Achieving Integrated Care for Older People: Shuffling the Deckchairs or Making the System Watertight For the Future?

Psychometric Validation of the Patient-Reported Experience Measure (PREM) Questionnaire "HowRwe" in Patients With Respiratory Disease Receiving Home Respiratory Therapies

Introduction

The patient experience is defined as all the interactions that occur between patients and the healthcare system. The experience of patients with respiratory disease with home respiratory treatments (HRT) is not captured in currently available Patient-Reported Outcome Measures (PROM). We present the psychometric validation of the Patient-Reported Experience Measure (PREM) 'HowRwe' in Spanish and for respiratory patients with HRT.

Methods

After translation following ISPOR guidelines (International Society for Pharmacoeconomics and Outcomes Research), the questionnaire was administered to adult respiratory patients who were receiving treatment at Hospital Universitario de La Princesa. The administration was done in two stages with 6 months of difference between the pre- and post-test.

Results

We studied 228 respiratory patients, with a mean (SD) age of 64.1 (13.2) years, 52.2% were men, 68.0% were married or coupled, and 56.6% were retired. Reliability coefficients of the scale were adequate, with α = .921 and Ω = .929 for pre-test, and α = .940 and Ω = .958 for post. The confirmatory factor analysis tested for pre- and post-intervention, showed an excellent overall fit: χ2(2) = 49.380 (p < .001), CFI = .941 and SRMR = .072; and χ2(2) = 37.579 (p < .001), CFI = .982 and SRMR = .046, respectively. No statistically significant associations were observed for neither age, adherence nor quality of life, except between HowRwe post-test and quality of life pre-test (r = .14 [.01,.26]; p = .035). No significant differences were found in sociodemographic variables. No differences in pre-test or post-test were found in effect of HRT. 85.6% of patients found the content of HowRwe "Useful", and the preferred channel to respond it were paper, app and email.

Conclusions

The Spanish version of the 'HowRwe' questionnaire to measure the experience in respiratory patients with home respiratory treatments (HRT), has adequate psychometric properties and conceptual and semantic equivalence with the original English version.

A Physiotherapy-Led Transition to Home Intervention for Older Adults Following Emergency Department Discharge: A Pilot Feasibility Randomised Controlled Trial (ED PLUS)

Background

Older adults frequently attend the emergency department (ED) and experience high rates of subsequent adverse outcomes including functional decline, ED re-presentation and unplanned hospital admission. The development of effective interventions to prevent such outcomes is a key priority for research and service provision. Our aim was to evaluate the feasibility of a physiotherapy-led integrated care intervention for older adults discharged from the ED (ED PLUS).

Patients and Methods

Older adults presenting to the ED of a university teaching hospital with undifferentiated medical complaints and discharged within 72 hours were computer randomised in a ratio of 1:1:1 to deliver usual care, Comprehensive Geriatric Assessment (CGA) in the ED, or ED PLUS. ED PLUS is an evidence-based and stakeholder-informed intervention to bridge the care transition between the ED and community by initiating a CGA in the ED and implementing a six-week, multi-component, self-management programme in the patient's home. Feasibility and acceptability were assessed quantitatively and qualitatively. All clinical and process outcomes were assessed by a research nurse blinded to group allocation. Data analyses were primarily descriptive.

Results

Twenty-nine participants were recruited indicating a 67% recruitment rate. At 6 months, there was 100% retention in the usual care group, 88% in the CGA group and 90% in the ED PLUS group. ED PLUS participants expressed positive feedback, and there was a trend towards improved function and quality of life and less ED revisits and unscheduled hospitalisations in the ED PLUS group.

Conclusion

ED PLUS bridges the transition of care between the index visit to the ED and the community and is feasible using systematic recruitment strategies. Despite recruitment challenges in the context of COVID-19, the intervention was successfully delivered and well received by participants. There was a lower incidence of functional decline and improved quality of life in the ED PLUS group.

