Home or foster home care versus institutional long-term care for functionally dependent older people

Community-based person-centred integrated care (PIC) networks for healthy ageing in place: a scoping review protocol

INTRODUCTION

The economic case for preventive care delivered in or near citizens' homes is strong, and there is growing evidence of the role of local-level support in supporting people's health and well-being as they age. However, effective and consistent delivery of person-centred integrated care (PIC) at the community level remains elusive. Previous systematic reviews have focused on specific processes such as case management, but none have focused on the operational delivery of community-based care networks. In this study, we aim to identify what practice-based models of PIC networks exist at the local/neighbourhood level and what evidence is available as to their effectiveness for healthy ageing in place.

METHODS AND ANALYSIS

We will undertake a scoping review following the framework proposed by Arksey and O'Malley and updated guidance by the Joanna Briggs Institute. Peer-reviewed sources will be identified through searches of seven databases, and relevant grey literature will be identified through websites of policy and voluntary sector organisations focused on integrated care and/or healthy ageing. Data from included studies will be extracted for relevance to the research questions, including aims and anticipated outcomes of network models, financial and management structures of networks, and evidence of evaluation. Summary tables and narrative comparisons of key PIC network features across settings will be presented.

ETHICS AND DISSEMINATION

As no primary data will be collected, ethical approval is not required to conduct this scoping review. In addition to publication as a peer-reviewed article, the results of this review will be summarised as shorter discussion papers for use in follow-up research.

Rural-urban differences in older adults' life satisfaction and its determining factors

Although determinants of life satisfaction in older adults have been well documented, research has to date failed to fully address the experience of older adults living in places with different levels of urbanization. Furthermore, there are conflictive findings regarding the type of residence environment that offers the greatest benefits for the wellbeing of older adults. Our study proposes an integrative research model to determine the nature of the relationships between loneliness, self-esteem and life satisfaction, with a particular focus on the living environment (rural-urban) of the older adults. Using a cross-sectional survey design volunteers (aged 60+) from rural (n = 198) and urban (n = 198) in Galicia (Spain) completed a questionnaire. Structural Equation Modelling (SEM) was used to test the relationships between loneliness, self-esteem and life satisfaction and multigroup analysis was performed to analyse the existence of differences in the relationships based on the area of residence of older adults. We found that higher levels of loneliness were a significant predictor of reduced life satisfaction and reduced self-esteem. Self-esteem not only increases life satisfaction, but also reduces the negative impact loneliness may have on it. Where the older adults lived had a significant effect on the relationships between loneliness, self-esteem and life satisfaction. The relationships were stronger for older adults living in urban areas. Differentiated policy initiatives should be considered, depending on the area of residence in order to increase the life satisfaction of older adults.

Association of Hospital Readmission Rates With Discharge Disposition for Patients With Psychotic Disorders

GOAL

We explored how readmissions may result from patients' lack of access to aftercare services, failure to adhere to psychotropic medication plans, and inability to understand and follow hospital discharge recommendations. We also investigated whether insurance status, demographics, and socioeconomic status are associated with hospital readmissions. This study is important because readmissions contribute to increased personal and hospital expenses and decreased community tenure (the ability to maintain stability between hospital admissions). Addressing hospital readmissions will promote optimal discharge practices beginning on day one of hospital admission.

METHODS

The study examined the differences in hospital readmission rates for patients with a primary psychotic disorder diagnosis. Discharge data were drawn in 2017 from the Nationwide Readmissions Database. Inclusion criteria included patients aged 0-89 years who were readmitted to a hospital between less than 24 hr and up to 30 days from discharge. Exclusion criteria were principal medical diagnoses, unplanned 30-day readmissions, and discharges against medical advice. The sampling frame included 269,906 weighted number of patients diagnosed with a psychotic disorder treated at one of 2,355 U.S. community hospitals. The sample size was 148,529 unweighted numbers of patients discharged.

