A system of integrated care for older persons with disabilities in Canada: results from a randomized controlled trial

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.

The role of frailty in the relationships between social relationships and health outcomes: a longitudinal study

BACKGROUND

Socially isolated older adults incur increased risks of adverse health outcomes, though the strength of this association is unclear. We examined whether changes in physical frailty moderated the associations between changes in social relationships and changes in health outcomes among older adults.

METHODS

This longitudinal study is based on three waves of the FRéLE study among 1643 Canadian community-dwelling older adults aged 65 years and older over 2 years. We performed latent growth curve modelling (LGMs) to assess changes with the assumption of missing not at random, adjusting for time-invariant covariates. We used the latent moderated structural equations (LMS) to test the interactions in LGMs. Social relationships were measured by social participation, social networks, and social support from different social ties. Frailty was assessed using the five components of the phenotype of frailty.

RESULTS

The results revealed that changes in frailty moderated changes in social participation (β = 3.229, 95% CI: 2.212, 4.245), social contact with friends (β = 4.980, 95% CI: 3.285, 6.675), and social support from friends (β = 2.406, 95% CI: 1.894, 2.917), children (β = 2.957, 95% CI: 1.932, 3.982), partner (β = 4.170, 95% CI: 3.036, 5.305) and extended family (β = 6.619, 95% CI: 2.309, 10.923) with changes in cognitive function and depressive symptoms, but not with chronic diseases. These results highlight the beneficial role of social relationships in declining depressive symptoms and improving cognitive health among older adults experiencing increases in frailty.

CONCLUSIONS

The findings suggest that changes in social support have a protective and compensatory role in decreasing depressive symptoms and enhancing cognitive health among older adults with increasing frailty. Public health policy and strategies should consider the impact of social support on multiple health outcomes among older adults with increasing frailty. Further experimental studies and interventions are warranted to extend findings on the relationships between social relationships and health outcomes, targeting frail older adults. Future studies may also consider other health-related risk factors that may impact the associations between social relationships and health outcomes among older adults.

Does competition support integrated care to improve quality?

Introduction

This work investigates the compatibility of integrated care and competition in China and analyses the impact of integrated care on regional care quality (DeptQ) within a competitive framework.

Method

The study was built on multivariate correspondence analysis and a two-way fixed-effects model. The data were collected from Xiamen's Big Data Application Open Platform and represent nine specialised departments that regularly performed inter-institutional referrals between 2016 and 2019.

Results

First, care quality for referred patients (ReferQ) and the relative scale of referred patients (ReferScale) and competition have an antagonistic but not completely mutually exclusive relationship. Second, ReferQ and competition both have a significant effect on DeptQ, but only when competition is weak can ReferQ and competition act synergistically on DeptQ. When competition is fierce, competition will weaken the impact of ReferQ on DeptQ.

Conclusion

Changes in the intensity of integrated care and competition ultimately affect care quality.

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.

Reducing hospital admissions and transfers to long-term inpatient care: A systematic literature review

Individuals in need of long-term care and their relatives prefer to receive and give care in their domestic environment for as long as possible. Residential long-term care is to be avoided for as long as possible. To achieve this goal, the care setting must be optimally oriented to the needs of the person in need of care. Moreover, relatives who provide care must be professionally supported. The Regional Care Competence Center (ReKo), launched on October 1, 2019, is a quasi-experimental study (two groups and pre-post design), funded by the Innovation Fund. As part of the ReKo project, people in need of care and their relatives are assisted by a case management (CM) system. An independent CM, supported by an IT network that includes the most important service providers, is to establish a comprehensive CM for people in need of care. Based on a literature review, this paper aimed to take a conceptual approach to the ReKo project by drawing on previous research and comparing the findings with the ReKo approach. The review considered CM projects that defined avoidance of hospitalization and/or delay in the transition of care recipients to long-term inpatient care as endpoints. Using PubMed and Google Scholar, the study screened 270 articles, abstracted and quality-assessed data, and included eight randomized clinical trials, two other studies, and seven reviews in the analysis. The review results and ReKo approaches are presented along the dimensions of clinical and medical benefits, community and public health benefits, economic benefits, and political and legislative benefits. CM organizations will continue to be established internationally in aging societies. The questions of improving quality of care, avoiding service costs, and the costs of establishing a CM must be raised, even if clear evidence is difficult to provide.

A qualitative study exploring hospital-based team dynamics in discharge planning for patients experiencing delayed care transitions in Ontario, Canada

BACKGROUND

In attempt to improve continuity of patient care and reduce length of stay, hospitals have placed an increased focus on reducing delayed discharges through discharge planning. Several benefits and challenges to team-based approaches for discharge planning have been identified. Despite this, professional hierarchies and power dynamics are common challenges experienced by healthcare providers who are trying to work as a team when dealing with delayed discharges. The objective of this study was to explore what was working well with formal care team-based discharge processes, as well as challenges experienced, in order to outline how teams can function to better support transitions for patients experiencing a delayed discharge.  METHODS: We conducted a descriptive qualitative study with hospital-based healthcare providers, managers and organizational leaders who had experience with delayed discharges. Participants were recruited from two diverse health regions in Ontario, Canada. In-depth, semi-structured interviews were conducted in-person, by telephone or teleconference between December 2019 and October 2020. All interviews were recorded and transcribed. A codebook was developed by the research team and applied to all transcripts. Data were analyzed inductively, as well as deductively through directed content analysis.

RESULTS

We organized our findings into three main categories - (1) collaboration with physicians makes a difference; (2) leadership should meaningfully engage with frontline providers and (3) partnerships across sectors are critical. Regular physician engagement, as equal members of the team, was recommended to improve consistent communication, relationship building between providers, accessibility, and in-person communication. Participants highlighted the need for a dedicated senior leader who ensured members of the team were treated as equals and advocated for the team. Improved partnerships across sectors included the enhanced integration of community-based providers into discharge planning by placing more focus on collaborative practice, combined discharge planning meetings, and having embedded and physically accessible care coordinators in the hospital.

CONCLUSIONS

Team-based approaches for delayed discharge can offer benefits. However, to optimize how teams function in supporting these processes, it is important to consistently collaborate with physicians, ensure senior leadership engage with and seek feedback from frontline providers through co-design, and actively integrate the community sector in discharge planning.

Effectiveness of community-based multidisciplinary integrated care for older people: a protocol for a systematic review

INTRODUCTION

The increasing number of older adults with multiple complex care needs has placed increased pressure on healthcare systems internationally to reorientate healthcare delivery. For many older adults, their first point of contact with the health service is with their general practitioner (GP) and GP participation with integrated care models is the foundation of a population-based approach. A knowledge gap remains in relation to the effectiveness of GP participation in community-based integrated health and social care approaches for older adults. This systematic review aims to examine the effectiveness of multidisciplinary-integrated care for community-dwelling older adults with GP participation.

