The relationship between staff skill mix, costs and outcomes in intermediate care services

Transitional care programs for older adults moving from hospital to home in Canada: A systematic review of text and opinion

BACKGROUND

Investing in transitional care programs is critical for ensuring continuity of health and coordinated care for older adults transitioning across health settings. However, literature delineating the scope of transitional care programs across Canada is limited. The aim of this systematic review of text and opinion is to characterize Canadian transitional care programs for older adults transitioning from hospital to home.

METHODS

Following JBI guidelines for systematic review of text and opinion, we conducted a search of Canadian grey literature sources published online between 2016 to 2023. A 3-phase search was undertaken for: 1) Canadian databases and organizational websites; 2) advanced Google search of national sources and news media reports; and 3) advanced Google search of provincial/territorial sources. Two reviewers independently screened sources for eligibility against inclusion criteria. Data were extracted by one reviewer and verified by a second. Textual data were extracted from multiple sources to characterize each transitional care program.

RESULTS

Grey literature search produced a total of 17,092 text and opinion sources, identifying 119 transitional care programs in Canada. Model of care was a key characteristic defining the design and delivery of transitional care programs within community (n = 42), hospital (n = 45), and facility-based (n = 32) settings. Programs were characterized by goal, population and eligibility, setting and length of program, intervention and services, and healthcare team members. Patient, caregiver, and health system outcomes were reported for 18 programs. The province of Ontario has the most transitional care programs (n = 84) and reported outcomes, followed by British Columbia (n = 10).

CONCLUSIONS

Characterizing transitional care programs is important for informing health services planning and scaling up of transitional care program models across Canada. Recognizing transitional care programs as a core health service is critical to meet the health care needs of older adults at the right time and place.

TRIAL REGISTRATION

PROSPERO ID 298821.

Transitional care programs in Canada for older adults transitioning from hospital to home: protocol for a systematic review of text and opinion

OBJECTIVE

The objective of this systematic review is to identify what transitional care programs exist across Canada, including the characteristics and outcomes of these programs.

INTRODUCTION

There is growing evidence of the benefits of transitional care programs to support older adults moving from hospital to home. However, there is limited literature identifying the types of transitional care programs that exist internationally and little evidence available within Canada.

INCLUSION CRITERIA

Sources of gray literature published from 2016 that focus on older adults receiving services from transitional care programs to move from hospital to home in Canada will be considered for inclusion. Sources of gray literature will be excluded if interventions are targeted at adults younger than 65 years, Indigenous adults younger than 55 years, or if the primary discharge destination is not an independent community dwelling. Interventions designed for older adults waiting in hospital for long-term care placement will also be excluded from this review.

METHODS

An initial limited search of Canadian national gray literature resources will be undertaken, followed by an advanced Google search of Canadian resources and news media reports. Lastly, an advanced search of Google for all 10 provinces and 3 territories will be undertaken to target examples of local transitional care programs that may not be found through a national search, such as local pilot projects, health region-specific programs, and provincial organizations. All identified sources will be retrieved and full text review of selected citations assessed in detail by 2 independent reviewers. Data about the characteristics and outcomes of transitional care programs and results will be extracted and synthesized, with a meta-aggregation approach for grading according to JBI ConQual method.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42022298821.

Skill-mix change and outcomes in primary care: Longitudinal analysis of general practices in England 2015-2019

BACKGROUND

Increasing the employment of staff with new clinical roles in primary care has been proposed as a solution to the shortages of GPs and nurses. However, evidence of the impacts this has on practice outcomes is limited. We examine how outcomes changed following changes in skill-mix in general practices in England.

METHODS

We obtained annual data on staff in 6,296 English general practices between 2015 and 2019 and grouped professionals into four categories: GPs, Nurses, Health Professionals, and Healthcare Associate Professionals. We linked 10 indicators of quality of care covering the dimensions of accessibility, clinical effectiveness, user experiences and health system costs. We used both fixed-effect and first-differences regressions to model changes in staff composition and outcomes, adjusting for practice and population factors.

