Michigan Center for Urban African American Aging Research
A key component of MCUAAAR is the support of pilot research by junior investigators that can lead to independent NIH-funded projects. The scientists who are selected each year into the program are given resources to conduct behavioral and social science research that focuses on the health and well-being of older African Americans. The title and abstract for each MCUAAAR Scientist by cohort can be found below.
2021 MCUAAAR Scientists
Ryon J. Cobb, PhD
“Early Life Adversity, Perceived Control, and Renal Aging Among Older Blacks: Evidence from the Health and Retirement Study”
CKD is a serious public health problem among older adults in the U.S. Population-based studies reveal the prevalence of CKD among older adults is 20%, and scientists project that 33% of adults will develop CKD in their lifetime. Older Blacks are at greater risk of CKD and end-stage renal disease (ESRD) than aging Whites, and these differences were not fully explained by traditional risk factors.
Racial disparities in renal aging contribute to Black/White disparities in ERSD Blacks’ disproportionate experience of psychosocial stressors may contribute to their faster rates of renal aging. Yet, longitudinal studies on this topic are rare, and a critical need exists to research how early life adversity relates to renal aging among older Blacks. Consistent with the stress model, exposures that occur during developmentally active phases of the lifecourse, exhibit a high degree of phenotypic plasticity. The overarching aim of this proposed research is to investigate how early life adversity shapes renal aging among older Blacks. The central hypothesis is that greater levels of early life adversity will be associated with faster rates of renal aging among older Blacks, and perceived control will mediate and moderate this relationship.
Angela Elam, MD
“Increasing Eye Care Utilization in Urban Black Americans Using a Community Engaged, Faith-Based Approach”
There are significant gaps in our understanding between well-established, evidence-based guidelines for detection and treatment of glaucoma and effectively applying those guidelines within the high-risk populations that continue to develop blindness. As outlined by the National Academy of Medicine, great opportunity exists to incorporate principles of population health and community engagement to close this observed glaucoma detection gap. The overall objective of this study is to design and implement a faith-based, community health worker-delivered (CHW) support program for individuals at high risk for glaucoma, specifically Black Americans. The central hypothesis is that a personalized faith-based support program will result in increased eye care utilization in Black Americans at high risk for glaucoma who currently underutilize eye care. The rationale is that increasing appropriate eye care utilization in high-risk individuals and beginning treatment at earlier stages of the disease will decrease the risk of unpreventable blindness. The candidate will reach the overall objective by achieving the following 2 specific aims: 1) Use implementation science framework and community-engaged methods to adapt an existing glaucoma coaching program and develop a multilevel intervention that addresses the key determinants of successfully increasing eye care utilization in Black Americans; and 2) Implement and evaluate the feasibility and acceptability of the Community-Based Treatment for Glaucoma program (ComBaT Glaucoma), for Black Americans. In Aim 1, the Tailored Implementation for Chronic Diseases (TICD) implementation science framework will be used to guide semi-structured interviews with community members, leaders, and local eye care providers to identify barriers and potential facilitators of increasing eye care utilization in Black Americans; and b) adapt the Support, Educate and Empower (SEE) Program to the needs and culture of the community to develop and the faith-based CHW-delivered program that uses implementation strategies and behavior change techniques linked to community-identified determinants for optimal success. In Aim 2, the ComBaT Glaucoma program will be implemented by conducting a single-arm pilot study with 50 Black Americans. The candidate will use mixed methods to assess the feasibility and acceptability of the ComBaT Glaucoma program. This study is significant because it addresses a gap between well-established guidelines for glaucoma and high-risk individuals that continue to go blind despite these data. It is innovative because it employs implementation science framework, a community-engaged, faith-based tailored approach to create a support program to increase eye care utilization in Black Americans at high risk for glaucoma.
Christy L. Erving, PhD
“Multiple Sources of Psychosocial Stress and Mental Health among Black Women across the Life Course”
Black women experience alarming rates of depression and anxiety. Furthermore, risk for mental health problems differs across Black women’s life course stage and socioeconomic position. National data shows that mood disorder prevalence rates for Black women are 14.8% for those in early midlife (30-44 years old), 15.7% in midlife (45-64 years old), and 5.8% in late-life (65 years and older). Anxiety disorder rates are even higher for Black women, at 24.3% among those 30 to 44 years old, 25.1% for those between 45 and 64 years old, and 13.8% for individuals 65 and older. With regards to economic position, higher educational attainment and household income are associated with better mental health. Psychosocial factors underlying mental health patterns within the Black female population remain underexplored.
