Activating patients with chronic disease for self-management: comparison of self-managing patients with those managing by frequent readmissions to hospital

Older persons with multiple chronic conditions' experiences of unplanned readmission: An integrative review

BACKGROUND

As persons, 60 years of age and older live longer, they are more likely to develop one or more chronic conditions. Rising numbers of older persons with multiple chronic conditions (MCCs) will increase the need for home healthcare services and hospital services and unplanned readmissions will increase globally.

AIM

The aim of this integrative review was to explore the experiences of older persons with MCCs' unplanned readmission from home to hospital within 30 days of discharge using an integrative review.

METHOD

Whittemore and Knafl's method was followed to address the research aim. Four databases (Ovid MEDLINE, Scopus, CINAHL and Embase) were searched between 2005 and 2020, suitability for inclusion was assessed, and data were extracted and analysed using content analysis.

RESULTS

Thirteen articles (10 qualitative, one quantitative, and two mixed methods) were included in this review. Three themes emerged from the data that reflected older persons with MCCs' unplanned readmission experiences. These themes included (a) feelings of security, support and relief; (b) undesirable challenges at home (struggling to manage care and balancing support needs); and (c) unpleasant feelings and emotions (feelings of fear and mistrust, feelings of disappointment and loss, feelings of anxiousness and pressure).

CONCLUSION

Research about unplanned readmission to the hospital does not provide sufficient detail or understanding about older persons with MCCs' experiences or their psychosocial experiences. Addressing research gaps related to the psychosocial processes and factors associated with unplanned readmission is needed to expand the current understanding of the process and concept of unplanned readmission.

Improving outcomes for marginalised rural families through a care navigator program

ISSUES ADDRESSED

Health promotion programs are based on the premise that health and well-being is impacted by a person's living circumstances, not just factors within the health arena. Chronic health issues require integrated services from health and social services. Navigator positions are effective in assisting chronic disease patients to access services. This family program in a small rural town in Western New South Wales targeted marginalised families with children under five years of age with a chronic health issue. The navigator developed a cross-sectoral care plan to provide services to address family issues. The study aimed to identify navigator factors supporting improved family outcomes.

METHODS

Participants included parent/clients (n = 4) and the cross-sectoral professional team (n = 9) involved in the program. During the interview, participants were asked about their perspective of the program. Interview transcripts were thematically analysed informed by the Chronic Care Model underpinned by Health Promotion Theory.

RESULTS

The program improved client family's lives in relation to children's health and other family health and social issues. Trust in the care navigator was the most important factor for parents to join and engage with the program. The care navigator role was essential to maintaining client engagement and supporting cooperation between services to support families.

CONCLUSION

Essential care navigator skills were commitment, ability to persuade and empower parents and other professionals. SO WHAT?: This descriptive study demonstrated the positive influence of the care navigator and the program on high risk families in a small isolated community. It can be adopted by other communities to improve life for families at risk.

Feasibility of the PHYZ X 2U program: a mobile and cloud-based outreach service to improve chronic disease outcomes in underserviced rural communities

Chronic disease is prevalent in rural communities, but access to health care is limited. Allied health intervention, incorporating behaviour change and exercise, may improve health outcomes. PHYZ X 2U is a new service delivery model incorporating face-to-face consultations via a mobile clinic and remote health coaching, delivered by physiotherapy and exercise physiology clinicians and university students on clinical placement, to provide exercise programs to people living with chronic disease in rural New South Wales, Australia. This pilot study evaluated the feasibility and acceptability of PHYZ X 2U by evaluating participants' goal attainment, exercise, quality of life and behaviour change following participation in the 12-week program, and amount of health coaching received. Sixty-two participants with one or more chronic diseases set a total of 123 goals. Thirty-nine (63%) participants completed the program, with 59% of these achieving their goals and 43% progressing in their attitudes and behaviour towards exercise. Weekly exercise increased by 1h following program participation (P=0.02), but quality of life remained unchanged (P=0.24). Participants who completed the program received more health coaching than those lost to follow up. PHYZ X 2U can increase access to allied health for people with chronic disease living in rural and remote areas. Refining the service to maximise program adherence and optimally manage a broad range of chronic diseases is required.

