Best place of care for older people after acute and during subacute illness: a systematic review

Post-Acute Care as a Key Component in a Healthcare System for Older Adults

Older adults often experience functional decline following acute medical care. This functional decline may lead to permanent disability, which will increase the burden on the medical and long-term care systems, families, and society as a whole. Post-acute care aims to promote the functional recovery of older adults, prevent unnecessary hospital readmission, and avoid premature admission to a long-term care facility. Research has shown that post-acute care is a cost-effective service model, with both the hospital-at-home and community hospital post-acute care models being highly effective. This paper describes the post-acute care models of the United States and the United Kingdom and uses the example of Taiwan’s highly effective post-acute care system to explain the benefits and importance of post-acute care. In the face of rapid demographic aging and smaller household size, a post-acute care system can lower medical costs and improve the health of older adults after hospitalization.

Does the Design of Settings Where Acute Care Is Delivered Meet the Needs of Older People? Perspectives of Patients, Family Carers, and Staff

BACKGROUND

Older people with an acute illness, many of whom are also frail, form a significant proportion of the acute hospital inpatient population. Attention is focusing on ways of improving the physical environment to optimize health outcomes and staff efficiency.

PURPOSE

This article explores the effects of the physical environment in three acute care settings: acute hospital site, in-patient rehabilitation hospital, and intermediate care provision (a nursing home with some beds dedicated to intermediate care) chosen to represent different steps on the acute care pathway for older people and gain the perspectives of patients, family carers, and staff.

METHODS

Semi structured interviews were undertaken with 40 patient/carer dyads (where available) and three staff focus groups were conducted in each care setting with a range of staff.

RESULTS

Multiple aspects of the physical environment were reported as important by patients, family carers, and staff. For example, visitors stressed the importance of access and parking, patients valued environments where privacy and dignity were protected, storage space was poor across all sites, and security was important to patients but visitors want easy access to wards.

CONCLUSIONS

The physical environment is a significant component of acute care for older people, many of whom are also frail, but often comes second to organization of care, or relationships between actors in an episode of care.

Comprehensive Geriatric Assessment

BACKGROUND

As an adjunct to the general and cancer-specific clinical and diagnostic examinations, comprehensive geriatric assessment (CGA) is an integral tool that examines factors affecting the course of disease and the outcome of treatment. The principal areas of focus of the CGA include the patient's functional, physical, mental, emotional, pharmacotherapeutic, and socioeconomic status.

METHODS

We describe the role of CGA in the identification and management of frail elderly patients. The literature is reviewed to outline the components, programmatic configurations, and process of CGA. Information from systematic reviews of clinical trials of different CGA program models is summarized, and observations relating to the research agenda concerning the applicability of CGA and CGA principles to management of older cancer patients are discussed.

RESULTS

Since age itself is not predictive of outcome in an elderly cancer patient, the CGA helps to distinguish between elderly patients who should be treated with intent to cure and those who will benefit from clinical oncologic and geriatric co-management.

CONCLUSIONS

A more accurate evaluation of prognostic indicators that includes CGA parameters could lead to a higher number of older patients being included in clinical cancer trials and being treated effectively in practice. It would also identify those who would benefit from gero-oncologic CGA and ongoing management aimed at maintaining function and community living.

Improving care for people with dementia: development and initial feasibility study for evaluation of life story work in dementia care

Background

Improving dementia care quality is an urgent priority nationally and internationally. Life story work (LSW) is an intervention that aims to improve individual outcomes and care for people with dementia and their carers. LSW gathers information and artefacts about the person, their history and interests, and produces a tangible output: the ‘life story’.

Objective

To establish whether or not full evaluation of LSW was feasible.

Design

Mixed-methods feasibility study.

Methods

In-depth interviews and focus groups explored experiences of LSW and best practice with people with dementia, family members and dementia care staff. A systematic review explored best practice and theories of change for LSW. These stages helped to identify the outcomes and resources to explore in the feasibility study. A representative sample survey of health and social care dementia care providers in England established LSW practice in different settings. A survey of a self-selected sample of family members of people with dementia explored how LSW is experienced. Two small outcome studies (stepped-wedge study in six care homes and pre-test post-test study in inpatient specialist dementia care wards) explored the feasibility of full evaluation of LSW in these settings.

Settings

Survey: generalist and specialist care homes; NHS dementia care settings; and community dementia services. Feasibility study: care homes and NHS inpatient dementia care wards.

Participants

NHS and social care services, people with dementia, family carers, care home staff and NHS staff.

Interventions

LSW.

Main outcome measures

Spread of LSW and good practice, quality of life (QoL) for the person with dementia and carers, relationships between people with dementia and family carers, staff attitudes about dementia, staff burnout, resource use and costs.

Review methods

Narrative review and synthesis, following Centre for Review and Dissemination guidelines.

Results

Good practice in LSW is identifiable, as are theories of change about how it might affect given outcomes. Indicators of best practice were produced. LSW is spreading but practice and use vary between care settings and are not always in line with identified good practice. Two different models of LSW are evident; these are likely to be appropriate at different stages of the dementia journey. The feasibility study showed some positive changes in staff attitudes towards dementia and, for some people with dementia, improvements in QoL. These may be attributable to LSW but these potential benefits require full evaluation. The feasibility work established the likely costs of LSW and highlighted the challenges of future evaluation in care homes and inpatient dementia care settings.

Limitations

There was insufficient evidence in the literature to allow estimation of outcome size. We did not carry out planned Markov chain modelling to inform decisions about carrying out future evaluation because of the dearth of outcome data in the literature; low levels of data return for people with dementia in the hospital settings; lack of detected effect for most people with dementia; and questions about implementation in the research settings.

Conclusions

LSW is used across different health and social care settings in England, but in different ways, not all of which reflect ‘good practice’. This large, complex study identified a wide range of challenges for future research, but also the possibility that LSW may help to improve care staff attitudes towards dementia and QoL for some people with dementia.

Future work

Full evaluation of LSW as an intervention to improve staff attitudes and care is feasible with researchers based in or very close to care settings to ensure high-quality data collection.

Funding

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

The social practice of rescue: the safety implications of acute illness trajectories and patient categorisation in medical and maternity settings

The normative position in acute hospital care when a patient is seriously ill is to resuscitate and rescue. However, a number of UK and international reports have highlighted problems with the lack of timely recognition, treatment and referral of patients whose condition is deteriorating while being cared for on hospital wards. This article explores the social practice of rescue, and the structural and cultural influences that guide the categorisation and ordering of acutely ill patients in different hospital settings. We draw on Strauss et al.'s notion of the patient trajectory and link this with the impact of categorisation practices, thus extending insights beyond those gained from emergency department triage to care management processes further downstream on the hospital ward. Using ethnographic data collected from medical wards and maternity care settings in two UK inner city hospitals, we explore how differences in population, cultural norms, categorisation work and trajectories of clinical deterioration interlink and influence patient safety. An analysis of the variation in findings between care settings and patient groups enables us to consider socio-political influences and the specifics of how staff manage trade-offs linked to the enactment of core values such as safety and equity in practice.

Providing effective and preferred care closer to home: a realist review of intermediate care

Intermediate care is one of the number of service delivery models intended to integrate care and provide enhanced health and social care services closer to home, especially to reduce reliance on acute care hospital beds. In order for health and social care practitioners, service managers and commissioners to make informed decisions, it is vital to understand how to implement the admission avoidance and early supported discharge components of intermediate care within the context of local care systems. This paper reports the findings of a theory-driven (realist) review conducted in 2011-2012. A broad range of evidence contained in 193 sources was used to construct a conceptual framework for intermediate care. This framework forms the basis for exploring factors at service user, professional and organisational levels that should be considered when designing and delivering intermediate care services within a particular local context. Our synthesis found that involving service users and their carers in collaborative decision-making about the objectives of care and the place of care is central to achieving the aims of intermediate care. This pivotal involvement of the service user relies on practitioners, service managers and commissioners being aware of the impact that organisational structures at the local level can have on enabling or inhibiting collaborative decision-making and care co-ordination. Through all interactions with service users and their care networks, health and social care professionals should establish the meaning which alternative care environments have for different service users. Doing so means decisions about the best place of care will be better informed and gives service users choice. This in turn is likely to support psychological and social stability, and the attainment of functional goals. At an organisational level, integrated working can facilitate the delivery of intermediate care, but there is not a straightforward relationship between integrated organisational processes and integrated professional practice.

