Integrated Care for Older Adults Improves Perceived Quality of Care: Results of a Randomized Controlled Trial of Embrace

Frailty as an Effect Modifier in Randomized Controlled Trials: A Systematic Review

BACKGROUND

The effect of clinical interventions may vary by patients' frailty status. Understanding treatment effect heterogeneity by frailty could lead to frailty-guided treatment strategies and reduce overtreatment and undertreatment. This systematic review aimed to examine the effect modification by frailty in randomized controlled trials (RCTs) that evaluate pharmacological, non-pharmacological, and multicomponent interventions.

METHODS

We searched PubMed, Web of Science, EMBASE, and ClinicalTrial.gov, from their inception to 8 December 2023. Two reviewers independently extracted trial data and examined the study quality with senior authors.

RESULTS

Sixty-one RCTs that evaluated the interaction between frailty and treatment effects in older adults were included. Frailty was evaluated using different tools such as the deficit accumulation frailty index, frailty phenotype, and other methods. The effect of several pharmacological interventions (e.g., edoxaban, sacubitril/valsartan, prasugrel, and chemotherapy) varied according to the degree of frailty, whereas other treatments (e.g., antihypertensives, vaccinations, osteoporosis medications, and androgen medications) demonstrated consistent benefits across different frailty levels. Some non-pharmacological interventions had greater benefits in patients with higher (e.g., chair yoga, functional walking, physical rehabilitation, and higher dose exercise program) or lower (e.g., intensive lifestyle intervention, psychosocial intervention) levels of frailty, while others (e.g., resistance-type exercise training, moderate-intensive physical activity, walking and nutrition or walking) produced similar intervention effects. Specific combined interventions (e.g., hospital-based disease management programs) demonstrated inconsistent effects across different frailty levels.

DISCUSSION

The efficacy of clinical interventions often varied by frailty levels, suggesting that frailty is an important factor to consider in recommending clinical interventions in older adults.

REGISTRATION

PROSPERO registration number CRD42021283051.

Integrated Care in Neurology: The Current Landscape and Future Directions

The rising burden of neurological disorders poses significant challenges to healthcare systems worldwide. There has been an increasing momentum to apply integrated approaches to the management of several chronic illnesses in order to address systemic healthcare challenges and improve the quality of care for patients. The aim of this paper is to provide a narrative review of the current landscape of integrated care in neurology. We identified a growing body of research from countries around the world applying a variety of integrated care models to the treatment of common neurological conditions. Based on our findings, we discuss opportunities for further study in this area. Finally, we discuss the future of integrated care in Canada, including unique geographic, historical, and economic considerations, and the role that integrated care may play in addressing challenges we face in our current healthcare system.

Personalized, interdisciplinary patient pathway for cross-sector care of multimorbid patients (eliPfad trial): study protocol for a randomized controlled trial

BACKGROUND

Multimorbid and frail elderly patients often carry a high burden of treatment. Hospitalization due to the onset of an acute illness can disrupt the fragile balance, resulting in further readmissions after hospital discharge. Current models of care in Germany do not meet the needs of this patient group. Rather lack of coordination and integration of care combined with a lack of interdisciplinary approaches result in fragmented and inadequate care and increase the burden of treatment even more.

METHODS

eliPfad is a randomized controlled trial conducted in 6 hospitals in Germany. Multimorbid elderly patients aged 55 or older are randomly assigned to the intervention or control group. Patients in the intervention group receive the eliPfad intervention additional to standard care. The core components of eliPfad are: Early assessment of patients' individual treatment burden and support through a specially trained case manager Involvement of the patient's general practitioner (GP) right from the beginning of the hospital stay Preparation of an individual, cross-sectoral treatment plan through the interdisciplinary hospital team with the involvement of the patient's GP Establishment of a cross-sectoral electronic patient record (e-ePA) for documentation and cross-sectoral exchange Support/Promote patient adherence Tailored early rehabilitation during the hospital stay, which is continued at home Close-tele-monitoring of medically meaningful vital parameters through the use of tablets, digital devices, and personal contacts in the home environment The intervention period begins in the hospital and continues 6 weeks after discharge. Patients in the control group will be treated according to standard clinical care and discharged according to current discharge management. The primary aim is the prevention/reduction of readmissions in the first 6 months after discharge. In addition, the impact on health-related quality of life, the burden of treatment, survival, self-management, medication prescription, health literacy, patient-centered care, cost-effectiveness, and process evaluation will be examined. Nine hundred forty-eight patients will be randomized 1:1 to intervention and control group.

DISCUSSION

If eliPfad leads to fewer readmissions, proves (cost-)effective, and lowers the treatment burden, it should be introduced as a new standard of care in the German healthcare system.

TRIAL REGISTRATION

The trial was registered in the German Clinical Trials Registry (Deutsches Register Klinischer Studien (DRKS)) on 08/14/2023 under the ID DRKS00031500 .

Older adults' perceptions and experiences of interprofessional communication as part of the delivery of integrated care in the primary healthcare sector: a meta-ethnography of qualitative studies

BACKGROUND

Communication between patients and healthcare providers, and effective interprofessional communication, are essential to the provision of high-quality care. Implementing a patient-centred approach may lead to patients experiencing a sense of comfort, validation, and active participation in own healthcare. However, home-dwelling older adults' perspectives on interprofessional communication (IPC) are lacking. The aim is therefore to explore how home-dwelling older adults experience communication in connection with the delivery of integrated care.

METHODS

The meta-synthesis was conducted in line with Noblit and Hare's seven phases of meta-ethnography. A systematic literature search was conducted by two university librarians in seven databases using the search terms 'older adults', 'communication', 'integrated care' and 'primary care'. All articles were reviewed by two authors independently. 11 studies were included for analysis.

RESULTS

Older adults are aware of IPC and have preferences regarding how it is conducted. Three main themes were identified in the reciprocal analysis: (1) Inconsistent care perceived as lack of IPC, (2) individual preferences regarding involvement and awareness of IPC and (3) lack of IPC may trigger negative feelings.

CONCLUSIONS

This meta-ethnography shows the perspective of older adults on IPC as part of integrated care. Our study shows that older adults are concerned about whether healthcare personnel talk to each other or not and recognise IPC as fundamental in providing consistent care. The perspectives of older adults are relevant for clinicians and politicians, as well as researchers, when developing and implementing future integrated care services for home-dwelling older adults.

Rehabilitation in primary care for an ageing population: a secondary analysis from a scoping review of rehabilitation delivery models

BACKGROUND

The world population is ageing rapidly. Rehabilitation is one of the most effective health strategies for improving the health and functioning of older persons. An understanding of the current provision of rehabilitation services in primary care (PC) is needed to optimise access to rehabilitation for an ageing population. The objectives of this scoping review are a) to describe how rehabilitation services are currently offered in PC to older persons, and b) to explore age-related differences in the type of rehabilitation services provided.

METHODS

We conducted a secondary analysis of a scoping review examining rehabilitation models for older persons, with a focus on PC. Medline and Embase (2015-2022) were searched to identify studies published in English on rehabilitation services for people aged 50 + . Two authors independently screened records and extracted data using the World Health Organization (WHO)'s operational framework, the Primary Health Care Systems (PRIMASYS) approach and the WHO paper on rehabilitation in PC. Data synthesis included quantitative and qualitative analysis.