METHODS AND ANALYSIS

This systematic review will include randomised controlled trials (RCTs), quasi and cluster RCTs focusing on integrated care interventions for community-dwelling older adults by multidisciplinary teams including health and social care professionals and GPs. The databases PUBMED, EMBASE, CINAHL, Central Register of Controlled Trials in the Cochrane Library and MEDLINE will be searched. The primary outcome measure will be functional status. Secondary outcomes will include: primary healthcare utilisation, secondary healthcare utilisation, participant satisfaction with care, health-related quality of life, nursing home admission and mortality. The methodological quality of the studies will be assessed using the Cochrane Risk of Bias Tool V.2. The elements of care integration will be mapped in the individual studies using the Rainbow Model of Integrated Care taxonomy. A meta-analysis will be completed, depending on the uniformity of the data. Grading of Recommendations, Assessment, Development and Evaluation will be used to assess the certainty of evidence.

ETHICS AND DISSEMINATION

Formal ethical approval is not required as all data included are anonymous secondary data. Scientific outputs will be presented at relevant conferences and in collaboration with our public and patient involvement stakeholder panel of older adults at the Ageing Research Centre at the University of Limerick.

PROSPERO REGISTRATION NUMBER

CRD42022309744.

Cost-effectiveness of a community-based integrated care model compared with usual care for older adults with complex needs: a stepped-wedge cluster-randomised trial

Objective

To assess the cost of implementation, delivery and cost-effectiveness (CE) of a flagship community-based integrated care model (OPEN ARCH) against the usual primary care.

Design

A 9-month stepped-wedge cluster-randomised trial.

Setting and participants

Community-dwelling older adults with chronic conditions and complex care needs were recruited from primary care (14 general practices) in Far North Queensland, Australia.

Methods

Costs and outcomes were measured at 3-month windows from the healthcare system and patient’s out-of-pocket perspectives for the analysis. Outcomes included functional status (Functional Independence Measure (FIM)) and health-related quality of life (EQ-5D-3L and AQoL-8D). Bayesian CE analysis with 10 000 Monte Carlo simulations was performed using the BCEA package in R (V.3.6.1).

Results

The OPEN ARCH model of care had an average cost of $A1354 per participant. The average age of participants was 81, and 55% of the cohort were men. Within-trial multilevel regression models adjusted for time, general practitioner cluster and baseline confounders showed no significant differences in costs, resource use or effect measures regardless of the analytical perspective. Probabilistic sensitivity analysis with 10 000 simulations showed that OPEN ARCH could be recommended over usual care for improving functional independence at a willing to pay above $A600 (US$440) per improvement of one point on the FIM Scale and for avoiding or reducing inpatient stay for any willingness-to-pay threshold up to $A50 000 (US$36 500).

Conclusions and implications

OPEN ARCH was associated with a favourable Bayesian CE profile in improving functional status and dependency levels, avoiding or reducing inpatient stay compared with usual primary care in the Australian context.

Trial registration number

ACTRN12617000198325.

Healthcare for older adults in North America: challenges, successes and opportunities

Older adults in North America face similar challenges to successful ageing as other adults around the world, including an increased risk of geriatric syndromes and functional decline, limited access to healthcare professionals specialising in geriatrics and constraints on healthcare spending for Long-Term Services and Supports. Geriatrics as a specialty has long been established, along with the creation of a variety of screening tools for early identification of geriatric syndromes. Despite this, workforce shortages in all older adult care service areas have led to significant gaps in care, particularly in community settings. To address these gaps, innovative programs that expand the reach of geriatric specialists and services have been developed. Opportunities exist for further dissemination of these programs and services, as well as for expansion of an ageing capable workforce.

A realist review of the home care literature and its blind spots

RATIONALE, AIMS AND OBJECTIVES

There is a large body of literature from all over the world that describes, analyzes, or evaluates home care models and interventions. The present article aims to identify the practical lessons that can be gained from a systematic examination of that literature.

METHOD

We conducted a three-step sequential search process from which 113 documents were selected. That corpus was then narratively analysed according to a realist review approach.

RESULTS

A first level of observation is that there are multiple blind spots in the existing literature on home care. The definition and delimitation of what constitutes home care services is generally under-discussed. In the same way, the composition of the basket of care provided and its fit with the need of recipients is under-addressed. Finally, the literature relies heavily on RCTs whose practical contribution to decisions or policy is disputable. At a second level, our analysis suggests that three mechanisms (system integration, case management and relational continuity) are core characteristics of home care models' effectiveness.

CONCLUSION

We conclude by providing advice for supporting the design and implementation of stronger home care delivery systems. Our analysis suggests that doing so implies a series of sequential steps: identify what system-level goals the model should achieve and which populations it should serve; identify what type of services are likely to achieve those goals in order to establish a basket of services; and finally, identify the best ways and specific means to effectively and efficiently provide those services. Those same steps can also support ex-post evaluations of existing home care systems.

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.

Models of integrated care for older people with frailty: a horizon scanning review

OBJECTIVES

Frailty, a multifaceted geriatric condition, is an emerging global health problem. Integrated care models designed to meet the complex needs of the older people with frailty are required. Early identification of innovative models may inform policymakers and other stakeholders of service delivery alternatives they can introduce and locally adapt so as to tackle system fragmentation and lack of coordination. This study used horizon scanning methodologies to systematically search for, prioritise and assess new integrated care models for older people with frailty and investigated experts' views on barriers and facilitators to the adoption of horizon scanning in health services research.

METHODS

A four-step horizon scanning review was performed. Frailty-specific integrated care models and interventions were identified through a review of published literature supplemented with grey literature searches. Results were filtered and prioritised according to preset criteria. An expert panel focus group session assessed the prioritised models and interventions on innovativeness, impact and potential for implementation. The experts further evaluated horizon scanning for its perceived fruitfulness in aiding decision-making.

RESULTS

Nine integrated care models and interventions at system level (n=5) and community level (n=4) were summarised and assessed by the expert panel (n=7). Test scores were highest for the Walcheren integrated care model (system-based model) and EuFrailSafe (community-based intervention). The participants stated that horizon scanning as a decision-making tool could aid in assessing knowledge gaps, criticising the status quo and developing new insights. Barriers to adoption of horizon scanning on individual, organisational and wider institutional level were also identified.