Secondary analysis and literature review of community rehabilitation and intermediate care: an information resource

Background and design

This research was based on a reanalysis of a merged data set from two intermediate care (IC) projects in order to identify patient characteristics associated with outcomes [Nancarrow SA, Enderby PM, Moran AM, Dixon S, Parker SG, Bradburn MJ,et al.The Relationship Between Workforce Flexibility and the Costs and Outcomes of Older Peoples’ Services (COOP). Southampton: National Institute for Health Research (NIHR) Service Delivery and Organisation (SDO); 2010 and Nancarrow SA, Enderby PM, Ariss SM, Smith T, Booth A, Campbell MJ,et al.The Impact of Enhancing the Effectiveness of Interdisciplinary Working (EEICC). Southampton: NIHR SDO; 2012]. Additionally, the impact of different team and staffing structures on patient outcomes and service costs was examined, when possible given the data sets, to enable identification of the most cost-effective service configurations and change over time with service provision. This secondary analysis was placed within updated literature reviews focused on the separate questions.

Research objectives

(1) To identify those patients most likely to benefit from IC and those who would be best placed to receive care elsewhere; (2) to examine the effectiveness of different models of IC; (3) to explore the differences between IC service configurations and how they have changed over time; and (4) to use the findings above to develop accessible evidence to guide service commissioning and monitoring.

Setting

Community-based services for older people are described in many different ways, among which are IC services and community rehabilitation. For the purposes of this report we call the services IC services and include all community-based provision for supporting older people who would otherwise be admitted to hospital or who would require increased length of stay in hospital (e.g. hospital at home schemes, post-acute care, step-up and step-down services).

Participants

The combined data set contained data on 8070 patient admissions from 32 IC teams across England and included details of the service context, costs, staffing/skill mix (800 staff), patient health status and outcomes.

Interventions

The interventions associated with the study cover the range of services and therapies available in IC settings. These are provided by a wide range of professionals and care staff, including nursing, allied health and social care.

Outcome measures

(1) Service data – each team provided information relating to the size, nature, staffing and resourcing of the services. Data were collected on a service pro forma. (2) Team data – all staff members of the teams participating in both studies provided individual information using the Workforce Dynamics Questionnaire. (3) Patient data – patient data were collected on admission and discharge using a client record pack. The client record pack recorded a range of data utilising a number of validated tools, such as demographic data, level of care (LoC) data, therapy outcome measure (TOM) scale, European Quality of Life-5 Dimensions (EQ-5D) questionnaire and patient satisfaction survey.

Results

(1) The provision of IC across England is highly variable with different referral routes, team structures, skill mix and cost-effectiveness; (2) in more recent years, patients referred to IC have more complex needs associated with more severe impairments; (3) patients most likely to improve were those requiring rehabilitation as determined by levels 3, 4 and 5 on the LoC (> 40% for impairment, activity and participation, and > 30% for well-being as determined on the TOM scale); (4) half of all patients with outcome data improved on at least one of the domains of the TOM scale; (5) for every 10-year increase in age there was a 6% decrease in the odds of returning home. The chance of remaining or returning home was greater for females than males; (6) a high percentage of patients referred to IC do not require the service; and (7) teams including clinical support staff and domiciliary staff were associated with a small relative improvement in TOM impairment scores when compared with other teams.

Conclusions

This study provides additional evidence that interdisciplinary teamworking in IC may be associated with better outcomes for patients, but care should be taken with overinterpretation. The measures that were used within the studies were found to be reliable, valid and practical and could be used for benchmarking. This study highlights the need for funding high-quality studies that attempt to examine what specific team-level factors are associated with better outcomes for patients. It is therefore important that studies in the future attempt empirically to examine what process-level team variables are associated with these outcomes.

Funding

The NIHR Health Services and Delivery Research programme.

Good practice in social care for disabled adults and older people with severe and complex needs: evidence from a scoping review

This article reports findings from a scoping review of the literature on good practice in social care for disabled adults and older people with severe and complex needs. Scoping reviews differ from systematic reviews, in that they aim to rapidly map relevant literature across an area of interest. This review formed part of a larger study to identify social care service models with characteristics desired by people with severe and complex needs and scope the evidence of effectiveness. Systematic database searches were conducted for literature published between January 1997 and February 2011 on good practice in UK social care services for three exemplar groups: young adults with life-limiting conditions; adults who had suffered a brain injury or spinal injury and had severe or complex needs; and older people with dementia and complex needs. Five thousand and ninety-eight potentially relevant records were identified through electronic searching and 51 by hand. Eighty-six papers were selected for inclusion, from which 29 studies of specific services were identified. However, only four of these evaluated a service model against a comparison group and only six reported any evidence of costs. Thirty-five papers advocated person-centred support for people with complex needs, but no well-supported evaluation evidence was found in favour of any particular approach to delivering this. The strongest evaluation evidence indicated the effectiveness of a multidisciplinary specialist team for young adults; intensive case management for older people with advanced dementia; a specialist social worker with a budget for domiciliary care working with psycho-geriatric inpatients; and interprofessional training for community mental health professionals. The dearth of robust evaluation evidence identified through this review points to an urgent need for more rigorous evaluation of models of social care for disabled adults and older people with severe and complex needs.

Diagnoses, problems and healthcare interventions amongst older people with an unscheduled hospital admission who have concurrent mental health problems: a prevalence study

Background

Frail older people with mental health problems including delirium, dementia and depression are often admitted to general hospitals. However, hospital admission may cause distress, and can be associated with complications. Some commentators suggest that their healthcare needs could be better met elsewhere.

Methods

We studied consecutive patients aged 70 or older admitted for emergency medical or trauma care to an 1800 bed general hospital which provided sole emergency medical and trauma services for its local population. Patients were screened for mental health problems, and those screening positive were invited to take part. 250 participants were recruited and a sub-sample of 53 patients was assessed by a geriatrician for diagnoses, impairments and disabilities, healthcare interventions and outstanding needs.

Results

Median age was 86 years, median Mini-Mental State Examination score at admission was 16/30, and 45% had delirium. 19% lived in a care home prior to admission. All the patients were complex. A wide range of main admission diagnoses was recorded, and these were usually complicated by falls, immobility, pain, delirium, dehydration or incontinence. There was a median of six active diagnoses, and eight active problems. One quarter of problems was unexplained. A median of 13 interventions was recorded, and a median of a further four interventions suggested by the geriatrician. Those with more severe cognitive impairment had no less medical need.

Conclusions

This patient group, admitted to hospital in the United Kingdom, had numerous healthcare problems, and by implication, extensive healthcare needs. Patients with simpler conditions were not identified, but may have already been rapidly discharged or redirected to non-hospital services by the time assessments were made. To meet the needs of this group outside the hospital would need considerable investment in medical, nursing, therapy and diagnostic facilities. In the meantime, acute hospitals should adapt to deliver comprehensive geriatric assessment, and provide for their mental health needs.

The effect of clinical interventions on hospital readmissions: a meta-review of published meta-analyses

BACKGROUND

The economic impact and ease of measurement of all-cause hospital readmission rates (HRR) have led to the current debate as to whether they are reducible, and whether they should be used as a publicly reported quality indicators of medical care.

