics care transitions

Introduction

Age-Friendly Health Systems (AFHS) aim to improve care for older adults through evidence-based practices centered on the “4Ms”: What Matters, Medication, Mentation, and Mobility.¹ At the core of the AFHS framework are “What Matters” discussions, which elicit older adults’ values and health outcome goals to align care with their preferences. By incorporating “What Matters” into care planning, clinicians can prioritize treatments that reduce burdensome care and enhance shared decision-making, potentially improving quality of life, functional outcomes, and long-term care alignment.^2,3

Eliciting “What Matters” is particularly important for hospitalized older adults, as hospitalization often marks a pivotal point in one’s health trajectory.⁴ During this period, older adults frequently experience functional decline,⁵ cognitive changes,⁶ and emotional stress,^7,8 complicating decision-making. Many face transitions to post-acute or long-term care, and decisions made during hospitalization can have lasting impacts on their quality of life.^4,9 Understanding patients’ values and goals during this vulnerable time can help ensure care aligns with their priorities, potentially improving outcomes and reducing unnecessary interventions.¹⁰ While value-goal elicitation tools like the Patient Priorities Care (PPC) model have demonstrated benefits in outpatient and long-term care settings,^3,10
-12 their adoption in inpatient care remains limited.

The PPC model is an evidence-based age-friendly approach for identifying and acting on “What Matters” most to patients³ to facilitate care aligned with their values, goals, and preferences (i.e., what someone is able/willing to do/receive). PPC helps clinicians explore patients’ values, consider tradeoffs between care options, set health goals based on those values, and identify symptoms, environmental barriers, or psychosocial concerns preventing goal achievement. Identification of health priorities enables patient-clinician shared decision making and recommendations to start, stop, or continue treatments aligned with goals and preferences.

With a growing policy emphasis on eliciting patient health goals – such as Medicare’s 2025 requirement for hospitals to report on AFHS measures¹³ – there is an urgent need for tools that support goal-concordant care during transitions from inpatient to post-acute care. A universal value-goal elicitation tool could enhance continuity of care by consistently communicating patients’ priorities across settings. Such a tool may reduce variability in clinical practice, foster interdisciplinary collaboration, and offer scalable solutions to meet emerging policy requirements. The Health Priorities Primer Tool (HPPT),^14
-16 informed by PPC principles,^3,10
-12 is a structured tool with pre-determined checkbox options for patients to indicate their core values, burdensome tasks, preferred activities, and health goals. Initially used in VA-operated skilled nursing facilities (SNFs), the HPPT was designed to require minimal assistance and facilitates discussions between patients and their healthcare teams.¹⁶ Preliminary data supports the use of HPPT in primary care and SNF settings,¹⁶ but its applicability and usability in inpatient care remains unexplored.

Given the contextual differences between outpatient and inpatient settings, we aimed to evaluate HPPT’s usability and acceptability among older hospitalized adults who were likely to require formal post-acute care services. Older hospitalized patients often face acute stress, shifting short-term priorities, and constrained time for reflection, which may affect the tool’s effectiveness. Usability testing in the inpatient setting is essential to identify barriers, ensure relevance, and support personalized, patient-centered care during a vulnerable period. Specifically, we aimed to (a) assess the tool’s usability and acceptability from the patient perspective; (b) identify potential adaptations to its fit for inpatient use and discharge planning; and (c) explore “What Matters” to hospitalized older adults using the HPPT.

Methods

Design Overview

Using a mixed-methods convergent approach,^17,18 we merged observations, interview responses, survey data (demographics, responses to HPPT items), and usability metrics (e.g., task completion rate, time, tool preferences, and data completeness) to provide insights into future patient end-users’ experiences using the HPPT in capturing “What Matters” for older adults preparing for hospital discharge. Informed by user-centered design principles,^19
-21 we triangulated findings from multiple data sources to understand critical aspects of the user experience, identify potential adaptations for eliciting “What Matters” with older hospitalized adults, and summarize responses to the HPPT. To examine the user’s experience, we focused on describing their perceived acceptability of the tool (e.g., how willing user is to receive and interact with tool), their actual interactions with the tool (e.g., tool administration preferences, time to complete, and role of environment), usability considerations (e.g., how easily can users interact with tool to achieve intended aims including eliciting patient’s values/care goals), and adaptations for an inpatient setting.²² This study was determined to be exempt under the Common Rule by each site’s Institutional Review Board (IRB). To enhance study rigor, we adhered to the Standards for Reporting Qualitative Research Guidelines (Supplemental Appendix A).²³

Sample: Setting and Participants

We collected data from April to December 2024 at three urban Pennsylvania hospitals, including two Veteran Medical Centers and 1 non-VA hospital. Participants were a purposive sample of older patients identified by the inpatient team^24,25 as likely to need post-acute care services (e.g., SNF referral). We targeted this population due to their high-risk health trajectories and significance within an AFHS,^4,5,9,26 as 30% of older Veterans do not regain independent functioning after post-acute care and transition to long-term institutional care.^27,28

Inclusion criteria consisted of hospitalized patients aged 60 or older, previously community-dwelling, and without cognitive impairment (e.g., without dementia on Electronic Health Record [EHR] problem list and confirmed by inpatient team). Since discharge plans often evolve, patients did not need to be discharged to a SNF to participate. We excluded non-English speakers; those residing in long-term care facilities or enrolled in hospice or palliative care (due to variations in value-goal identification); individuals with documented moderate to severe cognitive impairment or dementia (as they likely need caregiver involvement); those with behavioral concerns (due to staff safety); and individuals without access to a postal address or smartphone (for secondary study aims). Prior usability studies have indicated that a minimum of 10 (±2) participants are sufficient to achieve thematic saturation; our recruitment continued until no new data patterns around usability emerged.^29
-31

Health Priorities Primer Tool (HPPT)

The HPPT builds on PPC, and was developed by a VA-based interprofessional healthcare quality improvement team to improve efficiency of value-goal elicitation by offering discrete, pre-determined checkbox options for values, burdensome and preferred tasks, and activities of older adults (Table 1).¹⁶ Early quality improvement data indicated a paper tool could be completed with minimal assistance in primary care and rehabilitation settings, helping “prime” further discussions on health priorities with the care team.¹⁶ In addition to the tool’s theoretical and evidence-base, a strength of the HPPT is that the VA is currently using this tool in several primary care settings and SNFs nationally.

