Stakeholders perspectives on the key components of community-based interventions coordinating care in dementia: a qualitative systematic review

Collaborative Care Models of Primary Care Clinics for People with Early-Stage Dementia: A Cross-Sectional Survey of Primary Care Physicians in Japan

Objectives

This study explored collaboration models between primary care physicians (PCPs) and care managers (CMs) and assessed each model's potential in meeting the support needs of individuals with early-stage dementia.

Methods

In 2022, a cross-sectional survey was conducted among the PCPs in Tokyo. The data regarding the participant and clinic characteristics and daily practices for individuals with early-stage dementia were collected. The clinical collaborative practice was classified using a latent class analysis; comparisons were made between the identified classes based on 14 items in seven domains of support.

Results

Two collaborative and one stand-alone models were identified. The former varied in the professionals' roles, with one led by PCPs and the other by CMs. We named them PCP-led, CM-led, and stand-alone models, accounting for 46.4%, 32.8%, and 20.6% of the clinics, respectively. The PCP-led clinics were significantly more likely to provide support than the stand-alone ones across five domains: cognitive function, care planning, carers' support, information, and social health. The CM-led model clinics generally fell between those of the other two models.

Conclusion

Different leadership styles exist in the PCP-CM collaborations in care delivery for people with early-stage dementia. This collaboration offers distinct advantages for clinics in addressing their needs.

Experiences of Ambulatory Patients With Huntington's Disease With Case Management: A Qualitative Study

PURPOSE/OBJECTIVES

Huntington's disease (HD) requires high-quality care to reduce disruption of the patient system, prevent crisis situations, and prevent early admission in a nursing home. In the Netherlands, case management has been available for the last to 9 years for people with HD. However, there is a notable gap in understanding experiences and beliefs of HD patients regarding case managers' care, guidance, and support for quality of life. To improve the international quality of care for people with HD, insight in experiences of ambulatory HD patients with the care, guidance, and support received from a case manager HD (CMHD) is crucial.

PRIMARY PRACTICE SETTING

Ambulatory care.

FINDINGS/CONCLUSIONS

Ambulatory patients with HD highly appreciate and value the role and support of the CMHD. This was reflected in four themes: (1) the CMHD as a person, with commitment, sympathy, and reliability as central concepts; (2) the CMHD as a professional, with the key roles of coordinator, point of contact, expert, and supporter; (3) impact of the CMHD on quality of life, with support of coping with decline and monitoring the home situation as important subthemes; and (4) support of the CMHD for family members, with providing help and giving attention as subthemes. This insight into patients' experiences of the CMHD's role adds value to the improvement of the international quality of care for people with HD.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

Commitment, expertise, support for both family members and patients, and bond of trust from the CMHD are experienced as very valuable. These qualitative findings from a patient's perspective add significantly to the body of knowledge on CMHD's role and practices as "spider at the center of the web."

Care coordination across healthcare systems: development of a research agenda, implications for practice, and recommendations for policy based on a modified Delphi panel

OBJECTIVE

For large, integrated healthcare delivery systems, coordinating patient care across delivery systems with providers external to the system presents challenges. We explored the domains and requirements for care coordination by professionals across healthcare systems and developed an agenda for research, practice and policy.

DESIGN

The modified Delphi approach convened a 2-day stakeholder panel with moderated virtual discussions, preceded and followed by online surveys.

SETTING

The work addresses care coordination across healthcare systems. We introduced common care scenarios and differentiated recommendations for a large (main) healthcare organisation and external healthcare professionals that contribute additional care.

PARTICIPANTS

The panel composition included health service providers, decision makers, patients and care community, and researchers. Discussions were informed by a rapid review of tested approaches to fostering collaboration, facilitating care coordination and improving communication across healthcare systems.

OUTCOME MEASURES

The study planned to formulate a research agenda, implications for practice and recommendations for policy.

RESULTS

For research recommendations, we found consensus for developing measures of shared care, exploring healthcare professionals' needs in different care scenarios and evaluating patient experiences. Agreed practice recommendations included educating external professionals about issues specific to the patients in the main healthcare system, educating professionals within the main healthcare system about the roles and responsibilities of all involved parties, and helping patients better understand the pros and cons of within-system and out-of-system care. Policy recommendations included supporting time for professionals with high overlap in patients to engage regularly and sustaining support for care coordination for high-need patients.