OBJECTIVE

To assess the efficacy of broad clinical interventions in preventing HRR of patients with chronic diseases

METHOD

A meta-review of published systematic reviews of randomized controlled trials (RCTs) of clinical interventions that have included HRR among the patients' outcomes of interest.

MAIN FINDINGS

Meta-analyses of RCTs have consistently found that, in the community, disease management programs significantly reduced HRR in patients with heart failure, coronary heart disease and bronchial asthma, but not in patients with stroke and in unselected patients with chronic disorders. Inhospital interventions, such as discharge planning, pharmacological consultations and multidisciplinary care, and community interventions in patients with chronic obstructive pulmonary diseases had an inconsistent effect on HRR. MAIN STUDY LIMITATION: Despite their economic impact and ease of measurement, HRR are not the most important outcome of patient care, and efforts aimed at their reduction may compromise patients' health by reducing also justified re-admissions.

CONCLUSIONS

The efficacy of inhospital interventions in reducing HRR is in need of further study. In patients with heart diseases and bronchial asthma, HRR may be considered as a publicly reported quality indicator of community care, provided that future research confirms that efforts to reduce HRR do not adversely affect other patients' outcomes, such as mortality, functional capacity and quality of life. Future research should also focus on the reasons for the higher efficacy of community interventions in patients with heart diseases and bronchial asthma than in those with other chronic diseases.

Effectiveness of acute geriatric unit care using acute care for elders components: a systematic review and meta-analysis

Objectives

To compare the effectiveness of acute geriatric unit care, based on all or part of the Acute Care for Elders (ACE) model and introduced in the acute phase of illness or injury, with that of usual care.

Design

Systematic review and meta-analysis of 13 randomized controlled and quasi-experimental trials with parallel comparison groups retrieved from multiple sources.

Setting

Acute care geriatric and nongeriatric hospital units.

Participants

Acutely ill or injured adults (N = 6,839) with an average age of 81.

Interventions

Acute geriatric unit care characterized by one or more ACE components: patient-centered care, frequent medical review, early rehabilitation, early discharge planning, prepared environment.

Measurements

Falls, pressure ulcers, delirium, functional decline at discharge from baseline 2-week prehospital and hospital admission statuses, length of hospital stay, discharge destination (home or nursing home), mortality, costs, and hospital readmissions.

Results

Acute geriatric unit care was associated with fewer falls (risk ratio (RR) = 0.51, 95% confidence interval (CI) = 0.29–0.88), less delirium (RR = 0.73, 95% CI = 0.61–0.88), less functional decline at discharge from baseline 2-week prehospital admission status (RR = 0.87, 95% CI = 0.78–0.97), shorter length of hospital stay (weighted mean difference (WMD) = −0.61, 95% CI = −1.16 to −0.05), fewer discharges to a nursing home (RR = 0.82, 95% CI = 0.68–0.99), lower costs (WMD = −$245.80, 95% CI = −$446.23 to −$45.38), and more discharges to home (RR = 1.05, 95% CI = 1.01–1.10). A nonsignificant trend toward fewer pressure ulcers was observed. No differences were found in functional decline between baseline hospital admission status and discharge, mortality, or hospital readmissions.

Conclusion

Acute geriatric unit care, based on all or part of the ACE model and introduced during the acute phase of older adults' illness or injury, improves patient- and system-level outcomes.

How effective are programs at managing transition from hospital to home? A case study of the Australian Transition Care Program

Background

An increasing demand for acute care services due in part to rising proportions of older people and increasing rates of chronic diseases has led to new models of post-acute care for older people that offer coordinated discharge, ongoing support and often a focus on functional restoration. Overall, review of the literature suggests there is considerable uncertainty around the effectiveness and resource implications of the various model configurations and delivery approaches. In this paper, we review the current evidence on the efficacy of such programs, using the Australian Transition Care Program as a case study.

Discussion

The Australian Transition Care Program was established at the interface of the acute and aged care sectors with particular emphasis on transitions between acute and community care. The program is intended to enable a significant proportion of care recipients to return home, rather than prematurely enter residential aged care, optimize their functional capacity, and reduce inappropriate extended lengths of hospital stay for older people. Broadly, the model is configured and targeted in accordance with programs reported in the international literature to be effective. Early evaluations suggest good acceptance of the program by hospitals, patients and staff. Ultimately, however, the program's place in the array of post-acute services should be determined by its demonstrated efficacy relative to other services which cater for similar patient groups.

Summary

Currently there is a lack of robust evaluation to provide convincing evidence of efficacy, either from a patient outcome or cost reduction perspective. As the program expands and matures, there will be opportunity to scrutinise the systematic effects, with lessons for both Australian and international policy makers and clinical leaders.

From 'conductor' to 'second fiddle': older adult care recipients' perspectives on transitions in family caring at hospital admission

BACKGROUND

Family carers provide strong support for many older adults, often enabling older adults to remain at home. Little is known about the care recipients' perspectives of the role and contributions of family carers, particularly when hospital admissions occur as part of end of life care.

AIM

This paper explores the meanings of family caring for care recipients by drawing on older adults' perspectives about the impact of hospital admission on established family caring relationships.

DESIGN

Exploratory semi-structured qualitative interviews. Key findings reported in this paper emerged from within the inductive research design.

SETTING

Interviews were conducted in older adults' place of residence in northwest England between June 2009 and July 2010.

PARTICIPANTS

Participants were 27 older adults living with heart failure (n=13) or lung cancer (n=14), aged 69-89 years (mean 79 ± 4.3 years) and considered by their health professionals to be in their last year of life. In 12 of the interviews, a family carer was also present and made contributions.

FINDINGS

For community-dwelling older adults, family carers are conceptualised as 'conductors'; making strong contributions to maintaining the rhythm of good care throughout the illness trajectory. Following older adults' hospital admission, family carers find themselves in the role of 'second fiddle', their ability to work with the individual and to make or influence decisions vastly reduced. Despite this, carers continue to invest considerable effort in maintaining continuity in the carer relationship to maximise the individual's wellbeing by identifying needs, filling gaps in provision and advocating on patients' behalf. Family carers act flexibly to provide continuity, support and take responsibility for older adults' wellbeing across settings.

CONCLUSIONS

Nurses and family carers working together, and greater appreciation of the contribution and role of family carers by health professionals may contribute to improving the quality and continuity of care for older adults.

Rehabilitation of older patients: day hospital compared with rehabilitation at home. Clinical outcomes

OBJECTIVES

to test the hypothesis that older people and their informal carers are not disadvantaged by home-based rehabilitation (HBR) relative to day hospital rehabilitation (DHR).

DESIGN

pragmatic randomised controlled trial.

SETTING

four geriatric day hospitals and four home rehabilitation teams in England.

PARTICIPANTS

eighty-nine patients referred for multidisciplinary rehabilitation. The target sample size was 460.

INTERVENTION

multidisciplinary rehabilitation either in the home or in the day hospital.

MEASUREMENTS

the primary outcome measure was the Nottingham extended activities of daily living scale (NEADL). Secondary outcome measures included EQ-5D, hospital anxiety and depression scale, therapy outcome measures, hospital admissions and the General Health Questionnaire for carers.

RESULTS

at the primary end point of 6 months NEADL scores were not significantly in favour of HBR cf. DHR; mean difference -2.139 (95% confidence interval -6.87 to 2.59, P = 0.37). A post hoc analysis suggested non-inferiority for HBR for NEADL but there was considerable statistical uncertainty.

CONCLUSION

taken together the statistical analyses and lack of power of the trial outcomes do not provide sufficient evidence to conclude that patients in receipt of HBR are disadvantaged compared with those receiving DHR.

A systematic review of comprehensive geriatric assessment to improve outcomes for frail older people being rapidly discharged from acute hospital: 'interface geriatrics'

BACKGROUND

many frail older people who attend acute hospital settings and who are discharged home within short periods (up to 72 h) have poor outcomes. This review assessed the role of comprehensive geriatric assessment (CGA) for such people.