Trial Registration

The trial was registered in Clinical Trials Protocols and Results System as of 21st July 2021, with registration number NCT04983602.

Routine measurement of patient experience

Patient experience is a key pillar of healthcare quality. We describe a framework of three short generic measures covering Patient Experience, Result Satisfaction and Service Integration. The Result Satisfaction measure is described for the first time.These measures capture twelve aspects of patient experience covering the relationship between patients and clinicians (Patient Experience), the immediate results of the consultation or treatment as perceived by patients (Result Satisfaction) and collaboration between different healthcare services and silos (Service Integration). Each measure has four items.These measures are compared with three national measures: the Friends and Family Test and the General Practice Patient Survey used in England, and HCAHPS used in US hospitals. The expected benefits of national measures are not being achieved and we need to think again about how best to tailor health services to meet patients' expectations.The three measures described (Patient Experience, Result Satisfaction and Service Integration) are generic, short and have low reading ages. They share common forms and scoring schemes, which mean that they can be used individually or in combination at all levels of a healthcare provider.

Understanding the Goals of Older Adults with Complex Care Needs, Their Family Caregivers and Their Care Providers Enrolled in a Patient Navigation Program

Patient navigation models of care are being used to support hospital-to-home transitions. The present paper aimed to explore the goals important to older adults, their caregivers, and care providers as they transition from hospital-to-home and how, if at all, patient navigation can enable goals of care. Data were comprised of 94 interviews with 16 older adults, 5 family caregivers and 48 healthcare providers. Data were analyzed thematically and similarities and differences in goals were identified. Shared goals included having someone to count on and easy access to services. Older adults expressed the goal of independence, whereas family caregivers and healthcare providers noted safety. Caregivers noted goals of developing skills. While patient navigation was viewed as meeting goals of care by participants, future research is required to determine how patient navigation can support goal setting as a standard clinical practice and the long-term patient outcomes of meeting goals.

General practitioners' perceptions of distributed leadership in providing integrated care for elderly chronic multi-morbid patients: a qualitative study

Background

Distributed Leadership (DL) has been suggested as being helpful when different health care professionals and patients need to work together across professional and organizational boundaries to provide integrated care (IC). This study explores whether General Practitioners (GPs) adopt leadership actions that transcend organizational boundaries to provide IC for patients and discusses whether the GPs’ leadership actions in collaboration with patients and health care professionals contribute to DL.

Methods

We interviewed GPs (n = 20) of elderly multimorbid patients in a municipality in Norway. A qualitative interpretive case design and Gioia methodology was applied to the collection and analysis of data from semi-structured interviews.

Results

GPs are involved in three processes when contributing to IC for elderly multimorbidity patients; the process of creating an integrated patient experience, the workflow process and the process of maneuvering organizational structures and medical culture. GPs take part in processes comparable to configurations of DL described in the literature. Patient micro-context and health care macro-context are related to observed configurations of DL.

Conclusion

Initiating or moving between different configurations of DL in IC requires awareness of patient context and the health care macro-context, of ways of working, capacity of digital tools and use of health care personnel.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08460-x.

Patient and Public Preferences for Coordinated Care in Switzerland: Development of a Discrete Choice Experiment

Objective

Our objective was to develop and test a discrete choice experiment (DCE) eliciting public and patient preferences for better-coordinated care in Switzerland.

Methods

We applied a multistage mixed-methods procedure using qualitative and quantitative approaches. First, to identify attributes, we performed a review of the DCE literature in healthcare with a focus on chronic care. Next, attribute selection involved stakeholders (N = 7) from various healthcare sectors to select the most relevant and actionable attributes, followed by three organized focus groups involving the general public and patients (N = 21) to verify the selection and the clarity of the DCE tasks and explanations. Finally, we conducted an online pilot in the target population to test the survey and obtain priors for a final six tested attributes to refine the final design of the experiment.