To fill this research gap, the proposed research integrates social stress theory, the life course perspective, and the intersectionality framework to examine heterogeneous effects of multiple sources of psychosocial stress exposures on Black women’s mental health across the life course as well as socioeconomic position (SEP). Given that a large majority of stress-mental health studies among Black women focus on discrimination, this research will also account for and assess the relative impact of discrimination stress, chronic work discrimination, neighborhood disorder, and financial strain on mental health. It is important to assess stress from multiple sources, as the marginalized racial and gender statuses Black women occupy expose them to disproportionately higher stress in general and a more diverse array of stressors.
Areeba Jawed, MD
“Racial Disparities in Palliative Care Utilization After Acute Stroke”
Racial disparity in stroke incidence has worsened over the years with black patients experiencing a disproportionate burden of disease. Black patients generally chose more aggressive interventions in the face of survival with disability and are known to receive more aggressive life-sustaining treatments after stroke. Additionally, there are racial/ ethnic differences in palliative care utilization and availability after stroke. All patients should have conversations about advance care planning after a stroke however racial disparities continue to exist in the quality of communication received by stroke patients. Black patients report concerns with providers’ efforts to listen to patients and the extent of information shared with them with heightened disparities in racially discordant physician patient relationships. It has been found that outcomes of communication can also vary by race, with end-of-life discussions between physicians and their black patients less likely to result in care consistent with patient preferences as compared to white patients. In our literature review we have identified racial disparities in stroke prevalence and outcomes. Moreover, there are very few studies addressing racial differences in quality of communication and palliative care delivered to black patients post stroke. Additionally, few studies examine the frequency, use, and outcomes associated with utilization of palliative care among black stroke patients. To develop focused interventions and improve palliative care utilization and delivery to minority patients with stroke, descriptive work first needs to be done. To address this, we will perform a secondary analysis of a retrospective observational study in stroke patients admitted to four acute care hospitals.
Hee Rin Lee, PhD
“Social Robots as a Mental Health Intervention for a Low-Income African American Older Adult Community”
As members of a socially underserved racial minority group in the US who experience discrimination and other stressors, African Americans have a high risk of facing mental health issues. For the low-income African Americans in Flint, Michigan, the risk is even higher, due to the two recent major crises: the tainted water crisis and the COVID-19 pandemic. Beginning in 2014, Flint’s public water system has been providing lead-contaminated water, which has negatively influenced its residents’ mental and physical health. Mental health issues in Flint have been exacerbated by the COVID-19 pandemic, due to the city’s limited healthcare infrastructure.
The long-term goal of this project is to develop social robots that can support a low-income African American older adult community in managing their mental health. For more than a decade, social robotics researchers have investigated how social robots can provide emotional support for older adults. However, social robotics research has minimal information on the perspectives of African Americans. As of writing, no study has been published in the flagship conference of social robotics that investigated the use of robots for African Americans. The objective of this proposal is to explore the feasibility of social robots via a participatory design study that invites low-income African American older adults in Flint to be co-designers. Through this collaboration, I will explore how social robots can benefit older adults who have experienced emotionally overwhelming situations.
2020 MCUAAAR Scientists
Christina N. Harrington, PhD
“Designing Health-Related Conversational Assistants for Health-Information Seeking Among Low-Income African- American Older Adults”
Older African Americans experience chronic health conditions and diseases at a disproportionate rate in comparison to the overall population, which may pose additional challenges related to one’s management of health in the home. With costs of medical care steadily increasing and posing a strain on many marginalized Americans, individuals have begun to look to in-home information communication technologies (ICTs) as convenient tools to seek, share, and track personal health information. There has been a recent emphasis in both public health and health information technology research in examining the ways information technologies can support minority populations due to higher rates of disparities and health risks. In-home health-related ICTs have great potential to provide immediate and low-cost access to health information and aid in decision-making and health management, proving to be an equitable solution to those who face additional challenges in this area of their health. Availability of real-time health information may help to address barriers to consistent healthcare access and improve quality of care for marginalized populations. Conversational or voice assistants (i.e. Amazon Echo, Amazon Alexa, Google Home, etc.) have become an increasingly popular approach to searching online information, presenting the possibility of serving health information seeking needs through voice-controlled communication (Bickmore et al., 2018). As the older adult population now makes up 37% of voice assistant owners (Olmstead, Pew Research Center, 2017), these devices are speculated to have great potential to be a welcomed alternative to having to type on small interfaces which may be difficult for individuals with lower dexterity or mobility impairments (Schlogl et al., 2013). As the development of conversational assistant functionality grows more robust, researchers posit that there is a need to better understand relevant scenarios for their use. However, little is known about the efficiency of these technologies among those who may have lower digital health literacy or technical proficiency. Low health literacy and digital proficiency have been determined to be prevalent barriers to obtaining health knowledge and maintaining self-care among older adults (Kim & Utz; 2018), and thus should be considered in the information exchange through conversational assistants as potential health ICTs.