RESULTS

We synthesised data from 96 studies, 88.6% conducted in high-income countries (HICs), with 31,956 participants and identified five models for delivering rehabilitation to older persons in PC: community, home, telerehabilitation, outpatient and eldercare. Nurses, physiotherapists, and occupational therapists were the most common providers, with task-shifting reported in 15.6% of studies. The most common interventions were assessment of functioning, rehabilitation coordination, therapeutic exercise, psychological interventions, and self-management education. Environmental adaptations and assistive technology were rarely reported.

CONCLUSIONS

We described how rehabilitation services are currently provided in PC and explored age-related differences in the type of rehabilitation services received. PC can play a key role in assessing functioning and coordinating the rehabilitation process and is also well-placed to deliver rehabilitation interventions. By understanding models of rehabilitation service delivery in PC, stakeholders can work towards developing more comprehensive and accessible services that meet the diverse needs of an ageing population. Our findings, which highlight the role of rehabilitation in healthy ageing, are a valuable resource for informing policy, practice and future research in the context of the United Nations Decade of Healthy Ageing, the Rehab2030 initiative and the recently adopted WHA resolution on strengthening rehabilitation in health systems, but the conclusions can only be applied to HICs and more studies are needed that reflect the reality in low- and middle-income countries.

Adapting Measurement-Based Care to VA Home-Based Primary Care Mental Health Treatment: A Quality Improvement Project

OBJECTIVES

This quality improvement project sought to develop guidance for Home-Based Primary Care (HPBC) Mental Health (MH) clinicians on integrating Measurement-Based Care (MBC) into their practice and gain participating psychologists' feedback on their experience using MBC for treating mental health concerns with HBPC Veterans.

METHODS

Based on feedback from the HBPC MH community and in consultation with national leadership, a workgroup of HBPC psychologists developed a guide tailoring MBC to HBPC Veterans. Eight HBPC psychologists piloted the adapted MBC approach with 53 Veterans. Participating psychologists provided feedback on measure administration, Veterans' responses to MBC, and perceived benefits and challenges.

RESULTS

Pilot participants' feedback suggested that MBC can be a highly useful tool for delivering mental health services in HBPC, although feedback varied about specific MBC measures. Qualitative feedback was primarily positive, but participants noted challenges based on the nature of the presenting problem and Veteran-specific characteristics.

CONCLUSIONS

Findings indicate that MBC can be utilized with appropriate HBPC Veterans and has the potential to benefit care. Further research is needed to clarify factors that enhance or reduce MBC's utility within HBPC.

CLINICAL IMPLICATIONS

HBPC MH providers identified MBC as a useful tool particularly when adapted to meet the needs of HBPC Veterans.

Effectiveness of information and communication technology-based integrated care for older adults: a systematic review and meta-analysis

Background

Information and communication technology (ICT) is a key factor in advancing the implementation of integrated care for older adults in the context of an aging society and the normalization of epidemics. This systematic review aims to comprehensively evaluate the effectiveness of ICT-based integrated care for older adults to provide input for the construction of intelligent integrated care models suitable for the context of an aging population in China.

Methods

A systematic review and meta-analysis were conducted using PubMed, Web of Science Core Collection, Scopus, MEDLINE, EBSCO, EMBASE, CINAHL with full text, ProQuest, and Cochrane Library databases, along with the Google Scholar search engine, for papers published between January 1, 2000, and July 25, 2022, to include randomized controlled trials and quasi-experimental studies of ICT-based integrated care for older adults. Two reviewers independently performed literature screening, quality assessment (JBI standardized critical appraisal tool), and data extraction. The results were pooled using a random effects model, and narrative synthesis was used for studies with insufficient outcome data.

Results

We included 32 studies (21 interventions) with a total of 30,200 participants (14,289 in the control group and 15,911 in the intervention group). However, the quality of the literature could be improved. The meta-analysis results showed that ICT-based integrated care significantly improved the overall perceived health status of older adults (n=3 studies, MD 1.29 (CI 0.11 to 2.46), no heterogeneity) and reduced the number of emergency department visits (n=11 studies, OR 0.46 (CI 0.25 to 0.86), high heterogeneity) but had no significant effect on improving quality of life, mobility, depression, hospital admissions and readmissions, or mortality in older adults, with a high degree of study heterogeneity. Narrative analysis showed that the overall quality of care, primary care service use, and functional status of older adults in the intervention group improved, but the cost-effectiveness was unclear.

Conclusions

ICT-based integrated care is effective in improving health outcomes for older adults, but the quality and homogeneity of the evidence base need to be improved. Researchers should develop intelligent integrated care programs in the context of local health and care welfare provision systems for older adults, along with the preferences and priorities of the older adults.

DementiaNet facilitates a sustainable transition toward integrated primary dementia care: A long-term evaluation

INTRODUCTION

Care integration is a promising strategy to achieve sustainable health-care systems. With DementiaNet, a 2-year program, we facilitated collaboration between primary health-care professionals. We studied changes in primary dementia care integration during and after DementiaNet participation.

METHODS

A longitudinal follow-up study was performed. Networks started between 2015 and 2020; follow-up ended in 2021. Quantitative and quantitative data were collected annually to assess quality of care, network collaboration, and number of crisis admissions. Growth modeling was used to identify changes over time.

RESULTS

Thirty-five primary care networks participated. Network collaboration and quality of care of newly formed networks increased significantly in the first 2 years (respectively, 0.35/year, P < .001; 0.29/year, P < .001) and thereafter stabilized.

CONCLUSION

Primary care networks improved their collaboration and quality of care during DementiaNet participation, which persisted after the program ended. This indicates that DementiaNet facilitated a sustainable transition toward integrated primary dementia care.

Information and Communication Technology Based Integrated Care for Older Adults: A Scoping Review

Background

Integrated care is an important initiative to respond positively to the ageing of society and information and communication technology(ICT) plays an important role in facilitating the integration of functional and normative health and social care. The scoping review aims to synthesize evidence on the experience and practice of ICT-based implementation of integrated care for older adults.

Methods

This study followed the research framework developed by Arksey and O'malley for the scoping review and systematically searched for relevant studies published between 1 January 2000 and 30 March 2022 from nine electronic databases, three specialist journals, three key institutional websites, 11 integrated care project websites, google scholar and references of the studies to be included. Two reviewers independently screened and extracted data and used thematic analysis to sort out and summarize the core elements, hindrances and facilitators of ICT-based integrated care.

Results

A total of 77 studies were included in this study, including 36 ICT-based practice models of integrated care with seven core elements of implementation including single entry point, comprehensive geriatric assessment, personalized care planning, multidisciplinary case conferences, coordinated care, case management and patient empowerment, which generally had a positive effect on improving quality of life, caregiver burden and primary care resource utilization for older adults, but effectiveness evaluations remained Heterogeneity exists. The barriers and facilitators to ICT-based implementation of integrated care were grouped into four themes: demand-side factors, provider factors, technology factors and system factors.

