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

Community health services in European literature: A systematic review of their features, outcomes, and nursing contribution to care

BACKGROUND

To meet the population's needs, community care should be customized and continuous, adequately equipped, and monitored.

INTRODUCTION

Considering their fragmented and heterogeneous nature, a summary of community healthcare services described in European literature is needed. The aim of this study was to summarize their organizational models, outcomes, nursing contribution to care, and nursing-related determinants of outcomes.

METHODS

A systematic review was performed by searching PubMed, CINAHL, Scopus, and Embase in October 2022 and October 2023 (for updated results). Quantitative studies investigating the effects of community care, including nursing contribution, on patient outcomes were included and summarized. Reporting followed the PRISMA checklist. The review protocol was registered on PROSPERO (CRD42022383856).

RESULTS

Twenty-three studies describing six types of community care services were included, which are heterogeneous in terms of target population, country, interventions, organizational characteristics, and investigated outcomes. Heterogeneous services' effects were observed for access to emergency services, satisfaction, and compliance with treatment. Services revealed a potential to reduce rehospitalizations of people with long-term conditions, frail or older persons, children, and heart failure patients. Models are mainly multidisciplinary and, although staffing and workload may also have an impact on provided care, this was not enough investigated.

DISCUSSION

Community health services described in European literature in the last decade are in line with population needs and suggest different suitable models and settings according to different care needs. Community care should be strengthened in health systems, although the influence of staffing, workload, and work environment on nursing care should be investigated by developing new management models.

CONCLUSIONS AND IMPLICATIONS FOR HEALTH POLICY

Community care models are heterogeneous across Europe, and the optimum organizational structure is not clear yet. Future policies should consider the impact of community care on both health and economic outcomes and enhance nursing contributions to care.

Impact of a Pilot Project for Integrated Care on Hospitalization Rate among Older Adults in South Korea

Introduction

Since 2019, the Korean government has implemented a pilot project for integrated care to encourage healthy aging of older adults. This study investigated the changes in hospitalization rates among older adults who participated in the integrated care pilot project.

Methods

Administrative survey data collected from 13 local governments and the National Health Insurance Database were used in present study. The participants comprised 17,801 older adults who participated in the pilot project between August 01, 2019 and April 30, 2022 and 68,145 matched controls. A propensity score matching method was employed to select the control group, and this study employed difference-in-differences (DID) approach to examine variations in the hospitalization rate.

Results

The DID analysis revealed that the odds ratio for rates of hospitalization among older adults who participated in the pilot project was 0.88 (95% confidence interval [CI] 0.84, 0.91) in comparison to control group. In specifically, as compared to the control group, the odds ratio for hospitalization rates among the pilot project's discharged patients was 0.17 (95% CI 0.15, 0.20). Although not statistically significant, the odds ratio of older adults who utilized LTCI services was 0.93 (95% CI 0.83, 1.05), and the odds ratio of older adults who applied for LTCI but were rejected or were intensive social care was 1.09 (95% CI 0.95, 1.26) compared to the comparison group.

Discussion

The findings imply that the discharged patient group had greater medical demands than the other types, and it can be claimed that this is the group that may anticipate greater efficacy while using health services. In addition, the integrated care services provided by the pilot project have the effect of reducing unnecessary hospitalization such as social hospitalization.

Conclusion

Participants in the integrated care pilot project showed a lower hospitalization rate than the older adults who did not participate in the project but had similar characteristics. In particular, the admission rate of discharged patients showed a sharp decline.

Effects of integrated care with case management and nutritional counselling for frail older adults with nutritional risk in the primary care setting

BACKGROUND

The effects of integrated care with case management and nutritional counselling for frail patients with nutritional risk are unclear.

OBJECTIVES

To assess the impact of the integrated care model for frail patients with nutritional risk in the primary care setting.

METHODS

This was a retrospective observational study. We enrolled 100 prefrail or frail patients according to Clinical Frailty Scale (CFS) aged ≥ 60 years with nutritional risk from the geriatric clinic. We implemented the frailty intervention model, including integrated care with comprehensive geriatric assessments (CGA), case management, and nutritional counselling by the dietitian. We obtained measures of CGA components, physical performance, body mass index (BMI), and daily caloric intake before and after the 2-month care program. We used the Wilcoxon signed-rank test to analyse differences after the care program and applied multiple linear regression to determine the predictive factors for CFS improvement.

RESULTS

Among the 100 patients (mean age, 75.0 ± 7.2 years; females, 71.0%; frail patients, 26%), 93% improved their CFS status, and 91% achieved > 80% of recommended daily caloric intake after the care program. The Mini Nutritional Assessment Short-Form significantly improved after the program. BMI and daily caloric intake increased significantly after nutritional counselling. The post-test short physical performance battery (SPPB) significantly increased with a faster 4 m gait speed. Baseline poor CFS was a significant predictor for CFS improvement.

CONCLUSIONS

Integrated care with case management and nutritional counselling for prefrail and frail patients with nutritional risk in the primary care setting may improve physical performance and nutritional status.

The Drug Burden Index and Level of Frailty as Determinants of Healthcare Costs in a Cohort of Older Frail Adults in New Zealand

OBJECTIVES

Frailty is common in older people and is associated with increased use of healthcare services and ongoing use of multiple medications. This study provides insights into the healthcare cost structure of a frail group of older adults in Aotearoa, New Zealand. Furthermore, we investigated the relationship between participants' anticholinergic and sedative medication burden and their total healthcare costs to explore the viability of deprescribing interventions within this cohort.

METHODS

Healthcare cost analysis was conducted using data collected during a randomized controlled trial within a frail, older cohort. The collected information included participant demographics, medications used, frailty, cost of service use of aged residential care and outpatient hospital services, hospital admissions, and dispensed medications.

RESULTS

Data from 338 study participants recruited between 25 September 2018 and 30 October 2020 with a mean age of 80 years were analyzed. The total cost of healthcare per participant ranged from New Zealand $15 (US dollar $10) to New Zealand $270 681 (US dollar $175 943) over 6 months postrecruitment into the study. Four individuals accounted for 26% of this cohort's total healthcare cost. We found frailty to be associated with increased healthcare costs, whereas the drug burden was only associated with increased pharmaceutical costs, not overall healthcare costs.

CONCLUSIONS

With no relationship found between a patient's anticholinergic and sedative medication burden and their total healthcare costs, more research is required to understand how and where to unlock healthcare cost savings within frail, older populations.

Case management for integrated care of older people with frailty in community settings

BACKGROUND

Ageing populations globally have contributed to increasing numbers of people living with frailty, which has significant implications for use of health and care services and costs. The British Geriatrics Society defines frailty as "a distinctive health state related to the ageing process in which multiple body systems gradually lose their inbuilt reserves". This leads to an increased susceptibility to adverse outcomes, such as reduced physical function, poorer quality of life, hospital admissions, and mortality. Case management interventions delivered in community settings are led by a health or social care professional, supported by a multidisciplinary team, and focus on the planning, provision, and co-ordination of care to meet the needs of the individual. Case management is one model of integrated care that has gained traction with policymakers to improve outcomes for populations at high risk of decline in health and well-being. These populations include older people living with frailty, who commonly have complex healthcare and social care needs but can experience poorly co-ordinated care due to fragmented care systems.

