A system of integrated care for older persons with disabilities in Canada: results from a randomized controlled trial

Consequences of clinical case management for caregivers: a systematic review

OBJECTIVE

Informal caregivers are deeply involved in the case management process. However, little is known about the consequences of such programs for informal caregivers. This systematic literature review, reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, addressed the consequences of clinical case management programs, whether positive or negative, for caregivers of frail older persons or persons with dementia.

METHODS

We systematically identified and analyzed published randomized trials and quasi-experimental studies comparing case management programs to usual care, which discussed outcomes concerning caregivers.

RESULTS

Sixteen studies were identified, and 12 were included after quality assessment. Seven identified at least one positive result for caregivers, and no negative effect of case management has been found. Characteristics associated with positive results for caregivers were a high intensity of case management and programs specifically addressed to dementia patients.

CONCLUSIONS

Despite the numerous methodological challenges in the assessment of such complex social interventions, our results show that case management programs can be beneficial for caregivers of dementia patients and that positive results for patients are achieved without increasing caregivers' burden. Copyright © 2017 John Wiley & Sons, Ltd.

Home- and Community-Based Occupational Therapy Improves Functioning in Frail Older People: A Systematic Review

OBJECTIVES

The objective is to assess the effectiveness of occupational therapy to improve performance in daily living activities in community-dwelling physically frail older people.

DESIGN

We conducted a systematic review and meta-analysis. We included randomized controlled trials reporting on occupational therapy as intervention, or as part of a multidisciplinary approach. This systematic review was carried out in accordance with the Cochrane methods of systematic reviews of interventions.

MEASUREMENTS

Meta-analyses were performed to pool results across studies using the standardized mean difference. The primary outcome measures were mobility, functioning in daily living activities, and social participation. Secondary outcome measures were fear of falling, cognition, disability, and number of falling persons.

RESULTS

Nine studies met the inclusion criteria. Overall, the studies were of reasonable quality with low risk of bias. There was a significant increase in all primary outcomes. The pooled result for functioning in daily living activities was a standardized mean difference of -0.30 (95% CI -0.50 to -0.11; P = .002), for social participation -0.44 (95% CI -0.69, -0.19; P = .0007) and for mobility -0.45 (95% CI -0.78 to -0.12; P = .007). All secondary outcomes showed positive trends, with fear of falling being significant. No adverse effects of occupational therapy were found.

CONCLUSION

There is strong evidence that occupational therapy improves functioning in community-dwelling physically frail older people.

Health benefits for health and social care clients attending an Integrated Health and Social Care day unit (IHSCDU): a before-and-after pilot study with a comparator group

It is thought that integrating health and social care provision can improve services, yet few evaluations of integrated health and social care initiatives have focused on changes in clinical outcomes and used comparator groups. The aim of this pilot study was to identify whether attendance at an integrated health and social care day unit (IHSCDU) affected selected outcomes of functional mobility, number of prescribed medications, and physical and psychological well-being. A secondary aim was to examine the utility of the tools to measure these outcomes in this context; the feasibility of the recruitment and retention strategy and the utility of the comparator group. A before-and-after comparison design was used with non-randomised intervention and comparator arms. The intervention arm comprised 30 service users attending the IHSCDU and the comparator arm comprised 33 service users on a community nursing caseload. Measures of functional mobility (Barthel's Index) and physical and psychological well-being (SF-12^® ) were taken from all participants in both arms at three data collection points: baseline, 4 and 9 months later, between November 2010 and September 2012. Participants and outcomes were identified prospectively and in both arms, the individual was the unit of assignment. No significant changes were noted in functional mobility and psychological well-being and the number of medications prescribed increased in both arms. There was a trend towards a significant difference between study arms in the change in the SF-12^® physical health outcome measure and this outcome measure could be usefully explored in future studies. The recruitment and retention strategy was feasible although our comparator group had some limitations in not being closely matched in terms of age, functional mobility and mental well-being.

Integrated care at home reduces unnecessary hospitalizations of community-dwelling frail older adults: a prospective controlled trial

Background

Care of frail and dependent older adults with multiple chronic conditions is a major challenge for health care systems. The study objective was to test the efficacy of providing integrated care at home to reduce unnecessary hospitalizations, emergency room visits, institutionalization, and mortality in community dwelling frail and dependent older adults.

Methods

A prospective controlled trial was conducted, in real-life clinical practice settings, in a suburban region in Geneva, Switzerland, served by two home visiting nursing service centers. Three hundred and one community-dwelling frail and dependent people over 60 years old were allocated to previously randomized nursing teams into Control (N = 179) and Intervention (N = 122) groups: Controls received usual care by their primary care physician and home visiting nursing services, the Intervention group received an additional home evaluation by a community geriatrics unit with access to a call service and coordinated follow-up. Recruitment began in July 2009, goals were obtained in July 2012, and outcomes assessed until December 2012. Length of follow-up ranged from 5 to 41 months (mean 16.3). Primary outcome measure was the number of hospitalizations. Secondary outcomes were reasons for hospitalizations, the number and reason of emergency room visits, institutionalization, death, and place of death.

Results

The number of hospitalizations did not differ between groups however, the intervention led to lower cumulative incidence for the first hospitalization after the first year of follow-up (69.8%, CI 59.9 to 79.6 versus 87 · 6%, CI 78 · 2 to 97 · 0; p = .01). Secondary outcomes showed that the intervention compared to the control group had less frequent unnecessary hospitalizations (4.1% versus 11.7%, p = .03), lower cumulative incidence for the first emergency room visit, 8.3%, CI 2.6 to 13.9 versus 23.2%, CI 13.1 to 33.3; p = .01), and death occurred more frequently at home (44.4 versus 14.7%; p = .04). No significant differences were found for institutionalization and mortality.

Conclusions

Integrated care that included a home visiting multidisciplinary geriatric team significantly reduced unnecessary hospitalizations, emergency room visits and allowed more patients to die at home. It is an effective tool to improve coordination and access to care for frail and dependent older adults.

Trial registration

Clinical Trials.gov Identifier: NCT02084108. Retrospectively registered on March 10^th 2014.

Stranded: causes and effects of discharge delays involving non-acute in-patients requiring maintenance care in a tertiary hospital general medicine service