Conclusion

The implementation of ICT-based integrated care for the elderly is expected to improve the health status of both the supply and demand of services, but there is still a need to strengthen the supply of human resources, team training and collaboration, ICT systems and financial support in order to promote the wider use of ICT in integrated care.

Components and Outcomes in Under- and Postgraduate Medical Education to Prepare for the Delivery of Integrated Care for the Elderly: A Scoping Review

Introduction

The ageing society requires physicians who can deliver integrated care, but it is unclear how they should be prepared for doing so. This scoping review aims to create an overview of educational programmes that prepare (future) physicians to deliver integrated care while addressing components and outcomes of the interventions.

Method

We included papers from five databases that contained: (1) integrated care (2) education programme (3) medical students (4) elderly, or synonyms. We divided the WHO definition of integrated care into ten components for the concept of 'integrated care'. Data were collected with a charting template, and template analysis was used to formulate themes.

Results

We found 17 educational programmes in different learning settings. All programmes addressed several components of the WHO definition. The programmes primarily focused on care for individual patients (micro-level), and the outcomes suggested that experiencing the complexity of care is key.

Conclusion

This review revealed the limited evidence on educational programmes about integrated care for the elderly. Our findings suggest that educational programmes on integrated care should not be limited to the micro-level, and that students should obtain adaptive expertise by experiencing complexity. Future research should contain an explicit description and definition of integrated care.

Factors and Mechanism Influencing Client Experience of Residential Integrated Health and Social Care for Older People: A Qualitative Model in Chinese Institutional Settings

BACKGROUND

An emerging service delivery model of integrating health and social care for older people has been actively promoted by the Chinese government since 2016, but the client experience and influencing mechanism still remain unclear.

METHODS

this study adopts a qualitative methodology to delve deeper into the factors and mechanism shaping the client experience of residential integrated health and social care for older people in the Chinese context, so as to understand the experiences of older residents during the whole process of receiving integrated care services, and on this basis, put forward suggestions for the improvement of a high-quality aged care service system. We coded and analyzed the in-depth interview data of twenty older adults and six staff members from June 2019 to February 2020, recruited from six institutions in Changsha, one of the ninety pilot cities for integrated health and social care in China.

RESULTS

the findings showed that the client experience of older adults is mainly affected by factors in three dimensions (scene construction, individual minds, and interaction and communication), which are comprised of six sub-categories (social foundation, institutional functions, perception and emotion, cognition and understanding, intimacy and trust, and participation). Based on the factors and mechanism (consisting of six influencing paths), we constructed a model of the client experience of integrated health and social care for older people in the Chinese population.

CONCLUSIONS

the factors and mechanism influencing the client experience of integrated health and social care for older people are complex and multifaceted. Attention should be paid to the direct effects of perception and emotion, institutional functions, intimacy and trust in the client experience, and the indirect effects of social foundation and participation on the client experience.

Integrated Care for Older People with Different Frailty Levels: A Qualitative Study of Local Implementation of a National Policy in Luton, England

Introduction

The NHS England General Medical Services 2017-18 contract made it mandatory for general practices in England to identify and manage older people proactively. In response to the national policy, the Luton Framework for Frailty (LFF) programme was developed to target older residents of Luton and offer interventions according to their frailty level. The aim of this study was to gain a deeper understanding of the LFF and the factors that affect the implementation of a proactive integrated care service for older people with different frailty levels (OPDFL).

Methods

We undertook document analyses and conducted semi-structured interviews with stakeholders to create a 'thick description' that provides insights into the LFF.

Results

Healthy ageing interventions bring beneficial outcomes but to increase the uptake they should be co-produced with older people. A common electronic system within primary care and multidisciplinary team meetings (MDT) aid implementation. However, variation in implementation across Luton, different levels of buy-in for MDT, and different data systems in primary and secondary care make implementation challenging.

Conclusion

The LFF is a promising initiative and lessons learned are likely to be transferable to other settings as proactive management of frailty takes on greater policy prominence in the UK and worldwide.

Construct Validation of the Rainbow Model of Integrated Care Measurement Tool in Dutch Primary Care for Older Adults

Introduction

Care integration in primary elderly care is suboptimal. Validated instruments are needed to enable the implementation of integrated primary care. We aimed to assess construct validity of the Rainbow Model of Integrated Care measurement tool (RMIC-MT) for healthcare professionals working in an integrated primary elderly care setting in the Netherlands.

Methods

In a cross-sectional study, the RMIC-MT, a 36-item questionnaire covering all domains of the Rainbow Model of Integrated Care (RMIC), was sent out to local networks of primary elderly care professionals. Confirmatory factor analysis with maximum likelihood estimation was used for the validation of the factor structure of the RMIC-MT. Model fit was assessed by the chi-square test and fit indices.

Results

The RMIC-MT was completed by 323 professionals, primarily general practitioners, community nurses, practice nurses, and case managers. Confirmatory factor analysis and corresponding fit indices showed moderate to good fit, thereby confirming a nine factor model with a total of 36 items.

Conclusions

The RMIC-MT is promising for the primary elderly care setting in the Netherlands. It can be used for evaluating integrated care initiatives in a primary care setting, thereby contributing to implementation of integrated primary elderly care.

Older Adults' Demand for Community-Based Adult Services (CBAS) Integrated with Medical Care and Its Influencing Factors: A Pilot Qualitative Study in China

INTRODUCTION

The number of older people in China who require formal care is increasing. In response, China is creating a service delivery mode of health and social care combination for older people-community-based adult services (CBAS) integrated with medical care-in some provincial capital cities, such as Changsha. However, the needs of most older people for this service delivery mode are not well understood.

AIM

To assess older people's awareness of and demand for CBAS integrated with medical care and to determine influencing factors.

METHODS

Semi-structured guideline interviews were conducted with 20 older people (aged 65+ years) from two communities at different economic development levels and from a nursing home in Changsha, China. Interviews were analyzed using qualitative content analysis.

RESULTS

The specific needs that older adults expect from CBAS integrated with medical care involve daily care, primary care, self-management guidance, rehabilitation therapy services, and mental health services. Contrary to expectations, most interviewees showed low awareness of and demand for CBAS integrated with medical care. Individual, family, and community factors influence older people's demand, as do exogenous variables such as gender and number of children.

DISCUSSION

The influencing mechanism of older people's demand for CBAS integrated with medical care is complex and multifaceted. To implement and promote CBAS integrated with medical care, attention should be given to older people's individual needs, family backgrounds and community environment improvement. Furthermore, improving awareness of integrated care and increasing ageing-in-place opportunities for more older adults is essential and urgent.

Protocol for a mixed-methods and multi-site assessment of the implementation process and outcomes of a new community-based frailty programme

Background

Frailty is increasing in prevalence internationally with population ageing. Frailty can be managed or even reversed through community-based interventions delivered by a multi-disciplinary team of professionals, but to varying degrees of success. However, many of these care models’ implementation insights are contextual and may not be applicable in different cultural contexts. The Geriatric Service Hub (GSH) is a novel frailty care model in Singapore that focuses on identifying and managing frailty in the community. It includes key components of frailty care such as comprehensive geriatric assessments, care coordination and the assembly of a multi-disciplinary team. This study aims to gain insights into the factors influencing the development and implementation of the GSH. We also aim to determine the programme’s effectiveness through patient-reported health-related outcomes. Finally, we will conduct a healthcare utilisation and cost analysis using a propensity score-matched comparator group.