Results

After identifying an initial 33 attributes, a final list of six attributes was selected following stakeholder involvement and the three focus groups involving the target population. At the online pilot-testing stage with 301 participants, the majority of respondents found the DCE choice tasks socially relevant for Switzerland but challenging. The quality of the answers was relatively high. Most attributes had signs matching those in the literature and focus group discussions.

Conclusion

This article will be useful to researchers designing DCEs from a broad health policy perspective. The multistage approach involving a range of stakeholders was essential for the development of a DCE that is relevant for policy makers and well-accepted by the general public and patients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40271-021-00568-2.

A 'plethora of services' but a lack of consistency: A qualitative study of service providers' perspectives about transitioning from hospital to home for older South Australians

OBJECTIVE

We explored the perspectives of professionals working in health and aged care services in South Australia about factors that influenced successful transitions from hospital to home or residential aged care home for older people. We examined successful and recommended strategies that could support safe transitions following hospital discharge and reduce avoidable hospital admissions in South Australia.

METHODS

Nineteen professionals from acute, post-acute, primary, community and aged care settings in South Australia participated in semi-structured interviews. Qualitative content analysis was conducted.

RESULTS

Participants reported that navigating service provision could be difficult, compounded by different funding arrangements for hospitals, community, primary care and aged care services. Some participants felt that there was an over-reliance on the hospital sector, leaving primary care and community-based services under-utilised to support hospital transitions. The importance of good communication between services and sectors was highlighted. Participants described different categories of services that supported safe transitions by supporting older people immediately post-discharge; services that provided support to stay at home in the weeks and months following discharge; and services that helped the person receive health care at locations other than hospitals or emergency departments when they were unwell. Participants noted that successful programs were not always maintained.

CONCLUSIONS

Division of responsibility of aged and health-care services between state and national governance contributes to fragmentation of care in South Australia. Careful planning of transitions and coordination of services across sectors is required to ensure older people are supported in the months following discharge from hospital to reduce avoidable rehospitalisations.

Pragmatic Randomized Control Trial of a Coordinated Community Response: Increasing Access to Services for At-Risk Older Adults

BACKGROUND

Elder abuse, neglect, and financial exploitation (EANF) impacts over five million community-dwelling older adults. Yet, no evidence-based intervention models exist that prevent EANF.

OBJECTIVES

In this article, we describe the assessment of process outcomes for a Community Complex Care Response Team (C3RT) model developed, via a practitioner-researcher partnership, to reduce instances of EANF victimization among higher risk community-dwelling older adults by identifying and coordinating their service needs. Specifically, we evaluated whether this C3RT approach produced more service coordination among providers (measured as documented interagency communications), more referrals for services, and more enrollment in services.

METHODS

A pragmatic randomized control trial using a 1:1 randomization scheme allocated participants to either the C3RT intervention (N = 74) or standard practice (N = 72) group offered by a local Area Agency on Aging. Outcome data were extracted from the participants' administrative service records.

RESULTS

The participants assigned to C3RT had significantly more interagency communications and services provided (p < 0.05) than those in standard practice.

CONCLUSIONS

Communications and services increased across a broad range of multidisciplinary services, which attend to the social determinants of health. This study is the first to use objective outcome measures to evaluate the processes of a coordinated community response approach systematically.

Evaluating the Co-design of an Age-Friendly, Rural, Multidisciplinary Primary Care Model: A Study Protocol

In the context of increased rates of frailty and chronic disease among older people, there is a need to develop age-friendly, integrated primary care models that place the older person at the centre of their care. However, there is little evidence about how age-friendly integrated care frameworks that are sensitive to the challenges of rural regions can be developed. This protocol paper outlines a study that will examine how the use of an age-friendly care framework (the Indigo 4Ms Framework) within a co-design process can facilitate the development of models of integrated care for rural older people within the Upper Hume region (Victoria, Australia). A co-design team will be assembled, which will include older people and individuals from local health, aged care, and community organisations. Process and outcome evaluation of the co-design activities will be undertaken to determine (1) the processes, activities and outputs that facilitate or hinder the co-design of a 4Ms integrated approach, and (2) how the use of the Indigo 4Ms Framework within a co-design process contributes to more integrated working practices. This protocol contributes to the development of a field of study examining how rural health and aged care services can become more age-friendly, with an emphasis on the role of co-design in developing integrated approaches to health care for older adults.