The Management of Chronic Back Pain in Primary Care Settings: Exploring Perceived Facilitators and Barriers to the Development of Patient-Professional Partnerships

Supporting patients in forming partnerships with health professionals is the key of effective self-management. This study aimed to explore the nature of patient-professional partnerships and its related factors that create facilitators and barriers to patients' self-management ability. A constructivist grounded theory approach was undertaken. Three main themes emerged: interaction and communication, integrated care, and service and system. A theoretical model was generated that posits effective communication, individualized integrated care, and high-quality service as key influences on the successful development of patient-professional partnerships and patients' ability to self-manage. Giving attention to these factors helps understand the development, implementation, mechanisms, and evaluation of building a patient-professional partnership and maximizes the opportunities for patient self-management of chronic pain. Future research and practice are needed to move beyond a simplistic focus on health outcomes to address the complex links between partnerships and treatment delivery processes, and interventions, effects, and patients' context.

Symptom burden and self-management in persons with chronic obstructive pulmonary disease

Purpose

Self-management is crucial for effective COPD management. This study aimed at identifying associations between self-management and sociodemographic characteristics, clinical characteristics, and symptom burden in people with COPD.

Patients and methods

In this cross-sectional study with 225 participants diagnosed with COPD grades II–IV, multiple linear regression analysis was conducted, using sociodemographic and clinical characteristics and symptom burden (COPD Assessment Test) as the independent variables and the eight self-management domains of the Health Education Impact Questionnaire (heiQ) as the outcome variables.

Results

Higher symptom burden was significantly associated with worse scores in all self-management domains (p<0.003), except for self-monitoring and insight (p=0.012). Higher disease severity (p=0.004) and numbers of comorbidities (p<0.001) were associated with more emotional distress, and women scored higher than men on positive and active engagement in life (p=0.001). Higher score in pack-years smoking was associated with lower score in health-directed activities (p=0.006) and self-monitoring and insight (p<0.001), and participation in organized physical training was associated with higher score in health-directed activities (p<0.001). The final models explained 3.7%–31.7% of variance (adjusted R²) across the eight heiQ scales.

Conclusion

A notable finding of this study was that higher symptom burden was associated with worse scores in all self-management domains, except for self-monitoring and insight. In addition, sex, disease severity, comorbidity, pack-years smoking, and participation in organized physical training were associated with one or two self-management domains. The study contributes to improved understanding of self-management in COPD. However, the explained variance levels indicate that more research needs to be done to uncover what else explains self-management domains in COPD.

Pattern and Predictors of Hospital Readmission During the First Year After Lung Transplantation

Hospital readmission after lung transplantation negatively affects quality of life and resource utilization. A secondary analysis of data collected prospectively was conducted to identify the pattern of (incidence, count, cumulative duration), reasons for and predictors of readmission for 201 lung transplant recipients (LTRs) assessed at 2, 6, and 12 mo after discharge. The majority of LTRs (83.6%) were readmitted, and 64.2% had multiple readmissions. The median cumulative readmission duration was 19 days. The main reasons for readmission were other than infection or rejection (55.5%), infection only (25.4%), rejection only (9.9%), and infection and rejection (0.7%). LTRs who required reintubation (odds ratio [OR] 1.92; p = 0.008) or were discharged to care facilities (OR 2.78; p = 0.008) were at higher risk for readmission, with a 95.7% cumulative incidence of readmission at 12 mo. Thirty-day readmission (40.8%) was not significantly predicted by baseline characteristics. Predictors of higher readmission count were lower capacity to engage in self-care (incidence rate ratio [IRR] 0.99; p = 0.03) and discharge to care facilities (IRR 1.45; p = 0.01). Predictors of longer cumulative readmission duration were older age (arithmetic mean ratio [AMR] 1.02; p = 0.009), return to the intensive care unit (AMR 2.00; p = 0.01) and lower capacity to engage in self-care (AMR 0.99; p = 0.03). Identifying LTRs at risk may assist in optimizing predischarge care, discharge planning and long-term follow-up.

'I have only little English': language anxiety of Filipino migrants with chronic disease

OBJECTIVE

This study investigates communication challenges faced by Filipino patients with chronic diseases when engaging with healthcare professionals (HCPs).

DESIGN

Nine focus groups were conducted between November 2010 and June 2011.

RESULTS

Two main categories of themes were identified: patient-related and HCP-related factors. Patient-related factors included three subthemes: (1) lack of confidence in their English language abilities in clinical situations; (2) cultural attitudes; and (3) strategies used to improve communication. Older Filipinos with chronic disease were anxious about their lack of ability to explain their symptoms in English and were concerned that asking questions was conveying distrust in the HCPs. Most of the elderly simply nodded their head to indicate they understood even if they did not, for fear of being thought 'stupid'. Many participants preferred Filipino GPs or have a relative interpret for them. Two subthemes were related to HCPs including (1) not being listened to and (2) assumptions of understanding. HCPs were thought to assume English language skills in Filipino patients and therefore were not careful about ensuring understanding.