Methods

We will adopt a mixed-methods approach that includes a qualitative evaluation among key stakeholders and participants in the programme, through in-depth interviews and focus group discussions. The main topics covered include factors that affected the development and implementation of each programme, operations and other contextual factors that influenced implementation outcomes. The quantitative evaluation monitors each programme’s care process through quality indicators. It also includes a multiple-time point survey study to compare programme participants’ pre- and post- outcomes on patient engagement, healthcare services experiences, health status and quality of life, caregiver burden and societal costs. A retrospective cohort study will compare healthcare and cost utilisation between participants of the programme and a propensity score-matched comparator group.

Discussion

The GSH sites share a common goal to increase the accessibility of essential services to frail older adults and provide comprehensive care. This evaluation study will provide invaluable insights into both the process and outcomes of the GSH and inform the design of similar programmes targeting frail older adults.

Trial Registration

ClinicalTrials.gov Identifier NCT04866316. Date of Registration April 26, 2021. Retrospectively registered.

Older Adults' Demand for Integrated Care and Its Influencing Factors: A Scoping Review

Introduction:

Integration has become a major concern for governments, healthcare and aged care systems in many countries. However, the research on and implementation of integrated care in China started relatively late, and there is no review on the needs of older adults with regard to integrated care and the influencing factors. Therefore, this paper aims to provide a scoping review by searching, evaluating, and summarizing the Chinese and international literature on the need for and the factors influencing integrated care for older people. In addition, this review highlights evidence of the gap between China and the world in integrated care.

Methods:

Using a framework proposed by Arksey and O’Malley, a systematic search of 12 domestic and international databases was conducted. Of the 890 original studies retrieved, those that met the established inclusion criteria were screened and scored using the Ekman quality assessment tool. The qualitative description method was used to summarize the demand for integrated care for older adults and the influencing factors.

Results:

A total of 49 papers were included. These studies were from eleven countries on five continents (most commonly China and the US) and were mostly cross-sectional quantitative studies that surveyed the integrated care needs of older people living in homes/communities or long-term care facilities. The analysis shows that existing research on the integrated care needs of older people in China adopts a single perspective and is inadequate and unsystematic in its assessment; the integrated care needs of older adults and the factors influencing them are multifaceted; and both in China and internationally, the community-home care scenario most consistently meets the needs and expectations of older adults.

Conclusion:

Although there is no uniform definition of integrated care in China or abroad and each country has its own national definition and system of integrated care, there are certain commonalities regarding the needs of older adults and the factors that influence them across countries. Our research reveals a gap between China and the international community in terms of integrated care.

Compromised intestinal integrity in older adults during daily activities: a pilot study

BACKGROUND

Malnutrition is a common and significant problem in older adults. Insight into factors underlying malnutrition is needed to develop strategies that can improve the nutritional status. Compromised intestinal integrity caused by gut wall hypoperfusion due to atherosclerosis of the mesenteric arteries in the aging gastrointestinal tract may adversely affect nutrient uptake. The presence of compromised intestinal integrity in older adults is not known. The aim of this study is to provide a proof-of-concept that intestinal integrity is compromised in older adults during daily activities.

METHODS

Adults aged ≥75 years living independently without previous gastrointestinal disease or abdominal surgery were asked to complete a standardized walking test and to consume a standardized meal directly afterwards to challenge the mesenteric blood flow. Intestinal fatty acid-binding protein (I-FABP) was measured as a plasma marker of intestinal integrity, in blood samples collected before (baseline) and after the walking test, directly after the meal, and every 15 min thereafter to 75 min postprandially.

RESULTS

Thirty-four participants (median age 81 years; 56% female) were included. Of the participants, 18% were malnourished (PG-SGA score ≥ 4), and 32% were at risk of malnutrition (PG-SGA score, 2 or 3). An I-FABP increase of ≥50% from baseline was considered a meaningful loss of intestinal integrity and was observed in 12 participants (35%; 8 females; median age 80 years). No significant differences were observed in either baseline characteristics, walking test scores, or calorie/macronutrient intake between the groups with and without a ≥ 50% I-FABP peak.

CONCLUSION

This study is first to indicate that intestinal integrity is compromised during daily activities in a considerable part of older adults living independently.

Can integrated care improve the efficiency of hospitals? Research based on 200 Hospitals in China

Background

The shift towards integrated care (IC) represents a global trend towards more comprehensive and coordinated systems of care, particularly for vulnerable populations, such as the elderly. When health systems face fiscal constraints, integrated care has been advanced as a potential solution by simultaneously improving health service effectiveness and efficiency. This paper addresses the latter. There are three study objectives: first, to compare efficiency differences between IC and non-IC hospitals in China; second, to examine variations in efficiency among different types of IC hospitals; and finally, to explore whether the implementation of IC impacts hospital efficiency.

Methods

This study uses Data Envelopment Analysis (DEA) to calculate efficiency scores among a sample of 200 hospitals in H Province, China. Tobit regression analysis was performed to explore the influence of IC implementation on hospital efficiency scores after adjustment for potential confounding. Moreover, the association between various input and output variables and the implementation of IC was investigated using regression techniques.

Results

The study has four principal findings: first, IC hospitals, on average, are shown to be more efficient than non-IC hospitals after adjustment for covariates. Holding output constant, IC hospitals are shown to reduce their current input mix by 12% and 4% to achieve optimal efficiency under constant and variable returns-to-scale, respectively, while non-IC hospitals have to reduce their input mix by 26 and 20% to achieve the same level of efficiency; second, with respect to the efficiency of each type of IC, we show that higher efficiency scores are achieved by administrative and virtual IC models over a contractual IC model; third, we demonstrate that IC influences hospitals efficiency by impacting various input and output variables, such as length of stay, inpatient admissions, and staffing; fourth, while bed density per nurse was positively associated with hospital efficiency, the opposite was shown for bed density per physician.

Conclusions

IC has the potential to promote hospital efficiency by influencing an array of input and output variables. Policies designed to facilitate the implementation of IC in hospitals need to be cognizant of the complex way IC impacts hospital efficiency.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12962-021-00314-3.

Evaluating Large-Scale Integrated Care Projects: The Development of a Protocol for a Mixed Methods Realist Evaluation Study in Belgium

BACKGROUND

The twelve Integrated Care Program pilot projects (ICPs) created by the government plan 'Integrated Care for Better Health' aim to achieve four outcome types (the Quadruple Aim) for people with chronic diseases in Belgium: improved population health, improved patient and provider experiences and improved cost efficiency. The aim of this article is to present the development of a mixed methods realist evaluation of this large-scale, whole system change programme.

METHODS

A scientific team was commissioned to co-design and implement an evaluation protocol in close collaboration with the government, the ICPs and several other involved stakeholders.