CONCLUSIONS

Recommendations from the stakeholder panel created an agenda to foster further research, practice and policy innovations in cross-system care coordination.

Components of case management in caring for patients with dementia: a mixed-methods study

BACKGROUND

Case management has shown improvements in some health outcomes for dementia patients and their families. However, despite its benefits the components of case management in order to provide effective patient and family care remain unknown at present. Thus, the aim of this study is to identify the specific components of case management in caring for patients with dementia and to determine the necessary intensity of its deployment to enhance outcomes for these patients and their caregivers.

METHODS

Mixed-methods study with a qualitative phase to characterise forms of service provision, according to the case management components involved, followed by a quantitative phase to analyse the correlations between different patterns of service provision, adverse events in patients and caregiver overload. This study will be based on the variables described in the RANGE.COM register.

DISCUSSION

This research is expected to achieve a reproducible, evaluable set of interventions that can be modelled to optimise case management effectiveness for patients with dementia. Interactions between patients with dementia, their family caregivers and case management healthcare services, the components of these interactions and their association with the conditions of the individuals concerned are issues of great interest in the field of case management, which is constantly evolving.

Case Management Programs for Improving Integrated Care for Frequent Users of Healthcare Services: An Implementation Analysis

Introduction:

Case management programs (CMP) for frequent users of healthcare services presenting complex healthcare needs constitute an effective strategy to improve patient experience of integrated care and to decrease healthcare overuse and cost. This study sought to identify characteristics of these programs, and their implementation contexts, that help to improve patient self-management, experience of integrated care, and healthcare services use.

Methods:

A mixed methods multiple embedded case study design was conducted, with six CMP implemented in six hospitals of a region of Quebec (Canada).

Results:

Within-case analysis describes the structural, environmental, organizational, practitioner, patient, and innovation level characteristics of each CMP and their services integration outcomes based on patient experience, self-management and healthcare services use. Cross-case analysis suggests that the skills, leadership and experience of the case manager, providers’ access to the individualized services plan, consideration of the needs of the patient and family members, their participation in decision-making, and the self-management approach, impact integrated care and healthcare services use.

Conclusion and discussion:

This study underscores the necessity of an experienced, knowledgeable and well-trained case manager with interpersonal skills to optimize CMP implementation such that patients are more proactive in their care and their outcomes improve.

Person-centered dementia care in home care services - highly recommended but still challenging to obtain: a qualitative interview study

BACKGROUND

Dementia is one of the main causes of disability and dependence in older people, and people with dementia need comprehensive healthcare services, preferably in their own homes. A well-organized home care service designed for people with dementia is necessary to meet their needs for health- and social care. Therefore, it is important to gain knowledge about how people with dementia experience the home care service and if the service responds to their wishes and needs. The aim of this study was to explore the experience of home care services among people with dementia, to understand the continuity in services, how the service was adapted to people with dementia, and how the patient experienced person-centered care and shared decision-making.

METHODS

We used a qualitative, exploratory design based on a phenomenological-hermeneutic approach and performed individual in-depth interviews with persons with dementia. A convenience sample of 12 persons with moderate to severe degrees of dementia from four Norwegian municipalities participated in the study. The interviews were conducted in February 2019.

RESULTS

The findings identified that the participants appreciated the possibility to stay safely in their own homes and mostly experienced good support from staff. They expressed various views and understanding of the service and experienced limited opportunities for user involvement and individualized, tailored service. The overall theme summarizing the findings was: "It is difficult for people with dementia to understand and influence home care services, but the services facilitate the possibility to stay at home and feel safe with support from staff."

CONCLUSION

The participants did not fully understand the organization of the care and support they received from the home care services, but they adapted to the service without asking for changes based on their needs or desires. Although person-centered care is recommended both nationally and internationally, the participants experienced little inclusion in defining the service they received, and it was perceived as unclear how they could participate in shared decision-making.

