Generic care pathway for elderly patients in need of home care services after discharge from hospital: a cluster randomised controlled trial

Standardizing Integrated Oncology and Palliative Care Across Service Levels: Challenges in Demonstrating Effects in a Prospective Controlled Intervention Trial

INTRODUCTION

Patients with cancer often want to spend their final days at home. In Norway, most patients with cancer die in institutions. We hypothesized that full integration of oncology and palliative care services would result in more time spent at home during end-of-life.

METHODS

A prospective non-randomized intervention trial was conducted in two rural regions of Mid-Norway. The hospitals' oncology and palliative care outpatient clinics and surrounding communities participated. An intervention including information, education, and a standardized care pathway was developed and implemented. Adult non-curative patients with cancer were eligible. Proportion of last 90 days of life spent at home was the primary outcome.

RESULTS

We included 129 patients in the intervention group (I) and 76 patients in the comparison group (C), of whom 82% of patients in I and 78% of patients in C died during follow-up. The mean proportion of last 90 days of life spent at home was 0.62 in I and 0.72 in C (p = 0.044), with 23% and 36% (p = 0.073), respectively, dying at home. A higher proportion died at home in both groups compared to pre-study level (12%). During the observation period the comparison region developed and implemented an alternative intervention to the study intervention, with the former more focused on end-of-life care.

CONCLUSION

A higher proportion of patients with cancer died at home in both groups compared to pre-study level. Patients with cancer in I did not spend more time at home during end-of-life compared to those in C. The study intervention focused on the whole disease trajectory, while the alternative intervention was more directed towards end-of-life care. "Simpler" and more focused interventions on end-of-life care may be relevant for future studies on integration of palliative care into oncology.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02170168.

A Retrospective Analysis of Internet-Based Sharing Nursing Service Appointment Data

Aims

To investigate the historical data of the "Internet+ Nursing" service platform and provide a theoretical basis to optimize the "Internet+ Nursing" service model by analyzing a population in need of nursing care services, service prices, services in demand, willingness to place orders, and feedback on use.

Methods

A retrospective analysis of data related to home care services on the "Jiuzhou Nursing Care" platform from April 2020 to August 2021, a total of 279 person-times, relevant information about the research subjects, and the status of home care services was conducted. SPSS 24.0 software was used for data analyses, such as calculating frequencies and percentages and conducting chi-square tests.

Results

The "Jiuzhou Online Nurse" primarily serves elderly patients, and the majority of these patients have lost their ability to care for themselves. The average cost of nursing services was ¥183.45, and the unit cost of services had no effect on the number of service items. This particular internet-based home nursing service has a high level of satisfaction. Patients aged 60 to 74 have the highest number of Internet-based home care service orders (χ 2 = 11.791, P < 0.05). Patients who reuse the platform are more willing to assign people to provide services (χ 2 = 238.078, P < 0.05). Patients who were unable to care for themselves had a higher rate of repeat order (χ 2 = 10.877, P < 0.05).

Conclusion

The "Internet+ Nursing" service platform specifically meets the individual needs of elderly patients, provides them with home nursing services, and improves local medical treatment and door-to-door services. This platform also provides convenience for elderly individuals who cannot care for themselves so that they can receive prompt treatment and assistance to improve their quality of life.

Dilemmas and deliberations in managing the care trajectory of elderly patients with complex health needs: a single-case study

Background

Today, the ageing population is larger than ever before, and people who are living longer with chronic illnesses and multimorbidity need support from multiple healthcare service levels. Similarly, healthcare systems are becoming increasingly specialised and fragmented. The World Health Organization has highlighted novel policies for developing integrated and person-centred services. However, patients, next of kin and health professionals face several challenges in managing healthcare during the care trajectory. Limited literature has addressed the challenges experienced by these groups. Therefore, this study aimed to identify the dilemmas and deliberations faced by patients, next of kin and health professionals during the care trajectory of elderly patients with complex healthcare needs.

Method

The study had a qualitative single-case design. The case was taken from a multi-case study exploring the care trajectory of elderly patients. The participants were the patient, their next of kin and the health professionals involved in the patient’s care trajectory. Data were obtained via observation and individual interviews conducted during the patient’s hospital stay and after the patient returned home.

Results

The dilemmas and deliberations in managing the care trajectory were divided into four main themes: the health professionals’ pursuit of appropriate and feasible healthcare services, the next of kin’s planning horizons, being the person left in limbo and reorganising the home for comprehensive healthcare.