RESULTS

Employment increased over time for all four staff groups, with largest increases for Healthcare Professionals (from 0.04 FTE per practice in 2015 to 0.28 in 2019) and smallest for Nurses who experienced a 3.5 percent growth. Increases in numbers of GPs and Nurses were positively associated with changes in practice activity and outcomes. The introduction of new roles was negatively associated with patient satisfaction: a one FTE increase in Health Professionals was associated with decreases of 0.126 [-0.175, -0.078] and 0.116 [-0.161, -0.071] standard deviations in overall patient satisfaction and satisfaction with making an appointment. Pharmacists improved medicine prescribing outcomes. All staff categories were associated with higher health system costs. There was little evidence of direct complementarity or substitution between different staff groups.

CONCLUSIONS

Introduction of new roles to support GPs does not have straightforward effects on quality or patient satisfaction. Problems can arise from the complex adaptation required to adjust practice organisation and from the novelty of these roles to patients. These findings suggest caution over the implementation of policies encouraging more employment of different professionals in primary care.

Identifying the Main Predictors of Length of Care in Social Care in Portugal

In this paper, we aim to identify the main predictors at admission and estimate patients' length of care (LOC), within the framework of the Portuguese National Network for Long-Term Integrated Care, considering two care settings: (1) home and community-based services (HCBS) and (2) nursing home (NH) units comprising Short, Medium, or Long Stay Care. This study relied on a database of 20,984 Portuguese individuals who were admitted to the official long-term care (LTC) system and discharged during 2015. A generalised linear model (GLM) with gamma distribution was adjusted to HCBS and NH populations. Two sets of explanatory variables were used to model the random variable, LOC, namely, patient characteristics (age, gender, family/neighbour support, dependency levels at admission for locomotion, cognitive status, and activities of daily living [ADL]) and external factors (referral entity, number of beds/treatment places per 1,000 inhabitants ≥65 years of age), maturity and occupancy rate of the institution, and care setting. The features found to most influence the reduction of LOC are: male gender, having family/neighbour support, being referred by hospitals to NH (or by primary care to HCBS), and being admitted to units with a lower occupancy rate and with fewer months in operation. Regarding the dependency levels, as the number of ADL considered "dependent" increases, LOC also increases. As for the cognitive status, despite the opposite trend, it was only statistically significant for NH. Furthermore, two additional models were applied by including "death," although this feature is not observable upon admission. By creating a model that allows for an estimate of the expected LOC for a new individual entering the Portuguese LTC system, policy-makers are able to estimate future costs and optimise resources.

The Contribution of Case Mix, Skill Mix and Care Processes to the Outcomes of Community Hospitals: A Population-Based Observational Study

Introduction:

Community hospitals (CHs) could address the emerging complex care needs of patients. We investigated which characteristics of patients’ and CHs affect patient outcomes, in order to identify who could benefit the most from CH care and the best skill mix to deliver this care.

Methods:

We analysed all elderly patients discharged from the CHs of Emilia-Romagna, Italy. CH skill mix and care processes were collected with an ad hoc survey. The primary outcome was improvement in the Barthel index (BI) on discharge. Hierarchical regression analysis was performed to test the associations under study.

Results:

53% of the patients had a BI improvement ≥10. After adjusting for the diverse case mix of the patients, no significant association was found between CH characteristics and BI improvement. Patient characteristics explained only a portion of the variability in CH performance.

Discussion:

Heterogeneity in case mix reflects the nature of CHs, which play context-specific roles as integrators between primary care services and hospitals. Residual variability in BI improvement rates across CHs might be attributed to aspects of care not detected in our survey.

Conclusions:

More research is needed to study the impact of CH skill mix and care processes on patient outcomes.

Panorama da produção científica sobre Cuidados Intermediários e Hospitais Comunitários: uma revisão integrativa