RESULTS

A protocol for a mixed methods realist evaluation was developed to gain insights into the mechanisms that foster successful results in ICPs. The qualitative evaluation proposed will be based on the document analysis of yearly ICP progress reports, selected case studies and focus group interviews with stakeholders. Processes and outcomes of all the projects will be monitored using indicators based on administrative data on population health and the quality and costs of care. A yearly survey will be organized to collect data on patient-reported outcomes and experiences and on provider-reported measures of inter-professional collaboration and proper wellbeing. Using both quantitative and qualitative data, we will develop theories about the mechanisms and the associated contextual factors that lead to integrated care and the Quadruple Aim outcomes.

DISCUSSION

The objective of this study is to deliver policy recommendations on strategies and best practices to improve care integration in Belgium and to implement a sustainable monitoring system that serves both policy makers and the stakeholders within the ICPs. Some challenges due to the large scale of the project and the multiple stakeholders involved may impede the successful implementation of this proposal.

A systematic review on implementation of person-centered care interventions for older people in out-of-hospital settings

THE PURPOSE

of this study was to explore the content and essential components of implemented person-centered care in the out-of-hospital context for older people (65+).

METHOD

A systematic review was conducted, searching for published research in electronic databases: PubMed, CINAHL, Scopus, PsycInfo, Web of Science and Embase between 2017 and 2019. Original studies with both qualitative and quantitative methods were included and assessed according to the quality assessment tools EPHPP and CASP. The review was limited to studies published in English, Swedish, Danish, Norwegian and Spanish.

RESULTS

In total, 63 original articles were included from 1772 hits. The results of the final synthesis revealed the following four interrelated themes, which are crucial for implementing person-centered care: (1) Knowing and confirming the patient as a whole person; (2) Co-creating a tailored personal health plan; (3) Inter-professional teamwork and collaboration with and for the older person and his/her relatives; and (4) Building a person-centered foundation.

CONCLUSION

Approaching an interpersonal and inter-professional teamwork and consultation with focus on preventive and health promoting actions is a crucial prerequisite to co-create optimal health care practice with and for older people and their relatives in their unique context.

Integrated Care for Older Adults: A Struggle for Sustained Implementation in Northern Netherlands

Introduction:

Integrated care has been suggested as a promising solution to the disparities in access and sustained high quality long-term care emerging in Europe’s ageing population. We aim to gain a better understanding of context-specific barriers to and facilitators of implementation of integrated care by doing a retrospective assessment of seven years of Embrace. This Dutch integrated person-centred health service for older adults was based on two evidence-based models (the Chronic Care Model and the Kaiser Permanente Triangle). Despite successful deployment the programme ended in 2018. In this case study we assess the impact of the programme based on past evaluations, reflect on why it ended, lessons learned and ideas to take forward.

Discussion:

The majority of health outcomes were positive and the perceived quality of care improved, albeit no clear-cut savings were observed, and the costs were not balanced across stakeholders. The Embrace payment model did not support the integration of health services, despite reforms in long-term care in 2015.

Key lessons:

Enabling policy and funding are crucial to the sustained implementation of integrated person-centred health services. The payment model should incentivize the integration of care before the necessary changes can be made at organizational and clinical levels towards providing proactive and preventive health services.

Self-reported oral health problems and the ability to organize dental care of community-dwelling elderly aged ≥75 years

Background

It is unclear how many community-dwelling elderly (≥75 years) experience oral health problems (e.g. pain, dry mouth, chewing problems) and how they manage their dental care needs. This study aimed to assess self-reported oral health problems in elderly who are frail or have complex care needs, and their ability to organize dental care when reporting oral pain.

Methods

Three thousand five hundred thirty-three community-dwelling elderly participating in the “Embrace” project were asked to complete questionnaires regarding oral status and oral health problems. Frailty was assessed with the Groningen Frailty Indicator (GFI). Intermed for Elderly Self-Assessment (IM-E-SA) was used to determine complexity of care needs. Next, elderly who reported oral pain were interviewed about their oral pain complaints, their need for dental care, and their ability to organize and receive dental care. For statistical analyses Chi²-tests and the one-way ANOVA were used.

Results

One thousand six hundred twenty-two elderly (45.9%) completed the questionnaires. Dry mouth (11.7%) and oral pain (6.2%) were most frequently reported. Among the elderly reporting oral pain, most were registered at a local dentist and could go there when needed (84.3%). Robust elderly visited the dentist independently (87%), frail (55.6%) and complex (26.9%) elderly more often required assistance from caregivers.

Conclusions

Dry mouth and oral pain are most reported oral health problems among community-dwelling elderly. Elderly with complex care needs report most oral health problems. In case an elderly seeks dental treatment to alleviate an oral pain complaint, most elderly in this study were able to organize dental care and transport to the dentist. Frail and complex elderly often need assistance from caregivers to visit the dentist. Therefore caretakers should keep in mind that when frailty progresses, visiting a dentist may become more and more difficult and the risk for poor oral health increases.

Addressing safety risks in integrated care programs for older people living at home: a scoping review

BACKGROUND

Many older people live at home, often with complex and chronic health and social care needs. Integrated care programs are increasingly being implemented as a way to better address these needs. To support older people living at home, it is also essential to maintain their safety. Integrated care programs have the potential to address a wide range of risks and problems that could undermine older people's ability to live independently at home. The aim of this scoping review is to provide insight into how integrated care programs address safety risks faced by older people living at home - an area that is rather underexplored.

METHODS

Safety was conceptualised as preventing or reducing the risk of problems, associated with individual functioning and behaviour, social and physical environments, and health and social care management, which could undermine older people's ability to live independently at home. For this scoping review a systematic literature search was performed to identify papers describing integrated care programs where at least one intervention component addressed safety risks. Data were extracted on the programs' characteristics, safety risks addressed, and the activities and interventions used to address them.

RESULTS

None of the 11 programs included in this review explicitly mentioned safety in their goals. Nevertheless, following the principles of our conceptual framework, the programs appeared to address risks in multiple domains. Most attention was paid to risks related to older people's functioning, behaviour, and the health and social care they receive. Risks related to people's physical and social environments received less attention.

CONCLUSION

Even though prevention of safety risks is not an explicit goal of integrated care programs, the programs address a wide range of risks on multiple domains. The need to address social and environmental risks is becoming increasingly important given the growing number of people receiving care and support at home. Prioritising a multidimensional approach to safety in integrated care programs could enhance the ability of health and social care systems to support older people to live safely at home.

Caring for the elderly: A person-centered segmentation approach for exploring the association between health care needs, mental health care use, and costs in Germany

BACKGROUND

Person-centered care demands the evaluation of needs and preferences of the patients. In this study, we conducted a segmentation analysis of a large sample of older people based on their bio-psycho-social-needs and functioning. The aim of this study was to clarify differences in health care use and costs of the elderly in Germany.

METHODS

Data was derived from the 8-year follow-up of the ESTHER study-a German epidemiological study of the elderly population. Trained medical doctors visited n = 3124 participants aged 57 to 84 years in their home. Bio-psycho-social health care needs were assessed using the INTERMED for the Elderly (IM-E) interview. Further information was measured using questionnaires or assessment scales (Barthel index, Patients Health Questionnaire (PHQ) etc.). The segmentation analysis applied a factor mixture model (FMM) that combined both a confirmatory factor analysis and a latent class analysis.