CONCLUSION

Study findings demonstrated that horizon scanning is a potentially valuable tool in the search for innovative service delivery models. Further studies should evaluate how horizon scanning can be institutionalised and effectively used for serving this purpose.

Defining Pooled' Place-Based' Budgets for Health and Social Care: A Scoping Review

Introduction

Current descriptions of pooled budgets in the literature pose challenges to good quality evaluation of their contribution to integrated care. Addressing this gap is increasingly important given the shift from early models of integrated care targeting segments of the population, to more recent approaches that aim to target 'places', broader geographically defined populations. This review draws on the current international evidence to describe practical examples of pooled health and social care budgets, highlighting specific place-based approaches.

Methods

We initially conducted a scoping review, a systematic database search ('Medline', 'Embase', 'Econ Lit' and 'Google Scholar') complemented by further snowballing for academic and 'grey literature' publications (1995 - 2020). Results were analysed thematically according to budget characteristics and macro-environment, with additional specific case studies.

Results

Thirty-six primary studies were included, describing ten broad models of pooled budgets across seven countries. Most budgets targeted specific sub-populations rather than an entire geographically defined population. Specific budget structures varied and were generally under-described. The closest place-based models were for small populations and implemented in a national health system, or insurance-based with natural geographical boundaries.

Conclusion

Despite their increasing relevance in the current political debate, pooled place-based budgets are still at an early stage of implementation and research. Adequate description is required for future meta-analysis of effectiveness on outcomes.

Out-of-pocket expenses related to aging in place for frail older people: a scoping review

Objective:

The objective of this scoping review was to map and describe the available evidence reporting out-of-pocket expenses related to aging in place for older people with frailty and their caregivers.

Introduction:

As the global population ages, there has been increasing attention on supporting older people to live at home in the community as they experience health and functional changes. Older people with frailty often require a variety of supports and services to live in the community, yet the out-of-pockets costs associated with these resources are often not accounted for in health and social care literature.

Inclusion criteria:

Sources that reported on the financial expenses incurred by older people (60 years or older) with frailty living in the community, or on the expenses incurred by their family and friend caregivers, were eligible for inclusion in the review.

Methods:

We searched for published and unpublished (ie, policy papers, theses, and dissertations) studies written in English or French between 2001 and 2019. The following databases were searched: CINAHL, MEDLINE, Scopus, Embase, PsycINFO, Sociological Abstracts, and Public Affairs Index. We also searched for gray literature in a selection of websites and digital repositories. JBI scoping review methodology was used, and we consulted with a patient and family advisory group to support the relevance of the review.

Results:

A total of 42 sources were included in the review, including two policy papers and 40 research papers. The majority of the papers were from the United States (n = 18), with others from Canada (n = 6), the United Kingdom (n = 3), Japan (n = 2), and one each from Australia, Brazil, China, Denmark, Israel, Italy, The Netherlands, Poland, Portugal, Singapore, South Korea, Taiwan, and Turkey. The included research studies used various research designs, including cross-sectional (n = 18), qualitative (n = 15), randomized controlled trials (n = 2), longitudinal (n = 2), cost effectiveness (n = 1), quasi-experimental (n = 1), and mixed methods (n = 1). The included sources used the term “frailty” inconsistently and used various methods to demonstrate frailty. Categories of out-of-pocket expenses found in the literature included home care, medication, cleaning and laundry, food, transportation, medical equipment, respite, assistive devices, home modifications, and insurance. Five sources reported on out-of-pocket expenses associated with people who were frail and had dementia, and seven reported on the out-of-pocket expenses for caregivers of people with frailty. While seven articles reported on specific programs, there was very little consistency in how out-of-pocket expenses were used as outcome measures. Several studies used measures of combined out-of-pocket expenses, but there was no standard approach to reporting aggregate out-of-pocket expenses.

Conclusions:

Contextual factors are important to the experiences of out-of-pocket spending for older people with frailty. There is a need to develop a standardized approach to measuring out-of-pocket expenses in order to support further synthesis of the literature. We suggest a measure of out-of-pocket spending as a percentage of family income. The review supports education for health care providers to assess the out-of-pocket spending of community-dwelling older people with frailty and their caregivers. Health care providers should also be aware of the local policies and resources that are available to help older people with frailty address their out-of-pocket spending.

Avoidable Hospitalizations in Persons with Dementia: a Population-Wide Descriptive Study (2000-2015)

Background

Whether avoidable hospitalizations in community-dwelling persons with dementia have decreased during primary care reforms is unknown.

Methods

We described the prevalence and trends in avoidable hospitalizations in population-based repeated yearly cohorts of 192,144 community-dwelling persons with incident dementia (Quebec, 2000-2015) in the context of a province-wide primary care reform, using the provincial health administrative database.

Results

Trends in both types of Ambulatory Care Sensitive Condition (ACSC) hospitalization (general and older population) and 30-day readmission rates remained constant with average rates per 100 person-years: 20.5 (19.9-21.1), 31.7 (31.0-32.4), 20.6 (20.1-21.2), respectively. Rates of delayed hospital discharge (i.e., alternate level of care (ALC) hospitalizations) decreased from 23.8 (21.1-26.9) to 17.9 (16.1-20.1) (relative change -24.6%).

Conclusions

These figures shed light on the importance of the phenomenon, its lack of improvement for most outcomes over the years, and the need to develop evidence-based policies to prevent avoidable hospitalizations in this vulnerable population.

Supporting government policies to embed and expand rehabilitation in health systems in Europe: A framework for action

Investment in action is vital to confront the challenges associated with chronic diseases and disability facing European health systems. Although relevant policy responses are being increasingly developed, most of them fail to recognize the role of rehabilitation services in achieving public health and social goals. Comprehensive guidance is thus urgently needed to support rehabilitation policy development and expand access to rehabilitation care to meet population needs effectively. This paper describes a framework to guide policy action for rehabilitation in Europe. The framework was developed in collaboration with the European Academy of Rehabilitation Medicine based on a focused literature review and expert consultations. A review in PubMed and grey literature sources identified 458 references and resulted in 135 relevant documents published between 2006 and 2019. Thematic analysis of extracted information helped summarize the findings and develop the draft policy action framework. This was circulated to a wider group of experts and discussed in three workshops in 2018-2019. The framework was revised according to their feedback. The proposed framework contains 48 options for policy action organized in six domains and twelve subdomains that address several areas of health programming. The proposed framework provides a structure to understand the policy terrain related to rehabilitation in Europe and the measures required for translating aspirational political pronouncements into targeted programmatic action and tangible health and social outcomes.

