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King P, Jadzinski P, Pocock H, Lofthouse-Jones C, Brown M, Fogg C. Introduction of a section for recording dementia improves data capture on the ambulance electronic patient record: evidence from a regional quality improvement project. Br Paramed J 2024; 9:29-37. [PMID: 39246834 PMCID: PMC11376324 DOI: 10.29045/14784726.2024.9.9.2.29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/10/2024] Open
Abstract
Introduction Dementia is a common co-morbidity in older people who require urgent or emergency ambulance attendance and influences clinical decisions and care pathways. Following an initial audit of dementia data and consultation with staff, a specific section (tab) to record dementia was introduced on an ambulance service electronic patient record (ePR). This includes a dementia diagnosis button and a free-text section. We aimed to assess whether and how this improved recording. Methods To re-audit the proportion of ambulance ePRs where dementia is recorded for patients aged ≥65 years, and to describe the frequency of recording in patients aged <65; to analyse discrepancies in the place of recording dementia on the ePR by comparing data from the new dementia tab and other sections of the ePR. Results We included 112,193 ePRs of patients aged ≥65 with ambulance attendance from a six-month period. The proportion with dementia recorded in patients aged ≥65 was 16.5%, increasing to 19.9% in patients aged ≥75, as compared to 13.5% (≥65) and 16.5% (≥75) in our previous audit. In this audit, of the 16.5% (n = 18,515) of records with dementia recorded, 69.9% (n = 12,939) used the dementia button and 25.4% (n = 4704) recorded text in the dementia tab. Dementia was recorded in ePR free-text fields (but not the dementia tab) in 29.7% of records. Eighteen other free-text fields were used in addition to, or instead of, the dementia tab, including the patient's social history, previous medical history and mental health. Dementia was present on the ePR of 0.4% (n = 461) of patients aged <65. Conclusions An ePR dementia tab enabled ambulance clinicians to standardise the location of recording dementia and may have facilitated increased recording. We would recommend other ambulance trusts capture this information in a specific section to improve information sharing and to inform care planning for this patient group.
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Affiliation(s)
- Phil King
- South Central Ambulance Service NHS Foundation Trust ORCID iD: https://orcid.org/0000-0001-7736-7183
| | - Patryk Jadzinski
- South Central Ambulance Service NHS Foundation Trust; University of Portsmouth ORCID iD: https://orcid.org/0000-0002-6752-0807
| | - Helen Pocock
- South Central Ambulance Service NHS Foundation Trust ORCID iD: https://orcid.org/0000-0001-7648-5313
| | - Chloe Lofthouse-Jones
- South Central Ambulance Service NHS Foundation Trust ORCID iD: https://orcid.org/0000-0001-8118-3934
| | - Martina Brown
- South Central Ambulance Service NHS Foundation Trust ORCID iD: https://orcid.org/0000-0003-3083-8958
| | - Carole Fogg
- University of Southampton ORCID iD: https://orcid.org/0000-0002-3000-6185
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Han MX, Ross L, Hemingway L, Anderson D, Gosling C. Out-of-hospital paramedic interactions with people living with dementia: a scoping review. Age Ageing 2024; 53:afae143. [PMID: 38994589 DOI: 10.1093/ageing/afae143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Indexed: 07/13/2024] Open
Abstract
BACKGROUND Dementia encompasses neurodegenerative disorders that account for a global estimated healthcare expenditure of 1.3 trillion US dollars. In Australia, one in 12 people aged ≥65 has a diagnosis of dementia and it is the second leading cause of death. Paramedics play a crucial role in person-centred dementia care, particularly in the community. While consensus has been established on paramedicine's integration into interdisciplinary care teams, there remains a lack of clarity regarding the paramedic role in dementia care. OBJECTIVE This study aimed to examine and report paramedic interactions with people living with dementia in the out-of-hospital setting. DESIGN AND SETTING This was a scoping review study of paramedics and people living with dementia within the out-of-hospital setting. METHODS This study was guided by the Joanna Briggs Institute (JBI) scoping review framework. Databases were searched without date limits, up to 4 April 2023. These encompassed OVID Medline, CINAHL, Scopus, APA PsycInfo and OVID Embase. Articles were included if they were primary, peer-reviewed studies in English and reporting on paramedic-specific interactions with people living with dementia in the out-of-hospital setting. Data extraction was performed based on study setting, design, population and key findings. RESULTS Twenty-nine articles were included in the thematic analysis. Four themes emerged: need for training, patterns of attendances, patterns of documentation and the integrative potential of paramedicine. Paramedics reported feeling ill-equipped and unprepared in caring for patients living with dementia due to challenges in assessment and management of caregiver tensions. They were often called as a last resort due to poor service integration and a lack of alternative care pathways. Despite high conveyance rates, there was low incidence of paramedic interventions initiated. Underdocumentation of dementia and pain was found. CONCLUSION Emergency ambulance conveyance of people living with dementia is a surface reaction compounded by a lack of direction for paramedics in the provision of out-of-hospital care. There is a pressing need for establishment of research and educational priorities to improve paramedic training in dementia-specific skillsets.