PRINCIPAL FINDINGS

In a logistic regression model, weighted variables were calculated and used to determine an association between the discharge dispositions and readmissions. After controlling for hospital characteristics and patient demographics, we found that the odds for readmission for routine and short-term hospital discharge dispositions decreased for home health care discharges, which indicated that home health care can prevent readmissions. The finding was statistically significant when controlling for payer type and patient age and gender.

PRACTICAL APPLICATIONS

The findings support home health care as an effective option for patients with severe psychosis. Home health care reduces readmissions and is recommended, when appropriate, as an aftercare service following inpatient hospitalization and may enhance the quality of patient care. Improving healthcare quality involves optimizing, streamlining, and promoting standardized processes in discharge planning and direct transitions to aftercare services.

The Health Care Trajectories of Older People in Foster Families: Protocol for an Observational Study

BACKGROUND

With aging of the population, the search for alternative models of care adapted to older people with dependency is necessary. In this setting, foster families (1-3 older people per family) could be an alternative to nursing homes, residential care facilities, or community- and home-based care.

OBJECTIVE

The KArukera Study of Ageing in Foster Families is a prospective cohort study designed to investigate the care pathways of older people with dependency in foster care over a year. The 1-year hospitalization rate (main objective), cost of hospitalization, incidence of mortality, prevalence of geriatric syndromes, and quality of life of residents will be assessed. Quality of life and burnout of their respective foster caregivers will also be studied.

METHODS

This study cohort will include 250 older people living in foster families in Guadeloupe (French West Indies), as well as their respective foster caregivers. Both older people and caregivers will be interviewed concurrently on site at three time points: (1) at baseline, (2) at 6 months, and (3) at 12 months. For older people, we will collect anthropometric measures, cognitive impairment, depressive and anxiety symptoms, functional abilities, physical frailty, information on general health status, quality of life, and care pathways (hospitalization, mortality, and medical and paramedical consultations). We will also assess the quality of life and burnout symptoms of family caregivers at each follow-up. A phone update of vital status (alive or death) and care pathways of residents will be carried out at 3 and 9 months after the baseline examination.

RESULTS

Recruitment opened in September 2020 and ended in May 2021, with 109 older people recruited and 56 respective foster caregivers. The 1-year follow-up was ended in June 2022. Data analyses are ongoing and the first results are expected to be published in May 2023.

CONCLUSIONS

Foster families are a potentially innovative way to accommodate dependent older people. This study could help define the clinical profile of older people adapted to foster families in the transition from frailty to dependency. The effectiveness of foster families, in terms of hospitalizations and mortality, will be compared with other models of care, particularly nursing homes. In this setting, a twin study carried out in nursing homes in Guadeloupe with similar aims and outcomes will be conducted. Beyond mortality and morbidity, the numerous outcomes will allow us to assess the evolution of geriatric syndromes over time.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04545775; https://clinicaltrials.gov/ct2/show/NCT04545775.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/40604.

Well-being right before and after a permanent nursing home admission

Permanent nursing home (NH) admissions are a frequent and major life event aimed at maintaining quality of life in old age. Yet, insights into the impact of a NH admission on well-being are scarce and inconclusive. We evaluate the effect of a NH admission on domains of well-being among those who are admitted using event study methodology for cross-sections combined with inverse probability weighting. We apply this doubly robust approach to Dutch survey data on well-being linked to extensive administrative data on NH admissions, health, and socio-economic status. We find that a NH admission leads to a temporary increase in loneliness, the risk of anxiety and depression, and a loss of control over one's life. However, these scores revert to pre-admission levels after 6 months. These findings may contribute to better-informed individual-level and policy decisions about potential NH entry and aging in place policies.