Conclusion

The pursuit of a tailored and suitable healthcare service lead to a comprehensive mobilisation of and work by all actors involved. Having a comprehensive understanding of these conditions are of importance in developing an appropriate care trajectory for the elderly patient with complex need.

Effectiveness of integrating primary healthcare in aftercare for older patients after discharge from tertiary hospitals-a systematic review and meta-analysis

Background

Quality of aftercare can crucially impact health status of older patients and reduce the extra burden of unplanned healthcare resource utilisation. However, evidence of effectiveness of primary healthcare in supporting aftercare, especially for older patients after discharge are limited.

Methods

We searched for English articles of randomised controlled trials published between January 2000 and March 2022. All-cause hospital readmission rate and length of hospital stay were pooled using a random-effects model. Subgroup analyses were conducted to identify the relationship between intervention characteristics and the effectiveness on all-cause hospital readmission rate.

Results

A total of 30 studies with 11,693 older patients were included in the review. Compared with patients in the control group, patients in the intervention group had 32% less risk of hospital readmission within 30 days (RR = 0.68, P < 0.001, 95%CI: 0.56–0.84), and 17% within 6 months (RR = 0.83, P < 0.001, 95%CI: 0.75–0.92). According to the subgroup analysis, continuity of involvement of primary healthcare in aftercare had significant effect with hospital readmission rates (P < 0.001). Economic evaluations from included studies suggested that aftercare intervention was cost-effective due to the reduction in hospital readmission rate and risk of further complications.

Conclusion

Integrating primary healthcare into aftercare was designed not only to improve the immediate transition that older patients faced but also to provide them with knowledge and skills to manage future health problems. There is a pressing need to introduce interventions at the primary healthcare level to support long-term care.

Implementing a Standardized Care Pathway Integrating Oncology, Palliative Care and Community Care in a Rural Region of Mid-Norway

INTRODUCTION

To improve quality across levels of care, we developed a standardized care pathway (SCP) integrating palliative and oncology services for hospitalized and home-dwelling palliative cancer patients in a rural region.

METHODS

A multifaceted implementation strategy was directed towards a combination of target groups. The implementation was conducted on a system level, and implementation-related activities were registered prospectively. Adult patients with advanced cancer treated with non-curative intent were included and interviewed. Healthcare leaders (HCLs) and healthcare professionals (HCPs) involved in the development of the SCP or exposed to the implementation strategy were interviewed. In addition, HCLs and HCPs exposed to the implementation strategy answered standardized questionnaires. Hospital admissions were registered prospectively.

RESULTS

To assess the use of the SCP, 129 cancer patients were included. Fifteen patients were interviewed about their experiences with the patient-held record (PHR). Sixty interviews were performed among 1320 HCPs exposed to the implementation strategy. Two hundred and eighty-seven HCPs reported on their training in and use of the SCP. Despite organizational cultural differences, developing an SCP integrating palliative and oncology services across levels of care was feasible. Both HCLs and HCPs reported improved quality of care in the wake of the implementation process. Two and a half years after the implementation was launched, 28% of the HCPs used the SCP and 41% had received training in its use. Patients reported limited use and benefit of the PHR.

CONCLUSION

An SCP may be a usable tool for integrating palliative and oncology services across care levels in a rural region. An extensive implementation process resulted in improvements of process outcomes, yet still limited use of the SCP in clinical practice. HCLs and HCPs reported improved quality of cancer care following the implementation process. Future research should address mandatory elements for usefulness and successful implementation of SCPs for palliative cancer patients.

Evaluating an integrated care pathway for frail elderly patients in Norway using multi-criteria decision analysis

Background

To provide value-based care for patients with multi-morbidity, innovative integrated care programmes and comprehensive evaluations of such programmes are required. In Norway, a new programme called “Holistic Continuity of Patient Care” (HCPC) addresses the issue of multi-morbidity by providing integrated care within learning networks for frail elderly patients who receive municipal home care services or a short-term stay in a nursing home. This study conducts a multi-criteria decision analysis (MCDA) to evaluate whether the HCPC programme performs better on a large set of outcomes corresponding to the ‘triple aim’ compared to usual care.

Methods

Prospective longitudinal survey data were collected at baseline and follow-up after 6-months. The assessment of HCPC was implemented by a novel MCDA framework. The relative weights of importance of the outcomes used in the MCDA were obtained from a discrete choice experiment among five different groups of stakeholders. The performance score was estimated using a quasi-experimental design and linear mixed methods. Performance scores were standardized and multiplied by their weights of importance to obtain the overall MCDA value by stakeholder group.