Implementing mHealth-Enabled Integrated Care for Complex Chronic Patients With Osteoarthritis Undergoing Primary Hip or Knee Arthroplasty: Prospective, Two-Arm, Parallel Trial

Background

Osteoarthritis is a disabling condition that is often associated with other comorbidities. Total hip or knee arthroplasty is an effective surgical treatment for osteoarthritis when indicated, but comorbidities can impair their results by increasing complications and social and economic costs. Integrated care (IC) models supported by eHealth can increase efficiency through defragmentation of care and promote patient-centeredness.

Objective

This study aims to assess the effectiveness and cost-effectiveness of implementing a mobile health (mHealth)–enabled IC model for complex chronic patients undergoing primary total hip or knee arthroplasty.

Methods

As part of the Horizon 2020 Personalized Connected Care for Complex Chronic Patients (CONNECARE) project, a prospective, pragmatic, two-arm, parallel implementation trial was conducted in the rural region of Lleida, Catalonia, Spain. For 3 months, complex chronic patients undergoing total hip or knee arthroplasty and their caregivers received the combined benefits of the CONNECARE organizational IC model and the eHealth platform supporting it, consisting of a patient self-management app, a set of integrated sensors, and a web-based platform connecting professionals from different settings, or usual care (UC). We assessed changes in health status (12-item short-form survey [SF-12]), unplanned visits and admissions during a 6-month follow-up, and the incremental cost-effectiveness ratio.

Results

A total of 29 patients were recruited for the mHealth-enabled IC arm, and 30 patients were recruited for the UC arm. Both groups were statistically comparable for baseline characteristics, such as age; sex; type of arthroplasty; and Charlson index, American Society of Anesthesiologists classification, Barthel index, Hospital Anxiety and Depression scale, Western Ontario and McMaster Universities Osteoarthritis Index, and Pfeiffer mental status questionnaire scores. Patients in both groups had significant increases in the SF-12 physical domain and total SF-12 score, but differences in differences between the groups were not statistically significant. IC patients had 50% fewer unplanned visits (P=.006). Only 1 hospital admission was recorded during the follow-up (UC arm). The IC program generated savings in different cost scenarios, and the incremental cost-effectiveness ratio demonstrated cost-effectiveness.

Conclusions

Chronic patients undergoing hip or knee arthroplasty can benefit from the implementation of patient-centered mHealth-enabled IC models aimed at empowering patients and facilitating transitions from specialized hospital care to primary care. Such models can reduce unplanned contacts with the health system and reduce overall health costs, proving to be cost-effective. Overall, our findings support the notion of system-wide cross-organizational care pathways supported by mHealth as a successful way to implement IC for patients undergoing elective surgery.

Maneuvering the care puzzle: Experiences of participation in care by frail older persons with significant care needs living at home

PURPOSE

Despite evidence that older persons want to be involved in care, little is known about how frail older people with significant care needs living at home experience participation in care provided by different stakeholders. This study investigates the experiences of participation in care by older people following their involvement in an intervention of a health care model called Focused Primary care (FPC).

METHODS

Individual semi-structured interviews were conducted with 20 older persons in five municipalities in Sweden.

RESULTS

The results show that older persons highlighted opportunities and limitations for participation on a personal level i.e., conditions for being involved in direct care and in relation to independence. Experiences of participation on organizational levels were reported to a lesser degree. This included being able to understand the organizational system underpinning care. The relational dimensions of caregiving were emphasized by the older persons as the most central aspects of caregiving in relation to participation.