The research study seeks to understand the ways in which African American older adults in lower-income areas pose health-related questions using online health resources. To best design ICTs that support health information seeking among individuals who may have difficulties in comprehending online health information, it is imperative to understand how this community forms health-related questions and what resources they find useful. This research will advance our understanding of how marginalized groups such as low-income African American older adults frame health-related questions when interacting with conversational assistants and the potential of these devices to support health information seeking. This research has the potential to increase our understanding of voice-controlled conversational devices as health information tools for older adults. This project will also help to provide foundational data for developing and testing culturally informed conversational assistants among African American older adults.
To this end, we will: (Aim 1) Understand what health-related questions low-income, African American older adults ask and in what ways they ask them. We aim to identify common topics, questions, and phrasing among this population to inform a taxonomy aimed to contribute to existing understandings of health information behaviors among marginalized populations.
Capturing health information behaviors in real-time through convenience research methods such as diary studies has been proven effective in previous research efforts (Elsweiler et al. 2010; Church & Smyth, 2012) and thus we have designed this as the foundation of this research agenda. (Aim 2 & 3) Identify the potential for conversational assistants (smart speakers) to support health information seeking among and understand perceptions of trust and credibility related to these devices. Through scenario-based feasibility testing and co-design focus groups, we aim to understand the perceptions and attitudes related to conversational assistants, including perceptions of information credibility and trust of these devices as a health information resource.
Mieka Smart, DrPH, MHS
“Barriers and Facilitators to Genomic Research Participation Reported by Older Adults”
This project is an examination of genomic research participation barriers and facilitators reported by older adults (50+ years) in Flint, Michigan. It is well documented for White populations that aspects of the exposome (e.g. living in poverty, or exposure to lead) are correlated with genomic change (e.g. reduced DNA methylation, or shortened telomere length). By contrast, for Black people, the synergistic effects between aspects of the exposome and their impacts on subsequent genomic changes are understudied, primarily because most genomic study samples do not include sufficient numbers of Black participants. Research has revealed robust associations between demographic characteristics and the likelihood of consenting to provide a sample to genomic research. Simply, Black people are less likely to participate in genomic research, but it remains unclear why. Furthermore, genomic research attitudes among older Black adults are particularly understudied. A deep examination of self-reported genomic research participation barriers and facilitators in a diverse geographic locale is critically important to eliminate disparities in genomic research participation rates.
In 2017, I designed the Flint Area Study (FASt) to longitudinally monitor genomic and exposome interactions that might impact the health of Flint residents. Despite extensive input from community partners to conceive and promote the FASt, initial recruitment efforts demonstrated that the overwhelming majority of individuals in Flint were disinclined to participate. My current project will explore and seek solutions to minimize that disinclination via the completion of the first stage of a two-stage mixed methods explanatory sequence design. I will utilize a previously piloted brief survey and a series of focus groups to obtain qualitative data regarding genomic research participation barriers and facilitators among older adult respondents. First, I will identify participation factors (barriers and facilitators) to understand which specific aspects of these factors have the most impact on participation in genomics research. Second, I will design a protocol for focus groups to solicit community members’ ideas for solutions for minimizing barriers and activating facilitators. Increased understanding of these factors in Flint could inform the success of genomics studies in other similar communities and will be useful for successfully recruiting diverse longitudinal cohorts nationwide.