Results

At baseline in the HCPC and usual care groups, respectively, 120 and 89 patients responded, of whom 87 and 41 responded at follow-up. The average age at baseline was 80.0 years for HCPC and 83.6 for usual care. Matching reduced the standardized differences between the groups for patient background characteristics and outcome variables. The MCDA results indicated that HCPC was preferred to usual care irrespective of stakeholders. The better performance of HCPC was mostly driven by improvements in enjoyment of life, psychological well-being, and social relationships and participation. Results were consistent with sensitivity analyses using Monte Carlo simulation.

Conclusion

Frail elderly with multi-morbidity represent complex health problems at large costs for society in terms of health- and social care. This study is a novel contribution to assessing and understanding HCPC programme performance respecting the multi-dimensionality of desired outcomes. Integrated care programmes like HCPC may improve well-being of patients, be cost-saving, and contribute to the pursuit of evidence based gradual reforms in the care of frail elderly.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06805-6.

Crossing knowledge boundaries: health care providers' perceptions and experiences of what is important to achieve more person-centered patient pathways for older people

BACKGROUND

Improving the transitional care of older people, especially hospital-to-home transitions, is a salient concern worldwide. Current research in the field highlights person-centered care as crucial; however, how to implement and enact this ideal in practice and thus achieve more person-centered patient pathways remains unclear. The aim of this study was to explore health care providers' (HCPs') perceptions and experiences of what is important to achieve more person-centered patient pathways for older people.

METHODS

This was a qualitative study. We performed individual semistructured interviews with 20 HCPs who participated in a Norwegian quality improvement collaborative. In addition, participant observation of 22 meetings in the quality improvement collaborative was performed.

RESULTS

A thematic analysis resulted in five themes which outline central elements of the HCPs' perceptions and experiences relevant to achieving more person-centered patient pathways: 1) Finding common ground through the mapping of the patient journey; 2) the importance of understanding the whole patient pathway; 3) the significance of getting to know the older patient; 4) the key role of home care providers in the patient pathway; and 5) ambiguity toward checklists and practice implementation.

CONCLUSIONS

The findings can assist stakeholders in understanding factors important to practicing person-centered transitional care for older people. Through collaborative knowledge sharing the participants developed a more shared understanding of how to achieve person-centered patient pathways. The importance of assuming a shared responsibility and a more holistic understanding of the patient pathway by merging different ways of knowing was highlighted. Checklists incorporating the What matters to you? question and the mapping of the patient journey were important tools enabling the crossing of knowledge boundaries both between HCPs and between HCPs and the older patients. Home care providers were perceived to have important knowledge relevant to providing more person-centered patient pathways implying a central role for them as knowledge brokers during the patient's journey. The study draws attention to the benefits of focusing on the older patients' way of knowing the patient pathway as well as to placing what matters to the older patient at the heart of transitional care.

Comparative short-term outcomes of enhanced recovery after surgery (ERAS) program and non-ERAS traditional care in elderly patients undergoing lumbar arthrodesis: a retrospective study

Background

Enhanced recovery after surgery (ERAS) program is an evidence-based improvement over non-ERAS traditional care. The aim of the present study was to analyze the safety, feasibility, and efficacy of an ERAS program in patients over 70 years undergoing lumbar arthrodesis by comparison with non-ERAS traditional care.

Methods

During January 2018 to December 2018, patients enrolled received non-ERAS traditional care, while the ERAS program was implemented from January to December 2019. Demographic characteristics, comorbidities, surgical data and postoperative recovery parameters were collected from all patients. Postoperative pain scores were evaluated by visual analog scales (VAS). The clinical outcomes were length of stay (LOS), postoperative complications and postoperative pain scores. Compliance results were also collected.

Result

A total of 127 patients were enrolled, including 67 patients in the non-ERAS traditional care group and 60 patients in the ERAS group. The demographic characteristics and comorbidities of the two groups showed no significant differences. The LOS of patients treated with ERAS program (13.6 ± 4.0 days) was significantly less than that of patients treated with non-ERAS traditional care (15.6 ± 3.9 days) (p = 0.034). Complication rate was 8.3% in the ERAS group versus 20.9% in the non-ERAS traditional care group (p = 0.048). VAS (back) in the ERAS group was significantly lower on postoperative day (POD) 1 and POD2. Postoperative recovery parameters were improved in the ERAS group. The overall compliance with the ERAS program was 94%.