Objectives The aims of the present study were to identify causes of prolonged discharge delays among non-acute in-patients admitted to a tertiary general medicine service, quantify occupied bed days (OBDs) and propose strategies for eliminating avoidable delays. Methods A retrospective study was performed of patients admitted between 1 January 2012 and 31 May 2015 and discharged as non-acute cases requiring maintenance care and who incurred a total non-acute length of stay (LOS) >7 days and total hospital LOS >14 days. Long-stay patients with non-acute LOS ≥28 days were subject to chart review in ascertaining serial causes of discharge delay and their attributable OBDs. Literature reviews and staff feedback identified potential strategies for minimising delays. Results Of the 406 patients included in the present study, 131 incurred long-stays; for these 131 patients, delays were identified that accounted for 5420 of 6033 (90%) non-acute OBDs. Lack of available residential care beds was most frequent, accounting for 44% of OBDs. Waits for outcomes of guardianship applications accounted for 13%, whereas guardian appointments, Public Trustee applications and funding decisions for equipment or care packages each consumed between 4% and 5% of OBDs. Family and/or carer refusal of care accounted for 7%. Waits for aged care assessment team (ACAT) assessments, social worker reports, geriatrician or psychiatrist reviews and confirmation of enduring power of attorney each accounted for between 1% and 3% of OBDs. Of 30 proposed remedial strategies, those rated as high priority were: greater access to interim care or respite care beds or supported accommodation, especially for patients with special needs; dedicated agency officers for hospital guardianship applications and greater interagency collaboration and harmonisation of assessment and decision processes; and formal requests from hospital administrators to patients and family to accept care options and attend mediation meetings. Conclusions Delayed discharge of non-acute maintenance care patients results principally from impaired access to residential care, administrative delays involving external agencies and patient or family refusal of care. Proposed remedial actions require concerted interjurisdictional advocacy. What is known about this topic? Delays in discharge of non-acute patients requiring maintenance care can occur for many reasons and incur inordinately long hospital stays. What does this paper add? The present detailed chart review of 131 long-stay non-acute patients identified causes of serial discharge delays and quantified their prevalence and attributable bed days. Waits for residential care accounted for less than half the bed days, administrative delays involving decisions by agencies external to the hospital accounted for one-quarter and patient or family refusal of care options accounted for one-tenth. Strategies are proposed that may minimise these delays. What are the implications for practitioners? Delayed discharge of non-acute patients requiring maintenance care threatens to consume an ever-increasing proportion of acute hospital bed days. Remedial action is required from stakeholders both within and outside hospitals to reverse this trend.

Organizational interventions improving access to community-based primary health care for vulnerable populations: a scoping review

Access to community-based primary health care (hereafter, 'primary care') is a priority in many countries. Health care systems have emphasized policies that help the community 'get the right service in the right place at the right time'. However, little is known about organizational interventions in primary care that are aimed to improve access for populations in situations of vulnerability (e.g., socioeconomically disadvantaged) and how successful they are. The purpose of this scoping review was to map the existing evidence on organizational interventions that improve access to primary care services for vulnerable populations. Scoping review followed an iterative process. Eligibility criteria: organizational interventions in Organisation for Economic Cooperation and Development (OECD) countries; aiming to improve access to primary care for vulnerable populations; all study designs; published from 2000 in English or French; reporting at least one outcome (avoidable hospitalization, emergency department admission, or unmet health care needs).

SOURCES

Main bibliographic databases (Medline, Embase, CINAHL) and team members' personal files.

STUDY SELECTION

One researcher selected relevant abstracts and full text papers. Theory-driven synthesis: The researcher classified included studies using (i) the 'Patient Centered Access to Healthcare' conceptual framework (dimensions and outcomes of access to primary care), and (ii) the classification of interventions of the Cochrane Effective Practice and Organization of Care. Using pattern analysis, interventions were mapped in accordance with the presence/absence of 'dimension-outcome' patterns. Out of 8,694 records (title/abstract), 39 studies with varying designs were included. The analysis revealed the following pattern. Results of 10 studies on interventions classified as 'Formal integration of services' suggested that these interventions were associated with three dimensions of access (approachability, availability and affordability) and reduction of hospitalizations (four/four studies), emergency department admissions (six/six studies), and unmet healthcare needs (five/six studies). These 10 studies included seven non-randomized studies, one randomized controlled trial, one quantitative descriptive study, and one mixed methods study. Our results suggest the limited breadth of research in this area, and that it will be feasible to conduct a full systematic review of studies on the effectiveness of the formal integration of services to improve access to primary care services for vulnerable populations.

The effects of a pro-active integrated care intervention for frail community-dwelling older people: a quasi-experimental study with the GP-practice as single entry point

Background

This study explored the effectiveness of a pro-active, integrated care model for community-dwelling frail older people compared to care as usual by evaluating the effects on a comprehensive set of outcomes: health outcomes (experienced health, mental health and social functioning); functional abilities; and quality of life (general, health-related and well-being).

Methods

The design of this study was quasi-experimental. In this study, 184 frail older patients of three GP practices that implemented the Walcheren Integrated Care Model were compared with 193 frail older patients of five GP practices that provided care as usual. In the Walcheren Integrated Care Model, community-dwelling elderly were pro-actively screened for frailty from the GP practice using the Groningen Frailty Indicator, and care needs were assessed with the EASYcare instrument. The GP practice functioned as single entry point from which case management was provided, and the GP was the coordinator of care. The entire process was supported by multidisciplinary meetings, multidisciplinary protocols and web-based patient files. The outcomes of this study were obtained at baseline, after 3 months and after 12 months and analyzed with linear mixed models of repeated measures.

Results

The Walcheren Integrated Care Model had a positive effect on love and friendship and a moderately positive effect on general quality of life. The ability to receive love and friendship and general quality of life decreased in the control group but was preserved in the experimental group. No significant differences were found on health outcomes such as experienced health, mental health, social functioning and functional abilities.

Conclusions

The results indicated that pro-active, integrated care can be beneficial for frail older people in terms of quality of life and love and friendship but not in terms of health outcomes and functional abilities. Recommendations for future research are to gain greater insight into what specific outcomes can be achieved with proactive and integrated care, considering the specific content of this care, and to allow for the heterogeneity of frail older people in evaluation research.

Trial registration

Current Controlled Trials ISRCTN05748494. Registration date: 14/03/2013.

A randomized controlled trial of the effect of an intensive 1-year care management program on measures of health status in independent, community-living old elderly: the Eldercare project

BACKGROUND

Primary care practitioners are familiar with the frail elderly and commonly have to deal with their multi-morbidity and their functional decline, both physically and mentally. However, there are well elderly with high quality of life and very few co-morbidities who seldom seek medical care.

OBJECTIVE

To determine if a nurse-based program of home-delivered care, linked directly with the primary care practitioner or primary care team, would improve quality of life, symptoms, satisfaction with care and utilization of community and medical services, in independent community living old elderly.

DESIGN

Randomized controlled trial.

SETTING

St. John's, Newfoundland, Canada.

PARTICIPANTS

Two hundred and thirty-six independent, community-dwelling, cognitively functioning, people aged 80 years and older.

INTERVENTION

A nurse-based program of care, carried out in the patients home, that involved a detailed assessment of needs, the development of a plan to meet the needs, and up to eight visits to the patients home during a 1-year period to facilitate the meeting of those needs.

CONTROL GROUP

Usual care

MAIN OUTCOME MEASUREMENTS

Quality of Life measured using the SF-36 and the CASP-19 scales; symptomology using the Comorbidity Symptom Scale; patient satisfaction using the PSQ-18; and assessment of health care services (community services, emergency room visits, hospitalizations, use of diagnostic services and family doctor visits) through patient recall, family physician chart review and assessment of hospitalization records.

RESULTS

There were no statistical or meaningful differences between the intervention and control groups in any of the outcomes measured.

CONCLUSION

The intensive, home-delivered, program of care for the well old elderly did not have an impact on the outcomes measured.

Cost-Effectiveness of a Chronic Care Model for Frail Older Adults in Primary Care: Economic Evaluation Alongside a Stepped-Wedge Cluster-Randomized Trial

OBJECTIVES

To evaluate the cost-effectiveness of the Geriatric Care Model (GCM), an integrated care model for frail older adults based on the Chronic Care Model, with that of usual care.

