Tools, methods, and strategies. Do innovative models of health care delivery improve quality of care for selected vulnerable populations? A systematic review

Effectiveness of a nurse-led case management home care model in Primary Health Care. A quasi-experimental, controlled, multi-centre study

Background

Demand for home care services has increased considerably, along with the growing complexity of cases and variability among resources and providers. Designing services that guarantee co-ordination and integration for providers and levels of care is of paramount importance. The aim of this study is to determine the effectiveness of a new case-management based, home care delivery model which has been implemented in Andalusia (Spain).

Methods

Quasi-experimental, controlled, non-randomised, multi-centre study on the population receiving home care services comparing the outcomes of the new model, which included nurse-led case management, versus the conventional one. Primary endpoints: functional status, satisfaction and use of healthcare resources. Secondary endpoints: recruitment and caregiver burden, mortality, institutionalisation, quality of life and family function. Analyses were performed at base-line, and at two, six and twelve months. A bivariate analysis was conducted with the Student's t-test, Mann-Whitney's U, and the chi squared test. Kaplan-Meier and log-rank tests were performed to compare survival and institutionalisation. A multivariate analysis was performed to pinpoint factors that impact on improvement of functional ability.

Results

Base-line differences in functional capacity – significantly lower in the intervention group (RR: 1.52 95%CI: 1.05–2.21; p = 0.0016) – disappeared at six months (RR: 1.31 95%CI: 0.87–1.98; p = 0.178). At six months, caregiver burden showed a slight reduction in the intervention group, whereas it increased notably in the control group (base-line Zarit Test: 57.06 95%CI: 54.77–59.34 vs. 60.50 95%CI: 53.63–67.37; p = 0.264), (Zarit Test at six months: 53.79 95%CI: 49.67–57.92 vs. 66.26 95%CI: 60.66–71.86 p = 0.002). Patients in the intervention group received more physiotherapy (7.92 CI95%: 5.22–10.62 vs. 3.24 95%CI: 1.37–5.310; p = 0.0001) and, on average, required fewer home care visits (9.40 95%CI: 7.89–10.92 vs.11.30 95%CI: 9.10–14.54). No differences were found in terms of frequency of visits to A&E or hospital re-admissions. Furthermore, patients in the control group perceived higher levels of satisfaction (16.88; 95%CI: 16.32–17.43; range: 0–21, vs. 14.65 95%CI: 13.61–15.68; p = 0,001).

Conclusion

A home care service model that includes nurse-led case management streamlines access to healthcare services and resources, while impacting positively on patients' functional ability and caregiver burden, with increased levels of satisfaction.

Trial registration

ISRCTN44054549

Effectiveness of a nurse-led case management home care model in Primary Health Care. A quasi-experimental, controlled, multi-centre study

BACKGROUND

Demand for home care services has increased considerably, along with the growing complexity of cases and variability among resources and providers. Designing services that guarantee co-ordination and integration for providers and levels of care is of paramount importance. The aim of this study is to determine the effectiveness of a new case-management based, home care delivery model which has been implemented in Andalusia (Spain).

METHODS

Quasi-experimental, controlled, non-randomised, multi-centre study on the population receiving home care services comparing the outcomes of the new model, which included nurse-led case management, versus the conventional one. Primary endpoints: functional status, satisfaction and use of healthcare resources. Secondary endpoints: recruitment and caregiver burden, mortality, institutionalisation, quality of life and family function. Analyses were performed at base-line, and at two, six and twelve months. A bivariate analysis was conducted with the Student's t-test, Mann-Whitney's U, and the chi squared test. Kaplan-Meier and log-rank tests were performed to compare survival and institutionalisation. A multivariate analysis was performed to pinpoint factors that impact on improvement of functional ability.

RESULTS

Base-line differences in functional capacity - significantly lower in the intervention group (RR: 1.52 95%CI: 1.05-2.21; p = 0.0016) - disappeared at six months (RR: 1.31 95%CI: 0.87-1.98; p = 0.178). At six months, caregiver burden showed a slight reduction in the intervention group, whereas it increased notably in the control group (base-line Zarit Test: 57.06 95%CI: 54.77-59.34 vs. 60.50 95%CI: 53.63-67.37; p = 0.264), (Zarit Test at six months: 53.79 95%CI: 49.67-57.92 vs. 66.26 95%CI: 60.66-71.86 p = 0.002). Patients in the intervention group received more physiotherapy (7.92 CI95%: 5.22-10.62 vs. 3.24 95%CI: 1.37-5.310; p = 0.0001) and, on average, required fewer home care visits (9.40 95%CI: 7.89-10.92 vs.11.30 95%CI: 9.10-14.54). No differences were found in terms of frequency of visits to A&E or hospital re-admissions. Furthermore, patients in the control group perceived higher levels of satisfaction (16.88; 95%CI: 16.32-17.43; range: 0-21, vs. 14.65 95%CI: 13.61-15.68; p = 0,001).

CONCLUSION

A home care service model that includes nurse-led case management streamlines access to healthcare services and resources, while impacting positively on patients' functional ability and caregiver burden, with increased levels of satisfaction.

TRIAL REGISTRATION

ISRCTN44054549.

Effects of a nursing intervention program on disabled patients and their caregivers

This study evaluated a continuous home-visiting program designed for disabled patients. An intervention program was also designed for caregivers that included education and disabled care skills training, and emotional support over a 22-week period. The criteria for the disabled patients were as follows: (1) aged 18 years or older, (2) Barthel activity of daily living (ADL) score of <80 on the first visit, and (3) onset of disability prior to study was less than 2 years. A total of 126 participants were transferred from several hospitals to the community to be cared for by caregivers. Patients were divided into two groups: control group (n=56), and intervention group (n=70). In the control group, caregivers were not provided with any special training and patients were just evaluated at the beginning and end of the program. In the intervention group, caregivers were given intensive training in care for the disabled and completed eight home-visits. The outcomes were measured before and after program using Barthel ADL index, life satisfaction scale (LSS) and caregiver's burnout scale (CBS). The results showed that improvements in ADL, LSS and CBS were significantly greater in the intervention group, compared to the control group. Multiple linear regression models showed that improvements in ADL were higher among patients with early-stage (onset of disability was less than 6 months before the start of the program) disability, patients whose caregivers had good health status, patients in the intervention group and patients who received more daily care hours. For LSS, there was a negative correlation with change in CBS and financial burden. In conclusion, the intervention program significantly improved disabled patients' ADL scores, as well as caregivers' LSS and CBS scores. It is necessary to coordinate medical and public health resources in the community to provide disabled patients and their caregivers with specific training and caregiving skills.