Samuele Zilioli, PhD and Jennifer Gomez, PhD
“Cultural Betrayal Trauma as a Novel Social Determinant of Cardiovascular Disease among Urban African American Elders”
Although the prevalence of cardiovascular diseases (CVD) in the U.S. has steadily declined since the 1960s, urban African American (AA) adults continue to bear a disproportionate share of disease burden. Psychosocial stressors—including within-group violence and the emotional reactivity to these stressors—are believed to contribute to the etiology and progression of CVD through their effects on health behaviors and stress-responsive neuroendocrine axes. As proposed by Cultural Betrayal Trauma Theory (CBTT), societal trauma (e.g., institutional racism, perceived discrimination) experienced by racial minorities exacerbates the pernicious effects of within-group violence minority individuals receive from other in-group members. This within-group violence, known as cultural betrayal trauma, may rupture the bond formed by racial minority members in response to societal trauma and be particularly salient for residentially-segregated, urban-dwelling middle-aged and older AAs. Unfortunately, most of the existing literature has focused exclusively on the effects of societal trauma on physical health and neglected the etiological role of within-group violence and dynamics. Further, all previous empirical work on CBTT has focused on psychological well-being among young adults. Therefore, there is a critical need to specify multilevel characterizations of the biobehavioral pathways through which within-group violence and dynamics shape CVD risk among middle-aged and older AA living in urban settings.
Our long-term goal is to establish a model of the most relevant social determinants of CVD risk faced by urban-dwelling middle-aged and older AAs. Our overall objective in this proposal is to clarify the psychological and biological pathways through which cultural betrayal trauma may exacerbate CVD risk among middle-aged and older AAs. To achieve this goal, we will work with a sample of 100 AAs aged 50 and older years living in Detroit. Specifically, this project will leverage psychological, behavioral, and biological data currently being collected as part of the Health among Older adults Living in Detroit (HOLD) study (PI: Zilioli), a Wayne State University-funded project aimed at understanding the links between social stressors, psychological well-being, and physical health among older African American adults living in urban Detroit. Support from the MCUAAAR Grant will allow us to continue data collection of an additional 100 HOLD participants while adding relevant measures of cultural betrayal trauma and within-group dynamics. Our central hypothesis is that cultural betrayal trauma will predict poor psychological well-being (i.e., high daily and global negative affect), high physiological stress (i.e., daily cortisol), and increased CVD risk (i.e., increased smoking behavior, low resting heart rate variability, and high resting blood pressure) above and beyond measures of societal trauma (i.e., lifetime and daily discrimination). Our preliminary studies support the scientific premise and feasibility of the present proposal.
2019 MCUAAAR Scientists
Riana Elyse Anderson, PhD
“Improving Racial Socialization Competency for Black Caregivers through a Culturally-Informed Familial Therapeutic Intervention”
Approximately 90% of Black youth report facing or witnessing racial discrimination in their proximal (e.g. classroom) and virtual (e.g., social network) environments. The association between discrimination and negative mental health outcomes (e.g., more severe and higher rates of depression) has been repeatedly established in the literature. Moreover, discrimination impairs the way youth cope, and it is this compromised coping that is associated with negative psychological4, academic, and health outcomes. Further, adolescent outcomes may lead to marked health complications and widening disparities in adulthood. Within adolescence, families can have a contributing role in the buffering or exacerbation of coping processes and behaviors to discriminatory experiences. The majority of Black families use racial socialization (RS)—or the verbal and nonverbal communication regarding racial matters—to facilitate coping with race. While RS has been shown to disrupt the trajectory from discrimination to negative psychological outcomes in some respects, it has also contributed to increased youth depressive and anxious symptoms given the wide variety of strategies observed in RS communication. Furthermore, less is known about the impact that grandparents have in the socialization process of their adolescent grandchildren, even though Black grandparents are more likely to rear their grandchildren compared to other races and given current trends. To address these gaps, the emergence of a new RS theory and accompanying clinical intervention seeks to investigate and improve upon this potentially protective cultural process by improving RS competency and enhancing coping processes. The Racial Encounter Coping Appraisal and Socialization Theory (RECAST) postulates that caregivers’ explicit and consistent delivery of psychoeducation-informed, skilled, and confident RS practices can reduce caregiver stress and subsequent psychological problems experienced by Black youth via greater coping self-efficacy and coping behaviors. The Engaging, Managing, and Bonding through Race (EMBRace) intervention is the application of RECAST and seeks to improve upon competent RS practices through therapeutic and empirically supported strategies. The use of culturally-relevant theory in clinical treatment is vital to Black youth’s coping with specific (i.e., racial) stressors linked to long-term health and wellness outcomes18. The empirical investigation of RECAST can also clarify whether aging caregivers (e.g., grandparents) develop the same competencies as other primary caregivers for an intergenerational exploration of RS practices.