CONCLUSIONS

Primary care should involve older persons more directly in planning and execution of care on all levels. An ongoing connection with one specialized elderly team and a coordinating person in Primary care who safeguards relationships is important for providing participation in care for frail older persons with significant care needs living at home.

Benefits, Challenges and Solutions for Implementing Personalised Music Playlist Programs in Residential Aged Care in Australia

INTRODUCTION

Residential aged care facilities face the immense challenge of adapting to the increasingly high needs of their residents, while delivering personalised, holistic care. There is considerable evidence that music can provide an affordable, accessible way to reduce changes in behaviour associated with dementia, in order to meet these standards of care. However, a number of barriers exist to the effective implementation of music programs in long-term aged care facilities.

METHODS

This study involved focus groups with 17 participants including staff in residential aged care facilities and family caregivers to investigate the benefits of music programs, as well as the challenges and possible solutions to them. A general inductive approach was taken to data analysis.

RESULTS

A number of benefits of music programs were identified, including improvements to the wellbeing of both residents of aged care facilities and their caregivers. However, an ingrained culture within residential aged care of focusing on physical care rather than thinking holistically about wellbeing was identified as a significant barrier.

DISCUSSION

These findings revealed that education is a key component of changing ingrained cultures of task-driven care at both a managerial level and in care staff, so that attention can be given to psychological and emotional needs as well as the physical.

What do older people want from integrated care? Experiences from a South Australian co-design case study

OBJECTIVES

The challenges of improving the integration of care for older people with complex care needs are well recognised. Evidence suggests that solutions should be co-designed with older people to ensure they are contextually relevant and person-centred.

METHODS

As a first step in a co-design project to improve integrated care for older people, seven interviews and three workshops were held with older people and service providers. Data collected via recordings, notes and journey maps were inductively analysed.

RESULTS

Five themes were identified: relationships and roles, patient capacity and safety, information and systems, multiway communication, and transitions and flow. This created a more holistic and person-centred picture of integrated care than typically derived from published literature.

CONCLUSIONS

Older people perceive integrated care from relational, organisational, informational and individual viewpoints. This reinforces the central importance of adopting a person-centred, as opposed to health system-focused, approach to designing and implementing integrated care solutions.

Implementing Mobile Health-Enabled Integrated Care for Complex Chronic Patients: Intervention Effectiveness and Cost-Effectiveness Study

Background

Integrated care can generate health and social care efficiencies through the defragmentation of care and adoption of patient-centered preventive models. eHealth can be a key enabling technology for integrated care.

Objective

The aim of this study was to assess the effectiveness and cost-effectiveness of the implementation of a mobile health (mHealth)-enabled integrated care model for complex chronic patients.

Methods

As part of the CONNECARE Horizon 2020 project, a prospective, pragmatic, two-arm, parallel implementation trial was held in a rural region of Catalonia, Spain. During 3 months, elderly patients with chronic obstructive pulmonary disease or heart failure and their carers experienced the combined benefits of the CONNECARE organizational integrated care model and the eHealth platform supporting it, consisting of a patient self-management app, a set of integrated sensors, and a web-based platform connecting professionals from different settings, or usual care. We assessed changes in health status with the 12-Item Short-Form Survey (SF-12), unplanned visits and admissions during a 6-month follow up, and the incremental cost-effectiveness ratio (ICER).

Results

A total of 48 patients were included in the integrated care arm and 28 patients receiving usual care were included in the control arm (mean age 82 years, SD 7 years; mean Charlson index 7, SD 2). Integrated care patients showed a significant increase in the SF-12 physical domain with a mean change of +3.7 (SD 8.4) (P=.004) and total SF-12 score with a mean change of +5.8 (SD 12.8) (P=.003); however, the differences in differences between groups were not statistically significant. Integrated care patients had 57% less unplanned visits (P=.004) and 50% less hospital admissions related to their main chronic diseases (P=.32). The integrated care program generated savings in different cost scenarios and the ICER demonstrated the cost-effectiveness of the program.