Effectiveness of a health and social care integration programme for home-dwelling frail older persons in Argentina

Introduction

The evidence of effectiveness of integrated care initiatives for home-dwelling frail older persons is still inconclusive. There is a need for more studies, especially in developing countries. Our objective was to assess the effectiveness of a health and social care integration programme versus the best standard of care to date in this population.

Methods

Quasi-experimental study performed in patients' homes in Buenos Aires, Argentina. The intervention arm had a health and social care counsellor that systematically reviewed the social and biological situation following a structured process, evaluating: functionality, nutrition, mobility, pain, cognition, medication reconciliation and adherence, need for care, quality of care, and environmental safety. The control group received the best standard of care to date, with access to the same health or social care services, but without the counsellor and related processes. The main outcome was the adjusted hazard ratio for hospitalizations after one year using a Cox-proportional hazards model.

Results

We recruited 121 persons in each group. The crude hazard ratio for hospital admissions, comparing the intervention to the control group was 0.622 (95% CI: 0.427–0.904; p = 0.013). The adjusted hazard ratio (aHR) was 0.503 (95% CI: 0.340–0.746; p = 0.001). The aHR for death was 0.993 (95% CI: 0.492–2.002; p = 0.984). The absolute difference in the quality of life was 16.59 points (95% CI: 12.03–21.14; p < 0.001).

Discussion

The integration programme had lower hospital admissions and better quality of life than the usual care. There was no significant difference in death rates.

Initiatives for improving delayed discharge from a hospital setting: a scoping review

OBJECTIVE

The overarching objective of the scoping review was to examine peer reviewed and grey literature for best practices that have been developed, implemented and/or evaluated for delayed discharge involving a hospital setting. Two specific objectives were to review what the delayed discharge initiatives entailed and identify gaps in the literature in order to inform future work.

DESIGN

Scoping review.

METHODS

Electronic databases and websites of government and healthcare organisations were searched for eligible articles. Articles were required to include an initiative that focused on delayed discharge, involve a hospital setting and be published between 1 January 2004 and 16 August 2019. Data were extracted using Microsoft Excel. Following extraction, a policy framework by Doern and Phidd was adapted to organise the included initiatives into categories: (1) information sharing; (2) tools and guidelines; (3) practice changes; (4) infrastructure and finance and (5) other.

RESULTS

Sixty-six articles were included in this review. The majority of initiatives were categorised as practice change (n=36), followed by information sharing (n=19) and tools and guidelines (n=19). Numerous initiatives incorporated multiple categories. The majority of initiatives were implemented by multidisciplinary teams and resulted in improved outcomes such as reduced length of stay and discharge delays. However, the experiences of patients and families were rarely reported. Included initiatives also lacked important contextual information, which is essential for replicating best practices and scaling up.

CONCLUSIONS

This scoping review identified a number of initiatives that have been implemented to target delayed discharges. While the majority of initiatives resulted in positive outcomes, delayed discharges remain an international problem. There are significant gaps and limitations in evidence and thus, future work is warranted to develop solutions that have a sustainable impact.

Health service delivery models for elderly people: A systematic review

Background: Current Health care delivery systems are not effective for the elderly. Countries with high elderly populations are expected to design special models to serve their elderly population. The aim of this study is to investigate the models of health care delivery to the elderly in different countries.

Methods: The present study is a systematic review based on PRISMA standard guidelines. The search for related studies was conducted in electronic databases (Cochran Library, Scopus, PubMed, Embase, Web of Science) and the Google Scholar search engine without time limits until May 2019. Keywords were extracted based on MeSH strategies. At first, 16243 articles were found. After the screening phase (elimination of duplicated articles, title screening, abstract screening, and full-text screening) 19 articles remained. Two articles deleted after text appraisal using the CASP checklist. In the next stage, after reviewing the gray literature and reviewing the references of remaining articles, three new articles were added (Included studies = 20).

Results: Twenty articles (models) corresponding to the study objectives were finally extracted. These models are limited to nine countries and most have local scopes. These models mainly use a case manager, an intra- or inter-disciplinary team, and an elderly assessment tool in their structure. In addition to the use of an information system, these models provide a wide range of services to the elderly.

Conclusion: Most of the models mentioned are local models. Smaller models to become applicable at the national level, they need to be reviewed and evaluated by policymakers and experts. Given the inefficiency of current systems in providing services to the elderly, it is recommended that countries use an integrated model of health care provision for the elderly.

The impact of different patterns of home- and community-based services on nursing home admission: National data from Taiwan

BACKGROUND

This study had two aims: (a) to identify the different patterns of use of home- and community-based services (HCBS) among older adults in Taiwan, and (b) to examine the effects of the different use patterns on HCBS recipients' use of institutional long-term care services.

METHODS

The study analyzed cohort data from Taiwan's first National 10-Year Long-Term Care Plan database and from National Health Insurance Claim Data. We extracted baseline information on older adults who were first evaluated for and prescribed HCBS from 2010 through 2013 (N = 71,260). We used latent class analysis to specify the underlying subgroups of recipients with similar patterns of HCBS use. We used hierarchical multinomial logistic regression to examine the effect of the different use patterns on the risk of institutional (e.g., nursing home) placement from 4 to 15 months after initial HCBS evaluation.

RESULTS

Four subgroups of HCBS recipients were identified, with patterns of home-based personal care (PC), home-based personal care and medical care (PC/MC), home-based medical care (MC), and community care services. Compared to the home-based PC/MC group, people in the home-based MC group had lower risk (OR = 0.54) and people in the community care group had higher risk (OR = 1.76) of admission to a nursing home.

CONCLUSIONS

Study findings may provide insights for policy makers regarding the usefulness of integrating medical care and other types of long-term care services into adult day care.

Goal-Oriented Care: A Catalyst for Person-Centred System Integration

Introduction

Person-centred integrated care is often at odds with how current health care systems are structured, resulting in slower than expected uptake of the model worldwide. Adopting goal-oriented care, an approach which uses patient priorities, or goals, to drive what kinds of care are appropriate and how care is delivered, may offer a way to improve implementation.

Description

This case report presents three international cases of community-based primary health care models in Ottawa (Canada), Vermont (USA) and Flanders (Belgium) that adopted goal-oriented care to stimulate clinical, professional, organizational and system integration. The Rainbow Model of Integrated Care is used to demonstrate how goal-oriented care drove integration at all levels.

Discussion

The three cases demonstrate how goal-oriented care has the potential to catalyse integrated care. Exploration of these cases suggests that goal-oriented care can serve to activate formative and normative integration mechanisms; supporting processes that enable integrated care, while providing a framework for a shared philosophy of care.