Research priorities for homecare for older people: A UK multi-stakeholder consultation

Homecare is generally understood to refer to services that support people to continue living in their own homes. Older people are the primary users and many countries report an increase in the number using homecare services and greater spending on such provision, driven in part by investment in 'ageing in place' policies. Despite this, and reflecting social care more generally, homecare is relatively under-researched. However, in the UK at least, there is growing interest and investment in social care research. In order that this investment is not wasted, it is essential that research addresses what stakeholders identify as research priorities. This study reports work undertaken in the UK during 2021/22 to identify research priorities for homecare for older people, and a broad scoping of existing evidence. A two-stage consultation process was used. First, topic areas for research were identified through consultations with stakeholders. Second, a survey ascertained agreement and differences between groups regarding the relative importance of topic areas as research priorities. Over 50 people participated including older people (n = 7), family members (n = 11), homecare workers (n = 16), homecare providers (n = 9) and national policy, evidence and advocacy leads (n = 13). Twenty discrete research topic areas were identified. Only one topic area (Joint working between homecare and health services) was a 'Top 5' research priority for all stakeholder groups. Timely engagement with homecare and Workforce: recruitment and retention were 'Top 5' priorities for three stakeholder groups. Scoping of existing research indicates that topic areas receiving the most research attention to date are not among those identified as being of high priority for research. To our knowledge, this is the first time research priorities for homecare have been generated. Findings will be of value to research funders, organisations using research evidence and the research community.

Caring for Frail Older People Living Alone in Italy: Future Housing Solutions and Responsibilities of Family and Public Services, a Qualitative Study

When frail older people age alone in place, with increasing functional limitations, they require support in performing daily living activities. In this respect, it is important to assess their preferences in terms of future housing solutions, and their opinions/orientations on the care responsibilities of both family and public services. The present study aimed to explore these aspects in Italy. Qualitative interviews were carried out in 2019 within the “Inclusive ageing in place” (IN-AGE) research project, involving 120 frail older people who lived at home in three Italian regions (Lombardy, Marche, and Calabria). A content analysis was conducted, and some quantifications of interviewees’ statements were provided. The results revealed that the majority of seniors prefer ageing at home, at least with a personal care assistant (PCA), whereas moving to a nursing home is typically deemed as a last option. Moreover, they considered the family to be primarily responsible for taking care of them, even with the support of public services. In addition, some territorial differences emerged. Strengthening an integrated model of long-term care (LTC) for older people, where both formal and informal supports allow frail older people to age at home, seems thus a good overall policy solution to pursue, with interventions based also on the needs and preferences of both seniors and their respective families.

Comparative Analysis of Factors Affecting Quality of Community-Based Care Services in Korea

Aging societies have an increased need for care services. To solve the problem of care, we suggest community care, through which medical services are provided that meet individual needs. Korea provides care services in advance of the community care project and implements quality control to improve the quality of these social services. Therefore, this study aims to compare and analyze the factors affecting user satisfaction in care services in both 2013 and 2016. We analyzed secondary data from 2013 and 2016 collected by the Social Security Information Service. These data include standardized metrics for the quality of care. Based on the evaluation indexes for care service in 2013 and 2016, we used commonly used indexes for analysis. Specifically, non-profit organizations were influenced by sales, accounting management, lifetime tenure rate, etc., while for-profit organizations were affected by number of users, contract termination, etc. In addition, on-site evaluation had a negative effect on the change rate of user satisfaction. Therefore, in order to increase satisfaction with care services, evaluation indexes by service type should be diversified and differentiated. In addition, field evaluations related to user satisfaction should be performed in order to provide care services appropriate for local characteristics.

Factors Associated with the Acceptance of New Technologies for Ageing in Place by People over 64 Years of Age

Background: In the context of growing population ageing, technologies aimed at helping people age in place play a fundamental role. Acceptance of the implementation of technological solutions can be defined as the intention to use a technology or the effective use of it. Approaches based on the technology acceptance model (TAM) have been shown to have good predictive power for pre-implementation attitudes towards new technologies. Objective: To analyze the degree of acceptability of the use of new technologies for ageing in place and the factors associated with greater acceptance in people older than 64 years. Methodology: A descriptive cross-sectional study was carried out. Sociodemographic, clinical and environmental variables, architectural barriers, social risk and quality of life, degree of autonomy, morbidity, and risk of falls were collected in a population sample over 64 years of age in a large region of western Spain. The degree of acceptance of the use of technologies was measured through a scale based on the TAM. Results: Of the 293 people included in the study, 36.2% exhibited a high acceptability of new technologies, 28.3% exhibited a medium acceptability, and 35.5% exhibited a low acceptability. Of all the factors, age, education level, and living alone were significantly associated with high acceptance in the adjusted analyses. Conclusions: Younger age, a higher education level, and living alone are factors associated with a greater degree of acceptance of the use of technologies for ageing in place.