METHODS

standard bibliographic databases were searched for high-quality randomised controlled trials (RCTs) of CGA in this setting. When appropriate, intervention effects were presented as rate ratios with 95% confidence intervals.

RESULTS

five trials of sufficient quality were included. There was no clear evidence of benefit for CGA interventions in this population in terms of mortality [RR 0.92 (95% CI 0.55-1.52)] or readmissions [RR 0.95 (95% CI 0.83-1.08)] or for subsequent institutionalisation, functional ability, quality-of-life or cognition.

CONCLUSIONS

there is no clear evidence of benefit for CGA interventions in frail older people being discharged from emergency departments or acute medical units. However, few such trials have been carried out and their overall quality was poor. Further well designed trials are justified.

The hospital-based, post-acute geriatric evaluation and management unit: the experience of the acute geriatric unit in Trieste

In 2005, the Azienda Ospedaliero-Universitaria of Trieste (AOUT) activated the hospital-based post-acute geriatric evaluation and management unit (PAGEMU). The purpose of the study is to illustrate the activities of the PAGEMU, and to evaluate the effects of personalized and multidisciplinary care on geriatric inpatients. The evaluation for admission in PAGEMU included general admitting criteria, co-morbidity, autonomy, and assessment of the patient's pre-morbid functional status. During the stay, inpatients completed their treatment plan, comprehensive geriatric assessment was carried out, and rehabilitation and nutritional interventions were implemented. If necessary, a new diagnostic-therapeutic plan was provided. A number of 826 patients were evaluated for admission in PAGEMU (612 patients from surgical departments and 214 from medical wards). The mean length of stay was 19.55 days. Re-evaluation of patients at discharge showed a statistically significant improvement in co-morbidity and in self-sufficiency, not in cognitive or mood status. PAGEMU is a valid model both for patient-oriented and for management-oriented objectives, shortening the length of stay in acute care settings and increasing hospital turnover.

Understanding service context: development of a service pro forma to describe and measure elderly peoples' community and intermediate care services

The purpose of this paper was to develop a pro forma which classifies the components of service delivery and organization which may impact on the outcomes of elderly peoples' community and intermediate care services. The resulting analytic template provides a basis for comparison between services and may help guide service commissioning and development. A qualitative approach was used in which key evaluations and reports were selected on the basis that they described elderly peoples' community and intermediate care services. These were analysed systematically using a qualitative (template) approach to draw out the key themes used to describe services. Themes were then structured hierarchically into an analytic template. Seventeen key documents were analysed. The initial coding framework classified 334 themes describing intermediate care services. These items were then clustered into 78 categories, which were reduced to 17 subcategories, then six overall groupings to describe the services, namely; (1) context; (2) reason for the service; (3) service-users; (4) access to the service; (5) service structure; and (6) the organization of care. The resulting analytic template has been developed into a 'service pro forma' which can be used as a basis to describe and compare a range of services. We propose that all service evaluations should describe, in detail, their context in a comparable way, so that other services can learn from and/or apply the findings from these studies.

[Subacute care unit]

Subacute care is usually used to define those units that because of their characteristics are situated very close to hospitalization. Levenson et al. had defined the subacute care concept as that orientated to treat immediately after an acute hospitalization period, in which one or more complex medical problems have been treated. Postacute care is not a continuation of acute care, but must contribute to improve health results. This model would be based in a complete geriatric assessment. The admittance criteria would be based, among others, in frail patients or those with chronic and developed disease with functional impairment risk with moderate to low complications that would benefit from a specific geriatric assessment.

Effectiveness of acute geriatric units on functional decline, living at home, and case fatality among older patients admitted to hospital for acute medical disorders: meta-analysis

OBJECTIVE

To assess the effectiveness of acute geriatric units compared with conventional care units in adults aged 65 or more admitted to hospital for acute medical disorders.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Medline, Embase, and the Cochrane Library up to 31 August 2008, and references from published literature. Review methods Randomised trials, non-randomised trials, and case-control studies were included. Exclusions were studies based on administrative databases, those that assessed care for a single disorder, those that evaluated acute and subacute care units, and those in which patients were admitted to the acute geriatric unit after three or more days of being admitted to hospital. Two investigators independently selected the studies and extracted the data.

RESULTS

11 studies were included of which five were randomised trials, four non-randomised trials, and two case-control studies. The randomised trials showed that compared with older people admitted to conventional care units those admitted to acute geriatric units had a lower risk of functional decline at discharge (combined odds ratio 0.82, 95% confidence interval 0.68 to 0.99) and were more likely to live at home after discharge (1.30, 1.11 to 1.52), with no differences in case fatality (0.83, 0.60 to 1.14). The global analysis of all studies, including non-randomised trials, showed similar results.

CONCLUSIONS

Care of people aged 65 or more with acute medical disorders in acute geriatric units produces a functional benefit compared with conventional hospital care, and increases the likelihood of living at home after discharge.

Challenges, benefits and weaknesses of intermediate care: results from five UK case study sites

The authors explore the views of practitioners and managers on the implementation of intermediate care for elderly people across England, including their perceptions of the challenges involved in its implementation, and their assessment of the main benefits and weaknesses of provision. Qualitative data were collected in five case study sites (English primary care trusts) via semistructured interviews (n = 61) and focus group discussions (n = 21) during 2003 to 2004. Interviewees included senior managers, intermediate care service managers, clinicians and health and social care staff involved in the delivery of intermediate care. The data were analysed thematically using an approach based on the 'framework' method. Workforce and funding shortages, poor joint working between health and social care agencies and lack of support/involvement on the part of the medical profession were identified as the main challenges to developing intermediate care. The perceived benefits of intermediate care for service-users included flexibility, patient centredness and the promotion of independence. The 'home-like' environment in which services were delivered was contrasted favourably with hospitals. Multidisciplinary teamworking and opportunities for role flexibility were identified as key benefits by staff. Insufficient capacity, problems of access and awareness at the interface between intermediate care and 'mainstream' services combined with poor co-ordination between intermediate care services emerged as the main weaknesses in current provision. Despite reported benefits for service-users and staff, the study indicates that intermediate care does not appear to be achieving its full potential for alleviating pressure within health and social care systems. The strengthening of capacity and workforce, improvements to whole systems working and the promotion of intermediate care among doctors and other referrers were identified as key future priorities.

Care home versus hospital and own home environments for rehabilitation of older people

BACKGROUND

Rehabilitation for older people has acquired an increasingly important profile for both policy-makers and service providers within health and social care agencies. This has generated an increased interest in the use of alternative care environments including care home environments. Yet, there appears to be limited evidence on which to base decisions.This review is the first update of the Cochrane review which was published in 2003.

OBJECTIVES

To compare the effects of care home environments (e.g. nursing home, residential care home and nursing facilities) versus hospital environments and own home environments in the rehabilitation of older people.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Specialised Register and Pending Folder, MEDLINE (1950 to March Week 3 2007), EMBASE (1980 to 2007 Week 13), CINAHL (1982 to March, Week 4, 2007), other databases and reference lists of relevant review articles were additionally reviewed. Date of most recent search: March 2007.

SELECTION CRITERIA

Randomised controlled trials (RCTs), controlled clinical trials (CCTs), controlled before and after studies (CBAs) and interrupted time series (ITS) that compared rehabilitation outcomes for persons 60 years or older who received rehabilitation whilst residing in a care home with those who received rehabilitation in hospital or own home environments.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data.

MAIN RESULTS

In this update, 8365 references were retrieved. Of these, 339 abstracts were independently assessed by 2 review authors, and 56 studies and 5 review articles were subsequently obtained. Full text papers were independently assessed by two or three review authors and none of these met inclusion criteria.