Lessons learned

By establishing a common vision and philosophy to drive shared processes, goal-oriented care can be a powerful tool to enable integrated care delivery. Offering plenty of opportunities for training in goal-oriented care within and across teams is essential to support this shift.

Typology of organizational innovation components: building blocks to improve access to primary healthcare for vulnerable populations

BACKGROUND

Achieving equity of access to primary healthcare requires organizations to implement innovations tailored to the specific needs and abilities of vulnerable populations. However, designing pro-vulnerable innovations is challenging without knowledge of the range of possible innovations tailored to vulnerable populations' needs. To better support decision-makers, we aimed to develop a typology of pro-vulnerable organizational innovation components - akin to "building blocks" that could be combined in different ways into new complex innovations or added to existing organizational processes to improve access to primary healthcare.

METHODS

To develop the typology, we used data from a previously conducted a) scoping review (2000-2014, searched Medline, Embase, CINAHL, citation tracking, n = 90 articles selected), and b) environmental scan (2014, online survey via social networks, n = 240 innovations). We conducted a typological analysis of the data. Our initial typology yielded 48 components, classified according to accessibility dimensions from the Patient-Centred Accessibility Framework. The initial typology was then field-tested for relevance and usability by health system stakeholders and refined from 2014 to 2018 (e.g., combined similar components, excluded non-organizational components).

RESULTS

The selected articles (n = 90 studies) and survey responses (n = 240 innovations) were mostly from the USA, Canada, Australia and the UK. Innovations targeted populations with various vulnerabilities (e.g., low income, chronic illness, Indigenous, homeless, migrants, refugees, ethnic minorities, uninsured, marginalized groups, mental illness, etc.). Our final typology had 18 components of organizational innovations, which principally addressed Availability & Accommodation (7/18), Approachability (6/18), and Acceptability (3/18). Components included navigation & information, community health worker, one-stop-shop, case management, group visits, defraying costs, primary healthcare brokerage, etc. CONCLUSIONS: This typology offers a comprehensive menu of potential components that can help inform the design of pro-vulnerable organizational innovations. Component classification according to the accessibility dimensions of the Patient-Centred Accessibility Framework is useful to help target access needs. Components can be combined into complex innovations or added to existing organizational processes to meet the access needs of vulnerable populations in specific contexts.

Challenges in measuring integrated care models: International knowledge and the case of Québec

Introduction

The implementation of integrated care models requires significant efforts, especially due to institutional and organisational inertial forces that characterize health and social care systems of developed countries. It is therefore crucial to deploy strategies that promote continuous adjustment to these barriers so as to improve the benefits of integrating care. Measuring the implementation and effects of integrated care models are key component of these strategies. However, measuring integrated care also faces major challenges. This study aims to identify and characterise integrated care measurement challenges.

Methods

A review of reviews on the measurement of integrated care identified 12 papers. A thematic analysis was conducted to identify and categorize measurement challenges. Document analysis was done on the measurement of an integrated care model for older adults in Québec.

Results

Eight categories of measurement challenges were identified. These challenges include difficulties in measuring structures, processes, and effects of models; conceptual ambiguity and heterogeneity of organisational forms; involving multiple actors in the measurement strategy; and including multiple data sources, amongst others. These challenges revealed and explained potential gaps in the measurement of integrated care for older adults in Québec. For instance, the Québec measurement strategy did not include effects indicators.

Conclusion

Although the measurement of integrated care is a complex endeavour, there is a need for adequate measurement strategies that allow to appreciate important elements of integrate care. The findings of this study could be used as a reflexive tool in advancing research and practice of measuring integrated care.

The evidence for services to avoid or delay residential aged care admission: a systematic review

BACKGROUND

Interventions that enable people to remain in their own home as they age are of interest to stakeholders, yet detailed information on effective interventions is scarce. Our objective was to systematically search and synthesise evidence for the effectiveness of community-based, aged care interventions in delaying or avoiding admission to residential aged care.

METHOD

Nine databases were searched from January 2000 to February 2018 for English publications. Reference lists of relevant publications were searched. The databases yielded 55,221 citations and 50 citations were gleaned from other sources. Where there was sufficient homogeneity of study design, population, intervention and measures, meta-analyses were performed. Studies were grouped by the type of intervention: complex multifactorial interventions, minimal/single focus interventions, restorative programs, or by the target population (e.g. participants with dementia).

RESULTS

Data from 31 randomised controlled trials (32 articles) that met our inclusion criteria were extracted and analysed. Compared to controls, complex multifactorial interventions in community aged care significantly improved older adults' ability to remain living at home (risk difference - 0.02; 95% CI -0.03, - 0.00; p = 0.04). Commonalities in the 13 studies with complex interventions were the use of comprehensive assessment, regular reviews, case management, care planning, referrals to additional services, individualised interventions, frequent client contact if required, and liaison with General Practitioners. Complex interventions did not have a significantly different effect on mortality. Single focus interventions did not show a significant effect in reducing residential aged care admissions (risk difference 0, 95% CI -0.01, 0.01; p = 0.71), nor for mortality or quality of life. Subgroup analysis of complex interventions for people with dementia showed significant risk reduction for residential aged care admissions (RD -0.05; 95% CI -0.09, -0.01; p = 0.02). Compared to controls, only interventions targeting participants with dementia had a significant effect on improving quality of life (SMD 3.38, 95% CI 3.02, 3.74; p < 0.000001).

CONCLUSIONS

Where the goal is to avoid residential aged care admission for people with or without dementia, there is evidence for multifactorial, individualised community programs. The evidence suggests these interventions do not result in greater mortality and hence are safe. Minimal, single focus interventions will not achieve the targeted outcomes.

TRIAL REGISTRATION

PROSPERO Registration CRD42016050086 .

Pré-implantation de l'Accompagnement-citoyen personnalisé d'intégration communautaire (APIC): Adaptabilité, collaboration et financement, les déterminants d'une implantation réussie

RÉSUMÉCette étude visait à identifier les facilitateurs, les obstacles et la faisabilité d'implanter un Accompagnement-citoyen personnalisé d'intégration communautaire (APIC) pour des aînés en perte d'autonomie et vivant dans la communauté. L'APIC est un suivi hebdomadaire de trois heures réalisé par un accompagnateur non professionnel formé et supervisé qui vise à optimiser la réalisation d'activités sociales et de loisirs de personnes ayant des incapacités. Une recherche-action a permis de réaliser des entretiens semi-dirigés auprès de 16 participants de la communauté. Les principaux facilitateurs de l'implantation sont l'adaptabilité de l'APIC et son appui scientifique, la reconnaissance d'un besoin, l'expertise et la collaboration. La présence de leaders ouverts à la nouveauté et d'individus offrant du soutien est favorable. Le financement de l'implantation, associé à un contexte économique défavorable, est un obstacle. La majorité des participants perçoivent qu'il serait faisable d'implanter l'APIC en l'intégrant à des structures bénévoles déjà existantes. Ces connaissances permettront d'optimiser l'implantation de l'APIC ou d'interventions similaires dans la communauté.