RESUMO Mudanças epidemiológicas decorrentes do envelhecimento populacional motivaram transformações nos sistemas de saúde mundiais. Desde 1990, emergem discussões sobre Cuidados Intermediários (CI), visando diminuir hospitalizações, melhorar a coordenação do cuidado e estimular políticas públicas de cuidados próximos ao território. Este trabalho objetivou apresentar e analisar a literatura científica sobre CI, enfatizando serviços de Hospitais Comunitários. Realizou-se uma revisão integrativa, combinando os descritores “Intermediate Care”, “Community Hospitals”, “Intermediate Care Facilities”, “Long-Term Care”, “Hospitals Chronic Disease” e “Rehabilitation Services”, nos idiomas português, inglês e espanhol, nas bases Portal Regional da Biblioteca Virtual em Saúde, PubMed e Biblioteca Digital Brasileira de Teses e Dissertações. Após processo de busca e elegibilidade, foram incluídos 30 documentos para síntese qualitativa, provenientes de: Reino Unido, Noruega, Espanha, Dinamarca, Austrália e Itália. Resultados apontam para a eficácia, a efetividade e a eficiência dos CI, com boas avaliações por parte de profissionais e usuários. Os CI, como estratégia de fortalecimento da Atenção Primária à Saúde, redução de internações, favorecimento da independência funcional dos pacientes e seu retorno à comunidade, apresentam-se como uma inovação em saúde e aposta promissora. Entretanto, persistem lacunas na literatura que ensejam mais estudos sobre o tema, com vistas a subsidiar a tomada de decisão.

Understanding transitional care programs for older adults who experience delayed discharge: a scoping review

Background

Many hospitalized older adults cannot be discharged because they lack the health and social support to meet their post-acute care needs. Transitional care programs (TCPs) are designed to provide short-term and low-intensity restorative care to these older adults experiencing or at risk for delayed discharge. However, little is known about the contextual factors (i.e., patient, staff and environmental characteristics) that may influence the implementation and outcomes of TCPs. This scoping review aims to answer: 1) What are socio-demographic and/or clinical characteristics of older patients served by TCPs?; 2) What are the core components provided by TCPs?; and 3) What patient, caregiver, and health system outcomes have been investigated and what changes in these outcomes have been reported for TCPs?

Methods

The six-step scoping review framework and PRISMA-ScR checklist were followed. Studies were included if they presented models of TCPs and evaluated them in community-dwelling older adults (65+) experiencing or at-risk for delayed discharge. The data synthesis was informed by a framework, consistent with Donabedian’s structure-process-outcome model.

Results

TCP patients were typically older women with multiple chronic conditions and some cognitive impairment, functionally dependent and living alone. The review identified five core components of TCPs: assessment; care planning and monitoring; treatment; discharge planning; and patient, family and staff education. The main outcomes examined were functional status and discharge destination. The results were discussed with a view to inform policy makers, clinicians and administrators designing and evaluating TCPs as a strategy for addressing delayed hospital discharges.

Conclusion

TCPs can influence outcomes for older adults, including returning home. TCPs should be designed to incorporate interdisciplinary care teams, proactively admit those at risk of delayed discharge, accommodate persons with cognitive impairment and involve care partners. Additional studies are required to investigate the contributions of TCPs within integrated health care systems.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02099-9.

Addressing the workforce capacity for public health surveillance through field epidemiology and laboratory training program: the need for balanced enhanced skill mix and distribution, a case study from Tanzania

Introduction

Skill mix refers to the range of professional development and competencies, skills and experiences of staff within a particular working environment that link with specific outcome while responding to client needs. A balanced skill-mix and distribution of core human resources is important to strengthen decision-making process and rapid responses. We analysed graduates´ information of the Tanzania Field Epidemiology and Laboratory Training Program (TFELTP) between 2008-2016, distribution of skill-mix and the surveillance workforce-gaps within regions.

Methods

Trainees´ data of nine cohorts enrolled between 2008 and 2016 were extracted from the program database. Distribution by sex, region and cadres/profession was carried out. An indicator to determine enhanced-skill mix was established based on the presence of a clinician, nurse, laboratory scientist and environmental health officer. A complete enhanced skill-mix was considered when all four were available and have received FELTP training.

Results

The TFELTP has trained 113 trainees (male=71.7%), originated from 17 regions of Tanzania Mainland (65.4% of all) and Zanzibar. Clinicians (34.5%) and laboratory scientists (38.1%) accounted for the most recruits, however, the former were widely spread in regions (83% vs. 56%). Environmental health officers (17.7%) were available in 39% of regions. The nursing profession, predominantly lacking (6.2%) was available in 22% of regions. Only two regions (11.7%) among 17 covered by TFELTP presented complete skill-mix, representing 7.7% of Tanzanian regions. Seven regions (41%) had an average of one trainee.

Conclusion

The TFELTP is yet to reach the required skill-mix in many regions within the country. The slow fill-rate for competent and key workforce cadres might impede effective response. Strategies to increase program awareness at subnational levels is needed to improve performance of surveillance and response system in Tanzania.