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Affiliation(s)
- Ming Xuan Han
- Department of Paramedicine, Monash University Peninsula Campus, Frankston, Victoria 3199, Australia
| | - Linda Ross
- Department of Paramedicine, Monash University Peninsula Campus, Frankston, Victoria 3199, Australia
| | - Liam Hemingway
- Department of Paramedicine, Monash University Peninsula Campus, Frankston, Victoria 3199, Australia
| | - David Anderson
- Department of Paramedicine, Monash University Peninsula Campus, Frankston, Victoria 3199, Australia
- Ambulance Victoria, Doncaster, Victoria 3108, Australia
| | - Cameron Gosling
- Department of Paramedicine, Monash University Peninsula Campus, Frankston, Victoria 3199, Australia
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Fonda N, Ross L. Interprofessional peer assisted learning: Paramedic students learning falls assessments from Occupational Therapy students. J Interprof Care 2023; 37:1032-1035. [PMID: 37190769 DOI: 10.1080/13561820.2023.2208606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 04/24/2023] [Accepted: 04/25/2023] [Indexed: 05/17/2023]
Abstract
Peer-assisted learning (PAL) describes a program in which students learn from students from the same health discipline. This teaching method has gained significant momentum over the past decade as an effective learning strategy for undergraduate healthcare students. Paramedic programs are increasingly utilizing PAL, however there is a scarcity of literature about interprofessional PAL, particularly between Paramedics and allied health students. This project was an evaluation of a pilot educational intervention involving final year undergraduate paramedic students. Occupational Therapy (OT) peer instructors facilitated a session on falls' risk assessments during a scheduled undergraduate Paramedic practical class. The OT peer instructors discussed pertinent considerations for Paramedics attending to elderly patients who have fallen, and then provided direct feedback to the Paramedic students during a case simulation. At the conclusion of the session, Paramedic students completed a survey evaluating their reaction to and learning from the teaching session. Results indicated that interprofessional PAL can improve undergraduate paramedic students' knowledge and confidence in performing a new skill that is well understood by another allied health profession. This adds to the body of empirical research on interprofessional PAL and supports its inclusion as a teaching modality into undergraduate healthcare programs such as Paramedicine.
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Affiliation(s)
- Natalie Fonda
- Department of Paramedicine, Monash University, Melbourne, Australia
| | - Linda Ross
- Department of Paramedicine, Monash University, Melbourne, Australia
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4
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Fehlmann CA, Stuby L, Graf C, Genoud M, Rigney R, Goldstein J, Eagles D, Suppan L. Assessment of frailty by paramedics using the clinical frailty scale - an inter-rater reliability and accuracy study. BMC Emerg Med 2023; 23:121. [PMID: 37833643 PMCID: PMC10576312 DOI: 10.1186/s12873-023-00875-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 08/25/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND Frailty assessment by paramedics in the prehospital setting is understudied. The goals of this study were to assess the inter-rater reliability and accuracy of frailty assessment by paramedics using the Clinical Frailty Scale (CFS). METHODS This was a cross-sectional study with paramedics exposed to 30 clinical vignettes created from real-life situations. There was no teaching intervention prior to the study and paramedics were only provided with the French version of the CFS (definitions and pictograms). The primary outcome was the inter-rater reliability of the assessment. The secondary outcome was the accuracy, compared with the expert-based assessment. Reliability was determined by calculating an intraclass correlation coefficient (ICC). Accuracy was assessed through a mixed effects logistic regression model. A sensitivity analysis was carried out by considering that an assessment was still accurate if the score differed from no more than 1 level. RESULTS A total of 56 paramedics completed the assessment. The overall assessment was found to have good inter-rater reliability (ICC = 0.87 [95%CI 0.81-0.93]). The overall accuracy was moderate at 60.6% (95%CI 54.9-66.1) when considering the full scale. It was however much higher (94.8% [95%CI 92.0-96.7] when close assessments were considered as accurate. The only factor associated with accurate assessment was field experience. CONCLUSION The assessment of frailty by paramedics was reliable in this vignette-based study. However, the accuracy deserved to be improved. Future research should focus on the clinical impact of these results and on the association of prehospital frailty assessment with patient outcomes. REGISTRATION This study was registered on the Open Science Framework registries ( https://doi.org/10.17605/OSF.IO/VDUZY ).