Research in Integrated Health Care and Publication Trends from the Perspective of Global Informatics

BACKGROUND

Integrated care has gained popularity in recent decades and is advocated by the World Health Organization. This study examined the global progress, current foci, and the future of integrated care.

METHODS

We conducted a scientometric analysis of data exported from the Web of Science database. Publication number and citations, co-authorship between countries and institutions and cluster analysis were calculated and clustered using Histcite12.03.07 and VOS viewer1.6.4.

RESULTS

We retrieved 6127 articles from 1997 to 2016. We found the following. (1) The United States, United Kingdom, and Canada had the most publications, citations, and productive institutions. (2) The top 10 cited papers and journals were crucial for knowledge distribution. (3) The 50 author keywords were clustered into 6 groups: digital medicine and e-health, community health and chronic disease management, primary health care and mental health, healthcare system for infectious diseases, healthcare reform and qualitative research, and social care and health policy services.

CONCLUSIONS

This paper confirmed that integrated care is undergoing rapid development: more categories are involved and collaborative networks are being established. Various research foci have formed, such as economic incentive mechanisms for integration, e-health data mining, and quantitative studies. There is an urgent need to develop performance measurements for policies and models.

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.

Effects of Intensive Primary Care on High-Need Patient Experiences: Survey Findings from a Veterans Affairs Randomized Quality Improvement Trial

BACKGROUND

Intensive primary care programs aim to coordinate care for patients with medical, behavioral, and social complexity, but little is known about their impact on patient experience when implemented in a medical home.

OBJECTIVE

Determine how augmenting the VA's medical home (Patient Aligned Care Team, PACT) with a PACT-Intensive Management (PIM) program influences patient experiences with care coordination, access, provider relationships, and satisfaction.

DESIGN

Cross-sectional analysis of patient survey data from a five-site randomized quality improvement study.

PARTICIPANTS

Two thousand five hundred sixty-six Veterans with hospitalization risk scores ≥ 90th percentile and recent acute care.

INTERVENTION

PIM offered patients intensive care coordination, including home visits, accompaniment to specialists, acute care follow-up, and case management from a team staffed by primary care providers, social workers, psychologists, nurses, and/or other support staff.

MAIN MEASURES

Patient-reported experiences with care coordination (e.g., health goal assessment, test and appointment follow-up, Patient Assessment of Chronic Illness Care (PACIC)), access to healthcare services, provider relationships, and satisfaction.

KEY RESULTS

Seven hundred fifty-nine PIM and 768 PACT patients responded to the survey (response rate 60%). Patients randomized to PIM were more likely than those in PACT to report that they were asked about their health goals (AOR = 1.26; P = 0.046) and that they have a VA provider whom they trust (AOR = 1.35; P = 0.005). PIM patients also had higher mean (SD) PACIC scores compared with PACT patients (2.91 (1.31) vs. 2.75 (1.25), respectively; P = 0.022) and were more likely to report 10 out of 10 on satisfaction with primary care (AOR = 1.25; P = 0.048). However, other effects on coordination, access, and satisfaction did not achieve statistical significance.

CONCLUSIONS

Augmenting VA's patient-centered medical home with intensive primary care had a modestly positive influence on high-risk patients' experiences with care coordination and provider relationships, but did not have a significant impact on most patient-reported access and satisfaction measures.

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

Background and aim:

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

Method:

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

Results:

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

Conclusion:

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

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.

Health status, emergency department visits, and oncologists' feedback: An analysis of secondary endpoints from a randomized phase II geriatric assessment trial

PURPOSE

Geriatric Assessment (GA) can help uncover previously unknown health issues and recommend tailored interventions to optimize outcomes; however, no completed randomized trial has examined the impact of GA on utility-based health status, healthcare use, and oncologists' opinions about GA. We examined these secondary outcomes of a randomized phase II trial.

METHODS

A planned analysis of secondary outcomes of a two-group parallel single-blind randomized phase II trial of GA (ClinicalTrials.gov Identifier:NCT02222259) recruited patients ≥ age 70, diagnosed with stage II-IV breast/gastrointestinal/genitourinary cancer within six weeks of beginning chemotherapy at the Princess Margaret Cancer Centre, Toronto, Canada. Descriptive analyses using intent-to-treat were conducted for health status (EuroQol EQ-5D-3L) and healthcare utilization (patient self-report). Oncologist opinions were captured via open-ended interviews and summarized.

RESULTS

A total of 95 patients who met the inclusion criteria were approached; 61 of them consented (64%). For health status, at all time-points, there were no significant differences between the two groups. The number of emergency department and family physician visits was low overall; there were no statistically significant differences between the two groups at any time point. All interviewed oncologists (eight of fourteen invited) were satisfied with the intervention, but wanted more straightforward recommendations and earlier GA results.

CONCLUSIONS

No difference was found in terms of relationships between GA and utility-based health status or GA and healthcare use. Underreporting of healthcare use was possible. Oncologists welcome GA feedback and prefer to receive it in pre-treatment decision context. Larger trials with earlier GA are warranted.

Change in health care use after coordinated care planning: a quasi-experimental study

BACKGROUND

We sought to determine whether patients with a coordinated care plan developed using the Health Links model of care in the Hamilton Niagara Haldimand Brant Local Health Integration Network differed in their use of health care (no. of emergency department visits, inpatient admissions, length of inpatient stay) when compared with a matched control group of patients with no care plans.

METHODS

We performed a propensity score-matched study of 12 months pre- and 12 months post-health care use. Patients who had a coordinated care plan that started between 2013 and 2015 were propensity score matched to patients in a control group. Patient information was obtained from Client Health and Related Information System, National Ambulatory Care Reporting System and Discharge Abstract Database. Differences in health care use pre- and post-index date were compared using the Wilcoxon signed-rank test. A negative binomial regression model was fit for each health care use outcome at 6 and 12 months post-index date.