Innovation to enhance health in care homes and evaluation of tools for measuring outcomes of care: rapid evidence synthesis

Background

Flexible, integrated models of service delivery are being developed to meet the changing demands of an ageing population. To underpin the spread of innovative models of care across the NHS, summaries of the current research evidence are needed. This report focuses exclusively on care homes and reviews work in four specific areas, identified as key enablers for the NHS England vanguard programme.

Aim

To conduct a rapid synthesis of evidence relating to enhancing health in care homes across four key areas: technology, communication and engagement, workforce and evaluation.

Objectives

(1) To map the published literature on the uses, benefits and challenges of technology in care homes; flexible and innovative uses of the nursing and support workforce to benefit resident care; communication and engagement between care homes, communities and health-related organisations; and approaches to the evaluation of new models of care in care homes. (2) To conduct rapid, systematic syntheses of evidence to answer the following questions. Which technologies have a positive impact on resident health and well-being? How should care homes and the NHS communicate to enhance resident, family and staff outcomes and experiences? Which measurement tools have been validated for use in UK care homes? What is the evidence that staffing levels (i.e. ratio of registered nurses and support staff to residents or different levels of support staff) influence resident outcomes?

Data sources

Searches of MEDLINE, CINAHL, Science Citation Index, Cochrane Database of Systematic Reviews, DARE (Database of Abstracts of Reviews of Effects) and Index to Theses. Grey literature was sought via Google™ (Mountain View, CA, USA) and websites relevant to each individual search.

Design

Mapping review and rapid, systematic evidence syntheses.

Setting

Care homes with and without nursing in high-income countries.

Review methods

Published literature was mapped to a bespoke framework, and four linked rapid critical reviews of the available evidence were undertaken using systematic methods. Data were not suitable for meta-analysis, and are presented in narrative syntheses.

Results

Seven hundred and sixty-one studies were mapped across the four topic areas, and 65 studies were included in systematic rapid reviews. This work identified a paucity of large, high-quality research studies, particularly from the UK. The key findings include the following. (1) Technology: some of the most promising interventions appear to be games that promote physical activity and enhance mental health and well-being. (2) Communication and engagement: structured communication tools have been shown to enhance communication with health services and resident outcomes in US studies. No robust evidence was identified on care home engagement with communities. (3) Evaluation: 6 of the 65 measurement tools identified had been validated for use in UK care homes, two of which provide general assessments of care. The methodological quality of all six tools was assessed as poor. (4) Workforce: joint working within and beyond the care home and initiatives that focus on staff taking on new but specific care tasks appear to be associated with enhanced outcomes. Evidence for staff taking on traditional nursing tasks without qualification is limited, but promising.

Limitations

This review was restricted to English-language publications after the year 2000. The rapid methodology has facilitated a broad review in a short time period, but the possibility of omissions and errors cannot be excluded.

Conclusions

This review provides limited evidential support for some of the innovations in the NHS vanguard programme, and identifies key issues and gaps for future research and evaluation.

Future work

Future work should provide high-quality evidence, in particular experimental studies, economic evaluations and research sensitive to the UK context.

Study registration

This study is registered as PROSPERO CRD42016052933, CRD42016052933, CRD42016052937 and CRD42016052938.

Funding

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

Is the effectiveness of memory assessment services associated with their structural and process characteristics?

OBJECTIVES

The aim of this study was to investigate whether structural and process characteristics of memory assessment services (MASs) are associated with outcomes (changes in patients' health-related quality of life (HRQL), carers' HRQL and carers' burden) over the first 6 months following the first appointment.

METHODS

Data from 785 patients referred to 69 MASs and 511 of their lay carers, collected at the first appointment and 6 months later. Data on MAS characteristics were collected using a questionnaire at baseline. We used multilevel linear regression models to explore the associations of patients' HRQL and carers' outcomes with structural and process characteristics of MASs. Analyses were conducted on the full sample of patients and carers, and separately on those patients diagnosed with dementia.