RESULTS

In total, n = 3017 persons were included in the study. Results of the latent class analysis indicated that a five-cluster-model best fit the data. The largest cluster (48%) can be described as healthy, one cluster (13.9%) shows minor physical complaints and higher social support, while the third cluster (24.3%) includes persons with only a few physical and psychological difficulties ("minor physical and psychological complaints"). One of the profiles (10.5%) showed high and complex bio-psycho-social health care needs ("complex needs") while another profile (2.5%) can be labelled as "frail". Mean values of all psychosomatic variables-including the variable health care costs-gradually increased over the five clusters. Use of mental health care was comparatively low in the more burdened clusters. In the profiles "minor physical and psychological complaints" and "complex needs", only half of the persons suffering from a mental disorder were treated by a mental health professional; in the frail cluster, only a third of those with a depression or anxiety disorder received mental health care.

CONCLUSIONS

The segmentation of the older people of this study sample led to five different clusters that vary profoundly regarding their bio-psycho-social needs. Results indicate that elderly persons with complex bio-psycho-social needs do not receive appropriate mental health care.

Effects Of Increasing The Involvement Of Community-Dwelling Frail Older Adults In A Proactive Assessment Service: A Pragmatic Trial

BACKGROUND

Older adults and care professionals advocate a more integrated and proactive care approach. This can be achieved by proactive outpatient assessment services that offer comprehensive geriatric assessments to better understand the needs of older adults and deliver person-centered and preventive care. However, the effects of these services are inconsistent. Increased involvement of the older adult during the assessment service could increase the effects on older adult's well-being.

METHODS

We studied the effect of an assessment service (Sage-atAge) for community-dwelling frail adults aged ≥65 years. After studying the local experiences, this service was adapted with the aim to increase participant involvement through individual goal setting and using motivational interviewing techniques by health-care professionals (Sage-atAge+). Within Sage-atAge+, when finishing the assessment, a "goal card" was written together with the older adult: a summary of the assessment, including goals and recommendations. We measured well-being with a composite endpoint consisting of health, psychological, quality of life, and social components. With regression analysis, we compared the effects of the Sage-atAge and Sage-atAge+ services on the well-being of participants.

RESULTS

In total, 453 older adults were eligible for analysis with a mean age of 77 (± 7.0) years of whom 62% were women. We found no significant difference in the change in well-being scores between the Sage-atAge+ service and the original Sage-atAge service (B, 0.037; 95% CI, -0.188 to 0.263). Also, no change in well-being scores was found even when selecting only those participants for the Sage-atAge+ group who received a goal card.

CONCLUSION

Efforts to increase the involvement of older adults through motivational interviewing and goal setting showed no additional effect on well-being. Further research is needed to explore the relationship between increased participant involvement and well-being to further develop person-centered care for older adults.

Integrated Care for Frail Elderly: A Qualitative Study of a Promising Approach in The Netherlands

INTRODUCTION

Increasingly, frail elderly need to live at home for longer, relying on support from informal caregivers and community-based health- and social care professionals. To align care and avoid fragmentation, integrated care programmes are arising. A promising example of such a programme is the Care Chain Frail Elderly (CCFE) in the Netherlands, which supports elderly with case and care complexity living at home with the best possible health and quality of life. The goal of the current study was to gain a deeper understanding of this programme and how it was successfully put into practice in order to contribute to the evidence-base surrounding complex integrated care programmes for persons with multi-morbidity.

METHODS

Document analyses and semi-structured interviews with stakeholders were used to create a 'thick description' that provides insights into the programme.

RESULTS

Through case finding, the CCFE-programme targets the frailest primary care population. The person-centred care approach is reflected by the presence of frail elderly at multidisciplinary team meetings. The innovative way of financing by bundling payments of multiple providers is one of the main facilitators for the success of this programme. Other critical success factors are the holistic assessment of unmet health and social care needs, strong leadership by the care groups, close collaboration with the healthcare insurer, a shared ICT-system and continuous improvements.

CONCLUSION

The CCFE is an exemplary initiative to integrate care for the frailest elderly living at home. Its innovative components and critical success factors are likely to be transferable to other settings when providers can take on similar roles and work closely with payers who provide integrated funding.

Comprehensive geriatric assessments in integrated care programs for older people living at home: A scoping review

In many integrated care programs, a comprehensive geriatric assessment (CGA) is conducted to identify older people's problems and care needs. Different ways for conducting a CGA are in place. However, it is still unclear which CGA instruments and procedures for conducting them are used in integrated care programs, and what distinguishes them from each other. Furthermore, it is yet unknown how and to what extent CGAs, as a component of integrated care programs, actually reflect the main principles of integrated care, being comprehensiveness, multidisciplinarity and person-centredness. Therefore, the objectives of this study were to: (a) describe and compare different CGA instruments and procedures conducted within integrated care programs for older people living at home, and (b) describe how the principles of integrated care were applied in these CGAs. A scoping review of the scientific literature on CGAs in the context of integrated care was conducted for the period 2006-2018. Data were extracted on main characteristics of the identified CGA instruments and procedures, and on how principles of integrated care were applied in these CGAs. Twenty-seven integrated care programs were included in this study, of which most were implemented in the Netherlands and the United States. Twenty-one different CGAs were identified, of which the EASYcare instrument, RAI-HC/RAI-CHA and GRACE tool were used in multiple programs. The majority of CGAs seemed to reflect comprehensiveness, multidisciplinarity and person-centredness, although the way and extent to which principles of integrated care were incorporated differed between the CGAs. This study highlights the high variability of CGA instruments and procedures used in integrated care programs. This overview of available CGAs and their characteristics may promote (inter-)national exchange of CGAs, which could enable researchers and professionals in choosing from the wide range of existing CGAs, thereby preventing them from unnecessarily reinventing the wheel.

Impact of Integrated Care on Patient-Related Outcomes Among Older People - A Systematic Review

Introduction

The growing number of older adults with multiple needs increases the pressure to reform existing healthcare systems. Integrated care may be part of such reforms. The aim of this systematic review was to identify important patient-related outcomes of integrated care provided to older adults.

Methods

A systematic search of 5 databases to identify studies comprising older adults assessing hospital admission, length of hospital stay, hospital readmission, patient satisfaction and mortality in integrated care settings. Retrieved literature was analysed employing a narrative synthesis.

Results

Twelve studies were included (2 randomised controlled trials, 7 quasi-experimental design, 2 comparison studies, 1 survey evaluation). Five studies investigated patient satisfaction, 9 hospital admission, 7 length of stay, 3 readmission and 5 mortality. Findings show that integrated care tends to have a positive impact on hospital admission rates, some positive impact on length of stay and possibly also on readmission and patient satisfaction but not on mortality.

Conclusions

Integrated care may reduce hospital admission rates and lengths of hospital stay. However due to lack of robust findings, the effectiveness of integrated care on patient-related outcomes in later life remain largely unknown. Further research is needed to establish the effect of integrated care on these patient-related outcomes.