OBJECTIVES

To assess the effects of case management for integrated care of older people living with frailty compared with usual care.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, Health Systems Evidence, and PDQ Evidence and databases from inception to 23 September 2022. We also searched clinical registries and relevant grey literature databases, checked references of included trials and relevant systematic reviews, conducted citation searching of included trials, and contacted topic experts.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared case management with standard care in community-dwelling people aged 65 years and older living with frailty.

DATA COLLECTION AND ANALYSIS

We followed standard methodological procedures recommended by Cochrane and the Effective Practice and Organisation of Care Group. We used the GRADE approach to assess the certainty of the evidence.

MAIN RESULTS

We included 20 trials (11,860 participants), all of which took place in high-income countries. Case management interventions in the included trials varied in terms of organisation, delivery, setting, and care providers involved. Most trials included a variety of healthcare and social care professionals, including nurse practitioners, allied healthcare professionals, social workers, geriatricians, physicians, psychologists, and clinical pharmacists. In nine trials, the case management intervention was delivered by nurses only. Follow-up ranged from three to 36 months. We judged most trials at unclear risk of selection and performance bias; this consideration, together with indirectness, justified downgrading the certainty of the evidence to low or moderate. Case management compared to standard care may result in little or no difference in the following outcomes. • Mortality at 12 months' follow-up (7.0% in the intervention group versus 7.5% in the control group; risk ratio (RR) 0.98, 95% confidence interval (CI) 0.84 to 1.15; I2 = 11%; 14 trials, 9924 participants; low-certainty evidence) • Change in place of residence to a nursing home at 12 months' follow-up (9.9% in the intervention group versus 13.4% in the control group; RR 0.73, 95% CI 0.53 to 1.01; I2 = 0%; 4 trials, 1108 participants; low-certainty evidence) • Quality of life at three to 24 months' follow-up (results not pooled; mean differences (MDs) ranged from -6.32 points (95% CI -11.04 to -1.59) to 6.1 points (95% CI -3.92 to 16.12) when reported; 11 trials, 9284 participants; low-certainty evidence) • Serious adverse effects at 12 to 24 months' follow-up (results not pooled; 2 trials, 592 participants; low-certainty evidence) • Change in physical function at three to 24 months' follow-up (results not pooled; MDs ranged from -0.12 points (95% CI -0.93 to 0.68) to 3.4 points (95% CI -2.35 to 9.15) when reported; 16 trials, 10,652 participants; low-certainty evidence) Case management compared to standard care probably results in little or no difference in the following outcomes. • Healthcare utilisation in terms of hospital admission at 12 months' follow-up (32.7% in the intervention group versus 36.0% in the control group; RR 0.91, 95% CI 0.79 to 1.05; I2 = 43%; 6 trials, 2424 participants; moderate-certainty evidence) • Change in costs at six to 36 months' follow-up (results not pooled; 14 trials, 8486 participants; moderate-certainty evidence), which usually included healthcare service costs, intervention costs, and other costs such as informal care.

AUTHORS' CONCLUSIONS

We found uncertain evidence regarding whether case management for integrated care of older people with frailty in community settings, compared to standard care, improved patient and service outcomes or reduced costs. There is a need for further research to develop a clear taxonomy of intervention components, to determine the active ingredients that work in case management interventions, and identify how such interventions benefit some people and not others.

The impact of including a medication review in an integrated care pathway: A pilot study

AIM

The objective of the present study was to measure the impact of the intervention of combining a medication review with an integrated care approach on potentially inappropriate medications (PIMs) and hospital readmissions in frail older adults.

METHODS

A cohort of hospitalized older adults enrolled in the French PAERPA integrated care pathway (the exposed cohort) was matched retrospectively with hospitalized older adults not enrolled in the pathway (unexposed cohort) between January 1st, 2015, and December 31st, 2018. The study was an analysis of French health administrative database. The inclusion criteria for exposed patients were admission to an acute care department in a general hospital, age 75 years or over, at least three comorbidities or the prescription of diuretics or oral anticoagulants, discharge alive and performance of a medication review.

RESULTS

For the study population (n = 582), the mean ± standard deviation age was 82.9 ± 4.9 years, and 380 (65.3%) were women. Depending on the definition used, the overall median number of PIMs ranged from 2 [0;3] on admission to 3 [0;3] at discharge. The intervention was not associated with a significant difference in the mean number of PIMs. Patients in the exposed cohort were half as likely to be readmitted to hospital within 30 days of discharge relative to patients in the unexposed cohort.

CONCLUSION

Our results show that a medication review was not associated with a decrease in the mean number of PIMs. However, an integrated care intervention including the medication review was associated with a reduction in the number of hospital readmissions at 30 days.

The Association Between Age and Admission to an Inappropriate Ward: A Cross-Sectional Survey in France

Half of elderly patient hospitalizations are preceded by an emergency department (ED) visit. Hospitalization in inappropriate wards (IWs), which is more frequent in case of ED overcrowding and high hospital occupancy, leads to increased morbidity. Elderly individuals are the most exposed to these negative health care outcomes. Based on a nationwide cross-sectional survey involving all EDs in France, the aim of this study was to explore whether age was associated with admission to an IW after visiting an ED. Among the 4384 patients admitted in a medical ward, 4065 were admitted in the same hospital where the ED was located, among which 17.7% were admitted to an IW. Older age was associated with an increased likelihood of being admitted to an IW (OR = 1.39; 95% CI = 1.02-1.90 for patients aged 85 years and older and OR = 1.40; 95% CI = 1.02-1.91 for patients aged 75-84 years, compared with those under 45 years). ED visits during peak periods and cardio-pulmonary presenting complaint were also associated with an increased likelihood of admission to an IW. Despite their higher vulnerability, elderly patients are more likely to be admitted to an IW than younger patients. This result reinforces the need for special attention to be given to the hospitalization of this fragile population.

Understanding the implementation of interventions to improve the management of frailty in primary care: a rapid realist review

OBJECTIVE

Identifying and managing the needs of frail people in the community is an increasing priority for policy makers. We sought to identify factors that enable or constrain the implementation of interventions for frail older persons in primary care.

DESIGN

A rapid realist review.

DATA SOURCES

Cochrane Library, SCOPUS and EMBASE, and grey literature. The search was conducted in September 2019 and rerun on 8 January 2022.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We considered all types of empirical studies describing interventions targeting frailty in primary care.

ANALYSIS

We followed the Realist and Meta-narrative Evidence Syntheses: Evolving Standards quality and publication criteria for our synthesis to systematically analyse and synthesise the existing literature and to identify (intervention-context-mechanism-outcome) configurations. We used normalisation processes theory to illuminate mechanisms surrounding implementation.