Table 1.

Core content of the Health Priorities Primer Tool.

Topic	Type	Questions
Values	Open-ended	Who or what matters in your daily life?
Values	Pre-determined answer choices	In general, what values are important to you? (Select your top 3 – physical/mental well-being, dignity, quality of life, independence, family and friends, being productive, community, spirituality, health and symptoms, recreation, personal growth/learning, and other)
Health goals	Open-ended	What are your health goals over the next 4 weeks after you leave the hospital? For example, what do you want to be able to do? What do you hope your health looks or feels like in the next month?
	Pre-determined answer choices	• What tasks related to taking care of yourself do you find burdensome? (Select your top 3 – e.g., doctor/hospital visits, medications, housework, transportation, bathing, shopping, etc.) • What things would you like to spend more time doing? (Select your top 3 – e.g., Participating in activities with family and friends, walking as exercise, traveling, going out to eat, caring for a pet, etc.)

Initial Adaptations

Prior to data collection, we conducted preliminary iterative usability testing of the HPPT to prepare the tool and accompanying interview script for testing in the inpatient setting. First, we sought input on the tool from established patient engagement panels (n = 3), as well as clinicians and researchers with expertise in post-acute care transitions and decision-tools (n = 12). Based on this iterative feedback, we made minor adaptations to the HPPT, including simplifying the pre-determined options for burdensome tasks and preferred activities, adding an open-ended goal question, and including a verbal administration option (Supplemental Appendix B for modifications and Supplemental Appendix C for full tool). We conducted rapid-cycle pilot testing with older Veterans who had post-acute care experience (n = 8), with no acceptability concerns identified in the final three interviews.

Data Collection

Guided by user-centered design principles,^19
-21 we conducted structured interviews, observations, and survey data to evaluate the HPPT in the inpatient setting. A PhD-trained nurse (Kirstin M. Piazza) developed the interview guide, refined through research team feedback and input from an older patient-engagement panel. Interviews were conducted while patients were hospitalized to capture real-time experiences within the context of the tool’s potential use.³² Trained research assistants (Caroline Pascal, Syama R. Patel, and Caroline Sefcik) identified participants through interprofessional hospital rounds. Participants received IRB-approved information and provided verbal agreement. They shared reasons for hospitalization, post-discharge plans, and completed a demographic survey before interacting with the HPPT, which they could self-administer or complete verbally. Usability metrics, observations, and responses were recorded by the research assistant using structured memos including quotations as applicable (Supplemental Appendix D).^20,21 Participants were asked to think-out-loud to describe their interactions with the tool.^22,33

After HPPT administration, participants debriefed about their reactions, preferences, and experience completing the tool. To examine acceptability, we asked how the values-based goal elicitation exercise would be useful to consider post-acute care discharge priorities. Likewise, to better understand how the HPPT achieves one of its core functions (e.g., eliciting value-based goals), participants identified which PPC values domains aligned with their goals. Post-interview reflexivity memos^34,35 were used to summarize the participant’s situation, assumption checks, and methodological considerations. Patient’s primary diagnosis, co-morbid conditions (type and number), length of hospitalization, and post-acute care service were also collected from the EHR. Participants were compensated $50.

Analysis

To facilitate analysis, all data (e.g., interview, observations, responses to tool, demographics, and reflexivity memos) were triangulated, merged per patient case, and entered into a REDCap database.^36,37 As a quality check, interviews were audio-recorded, and 23% (n = 6) were audited by 2 staff comparing interviewer structure memos to audio-recordings – for which we found high note-recording accuracy. We used descriptive statistics to summarize participant demographics, HPPT content output, and usability metrics (e.g., tool preferences, completion times, data completeness, help request frequency, and error rates). Thematic analysis^38,39 was applied to understand participant values, goals, and experience using the HPPT. To become familiarized with the dataset and build analytical sensitivity across cases and sites, our analysis team (KP, CP, SP, CS, CM) first regularly discussed the reflexivity memos during data collection.^38
-40 As we became immersed in the data,^38,39 we focused on understanding the users’ experience (e.g., acceptability, patient-tool interaction, and usability), tool content output (e.g., values and goals), and adaptations (e.g., suggested modifications for an inpatient setting). Specifically, we developed summary templates to code patient cases and identify cross-cutting patterns.^38,39 Data were triangulated using the summary templates and through merging multiple data sources (Supplemental Appendix E). Following summary template review, we (re)defined patterns and selected candidate themes through weekly discussions, memo-ing, matrix analysis, and visual mapping.³⁸ Using a recursive approach, we tested themes within the broader context of the full dataset, relevant literature, and discussions with the larger research team as well as a patient engagement group of older adults with post-acute care experience. This iterative process produced refined themes, selection of representative data extracts, and presentation of core findings using summary tables.