RESULTS

Six hundred coordinated care plan enrollees and 25 449 potential control patients were included in the matching algorithm, which resulted in 548 matched pairs (91.3%). Both groups showed decreases in health care use post-index date. Matched care plan enrollees had significantly fewer emergency department visits at 6 (incidence rate ratio [IRR] 0.81, 95% confidence interval [CI] 0.72-0.91, p < 0.01) and 12 months post-index date (IRR 0.88, 95% CI 0.79-0.99, p < 0.05) compared with the matched controls. Other use parameters were not significantly different between care plan enrollees and the control group.

INTERPRETATION

Care plan enrollees show a decrease in the number of times they visit emergency departments, which may be attributed to integrated and coordinated care planning. This association should be examined to see whether these reductions persist for more than 1 year.

Cost-effectiveness of a multicomponent primary care program targeting frail elderly people

BACKGROUND

Over the last 20 years, integrated care programs for frail elderly people aimed to prevent functional dependence and reduce hospitalization and institutionalization. However, results have been inconsistent and merely modest. To date, evidence on the cost-effectiveness of these programs is scarce. We evaluated the cost-effectiveness of the CareWell program, a multicomponent integrated care program for frail elderly people.

METHODS

Economic evaluation from a healthcare perspective embedded in a cluster controlled trial of 12 months in 12 general practices in (the region of) Nijmegen. Two hundred and four frail elderly from 6 general practices in the intervention group received care according to the CareWell program, consisting of multidisciplinary team meetings, proactive care planning, case management, and medication reviews; 165 frail elderly from 6 general practices in the control group received usual care. In cost-effectiveness analyses, we related costs to daily functioning (Katz-15 change score i.e. follow up score minus baseline score) and quality adjusted life years (EQ-5D-3 L).

RESULTS

Adjusted mean costs directly related to the intervention were €456 per person. Adjusted mean total costs, i.e. intervention costs plus healthcare utilization costs, were €1583 (95% CI -4647 to 1481) higher in the intervention group than in the control group. Incremental Net Monetary Benefits did not show significant differences between groups, but on average tended to favour usual care.

CONCLUSIONS

The CareWell primary program was not cost-effective after 12 months. From a cost-effectiveness perspective, widespread implementation of the program in its current form cannot be recommended.

TRIAL REGISTRATION

The study was registered in the ClinicalTrials.govProtocol Registration System: ( NCT01499797 ; December 26, 2011). Retrospectively registered.

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 .

A Research Program on Implementing Integrated Care for Older Adults with Complex Health Needs (iCOACH): An International Collaboration

Health and social care systems across western developed nations are being challenged to meet the needs of an increasing number of people aging with multiple complex health and social needs. Community based primary health care (CBPHC) has been associated with more equitable access to services, better population level outcomes and lower system level costs. Itmay be well suited to the increasingly complex needs of populations; however the implementation of CBPHC models of care faces many challenges. This paper describes a program of research by an international, multi-university, multidisciplinary research team who are seeking to understand how to scale up and spread models of Integrated CBPHC (ICBPHC). The key question being addressed is “What are the steps to implementing innovative integrated community-based primary health care models that address the health and social needs of older adults with complex care needs?” and will be answered in three phases. In the first phase we identify and describe exemplar models of ICBPHC and their context in relation to relevant policies and performance across the three jurisdictions (New Zealand, Ontario and Québec, Canada). The second phase involves a series of theory-informed, mixed methods case studies from which we shall develop a conceptual framework that captures not only the attributes of successful innovative ICBPHC models, but also how these models are being implemented. In the third phase, we aim to translate our research into practice by identifying emerging models of ICBPHC in advance, and working alongside policymakers to inform the development and implementation of these models in each jurisdiction. The final output of the program will be a comprehensive guide to the design, implementation and scaling-up of innovative models of ICBPHC.

Care and support for older adults in The Netherlands living independently

The growth in the numbers of older adults needing long-term care has resulted in rising costs which have forced the Dutch government to change its long-term care system. Now, the local authorities have greater responsibility for supporting older adults and in prolonging independent living with increased support provided by the social network. However, it is unclear whether these older adults have such a network to rely upon. The objective of this study was to gain insight into the providers of formal and informal care to older adults, and to assess possible differences between older adults who are frail and those who are not. In addition, we investigated their care and support needs. We used data from a quantitative survey using a cross-sectional design in different regions of the Netherlands from July until September 2014 (n = 181). Frailty was measured using the Tilburg Frailty indicator. To analyse the data chi-square tests, crosstabs and odds ratios were used for dichotomous data and the Mann-Whitney U-Test for nominal data. The number of formal care providers involved was significantly higher (median = 2) for those deemed frail than for those not deemed frail (median = 1), U = 2,130, p < .005. However, more than one-third of the respondents deemed frail did not get the care or support they needed (33.7%). There was a significant positive association between being frail and having an informal care provider (χ²  = 18.78, df = 1, p < .005). However, more than one-third of those deemed frail did not have an informal care provider (36.8%). One-third of older adults deemed to be frail did not have their needs sufficiently addressed by their care network. For a substantial part of this group of older adults, the informal network seems to be unable to support them sufficiently. Additional attention for their needs and wishes is required to implement the policy reforms successfully.

Integrated Care Approaches Used for Transitions from Hospital to Community Care: A Scoping Review

ABSTRACTIntegrated care is a promising approach for improving care transitions for older adults, but this concept is inconsistently defined and applied. This scoping review describes the size and nature of literature on integrated care initiatives for transitions from hospital to community care for older adults (aged 65 and older) and how this literature conceptualizes integrated care. A systematic search of literature from the past 10 years yielded 899 documents that were screened for inclusion by two reviewers. Of the 48 included documents, there were 26 journal articles and 22 grey literature documents. Analysis included descriptive statistics and a content analysis approach to summarize features of the integrated care initiatives. Results suggest that clinical and service delivery integration is being targeted rather than integration of funding, administration, and/or organization. To promote international comparison of integrated care initiatives aiming to improve care transitions, detailed descriptions of organizational context are also needed.

Admission rates in a general practitioner-based versus a hospital specialist based, hospital-at-home model: ACCESS, an open-labelled randomised clinical trial of effectiveness

BACKGROUND

Hospital at home (HaH) is an alternative to acute admission for elderly patients. It is unclear if should be cared for a primarily by a hospital intern specialist or by the patient's own general practitioner (GP). The study assessed whether a GP based model was more effective than a hospital specialist based model at reducing number of hospital admissions without affecting the patient's recovery or number of deaths.