Regulation of Long-Term Care Homes for Older Adults in India

The rising aging population in India has led to an increased caregiving burden, and accordingly, the number of residential care facilities is also burgeoning. There is no regulatory framework or registration authority specifically for residential care homes in India. The article's objective is to understand the need for a regulatory framework in India in the context of historic and global experiences in the UK, USA, and Europe. Although there is a lack of literature comparing the community home-based care and residential care, one study reported a preference for home-based care in the South Asian context. Elder abuse and deprivation of rights of seniors are common, and there is a need to bring in more safeguards to prevent these from the perspective of the older adults, their family members, the care providers, and the state. While the main priority of meeting care needs in long-term care is a challenge given the lack of trained care staff, the quality control mechanisms also need to evolve. A review of adverse incidents, complaints, and litigations also highlights the need for regulation to improve the standards and quality of care. The article explores lacunae of residential care facilities in the Indian context and provides recommendatory parameters for evaluating the quality of care provided. Relevant sections of the statutory new Mental Healthcare Act of 2017 in India could provide a regulatory framework ensuring rights and liberties of the residents are upheld. The authors propose a state-run model for elderly care homes and commencement of framing regulations appropriate to the Indian context.

Demographic Characteristics Driving Disparities in Receipt of Long-term Services and Supports in the Community Setting

BACKGROUND

Research suggests that growth in Black and Hispanic (minority) older adults' nursing home (NH) use may be the result of disparities in access to community-based and alternative long-term services and supports (LTSS).

OBJECTIVE

We aimed to determine whether minority groups receiving care in NHs versus the community had fewer differences in their functional needs compared with the differences in nonminority older adults, suggesting a disparity.

METHODS

We identified respondents aged 65 years or above with a diagnosis of Alzheimer disease or dementia in the 2016 Health and Retirement Study who reported requiring LTSS help. We performed unadjusted analyses to assess the difference in functional need between community and NH care. Functional need was operationalized using a functional limitations score and 6 individual activities of daily living. We compared the LTSS setting for minority older adults to White older adults using difference-in-differences.

RESULTS

There were 186 minority older adults (community=75%, NH=25%) and 357 White older adults (community=50%, NH=50%). Between settings, minority older adults did not differ in education or marital status, but were younger and had greater income in the NH versus the community. The functional limitations score was higher in NHs than in the community for both groups. Functional needs for all 6 activities of daily living for the minority group were greater in NHs compared with the community.

CONCLUSION

Functional need for minority older adults differed by setting while demographics varied in unexpected ways. Factors such as familial and financial support are important to consider when implementing programs to keep older adults out of NHs.

Users Of Veteran-Directed Care And Other Purchased Care Have Similar Hospital Use And Costs Over Time

The Veteran-Directed Care (VDC) program facilitates independent community living among adults with multiple chronic conditions and functional limitations. Family caregivers value the choice and flexibility afforded by VDC, but rigorous evidence to support its impact on health care costs and use is needed. We identified veterans enrolled in VDC in fiscal year 2017 and investigated differences in hospital admissions and costs after initial receipt of VDC services. We compared VDC service recipients to a matched comparison group of veterans receiving homemaker or home health aide, home respite, and adult day health care services and found similar decreases in hospital use and costs from before to after enrollment in the groups. Further investigation into trends of nursing home use, identification of veterans most likely to benefit from VDC, and relative costs of operating VDC versus other purchased care programs is needed, but our results suggest that VDC remains a valuable option for supporting veterans and caregivers.

The impact of frailty on admission to home care services and nursing homes: eight-year follow-up of a community-dwelling, older adult, Spanish cohort

Background

Frailty in older adults is a common multidimensional clinical entity, a state of vulnerability to stressors that increases the risk of adverse outcomes such as functional decline, institutionalization or death. The aim of this study is to identify the factors that anticipate the future inclusion of community-dwelling individuals aged ≥70 years in home care programmes (HC) and nursing homes (NH), and to develop the corresponding prediction models.