Conclusions

The implementation of a patient-centered mHealth-enabled integrated care model empowering the patient, and connecting primary, hospital, and social care professionals reduced unplanned contacts with the health system and health costs, and was cost-effective. These findings support the notion of system-wide cross-organizational care pathways supported by mHealth as a successful way to implement integrated care.

Can Comprehensive Geriatric Assessment Meet Frail Older People's Needs? Results from the Randomized Controlled Study CGA-Swed

BACKGROUND

The comprehensive geriatric assessment (CGA) designed to manage frail older people requiring acute medical care, is responsible for diagnostics, assessment, treatment, and planning while addressing a person's medical, psychological, social, and functional capabilities. The aim was to investigate if CGA had an impact on frail older people's activities of daily living (ADL) status, self-rated health, and satisfaction with hospital care.

METHODS

A two-armed design with frail people aged 75 or older who required an unplanned hospital admission were randomized to either the CGA ward or to an acute medical ward. Analyses were made based on the intention-to-treat principle (ITT). The primary outcome was ADL. Data were analyzed using Chi-square and odds ratio. A subgroup analysis was performed due to non-adherence and contamination.

RESULTS

One-hundred and fifty-five people participated in the study; 78 in the intervention and 77 in the control. Participants in the intervention group had a higher odds ratio of reporting having received written information and felt that care met their needs during their hospital stay. No additional statistically significant results for the primary or secondary outcomes in the ITT analysis were achieved.

CONCLUSION

Participants felt that the care they received with the CGA ward met their needs. The lack of additional results supporting the CGA could be due to difficulties performing pragmatic intervention trials in clinical hospital settings, and because a CGA during one hospital stay is probably not enough to have long-term effects.

Implementing Mobile Health-Enabled Integrated Care for Complex Chronic Patients: Patients and Professionals' Acceptability Study

Background

Integrated care (IC) can promote health and social care efficiency through prioritization of preventive patient-centered models and defragmentation of care and collaboration across health tiers, and mobile health (mHealth) can be the cornerstone allowing for the adoption of IC.

Objective

This study aims to assess the acceptability, usability, and satisfaction of an mHealth-enabled IC model for complex chronic patients in both patients and health professionals.

Methods

As part of the CONNECARE Horizon 2020 project, a prospective, pragmatic, 2-arm, parallel, hybrid effectiveness-implementation trial was conducted from July 2018 to August 2019 in a rural region of Catalonia, Spain. Home-dwelling patients 55 years and older with chronic conditions and a history of hospitalizations for chronic obstructive pulmonary disease or heart failure (use case [UC] 1), or a scheduled major elective hip or knee arthroplasty (UC2) were recruited. During the 3 months, patients experienced an mHealth-enabled IC model, including a self-management app for patients, a set of integrated sensors, and a web-based platform connecting professionals from different settings or usual care. The Person-Centered Coordinated Care Experience Questionnaire (P3CEQ) and the Nijmegen Continuity Questionnaire (NCQ) assessed person-centeredness and continuity of care. Acceptability was assessed for IC arm patients and staff with the Net Promoter Score (NPS) and the System Usability Scale (SUS).

Results

The analyses included 77 IC patients, 58 controls who completed the follow-up, and 30 health care professionals. The mean age was 78 (SD 9) years in both study arms. Perception of patient-centeredness was similarly high in both arms (usual care: mean P3CEQ score 16.1, SD 3.3; IC: mean P3CEQ score 16.3, SD 2.4). IC patients reported better continuity of care than controls (usual care: mean NCQ score 3.7, SD 0.9; IC: mean NCQ score 4.0, SD 1; P=.04). The scores for patient acceptability (UC1: NPS +67%; UC2: NPS +45%) and usability (UC1: mean SUS score 79, SD 14; UC2: mean SUS score 68, SD 24) were outstanding. Professionals’ acceptability was low (UC1: NPS −25%; UC2: NPS −35%), whereas usability was average (UC1: mean SUS score 63, SD 20; UC2: mean SUS score 62, SD 19). The actual use of technology was high; 77% (58/75) of patients reported physical activity for at least 60 days, and the ratio of times reported over times prescribed for other sensors ranged from 37% for oxygen saturation to 67% for weight.