The compound role of a coordinator for home-dwelling persons with dementia and their informal caregivers: qualitative study

Background

As the number of persons with dementia is increasing, there has been a call for establishing sustainable clinical pathways for coordinating care and support for this group. The LIVE@Home.Path trial is a multicomponent, multi-disciplinary intervention combining learning, innovation, volunteer support and empowerment. To implement the intervention, a municipal coordinator has a crucial role. Implementation research on multicomponent interventions is complex and we conducted a qualitative study, aiming to explore the coordinator role and how a coordinator may empower persons with dementia in decision-making processes.

Methods

Qualitative program evaluation combined with a hermeneutic interpretive approach was chosen as methodological approach. Sixteen dyads, consisting of the person with dementia and their main informal caregiver received the intervention by two coordinators. Of these, six dyads, three informal caregivers alone and the two care coordinators along with their leader, in sum, eighteen persons, participated in in-depth or focus group interviews, sharing their experiences after 6 months intervention.

Results

We found that the coordinators fulfilled three functions for the participating dyads: being a safety net, meaning that the dyads might have little needs at the moment, but found safety in a relation to someone who might help if the situation should change; being a pathfinder, meaning that they supported the dyads in finding their way through the complicated system of care and support services; being a source for emotional care and support, meaning that they listened, acknowledged and gave counsel in times of distress. The coordinators emphasized that a trusting leader and work environment was crucial for them to fulfill these functions. We also found that it was challenging for the coordinators to build a relation to the persons with dementia in order to pursue genuine empowerment in decision-making processes.

Conclusion

We found the framework for follow-up to be a feasible starting point for establishing empowering coordination and a sustainable care pathway for persons with dementia and their informal caregivers. More meeting points between coordinator and person with dementia should be pursued in order to fulfill the persons’ fundamental rights to participate in decision-making processes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-020-05913-z.

Urgent care for patients with dementia: a scoping review of associated factors and stakeholder experiences

OBJECTIVES

People with dementia are more vulnerable to complications in urgent health situations due to older age, increased comorbidity, higher dependency on others and cognitive impairment. This review explored the factors associated with urgent care use in dementia and the experiences of people with dementia, informal carers and professionals.

DESIGN

Scoping review. The search strategy and data synthesis were informed by people with dementia and carers.

DATA SOURCES

Searches of CINAHL, Embase, Medline, PsycINFO, PubMed were conducted alongside handsearches of relevant journals and the grey literature through 15 January 2019.

ELIGIBILITY CRITERIA

Empirical studies including all research designs, and other published literature exploring factors associated with urgent care use in prehospital and emergency room settings for people with dementia were included. Two authors independently screened studies for inclusion.

DATA EXTRACTION AND SYNTHESIS

Data were extracted using charting techniques and findings were synthesised according to content and themes.

RESULTS

Of 2967 records identified, 54 studies were included in the review. Specific factors that influenced use of urgent care included: (1) common age-related conditions occurring alongside dementia, (2) dementia as a diagnosis increasing or decreasing urgent care use, (3) informal and professional carers, (4) patient characteristics such as older age or behavioural symptoms and (5) the presence or absence of community support services. Included studies reported three crucial components of urgent care situations: (1) knowledge of the patient and dementia as a condition, (2) inadequate non-emergency health and social care support and (3) informal carer education and stress.

CONCLUSIONS

The scoping review highlighted a wider variety of sometimes competing factors that were associated with urgent care situations. Improved and increased community support for non-urgent situations, such as integrated care, caregiver education and dementia specialists, will both mitigate avoidable urgent care use and improve the experience of those in crisis.

Effectiveness of different post-diagnostic dementia care models delivered by primary care: a systematic review

BACKGROUND

Global policy recommendations suggest a task-shifted model of post-diagnostic dementia care, moving towards primary and community-based care. It is unclear how this may best be delivered.

AIM

To assess the effectiveness and cost-effectiveness of primary care-based models of post-diagnostic dementia care.

DESIGN AND SETTING

A systematic review of trials and economic evaluations of post-diagnostic dementia care interventions where primary care was substantially involved in care plan decision making.