DESIGN

Economic evaluation alongside a 24-month stepped-wedge cluster-randomized controlled trial.

SETTING

Primary care (35 practices) in two regions in the Netherlands.

PARTICIPANTS

Community-dwelling older adults who were frail according to their primary care physicians and the Program on Research for Integrating Services for the Maintenance of Autonomy case-finding tool questionnaire (N = 1,147).

INTERVENTION

The GCM consisted of the following components: a regularly scheduled in-home comprehensive geriatric assessment by a practice nurse followed by a customized care plan, management and training of practice nurses by a geriatric expert team, and coordination of care through community network meetings and multidisciplinary team consultations of individuals with complex care needs.

MEASUREMENTS

Outcomes were measured every 6 months and included costs from a societal perspective, health-related quality of life (Medical Outcomes Study 12-item Short-Form Survey (SF-12) physical (PCS) and mental component summary (MCS) scales), functional limitations (Katz activities of daily living and instrumental activities of daily living), and quality-adjusted life years based on the EQ-5D.

RESULTS

Multilevel regression models adjusted for time and baseline confounders showed no significant differences in costs ($356, 95% confidence interval = -$488-1,134) and outcomes between intervention and usual care phases. Cost-effectiveness acceptability curves showed that, for the SF-12 PCS and MCS, the probability of the intervention being cost-effective was 0.76 if decision-makers are willing to pay $30,000 per point improvement on the SF-12 scales (range 0-100). For all other outcomes the probability of the intervention being cost-effective was low.

CONCLUSION

Because the GCM was not cost-effective compared to usual care after 24 months of follow-up, widespread implementation in its current form is not recommended.

Transitional Care for Patients With Congestive Heart Failure: A Systematic Review and Meta-Analysis

PURPOSE

We aimed to determine the impact of transitional care interventions (TCIs) on acute health service use by patients with congestive heart failure in primary care and to identify the most effective TCIs and their optimal duration.

METHODS

We conducted a systematic review and meta-analysis of randomized controlled trials, searching the Medline, PsycInfo, EMBASE, and Cochrane Library databases. We performed a meta-analysis to assess the impact of TCI on all-cause hospital readmissions and emergency department (ED) visits. We developed a taxonomy of TCIs based on intensity and assessed the methodologic quality of the trials. We calculated the relative risk (RR) and a 95% confidence interval for each outcome. We conducted a stratified analysis to identify the most effective TCIs and their optimal duration.

RESULTS

We identified 41 randomized controlled trials. TCIs significantly reduced risks of readmission and ED visits by 8% and 29%, respectively (relative risk = 0.92; 95% CI, 0.87-0.98; P = .006 and relative risk = 0.71; 95% CI, 0.51-0.98; P = .04). High-intensity TCIs (combining home visits with telephone followup, clinic visits, or both) reduced readmission risk regardless of the duration of follow-up. Moderate-intensity TCIs were efficacious if implemented for a longer duration (at least 6 months). In contrast, low-intensity TCIs, entailing only followup in outpatient clinics or telephone follow-up, were not efficacious.

CONCLUSIONS

Clinicians and managers who implement TCIs in primary care can incorporate these results with their own health care context to determine the optimal balance between intensity and duration of TCIs. High-intensity interventions seem to be the best option. Moderate-intensity interventions implemented for 6 months or longer may be another option.

Effectiveness of Case Management for 'At Risk' Patients in Primary Care: A Systematic Review and Meta-Analysis

BACKGROUND

An ageing population with multimorbidity is putting pressure on health systems. A popular method of managing this pressure is identification of patients in primary care 'at-risk' of hospitalisation, and delivering case management to improve outcomes and avoid admissions. However, the effectiveness of this model has not been subjected to rigorous quantitative synthesis.

METHODS AND FINDINGS

We carried out a systematic review and meta-analysis of the effectiveness of case management for 'at-risk' patients in primary care. Six bibliographic databases were searched using terms for 'case management', 'primary care', and a methodology filter (Cochrane EPOC group). Effectiveness compared to usual care was measured across a number of relevant outcomes: Health--self-assessed health status, mortality; Cost--total cost of care, healthcare utilisation (primary and non-specialist care and secondary care separately), and; Satisfaction--patient satisfaction. We conducted secondary subgroup analyses to assess whether effectiveness was moderated by the particular model of case management, context, and study design. A total of 15,327 titles and abstracts were screened, 36 unique studies were included. Meta-analyses showed no significant differences in total cost, mortality, utilisation of primary or secondary care. A very small significant effect favouring case management was found for self-reported health status in the short-term (0.07, 95% CI 0.00 to 0.14). A small significant effect favouring case management was found for patient satisfaction in the short- (0.26, 0.16 to 0.36) and long-term (0.35, 0.04 to 0.66). Secondary subgroup analyses suggested the effectiveness of case management may be increased when delivered by a multidisciplinary team, when a social worker was involved, and when delivered in a setting rated as low in initial 'strength' of primary care.

CONCLUSIONS

This was the first meta-analytic review which examined the effects of case management on a wide range of outcomes and considered also the effects of key moderators. Current results do not support case management as an effective model, especially concerning reduction of secondary care use or total costs. We consider reasons for lack of effect and highlight key research questions for the future.

REVIEW PROTOCOL

The review protocol is available as part of the PROSPERO database (registration number: CRD42014010824).

Community-based primary health care for older adults: a qualitative study of the perceptions of clients, caregivers and health care providers

Background

Older persons are often poorly served by existing models of community-based primary health care (CBPHC). We sought input from clients, informal caregivers, and health care providers on recommendations for system improvements.

Methods

Focus group interviews were held with clients, informal caregivers, and health care providers in mid-sized urban and rural communities in Ontario. Data were analyzed using a combination of directed and emergent coding. Results were shared with participants during a series of feedback sessions.

Results

An extensive list of barriers, facilitators, and recommended health system improvements was generated. Barriers included poor system integration and limited access to services. Identified facilitators were person and family-focused care, self-management resources, and successful collaborative practice. Recommended system improvements included expanding and integrating care teams, supports for system navigation, and development of standardized information systems and care pathways.

Conclusions

Older adults still experience frustrating obstacles when trying to access CBPHC. Identified barriers and facilitators of improved system integration aligned well with current literature and Wagner’s Chronic Care Model. Additional work is needed to implement the recommended improvements and to discern their impact on patient and system outcomes.

Electronic supplementary material

The online version of this article (doi:10.1186/s12877-015-0052-x) contains supplementary material, which is available to authorized users.

Exploring patterns of care coordination within services for older people

Introduction

Supporting frail older people at home is an international policy objective. This article explored variations in care coordination arrangements and their relationship with service level outcomes using England as a case study.

Method

Survey data and routinely generated data collected in 2006 from 119 local authorities responsible for social care were combined. Using cluster analysis, distinct groups were identified with regard to forms of care coordination.

Results

Considerable variation was evident both within and between different types of care coordination, reflecting implementation guidance. Links with service level outcomes were weak, the most notable being the provision of intensive home care, a component of intensive care management.

Discussion

Thus this study, using agency level data, confirmed the variability in care coordination arrangements and the relative absence of intensive care management, central to shifting the balance of care from residential and nursing provision to care at home.