METHODS

Pragmatic, randomised, open-labelled multicentre parallel group trial with two arms in four municipalities, four emergency departments and 150 GPs in Southern Denmark, including + 65 years old patients with an acute medical condition that required acute hospital in-patient care. The patients were randomly assigned to hospital specialist based model or GP model of HaH care. Five physical and cognitive performance tests were performed at inclusion and after 7 days. Primary outcome was number of hospital admissions within 7 days. Secondary outcomes were number of admissions within 14, 21 and 30 days, deaths within 30 and 90 days and changes in performance tests.

RESULTS

Sixty seven patients were enrolled in the GP model and 64 in the hospital specialist model. 45% in the hospital specialist arm versus 24% in the GP arm were admitted within 7 days (effect size 2.7, 95% CI 1.3-5.8; p = 0.01) and this remained significant within 30 days. No differences were found in death or changes in performance tests from day 0-7 days between the two groups.

CONCLUSIONS

The GP based HaH model was more effective than the hospital specialist model in avoiding hospital admissions within 7 days among elderly patients with an acute medical condition with no differences in mental or physical recovery rates or deaths between the two models.

REGISTRATION

No. NCT02422849 Registered 27 March 2015. Retrospectively registered.

Formal and informal care for community-dwelling frail elderly people over time: A comparison of integrated and usual care in the Netherlands

While integration has become a central tenet of community-based care for frail elderly people, little is known about its impact on formal and informal care and their dynamics over time. The aim of this study was therefore to examine how an integrated care intervention for community-dwelling frail elderly people affects the amount and type of formal and informal care over 12 months as compared to usual care. A quasi-experimental design with a control group was used. Data regarding formal and informal care were collected from frail elderly patients (n = 207) and informal caregivers (n = 74) with pre/post-questionnaires. Within- and between-group comparisons and multiple linear regression analyses were performed. The results showed marginal changes over time in the amount of formal and informal care in both integrated care and usual care. However, different associations between changes in formal and informal care were found in integrated and usual care. Most notably, informal caregivers provided more instrumental assistance over time if formal caregivers provided less personal care (and vice versa) in integrated care but not in usual care. These results suggest that integrated care does not necessarily change the contribution of formal or informal care, but changes the interaction between formal (personal care) and informal (instrumental) activities. Implications and recommendations for research and practice are discussed.

TRIAL REGISTRATION

Current Controlled Trials ISRNT05748494.

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

Objective

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

Methods

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

Results

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

Conclusions

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

Effectiveness of Intensive Primary Care Interventions: A Systematic Review

BACKGROUND

Multicomponent, interdisciplinary intensive primary care programs target complex patients with the goal of preventing hospitalizations, but programs vary, and their effectiveness is not clear. In this study, we systematically reviewed the impact of intensive primary care programs on all-cause mortality, hospitalization, and emergency department use.

METHODS

We searched PubMed, CINAHL, the Cochrane Central Register of Controlled Trials, and the Cochrane Database of Reviews of Effects from inception to March 2017. Additional studies were identified from reference lists, hand searching, and consultation with content experts. We included systematic reviews, randomized controlled trials (RCTs), and observational studies of multicomponent, interdisciplinary intensive primary care programs targeting complex patients at high risk of hospitalization or death, with a comparison to usual primary care. Two investigators identified studies and abstracted data using a predefined protocol. Study quality was assessed using the Cochrane risk of bias tool.

RESULTS

A total of 18 studies (379,745 participants) were included. Three major intensive primary care program types were identified: primary care replacement (home-based; three RCTs, one observational study, N = 367,681), primary care replacement (clinic-based; three RCTs, two observational studies, N = 9561), and primary care augmentation, in which an interdisciplinary team was added to existing primary care (five RCTs, three observational studies, N = 2503). Most studies showed no impact of intensive primary care on mortality or emergency department use, and the effectiveness in reducing hospitalizations varied. There were no adverse effects reported.

DISCUSSION

Intensive primary care interventions demonstrated varying effectiveness in reducing hospitalizations, and there was limited evidence that these interventions were associated with changes in mortality. While interventions could be grouped into categories, there was still substantial overlap between intervention approaches. Further work is needed to identify program features that may be associated with improved outcomes.

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.

A novel primary-specialist care collaborative demonstration project to improve the access and health care of medically complex patients

Objective Medically complex patients experience fragmented health care compounded by long wait times. The MedREACH program was developed to improve access and overall system experience for medically complex patients. Program description MedREACH is a novel primary-tertiary care collaborative demonstration program that features community nursing outreach, community specialist outreach, and a multi-specialty consultation clinic. Methods All 179 patients, referring primary care clinicians, and specialists involved were eligible to participate. Patient and clinician feedback were elicited by feedback surveys. Process measures were evaluated by participant retrospective chart reviews. Community nursing outreach patients completed the Goal Attainment Scale. Results Forty-eight patients and 22 clinicians consented to the feedback survey. About 75% of patients were seen within 2 weeks of referral. Patients spent an average of 3, 1.63, and 1.2 visits with the nursing outreach, multi-specialty clinic, and specialist outreach, respectively. Patients indicated a better medical experience, health enablement, and goals attainment. Family physicians felt more supported in the community management of medically complex patients and, overall, physicians felt MedREACH could improve collaborative care for medically complex patients. Qualitative analysis of clinician responses identified the need for increased mental health services. Discussion MedREACH demonstrates a patient-centered link between primary and tertiary care that could improve health care access and overall experience.

Preliminary Results of the Adoption and Application of the Integrated Comprehensive Care Bundle Care Program When Treating Patients with Chronic Obstructive Pulmonary Disease

BACKGROUND

St. Joseph's Health System has implemented an integrated comprehensive care bundle care (ICC) program with the hopes that it would improve patients' care while reducing overall costs. The aim of this analysis was to evaluate the performance of the ICC program within patients admitted with chronic pulmonary obstructive disease (COPD).

METHODS

We conducted a retrospective observational cohort study comparing ICC patients to non-ICC patients admitted to St. Joseph's Healthcare Hamilton for COPD being discharged with support services between June 2012 and March 2015, using administrative data. Confounding adjustment was achieved through the use of propensity score matching. Medical resource utilizations during the initial hospitalization and within the 60 days following discharge were compared using regression models.

RESULTS

All 76 patients who entered the ICC program (100.0%) were matched 1 : 1 to 76 eligible non-ICC patients (28.4%). Length of stay (6.47 [7.29] versus 9.55 [10.21] days) and resource intensity weights (1.16 [0.80] versus 1.64 [1.69]) were lower in the ICC group within the initial hospitalization but, while favoring the ICC program, healthcare resource use tended not to differ statistically following discharge.

INTERPRETATION

The ICC program was able to reduce initial medical resource utilization without increasing subsequent medical resource use.