AUTHORS' CONCLUSIONS

There is insufficient evidence to compare the effects of care home environments versus hospital environments or own home environments on older persons rehabilitation outcomes. Although the authors acknowledge that absence of effect is not no effect. There are three main reasons; the first is that the description and specification of the environment is often not clear; secondly, the components of the rehabilitation system within the given environments are not adequately specified and; thirdly, when the components are clearly specified they demonstrate that the control and intervention sites are not comparable with respect to the methodological criteria specified by Cochrane EPOC group. The combined effect of these factors resulted in the comparability between intervention and control groups being very weak.

A randomized study of a multidisciplinary program to intervene on geriatric syndromes in vulnerable older people who live at home (Dutch EASYcare Study)

BACKGROUND

The effectiveness of community-based geriatric intervention models for vulnerable older adults is controversial. We evaluated a problem-based multidisciplinary intervention targeting vulnerable older adults at home that promised efficacy through better timing and increased commitment of patients and primary care physicians. This study compared the effects of this new model to usual care.

METHODS

Primary care physicians referred older people for problems with cognition, nutrition, behavior, mood, or mobility. One hundred fifty-one participants (mean age 82.2 years, 74.8% women) were included in a pseudocluster randomized trial with 6-month follow-up for the primary outcomes. Eighty-five participants received the new intervention, and 66 usual care. In the intervention arm, geriatric nurses visited patients at home for geriatric assessment and management in cooperation with primary care physicians and geriatricians. Modified intention-to-treat analyses focused on differences between treatment arms in functional abilities (Groningen Activity Restriction Scale-3) and mental well-being (subscale mental health Medical Outcomes Study [MOS]-20), using a mixed linear model.

RESULTS

After 3 months, treatment arms showed significant differences in favor of the new intervention. Functional abilities improved 2.2 points (95% confidence interval [CI], 0.3-4.2) and well-being 5.8 points (95% CI, 0.1-11.4). After 6 months, the favorable effect increased for well-being (9.1; 95% CI, 2.4-15.9), but the effect on functional abilities was no longer significant (1.6; 95% CI, -0.7 to 3.9).

CONCLUSIONS

This problem-based geriatric intervention improved functional abilities and mental well-being of vulnerable older people. Problem-based interventions can increase the effectiveness of primary care for this population.

Interventions aimed at reducing problems in adult patients discharged from hospital to home: a systematic meta-review

BACKGROUND

Many patients encounter a variety of problems after discharge from hospital and many discharge (planning and support) interventions have been developed and studied. These primary studies have already been synthesized in several literature reviews with conflicting conclusions. We therefore set out a systematic review of the reviews examining discharge interventions. The objective was to synthesize the evidence presented in literature on the effectiveness of interventions aimed to reduce post-discharge problems in adults discharged home from an acute general care hospital.

METHODS

A comprehensive search of seventeen literature databases and twenty-five websites was performed for the period 1994-2004 to find relevant reviews. A three-stage inclusion process consisting of initial sifting, checking full-text papers on inclusion criteria, and methodological assessment, was performed independently by two reviewers. Data on effects were synthesized by use of narrative and tabular methods.

RESULTS

Fifteen systematic reviews met our inclusion criteria. All reviews had to deal with considerable heterogeneity in interventions, populations and outcomes, making synthesizing and pooling difficult. Although a statistical significant effect was occasionally found, most review authors reached no firm conclusions that the discharge interventions they studied were effective. We found limited evidence that some interventions may improve knowledge of patients, may help in keeping patients at home or may reduce readmissions to hospital. Interventions that combine discharge planning and discharge support tend to lead to the greatest effects. There is little evidence that discharge interventions have an impact on length of stay, discharge destination or dependency at discharge. We found no evidence that discharge interventions have a positive impact on the physical status of patients after discharge, on health care use after discharge, or on costs.

CONCLUSION

Based on fifteen high quality systematic reviews, there is some evidence that some interventions may have a positive impact, particularly those with educational components and those that combine pre-discharge and post-discharge interventions. However, on the whole there is only limited summarized evidence that discharge planning and discharge support interventions have a positive impact on patient status at hospital discharge, on patient functioning after discharge, on health care use after discharge, or on costs.

The organisation, form and function of intermediate care services and systems in England: results from a national survey

This paper reports the results of a postal survey of intermediate care coordinators (ICCs) on the organisation and delivery of intermediate care services for older people in England, conducted between November 2003 and May 2004. Questionnaires, which covered a range of issues with a variety of quantitative, tick-box and open-ended questions, were returned by 106 respondents, representing just over 35% of primary care trusts (PCTs). The authors discuss the role of ICCs, the integration of local systems of intermediate care provision, and the form, function and model of delivery of services described by respondents. Using descriptive and statistical analysis of the responses, they highlight in particular the relationship between provision of admission avoidance and supported discharge, the availability of 24-hour care, and the locations in which care is provided, and relate their findings to the emerging evidence base for intermediate care, guidance on implementation from central government, and debate in the literature. Whilst the expansion and integration of intermediate care appear to be continuing apace, much provision seems concentrated in supported discharge services rather than acute admission avoidance, and particularly in residential forms of post-acute intermediate care. Supported discharge services tend to be found in residential settings, while admission avoidance provision tends to be non-residential in nature. Twenty-four-hour care in non-residential settings is not available in several responding PCTs. These findings raise questions about the relationship between the implementation of intermediate care, and the evidence for and aims of the policy as part of National Health Service modernisation, and the extent to which intermediate care represents a genuinely novel approach to the care and rehabilitation of older people.

Effectiveness of intermediate care delivered in nurse-led units

This mini-review provides an overview of evidence regarding the effectiveness, costs and patient experience relating the intermediate care in nursing-led units. The core of the evidence is derived from a high quality systematic review of 10 controlled trials involving 1669 patients. Other studies on patient experience and costs not included in the review are also considered. There is some evidence of patient benefit in the short term in terms of independence. However this does not seem to be sustained. Total inpatient stay is increased and hence overall costs of the initial episode are increased with no evidence of longer-term savings. The approach seems to be broadly acceptable to patients. Provided it is not simply used to house patients who cannot benefit, nursing-led units may be a viable alternative to acute care for some patients. However, the core features of the units that provided the evidence must be considered in order to maximize the potential for delivering quality care.

Buying time II: an economic evaluation of a joint NHS/Social Services residential rehabilitation unit for older people on discharge from hospital

The study's aim was to investigate the cost-effectiveness of an NHS/Social Services short-term residential rehabilitation unit (a form of intermediate care) for older people on discharge from community hospital compared with 'usual' community services. An economic evaluation was conducted alongside a prospective controlled trial, which explored the effectiveness of a rehabilitation unit in a practice setting. The aim of the unit was to help individuals regain independence. A matched control group went home from hospital with the health/social care services they would ordinarily receive. The research was conducted in two matched geographical areas in Devon: one with a rehabilitation unit, one without. Participants were recruited from January 1999 to October 2000 in 10 community hospitals and their eligibility determined using the unit's strict inclusion/exclusion criteria, including 55 years or older and likely to benefit from a short-term rehabilitation programme: potential to improve, realistic, achievable goals, motivation to participate. Ninety-four people were recruited to the intervention and 112 to the control group. Details were collated of the NHS and Social Services resources participants used over a 12-month follow-up. The cost of the resource use was compared between those who went to the unit and those who went straight home. Overall, costs were very similar between the two groups. Aggregated mean NHS/Social Services costs for the 12 months of follow-up were pound 8542.28 for the intervention group and pound 8510.68 for the control. However, there was a clear 'seesaw' effect between the NHS and Social Services: the cost of the unit option fell more heavily on Social Services (pound 5011.56, whereas pound 3530.72 to the NHS), the community option more so on the NHS (pound 5146.74, whereas pound 3363.94 to Social Services). This suggests that residential rehabilitation for older people is no more cost-effective over a year after discharge from community hospital than usual community services. The variability in cost burden between the NHS and Social Services has implications for 'who pays' and being sure that agencies share both pain and gain.