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Affiliation(s)
- Christophe A Fehlmann
- Division of Emergency Medicine, Department of Acute Medicine, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, Geneva, CH-1211, Switzerland.
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, K1G 5Z3, Canada.
| | - Loric Stuby
- Genève TEAM Ambulances, Emergency Medical Services, Geneva, CH-1201, Switzerland
| | - Christophe Graf
- Department of rehabilitation and geriatrics, Geneva University Hospitals, Geneva, CH-1211, Switzerland
| | - Matthieu Genoud
- Division of Emergency Medicine, Department of Acute Medicine, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, Geneva, CH-1211, Switzerland
| | | | - Judah Goldstein
- Dalhousie Department of Emergency Medicine, Division of EMS, Halifax, NS, Canada
| | - Debra Eagles
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, K1G 5Z3, Canada
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Laurent Suppan
- Division of Emergency Medicine, Department of Acute Medicine, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, Geneva, CH-1211, Switzerland
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Lydon S, Masterson S, Deasy C, O'Connor P. Progressing patient safety in the Emergency Medical Services. BMJ Qual Saf 2023; 32:562-565. [PMID: 37353315 DOI: 10.1136/bmjqs-2023-016184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2023] [Indexed: 06/25/2023]
Affiliation(s)
- Sinéad Lydon
- Discipline of General Practice, School of Medicine, University of Galway, Galway, Ireland
- Irish Centre for Applied Patient Safety and Simulation, University of Galway, Galway, Ireland
| | - Siobhán Masterson
- Discipline of General Practice, School of Medicine, University of Galway, Galway, Ireland
- Clinical Directorate, National Ambulance Service, Health Service Executive, Limerick, Ireland
| | - Conor Deasy
- Emergency Medicine, Cork University Hospital, Cork, Ireland
- School of Medicine, University College Cork, Cork, Ireland
| | - Paul O'Connor
- Discipline of General Practice, School of Medicine, University of Galway, Galway, Ireland
- Irish Centre for Applied Patient Safety and Simulation, University of Galway, Galway, Ireland
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Corcoran G, Bernard P, Kenna L, Malone A, Horgan F, O'Brien C, Ward P, Howard W, Hogan L, Mooney R, Masterson S. "Older People Want to Be in Their Own Homes": A Service Evaluation of Patient and Carer Feedback after Pathfinder Responded to Their Emergency Calls. PREHOSP EMERG CARE 2023; 27:866-874. [PMID: 36633524 DOI: 10.1080/10903127.2023.2168094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 01/09/2023] [Accepted: 01/10/2023] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Older people experience high rates of adverse outcomes following emergency department (ED) presentation. There is growing evidence to support alternative care pathways for certain types of emergency medical services (EMS) calls. Pathfinder is one such service and targets patients aged 65 years and over, whose presenting issues can be safely managed at home by immediate paramedic, occupational therapy, and/or physiotherapy interventions. The aim of this service evaluation was to understand how older people feel about being treated at home as a result of EMS calls and to understand their experiences of the Pathfinder service. METHODS This was a thematic analysis of open-ended responses recorded from telephone interviews during routine service evaluation with service users (patients or their next-of-kin). RESULTS Of 573 service users, telephone interviews were conducted with 429 (75%). Five primary themes were identified: (1) professionalism of the multidisciplinary clinical team; (2) "the right service, in the right place, at the right time"; (3) role of Pathfinder in "getting the ball rolling"; (4) lasting effects of the experience on the patient and his or her next-of-kin; (5) value of skilled communication with the older person. CONCLUSION Older people and their next-of-kin voiced a clear preference for hospital avoidance, and strongly valued the opportunity to be treated in their homes at the time of an EMS call rather than default conveyance to the ED. They appreciated the importance of a skilled multidisciplinary team with a follow-up service that effectively positions itself between the acute hospital and community services.