Results

Participant Characteristics

Of 43 eligible individuals approached for interviews, 26 participated, with a mean age of 73, 76.9% male, 80.7% Veterans, and 53.8% African American (Table 2). Reasons for declining included lack of interest (n = 8), medical issues (n = 4), frustration with care (n = 3), and wanting an (unavailable) caregiver present (n = 2).

Table 2.

Participant characteristics across sites (n = 26).

Patient characteristic	Statistic
Sex (male), n (%)	20 (76.9%)
Age (years), average (Min, Max)	72.5 (61, 85)
Has 2 or more comorbid conditions	26 (100.0%)
Educational background, n (%)
Less than high school	4 (15.4%)
High school graduate, vocational, or trade school	10 (38.5%)
Some college or associate degree	8 (30.8%)
Bachelor’s degree or higher	4 (15.4%)
Veteran status (yes), n (%)	21 (80.7%)
Partner status* n (%)
Single/divorced/separated	13 (50%)
Married or partnered	10 (38.5%)
Widowed	6 (23.1%)
Race/ethnicity, n (%)
Black or African American	14 (53.8%)
Hispanic or Latino	2 (7.7%)
White	10 (38.5%)
Living situation, n (%)
Alone	8 (30.7%)
With my spouse (only)	10 (38.4%)
With my child (no spouse)	3 (11.5%)
Other	5 (19.2%)
Caregiver support*, n (%)	16 (61.5%)
Spouse	6 (23.1%)
Child	8 (30.8%)
Friend/other family	3 (11.5%)
Length of hospitalization (days), average (min, max)	10.5 (3, 31)
Number of days from admission to enrollment, average (min, max)	6.2 (1, 22)
Number of days from enrollment to discharge, average (min, max)	4.5 (0, 25)
Surgery during hospitalization, n (%)	6 (23.1%)
ICU stay during hospitalization, n (%)	3 (11.5%)
Discharge location, n (%)
Skilled nursing facility	20 (76.9%)
Home health care	2 (7.7%)
Other	4 (15.4%)
Hospital sites, n (%)
Hospital A (VA)	17 (64.0%)
Hospital B (VA)	3 (11.5%)
Hospital C (non-VA)	6 (23.1%)

Note. Variables marked with an asterisk (*) allowed participants to select multiple categories.

User Experience with the Health Priorities Primer Tool (HPPT)

Acceptability

We examined tool acceptability, including participants’ approval and welcomeness of using the HPPT in the inpatient setting (Supplemental Appendix E). Thematic analysis indicated most participants (n = 19) strongly reported that a value-goal elicitation exercise would be useful to consider post-acute care discharge priorities. Yet, participants varied in their acceptability of the HPPT in achieving this aim.

More than half (n = 14) viewed the HPPT favorably, appreciating the value-goal elicitation exercise of discussing “What Matters” while hospitalized. For example, participants reported the tool was “helpful to set [discharge] priorities” (P101), provided motivation to “think more positively” (P101), and have a “more helpful mindset” about recovery (P009). The tool encouraged them to “make an agreement with [my]self for accountability” (P003) and thought it could open the door to having conversations with family about what matters most when making healthcare decisions, especially discharge planning (P205). As one participant explained, completing the worksheet would “help me focus on what I would like to accomplish through physical therapy and what I’d like to get back, like my independence [at home]” (P201). Another participant mentioned they welcomed the tool because “it means the VA is concerned about the Vet as a person,” and it was “enlightening and surprising” because they “didn’t think that anyone cared” (P009).

Meanwhile, a third had mixed or neutral feelings (n = 9), and a few (n = 3) reacted negatively. Concerns included unclear impact on discharge planning without additional information regarding care options and complexity of the tool. As one participant explained, “it is good to think about so that Veterans will get to the bottom of their needs, and that it tends to make you think about things you wouldn’t otherwise. . .but [the tool] was too complicated, and people won’t know or pretend to know [without more information]” (P008). Similarly, others felt the tool was too complex or burdensome given their hospital condition, as “being in the hospital is hard” (P102).

Participant and Tool Interactions

We examined how participants interacted with the tool to gain a better understanding of participants’ preferences for tool administration, time to complete the tool, and potential role of environmental context in tool administration. Most participants (n = 22) preferred the tool to be verbally administered. In one case, the participant reported preferring having the tool verbally administered, but switched to self-administering using the paper worksheet, as it was easier to “see the options” and he felt he could “expedite things” (P009). Participants reported preferring verbal facilitator-administration for reasons such as: fatigue or not feeling well, not having their glasses, difficulty writing due to a baseline tremor, and environmental challenges (e.g., having an intravenous catheter in extremity; wearing an oxygen mask; and limited room on bedside table). On average, the tool took 10 minutes to complete (range 5-20 min), with verbal administration generally faster than self-administration on paper (9 vs 11 min). Notably, only two participants expressed concerns about tool length. Participants answered all questions in order. Minor interruptions (e.g., physicians rounding, placing food orders, requesting medications, and phone calls) occurred in about a third of cases (n = 9).

Tool Usability Considerations

To examine tool usability (e.g., how easily users can interact with the tool to achieve its intended aims), we examined elements of tool complexity (e.g., data completeness, ease of use, perception of length, and areas of confusion), perceived fit in the hospital setting, and linking values and goals (as part of achieving the intended tool aim).