Prospero registration number

CRD42018110491.

Health-Related Problems and Changes After 1 Year as Assessed With the Geriatric ICF Core Set (GeriatrICS) in Community-Living Older Adults Who Are Frail Receiving Person-Centered and Integrated Care From Embrace

OBJECTIVE

To assess the prevalence, severity, and change in health-related problems in a sample of older adults who received individual care and support from Embrace, for the whole sample, per subgroup based on complexity of care needs and frailty, and for those who had at baseline a health-related problem.

DESIGN

A pretest-posttest study with assessments at baseline and after 12 months.

SETTING

Community.

PARTICIPANTS

Older adults aged 75 years and older (N=136) who are frail (n=56) or who have complex care needs (n=80).

INTERVENTION

Participants received care and support by Embrace, a person-centered and integrated care service for community-living older adults supporting them to age in place. A multidisciplinary team provided care and support, with intensity depending on the older adults' risk profile.

MAIN OUTCOME MEASURE

Health-related problems as perceived by older adults and measured with the Geriatric International Classification of Functioning, Disability and Health Core Set.

RESULTS

Health-related problems were related to 6 coherent clusters: (1) Mental Functions; (2) Physical Health; (3) Mobility; (4) Personal Care; (5) Nutrition; and (6) Support. The most prevalent and most severe problems at baseline were related to Mental Functions and Mobility. Changes in the prevalence of problems after 12 months varied. Severity scores decreased or remained stable, except for Mobility items which showed a varying changing pattern in participants with complex care needs. Prevalence and severity of problems for those with a problem at baseline decreased after 12 months. Frail participants with a problem had higher baseline severity scores than those with complex care needs experiencing a problem, but differences in changes between individuals who are frail and those with complex care needs were small.

CONCLUSIONS

The results are encouraging and may indicate that individual, person-centered and integrated care and support from Embrace offers a route to counteracting the decline in physical, cognitive and social functioning associated with aging.

Combining Integration of Care and a Population Health Approach: A Scoping Review of Redesign Strategies and Interventions, and their Impact

Background and aim:

Many health systems attempt to develop integrated and population health-oriented systems of care, but knowledge of strategies and interventions to support this effort is lacking. We aimed to identify specific redesign strategies and interventions, and to present evidence of their effectiveness.

Method:

A modified scoping review process was carried out. Fifteen relevant examples of integrated care organizations that incorporated a broad population health approach in countries of the Organization for Economic Cooperation and Development described in 57 articles and reports were included in analysis.

Results:

Seven key redesign strategies and multiple redesign interventions have been identified and are described. Most commonly used redesign strategies included focusing on health and wellness, embracing intersectoral action and partnerships, addressing health in vulnerable groups, and addressing a wide range of determinants of health, including making improvements in health services. Redesign interventions included creative and innovative ways of addressing clinical and non-clinical issues such as establishing housing surgeries in primary care, establlishing vast social and provider networks to support patients with complex needs and also broadening of the scope of services, workforce redesign and other. Potential reductions in the utilization of care and costs could be derived by the wider adoption of these strategies and interventions.

Conclusion:

Development of integrated and population health-oriented systems of care requires the redesign of how services are organized and delivered, and how organizations and care systems operate. Combining integration of care with the population health approach can be supported by a set of cohesive strategies and interventions aimed at preventing disease, addressing social determinants of health and improving health equity at both population- and individual-level.

Are Edentulousness, Oral Health Problems and Poor Health-Related Quality of Life Associated with Malnutrition in Community-Dwelling Elderly (Aged 75 Years and Over)? A Cross-Sectional Study

As the population ages, the risk of becoming malnourished increases. Research has shown that poor oral health can be a risk factor for malnutrition in institutionalized elderly. However, it remains unclear whether oral health problems, edentulousness and health-related quality of life also pose a risk for malnutrition in community-dwelling older adults. In this cross-sectional observational study, 1325 community-living elderly (≥75 years) were asked to complete questionnaires regarding nutritional status, oral status (edentulous, remaining teeth, or implant-supported overdentures), oral health problems, health-related quality of life (HRQoL), frailty, activities of daily living (ADL) and complexity of care needs. Univariate and multivariate logistic regression analyses were performed with nutritional status as dependent variable. Of the respondents, 51% (n = 521) were edentulous, 38.8% (n = 397) had remaining teeth and 10.2% (n = 104) had an implant-supported overdenture. Elderly with complex care needs were malnourished most frequently, followed by frail and robust elderly (10%, 4.5% and 2.9%, respectively). Malnourished elderly reported more frequent problems with chewing and speech when compared with well-nourished elderly (univariate analysis). However, multivariate analysis did not show an association between malnutrition and oral health problems and edentulousness, although HRQoL was associated with malnutrition (odds ratio (OR) 0.972, confidence interval (CI) 0.951–0.955). Based on the results of this cross-sectional study, it can be concluded that poor HRQoL is significantly associated with malnutrition; however, edentulousness and oral health problems are not.

The effectiveness of patient-centred medical home model versus standard primary care in chronic disease management: protocol for a systematic review and meta-analysis of randomised and non-randomised controlled trials

BACKGROUND

Studies suggest that the Patient-Centred Medical Home (PCMH) model of primary care is more effective than standard care for improving clinical outcomes in patients with chronic diseases (non-communicable diseases), but the strength of the evidence base is unclear. The aim of the proposed systematic review is to generate a current synthesis of relevant studies on the effectiveness of PCMH model of primary care versus standard care in chronic disease management.

METHODS

Electronic databases such as MEDLINE, CINAHL, Embase, Cochrane Library, and Scopus will be searched using predefined search terms for PCMH, primary care, and chronic diseases for articles published up to November 2018. Reference lists of included articles and relevant reviews will also be hand searched. This review will consider eligible randomised controlled trials and controlled trials against predetermined criteria including two or more principles of PCMH model endorsed by Australian Medical Association. Data extraction will be performed independently by two reviewers, and retrieved papers will be assessed for quality using JBI Critical Appraisal Tools. Where possible, quantitative data will be pooled in statistical meta-analysis using the R packages 'Meta' and 'metafor'. Effect sizes will be expressed as odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for meta-analysis; robustness will be explored using sensitivity analysis. Heterogeneity will be assessed narratively and statistically using the Q statistics and visualised using Baujat plots including subgroup or sensitivity analyses techniques where possible. Where statistical pooling is not possible, the findings will be presented narratively.

DISCUSSION

The findings of the proposed systematic review will provide the highest level of evidence to date on the effectiveness of the PCMH model versus standard primary care in chronic disease management. We believe that our findings will inform patients, primary care providers, and public health administrators and policy-makers on the benefits and risks of PCMH model of care.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018085378.

Experiences of case managers in providing person-centered and integrated care based on the Chronic Care Model: A qualitative study on embrace

Background

Due to the rise in the number of older adults within the population, healthcare demands are changing drastically, all while healthcare expenditure continues to grow. Person-centered and integrated-care models are used to support the redesigning the provision of care and support. Little is known, however, about how redesigning healthcare delivery affects the professionals involved.