RESULTS

Our primary research returned 1755 articles, narrowed down to 29 relevant frailty intervention studies conducted in primary care. Our review identified two families of interventions. They comprised: (1) interventions aimed at the comprehensive assessment and management of frailty needs; and (2) interventions targeting specific frailty needs. Key factors that facilitate or inhibit the translation of frailty interventions into practice related to the distribution of resources; patient engagement and professional skill sets to address identified need.

CONCLUSION

There remain challenges to achieving successful implementation of frailty interventions in primary care. There were a key learning points under each family. First, targeted allocation of resources to address specific needs allows a greater alignment of skill sets and reduces overassessment of frail individuals. Second, earlier patient involvement may also improve intervention implementation and adherence.

PROSPERO REGISTRATION NUMBER

The published protocol for the review is registered with PROSPERO (CRD42019161193).

Comprehensive Geriatric Assessment for community-dwelling, high-risk, frail, older people

BACKGROUND

Comprehensive Geriatric Assessment (CGA) is a multidimensional interdisciplinary diagnostic process focused on determining an older person's medical, psychological and functional capability in order to develop a co-ordinated and integrated care plan. CGA is not limited simply to assessment, but also directs a holistic management plan for older people, which leads to tangible interventions. While there is established evidence that CGA reduces the likelihood of death and disability in acutely unwell older people, the effectiveness of CGA for community-dwelling, frail, older people at risk of poor health outcomes is less clear.

OBJECTIVES

To determine the effectiveness of CGA for community-dwelling, frail, older adults at risk of poor health outcomes in terms of mortality, nursing home admission, hospital admission, emergency department visits, serious adverse events, functional status, quality of life and resource use, when compared to usual care.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, three trials registers (WHO ICTRP, ClinicalTrials.gov and McMaster Aging Portal) and grey literature up to April 2020; we also checked reference lists and contacted study authors.

SELECTION CRITERIA

We included randomised trials that compared CGA for community-dwelling, frail, older people at risk of poor healthcare outcomes to usual care in the community. Older people were defined as 'at risk' either by being frail or having another risk factor associated with poor health outcomes. Frailty was defined as a vulnerability to sudden health state changes triggered by relatively minor stressor events, placing the individual at risk of poor health outcomes, and was measured using objective screening tools. Primary outcomes of interest were death, nursing home admission, unplanned hospital admission, emergency department visits and serious adverse events. CGA was delivered by a team with specific gerontological training/expertise in the participant's home (domiciliary Comprehensive Geriatric Assessment (dCGA)) or other sites such as a general practice or community clinic (community Comprehensive Geriatric Assessment (cCGA)).

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted study characteristics (methods, participants, intervention, outcomes, notes) using standardised data collection forms adapted from the Cochrane Effective Practice and Organisation of Care (EPOC) data collection form. Two review authors independently assessed the risk of bias for each included study and used the GRADE approach to assess the certainty of evidence for outcomes of interest.

MAIN RESULTS

We included 21 studies involving 7893 participants across 10 countries and four continents. Regarding selection bias, 12/21 studies used random sequence generation, while 9/21 used allocation concealment. In terms of performance bias, none of the studies were able to blind participants and personnel due to the nature of the intervention, while 14/21 had a blinded outcome assessment. Eighteen studies were at low risk of attrition bias, and risk of reporting bias was low in 7/21 studies. Fourteen studies were at low risk of bias in terms of differences of baseline characteristics. Three studies were at low risk of bias across all domains (accepting that it was not possible to blind participants and personnel to the intervention). CGA probably leads to little or no difference in mortality during a median follow-up of 12 months (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.76 to 1.02; 18 studies, 7151 participants (adjusted for clustering); moderate-certainty evidence). CGA results in little or no difference in nursing home admissions during a median follow-up of 12 months (RR 0.93, 95% CI 0.76 to 1.14; 13 studies, 4206 participants (adjusted for clustering); high-certainty evidence). CGA may decrease the risk of unplanned hospital admissions during a median follow-up of 14 months (RR 0.83, 95% CI 0.70 to 0.99; 6 studies, 1716 participants (adjusted for clustering); low-certainty evidence). The effect of CGA on emergency department visits is uncertain and evidence was very low certainty (RR 0.65, 95% CI 0.26 to 1.59; 3 studies, 873 participants (adjusted for clustering)). Only two studies (1380 participants; adjusted for clustering) reported serious adverse events (falls) with no impact on the risk; however, evidence was very low certainty (RR 0.82, 95% CI 0.58 to 1.17).

AUTHORS' CONCLUSIONS

CGA had no impact on death or nursing home admission. There is low-certainty evidence that community-dwelling, frail, older people who undergo CGA may have a reduced risk of unplanned hospital admission. Further studies examining the effect of CGA on emergency department visits and change in function and quality of life using standardised assessments are required.

Prioritization of indicators of the quality of care provided to older adults with frailty by key stakeholders from five canadian provinces

Background

To meet the needs of older adults with frailty better, it is essential to understand which aspects of care are important from their perspective. We therefore sought to assess the importance of a set of quality indicators (QI) for monitoring outcomes in this population.

Methods

In this mixed-method study, key stakeholders completed a survey on the importance of 36 QIs, and then explained their ratings in a semi-structured interview. Stakeholders included older adults with frailty and their caregivers, healthcare providers (HCPs), and healthcare administrators or policy/decision makers (DMs). We conducted descriptive statistical analyses of quantitative variables, and deductive thematic qualitative analyses of interview transcripts.

Results

The 42 participants (8 older adults, 18 HCPs, and 16 DMs) rated six QIs as more important: increasing the patients’ quality of life; increasing healthcare staff skills; decreasing patients’ symptoms; decreasing family caregiver burden; increasing patients’ satisfaction with care; and increasing family doctor continuity of care.

Conclusions

Key stakeholders prioritized QIs that focus on outcomes targeted to patients and caregivers, whereas the current healthcare systems generally focus on processes of care. Quality improvement initiatives should therefore take better account of aspects of care that are important for older adults with frailty, such as having a chance to express their individual goals of care, receiving quality communications from HCPs, or monitoring symptoms that they might not spontaneously describe. Our results point to the need for patient-centred care that is oriented toward quality of life for older adults with frailty.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-022-02843-9.

Predicting unplanned hospital visits in older home care recipients: a cross-country external validation study

Background

Accurate identification of older persons at risk of unplanned hospital visits can facilitate preventive interventions. Several risk scores have been developed to identify older adults at risk of unplanned hospital visits. It is unclear whether risk scores developed in one country, perform as well in another. This study validates seven risk scores to predict unplanned hospital admissions and emergency department (ED) visits in older home care recipients from six countries.