Conclusions

Based on our results, ERAS program is safer and more effective for elderly patients over 70 undergoing lumbar arthrodesis than non-ERAS traditional care.

Social factors influencing utilization of home care in community-dwelling older adults: a scoping review

BACKGROUND

Older adults want to live at home as long as possible, even in the face of circumstances that limit their autonomy. Home care services reflect this emergent preference, allowing older adults to 'age in place' in familiar settings rather than receiving care for chronic health conditions or ageing needs in an institutionalized setting. Numerous social factors, generally studied in isolation, have been associated with home care utilization. Even so, social circumstances are complex and how these factors collectively influence home care use patterns remains unclear.

OBJECTIVES

To provide a broad and comprehensive overview of the social factors influencing home care utilization; and to evaluate the influence of discrete social factors on patterns of home care utilization in community-dwelling older adults in high-income countries.

METHODS

A scoping review was conducted of six electronic databases for records published between 2010 and 2020; additional records were obtained from hand searching review articles, reference lists of included studies and documents from international organisations. A narrative synthesis was presented, complemented by vote counting per social factor, harvest plots and an evaluation of aggregated findings to determine consistency across studies.

RESULTS

A total of 2,365 records were identified, of which 66 met inclusion criteria. There were 35 discrete social factors grouped into four levels of influence using a socio-ecological model (individual, relationship, community and societal levels) and grouped according to outcome of interest (home care propensity and intensity). Across all studies, social factors consistently showing any association (positive, negative, or equivocal in pattern) with home care propensity were: age, ethnicity/race, self-assessed health, insurance, housing ownership, housing problems, marital status, household income, children, informal caregiving, social networks and urban/rural area. Age, education, personal finances, living arrangements and housing ownership were associated with home care intensity, also with variable patterns in utilization. Additional community and societal level factors were identified as relevant but lacking consistency across the literature; these included rurality, availability of community services, methods of financing home care systems, and cultural determinants.

CONCLUSION

This is the first literature review bringing together a wide range of reported social factors that influence home care utilization. It confirms social factors do influence home care utilization in complex interactions, distinguishes level of influences at which these factors affect patterns of use and discusses policy implications for home care reform.

Impact of Compliance with an Enhanced Recovery After Surgery Program on the Outcomes Among Elderly Patients Undergoing Lumbar Fusion Surgery

Background and Aim

The benefits of the enhanced recovery after surgery (ERAS) program to elderly patients have not been evaluated in lumbar fusion surgery. Compliance with the ERAS program is associated with prognosis. There is currently no adequate assessment about the importance of the individual components of ERAS program in lumbar fusion surgery. The aim of the study was to analyze the effect of compliance with our ERAS program and the relative importance of the individual ERAS program components among elderly patients undergoing lumbar fusion surgery.

Methods

A retrospective case-review study was conducted from March 2018 to March 2020. The ERAS program for lumbar fusion surgery at our department was implemented. Overall compliance was found to be 92.9%, and this was used as a cutoff for dividing patients into higher compliance and lower compliance groups. Patient characteristics and clinical outcomes were compared between groups.

Results

The overall compliance rate was 92.9%, distributing 91 patients into the higher compliance group and 169 patients into the lower compliance group. Patients with higher compliance were younger (p=0.045). The length of stay (LOS) of patients with higher compliance was significantly shorter than that of patients with lower compliance. Patients with higher compliance had significantly fewer complications (p=0.031). A multivariate analysis showed that surgical time (p=0.029), lower compliance (p=0.034), and early oral feeding (p=0.026) were predictors of any postoperative complications. On multivariate analysis, the following items remained correlated with prolonged LOS (LOS≥12 days): older age (p=0.010), lower compliance (p<0.0001), early ambulation (p=0.018), and stick to discharge criteria (p=0.040).

Conclusion

Low compliance with ERAS program among elderly patients undergoing lumbar fusion surgery was associated with a higher incidence of complications and prolonged LOS. The failure of early oral feeding was associated with increased complications, and the failure of early ambulation or sticking to discharge criteria was significantly more influential on prolonged LOS.