Tool Complexity

Data completeness was high, with only one case missing an HPPT item. However, seven participants selected an incorrect number of values during prioritization. The initial question (“Who or what matters most in your day-to-day life?”) was perceived as thought-provoking and unexpected, while others expressed it was a “difficult question to start off with” (P003), as well as “broad [and] so challenging to answer” (P009). A few expressed concerns that the pre-determined lists of answer options had too many choices or were repetitive (Supplemental Appendix C), with a minority of participants expressing frustrations that options available were not applicable due to their age, life phase, and/or current health status while hospitalized. Three participants specifically noted the option “living longer for a specific important event” (Supplemental Appendix C, item 5) did not seem relevant, as one participant explained “you [participant or care team] have no control over that” (P008).

Perceived Fit in the Hospital Setting

Few participants (n = 4) reported being asked similar questions about “what matters,” their values, or post-acute care goals during hospitalization. These participants noted “a couple of questions here and there [they were asked], but I can’t remember the specifics” (P205) or “who asked them” (P001) during hospitalization. However, participants expressed a range of views toward the tool being administered while inpatient. In general, they viewed the tool as something that would be discussed with them verbally by a medical provider or nurse (n = 8), a social worker (n = 6) or someone they have an established relationship with, such as a family member, caregiver, or primary care clinician (n = 4). Some mentioned anyone could ask these questions and the content would be useful for the entire healthcare team to know. Other notable suggestions included the facilitator be a psychiatrist (n = 2, due to mental health goals) or a physical therapist (due to functional improvement goals), while another suggested an administrator or researcher, as clinicians were perceived as “not having enough time” (P202). Two participants suggested they would like to have family members present to better understand questions and improve communication.

Preferred timing of tool administration also varied. Only one participant suggested the tool should be administered upon hospital admission, with the majority preferring the questions to be reviewed throughout the hospital stay or closer to discharge when they had a better understanding of what they might expect after leaving the hospital. Some thought these questions should be asked not only in the inpatient setting, but also prior to hospitalization (e.g., in a primary care setting where they have an established patient-clinician relationship and more time) or followed-up on during the post-acute care period (e.g., when they have a “better grasp on what is realistic” [P002]). Several noted these “What Matters” conversations are best in mid-morning or mid-afternoon, as participants felt more comfortable after meals, felt “more with it” (P001), and anticipated fewer interruptions.

Linking Values and Goals

During debrief interviews, participants identified which PPC values domains – connecting, enjoying life, functioning, managing health (Supplemental Appendix D) – aligned with their goal(s) to better understand how the HPPT achieves one of its core functions (e.g., eliciting value-based goals). Participants exhibited four response patterns linking their values to post-acute goals. First, some saw a close connection and thought the tool would be useful for discharge planning. For example, one participant (P007) said his goal of “getting better, taking care of family, and having a beer in peace” closely aligned with his values of “enjoying life.” He thought the HPPT would be useful for articulating what matters to him and could help him better discuss his care preferences with his healthcare team and family. A second group struggled to prioritize certain values over others, “viewing all areas as important” (P203) to their post-acute care goal with few tradeoffs between them, thus making the exercise frustrating or less informative. A third group identified values and goals that were seemingly unlinked, such as selecting “connecting” as their prioritized value, while their goal was to improve functional status. Finally, a smaller fourth group of participants found little relevance in linking values to goals, describing the questions as “bad” and “not helpful,” since patients “don’t think of values and goals [while planning for discharge], you just have them” (P202).

Potential Areas for Adaptation for the Inpatient Setting

Participants provided feedback for improving the HPPT and eliciting “What Matters” while hospitalized (Table 3, Supplemental Appendix F). Suggestions included prioritizing verbal administration of the tool (while still having flexibility depending on participant preference), simplifying the tool (e.g., structure, revising pre-determined categories, and framing goals), clarifying its relevance to acute and post-acute care, and ensuring it could be more easily integrated into a hospital stay. Timing of administration was also highlighted as critical, with many participants preferring the tool be used closer to discharge, when they had a better sense of their recovery trajectory.

Table 3.

Areas for improvement linked to research-informed user-centered design adaptation considerations.

Participant suggestions	Rationale	Adaptation considerations
Prioritize facilitated administration, with flexibility for patient preference	Preferred having the tool read aloud	• Verbal facilitation protocols• Flexibility in delivery options• Speech-to-text EHR integration
Adjust timing of administration	Preferences varied regarding optimal timing for the tool	• Staggered delivery model• Readiness-responsive scheduling• Minimize interruptions• Align with existing tools
Incorporate family or caregiver involvement	Expressed a desire to complete the tool with family or caregivers to help with decision-making and communication	• Family-involved sessions• Proxy completion option• Caregiver input prompts
Simplify tool structure	Found the tool complex and cognitively demanding	• Prioritize content• Modular design• Guided conversations• Interactive features
Revise pre-determined answer choices	Found the pre-determined categories overly numerous, repetitive, or irrelevant, making it difficult to select values	• Streamlined category list• Personalized content• Ranked categories• Dynamic filtering
Improve framing of goals	Often reported broad general health goals (e.g., “getting better”) which may not provide actionable guidance for post-acute care planning	• Actionable goals• Prioritize a specific decision• Case management integration
Clarify link between values and goals	Struggled to connect their personal values to their post-acute care goals	• Provide scenario examples• Value-goal mapping• Educational videos or modules
Communicate purpose and impact of tool	Unclear about how their responses would be used by the healthcare team or how it would impact their care	• Pre-use orientation• Provider feedback loop• Visibility in care plans
Integrate into hospital stay	Expected the tool to be part of routine practice rather than a stand-alone, one-time assessment	• Role-specific utilization• EHR integration• Automated prompts for review
Ensure tool usability for diverse patient abilities and backgrounds	Varied in ability to use the tool depending on factors such as fatigue, cognitive load, the hospital environment, and their readiness for discussion	• Customized accessibility options• Accessible formats• Adaptive design

HPPT Content Output: Description of Participants’ Responses

Values

Using the open-ended “who or what matters most” question, participants responded with brief statements and emphasized family (n = 19), friends (n = 6), personal well-being (n = 5), and pets (n = 4). When prioritizing values from a pre-determined list, participants’ top choices included physical/mental well-being (n = 16), independence (n = 15), and quality of life (n = 14; Supplemental Appendix G, Figure F1).