Methods

We used the IBenC sample (n = 2446), a cohort of older home care recipients from six countries (Belgium, Finland, Germany, Iceland, Italy and The Netherlands) to validate four specific risk scores (DIVERT, CARS, EARLI and previous acute admissions) and three frailty indicators (CHESS, Fried Frailty Criteria and Frailty Index). Outcome measures were unplanned hospital admissions, ED visits or any unplanned hospital visits after 6 months. Missing data were handled by multiple imputation. Performance was determined by assessing calibration and discrimination (area under receiver operating characteristic curve (AUC)).

Results

Risk score performance varied across countries. In Iceland, for any unplanned hospital visits DIVERT and CARS reached a fair predictive value (AUC 0.74 [0.68–0.80] and AUC 0.74 [0.67–0.80]), respectively). In Finland, DIVERT had fair performance predicting ED visits (AUC 0.72 [0.67–0.77]) and any unplanned hospital visits (AUC 0.73 [0.67–0.77]). In other countries, AUCs did not exceed 0.70.

Conclusions

Geographical validation of risk scores predicting unplanned hospital visits in home care recipients showed substantial variations of poor to fair performance across countries. Unplanned hospital visits seem considerably dependent on healthcare context. Therefore, risk scores should be validated regionally before applied to practice. Future studies should focus on identification of more discriminative predictors in order to develop more accurate risk scores.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02521-2.

Building the capacity of community health workers to support health and social care for dependent older people in Latin America: a pilot study in Fortaleza, Brazil

Background

Brazil is seeing rapid population ageing, which is leading to new demands on primary health care services. There is a need to develop and assess the effectiveness of new interventions to build the capacity of staff, including community health workers, to meet the needs of groups such as care-dependent older people and their care-givers. This study examines the feasibility of a small training intervention piloted in the Brazilian city of Fortaleza.

Methods

The study evaluated participants’ own assessments of key knowledge and skills related to the needs of care-dependent older people, both before and after the training intervention. It also assessed their capacity to implement a simple screening tool of geriatric risk factors.

Results

The participant self-assessments indicate significant improvements in their perceived knowledge and capacity in responding to the health needs of care-dependent older people. Additionally, participants were able to successfully conduct the home visits and screening for risk factors.

Conclusions

The study demonstrates the feasibility of developing interventions to enhance the capacity of community health workers to meet the needs of dependent older people in countries like Brazil. The evidence of effectiveness, though limited and subjective, provides justification for a larger, formally evaluated intervention. The experience of Fortaleza provides valuable lessons for other cities and countries in the region which are facing similar challenges.

The Seniors' Community Hub: An Integrated Model of Care for the Identification and Management of Frailty in Primary Care

(1) Background: Integrated models of primary care deliver the comprehensive and preventative approach needed to identify and manage frailty in older people. Seniors' Community Hub (SCH) was developed to deliver person-centered, evidence-informed, coordinated, and integrated care services to older community dwelling adults living with frailty. This paper aims to describe the SCH model, and to present patient-oriented results of the pilot. (2) Methods: SCH was piloted in an academic clinic with six family physicians. Eligible patients were community dwelling, 65 years of age and older, and considered to be at risk of frailty (eFI > 0.12). Health professionals within the clinic received training in geriatrics and interprofessional teamwork to form the SCH team working with family physicians, patients and caregivers. The SCH intervention consisted of a team-based multi-domain assessment with person-centered care planning and follow-up. Patient-oriented outcomes (EQ-5D-5L and EQ-VAS) and 4-metre gait speed were measured at initial visit and 12 months later. (3) Results: 88 patients were enrolled in the pilot from April 2016-December 2018. No statistically significant differences in EQ-5D-5L/VAS or the 4-metre gait speed were detected in 38 patients completing the 12-month assessment. (4) Conclusions: Future larger scale studies of longer duration are needed to demonstrate impacts of integrated models of primary care on patient-oriented outcomes for older adults living with frailty.

The impact of community nurse-led interventions on the need for hospital use among older adults: An integrative review

BACKGROUND

Hospital avoidance services are important for older people who risk deteriorating health and independence when in hospital. However, the evidence base for nurse-led community services is equivocal.

OBJECTIVES

To determine the impact of community nurse-led interventions on the need for hospital use among older adults.

METHODS

The integrative review method of Whittemore and Knafl was employed and reported in accordance with PRIMSA guidelines. Medline, EMBASE and CINAHL were searched from January 2011 to January 2019. Outcomes were coded and findings reported by outcome domain to provide an integrated, narrative synthesis.

RESULTS

Nine studies were included in the review. Whilst disparities in the evidence base persist, specialist high-intensity, team-based hospital-at-home services were significantly more likely to reduce hospital admissions than standard care. An individual case management services that incorporated self-help education for chronic disease management also reduced hospital admissions. Financial data suggest that whilst high-intensity services are costly, they can lead to significant efficiency savings in the longer-term.

CONCLUSION

This topic remains an important area for further investment, managerial support and research because of the risks faced by older people when admitted to hospital, for whom health, quality of life and independence are vital considerations.

IMPLICATIONS FOR PRACTICE

The provision of high-intensity team-based services and self-help education can optimise health outcomes and reduce the need for hospital use among older adults living in the community.

Multicomponent interventions for enhancing primary care: a systematic review

Background

Many countries have implemented interventions to enhance primary care to strengthen their health systems. These programmes vary widely in features included and their impact on outcomes.

Aim

To identify multiple-feature interventions aimed at enhancing primary care and their effects on measures of system success — that is, population health, healthcare costs and utilisation, patient satisfaction, and provider satisfaction (quadruple-aim outcomes).

Design and setting

Systematic review and narrative synthesis.

Method

Electronic, manual, and grey-literature searches were performed for articles describing multicomponent primary care interventions, providing details of their innovation features, relationship to the ‘4Cs’ (first contact, comprehensiveness, coordination, and continuity), and impact on quadruple-aim outcomes. After abstract and full-text screening, articles were selected and their quality appraised. Results were synthesised in a narrative form.

Results

From 37 included articles, most interventions aimed to improve access, enhance incentives for providers, provide team-based care, and introduce technologies. The most consistent improvements related to increased primary care visits and screening/preventive services, and improved patient and provider satisfaction; mixed results were found for hospital admissions, emergency department visits, and expenditures. The available data were not sufficient to link interventions, achievement of the 4Cs, and outcomes.

Conclusion

Most analysed interventions improved some aspects of primary care while, simultaneously, producing non-statistically significant impacts, depending on the features of the interventions, the measured outcome(s), and the populations being studied. A critical research gap was revealed, namely, in terms of which intervention features to enhance primary care (alone or in combination) produce the most consistent benefits.

[Clinical characteristics, care professionals' intervention and care complexity for elderly patients in home hospitalization]

INTRODUCTION

The number of elderly patients in home care in France is currently increasing. Our objective is to describe the clinical characteristics, the care professionals' intervention and the complexity of follow-up care for this elderly population.

METHODS

This is a cross-sectional study with a sample of 50 elderly patients aged 75 and over living at home and followed-up in home hospitalization in 2016 by the Assistance Publique Hôpitaux de Paris. The collection of data used the interRAI-CA tool (Resident Assessment Instrument - Contact Assessment).