Objectives

To explore how district nurses and social workers experience their new professional roles as case managers within Embrace, a person-centered and integrated-care service for community-living older adults.

Methods

We performed a qualitative study consisting of in-depth interviews with case managers (district nurses, n = 6; social workers, n = 5), using a topic-based interview guide. Audiotaped interviews were transcribed verbatim and analyzed using qualitative content analysis.

Results

The experiences of the case managers involved four major themes: 1) the changing relationship with older adults, 2) establishing the case-manager role, 3) the case manager’s toolkit, and 4) the benefits of case management. Within these four themes, subthemes addressed the shift to a person-centered approach, building a relationship of trust, the process of case management, knowledge and experience, competencies of and requirements for case managers, and the differences in professional background.

Discussion

We found that this major change in role was experienced as a learning process, one that provided opportunities for personal and professional growth. Case managers felt that they were able to make a difference, and found their new roles satisfying and challenging, although stressful at times. Ongoing training and support were found to be a prerequisite in helping to shift the focus towards person-centered and integrated care.

Effectiveness and cost-effectiveness of proactive and multidisciplinary integrated care for older people with complex problems in general practice: an individual participant data meta-analysis

Purpose

to support older people with several healthcare needs in sustaining adequate functioning and independence, more proactive approaches are needed. This purpose of this study is to summarise the (cost-) effectiveness of proactive, multidisciplinary, integrated care programmes for older people in Dutch primary care.

Methods design

individual patient data (IPD) meta-analysis of eight clinically controlled trials.

Setting

primary care sector.

Interventions

combination of (i) identification of older people with complex problems by means of screening, followed by (ii) a multidisciplinary integrated care programme for those identified.

Main outcome

activities of daily living, i.e. a change on modified Katz-15 scale between baseline and 1-year follow-up.

Secondary outcomes

quality of life (visual analogue scale 0–10), psychological (mental well-being scale Short Form Health Survey (SF)-36) and social well-being (single item, SF-36), quality-adjusted life years (Euroqol-5dimensions-3level (EQ-5D-3L)), healthcare utilisation and cost-effectiveness.

Analysis

intention-to-treat analysis, two-stage IPD and subgroup analysis based on patient and intervention characteristics.

Results

included were 8,678 participants: median age of 80.5 (interquartile range 75.3; 85.7) years; 5,496 (63.3%) women. On the modified Katz-15 scale, the pooled difference in change between the intervention and control group was −0.01 (95% confidence interval −0.10 to 0.08). No significant differences were found in the other patient outcomes or subgroup analyses. Compared to usual care, the probability of the intervention group to be cost-effective was less than 5%.

Conclusion

compared to usual care at 1-year follow-up, strategies for identification of frail older people in primary care combined with a proactive integrated care intervention are probably not (cost-) effective.

Integrated and Person-Centered Care for Community-Living Older Adults: A Cost-Effectiveness Study

OBJECTIVES

To assess the cost-effectiveness of Embrace, an integrated primary care service for older adults.

DATA SOURCES

Care and support claims from health care insurers, long-term care administration, and municipalities for enrolled older adults between 2011 and 2013.

STUDY DESIGN

A total of 1,456 older adults, listed with 15 general practitioners practices in the Netherlands, were stratified into risk profiles ("Robust," "Frail," and "Complex care needs") and randomized to Embrace or care-as-usual groups. Incremental costs were calculated per quality-adjusted life year, per day able to age in place, and per percentage point risk profile improvement.

PRINCIPAL FINDINGS

Total average costs were higher for Embrace compared to care-as-usual. Differences in health-associated outcomes were small and not statistically significant. Probabilities that Embrace is cost-effective were below 80 percent, except for "risk profile improvements" within risk profile "Complex care needs." Complete case analysis resulted in smaller differences in total average costs across conditions and differences in health-associated outcomes remained small.

CONCLUSIONS

According to current standards, Embrace is not considered cost effective after 12 months. However, it could be considered worthwhile in terms of "risk profile improvements" for older adults with "Complex care needs," if society is willing to invest substantially.

Effects of a population-based, person-centred and integrated care service on health, wellbeing and self-management of community-living older adults: A randomised controlled trial on Embrace

Objective

To evaluate the effects of the population-based, person-centred and integrated care service ‘Embrace’ at twelve months on three domains comprising health, wellbeing and self-management among community-living older people.

Methods

Embrace supports older adults to age in place. A multidisciplinary team provides care and support, with intensity depending on the older adults’ risk profile. A randomised controlled trial was conducted in fifteen general practices in the Netherlands. Older adults (≥75 years) were included and stratified into three risk profiles: Robust, Frail and Complex care needs, and randomised to Embrace or care as usual (CAU). Outcomes were recorded in three domains. The EuroQol-5D-3L and visual analogue scale, INTERMED for the Elderly Self-Assessment, Groningen Frailty Indicator and Katz-15 were used for the domain ‘Health.’ The Groningen Well-being Indicator and two quality of life questions measured ‘Wellbeing.’ The Self-Management Ability Scale and Partners in Health scale for older adults (PIH-OA) were used for ‘Self-management.’ Primary and secondary outcome measurements differed per risk profile. Data were analysed with multilevel mixed-model techniques using intention-to-treat and complete case analyses, for the whole sample and per risk profile.

Results

1456 eligible older adults participated (49%) and were randomized to Embrace (n(T0) = 747, n(T1) = 570, mean age 80.6 years (SD 4.5), 54.2% female) and CAU (n(T0) = 709, n(T1) = 561, mean age 80.8 years (SD 4.7), 55.6% female). Embrace participants showed a greater–but clinically irrelevant–improvement in self-management (PIH-OA Knowledge subscale effect size [ES] = 0.14), and a greater–but clinically relevant–deterioration in health (ADL ES = 0.10; physical ADL ES = 0.13) compared to CAU. No differences in change in wellbeing were observed. This picture was also found in the risk profiles. Complete case analyses showed comparable results.

Conclusions

This study found no clear benefits to receiving person-centred and integrated care for twelve months for the domains of health, wellbeing and self-management in community-living older adults.

Unravelling complex primary-care programs to maintain independent living in older people: a systematic overview

OBJECTIVES

Complex interventions are criticized for being a "black box", which makes it difficult to determine why they succeed or fail. Recently, nine proactive primary-care programs aiming to prevent functional decline in older adults showed inconclusive effects. The aim of this study was to systematically unravel, compare, and synthesize the development and evaluation of nine primary-care programs within a controlled trial to further improve the development and evaluation of complex interventions.

STUDY DESIGN AND SETTING

A systematic overview of all written data on the nine proactive primary-care programs was conducted using a validated item list. The nine proactive primary-care programs involved 214 general practices throughout the Netherlands.

RESULTS

There was little or no focus on the (1) context surrounding the care program, (2) modeling of processes and outcomes, (3) intervention fidelity and adaptation, and (4) content and evaluation of training for interventionists.

CONCLUSIONS

An in-depth analysis of the context, modeling of the processes and outcomes, measurement and reporting of intervention fidelity, and implementation of effective training for interventionists is needed to enhance the development and replication of future complex interventions.