Methods

A prospective cohort study was conducted in 23 primary healthcare centers located in Catalonia, Spain, with an eight-year follow-up (2005–2013). The cohort was made up of 616 individuals. Data collection included a baseline multidimensional assessment carried out by primary health care professionals. Outcome variables were collected during follow-up by consulting electronic healthcare records, and the Central Registry of Catalonia for mortality. A prognostic index for a HC and NH at 8 years was estimated for each patient. Death prior to these events was considered a competing risk event, and Fine–Gray regression models were used.

Results

At baseline, mean age was 76.4 years and 55.5% were women. During follow-up, 19.2% entered a HC program, 8.2% a NH, and 15.4% died without presenting an event. Of those who entered a NH, 31.5% had previously been in a HC program.

Multivariate models for a HC and NH showed that the risk of a HC entry was associated with older age, dependence on the Instrumental Activities of Daily Living, and slow gait measured by Timed-up-and-go test. An increased risk of being admitted to a NH was associated with older age, dependence on the Instrumental Activities of Daily Living, number of prescriptions, and the presence of social risk.

Conclusions

Prognostic models based on comprehensive geriatric assessments can predict the need for the commencement of HC and NH admission in community-dwelling older adults. Our findings underline the necessity to measure functional capacity, mobility, number of prescriptions, and social aspects of older adults in primary healthcare centers. In such a setting they can be offered longitudinal holistic assessments so as to benefit from preventive actions in order to remain independent in the community for as long as possible.

Nudge strategies to improve healthcare providers' implementation of evidence-based guidelines, policies and practices: a systematic review of trials included within Cochrane systematic reviews

BACKGROUND

Nudge interventions are those that seek to modify the social and physical environment to enhance capacity for subconscious behaviours that align with the intrinsic values of an individual, without actively restricting options. This study sought to describe the application and effects of nudge strategies on clinician implementation of health-related guidelines, policies and practices within studies included in relevant Cochrane systematic reviews.

METHODS

As there is varied terminology used to describe nudge, this study examined studies within relevant systematic reviews. A two-stage screening process was undertaken where, firstly, all systematic reviews published in the Cochrane Library between 2016 and 2018 were screened to identify reviews that included quantitative studies to improve implementation of guidelines among healthcare providers. Secondly, individual studies within relevant systematic reviews were included if they were (i) randomised controlled trials (RCTs), (ii) included a nudge strategy in at least one intervention arm, and (iii) explicitly aimed to improve clinician implementation behaviour. We categorised nudge strategies into priming, salience and affect, default, incentives, commitment and ego, and norms and messenger based on the Mindspace framework.

SYNTHESIS

The number and percentage of trials using each nudge strategy was calculated. Due to substantial heterogeneity, we did not undertake a meta-analysis. Instead, we calculated within-study point estimates and 95% confidence intervals, and used a vote-counting approach to explore effects.

RESULTS

Seven reviews including 42 trials reporting on 57 outcomes were included. The most common nudge strategy was priming (69%), then norms and messenger (40%). Of the 57 outcomes, 86% had an effect on clinician behaviour in the hypothesised direction, and 53% of those were statistically significant. For continuous outcomes, the median effect size was 0.39 (0.22, 0.45), while for dichotomous outcomes the median Odds Ratio was 1.62 (1.13, 2.76).

CONCLUSIONS

This review of 42 RCTs included in Cochrane systematic reviews found that the impact of nudge strategies on clinician behaviour was at least comparable to other interventions targeting implementation of evidence-based guidelines. While uncertainty remains, the review provides justification for ongoing investigation of the evaluation and application of nudge interventions to support provider behaviour change.

TRIAL REGISTRATION

This review was not prospectively registered.

Can your house keep you out of a nursing home?