RESULTS

The average age of the sample was 84 years with 48% women, 26% living alone and 96% having a caregiver who had difficulty in caring in 33.3% of cases. Patients had numerous diseases with 68% of the sample who had cognitive difficulties with functional disabilities; Most of them reported pain and 52% had unstable clinical situation. The main care interventions were complex wounds, supportive care and palliative care with technical care and 80% of the sample mobilized more than 3 professionals. Care was considered to be of a high level of complexity for 74% of the elderly patients.

CONCLUSION

Our study showed that elderly patients had care complexity with technical and multi-faceted care implying coordination of stakeholders and support for caregivers. Implementing at-home hospitalization allows to transfer some geriatric patients from hospitalization to the home care and helps the structuration of the geriatric expertise among the primary care services.

Identifying Populations with Complex Needs: Variation in Approaches Used to Select Complex Patient Populations

Interventions to support patients with complex needs are proliferating. However, little attention has been paid to methods for identifying complex patients. This study aims to summarize approaches used to define populations with complex needs in practice, by cataloging specific population criteria and organizing them into a taxonomy. The authors conducted a pragmatic review of literature published January 2000-December 2018 using PubMed. Search results were limited to English-language studies of adults that specified a set of objective criteria to identify a population with complex needs. The authors abstracted data from each article on population parameters, and conducted thematic analysis guided by deductive coding. The review identified 70 studies reflecting 90 unique complex population definitions. Complex populations criteria reflected 3 approaches: stratification, segmentation, and targeting. Six domains of population criteria were found within, including age-based criteria (59 populations); income (12); health care costs (45); health care utilization (39); health conditions (35); and subjective criteria (15). Criteria from multiple domains were frequently used in combination, and exact specifications were highly variable within each domain. Overall, 83% of the 90 population definitions included at least 1 cost- or utilization-based criterion. Nearly every study in the review presented a unique approach to identifying patients with complex needs but a limited number of "schools of thought" were found. Variability in definitions and inconsistent terminology are potential sources of ambiguity between stakeholders. Greater specificity and transparency in complex population definition would be a substantial contribution to the emerging field of complex care.

Clinical effectiveness of an intermediate care inpatient model based on integrated care pathways

AIM

The aim of this study was to compare the clinical impact of two intermediate care pathways.

METHODS

A prospective, uncontrolled before-after study was carried out to compare two non-synchronic intermediate care frameworks in Spain. Participants in the control group were transferred to the intermediate care center by hospital request, whereas those in the intervention group (Badalona Integrated Care Model [BICM]) were transferred based on a territory approach considering the assessment of an intermediate care team. The clinical characteristics of study participants were assessed at admission and discharge.

RESULTS

Compared with participants in the control group, those in the BICM group were significantly older (mean age 81.6 years [SD 10.3] vs 78.3 years [10.1], P < 0.001) and had a lower Barthel score (mean score 32.8 [SD 25.9] vs 39.9 [28.4]; P < 0.001), and a higher proportion of participants with total dependence (38.4% vs 32.2%; P = 0.001). The length of stay in intermediate care was similar in both groups; however, stay in acute care was significantly shorter in the BICM group than in the control group (mean 21 days [SD 19.5] vs 25 days [SD 23]; P < 0.001). No significant differences were found regarding the Barthel Index at discharge, although participants in the BICM group had significantly higher functional gain.

CONCLUSIONS

The implementation of a territory-based integrated care pathway in an intermediate care center shifted the profile of admitted patients toward higher complexity. Despite this, patients managed under the integrated care model reduced their dependency and the referral rate to an acute unit during their stay in the intermediate care center. Geriatr Gerontol Int 2020; 20: 366-372.

Comprehensive geriatric assessment in primary care: a systematic review

Background

Comprehensive geriatric assessment (CGA) involves the multidimensional assessment and management of an older person. It is well described in hospital and home-based settings. A novel approach could be to perform CGA within primary healthcare, the initial community located healthcare setting for patients, improving accessibility to a co-located multidisciplinary team.

Aim

To appraise the evidence on CGA implemented within the primary care practice.

Methods

The review followed PRISMA recommendations. Eligible studies reported CGA on persons aged ≥ 65 in a primary care practice. Studies focusing on a single condition were excluded. Searches were run in five databases; reference lists and publications were screened. Two researchers independently screened for eligibility and assessed study quality. All study outcomes were reviewed.

Results

The authors screened 9003 titles, 145 abstracts and 97 full texts. Four studies were included. Limited study bias was observed. Studies were heterogeneous in design and reported outcomes. CGAs were led by a geriatrician (n = 3) or nurse practitioner (n = 1), with varied length and extent of follow-up (12–48 months). Post-intervention hospital admission rates showed mixed results, with improved adherence to medication modifications. No improvement in survival or functional outcomes was observed. Interventions were widely accepted and potentially cost-effective.

Discussion

The four studies demonstrated that CGA was acceptable and provided variable outcome benefit. Further research is needed to identify the most effective strategy for implementing CGA in primary care. Particular questions include identification of patients suitable for CGA within primary care CGA, a consensus list of outcome measures, and the role of different healthcare professionals in delivering CGA.

Electronic supplementary material

The online version of this article (10.1007/s40520-019-01183-w) contains supplementary material, which is available to authorized users.

Older Adults' Views on the Repositioning of Primary and Community Care

Older adults are rarely consulted on health care restructuring. To address this gap, our study explored older adults' views on "repositioning", a restructuring initiative to support independent living for older adults with complex chronic disease (CCD). We collected and analysed data from 83 older adults living in one small city and nine rural small towns where "repositioning" of primary and community care was occurring. Average participant age was 75 years; 56 (67%) were women, 44 (53%) had CCD, and 20 (24%) identified as Indigenous or South Asian. The four themes were: unfamiliarity with repositioning; optimism versus skepticism; improving primary and community care (through better home care, improved transportation, and more doctors); and, playing an active role to effect change. For repositioning to be successful, diverse service users must be fully included; rural-dwelling older adults' priorities for primary and community care need to be addressed, rather than using a "cookie-cutter" approach.

Multidisciplinary interventions for reducing the avoidable displacement from home of frail older people: a systematic review

OBJECTIVES

To synthesise existing literature on interventions addressing a new concept of avoidable displacement from home for older people with multimorbidity or frailty. The review focused on home-based interventions by any type of multidisciplinary team aimed at reducing avoidable displacement from home to hospital settings. A second objective was to characterise these interventions to inform policy.

DESIGN

A systematic search of the main bibliographic databases was conducted to identify studies relating to interventions addressing avoidable displacement from home for older people. Studies focusing on one specific condition or interventions without multidisciplinary teams were excluded. A narrative synthesis of data was conducted, and themes were identified by using an adapted thematic framework analysis approach.