CONCLUSIONS

These findings highlighted the need for HCPs to be more aware of 'grey areas' in English-language proficiency and the cultural lens through which migrants understand health.

What's in a name? Concordance is better than adherence for promoting partnership and self-management of chronic disease

The choice of language health professionals use to discuss self-management of chronic disease is important and influences patients' self-management. The words compliance, adherence and concordance are used to discuss patients' agreement with prescribed treatment plans, but have different tone and meanings. Models of care linked to the words compliance and adherence are underpinned by interactions between patients and healthcare providers that merely reinforce instructions about treatments. The 'patient-professional partnership' is introduced as a model by Bodenheimer et al. (2002, p. 2469) whereby true partnership working should be an opportunity to pool the expertise of both parties to arrive at mutually agreed goals in concordance. The impact these words might have on partnership working is important in defining the patient-health professional relationship, and for the patients' healthcare outcomes and the potential effect on healthcare utilisation.

Patients' perspectives on the impact of a new COPD diagnosis in the face of multimorbidity: a qualitative study

Background:

Chronic obstructive pulmonary disease (COPD), a major cause of morbidity and mortality worldwide, often occurs in the presence of comorbidities, which may influence experience and management of the disease. No prior research seems to have gained perspectives of newly diagnosed primary care COPD patients in the context of multimorbidity.

Aims:

This qualitative study aimed to explore the impact of a new diagnosis of COPD in the context of multimorbidity and also sought to gain a better understanding of how patients react to the diagnosis and incorporate it into their lives.

Methods:

Participants were identified from a cohort of primary care patients with multimorbidity recently diagnosed with COPD. Data was collected via semi-structured interviews from nine male and eight female participants. Thematic analysis was performed and the data interpreted from a constructivist perspective.

Results:

Five core themes regarding COPD were induced: (i) reaction to diagnosis, (ii) impact on function and health behaviour, (iii) factors influencing self-management capacity, (iv) healthcare utilisation and (v) interplay of comorbidities. Most participants had difficulty recognising the importance of COPD and its long-term implications. For many, the salience of another chronic condition outweighed COPD. Self-management capacity and utilisation of healthcare services were challenged by low prioritisation of COPD among other comorbidities.

Conclusions:

This study provides an insight into how primary care patients feel about being diagnosed with COPD, as well as their prioritisation of the disease in the context of multimorbidity. It highlights the need for tailored education and personalised management incorporating patients’ perspectives in primary care.

Frequent hospital admission of older people with chronic disease: a cross-sectional survey with telephone follow-up and data linkage

BACKGROUND

The continued increase in hospital admissions is a significant and complex issue facing health services. There is little research exploring patient perspectives or examining individual admissions among patients with frequent admissions for chronic ambulatory care sensitive (ACS) conditions. This paper aims to describe characteristics of older, rural patients frequently admitted with ACS conditions and identify factors associated with their admissions from the patient perspective.

METHODS

Patients aged 65+ resident in North Coast NSW with three or more admissions for selected ACS chronic conditions within a 12 month period, were invited to participate in a postal survey and follow up telephone call. Survey and telephone data were linked to admission and health service program data. Descriptive statistics were generated for survey respondents; logistic regression models developed to compare characteristics of patients with 3 or with 4+ admissions; and comparisons made between survey respondents and non-respondents.

RESULTS

Survey respondents (n=102) had a mean age of 77.1 years (range 66-95 years), and a mean of 4.1 admissions within 12 months; 49% had at least three chronic conditions; the majority had low socioeconomic status; one in five (22%) reported some difficulty affording their medication; and 35% lived alone. The majority reported psychological distress with 31% having moderate or severe psychological distress. While all had a GP, only 38% reported having a written GP care plan. 22% of those who needed regular help with daily tasks did not have a close friend or relative who regularly cared for them. Factors independently associated with more frequent (n=4+) relative to less frequent (n=3) admissions included having congestive heart failure (p=0.003), higher social isolation scores (p=0.040) and higher Charlson Comorbidity Index scores (p=0.049). Most respondents (61%) felt there was nothing that could have avoided their most recent admission, although some potential avoidability of admission was described around medication and health behaviours. Respondents were younger and less sick than non-respondents.

CONCLUSIONS

This study provides a detailed description of older patients with multiple chronic conditions and a history of frequent admission in rural Australia. Our results suggest that programs targeting medication use, health behaviours and social isolation may help reduce multiple hospital admissions for chronic disease.