METHOD

Searches were undertaken of MEDLINE, PsychINFO, EMBASE, Web of Science, and CINAHL (from inception to March 2019). Two authors independently critically appraised studies and inductively classified interventions into types of care models. Random effects meta-analysis or narrative synthesis was conducted for each model where appropriate.

RESULTS

From 4506 unique references and 357 full texts, 23 papers were included from 10 trials of nine interventions, delivered in four countries. Four types of care models were identified. Primary care provider (PCP)-led care (n = 1) led to better caregiver mental health and reduced hospital and memory clinic costs compared with memory clinics. PCP-led care with specialist consulting support (n = 2) did not have additional effects on clinical outcomes or costs over usual primary care. PCP-case management partnership models (n = 6) offered the most promise, with impact on neuropsychiatric symptoms, caregiver burden, distress and mastery, and healthcare costs. Integrated primary care memory clinics (n = 1) had limited evidence for improved quality of life and cost-effectiveness compared with memory clinics.

CONCLUSION

Partnership models may impact on some clinical outcomes and healthcare costs. More rigorous evaluation of promising primary care-led care models is needed.

An update on dementia training programmes in home and community care

PURPOSE OF REVIEW

Many people living with dementia (PLWD) wish to continue living at home. The quality of home care services directly influences their ability to stay at home, their quality of life, and can promote independence for PLWD, and reduce burden for the family carer. For high-quality, effective, person-centred community-based dementia care, a knowledgeable and empathetic workforce is crucial. This article presents an up-to-date review and summary of the literature investigating dementia training programmes for community home care professionals and care workers, referred to collectively as home care workers (HCWs).

RECENT FINDINGS

We reviewed the literature between October 2016 and April 2018 on dementia training for HCWs. We found a significant lack of evidence-based, codesigned specialist dementia training programmes for HCWs that address the needs of all stakeholders in home care, and which formally measure outcomes.

SUMMARY

In order to enable PLWD to maintain living at home in the community, dementia-friendly and knowledgeable HCWs are needed. This review highlights the need for more research into the design and evaluation of evidence-based dementia specialist training programmes for community care.

The importance of trust-based relations and a holistic approach in advance care planning with people with dementia in primary care: a qualitative study

Background

ACP enables individuals to define and discuss goals and preferences for future medical treatment and care with family and healthcare providers, and to record these goals and preferences if appropriate. Because general practitioners (GPs) often have long-lasting relationships with people with dementia, GPs seem most suited to initiate ACP. However, ACP with people with dementia in primary care is uncommon. Although several barriers and facilitators to ACP with people with dementia have already been identified in earlier research, evidence gaps still exist. We therefore aimed to further explore barriers and facilitators for ACP with community-dwelling people with dementia.

Methods

A qualitative design, involving all stakeholders in the care for community-dwelling people with dementia, was used. We conducted semi-structured interviews with community dwelling people with dementia and their family caregivers, semi structured interviews by telephone with GPs and a focus group meeting with practice nurses and case managers. Content analysis was used to define codes, categories and themes.

Results

Ten face to face interviews, 10 interviews by telephone and one focus group interview were conducted. From this data, three themes were derived: development of a trust-based relationship, characteristics of an ACP conversation and the primary care setting.

ACP is facilitated by a therapeutic relationship between the person with dementia/family caregiver and the GP built on trust, preferably in the context of home visits. Addressing not only medical but also non-medical issues soon after the dementia diagnosis is given is an important facilitator during conversation. Key barriers were: the wish of some participants to postpone ACP until problems arise, GPs’ time restraints, concerns about the documentation of ACP outcomes and concerns about the availability of these outcomes to other healthcare providers.

Conclusions

ACP is facilitated by an open relationship based on trust between the GP, the person with dementia and his/her family caregiver, in which both medical and non-medical issues are addressed. GPs’ availability and time restraints are barriers to ACP. Transferring ACP tasks to case managers or practice nurses may contribute to overcoming these barriers.

Electronic supplementary material

The online version of this article (10.1186/s12877-018-0872-6) contains supplementary material, which is available to authorized users.