RESULTS

The search strategy was performed using the following electronic databases: the American National Library of Medicine and the National Institutes of Health (PubMed), Scopus, Cochrane Library (Central and CDRS), CINAHL, Social Care Online, Web of Science as well as the database of the Latin American and Caribbean Health Sciences Literature. The database search was done in September 2018 and completed in October 2018. Overall 3927 articles were identified and 364 were retained for full text screening. Fifteen studies were included in the narrative review. Four themes were identified and discussed: (1) types of interventions, (2) composition of teams, (3) intervention effectiveness and (4) types of outcomes. Within intervention types, three categories of care types were identified; transitional care, case-management services and hospital at home. Each individual article was assessed in terms of risk of bias following Cochrane Collaboration guidelines.

CONCLUSIONS

The review identified some potential interventions and relevant topics to be addressed in order to develop effective and sustainable interventions to reduce the avoidable displacement from home of older people. However the review was not able to identify robust impact evidence, either in terms of quantity or quality from the studies presented. As such, the available evidence is not sufficiently robust to inform policy or interventions for reducing avoidable displacement from home. This finding reflects the complexity of these interventions and a lack of systematic data collection.

PROSPERO REGISTRATION NUMBER

CRD42018108116.

Factors associated with emergency department revisits among older adults in two Swedish regions: A prospective cohort study

OBJECTIVES

To assess the association between baseline characteristics at an index ED visit and ED revisit within 30 days among adults aged ≥ 65 years in two Swedish regions.

METHODS

This was a register-based prospective cohort study. The sample included (N=16 688; N=101 017) older adults who have had an index ED visit in 2014 at hospital based EDs in the regions of Dalarna and Stockholm, Sweden. Several registers were linked to obtain information on sociodemographic factors, living conditions, social care, polypharmacy and health care use. Multivariate logistic regression was used to analyse the data.

RESULTS

Seventeen percent of the study sample in Dalarna and 20.1% in Stockholm revisited ED within 30 days after an index ED visit. In both regions, male gender, being in the last year of life, excessive polypharmacy (≥ 10 drugs), ≥11 primary care visits and ED care utilization were positively associated with ED revisits. In Stockholm, but not in Dalarna, low level of education, polypharmacy, and institutional care was also associated with ED revisits. In contrast, home help was associated with ED revisits in Dalarna but not in Stockholm.

CONCLUSION

These findings call for further in-depth examinations of variations within single countries. ED revisits among older adults are driven by need of care but also by the social and care situation.

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.

Home Safety Fall and Accident Risk Among Prematurely Aging, Formerly Homeless Adults

OBJECTIVE

Homelessness prematurely ages people. A large subgroup of formerly homeless adults between ages 40 and 64 yr have health conditions similar to or worse than people categorized as elderly. Little is known about the impact of this group's chronic health conditions on their ability to safely function in supportive housing.

METHOD

Home safety visits were carried out with 25 formerly homeless adults, ages 40-64 yr, now residing in supportive housing.

RESULTS

Participants had physical, cognitive, and mental health problems that significantly interfered with their ability to perform daily life skills, safely function in an apartment, and manage chronic health conditions. Home safety hazards included cluttered walking paths, the presence of steps, and the lack of grab bars and nonskid flooring.

CONCLUSION

The homeless population would benefit from aging specialists, such as occupational therapists, who could help people to maintain and function more safely in their homes. Without such services, this population may be at risk for home safety events leading to hospitalization and mortality.

The (cost-)effectiveness of preventive, integrated care for community-dwelling frail older people: A systematic review

Integrated care is increasingly promoted as an effective and cost-effective way to organise care for community-dwelling frail older people with complex problems but the question remains whether high expectations are justified. Our study aims to systematically review the empirical evidence for the effectiveness and cost-effectiveness of preventive, integrated care for community-dwelling frail older people and close attention is paid to the elements and levels of integration of the interventions. We searched nine databases for eligible studies until May 2016 with a comparison group and reporting at least one outcome regarding effectiveness or cost-effectiveness. We identified 2,998 unique records and, after exclusions, selected 46 studies on 29 interventions. We assessed the quality of the included studies with the Effective Practice and Organization of Care risk-of-bias tool. The interventions were described following Rainbow Model of Integrated Care framework by Valentijn. Our systematic review reveals that the majority of the reported outcomes in the studies on preventive, integrated care show no effects. In terms of health outcomes, effectiveness is demonstrated most often for seldom-reported outcomes such as well-being. Outcomes regarding informal caregivers and professionals are rarely considered and negligible. Most promising are the care process outcomes that did improve for preventive, integrated care interventions as compared to usual care. Healthcare utilisation was the most reported outcome but we found mixed results. Evidence for cost-effectiveness is limited. High expectations should be tempered given this limited and fragmented evidence for the effectiveness and cost-effectiveness of preventive, integrated care for frail older people. Future research should focus on unravelling the heterogeneity of frailty and on exploring what outcomes among frail older people may realistically be expected.

Effectiveness and cost-effectiveness of integrated care models for elderly, complex patients: A narrative review. Don’t we need a value-based approach?

Introduction

The management of patients with complex health and social needs is one of the main challenges for healthcare systems. Integrated care seems to respond to this issue, with collaborative working and integration efforts of the care system components professionals and service providers aimed at improving efficiency, appropriateness and person centeredness of care. We conducted a narrative review to analyse the available evidences published on effectiveness and cost-effectiveness of integrated care models targeted on the management of such elderly patients.

Methods

MEDLINE, Scopus and EBSCO were searched. We reported this narrative review according to the PRISMA Checklist. For studies to be included, they had to: (i) refer to integrated care models through implemented experimental or demonstration projects; (ii) focus on frail elderly ≥65 years old, with complex health and social needs, not disease-specific; (iii) evaluate effectiveness and/or cost and/or cost-effectiveness; (iv) report quantitative data (e.g. health outcomes, utilization outcomes, cost and cost-effectiveness).

Results

Thirty articles were included, identifying 13 integrated care models. Common features were identified in case management, geriatric assessment and multidisciplinary team. Favourable impacts on healthcare facilities utilization rates, though with mixed results on costs, were found. The development of community-based and cost-effective integrated systems of care for the elderly is possible, thanks to the cooperation across care professionals and providers, to achieving a relevant impact on healthcare and efficient resource management. The elements of success or failure are not always unique and identifiable, but the potential clearly exists for these models to be successful and generalized on a large scale.

Discussion

We found out a favourable impact of integrated care models/methods on health outcomes, care utilization and costs. The selected interventions are likely to be implemented at community level, focused on the patient management in terms of continuity of care. Thus, we propose a value-based framework for the evaluation of these services.

Understanding new models of integrated care in developed countries: a systematic review

Background

The NHS has been challenged to adopt new integrated models of service delivery that are tailored to local populations. Evidence from the international literature is needed to support the development and implementation of these new models of care.

Objectives

The study aimed to carry out a systematic review of international evidence to enhance understanding of the mechanisms whereby new models of service delivery have an impact on health-care outcomes.