Buying Time I: a prospective, controlled trial of a joint health/social care residential rehabilitation unit for older people on discharge from hospital

The study's objective was to determine the effectiveness of a joint NHS/Social Services rehabilitation unit (a form of intermediate care) for older people on discharge from community hospital, compared with 'usual' community services. This was a controlled clinical trial in a practice setting. The intervention was 6 weeks in a rehabilitation unit where individuals worked with care/rehabilitation assistants and occupational therapists to regain independence. Controls went home with the health/social care services they would ordinarily receive. Participants were from two matched geographical areas in Devon: one with a rehabilitation unit, one without. Recruitment was from January 1999 to October 2001 in 10 community hospitals. Study eligibility was assessed using the unit's inclusion/exclusion criteria: 55 years or older and 'likely to benefit from a short-term rehabilitation programme' ('potential to improve', 'realistic and achievable goals' and 'motivation to participate'). Ninety-four people were recruited to the intervention and 112 to the control. The mean (standard deviation) age was 81.8 (8.0) years. The main outcome measure was prevention of institutionalisation assessed by the number of days from baseline interview to admission to residential/nursing care or death ('survival-at-home time'). Secondary outcome measures were time to hospital re-admission over 12 months, quality of life and coping ability. There were no significant differences between the groups on any outcome measure. Adjusted hazard ratio (95% CI) for 'survival-at-home time' was 1.13 (0.70-1.84), and 0.84 (0.53-1.33) for 'time to hospital re-admission'. However, attending the unit was associated with earlier hospital discharge. Median (interquartile range) days in hospital for the intervention graph was 27 (20, 40), and for the control graph was 35 (22, 47) (U = 4234, P = 0.029). These findings suggest a stay in a rehabilitation unit is no more effective than 'usual' care at diverting older people from hospital/long-term care. Alternative service configurations may be as effective, having implications for tailoring services more specifically to individual need and/or user preferences. However, the unit did appear to facilitate earlier discharges from community hospital.

Methodological understandings and misunderstandings in interprofessional research: experiences of researching transitional rehabilitation for older people

Drawing on our shared experience of a mixed-methods evaluation of a rehabilitation scheme for older people in six residential care homes in Nottingham, this paper examines the challenges and rewards of interprofessional research. A social anthropologist, social work academic and medical academic respectively, we explore understandings and misunderstandings that arose during the two-year research process as we sought to integrate quantitative and qualitative findings from a randomized controlled trial (RCT) and an ethnographic study conducted in parallel. We identify ways in which it was possible to overcome the danger of fragmentation, which we argue may be inherent in interprofessional research. This includes a recognition that researchers from different disciplinary backgrounds may use different "key symbols" to view the world but that professional knowledge and expertise may enable researchers to transcend such disciplinary boundaries and to hear what each is saying to the other for the benefit of improved collaboration.

The design of the Dutch EASYcare study: a randomised controlled trial on the effectiveness of a problem-based community intervention model for frail elderly people [NCT00105378]

BACKGROUND

Because of their complex clinical presentations and needs frail elderly people require another approach than people who age without many complications. Several inpatient geriatric health services have proven effectiveness in frail persons. However, the wish to live independently and policies that promote independent living as an answer to population aging call for community intervention models for frail elderly people. Maybe models such as preventive home visits, comprehensive geriatric assessment, and intermediate care qualify, but their efficacy is controversial, especially in frail elderly persons living in the community. With the Dutch EASYcare Study Geriatric Intervention Programme (DGIP) we developed a model to study effectiveness of problem based community intervention models in frail elderly people.

METHODS/DESIGN

DGIP is a community intervention model for frail elderly persons where the GP refers elderly patients with a problem in cognition, mood, behaviour, mobility, and nutrition. A geriatric specialist nurse applies a guideline-based intervention with a limited number of follow up visits. The intervention starts with the application of the EASYcare instrument for geriatric screening. The EASYcare instrument assesses (instrumental) activities of daily life, cognition, mood, and includes a goal setting item. During the intervention the nurse regularly consults the referring GP and a geriatrician. Effects on functional performance (Groningen Activity Restriction Scale), health related quality of life (MOS-20), and carer burden (Zarit Burden Interview) are studied in an observer blinded randomised controlled trial. 151 participants were randomised over two treatment arms--DGIP and regular care--using pseudo cluster randomisation. We are currently performing the follow up visits. These visits are planned three and six months after inclusion. Process measures and cost measures will be recorded. Intention to treat analyses will focus on post intervention differences between treatment groups.

DISCUSSION

The design of a trial evaluating the effects of a community intervention model for frail elderly people was presented. The problem-based participant selection procedure satisfied; few patients that the GP referred did not meet our eligibility criteria. The use of standard terminology makes detailed insight into the contents of our intervention possible using terminology others can understand well.

Care needs and point prevalence of post-acute patients in the acute medical wards of an Italian hospital

BACKGROUND

Despite considerable literature identifying large numbers of post-acute patients in acute medical wards, their needs have not been clearly described. Such information is required to plan alternative services.

OBJECTIVE

Identify the size of and care needs of the post-acute population within the group of patients receiving acute medical care in an Italian General Hospital.

SETTING

Five medical wards of a District General Hospital in Northern Italy.

DESIGN

Point prevalence survey. Data were collected on all 211 patients using the most recent Italian version of the Appropriateness Evaluation protocol, Barthel Index, and the Northwick Park Dependency Score. Length of stay up to the data collection (index) day and total length of stay were identified and pre- and post-discharge dependence was assessed.

RESULTS

The mean of the length of stay of the patients up to the index day was 12 days. Fourty four percent of patients were assessed as inappropriate. The mean age was 70 years. They were moderately physically dependent and stayed in hospital for a further 8 days after the day of the survey. The family met most of the care needs both before and after admission to hospital. Inappropriate patients differed little from the appropriate patients in terms of their care needs, which were relatively high.

CONCLUSION

There is scope for the development of alternatives to acute care in the Italian health service but the intensity on non-medical care needs is not discernibly lower than for acute care. Prospective identification of patients who might require such services using tools that focus on needs other than medical needs remains problematic.

Away from home: an ethnographic study of a transitional rehabilitation scheme for older people in the UK

While intermediate care is an international phenomenon, it is particularly developed in the UK where it is a central element of the Government's response to the care needs for older people (The National Service Framework of Older People. London: HMSO). In the UK, intermediate care services are proliferating despite lack of evidence of effectiveness. We present the findings of an ethnographic study of an intermediate care scheme in six residential care homes that examined the perspectives of three key groups--older people, care home managers and rehabilitation staff. We discovered a consensus among managers and rehabilitation staff that the scheme was successful, yet no such agreement existed amongst older people. We also found that the scheme created the conditions for the emergence of a more optimistic vision of the potential of older people, with rehabilitation assistants seeing core elements of their work in a new light. However, much of what was characterised as 'rehabilitation' was more a process of adaptation to the norms, expectations and values of the institution. Our findings point in positive and negative directions: positive in that this scheme may have generated a new culture of more personalised care amongst experienced care staff, and negative in showing the limitations of a rehabilitation scheme that is not based within a person's own living environment. Our findings have implications for policy makers, researchers and managers of services.

Post-acute intermediate care in nursing-led units: a systematic review of effectiveness

OBJECTIVE

In order to determine whether post-acute intermediate care in nursing-led inpatient units (NLUs) is effective in preparing patients for discharge from hospital we conducted a systematic review of the evidence.