Integration and continuity of Care in health care network models for frail older adults

A detailed review was conducted of the literature on models evaluating the effectiveness of integrated and coordinated care networks for the older population. The search made use of the following bibliographic databases: Pubmed, The Cochrane Library, LILACS, Web of Science, Scopus and SciELO. Twelve articles on five different models were included for discussion. Analysis of the literature showed that the services provided were based on primary care, including services within the home. Service users relied on the integration of primary and hospital care, day centers and in-home and social services. Care plans and case management were key elements in care continuity. This approach was shown to be effective in the studies, reducing the need for hospital care, which resulted in savings for the system. There was reduced prevalence of functional loss and improved satisfaction and quality of life on the part of service users and their families. The analysis reinforced the need for change in the approach to health care for older adults and the integration and coordination of services is an efficient way of initiating this change.

Integrating funds for health and social care: an evidence review

OBJECTIVES

Integrated funds for health and social care are one possible way of improving care for people with complex care requirements. If integrated funds facilitate coordinated care, this could support improvements in patient experience, and health and social care outcomes, reduce avoidable hospital admissions and delayed discharges, and so reduce costs. In this article, we examine whether this potential has been realized in practice.

METHODS

We propose a framework based on agency theory for understanding the role that integrated funding can play in promoting coordinated care, and review the evidence to see whether the expected effects are realized in practice. We searched eight electronic databases and relevant websites, and checked reference lists of reviews and empirical studies. We extracted data on the types of funding integration used by schemes, their benefits and costs (including unintended effects), and the barriers to implementation. We interpreted our findings with reference to our framework.

RESULTS

The review included 38 schemes from eight countries. Most of the randomized evidence came from Australia, with nonrandomized comparative evidence available from Australia, Canada, England, Sweden and the US. None of the comparative evidence isolated the effect of integrated funding; instead, studies assessed the effects of 'integrated financing plus integrated care' (i.e. 'integration') relative to usual care. Most schemes (24/38) assessed health outcomes, of which over half found no significant impact on health. The impact of integration on secondary care costs or use was assessed in 34 schemes. In 11 schemes, integration had no significant effect on secondary care costs or utilisation. Only three schemes reported significantly lower secondary care use compared with usual care. In the remaining 19 schemes, the evidence was mixed or unclear. Some schemes achieved short-term reductions in delayed discharges, but there was anecdotal evidence of unintended consequences such as premature hospital discharge and heightened risk of readmission. No scheme achieved a sustained reduction in hospital use. The primary barrier was the difficulty of implementing financial integration, despite the existence of statutory and regulatory support. Even where funds were successfully pooled, budget holders' control over access to services remained limited. Barriers in the form of differences in performance frameworks, priorities and governance were prominent amongst the UK schemes, whereas difficulties in linking different information systems were more widespread. Despite these barriers, many schemes - including those that failed to improve health or reduce costs - reported that access to care had improved. Some of these schemes revealed substantial levels of unmet need and so total costs increased.

CONCLUSIONS

It is often assumed in policy that integrating funding will promote integrated care, and lead to better health outcomes and lower costs. Both our agency theory-based framework and the evidence indicate that the link is likely to be weak. Integrated care may uncover unmet need. Resolving this can benefit both individuals and society, but total care costs are likely to rise. Provided that integration delivers improvements in quality of life, even with additional costs, it may, nonetheless, offer value for money.

[Use of social and health primary care services for older people with complex needs: Comparison of three types of gerontological coordination]

BACKGROUND

Older people with complex needs live mainly at home. Several types of gerontological coordinations have been established on the French territory to meet their needs and to implement social and primary health care services. But we do not have any information on the use of these services at home as a function of the coordination method used.

METHODS

We compared the use of home care services for older people with complex needs in three types of coordination with 12 months' follow-up. The three coordinations regrouped a gerontological network with case management (n=105 persons), a nursing home service (SSIAD) with a nurse coordination (n=206 persons) and an informal coordination with a non-professional caregiver (n=117 persons).

RESULTS

At t0, the older people addressed to the gerontological network had less access to the services offered at home; those followed by the SSIAD had the highest number of services and of weekly interventions. Hours of weekly services were two-fold higher in those with the informal coordination. At t12, there was an improvement in access to services for the network group with case management and an overall increase in the use of professional services at home with no significant difference between the three groups.

CONCLUSION

The use of social and primary health care services showed differences between the three gerontological coordinations. The one-year evolution in the use of home services was comparable between the groups without an explosion in the number of services in the network group with case management.

Specialist rehabilitation for people with Parkinson’s disease in the community: a randomised controlled trial

Background

Multidisciplinary rehabilitation is recommended for Parkinson’s disease, but evidence suggests that benefit is not sustained.

Objectives

(1) Implement a specialist domiciliary rehabilitation service for people with Parkinson’s and carers. (2) Provide continuing support from trained care assistants to half receiving the rehabilitation. (3) Evaluate the clinical effectiveness of the service, and the value added by the care assistants, compared with usual care. (4) Assess the costs of the interventions. (5) Investigate the acceptability of the service. (6) Deliver guidance for commissioners.

Design

Pragmatic three-parallel group randomised controlled trial.

Setting

Community, county of Surrey, England, 2010–11.

Participants

People with Parkinson’s, at all stages of the disease, and live-in carers.

Interventions

Groups A and B received specialist rehabilitation from a multidisciplinary team (MDT) – comprising Parkinson’s nurse specialists, physiotherapists, occupational therapists, and speech and language therapists – delivered at home, tailored to individual needs, over 6 weeks (about 9 hours’ individual therapy per patient). In addition to the MDT, participants in group B received ongoing support for a further 4 months from a care assistant trained in Parkinson’s (PCA), embedded in the MDT (1 hour per week per patient). Participants in control group (C) received care as usual (no co-ordinated MDT or ongoing support).

Main outcome measures

Follow-up assessments were conducted in participants’ homes at 6, 24 and 36 weeks after baseline. Primary outcomes: Self-Assessment Parkinson’s Disease Disability Scale (patients); the Modified Caregiver Strain Index (carers). Secondary outcomes included: for patients, disease-specific and generic health-related quality of life, psychological well-being, self-efficacy, mobility, falls and speech; for carers, strain, stress, health-related quality of life, psychological well-being and functioning.

Results

A total of 306 people with Parkinson’s (and 182 live-in carers) were randomised [group A,n = 102 (n = 61); group B,n = 101 (n = 60); group C,n = 103 (n = 61)], of whom 269 (155) were analysed at baseline, pilot cohort excluded. Attrition occurred at all stages. A per-protocol analysis [people with Parkinson’s,n = 227 (live-in carers,n = 125)] [group A,n = 75 (n = 45); group B,n = 69 (n = 37); group C,n = 83 (n = 43)] showed that, at the end of the MDT intervention, people with Parkinson’s in groups A and B, compared with group C, had reduced anxiety (p = 0.02); their carers had improved psychological well-being (p = 0.02). People with Parkinson’s in groups A and B also had marginally reduced disability (primary outcome,p = 0.09), and improved non-motor symptoms (p = 0.06) and health-related quality of life (p = 0.07), compared with C. There were significant differences in change scores between week 6 (end of MDT) and week 24 (end of PCA for group B) in favour of group B, owing to worsening in group A (no PCA support) in posture (p = 0.001); non-motor symptoms (p = 0.05); health-related quality of life (p = 0.07); and self-efficacy (p = 0.09). Carers in group B (vs. group A) reported a tendency for reduced strain (p = 0.06). At 36 weeks post recruitment, 3 months after the end of PCA support for group B, there were few differences between the groups. Participants reported learning about Parkinson’s, and valued individual attention. The MDT cost £833; PCA support was £600 extra, per patient (2011 Great British pounds).