Design

The study combined rigorous and systematic methods for identification of literature, together with innovative methods for synthesis and presentation of findings.

Setting

Any setting.

Participants

Patients receiving a health-care service and/or staff delivering services.

Interventions

Changes to service delivery that increase integration and co-ordination of health and health-related services.

Main outcome measures

Outcomes related to the delivery of services, including the views and perceptions of patients/service users and staff.

Study design

Empirical work of a quantitative or qualitative design.

Data sources

We searched electronic databases (between October 2016 and March 2017) for research published from 2006 onwards in databases including MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Science Citation Index, Social Science Citation Index and The Cochrane Library. We also searched relevant websites, screened reference lists and citation searched on a previous review.

Review methods

The identified evidence was synthesised in three ways. First, data from included studies were used to develop an evidence-based logic model, and a narrative summary reports the elements of the pathway. Second, we examined the strength of evidence underpinning reported outcomes and impacts using a comparative four-item rating system. Third, we developed an applicability framework to further scrutinise and characterise the evidence.

Results

We included 267 studies in the review. The findings detail the complex pathway from new models to impacts, with evidence regarding elements of new models of integrated care, targets for change, process change, influencing factors, service-level outcomes and system-wide impacts. A number of positive outcomes were reported in the literature, with stronger evidence of perceived increased patient satisfaction and improved quality of care and access to care. There was stronger UK-only evidence of reduced outpatient appointments and waiting times. Evidence was inconsistent regarding other outcomes and system-wide impacts such as levels of activity and costs. There was an indication that new models have particular potential with patients who have complex needs.

Limitations

Defining new models of integrated care is challenging, and there is the potential that our study excluded potentially relevant literature. The review was extensive, with diverse study populations and interventions that precluded the statistical summary of effectiveness.

Conclusions

There is stronger evidence that new models of integrated care may enhance patient satisfaction and perceived quality and increase access; however, the evidence regarding other outcomes is unclear. The study recommends factors to be considered during the implementation of new models.

Future work

Links between elements of new models and outcomes require further study, together with research in a wider variety of populations.

Study registration

This study is registered as PROSPERO CRD37725.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

The effects of integrated care: a systematic review of UK and international evidence

BACKGROUND

Healthcare systems around the world have been responding to the demand for better integrated models of service delivery. However, there is a need for further clarity regarding the effects of these new models of integration, and exploration regarding whether models introduced in other care systems may achieve similar outcomes in a UK national health service context.

METHODS

The study aimed to carry out a systematic review of the effects of integration or co-ordination between healthcare services, or between health and social care on service delivery outcomes including effectiveness, efficiency and quality of care. Electronic databases including MEDLINE; Embase; PsycINFO; CINAHL; Science and Social Science Citation Indices; and the Cochrane Library were searched for relevant literature published between 2006 to March 2017. Online sources were searched for UK grey literature, and citation searching, and manual reference list screening were also carried out. Quantitative primary studies and systematic reviews, reporting actual or perceived effects on service delivery following the introduction of models of integration or co-ordination, in healthcare or health and social care settings in developed countries were eligible for inclusion. Strength of evidence for each outcome reported was analysed and synthesised using a four point comparative rating system of stronger, weaker, inconsistent or limited evidence.

RESULTS

One hundred sixty seven studies were eligible for inclusion. Analysis indicated evidence of perceived improved quality of care, evidence of increased patient satisfaction, and evidence of improved access to care. Evidence was rated as either inconsistent or limited regarding all other outcomes reported, including system-wide impacts on primary care, secondary care, and health care costs. There were limited differences between outcomes reported by UK and international studies, and overall the literature had a limited consideration of effects on service users.

CONCLUSIONS

Models of integrated care may enhance patient satisfaction, increase perceived quality of care, and enable access to services, although the evidence for other outcomes including service costs remains unclear. Indications of improved access may have important implications for services struggling to cope with increasing demand.

TRIAL REGISTRATION

Prospero registration number: 42016037725 .

Theoretical Perspectives of Hospitalized Older Patients and Their Health-Related Problems and Quality of Care: Systematic Literature Review

Introduction:

The proportion of aged people is growing worldwide. Older persons are affected by a number of physical, psychological and social factors that influence their health and quality of life. These factors are usually multiple and are often masked by sensory and cognitive impairments.

Purpose:

The purpose of this study was to examine the available literature emphasizing older persons’ care, care-related problems, and older persons’ quality of healthcare. Also, the paper aimed at exploring the future direction of research needs.

Results:

Good quality older patients’ care involves safety, professional interventions, recognition and management of physical and emotional wellbeing. Care of older patients requires addressing the aging process itself, the expected decrease in functionality, and diminished cognitive ability. Little statistical data were found to address the quality of hospitalized elderly patients in particular as well as study on healthcare facilities and nursing homes. Literature does not provide much guidance to the effectiveness of care strategies.

Conclusion:

The results assert that elderly health care is a priority. However, health care systems are not specific about elderly patients’ needs, leading to low quality of elderly care. There is a need to use an integrated model of care to improve the quality of life and quality of care provided to hospitalized older patients.

What works in implementation of integrated care programs for older adults with complex needs? A realist review

PURPOSE

A realist review of the evaluative evidence was conducted on integrated care (IC) programs for older adults to identify key processes that lead to the success or failure of these programs in achieving outcomes such as reduced healthcare utilization, improved patient health, and improved patient and caregiver experience.

DATA SOURCES

International academic literature was searched in 12 indexed, electronic databases and gray literature through internet searches, to identify evaluative studies.

STUDY SELECTION

Inclusion criteria included evaluative literature on integrated, long-stay health and social care programs, published between January 1980 and July 2015, in English.

DATA EXTRACTION

Data were extracted on the study purpose, period, setting, design, population, sample size, outcomes, and study results, as well as explanations of mechanisms and contextual factors influencing outcomes.

RESULTS OF DATA SYNTHESIS

A total of 65 articles, representing 28 IC programs, were included in the review. Two context-mechanism-outcome configurations (CMOcs) were identified: (i) trusting multidisciplinary team relationships and (ii) provider commitment to and understanding of the model. Contextual factors such as strong leadership that sets clear goals and establishes an organizational culture in support of the program, along with joint governance structures, supported team collaboration and subsequent successful implementation. Furthermore, time to build an infrastructure to implement and flexibility in implementation, emerged as key processes instrumental to success of these programs.

CONCLUSIONS

This review included a wide range of international evidence, and identified key processes for successful implementation of IC programs that should be considered by program planners, leaders and evaluators.

[New integrated care model for older people admitted to Intermediate Care Units in Catalonia: A quasi-experimental study protocol]

OBJECTIVE

To evaluate the clinical effectiveness of an intermediate care model based on a system of care focused on integrated care pathways compared to the traditional model of geriatric care (usual care) in Catalonia.

PATIENTS AND METHODS

The design is a quasi-experimental pre-post non-randomised study with non-synchronous control group. The intervention consists of the development and implementation of integrated care pathways and the creation of specialised interdisciplinary teams in each of the processes. The two groups will be compared for demographic, clinical variables on admission and discharge, geriatric syndromes, and use of resources.