RESULTS

None of the structural (skill mix, workload, volume, provision of clinical assessments and provision of psychosocial support) or process (waiting time, length and number of appointments, anti-dementia drug use and psychosocial interventions use) characteristics included in the analyses were associated with patients' or carers' outcomes at 6 months, apart from the presence of allied health professionals (AHPs), which was associated with a DEMQOL score 2.7 points higher. When only those with a diagnosis of dementia were considered, the association with presence of AHPs was no longer observed.

CONCLUSIONS

Apart from involving AHPs, alterations to the way MASs are structured or function appear unlikely to improve their effectiveness in improving patients' and carers' HRQL. It is possible that the characteristics of MASs may influence patients' and carers' experience, but this was not studied. Copyright © 2017 John Wiley & Sons, Ltd.

Exploration of workforce changes in integrated chronic care: Findings from an interactive and emergent research design

INTRODUCTION

Integrated care interventions introduced in response to the increased demand for long-term care entail profound changes to the health workforce. This exploratory study aims to provide an overview of the workforce changes implemented as part of integrated chronic care interventions.

METHODS

An interactive and emergent research design was used consisting of a literature review, qualitative expert questionnaires and case reports. We defined integrated care as interventions targeting at least two of the six Chronic Care Model components. Workforce changes were defined as those changes experienced by clinical and non-clinical staff responsible for public and individual health intervention.

RESULTS

Seven workforce changes were identified: (1) nurse involvement, (2) multidisciplinary staff, (3) multidisciplinary protocols/pathways, (4) provider training, (5) case manager/care coordinator, (6) team meetings, and (7) new positions. Most interventions included more than one of these workforce changes.

CONCLUSION

The results of this study provide detailed insights into the current implementation of workforce changes in integrated care interventions and thereby pave the way for further investigations into the relative effectiveness of different workforce changes within the scope of complex interventions. Advancing knowledge in this area is essential for fostering health systems' capacity to cope with the challenges related to the current demographic and epidemiological trends.

The Development, Description and Appraisal of an Emergent Multimethod Research Design to Study Workforce Changes in Integrated Care Interventions

Introduction:

In this paper, we provide a detailed and explicit description of the processes and decisions underlying and shaping the emergent multimethod research design of our study on workforce changes in integrated chronic care.

Theory and methods:

The study was originally planned as mixed method research consisting of a preliminary literature review and quantitative check of these findings via a Delphi panel. However, when the findings of the literature review were not appropriate for quantitative confirmation, we chose to continue our qualitative exploration of the topic via qualitative questionnaires and secondary analysis of two best practice case reports.

Results:

The resulting research design is schematically described as an emergent and interactive multimethod design with multiphase combination timing. In doing so, we provide other researchers with a set of theory- and experience-based options to develop their own multimethod research and provide an example for more detailed and structured reporting of emergent designs.

Conclusion and discussion:

We argue that the terminology developed for the description of mixed methods designs should also be used for multimethod designs such as the one presented here.

Assessing patient preferences for the delivery of different community-based models of care using a discrete choice experiment

OBJECTIVES

To assess patient preferences for different models of care defined by location of care, frequency of care and principal carer within community-based health-care services for older people.

DESIGN

Discrete choice experiment administered within a face-to-face interview.

SETTING

An intermediate care service in a large city within the United Kingdom.

PARTICIPANTS

The projected sample size was calculated to be 200; however, 77 patients were recruited to the study. The subjects had recently been discharged from hospital and were living at home and were receiving short-term care by a publicly funded intermediate care service.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURE

The degree of preference, measured using single utility score, for individual service characteristics presented within a series of potential care packages.

RESULTS

Location of care was the dominant service characteristics with care at home being the strongly stated preference when compared with outpatient care (0.003), hospital care (<0.001) and nursing home care (<0.001) relative to home care, although this was less pronounced among less sick patients. Additionally, the respondents indicated a dislike for very frequent care contacts. No particular type of professional carer background was universally preferred but, unsurprisingly, there was evidence that sick patients showed a preference for nurse-led care.

CONCLUSIONS

Patients have clear preferences for the location for their care and were able to state preferences between different care packages when their ideal service was not available. Service providers can use this information to assess which models of care are most preferred within resource constraints.