Conclusions

Further research is needed into ways of sustaining benefits from rehabilitation including the use of care assistants.

Study registration

Current Controlled Trials: ISRCTN44577970.

Funding

This project was funded by the National Institute for Health Research Health Services and Delivery Research programme and the South East Coast Dementias and Neurodegenerative Disease Research Network (DeNDRoN), and the NHS South East Coast. The report will be published in full inHealth Services and Delivery Research; Vol. 2, No. 51. See the NIHR Journals Library website for further project information.

Systematic review of outcomes from home-based primary care programs for homebound older adults

OBJECTIVES

To describe the effect of home-based primary care for homebound older adults on individual, caregiver, and systems outcomes.

DESIGN

A systematic review of home-based primary care interventions for community-dwelling older adults (aged ≥65) using the Cochrane, PubMed, and MEDLINE databases from the earliest available date through March 15, 2014. Studies were included if the house calls visitor was the ongoing primary care provider and if the intervention measured emergency department visits, hospitalizations, hospital beds days of care, long-term care admissions, or long-term care bed days of care.

SETTING

Home-based primary care programs.

PARTICIPANTS

Homebound community-dwelling older adults (N = 46,154).

MEASUREMENTS

Emergency department visits, hospitalizations, hospital bed days of care, long-term care admissions, long-term care bed days of care, costs, program design, and individual and caregiver quality of life and satisfaction with care.

RESULTS

Of 357 abstracts identified, nine met criteria for review. The nine interventions were all based in North America, with five emerging from the Veterans Affairs system. Eight of nine programs demonstrated substantial effects on at least one inclusion outcome, with seven programs affecting two outcomes. Six interventions shared three core program components: interprofessional care teams, regular interprofessional care meetings, and after-hours support.

CONCLUSION

Specifically designed home-based primary care programs may substantially affect individual, caregiver and systems outcomes. Adherence to the core program components identified in this review could guide the development and spread of these programs.

[Disability and use of health services by the elderly in Greater Metropolitan Belo Horizonte, Minas Gerais State, Brazil: a population-based study]

This study focused on the association between disability and use of health services among elderly individuals in Greater Metropolitan Belo Horizonte, Minas Gerais State, Brazil. The study included 1,624 elderly patients (≥ 60 years) selected by representative sampling. The dependent variable was use of health services, based on three descriptors: number of physician visits, home consultations, and hospitalizations. The target independent variable was disability, including difficulty in performing activities of daily living (ADL) and instrumental activities of daily living (IADL). IADL was only associated with hospitalization (PR = 1.62; 95%CI: 1.16-2.26), while ADL was associated with hospitalization (PR = 1.73; 95%CI: 1.24-2.42) and home consultations (PR = 8.54; 95%CI: 4.22-17.27). The findings show increased use of health services (especially more costly ones) among older adults with disabilities, and that functional health dimensions have not oriented health services, still largely conditioned on the presence of diseases.

Alternate level of care patients in hospitals: what does dementia have to do with this?

Background

Patients in acute care hospitals no longer in need of acute care are called Alternate Level of Care (ALC) patients. This is growing and common all across Canada. A better understanding of this patient population would help to address this problem.

Methods

A chart review was conducted in two hospitals in New Brunswick. All patients designated as ALC on July 1, 2009 had their charts reviewed.

Results

Thirty-three per cent of the hospital beds were occupied with ALC patients; 63% had a diagnosis of dementia. The mean length of stay was 379.6 days. Eighty-six per cent were awaiting a long-term care bed in the community. Most patients experienced functional decline during their hospitalization. One year prior to admission, 61% had not been admitted to hospital and 59.2% had had at least one visit to the emergency room.

Conclusions

The majority of the ALC patients in hospital have a diagnosis of dementia and have been waiting in hospital for over one year for a long-term care bed in the community. Many participants were recipients of maximum home care in the community, suggesting home maker services alone may not be adequate for some community-dwelling older adults. Early diagnosis of dementia, coupled with appropriate care in the community, may help to curtail the number of patients with dementia who end up in hospital as ALC patients.

The effects of an integrated care intervention for the frail elderly on informal caregivers: a quasi-experimental study

BACKGROUND

This study explored the effects of an integrated care model aimed at the frail elderly on the perceived health, objective burden, subjective burden and quality of life of informal caregivers.

METHODS

A quasi-experimental design with before/after measurement (with questionnaires) and a control group was used. The analysis encompassed within and between groups analyses and regression analyses with baseline measurements, control variables (gender, age, co-residence with care receiver, income, education, having a life partner, employment and the duration of caregiving) and the intervention as independent variables.

RESULTS

The intervention significantly contributed to the reduction of subjective burden and significantly contributed to the increased likelihood that informal caregivers assumed household tasks. No effects were observed on perceived, health, time investment and quality of life.

CONCLUSIONS

This study implies that integrated care models aimed at the frail elderly can benefit informal caregivers and that such interventions can be implemented without demanding additional time investments from informal caregivers. Recommendations for future interventions and research are provided.

TRIAL REGISTRATION

Current Controlled Trials http://ISRCTN05748494. Registration date: 14/03/2013.

A quasi-experimental study of the effects of an integrated care intervention for the frail elderly on informal caregivers' satisfaction with care and support

Background

This study explored the effects of an integrated care model for the frail elderly on informal caregivers’ satisfaction with care and support services.

Methods

A 62-item instrument was developed and deployed in an evaluative before/after study using a quasi-experimental design and enrolling a control group. The definitive study population (n = 63) consisted mainly of female informal caregivers who did not live with the care recipient. Analysis of separate items involved group comparisons, using paired and unpaired tests, and regression analyses, with baseline measurements, control variables (sex, age and living together with care recipient) and the intervention as independent variables. Subsequently, the underlying factor structure of the theoretical dimensions was investigated using primary component analysis. Group comparisons and regression analyses were performed on the resulting scales.

Results

Satisfaction with the degree to which care was provided according to the need for care of the recipients increased, while satisfaction with the degree to which professionals provided help with administrative tasks, the understandability of the information provided and the degree to which informal caregivers knew which professionals to call, decreased. Primary component analysis yielded 6 scales for satisfaction with care and 5 scales for satisfaction with caregiver support, with sufficient reliability.

Conclusions

The results suggest that expectations regarding the effects of integrated care on informal caregiver satisfaction may not be realistic. However, the results must be seen in light of the small sample size and should therefore be considered as preliminary. Nonetheless, this study provides guidance for further research and integrated care interventions involving informal caregivers.

Trial registration

Current Controlled Trials ISRCTN05748494. Date of registration: 14/03/2013.