Goals

For post-discharge goals using the open-ended option, responses varied widely; however, most were broad and health-related (Supplemental Appendix H). The most common goal was focused on health recovery and “to get better,” while others included symptom management (such as pain control), improving physical health and mobility, maximizing mental and emotional well-being, and focusing on social connections and personal fulfillment. Using the pre-determined prompts, participants reported the most burdensome tasks as housework (n = 13), bathing (n = 6), and transportation (n = 5; Supplemental Appendix G, Figure F2). In contrast, they expressed a desire to spend more time doing the following: engaging with family and friends (n = 14), staying home and living independently (n = 10), exercising (n = 9), and/or increasing capacity for mobility or self-care (n = 7; Supplemental Appendix G, Figure F3).

Discussion

This study explored the acceptability and usability of the HPPT, potential adaptations for its use in the inpatient setting, and “What Matters” most to older hospitalized patients. The HPPT shows promise in identifying “What Matters” to older hospitalized patients, yet refinements are needed to improve its usability. Findings can guide clinical staff, leaders, and implementation scientists in implementing the HPPT and/or developing similar interventions to support AFHS.

A key finding was the variability in how older patients link values to health goals. While some articulated clear connections, others struggled, suggesting that translating values into actionable goals is not always intuitive. Participants noted HPPT’s potential to guide discharge planning, but found certain aspects challenging, indicating a need for refinements that make goal setting more straightforward. This highlights a major tension of leveraging universal value-goal elicitation tools, such as the HPPT, aimed to be used in multiple settings.⁴¹ These standardized tools offer consistency and scalability by streamlining workflows but may lack the personalization needed to engage patients effectively. Conversely, tools tailored to populations or settings may improve communication and relevance, yet can increase complexity, training demands, and costs.⁴¹ Hospitals considering implementing value-goal elicitation tools must balance broad applicability with contextual relevance to ensure patients understand how tools and their output support care.

Yet, overall, our findings suggest that with guidance, hospitalized older adults can identify health values to inform post-discharge goal-setting. Participants most often endorsed family and friends when responding to an open-ended question about “who or what matters most.” When asked to prioritize values from a predetermined list, participants most often endorsed physical/mental well-being, quality of life, and independence. While health goals may not be intuitive, our work demonstrates patients can readily identify health values when prompted. Health values exist across a few recurring domains, and patients can often identify more than one value concurrently. Effective goal-setting involves translating multiple health values into specific actionable goals, a process consistent with prior research.⁴² Future studies should evaluate how value-goal elicitation tools like the HPPT fit and perform across different populations and settings, as adaptations may be required.

A strength of this study is examining HPPT usability from the patient’s perspective, as early end-user engagement enhances meaningful tool development.²⁶ Hospitalized participants’ experiences with the HPPT’s usability were mixed – indicating a need for additional adaptations prior to implementing into practice. Interestingly, verbal administration was preferred and faster than self-administration, reinforcing the need for flexible delivery options. Participants expressed a desire for clinician involvement in the value-goal discussions for post-acute planning, emphasizing the role of shared decision-making in the clinician-patient relationship.^43,44 Together, these findings suggest a potential role for a facilitator – such as a case manager well-versed in values-based goal-elicitation – during the discharge planning process. Yet, given the range of adaptation needs identified (Table 3), alternative value-goal elicitation tools or approaches may be warranted.

Our findings offer practical guidance for designing, adapting, and implementing the HPPT, and similar values-goal elicitation tools, for older hospitalized adults. Suggested adaptations, summarized in Table 3 and detailed in Supplemental Appendix F, include modifications informed by user-centered design strategies,^20,45,46 decision-making tool literature,³² and geriatric intervention best practices.^47,48 These suggestions range from minor modifications to more comprehensive redesigns, offering flexibility for different clinical contexts. Future work should balance patient’s perspectives of tool usability with other key end-users: clinicians.

Successful implementation requires both patient engagement and trained clinicians willing to integrate value-goal elicitation tools into practice. With increasing emphasis on documenting older hospitalized patient’s values and goals,¹³ evidence-based approaches are essential for ensuring actionable, patient-centered conversations in busy inpatient settings. However, feasibility concerns remain for implementing values-based goal elicitation tools in fast-paced inpatient settings due to staffing shortages, time constraints, and documentation burdens.^49
-52 Without clear benefits, staff training, and integration into clinical workflows, a 10-minute assessment per patient is likely not be feasible. For post-acute care patients, focusing on specific populations (such as surgical patients with clearer goals) or those in transitional care programs (where staff can build trusting relationships over time), may improve practicality. Further user-centered design studies incorporating clinician input could enhance the accessibility and integration of tools like HPPT into routine care.^20,21,45

This study has limitations. Our small, predominantly Veteran sample may limit transferability. Although participants were diverse in race/ethnicity, socioeconomic status, and education, a 40% non-participation rate introduces potential selection bias. Additionally, research staff administered the HPPT rather than clinicians, which may have influenced responses. The structured qualitative data collection and HPPT focus may have constrained emergent themes: more open-ended approaches, having additional staff available for observations, or different tools may have provided alternative perspectives. Likewise, low uptake of self-administration and the absence of digital options limits our understanding of optimal delivery methods. Last, the broad range of identified adaptations indicates further input from patients (and clinicians) may be needed to refine content, format, and delivery of inpatient value-goal elicitation tools. Despite these limitations, the summary tables can be used by practitioners to assess our findings’ relevance to their settings, and inform future research on usability of value-goal elicitation tools like the HPPT across diverse patient populations and clinical contexts.