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Affiliation(s)
- Grace Corcoran
- Physiotherapy Department, Beaumont Hospital, Dublin, Ireland
| | - Paul Bernard
- Occupational Therapy Department, Beaumont Hospital, Dublin, Ireland
| | - Lawrence Kenna
- National Ambulance Service, Health Service Executive, Dublin, Ireland
| | - Ailish Malone
- School of Physiotherapy, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Frances Horgan
- School of Physiotherapy, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Claire O'Brien
- Occupational Therapy Department, Beaumont Hospital, Dublin, Ireland
| | - Peter Ward
- Physiotherapy Department, Beaumont Hospital, Dublin, Ireland
| | - Willie Howard
- National Ambulance Service, Health Service Executive, Dublin, Ireland
| | - Laura Hogan
- National Ambulance Service, Health Service Executive, Dublin, Ireland
| | - Rebecca Mooney
- National Ambulance Service, Health Service Executive, Dublin, Ireland
| | - Siobhan Masterson
- National Ambulance Service, Health Service Executive, Dublin, Ireland
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Adibhatla S, Lurie T, Betz G, Palmer J, Raffman A, Andhavarapu S, Harris A, Tran QK, Gingold DB. A Systematic Review of Methodologies and Outcome Measures of Mobile Integrated Health-Community Paramedicine Programs. PREHOSP EMERG CARE 2022; 28:168-178. [PMID: 36260780 DOI: 10.1080/10903127.2022.2138654] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 10/10/2022] [Accepted: 10/16/2022] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Mobile integrated health-community paramedicine (MIH-CP) uses patient-centered, mobile resources in the out-of-hospital environment to increase access to care and reduce unnecessary emergency department (ED) usage. The objective of this systematic review is to characterize the outcomes and methodologies used by MIH-CP programs around the world and assess the validity of the ways programs evaluate their effectiveness. METHODS The PubMed, Embase, CINAHL, and Scopus databases were searched for peer-reviewed literature related to MIH-CP programs. We included all full-length studies whose programs met the National Association of Emergency Medical Technicians definition, had MIH-CP-related interventions, and measured outcomes. We excluded all non-English papers, abstract-only, and incomplete studies. RESULTS Our initial literature review identified 6434 titles. We screened 178 full-text studies to assess for eligibility and identified 33 studies to include in this review. These 33 include four randomized controlled trials, 17 cohort studies, eight 8 case series, and four 4 cross-sectional studies. Of the 29 non-randomized trials, five used matched controls, 13 used pre-post, and 11 used no controls. Outcomes measured were hospital usage (24 studies), ED visits (15), EMS usage (23), patient satisfaction (8), health-related outcomes (8), and cost (9). Studies that evaluated hospital usage reported one of several outcome measures: hospital admissions (11), ED length of stay (3), and hospital readmission rate (2). EMS usage was measured by ambulance transports (12) and EMS calls (10). Cost outcomes observed were ambulance transport savings (7), ED visit savings (4), hospital admission savings (3), and cost per quality-adjusted life year (2). CONCLUSION Most studies assessing MIH-CP programs reported success of their interventions. However, significant heterogeneity of outcome measures and varying quality of study methodologies exist among studies. Future studies designed with adequately matched controls and applying uniform core metrics for cost savings and health care usage are needed to better evaluate the effectiveness of MIH-CP programs.