We examine the impact of the accessibility of an older individual's house on her use of nursing home care. We link administrative data on the accessibility of all houses in the Netherlands to data on long-term care use of all older persons from 2011 to 2014. We find that older people living in more accessible houses are less likely to use nursing home care. The effects increase with age and are largest for individuals aged 90 or older. The effects are stronger for people with physical limitations than for persons with cognitive problems. We also provide suggestive evidence that older people living in more accessible houses substitute nursing home care by home care.

The experience of patients and family caregivers during hospital-at-home in France

Background

Public health policies tend to generalize the use of Hospital-At-Home (HAH) to answer the growing will of patients to be treated or to die at home. HAH is a model of care that provides acute-level services in the patient’s home with the interventions of variety of health care professionals. Relatives participate also in the interventions by helping for sick patients at home, but we lack data on the care of patients and caregivers in HAH. The aim of this study was to make an inventory of the experiences of patients and family caregivers in HAH.

Methods

The research was qualitative using nineteen semi-directed interviews from nine patients and ten caregivers of one care unit of Greater Paris University Hospitals’ HAH, and the grounded theory was used to analyze the transcripts. Caregivers were also asked, after the interview, to fill in the Zarit Burden Inventory.

Results

HAH remained mostly unknown for patients and caregivers before the admission proposition and the outlook of being admitted in HAH was perceived as positive, for both of them. Caregivers had a versatile role throughout HAH, leading to situations of suffering, but also had sources of support. The return home was considered satisfactory by both caregivers and patients, related to the quality of care and increased morale despite HAH’s organizational constraints. We noted an impact of HAH on the relationship between the patient and the caregiver(s), but caused by multiple factors: the fact that the care takes places at home, its consequences but also the disease itself.

Conclusion

HAH strongly involved the patient’s caregiver(s) all along the process. HAH’s development necessitates to associate both patients and caregivers and to take into account their needs at every step. This study highlights the need to better assess the ability of the caregiver to cope with his or her relative in HAH with acute and subacute care at home.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4295-7) contains supplementary material, which is available to authorized users.

Service Delivery Models to Maximize Quality of Life for Older People at the End of Life: A Rapid Review

Policy Points We identified two overarching classifications of integrated geriatric and palliative care to maximize older people's quality of life at the end of life. Both are oriented to person-centered care, but with differing emphasis on either function or symptoms and concerns. Policymakers should both improve access to palliative care beyond just the last months of life and increase geriatric care provision to maintain and optimize function. This would ensure that continuity and coordination for potentially complex care needs across the continuum of late life would be maintained, where the demarcation of boundaries between healthy aging and healthy dying become increasingly blurred. Our findings highlight the urgent need for health system change to improve end-of-life care as part of universal health coverage. The use of health services should be informed by the likelihood of benefits and intended outcomes rather than on prognosis.

CONTEXT

In an era of unprecedented global aging, a key priority is to align health and social services for older populations in order to support the dual priorities of living well while adapting to a gradual decline in function. We aimed to provide a comprehensive synthesis of evidence regarding service delivery models that optimize the quality of life (QoL) for older people at the end of life across health, social, and welfare services worldwide.

METHODS

We conducted a rapid scoping review of systematic reviews. We searched MEDLINE, CINAHL, EMBASE, and CDSR databases from 2000 to 2017 for reviews reporting the effectiveness of service models aimed at optimizing QoL for older people, more than 50% of whom were older than 60 and in the last one or two years of life. We assessed the quality of these included reviews using AMSTAR and synthesized the findings narratively.

RESULTS

Of the 2,238 reviews identified, we included 72, with 20 reporting meta-analysis. Although all the World Health Organization (WHO) regions were represented, most of the reviews reported data from the Americas (52 of 72), Europe (46 of 72), and/or the Western Pacific (28 of 72). We identified two overarching classifications of service models but with different target outcomes: Integrated Geriatric Care, emphasizing physical function, and Integrated Palliative Care, focusing mainly on symptoms and concerns. Areas of synergy across the overarching classifications included person-centered care, education, and a multiprofessional workforce. The reviews assessed 117 separate outcomes. A meta-analysis demonstrated effectiveness for both classifications on QoL, including symptoms such as pain, depression, and psychological well-being. Economic analysis and its implications were poorly considered.