Impact on hospital admissions of an integrated primary care model for very frail elderly patients

Very frail elderly patients living in the community, present complex needs and have a higher rate of hospital admissions with emergency department (ED) visits. Here, we evaluated the impact on hospital admissions of the COPA model (CO-ordination Personnes Agées), which provides integrated primary care with intensive case management for community-dwelling, very frail elderly patients. We used a quasi-experimental study in an urban district of Paris with four hundred twenty-eight very frail patients (105 in the intervention group and 323 in the control group) with one-year follow-up. The primary outcome measures were the presence of any unplanned hospitalization (via the ED), any planned hospitalizations (direct admission, no ED visit) and any hospitalization overall. Secondary outcome measures included health parameters assessed with the RAI-HC (Resident Assessment Instrument-Home Care). Comparing the intervention group with the control group, the risk of having at least one unplanned hospital admission decreased at one year and the planned hospital admissions rate increased, without a significant change in total hospital admissions. Among patients in the intervention group, there was less risk of depression and dyspnea. The COPA model improves the quality of care provided to very frail elderly patients by reducing unplanned hospitalizations and improving some health parameters.

A framework for understanding outcomes of integrated care programs for the hospitalised elderly

INTRODUCTION

Integrated care has emerged as a new strategy to enhance the quality of care for hospitalised elderly. Current models do not provide insight into the mechanisms underlying integrated care delivery. Therefore, we developed a framework to identify the underlying mechanisms of integrated care delivery. We should understand how they operate and interact, so that integrated care programmes can enhance the quality of care and eventually patient outcomes.

THEORY AND METHODS

Interprofessional collaboration among professionals is considered to be critical in integrated care delivery due to many interdependent work requirements. A review of integrated care components brings to light a distinction between the cognitive and behavioural components of interprofessional collaboration.

RESULTS

Effective integrated care programmes combine the interacting components of care delivery. These components affect professionals' cognitions and behaviour, which in turn affect quality of care. Insight is gained into how these components alter the way care is delivered through mechanisms such as combining individual knowledge and actively seeking new information.

CONCLUSION

We expect that insight into the cognitive and behavioural mechanisms will contribute to the understanding of integrated care programmes. The framework can be used to identify the underlying mechanisms of integrated care responsible for producing favourable outcomes, allowing comparisons across programmes.

Examining waiting placement in hospital: utilization and the lived experience

This mixed-methods study addressed the problem that although waiting placement is considered a major hospital utilization issue, minimal evidence exists to highlight the extent of it and the personal impact of waiting placement. An analysis of two years of complete hospital data for the Canadian province of Alberta was undertaken to examine waiting placement rates and describe waiting placement patients. Qualitative interviews and observations of elderly patients waiting in hospital for nursing home placement were also undertaken to gain an understanding of the lived experience of waiting for placement in hospital. Only 1.8% of all inpatients were waiting placement with an ALC (Alternative Level of Care) designation, 80% of ALC waits were less than 41 days (mean=29.85, median=14), and 2.2% of total hospital bed days in these two years were used by ALC patients. Three qualitative themes emerged: (a) coming to a realization of this significant move, (b) waiting is boring and distressing, and (c) hospitals are not designed for waiting placement. The findings of this study should raise awareness that although relatively few people wait placement in hospital, there are some major possible negative effects of waiting for placement in hospital for those who wait; with remedies to address waiting placement care deficits needed.

Understanding and meeting the needs of the older population: a global challenge

BACKGROUND

In the past century, there has been a significant rise in life expectancy in almost all regions of the world, contributing to an increasingly older population. The aging of the population, in conjunction with urbanization and industrialization, has resulted in an important epidemiological transition marked by a widespread increase in the prevalence of chronic diseases and their sequelae. Current trends suggest that the transition will have a greater impact on developing countries compared to developed countries. An adequate response to the transition requires a strong emphasis on primary prevention and adequate resource allocation.

The UP-TECH project, an intervention to support caregivers of Alzheimer's disease patients in Italy: study protocol for a randomized controlled trial

BACKGROUND

The epidemic of Alzheimer's disease (AD) represents a significant challenge for the health care and social service systems of many developed countries. AD affects both patients and family caregivers, on whom the main burden of care falls, putting them at higher risk of stress, anxiety, mortality and lower quality of life. Evidence remains controversial concerning the effectiveness of providing support to caregivers of AD patients, through case management, counseling, training, technological devices and the integration of existing care services. The main objectives of the UP-TECH project are: 1) to reduce the care burden of family caregivers of AD patients; and 2) to maintain AD patients at home.

METHODS/DESIGN

A total of 450 dyads comprising AD patients and their caregivers in five health districts of the Marche region, Italy, will be randomized into three study arms. Participants in the first study arm will receive comprehensive care and support from a case manager (an ad hoc trained social worker) (UP group). Subjects in the second study arm will be similarly supported by a case manager, but in addition will receive a technological toolkit (UP-TECH group). Participants in the control arm will only receive brochures regarding available services. All subjects will be visited at home by a trained nurse who will assess them using a standardized questionnaire at enrollment (M0), 6 months (M6) and 12 months (M12). Follow-up telephone interviews are scheduled at 24 months (M24). The primary outcomes are: 1) caregiver burden, measured using the Caregiver Burden Inventory (CBI); and 2) the actual number of days spent at home during the study period, defined as the number of days free from institutionalizations, hospitalizations and stays in an observation unit of an emergency room.

DISCUSSION

The UP-TECH project protocol integrates previous evidence on the effectiveness of strategies in dementia care, that is, the use of case management, new technologies, nurse home visits and efforts toward the integration of existing services in an ambitious holistic design. The analysis of different interventions is expected to provide sound evidence of the effectiveness and cost of programs supporting AD patients in the community.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01700556.

Derivation of a nomogram to estimate probability of revisit in at-risk older adults discharged from the emergency department

Estimation of the risk of revisit to the emergency department (ED) soon after discharge in the older population may assist discharge planning and targeting of post discharge intervention in high risk patients. In this study we sought to derive a risk prediction calculator for this purpose. In a prospective observational study in two tertiary ED, we conducted a comprehensive assessment of people aged 65 and over, and followed them for a minimum of 28 days post discharge. Cox proportional hazard models relating any unplanned ED revisit in the follow up period to observed risk factors were used to compute a probability nomogram. From 1,439 patients, 189 (13.1 %) had at least one unplanned revisit within 28 days. Revisit probability was weighted towards chronic and difficult to modify risk factors such as depression, malignancy and cognitive impairment. We conclude that the risk of revisit post discharge is calculable using a probability nomogram. However, revisit is largely related to immutable factors reflecting chronic illness burden, and does not necessarily reflect poor ED care during the initial index presentation.

Development of integrated care pathways: toward a care management system to meet the needs of frail and disabled community-dwelling older people

INTRODUCTION

The home care and services provided to older adults with the same needs are often inadequate and highly varied. Integrated care pathways (ICPs) can resolve these issues. The aim of this study was to develop the content of ICPs to follow-up frail and disabled community-dwelling older people.

THEORY AND METHOD

A RIGOROUS PROCESS WAS APPLIED ACCORDING TO A SERIES OF STEPS: identification of desirable characteristics and a theoretical framework; review of evidence-based practices and current practices; and determination of ICPs by an interdisciplinary task team.