DISCUSSION

This quasi-experimental study, aims to assess the clinical impact of the transformation of a traditional model of geriatric care to an intermediate care model in an integrated healthcare organisation. It is believed that the results of this study may be useful for future randomised controlled studies.

The Impact of Telehealth and Care Coordination on the Number and Type of Clinical Visits for Children With Medical Complexity

INTRODUCTION

The purpose of this analysis was to evaluate the effects of an advanced practice nurse-delivered telehealth intervention on health care use by children with medical complexity (CMC). Because CMC account for a large share of health care use costs, finding effective ways to care for them is an important challenge requiring exploration.

METHOD

This was a secondary analysis of data from a randomized clinical trial with a control group and two intervention groups. The focus of the analysis was planned and unplanned clinical and therapy visits by CMC over a 30-month data collection period. Nonparametric tests were used to compare visit counts among and within the three groups.

RESULTS

The number of unplanned visits decreased over time across all groups, with the greatest decrease in the video telehealth intervention group. Planned visits were higher in the video telehealth group across all time periods.

DISCUSSION

Advanced practice registered nurse-delivered telehealth care coordination may support a shift from unplanned to planned health care service use among CMC.

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

Background

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

Methods

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

Results

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

Conclusions

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

Trial registration

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

Frequent Use of Emergency Departments by the Elderly Population When Continuing Care Is Not Well Established

Introduction

The elderly, who suffer from multiple chronic diseases, represent a substantial proportion of Emergency Department (ED) frequent users, thus contributing to ED overcrowding, although they could benefit from other health care facilities, if those were available. The aim of this study was to evaluate and characterize hospital visits of older patients (age 65 or greater) to the ED of a university teaching hospital in Rome from the 1st of January to the 31st of December 2014, in order to identify clinical and social characteristics potentially associated with “elderly frequent users”.

Material and Methods

A retrospective study was performed during the calendar year 2014 (1^st January 2014 – 31^st December 2014) analyzing all ED admissions to the University Hospital of Rome Tor Vergata. Variables collected included age, triage code, arrival data, discharge diagnosis, and visit outcome. We performed a risk analysis using univariate binary logistic regression models.

Results

A total number of 38,016 patients accessed the ED, generating 46,820 accesses during the study period, with an average of 1.23 accesses for patient. The elderly population represented a quarter of the total ED population and had an increased risk of frequent use (OR 1.5: CI 1.4–1.7) and hospitalization (OR 3.8: CI 3.7–4). Moreover, they showed a greater diagnostic complexity, as demonstrated by the higher incidence of yellow and red priority codes compared to other ED populations (OR 3.1: CI 2.9–3.2).

Discussion

Older patients presented clinical and social characteristics related to the definition of “elderly frail frequent users”. The fact that a larger number of hospitalizations occurred in such patients is indirect evidence of frailty in this specific population, suggesting that hospital admissions may be an inappropriate response to frailty, especially when continued care is not established.

Conclusion

Enhancement of continuity of care, establishment of a tracking system for those who are at greater risk of visiting the ED and evaluating fragile individuals should be the highest priority in addressing ED frequent usage by the elderly.

The Geriatrics in Primary Care Demonstration: Integrating Comprehensive Geriatric Care into the Medical Home: Preliminary Data

Three thousand nine hundred thirty-one veterans aged 75 and older receive primary care (PC) in two large practices of the Department of Veterans Affairs (VA) Boston Healthcare System. Cognitive and functional disabilities are endemic in this group, creating needs that predictably exceed available or appropriate resources. To address this problem, Geriatrics in Primary Care (GPC) embeds geriatric services directly into primary care. An on-site consulting geriatrician and geriatric nurse care manager work directly with PC colleagues in medicine, nursing, social work, pharmacy, and mental health within the VA medical home. This design delivers interdisciplinary geriatric care within PC that emphasizes comprehensive evaluations, care management, planned transitions, informed resource use, and a shift in care focus from multiple subspecialties to PC. Four hundred thirty-five veterans enrolled during the project's 4-year course. Complex, fragmented care was evident in a series of 50 individuals (aged 82 ± 7) enrolled during Months 1 to 6. The year before, these individuals made 372 medical or surgical subspecialty clinic visits (7.4 ± 9.8); 34% attended five or more subspecialty clinics, 48% had dementia, and 18% lacked family caregivers. During the first year after enrollment the mean number of subspecialty clinic visits declined significantly (4.7 ± 5.0, P = .01), whereas the number of PC-based visits remained stable (3.1 ± 1.5 and 3.3 ± 1.5, respectively, P = .50). Telephone contact by GPC (2.3 ± 2.0) and collaboration with PC clinicians replaced routine follow-up geriatric care. GPC facilitated planned transitions to rehabilitation centers (n = 5), home hospice (n = 2), dementia units (n = 3), and home care (n = 37). GPC provides efficient, comprehensive geriatric care and case management while preserving established relationships between patients and the PC team. Preliminary results suggest "care defragmentation," as reflected by a significant reduction in subspecialty clinic use. Model simplicity and flexibility facilitated ready implementation.

Predicting Inpatient Readmission and Outpatient Admission in Elderly: A Population-Based Cohort Study

Recognizing potentially avoidable hospital readmission and admissions are important health care quality issues. We develop prediction models for inpatient readmission and outpatient admission to hospitals for older adults In the retrospective cohort study with 2 million sampling file of the National Health Insurance Research Database in Taiwan, older adults (aged ≥65 y/o) with a first admission in 2008 were enrolled in the inpatient cohort (N = 39,156). The outpatient cohort included subjects who had ≥1 outpatient visit in 2008 (N = 178,286). Each cohort was split into derivation (3/4) and validation (1/4) data set. Primary outcome of the inpatient cohort: 30-day readmission from the date of discharge. The outpatient cohort included hospital admissions within the 1-year follow-up period. Candidate risk factors include demographics, comorbidities, and previous health care utilizations. Series of logistic regression models were applied with area under the receiver operating curves (AUCs) to identify the best model. Roughly 1 of 7 (14.6%) of the inpatients was readmitted within 30 days, and 1 of 5 (19.1%) of the outpatient cohort was admitted within 1 year. Age, education, use of home health care, and selected comorbidities (e.g., cancer with metastasis) were included in the final model. The AUC of the inpatient readmission model was 0.655 (95% confidence interval [CI] 0.646-0.664) and outpatient admission model was 0.642 (95% CI 0.639-0.646). Predictive performance was maintained in both validation data sets. The goodness-to-fit model demonstrated good calibration in both groups. We developed and validated practical clinical prediction models for inpatient readmission and outpatient admissions for general older adults with indicators easily obtained from an administrative data set.

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

BACKGROUND

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

METHODS AND FINDINGS

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

CONCLUSIONS

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

REVIEW PROTOCOL

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