Conclusion

Our findings underscore the importance of early patient end-user engagement in adapting value-goal elicitation tools, like the HPPT, for hospitalized older adults. Key findings highlight the need for facilitated administration, clinician involvement, and alignment with clinical workflows to improve usability. Overall, older adults welcomed the use of a value-goal clarification tool during hospitalization and noted its potential to support post-acute care planning, though translating values into actionable goals remains challenging. Further refinements, including simplification of choice categories and healthcare team engagement, could enhance usability and support goal-concordant care during critical transitions. Given the range of adaptation needs identified, alternative tools or approaches may be warranted. Without valid tools nor implementation strategies for eliciting values and goals in the inpatient setting, it will be challenging for hospitals to meet Medicare’s 2025 AFHS “What Matters Most” Measure.¹³ With the increased focus on improving goal documentation in the inpatient setting,¹³ our findings can be leveraged to inform the development and implementation of other age-friendly “What Matters” tools for the inpatient setting.

Supplemental Material

sj-docx-1-inq-10.1177_00469580251332131 – Supplemental material for A Mixed-Methods Usability Pilot of a Value-Goal Elicitation Tool in the Inpatient Setting for Older Adults Anticipating Post-Acute Care

Supplemental material, sj-docx-1-inq-10.1177_00469580251332131 for A Mixed-Methods Usability Pilot of a Value-Goal Elicitation Tool in the Inpatient Setting for Older Adults Anticipating Post-Acute Care by Kirstin M. Piazza, Caroline Pascal, Syama R. Patel, Caroline Sefcik, Marilyn M. Schapira, Caroline Madrigal, Katherine C. Ritchey, Longyi Yip, Aanand D. Naik and Robert E. Burke in INQUIRY: The Journal of Health Care Organization, Provision, and Financing

Footnotes

Acknowledgements

The authors would like to acknowledge the thoughtfulness of the clinician experts and patients who shared their insights with us.

ORCID iDs

Kirstin M. Piazza

Caroline Pascal

Syama R. Patel

Caroline Sefcik

Caroline Madrigal

Katherine C. Ritchey

Longyi Yip

Robert E. Burke

Abbreviations

AFHS Age-Friendly Health System

EHR Electronic Health Record

HPPT Health Priorities Primer Tool

PPC Patient Priorities Care

VA Department of Veterans’ Affairs

Ethical Considerations

This study was approved by each site’s institutional review board: Corporal Michael J. Crescenz Department of Veterans Affairs Medical Center (approval number 1767605); Pittsburgh VA Medical Center (approval number 1798997); University of Pennsylvania (approval number 855583)

Consent to Participate

The research procedures of this study were reviewed by the Institutional Review Boards for each site and determined to be exempt.

Consent for Publication

Not applicable.

Author Contributions

Study concept and design: KP, RB, MS, CM, CP, and AN. Feedback on tool adaptation: KR, LK, CM, MS, CP, CS, SP, AN, and RB. Data collection: CP, CS, and SP. Analysis and interpretation of data: KP, CP, SP, IY, and CM. All authors discussed the results and contributed to preparation of the final manuscript.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article. This work was supported by the Veterans Affairs Health Services Research Career Development Award IK2-HX003470-01A1 and the Office of Geriatrics and Extended Care Mentored Partner Program. The funding body had no role in the design of the study, the collection, analysis, and interpretation of data, or in writing the manuscript.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The underlying data for this study consists of in-depth, qualitative interviews with patients. It is not possible to create a minimal data set as this study did not obtain ethical approval or informed consent from participants to publicly share underlying datasets. Relevant excerpts from transcripts of qualitative interviews are included within the paper. The datasets generated and/or analyzed during this study are not publicly available but may be available upon request at the Center for Health Equity Research and Promotion of the U.S. Department of Veterans Affairs administrative offices, at (215) 823-5817 ().

Reporting Guidelines

The Standards for Reporting Qualitative Research Guidelines checklist was used to ensure proper standards for reporting qualitative studies ().

Supplemental Material

Supplemental material for this article is available online.

References

Age Friendly Health Systems. Institute for Healthcare Improvement. Accessed October 17, 2024. https://www.ihi.org/networks/initiatives/age-friendly-health-systems

Laderman

Jackson

Little

Duong

Pelton

“What matters” to older adults: a toolkit for health systems to design better care with older adults. Institute for Healthcare Improvement. 2019. Accessed October 17, 2024, https://www.ihi.org/sites/default/files/2023-09/IHI_Age_Friendly_What_Matters_to_Older_Adults_Toolkit.pdf

Tinetti

Naik

Dindo

, et al Association of patient priorities-aligned decision-making with patient outcomes and ambulatory health care burden among older adults with multiple chronic conditions: a nonrandomized clinical trial. JAMA Intern Med. 2019;179(12):1688-1697. doi:10.1001/jamainternmed.2019.4235

Mor

Intrator

Feng

Grabowski

DC.