Case Management Models and Continuing Care: A Literature Review across nations, settings, approaches, and assessments

Older adults accessing continuing care often have multiple chronic conditions. Research suggests that case management is a promising approach to reduce health care expenditure and improve patient outcomes. To optimize healthcare delivery, an examination of existing case management models and their effectiveness is essential. This literature review was conducted using Joanna Briggs Institute (JBI) methods to explore case management models for older adults accessing continuing care services. Searches were conducted in PubMed and CINAHL from 2010 to 2018. A total of 37 articles were included in this review. Approaches to case management are diverse with respect to composition of care providers, method of care provision, and location of care. Findings from 27 quantitative studies demonstrated that nurse-led and interdisciplinary team case management models that include home visits can effectively reduce hospital admission/readmission while lowering costs. Mixed results were found on the impact of case management on patient satisfaction, ED visits, quality of life, length of stay, self-efficacy, social integration and caregiver burden. Among 10 qualitative studies, 3 facilitators for quality case management were identified that include receiving care at home, building trusting relationships, and improving self-efficacy. Based on these findings, we conclude that nurse-led and interdisciplinary team case management can effectively reduce hospital admission of frail older adults while lowering costs, particularly within home care settings.

Effects of applying a standardized assessment and evaluation protocol in housing adaptation implementation - results from a quasi-experimental study

BACKGROUND

Standardized, research-based strategies to guide the implementation and evaluate the effects of housing adaptations (HA) on client outcomes are rare. We hypothesized that, compared to ordinary practice, a standardized assessment and evaluation protocol for HA implementation would better maintain or improve client outcomes over 1 year.

METHOD

Using a cluster design, South Swedish municipalities were recruited to an intervention or control group. Data on activities of daily living, usability of the home, health related quality of life, and participation frequency and satisfaction were collected at home visits 1 month before the HA (baseline; T1), and at 3 (T2), 6 (T3) and 12 (T4) months after. In the intervention group (n = 112) data were collected according to a standardized protocol while in the control group (n = 129) ordinary routines were applied. Changes from baseline to subsequent time points were categorized as no deterioration (i.e. improvement or no change) or deterioration, for each outcome item separately. Differences in "no deterioration" between the groups were assessed using logistic regression.

RESULTS

Little effect of using the standardized protocol was detected. For activities of daily living, statistically significant differences between the groups were found for toileting (T1-T4; OR 3.14), dressing (T1-T4; OR2.89) and cooking (T1-T3 and T1-T4; OR 3.14). For usability of the home differences were found in personal hygiene (T1-T2; OR 2.32) using a wheelchair (T1-T2 and T1-T3; OR 9.50), picking up the mail (T1-T3; OR 4.06), and in participation, helping others (T1-T3 and T1-T4; OR 2.33 and 3.36).

CONCLUSION

The applied standardized protocol for HA implementation did not show any convincing effect, possibly due to the complexity of the intervention itself, and the implementation process. A process evaluation might generate in-depth knowledge about the reasons behind the findings.

TRIAL REGISTRATION

ClinicalTrials.gov . NCT01960582.

Discharge of older patients with chronic diseases: What nurses do and what they record. An observational study

AIMS AND OBJECTIVES

To describe which nursing activities are observed during the discharge of older patients with chronic diseases and to investigate the consistency between the nursing activities actually observed and those documented.

BACKGROUND

The discharge from hospital of older patients with chronic diseases is a critical transition that can lead to dissatisfaction, delays in discharge, re-admission, adverse events and increased mortality. Although nurses' interventions during discharge are important for patient outcomes, little is known about the nursing activities actually performed as compared with those documented.

DESIGN

An observational study of the nursing activities performed during patients' discharge and a retrospective audit of the nursing records of the same patients and nurses.

METHODS

Structured nonparticipant observations were conducted of the activities performed by nurses at discharge. A retrospective audit of the nursing records relating to patient discharge, including the nursing diary and the assessment of critical issues at hospital discharge, was also conducted. The STROBE guidelines were followed (See Supporting Information Appendix S2).

RESULTS

During hospital discharge of 102 patients, 1,224 nursing activities were observed. The number of activities was not related to patients' age, gender and educational level, nor to nurses' postgraduate education. Statistically significant correlations emerged between the number of activities observed and the nurses' work experience.

CONCLUSIONS

A predefined discharge plan guiding nurses' activities during discharge would enable them to respond better to the care needs of elderly patients.

RELEVANCE TO CLINICAL PRACTICE

Results from the study could help clinical nurses to address care priorities of patients at discharge, by using appropriate plans and checklists and improving recording rates. Novice nurses should be supported when caring for elderly patients with chronic disease at discharge.