RESULTS

ICPs are intended to prevent specific problems, maximize independence, and promote successful aging. They are organized according to a dynamic process: (1) needs assessment and assessment of risk/protection factors; (2) data-collection summary and goals identification; (3) planning of interventions from a client-centered view; (4) coordination, delivery, and follow-up; and (5) identification of variances, as well as review and adjustment of plans.

CONCLUSION

Once computerized, these ICPs will facilitate the exchange of information as well as the clinical decision-making process with a perspective to adequately matching the needs of an individual person with resources that delay or slow the progression of frailty and disability. Once aggregated, the data will also support managers in organizing teamwork and follow-up for clients.

[Factors facilitating and impairing implementation of integrated care]

BACKGROUND

Better integration of healthcare is the focus of many current reforms in Western countries. The goal is to reduce fragmentation of health and social care delivery for patients with chronic diseases. In France, Alzheimer autonomy integration experimentations (Maison Autonomie Intégration Alzheimer [MAIA]) were introduced as part of the 2008-2012 National Alzheimer Plan. To date, implementation of such organizations remains challenging. It is thus paramount to identify factors obstructing, and on the contrary facilitating, implementation of integrated care.

METHODS

After an in-depth literature review of qualitative studies published from January 1995 to December 2010. We selected 10 qualitative studies on health care professionals' perceptions of barriers and facilitators to the implementation of integrated care.

RESULTS

Barriers and facilitating factors linked to the implementation of integrated care were identified at several levels: leadership; collaboration between services and clinicians; and funding and policy making. The operative strategy applied to change care delivery and the role of the leading pilot are key elements during the implementation phase.

CONCLUSION

Strong leadership and active involvement of a broad spectrum of professionals from clinical practitioners to healthcare managers is crucial for a successful implementation of integrated care services.

The effectiveness of inter-professional working for older people living in the community: a systematic review

Health and social care policy in the UK advocates inter-professional working (IPW) to support older people with complex and multiple needs. Whilst there is a growing understanding of what supports IPW, there is a lack of evidence linking IPW to explicit outcomes for older people living in the community. This review aimed to identify the models of IPW that provide the strongest evidence base for practice with community dwelling older people. We searched electronic databases from 1 January 1990-31 March 2008. In December 2010 we updated the findings from relevant systematic reviews identified since 2008. We selected papers describing interventions that involved IPW for community dwelling older people and randomised controlled trials (RCT) reporting user-relevant outcomes. Included studies were classified by IPW models (Case Management, Collaboration and Integrated Team) and assessed for risk of bias. We conducted a narrative synthesis of the evidence according to the type of care (interventions delivering acute, chronic, palliative and preventive care) identified within each model of IPW. We retrieved 3211 records and included 37 RCTs which were mapped onto the IPW models: Overall, there is weak evidence of effectiveness and cost-effectiveness for IPW, although well-integrated and shared care models improved processes of care and have the potential to reduce hospital or nursing/care home use. Study quality varied considerably and high quality evaluations as well as observational studies are needed to identify the key components of effective IPW in relation to user-defined outcomes. Differences in local contexts raise questions about the applicability of the findings and their implications for practice. We need more information on the outcomes of the process of IPW and evaluations of the effectiveness of different configurations of health and social care professionals for the care of community dwelling older people.

Diffusion of a collaborative care model in primary care: a longitudinal qualitative study

BACKGROUND

Although collaborative team models (CTM) improve care processes and health outcomes, their diffusion poses challenges related to difficulties in securing their adoption by primary care clinicians (PCPs). The objectives of this study are to understand: (1) how the perceived characteristics of a CTM influenced clinicians' decision to adopt -or not- the model; and (2) the model's diffusion process.

METHODS

We conducted a longitudinal case study based on the Diffusion of Innovations Theory. First, diffusion curves were developed for all 175 PCPs and 59 nurses practicing in one borough of Paris. Second, semi-structured interviews were conducted with a representative sample of 40 PCPs and 15 nurses to better understand the implementation dynamics.

RESULTS

Diffusion curves showed that 3.5 years after the start of the implementation, 100% of nurses and over 80% of PCPs had adopted the CTM. The dynamics of the CTM's diffusion were different between the PCPs and the nurses. The slopes of the two curves are also distinctly different. Among the nurses, the critical mass of adopters was attained faster, since they adopted the CTM earlier and more quickly than the PCPs. Results of the semi-structured interviews showed that these differences in diffusion dynamics were mostly founded in differences between the PCPs' and the nurses' perceptions of the CTM's compatibility with norms, values and practices and its relative advantage (impact on patient management and work practices). Opinion leaders played a key role in the diffusion of the CTM among PCPs.

CONCLUSION

CTM diffusion is a social phenomenon that requires a major commitment by clinicians and a willingness to take risks; the role of opinion leaders is key. Paying attention to the notion of a critical mass of adopters is essential to developing implementation strategies that will accelerate the adoption process by clinicians.

The CareWell-primary care program: design of a cluster controlled trial and process evaluation of a complex intervention targeting community-dwelling frail elderly

Background

With increasing age and longevity, the rising number of frail elders with complex and numerous health-related needs demands a coordinated health care delivery system integrating cure, care and welfare. Studies on the effectiveness of such comprehensive chronic care models targeting frail elders show inconclusive results. The CareWell-primary care program is a complex intervention targeting community-dwelling frail elderly people, that aims to prevent functional decline, improve quality of life, and reduce or postpone hospital and nursing home admissions of community dwelling frail elderly.

Methods/design

The CareWell-primary care study includes a (cost-) effectiveness study and a comprehensive process evaluation. In a one-year pragmatic, cluster controlled trial, six general practices are non-randomly recruited to adopt the CareWell-primary care program and six control practices will deliver ‘care as usual’. Each practice includes a random sample of fifty frail elders aged 70 years or above in the cost-effectiveness study. A sample of patients and informal caregivers and all health care professionals participating in the CareWell-primary care program are included in the process evaluation. In the cost-effectiveness study, the primary outcome is the level of functional abilities as measured with the Katz-15 index. Hierarchical mixed-effects regression models / multilevel modeling approach will be used, since the study participants are nested within the general practices. Furthermore, incremental cost-effectiveness ratios will be calculated as costs per QALY gained and as costs weighed against functional abilities. In the process evaluation, mixed methods will be used to provide insight in the implementation degree of the program, patients’ and professionals’ approval of the program, and the barriers and facilitators to implementation.

Discussion

The CareWell-primary care study will provide new insights into the (cost-) effectiveness, feasibility, and barriers and facilitators for implementation of this complex intervention in primary care.

Trial registration

The CareWell-primary care study is registered in the ClinicalTrials.gov Protocol Registration System: NCT01499797

Patient satisfaction in home health care

AIMS AND OBJECTIVES

  To assess the current use of patient satisfaction measures in home health care and to examine the reliability and validity of current measures of patient satisfaction in home health care.

BACKGROUND

  Patient satisfaction has been one of the widely used measures in home health care as an indicator of quality of care. A few efforts have been made to develop psychometrically sound patient satisfaction scales for use in home health care.

DESIGN

  A critical review of the literature.

METHODS

  Electronic databases were systematically searched to identify the studies or publications that measured and addressed patient satisfaction and its measurement in home health care.

RESULTS

  The review of the literature showed that patient satisfaction measures have been used in the evaluation of care programmes including rehabilitation programmes, discharge and home follow-up programmes, care process and management practices. Also, patient satisfaction measures were used to evaluate new care protocols and treatments.