Thus, the goal of this study is to test the effectiveness of a unique culturally-relevant and family-based intervention developed to enhance RS competencies in Black caregivers and reduce negative psychological outcomes for adolescent children. Building on the preliminary data that I collected during the acceptability pilot testing of the EMBRace intervention in Philadelphia, the proposed study will test the mechanism of caregiver RS competency as a moderator of discrimination, coping self-efficacy, coping, and adolescent psychological outcomes.
Katrina R. Ellis, PhD, MPH, MSW
“Understanding and Supporting the Health of African Americans Cancer Survivors and Their Family Caregivers”
Middle-age and older adults represent the majority of individuals who are newly diagnosed with or living with a history of cancer in the United States (ACS, 2018). In 2018, it was estimated that 87% of patients diagnosed with cancer were ages 50 or older (ACS, 2018). Approximately two-thirds of US cancer survivors – any person with a history of cancer – are ages 60 and older (ACS survivorship 2016), and this proportion of older cancer survivors is expected to grow in the coming years as the population as a whole continues to age (Parry, 2011). The health and well-being of African American (AA) cancer patients and survivors, in particular, are a pressing concern. Despite noted decreases in racial/ethnic disparities in cancer deaths, death rates for all cancers combined remain higher in AAs (ACS, 2016). Consequently, improving cancer outcomes for AAs requires attention to their experiences and needs across the cancer continuum, including cancer treatment and survivorship.
Many AA men and women suffer poor outcomes from chronic diseases (e.g., diabetes, cardiovascular diseases), and high rates of obesity (Gaskin et al, 2014; Mensah, Mokdad, Ford, Greenlund & Croft, 2005; Flegal, Carroll, Ogden & Curtin, 2010). Previous research has noted that cancer affects both the severity of chronic illness and the outcomes of comorbid conditions (Ogle, Swanson, Woods & Azzouz, 2000; Smith et al., 2008), with comorbid health conditions disproportionately prevalent in older patient populations (Bellizzi & Rowland, 2007). While family members are a key source of support after a cancer diagnosis, their own health warrants more attention; many family members performing supportive roles may be managing chronic conditions of their own. Unfortunately, limited research has simultaneously taken into account the cancer and chronic illness experiences of people diagnosed with cancer and their family members (i.e., family caregivers; Rosland & Piette, 2010) and especially as it relates to the needs of AA and other populations of color. Understanding the interdependent relationship between patient and family caregiver health experiences in the cancer context can be useful for designing interventions that are relevant and useful for supporting their collective wellbeing.
Rodlescia S. Sneed, PhD, MPH
“The Health and Well-Being of African-American Older Adults with a History of Incarceration”
The United States has an incarceration rate higher than that of any other Western country, with more than 11 million people admitted to U.S. jails each year . Further, African-Americans are overrepresented in the criminal justice system. While making up only 12% of the U.S. population, they account for 33% of the U.S. sentenced population . Longer prison stays and release programs for older prisoners may result in an increased number of community-dwelling older adults with a history of incarceration. In recent years, there has been a substantial increase in research on the psychosocial and health-related needs of currently incarcerated older adults; however, there has been little inquiry into the needs of formerly incarcerated older adults following community re-entry. These individuals may face re-entry barriers that result in unaddressed psychosocial, economic, and health-related needs. In the current study, we will use a mixed methods approach to examine the psychosocial, economic, and health-related needs of African-American older adults with a history of incarceration. We will conduct secondary analyses of data from the Health and Retirement Study, a large-scale, nationally representative population-based study of U.S. community-dwelling adults aged>50 years. Further, we will utilize key informant interviews in Flint, Michigan, (a majority African-American community with high rates of crime and incarceration) to identify ways in which existing systems support or inhibit the needs of this vulnerable population of African-American older adults.