Mechanisms to enhance the effectiveness of allied health and social care assistants in community-based rehabilitation services: a qualitative study

This research aims to describe the factors associated with successful employment of allied health and social care assistants in community-based rehabilitation services (CBRS) in England. The research involved the thematic analysis of interviews and focus groups with 153 professionally qualified and assistant staff from 11 older people's interdisciplinary community rehabilitation teams. Data were collected between November 2006 and December 2008. Assistants were perceived as a focal point for care delivery and conduits for enabling a service to achieve goals within interdisciplinary team structures. Nine mechanisms were identified that promoted the successful employment of assistants: (i) Multidisciplinary team input into assistant training and support; (ii) Ensuring the timely assessment of clients by qualified staff; (iii) Establishing clear communication structures between qualified and assistant staff; (iv) Co-location of teams to promote communication and skill sharing; (v) Removing barriers that prevent staff working to their full scope of practice; (vi) Facilitating role flexibility of assistants, while upholding the principles of reablement; (vii) Allowing sufficient time for client-staff interaction; (viii) Ensuring an appropriate ratio of assistant to qualified staff to enable sufficient training and supervision of assistants; and (ix) Appropriately, resourcing the role for training and reimbursement to reflect responsibility. We conclude that upholding these mechanisms may help to optimise the efficiency and productivity of assistant and professionally qualified staff in CBRS.

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.

Mechanisms for the effective implementation of an allied health assistant trainee: a qualitative study of a speech language pathology assistant

Objective This paper explores the impact and mechanisms for successful implementation of a speech language pathology assistant (SLPA) role into a rehabilitation setting using a traineeship approach. Methods Multiple data sources were used, including interviews with key stakeholders, documentary evidence and a workload audit. Results The SLPA role increased clinical service capacity by 28 h per week across the service and required a total of 3 h per week of supervision input (the equivalent of 38 min per speech and language pathologist (SLP)). The SLPA used non-clinical time for training and administration. Mechanisms that facilitated the implementation of the SLPA role were: support for existing staff; formal knowledge and skills in training; consultation and engagement; access to a competency framework; close working with the registered training organisation; clearly defined role and delegation boundaries; clear supervision structures; confidence in own role; supportive organisational culture; vision for expansion of the role; engaging the SLPs in training and development; and a targeted recruitment approach. Conclusion The development and implementation of a new trainee SLPA role using a traineeship approach required a large amount of supervision and training input from the SLPs. However, it was perceived that these efforts were offset by the increased service capacity provided by the introduction of a trainee role and the high levels of satisfaction with the new role. What is known about this topic? Efficient delegation to assistants requires supervising staff to have a clear understanding of the roles and experience of assistants. There has been little evaluation of assistant training models to date. What does this paper add? The net benefit of an allied health assistant in speech pathology far outweighs the input required to provide training and supervision. The paper identifies a range of mechanisms to facilitate the implementation and efficient use of the assistant role. What are the implications for practitioners? The implementation of assistant roles requires support for both the assistant and the supervising staff member. Engaging the supervising staff in training the assistant enhances role understanding and effective delegation to the assistant staff member. Although the role development requires a great deal of local investment, there is potential for more efficient implementation of new roles through sharing of resources, such as competencies, assessments and training tools.

Can home health aids using the clinical algorithm Algo choose the right bath seat for clients having a straightforward problem?

Objective:

To determine if Algo, a clinical algorithm to select bathing equipment for ‘straightforward’ cases, guides home health aides in selecting the appropriate bath seat.

Design:

Criterion validity study.

Setting:

Community home care.

Subjects:

Eight home health aides used Algo with community-dwelling older adults having a straightforward problem.

Main measures:

Their bath-seat recommendations were compared with those proposed by an occupational therapist (OT), which were considered as the gold standard. In order to determine a clinically acceptable threshold of agreement between the recommendations, a subgroup of community-dwelling elderly people was assessed a third time by another OT.

Results:

Half of the clients (74/143) for whom bathroom assessments were requested qualified as potentially straightforward cases after triage and were visited at home by a home health aide using Algo. In 84% of cases (95% confidence interval (CI) = [75, 93]), the non-OTs using Algo identified a seat that would enable these older adults to bathe according to their preferences, abilities and environment, as confirmed by the gold standard OT. Moreover, this appropriateness rate did not statistically differ from that obtained when comparing another OT to the gold standard.

Conclusion:

Algo guides non-OTs toward a bath seat that meets the needs of community-dwelling older adults in the majority of cases.