CONCLUSIONS

Despite their different target outcomes, those service models classified as Integrated Geriatric Care or Integrated Palliative Care were effective in improving QoL for older people nearing the end of life. Both approaches highlight the imperative for integrating services across the care continuum, with service involvement triggered by the patient's needs and likelihood of benefits. To inform the sustainability of health system change we encourage economic analyses that span health and social care and examine all sources of finance to understand contextual inequalities.

Developing a new clinical governance framework for chronic diseases in primary care: an umbrella review

OBJECTIVES

Our goal is to conceptualise a clinical governance framework for the effective management of chronic diseases in the primary care setting, which will facilitate a reorganisation of healthcare services that systematically improves their performance.

SETTING

Primary care.

PARTICIPANTS

Chronic Care Model by Wagner et aland Clinical Governance statement by Scally et alwere taken for reference. Each was reviewed, including their various components. We then conceptualised a new framework, merging the relevant aspects of both.

INTERVENTIONS

We conducted an umbrella review of all systematic reviews published by the Cochrane Effective Practice and Organisation of Care Group to identify organisational interventions in primary care with demonstrated evidence of efficacy.

RESULTS

All primary healthcare systems should be patient-centred. Interventions for patients and their families should focus on their values; on clinical, professional and institutional integration and finally on accountability to patients, peers and society at large. These interventions should be shaped by an approach to their clinical management that achieves the best clinical governance, which includes quality assurance, risk management, technology assessment, management of patient satisfaction and patient empowerment and engagement. This approach demands the implementation of a system of organisational, functional and professional management based on a population health needs assessment, resource management, evidence-based and patient-oriented research, professional education, team building and information and communication technologies that support the delivery system. All primary care should be embedded in and founded on an active partnership with the society it serves.

CONCLUSIONS

A framework for clinical governance will promote an integrated effort to bring together all related activities, melding environmental, administrative, support and clinical elements to ensure a coordinated and integrated approach that sustains the provision of better care for chronic conditions in primary care setting.

Using benchmarking to assist the improvement of service quality in home support services for older people-IN TOUCH (Integrated Networks Towards Optimising Understanding of Community Health)

Service providers and funders need ways to work together to improve services. Identifying critical performance variables provides a mechanism by which funders can understand what they are purchasing without getting caught up in restrictive service specifications that restrict the ability of service providers to meet the needs of the clients. An implementation pathway and benchmarking programme called IN TOUCH provided contracted providers of home support and funders with a consistent methodology to follow when developing and implementing new restorative approaches for service delivery. Data from performance measurement was used to triangulate the personal and social worlds of the stakeholders enabling them to develop a shared understanding of what is working and what is not. The initial implementation of IN TOUCH involved five District Health Boards. The recursive dialogue encouraged by the IN TOUCH programme supports better and more sustainable service development because performance management is anchored to agreed data that has meaning to all stakeholders.

[Critical view and argumentation on chronic care programs in Primary and Community Care]

El análisis detallado de los planes de atención a la cronicidad desarrollados por los servicios regionales de salud pone de manifiesto un sorprendente nivel de uniformidad en su diseño y despliegue, a pesar de las diferencias existentes entre dichos servicios. La revisión de la literatura sobre los modelos teóricos que lo sustentan y los instrumentos que lo desarrollan no aporta evidencias concluyentes que permitan afirmar que los modelos de atención a pacientes crónicos alcanzan mejores resultados que modelos de atención alternativos. A pesar de que todos los planes de atención a la cronicidad incluyen sistemas de evaluación de los mismos, no se han publicado hasta la fecha estudios rigurosos sobre su efecto.

Dado que, por el contrario, sí existen pruebas sólidas y reiteradas de que modelos con una Atención Primaria fuerte obtienen mejores resultados, cabe preguntarse sobre la necesidad de buscar modelos alternativos, cuando las metas propuestas probablemente podrían alcanzarse de fortalecer realmente la Atención Primaria.