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Affiliation(s)
| | - Tucker Lurie
- Department of Emergency Medicine, Wellspan York Hospital, York, Pennsylvania
| | - Gail Betz
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Jamie Palmer
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Alison Raffman
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Sanketh Andhavarapu
- University of Maryland at College Park, College Park, Maryland
- The Research Associate Program in Emergency Medicine & Critical Care, University of Maryland School of Medicine, Baltimore, Maryland
| | - Andrea Harris
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Quincy K Tran
- University of Maryland School of Medicine, Baltimore, Maryland
- University of Maryland at College Park, College Park, Maryland
- The Research Associate Program in Emergency Medicine & Critical Care, University of Maryland School of Medicine, Baltimore, Maryland
- Program in Trauma, The R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland
| | - Daniel B Gingold
- University of Maryland School of Medicine, Baltimore, Maryland
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, Maryland
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Fehlmann CA, Nickel CH, Cino E, Al-Najjar Z, Langlois N, Eagles D. Frailty assessment in emergency medicine using the Clinical Frailty Scale: a scoping review. Intern Emerg Med 2022; 17:2407-2418. [PMID: 35864373 PMCID: PMC9302874 DOI: 10.1007/s11739-022-03042-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 06/20/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Frailty is a common condition present in older Emergency Department (ED) patients that is associated with poor health outcomes. The Clinical Frailty Scale (CFS) is a tool that measures frailty on a scale from 1 (very fit) to 9 (terminally ill). The goal of this scoping review was to describe current use of the CFS in emergency medicine and to identify gaps in research. METHODS We performed a systemic literature search to identify original research that used the CFS in emergency medicine. Several databases were searched from January 2005 to July 2021. Two independent reviewers completed screening, full text review and data abstraction, with a focus on study characteristics, CFS assessment (evaluators, timing and purpose), study outcomes and statistical methods. RESULTS A total of 4818 unique citations were identified; 34 studies were included in the final analysis. Among them, 76% were published after 2018, mainly in Europe or North America (79%). Only two assessed CFS in the pre-hospital setting. The nine-point scale was used in 74% of the studies, and patient consent was required in 69% of them. The main reason to use CFS was as a main exposure (44%), a potential predictor (15%) or an outcome (15%). The most frequently studied outcomes were mortality and hospital admission. CONCLUSION The use of CFS in emergency medicine research is drastically increasing. However, the reporting is not optimal and should be more standardized. Studies evaluating the impact of frailty assessment in the ED are needed. REGISTRATION https://doi.org/10.17605/OSF.IO/W2F8N.
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Affiliation(s)
- Christophe Alain Fehlmann
- Division of Emergency Medicine, Department of Acute Medicine, Geneva University Hospitals, Geneva, Switzerland
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON Canada
- Ottawa Hospital Research Institute, Ottawa, ON Canada
| | - Christian Hans Nickel
- Emergency Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Emily Cino
- Faculty of Medicine, University of Ottawa, Ottawa, ON Canada
| | | | - Nigèle Langlois
- Health Sciences Library, University of Ottawa, Ottawa, Canada
| | - Debra Eagles
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON Canada
- Ottawa Hospital Research Institute, Ottawa, ON Canada
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON Canada
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Pathfinder; alternative care pathways for older adults who phone the emergency medical services in North Dublin: a case study. IRISH JOURNAL OF OCCUPATIONAL THERAPY 2022. [DOI: 10.1108/ijot-12-2021-0030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Purpose
Emergency Department (ED) presentations in older people are associated with a wide range of adverse events, which increase the risk of lengthy hospitalisation and poor outcomes. Pathfinder is an inter-organisational initiative delivered in partnership between Beaumont Hospital Occupational Therapy and Physiotherapy departments and the National Ambulance Service. Pathfinder responds to non-serious and non-life-threatening emergency medical service (EMS) calls. This study aims to demonstrate how Pathfinder can safely treat a proportion of older people at home by using alternative care pathways (ACPs), therefore avoiding unnecessary ED presentations. Once a decision has been reached to treat the person at home, the Pathfinder follow-up team delivers functional rehabilitation and case management in the persons’ home over the subsequent days.
Design/methodology/approach
This paper outlines the Pathfinder assessment, management and interventions in one clinical case example. Outcome measures include the level of patient satisfaction obtained via routine telephone feedback questionnaire and re-presentation to Beaumont Hospital within 30 days.
Findings
This paper illustrates through a case example the benefit of a collaborative multi-disciplinary rapid response team for non-serious and non-life-threatening EMS calls in older adults. The patient in this case example had no further EMS calls or ED presentations for 30 days after Pathfinder intervention and reported a high level of satisfaction with the service.
Research limitations/implications
ED presentation was avoided through comprehensive multi-disciplinary assessment, including immediate access to intensive follow-up support in the person’s own home.
Practical implications
The Pathfinder service is improving access to ACPs for older people in the Beaumont Hospital catchment area. Pathfinder will now be spread nationally, with local adaptation, so that older people in other parts of Ireland will also benefit from this integrated model of care.
Originality/value
Patient feedback surveys confirm older adults want access to alternative care pathways.
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