Conclusions

The mHealth-enabled IC model showed outstanding results from the patients’ perspective in 2 different UCs but lacked maturity and integration with legacy systems to be fully accepted by professionals. This paper provides useful lessons learned through the development and assessment process and may be of use to organizations willing to develop or implement mHealth-enabled IC for older adults.

What does integrated care mean from an older person's perspective? A scoping review

OBJECTIVE

To systematically map and synthesise the literature on older adults' perceptions and experiences of integrated care.

SETTING

Various healthcare settings, including primary care, hospitals, allied health practices and emergency departments.

PARTICIPANTS

Adults aged ≥60 years.

INTERVENTIONS

Integrated (or similarly coordinated) healthcare.

PRIMARY AND SECONDARY OUTCOME MEASURES

Using scoping review methodology, four electronic databases (EMBASE, CINAHL, PubMed and ProQuest Dissertation and Theses) and the grey literature (Open Grey and Google Scholar) were searched to identify studies reporting on older adults' experiences of integrated care. Studies reporting on empirical, interpretive and critical research using any type of methodology were included. Four independent reviewers performed study selection, data extraction and analysis.

RESULTS

The initial search retrieved 436 articles, of which 30 were included in this review. Patients expressed a desire for continuity, both in terms of care relationships and management, seamless transitions between care services and/or settings, and coordinated care that delivers quick access, effective treatment, self-care support, respect for patient preferences, and involves carers and families.

CONCLUSIONS

Participants across the studies desired accessible, efficient and coordinated care that caters to their needs and preferences, while keeping in mind their rights and safety. This review highlights the salience of the relational, informational and organisational aspects of care from an older person's perspective. Findings are transferable and could be applied in various healthcare settings to derive patient-centred success measures that reflect the aspects of integrated care that are deemed important to older adults and their supporters.

Lower limb chronic edema management program: Perspectives of disengaged patients on challenges, enablers and barriers to program attendance and adherence

Background

Chronic edema (CO) is a progressive, physically disfiguring and currently incurable condition. A multifaceted program has been recommended to manage the swelling. However, there is little evidence investigating patients’ perspectives following the program, particularly for those who have poor adherence and/or are disengaged.

Aim

To investigate the perceived challenges faced by disengaged participants with lower limb CO by identifying their enablers and barriers to participating in a Physiotherapy CO program.

Method

An exploratory qualitative approach was used. A purposive sampling strategy was adopted to recruit participants. Those with more than three months swelling and who had low adherence and/or attendance (disengaged) to the CO program were invited to participate. Semi-structured interviews with six participants from a CO clinic in a tertiary hospital were conducted. Data were thematically analyzed and findings in terms of enablers and barriers were subsequently reflected in the light of a theoretical framework.

Results

All six participants were morbidly obese (BMI 47 ± 4 kg/m²) with multiple chronic comorbidities. Enablers and barriers detected included physical, psychological and social factors that interplay to present multidimensional challenges that influence the participants’ adjustment to managing their CO. For the disengaged participants in this study, their under-managed lower limb CO was a progression towards being housebound and having a gradually increasing level of disability.

Conclusion

This study has identified the multidimensional challenges faced by low adherent and/or disengaged participants with lower limb CO to participating in a hospital-based CO program. Perceived enablers and barriers included physical, psychological and social factors. These were mapped using a health behavior change theoretical framework. Understanding these challenges has implications for developing a multidisciplinary approach aimed at enhancing patient engagement and participation in the physiotherapy CO program.