2018 MCUAAAR Scientists
Lenette Jones, PhD
“Neurocognitive Mechanisms Associated with Self-Management in African American Women with Co-Morbid Hypertension and Type II Diabetes”
Poorly controlled blood pressure and glucose levels increase one’s risk of stroke, end-stage renal disease, and death. Forty-seven percent of African American women are living with hypertension and are twice as likely to be diagnosed with type 2 diabetes than White women (Centers for Disease Control Prevention, 2015). In fact, the prevalence of hypertension is 71% among adults diagnosed with diabetes (Centers for Disease Control Prevention, 2014). Although previous studies have outlined strategies to improve self-management behaviors among African American women, no studies to our knowledge explore the neurobiological mechanisms of self-management interventions (Centers for Disease Control Prevention, 2015; Chobanian et al., 2003). We need to know both if and how self-management interventions for this population work. Uncovering these basic neurobiological mechanisms is an important step in designing precise and effective interventions to produce behavior change. This pilot investigation is one of the first studies to move beyond psychosocial and cognitive factors to account for the neurobiological factors associated with the performance of self-management diet behaviors.
Review of the neuroscience literature reveals that we can “rewire” our brains (Doidge, 2007). A better understanding of brain-behavior interaction is needed to deepen understanding of how information practices modify the brain and enhance self-management behaviors (O’Brien, Gwizdka, Lopatovska, & Mostafa, 2015). Exploring relationships between information behavior and neuroprocessing will help scientists and practitioners better understand why messaging leads to behavior change in some cases, but not in others (Tompson, Lieberman, & Falk, 2015). Integrating knowledge of how our brains differ in processing information is an important step forward to enhance behavioral change and hypertension self-management. In a recent study, we found associations among information behavior, neuroprocessing (using fMRI), and self-management processes in African Americans with prehypertension (SBP 120-139 and/or DBP 80-89 mmHg). We also found that information seeking and sharing were associated with improved blood pressure self-management in African American women (Jones, Veinot, Pressler, Coleman-Burns, & McCall, 2017; Jones, Veinot, & Pressler, 2017).
The purpose of this descriptive study is to examine the neurobiological mechanisms associated with information behavior and self-management in African American women with hypertension. We will also assess their glucose status, to assess risk related to type 2 diabetes.
Elham Mahmoudi, PhD
“Predicting 30-day Hospital Readmissions among Older Ethnic Minority Adults”
Owing to age-related conditions, including disabilities and multiple chronic conditions, and less social support and caregiver support, 30-day hospital readmission is more common among older African American adults (Meddings et al., 2017). While the risk of 30-day hospital readmission is influenced by inpatient care and discharge planning, it is also strongly influenced by patients’ social, behavioral, and environmental conditions of life (Calvillo–King et al., 2013). However, risk-prediction tools used by hospitals typically lack information on patients’ social factors and functional limitations (Kansagara et al., 2011).
With annual costs of more than $17 billion, unplanned hospital readmissions are expensive and negatively affect the life quality of patients and caregivers. In 2012, the Centers for Medicare and Medicaid Services implemented the Hospital Readmission Reduction Program (Joynt & Jha, 2012), which penalizes hospitals that have higher-than-expected 30-day readmissions for certain diagnoses among Medicare patients. In 2016, despite efforts to reduce unplanned readmissions, more than half of the nation’s hospitals (2,597) were estimated to be charged a total of $528 million for higher-than-expected 30-day readmissions (National Quality Forum, 2016). The majority of these were safety-net hospitals serving ethnic minority and low-income older populations.
The majority of the risk-prediction tools hospitals currently use do not take into account social support and disability, factors that are more pronounced among older African Americans. With recent investments in electronic medical records (EMRs) and their increasing use and application in healthcare systems (Blumenthal, 2007), developing flexible, timely, and accurate risk-prediction tools will provide an innovative approach to improving the accuracy of predictive risk models. This research will examine these crucial issues using EMRs from two large teaching hospitals in Michigan: the UM Hospital is a tertiary center located in Ann Arbor, while the Henry Ford Hospital is in the inner city of Detroit, serving large ethnic minority and low socioeconomic status populations. We applied the Andersen conceptual model of access to care (Andersen, 1995) to examine early re-hospitalization.
The objective of this proposed project is to use EMRs to create a highly accurate tool for hospitals to employ in identifying older adults who are at high risk of early hospital readmission, and by acting on this knowledge, to limit these occurrences.