The revolving door of rehospitalization from skilled nursing facilities. Health Aff. 2010;29(1):57-64. doi:10.1377/hlthaff.2009.0629

Gill

Allore

Holford

Guo

Hospitalization, restricted activity, and the development of disability among older persons. JAMA. 2004;292(17):2115-2124. doi:10.1001/jama.292.17.2115

Merino Martín

Cruz-Jentoft

. Impact of hospital admission on functional and cognitive measures in older subjects. Eur Geriatr Med. 2012;3(4):208-212. doi:10.1016/j.eurger.2011.11.008

Alzahrani

The effect of hospitalization on patients’ emotional and psychological well-being among adult patients: an integrative review. Appl Nurs Res. 2021;61:151488. doi:10.1016/j.apnr.2021.151488

Heydari

Sharifi

Moghaddam

AB.

Challenges and barriers to providing care to older adult patients in the intensive care unit: a qualitative research. Open Access Maced J Med Sci. 2019;7(21):3682. doi:10.3889/oamjms.2019.846

Burke

Jones

Lawrence

, et al Evaluating the quality of patient decision-making regarding post-acute care. J Gen Intern Med. 2018;33(5):678-684. doi:10.1007/s11606-017-4298-1

10.

Naik

Dindo

Van Liew

, et al Development of a clinically feasible process for identifying individual health priorities. J Am Geriatr Soc. 2018;66(10):1872-1879. doi:10.1111/jgs.15437

11.

Samper-Ternent

Razjouyan

Dindo

, et al Patient priorities care increases long-term service and support use: propensity match cohort study. J Am Med Dir Assoc. 2024;25(5):751-756. doi:10.1016/j.jamda.2023.12.014

12.

Freytag

Dindo

Catic

, et al Feasibility of clinicians aligning health care with patient priorities in geriatrics ambulatory care. J Am Geriatr Soc. 2020;68(9):2112-2116. doi:10.1111/jgs.16662

13.

Centers for Medicare and Medicaid Services. Medicare and Medicaid Programs and the Children’s Health Insurance Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2025 Rates; Quality Programs Requirements; and Other Policy Changes. Federal Register. August 28, 2024. Accessed October 18, 2024. https://www.federalregister.gov/documents/2024/08/28/2024-17021/medicare-and-medicaid-programs-and-the-childrens-health-insurance-program-hospital-inpatient

14.

Mroz

Hernandez-Bigos

Esterson

Kiwak

Naik

Tinetti

ME.

Acceptability and use of an online health priorities self-identification tool for older adults: a qualitative investigation. PEC Innov. 2023;3:100242. doi:10.1016/j.pecinn.2023.100242

15.

Ritchey

Martinez

Keifer

, et al Patient priorities care VA Health Professional Toolkit. U.S. Department of Veterans Affairs. Accessed October 31, 2024. https://vappctools.patientprioritiescare.org/

16.

Ritchey

Solberg

Citty

, et al Guiding post-hospital recovery by “what matters”: implementation of patient priorities identification in a VA Community Living Center. Geriatrics. 2023;8(4):74. doi:10.3390/geriatrics8040074

17.

Fetters

Curry

Creswell

JW.

Achieving integration in mixed methods designs – principles and practices. Health Serv Res. 2013;48(6 Pt 2):2134. doi:10.1111/1475-6773.12117

18.

Creswell

Clark

VLP

. Designing and Conducting Mixed Methods Research. SAGE Publications; 2017.

19.

Moser

Korstjens

Series: practical guidance to qualitative research. Part 5: co-creative qualitative approaches for emerging themes in primary care research: experience-based co-design, user-centred design and community-based participatory research. Eur J Gen Pract 2022;28(1):1. doi:10.1080/13814788.2021.2010700

20.

Walden

Garvin

Smerek

Johnson

User-centered design principles in the development of clinical research tools. Clin Trials. 2020;17(6):703-711. doi:10.1177/1740774520946314

21.

Kushniruk

Patel

VL.

Cognitive and usability engineering methods for the evaluation of clinical information systems. J Biomed Inform. 2004;37(1):56-76. doi:10.1016/j.jbi.2004.01.003

22.

Yen

Bakken

Review of health information technology usability study methodologies. J Am Med Inform Assoc. 2012;19(3):413-422. doi:10.1136/amiajnl-2010-000020

23.

O’Brien

Harris

Beckman

Reed

Cook

DA.

Standards for reporting qualitative research: a synthesis of recommendations. Acad Med. 2014;89(9):1245-1251. doi:10.1097/ACM.0000000000000388

24.

Kujala

Kauppinen

Identifying and selecting users for user-centered design. In: Conference Proceedings of the Third Nordic Conference on Human-Computer Interaction, Tampere, 23-27 October 2004. Association for Computing Machinery; 2004. https://dl.acm.org/doi/10.1145/1028014.1028060

25.

Sarkar

Diversity in study participants and a critique of the “representative sample” in human-computer interaction research. In: Conference Proceedings of the 2024 IEEE Symposium on Visual Languages and Human-Centric Computing (VL/HCC), Liverpool. Institute of Electrical and Electronic Engineers (IEEE); 2024. https://ieeexplore.ieee.org/document/10714551

26.

Jaul

Barron

Rosenzweig

Menczel

An overview of co-morbidities and the development of pressure ulcers among older adults. BMC Geriatr. 2018;18(1):305. doi:10.1186/s12877-018-0997-7

27.

U.S. Government Accountability Office. VA Health Care: veterans’ use of long-term care is increasing, and VA faces challenges in meeting the demand. February 19, 2020. GAO-20-284. Accessed October 18, 2024. https://www.gao.gov/products/gao-20-284

28.