CONCLUSIONS

  Home healthcare agencies need valid and reliable patient satisfaction scales. Frameworks of patient satisfaction are still in their early developmental stage. Only some of the variables related to patient satisfaction are explained by many frameworks.

RELEVANCE TO CLINICAL PRACTICE

  Home healthcare mangers and researchers need to take in consideration the reliability and validity of measures and tools of patient satisfaction.

Measuring the degree of integration for an integrated service network

BACKGROUND

Integration involves the coordination of services provided by autonomous agencies and improves the organization and delivery of multiple services for target patients. Current measures generally do not distinguish between agencies' perception and expectation. We propose a method for quantifying the agencies' service integration. Using the data from the Children's Treatment Network (CTN), we aimed to measure the degree of integration for the CTN agencies in York and Simcoe.

THEORY AND METHODS

We quantified the integration by the agreement between perceived and expected levels of involvement and calculated four scores from different perspectives for each agency. We used the average score to measure the global network integration and examined the sensitivity of the global score.

RESULTS

Most agencies' integration scores were <65%. As measured by the agreement between every other agency's perception and expectation, the overall integration of CTN in Simcoe and York was 44% (95% CI: 39%-49%) and 52% (95% CI: 48%-56%), respectively. The sensitivity analysis showed that the global scores were robust.

CONCLUSION

Our method extends existing measures of integration and possesses a good extent of validity. We can also apply the method in monitoring improvement and linking integration with other outcomes.

[Autonomy insurance: An essential innovation in response to the challenges of aging]

The aging population and the epidemic of chronic diseases requires an accompanying finance reform of long-term care that will become increasingly dominant. Many countries have faced this situation and have set up a separate public funding for such care on the basis of a universal insurance covering both home care and institutions. Canada and Quebec must adopt such autonomy insurance and create a separate fund financed partly by a more judicious use of current budgets and tax credits, and also by a significant investment in home care. An autonomy support benefit could be allocated in kind to fund public services and by contract to pay for services delivered by private, voluntary, and social economy agencies. This benefit would be established following a standardized assessment of functional autonomy achieved by the case manager who will manage the services and control their quality.

A comparison of specialist rehabilitation and care assistant support with specialist rehabilitation alone and usual care for people with Parkinson's living in the community: study protocol for a randomised controlled trial

BACKGROUND

Parkinson's Disease is a degenerative neurological condition that causes movement problems and other distressing symptoms. People with Parkinson's disease gradually lose their independence and strain is placed on family members. A multidisciplinary approach to rehabilitation for people with Parkinson's is recommended but has not been widely researched. Studies are needed that investigate cost-effective community-based service delivery models to reduce disability and dependency and admission to long term care, and improve quality of life.

METHODS

A pragmatic three parallel group randomised controlled trial involving people with Parkinson's Disease and live-in carers (family friends or paid carers), and comparing: management by a specialist multidisciplinary team for six weeks, according to a care plan agreed between the professionals and the patient and carer (Group A); multidisciplinary team management and additional support for four months from a trained care assistant (Group B); usual care, no coordinated team care planning or ongoing support (Group C). Follow up will be for six months to determine the impact and relative cost-effectiveness of the two interventions, compared to usual care. The primary outcomes are disability (patients) and strain (carers). Secondary outcomes include patient mobility, falls, speech, pain, self efficacy, health and social care use; carer general health; patient and carer social functioning, psychological wellbeing, health related quality of life. Semi structured interviews will be undertaken with providers (team members, care assistants), service commissioners, and patients and carers in groups A and B, to gain feedback about the acceptability of the interventions. A cost - effectiveness evaluation is embedded in the trial.

DISCUSSION

The trial investigates components of recent national policy recommendations for people with long term conditions, and Parkinson's Disease in particular, and will provide guidance to inform local service planning and commissioning.

TRIAL REGISTRATION

ISRCTN: ISRCTN44577970.

Meeting the home-care needs of disabled older persons living in the community: does integrated services delivery make a difference?

BACKGROUND

The PRISMA Model is an innovative coordination-type integrated-service-delivery (ISD) network designed to manage and better match resources to the complex and evolving needs of elders. The goal of this study was to examine the impact of this ISD network on unmet needs among disabled older persons living in the community.

METHODS

Using data from the PRISMA study, we compared unmet needs of elders living in the community in areas with or without an ISD network. Disabilities and unmet needs were assessed with the Functional Autonomy Measurement System (SMAF). We used growth-curve analysis to examine changes in unmet needs over time and the variables associated with initial status and change. Sociodemographic characteristics, level of disability, self-perceived health status, cognitive functioning, level of empowerment, and the hours of care received were investigated as covariates. Lastly, we report the prevalence of needs and unmet needs for 29 activities in both areas at the end of the study.

RESULTS

On average, participants were 83 years old; 62% were women. They had a moderate level of disability and mild cognitive problems. On average, they received 2.07 hours/day (SD = 1.08) of disability-related care, mostly provided by family. The findings from growth-curve analysis suggest that elders living in the area where ISD was implemented and those with higher levels of disability experience better fulfillment of their needs over time. Besides the area, being a woman, living alone, having a higher level of disability, more cognitive impairments, and a lower level of empowerment were linked to initial unmet needs (r2 = 0.25; p < 0.001). At the end of the study, 35% (95% CI: 31% to 40%) of elders with needs living in the ISD area had at least one unmet need, compared to 67% (95% CI: 62% to 71%) in the other area. In general, unmet needs were highest for bathing, grooming, urinary incontinence, walking outside, seeing, hearing, preparing meals, and taking medications.

CONCLUSIONS

In spite of more than 30 years of home-care services in the province of Quebec, disabled older adults living in the community still have unmet needs. ISD networks such as the PRISMA Model, however, appear to offer an effective response to the long-term-care needs of the elderly.

Frailty Markers Predicting Emergency Department Visits in a Community-Dwelling Sample of Vulnerable Seniors in Montreal

La fragilité met les individus à un risque accru de mauvaise santé. Les personnes âgées consomment une quantité disproportionnée des ressources du service des urgence [SU]. Afin d’étudier la relation entre les marqueurs de fragilité et l’effet sur l’utilisation des services des urgence par les personnes âgées vivant dans les communautés, nous avons mené une analyse secondaire d’un essai prospectif randomisé contrôlé de 22 mois à Montreal, au Canada, en utilisant la base de données du Système de services intégrés pour personnes âgées en perte d’autonomie (SIPA). Nous avons evalué un échantillon de 565 individus, avec cinq marqueurs de fragilité : l’activité physique, la force, la cognition, l’énérgie et la mobilité. Une régression logistique univariée et multivariée a été réalisée afin d’évaluer la relation potentielle entre les marqueurs de fragilité et les visites aux urgences. Les résultats ont révelé que 70 pour cent des participants avaient au moins trois marqueurs de fragilité. Cependant, aucune relation n’a été trouvée entre les marqueurs de fragilité et les visites aux urgences. Ces résultats suggèrent, donc, que parmi les personnes âgées fonctionellement sévèrement handicapés au sein des communautés, la présence de marqueurs de fragilité ne semble pas prévoir les visites aux urgences.