Barriers and facilitators for GPs in dementia advance care planning: A systematic integrative review

BACKGROUND

Due to the disease's progressive nature, advance care planning (ACP) is recommended for people with early stage dementia. General practitioners (GPs) should initiate ACP because of their longstanding relationships with their patients and their early involvement with the disease, however ACP is seldom applied.

AIM

To determine the barriers and facilitators faced by GPs related to ACP with people with dementia.

DATA SOURCES

We systematically searched the relevant databases for papers published between January 1995 and December 2016, using the terms: primary healthcare, GP, dementia, and ACP. We conducted a systematic integrative review following Whittemore and Knafl's method. Papers containing empirical data about GP barriers and/or facilitators regarding ACP for people with dementia were included. We evaluated quality using the Mixed-Method-Appraisal-Tool and analyzed data using qualitative content analysis.

RESULTS

Ten qualitative, five quantitative, and one mixed-method paper revealed four themes: timely initiation of ACP, stakeholder engagement, important aspects of ACP the conversation, and prerequisites for ACP. Important barriers were: uncertainty about the timing of ACP, how to plan for an uncertain future, lack of knowledge about dementia, difficulties assessing people with dementia's decisional capacities, and changing preferences. Facilitators for ACP were: an early start when cognitive decline is still mild, inclusion of all stakeholders, and discussing social and medical issues aimed at maintaining normal life.

CONCLUSION

Discussing future care is difficult due to uncertainties about the future and the decisional capacities of people with dementia. Based on the facilitators, we recommend that GPs use a timely and goal-oriented approach and involve all stakeholders. ACP discussions should focus on the ability of people with dementia to maintain normal daily function as well as on their quality of life, instead of end-of-life-discussions only. GPs need training to acquire knowledge and skills to timely initiate collaborative ACP discussions.

The effectiveness of community-based coordinating interventions in dementia care: a meta-analysis and subgroup analysis of intervention components

Background

Interventions aiming to coordinate services for the community-based dementia population vary in components, organisation and implementation. In this review we aimed to evaluate the effectiveness of community-based care coordinating interventions on health outcomes and investigate whether specific components of interventions influence their effects.

Methods

We searched four databases from inception to April 2017: Medline, The Cochrane Library, EMBASE and PsycINFO. This was aided by a search of four grey literature databases, and backward and forward citation tracking of included papers. Title and abstract screening was followed by a full text screen by two independent reviewers, and quality was assessed using the CASP appraisal tool. We then conducted meta-analyses and subgroup analyses.

Results

A total of 14 randomised controlled trials (RCTs) involving 10,372 participants were included in the review. Altogether we carried out 12 meta-analyses and 19 subgroup analyses. Meta-analyses found coordinating interventions showed a statistically significant improvement in both patient behaviour measured using the Neuropsychiatric Inventory (NPI) (mean difference (MD) = −9.5; 95% confidence interval (CI): −18.1 to −1.0; p = 0.03; number of studies (n) = 4; I² = 88%) and caregiver burden (standardised mean difference (SMD) = −0.54; 95% CI: -1.01 to −0.07; p = 0.02; n = 5, I² = 92%) compared to the control group. Subgroup analyses found interventions using a case manager with a nursing background showed a greater positive effect on caregiver quality of life than those that used case managers from other professional backgrounds (SMD = 0.94 versus 0.03, respectively; p < 0.001). Interventions that did not provide supervision for the case managers showed greater effectiveness for reducing the percentage of patients that are institutionalised compared to those that provided supervision (odds ratio (OR) = 0.27 versus 0.96 respectively; p = 0.02). There was little evidence of effects on other outcomes, or that other intervention components modify the intervention effects.

Conclusion

Results show that coordinating interventions in dementia care has a positive impact on some outcomes, namely patient behaviour and caregiver burden, but the evidence is inconsistent and results were not strong enough to draw definitive conclusions on general effectiveness. With the rising prevalence of dementia, effective complex interventions will be necessary to provide high quality and effective care for patients, and facilitate collaboration of health, social and third sector services.

Electronic supplementary material

The online version of this article (10.1186/s12913-017-2677-2) contains supplementary material, which is available to authorized users.