Thomas

Cote

Makineni

, et al Change in VA Community Living Centers 2004-2011: shifting long-term care to the community. J Aging Soc Policy. 2018;30(2):93-108. doi:10.1080/08959420.2017.1414538

29.

Bastien

JMC

. Usability testing: a review of some methodological and technical aspects of the method. Int J Med Inform. 2010;79(4):e18-e23. doi:10.1016/j.ijmedinf.2008.12.004

30.

Madden

Bayapureddy

Briesacher

, et al Affordability of medical care among Medicare enrollees. JAMA Health Forum. 2021;2(12):e214104. doi:10.1001/jamahealthforum.2021.4104

31.

Glynn

Hernandez

Roberts

ET.

Consequences of forgoing prescription drug subsidies among Low-Income Medicare beneficiaries with diabetes. Health Serv Res. 2022;57(5):1136-1144. doi:10.1111/1475-6773.13990

32.

Witteman

Maki

Vaisson

, et al Systematic development of patient decision aids: an update from the IPDAS collaboration. Med Decis Making. 2021;41(7):736-754. doi:10.1177/0272989X211014163

33.

Suh

Trabasso

Inferences during reading: converging evidence from discourse analysis, talk-aloud protocols, and recognition priming. J Mem Lang. 1993;32(3):279-300. doi:10.1006/jmla.1993.1015

34.

Olmos-Vega

Stalmeijer

Varpio

Kahlke

R. A

practical guide to reflexivity in qualitative research: AMEE guide no. 149. Med Teach. 2023;45(3):241-251. doi:10.1080/0142159X.2022.2057287

35.

Braun

Clarke

Is thematic analysis used well in health psychology? A critical review of published research, with recommendations for quality practice and reporting. Health Psychol Rev. 2023;17(4):695-718. doi:10.1080/17437199.2022.2161594

36.

Harris

Taylor

Thielke

Payne

Gonzalez

Conde

JG.

Research electronic data capture (REDCap) – a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377-381. doi:10.1016/j.jbi.2008.08.010

37.

Harris

Taylor

Minor

, et al The REDCap consortium: building an international community of software platform partners. J Biomed Inform. 2019;95:103208. doi:10.1016/j.jbi.2019.103208

38.

Braun

Clarke

Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77-101. doi:10.1191/1478088706qp063oa

39.

Clarke

Braun

Thematic Analysis. SAGE Publications, Inc; 2021. https://us.sagepub.com/en-us/nam/thematic-analysis/book248481

40.

Lyons

AC.

Advancing and extending qualitative research in health psychology. Health Psychol Rev. 2011;5(1):1-8. doi:10.1080/17437199.2010.544638

41.

Kassab

Scott

Boyd

Puspitasari

Endicott

Lewis

CC.

Tailored isn’t always better: impact of standardized versus tailored training on intention to use measurement-based care. Implement Res Pract. 2022;3:26334895221087477. doi:10.1177/26334895221087477

42.

Shanahan

Naik

AD.

Using health values to inform collaborative goal-setting for chronic care of older adults. J Am Geriatr Soc. 2024;72(7):1955-1958. doi:10.1111/jgs.18948

43.

Bomhof-Roordink

Gärtner

Stiggelbout

Pieterse

AH.

Key components of shared decision making models: a systematic review. BMJ Open. 2019;9(12):e031763. doi:10.1136/bmjopen-2019-031763

44.

Treichler

EBH

Rabin

Cohen

Light

. How shared is shared decision making? Reaching the full potential of patient-clinician collaboration in mental health. Harv Rev Psychiatry. 2021;29(5):361-369. doi:10.1097/HRP.0000000000000304

45.

Dopp

Parisi

Munson

Lyon

AR.

Aligning implementation and user-centered design strategies to enhance the impact of health services: results from a concept mapping study. Implement Sci Commun. 2020;1:17. 2020 Feb 26. doi:10.1186/s43058-020-00020-w

46.

Lyon

Koerner

User-centered design for psychosocial intervention development and implementation. Clin Psychol Sci Pract. 2016;23(2):180-200. doi:10.1111/cpsp.12154

47.

Fisk

Czaja

Rogers

Charness

Czaja

Sharit

Maximizing the usefulness and usability of healthcare technologies. In: Designing for Older Adults. 2nd ed. CRC Press; 2009.

48.

Bunn

Goodman

Russell

, et al Supporting shared decision making for older people with multiple health and social care needs: a realist synthesis. BMC Geriatr. 2018;18(1):165. doi:10.1186/s12877-018-0853-9

49.

Greysen

Schiliro

Horwitz

Curry

Bradley

EH.

“Out of sight, out of mind”: housestaff perceptions of quality-limiting factors in discharge care at teaching hospitals. J Hosp Med. 2012;7(5):376-381. doi:10.1002/jhm.1928

50.

Manges

Groves

Farag

Peterson

Harton

Greysen

SR.

A mixed methods study examining teamwork shared mental models of interprofessional teams during hospital discharge. BMJ Qual Saf. 2020;29(6):499-508. doi:10.1136/bmjqs-2019-009716

51.

Manges

Ayele

Leonard

Lee

Galenbeck

Burke

RE.

Differences in transitional care processes among high-performing and low-performing hospital-SNF pairs: a rapid ethnographic approach. BMJ Qual Saf. 2021; 30(8):648-657. doi:10.1136/bmjqs-2020-011204

52.

Burke

Leonard

Lee

, et al Cognitive biases influence decision-making regarding postacute care in a skilled nursing facility. J Hosp Med. 2020;15(1):22-27. doi:10.12788/jhm.3273

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.77 MB