REVIEW METHODS

The Cochrane Library, Effective Practice and Organisation of Care specialist register, Medline, Cinahl, Embase, British Nursing Index and the HMIC databases were searched for all available dates up to mid-2003. The science and social science citation indices were searched for papers that cited key works. Authors of papers were asked to identify additional research. Randomised controlled trials, controlled clinical trials, controlled before and after studies and interrupted time-series designs that compared the NLU to usual post-acute inpatient care for adults were included in the review. Studies were assessed for quality. Statistical meta-analysis on the results of controlled trials was performed. Sensitivity analyses were conducted to determine the impact of methodological quality on conclusions.

OUTCOMES

Outcomes considered were mortality, institutionalisation after discharge, functional status early readmission, length of inpatient stay and cost.

RESULTS

Nine random or quasi-random controlled trials involving 1669 patients were reviewed. Quality was variable. The mean age of patients in all studies was over 70 years. There was no statistically significant difference in inpatient mortality between NLU and usual inpatient care (OR 1.10, 95% CI 0.56-2.16). The NLU was associated with reduced odds of discharge to institutional care (OR 0.44 95% CI 0.22-0.89), better functional status at discharge (SMD 0.37, 95% CI 0.20-0.54) and reduced odds of early readmission (OR 0.52 95% CI 0.34-0.80). Length of stay until discharge home was increased by 5.13 days (WMD) (95% CI-0.5-10.76 days). At longest follow up (3-6 months) there was no statistically significant difference in the proportion of patients in institutional care (OR 0.97, 95% CI 0.60-1.58). The results were not generally sensitive to study quality.

CONCLUSIONS

The NLU successfully functions as a form of intermediate care, so far there is no evidence of adverse outcome from the lower level of routine medical care. However, more research is required to confirm safety. Patients discharged from NLUs have higher levels of function although it is unclear if the benefit is simply a product of an increased stay. There is no evidence of benefit over the longer term.

Measuring healthcare outcomes to improve quality of care across post--acute care provider settings

Post-acute care (PAC) occurs in a variety of settings-skilled nursing facilities (nursing homes), rehabilitation facilities, and home health agencies. To evaluate the impact of care processes on clinical outcomes and implement changes designed to improve outcomes, one must begin by measuring outcomes in a valid, reliable manner that allows for comparisons to reference or benchmarking data. Currently, several data sets exist in PAC settings for the purpose of outcome measurement. However, there is a need for comparable information across settings to ensure the quality and continuity of care. This article reviews various existing data sets used in PAC settings, examines ongoing projects to create a single set of measures, and suggests some directions for future research.

Understanding complex trajectories in health and social care provision

Abstract Ensuring collaboration between health and social care providers is a well-established policy concern in most developed countries. Thus far, however, this has proved to be a frustratingly elusive goal. Despite the growing body of empirical work devoted to this issue, social scientific theorising on the management of complex caring trajectories remains under-developed. This paper is an attempt to begin to address this gap in the literature. Drawing on Strauss et al.'s (1985) writings on illness trajectories and Elias's (1978) game model, we offer a framework - centred on the notion of a caring trajectory game - that can assist understanding of the linkages between individual trajectories of care and broader health and social care systems. It is only when we have developed a more theoretically sophisticated understanding of this relationship that we can begin to explain why trajectories of care take the course that they do. The framework arises from our analysis of eight ethnographic case studies of adults undergoing rehabilitation from a first acute stroke. In this paper we illustrate its utility by reference to one specific case: Edward.

What can rural agencies do to address the additional costs of rural services? A typology of rural service innovation

There is a national commitment to ensuring that, regardless of where patients live, they should be provided with an acceptable level of service in terms of quality, effectiveness and accessibility. Because of differences in the distributions of their populations, rural and urban areas present quite different challenges for the optimal design of health services and social care. However, this has not been fully acknowledged in the development of national policies to unify service standards. The problems of providing services in sparsely populated areas are not new. However, until the case for a rural premium in English health resource allocation is accepted, rural agencies must either tolerate lower levels of services (an option made difficult by the introduction of national service standards) or develop very different approaches to service delivery. To date, there has been little systematic knowledge about the extent of innovative rural practice, a paucity of evaluation of such initiatives and few opportunities to disseminate learning from one area to another. The present paper begins to address this deficit. Drawing upon a review of the formal literature and a comprehensive evaluation of projects developed within a rural Health Action Zone, it presents a typology of innovative responses at the health/social care interface. Examples of service innovations which fall into six broad categories are provided. These not only suggest possibilities for the transfer of good practice, but also the potential for future research.

Effectiveness of intermediate care in nursing-led in-patient units

BACKGROUND

The Nursing led inpatient Unit (NLU) is one of a range of services that have been considered in order to manage more successfully the transition between hospital and home for patients with extended recovery times.

OBJECTIVES

To determine whether nursing-led inpatient units are effective in preparing patients for discharge from hospital compared to usual inpatient care.

SEARCH STRATEGY

We searched The Cochrane Library, the Specialized Register of the Cochrane Effective Practice and Organisation of Care (EPOC) group, MEDLINE, CINAHL, EMBASE, BNI and HMIC databases. Citation searches were undertaken on the science and social science citation indices. Authors were contacted to identify additional data.

SELECTION CRITERIA

Controlled trials and interrupted time series designs that compared the NLU to usual inpatient care managed by doctors. Patients over 18 years of age following an acute hospital admission for a physical health condition.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed study quality.

MAIN RESULTS

Ten random or quasi-random controlled trials reported on a total of 1896 patients. There was no statistically significant effect on inpatient mortality ( OR 1.10, 95% CI 0.56 to 2.16) or mortality to longest follow up (OR 0.92, 95% CI 0.65 to 1.29) but higher qaulity studies showed a larger non-significant increase in inpatient mortality (OR 1.52, 95% CI 0.86 to 2.68). Discharge to institutional care was reduced for the NLU (OR 0.44 95% CI 0.22 to 0.89) and functional status at discharge increased (SMD 0.37, 95% CI 0.20 to 0.54) but there was a near significant increase in inpatient stay (WMD 5.13 days 95% CI -0.5 days to 10.76 days). Early readmissions were reduced (OR 0.52 95% CI 0.34 to 0.80). One study compared a NLU for the chronically critically ill with ICU care. Mortality (OR 0.62 95% CI 0.35 to 1.10) and length of inpatient stay differ did not differ (WMD 2 days, 95% CI 10.96 to -6.96 days). Early readmissions were reduced (OR 0.33 95% CI 0.12 to 0.94). Costs of care on the NLU were higher for UK studies but lower for US based studies.

REVIEWERS' CONCLUSIONS

There is some evidence that patients discharged from a NLU are better prepared for discharge but it is unclear if this is simply a product of an increased length of inpatient stay. No statistically significant adverse effects were noted but the possibility of increased early mortality cannot be discounted. More research is needed.

An evaluation of a multidisciplinary team for intermediate care at home

Background

The implementation of the National Health Service Plan for the UK will see an expansion of services for intermediate care. Such services are usually targeted at older people and aim to: prevent ‘avoidable’ admissions to acute inpatient care; facilitate the timely discharge of patients from acute inpatient care; promote patient rehabilitation. A range of services might fall under the banner of intermediate care. They are usually delivered in patients' homes or in non-acute institutions. This paper describes an evaluation of a multidisciplinary Rapid Response Team (RRT). This service aimed to provide a home based alternative to care previously provided in an acute hospital bed which was acceptable to patients and carers and which maintained clinical care standards. The service was provided for the population of Hereford, a rural town in the middle of England.

Methods

A mixed-method descriptive design using quantitative and qualitative techniques was used to monitor: the characteristics of service users, the types and amounts of care received, any ‘adverse’ events arising from that care, and the acceptability of the service to patients and carers. A collaborative approach involving key stakeholders allowed appropriate data to be gathered from patient case notes, RRT staff, local health and social care providers, and patients and their carers. A suite of self-completed questionnaires was, therefore, designed to capture study data on patients and activities of care, and workshops and semi-structured interview schedules used to obtain feedback from users and stakeholders.

Results

Service users (231) were elderly (mean age 75.9), from three main diagnostic categories (respiratory conditions 19.0%, heart/stroke 16.2%, falls 13.4%), with the majority (57.0%) having both medical and social care needs. All patients received care at home (mean duration 5.6 days) with only 5.7% of patients having to be re-admitted to acute care. Overall, patients and carers had positive attitudes to the new service but some expressed concerns about their ability to influence the choice of care option (24.1% and 25.0% of patients and carers, respectively), whilst 22.7% of carers were concerned about the quality of information about care.

Conclusions

Both the nature of schemes for intermediate care, and the policy context in which they are introduced, mean that pragmatic methodologies are often required to evaluate their impacts. Unfortunately, this need for pragmatism can then mean that it is difficult to reach definitive conclusions about the merits of schemes. However, the findings of this evaluation suggest that the Rapid Response Team provided an ‘acceptable’ alternative to an extended period of care in an acute setting. Such schemes may have relevance beyond the NHS of the UK as a means of providing a more appropriate and cost efficient match between patients' needs for care, the types of care provided, and the place in which care is provided.

Diversity in intermediate care

This paper discusses the evolution of intermediate care (IC) and presents interim observations from a survey of providers in England being conducted as part of a national evaluation. Telephone interviews covering various issues concerning the level of provision and style of delivery have been conducted with 70 services to date. Data from these are used to discuss the progress, range and nature of IC in relation to clinician viewpoints and academic and official literature on the subject. IC 'on the ground' is a multiplicitous entity, with provision apparently evolving in accordance with the particularities of local need. While protocols for medical involvement in IC generally appear to be well established, there are some tensions concerning integration of services in a locality, care management processes and questions of flexibility and inclusiveness in relation to eligibility criteria.

The effectiveness and costs of comprehensive geriatric evaluation and management

Comprehensive geriatric assessment (CGA) is a multidimensional interdisciplinary diagnostic process focused on determining a frail elderly person's medical, psychological, and functional capabilities in order to develop a coordinated and integrated plan for treatment and long-term follow-up. Geriatrics interventions building on CGA are defined from their historical emergence to the present day in a discussion of their complexity, goals and normative components. Through literature review, questions of the effectiveness and costs of these interventions are addressed. Evidence of effectiveness is derived from individual trials and, particularly, recent systematic reviews. While the trial evidence lends support to the proposition that geriatric interventions can be effective, the results have not been uniform. Review of meta-regression studies suggests that much of this outcome variability is related to identifiable program design parameters. In particular, targeting the frail, an interdisciplinary team structure with clinical control of care, and long-term follow-up, tend to be associated with effective programs. Answers to cost-effectiveness questions also vary and are more rare. With some exceptions, existing evidence as exists suggest that geriatrics interventions can be effective without raising total costs of care. Despite the attention given to these questions in recent years, there is still much room for clinical and scientific advance as we move to better understand what CGA interventions do well and in whom.

Development and evaluation of intermediate care

Intermediate care is being developed as part of the national strategy for older people in England and Wales to prevent their admission to hospital and facilitate early discharge. Evaluation of intermediate care is implicit within current policy directives. This project evaluated the client information across a number of intermediate care schemes within one National Health Service community trust for 3 months and disseminated the results to staff as part of a reflective workshop which also provided an opportunity for additional data collection. Rates of referral and acceptance on intermediate care were high for all the schemes except one, indicating reliable referral and inclusion criteria. Older people were the recipients of intermediate care with nearly half of them having experienced falls. A number of developments were identified by staff covering both current services and long-term strategy for intermediate care and indicating the importance of involving providers in the evaluation and development of services. Fall prevention initiatives and involvement of users and carers in the evaluation and development of intermediate care were also identified.

Care home versus hospital and own home environments for rehabilitation of older people

BACKGROUND

Rehabilitation for older people has acquired an increasingly important profile for both policy-makers and service providers within health and social care agencies. This growing demand for rehabilitation services has generated an increased interest in the use of alternative care environments, for example care home environments, for older persons' rehabilitation. At a time when there is pressure for policy decision-makers and service providers to explore the use of such care settings for the provision of rehabilitation for older people, there appears limited evidence on which to base decisions.

OBJECTIVES

The objective of this review is to compare the effects of care home environments (e.g. nursing home, residential care home and nursing facilities) versus hospital environments and own home environments in the rehabilitation of older people.

SEARCH STRATEGY

The following databases were searched. The Cochrane Effective Practice and Organisation of Care Specialised Register, the Cochrane Rehabilitation Specialist Register; Cochrane Controlled Trials Register (CCTR); MEDLINE (1966-2000); EMBASE (1980-2000), Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982-2000): Science Citation Index (1982-2000); Social Science Citation Index (1982-2000); Best Evidence (1991-2000); HMIC (1979-2000); PsycINFO(1967-2000); ASSIA (1987-2000); Ageline (1978-2000); AgeInfo (1971-2000); Sociological Abstracts (1963-2000); System for Information on Grey Literature (SIGLE) (1980-2000); UK National Research Registers Project Database( Issue 1 2001); Architecture Publication Index (1977-2000). The following Journals were hand searched: Disability and Rehabilitation (1992-2000); Disability and Society (1986-2000); Archives of Physical Medicine and Rehabilitation (1985-2000); Journal of the American Geriatric Society (1980-2000); International Journal of Rehabilitation Research (1980-2000); American Journal of Physical Medicine and Rehabilitation (1980-2000) and: Clinical Rehabilitation (1992-2000). The reviewers also consulted subject area experts and obtained full text review articles and forward tracked any references from these sources.

SELECTION CRITERIA

Randomised controlled trials (RCTs), controlled clinical trials (CCTs), controlled before and after studies (CBAs) and interrupted time series (ITS) that compared rehabilitation outcomes for persons 60 years or older who received rehabilitation whilst residing in a care home with those for persons 60 years or older who received rehabilitation in hospital or own home environments. Primary outcomes included functional outcomes using activities of daily living measurement (both personal and instrumental). Secondary outcomes included subjective health status; quality of life measures; return to place of usual residency; all cause mortality; adverse effects; readmission to an acute care facility; patient and carer satisfaction; number of days in facility and number of days receiving rehabilitation.

DATA COLLECTION AND ANALYSIS

One reviewer (DW) completed the initial search and identified potential papers for inclusion. Abstracts for these papers were independently scrutinised by two reviewers (DW/MS) to assess their eligibility. Full text versions of potentially eligible papers were independently assessed by two reviewers (DW/MS). Papers that fulfilled the comparison inclusion criteria were then independently scrutinised by all reviewers to assess whether they met EPOC methodological criteria for inclusion.

MAIN RESULTS

The total yield from the initial search strategy was 19,457. A total of 1,247 abstracts were independently scrutinised by two reviewers (DW/MS) to assess their eligibility. Full text papers for 99 studies were obtained to assess if they fulfilled the review's comparison inclusion criteria. This process resulted in 12 papers being assessed further for methodological validity. However, none of these studies met the inclusion criteria.

REVIEWER'S CONCLUSIONS

There is insufficient evidence to compare the effects of care home environments, hospital environments and own home environments on older persons rehabilitation outcomes. Although the authors acknowledge that absence of effect is not no effect. There are three main reasons; the first is that the description and specification of the environment is often not clear; secondly, the components of the rehabilitation system within the given environments are not adequately specified and; thirdly, when the components are clearly specified they demonstrate that the control and intervention sites are not comparable with respect to the methodological criteria specified by Cochrane EPOC group (Cochrane 1998). The combined effect of these factors resulted in the comparability between intervention and control groups being very weak. For example, there were differences in the services provided in the intervention and control arms, due possibly to differences in dominant remuneration systems, nature of the rehabilitation transformation, patient characteristics, skill mix and academic status of the care environment.