An Adaptive, Contextual, Technology-Aided Support (ACTS) System for Chronic Illness Self-Management

Policy Points Fundamental changes are needed in how complex chronic illness conditions are conceptualized and managed. Health management plans for chronic illness need to be integrated, adaptive, contextual, technology aided, patient driven, and designed to address the multilevel social environment of patients' lives. Such primary care-based health management plans are feasible today but will be even more effective and sustainable if supported by systems thinking, technological advances, and policies that create and reinforce home, work, and health care collaborations.

CONTEXT

The current health care system is failing patients with chronic illness, especially those with complex comorbid conditions and social determinants of health challenges. The current system combined with unsustainable health care costs, lack of support for primary care in the United States, and aging demographics create a frightening probable future.

METHODS

Recent developments, including integrated behavioral health, community resources to address social determinants, population health infrastructure, patient-centered digital-health self-management support, and complexity science have the potential to help address these alarming trends. This article describes, first, the opportunity to integrate these trends and, second, a proposal for an integrated, patient-directed, adaptive, contextual, and technology-aided support (ACTS) system, based on a patient's life context and home/primary care/work-setting "support triangle."

FINDINGS

None of these encouraging trends is a panacea, and although most have been described previously, they have not been integrated. Here we discuss an example of integration using these components and how our proposed model (termed My Own Health Report) can be applied, along with its strengths, limitations, implications, and opportunities for practice, policy, and research.

CONCLUSIONS

This ACTS system builds on and extends the current chronic illness management approaches. It is feasible today and can produce even more dramatic improvements in the future.

Cost-effectiveness of a proactive, integrated primary care approach for community-dwelling frail older persons

BACKGROUND

The article reports on the cost-effectiveness of the proactive, integrated primary care program Finding and Follow-up of Frail older persons (FFF) compared with usual primary care for community-dwelling frail older persons in the Netherlands.

METHODS

This study had a matched quasi-experimental design (pretest and posttest). The economic evaluation was performed from a healthcare perspective with a time horizon of 12 months. The target population consisted of community-dwelling frail older persons aged ≥ 75 years in the FFF intervention group (11 general practitioner (GP) practices) and in the control group receiving usual care (4 GP practices). The effectiveness measures for the cost-effectiveness and cost-utility analyses were subjective well-being (Social Production Function Instrument for the Level of well-being short; SPF-ILs) and QALYs (EuroQol; EQ-5D-3L), respectively. Costs were assessed using resource use questionnaires. Differences in mean effectiveness between groups were assessed using univariate, multilevel and propensity score matched analyses, with and without imputation of missing values. Differences in costs were assessed using Mann-Whitney U-tests and independent samples t-tests. Bootstrapping was performed, and predicted incremental cost-effectiveness ratios (ICERs) and incremental cost-utility ratios (ICURs) were depicted on cost-effectiveness planes.

RESULTS

The various analyses showed slightly different results with respect to differences in estimated costs and effects. Multilevel analyses showed a small but significant difference between the groups for well-being, in favor of the control group. No significant differences between groups in terms of QALYs were found. Imputed data showed that mean total costs were significantly higher in the intervention group at follow-up.

CONCLUSION

Proactive, integrated care for community-dwelling frail older persons as provided in the FFF program is most likely not a cost-effective initiative, compared with usual primary care in the Netherlands, in terms of well-being and QALYs over a 12-month period.

Democratic Accountability in Strategic Coordination Bodies — An Investigation of Governance in Swedish Elder Care

The establishment of strategic coordination bodies with members from different agencies and that are governed by various laws and regulations can be understood as an answer to the demand for improved coordinated care for citizens with complex needs, such as frail older people. However, this demand raises fundamental questions of democratic control and accountability in the modern welfare state. Although these issues are addressed in current literature on network governance, they have not been investigated empirically very much.

The aim of this paper is to investigate coordination bodies as important actors in integrated care, and especially to investigate how the members of these governance networks perceive their own influence and how they are held accountable by their principals.

This study is conceptually built on theories of network governance and accountability. The empirical investigation is based on a survey with 545 respondents from 73 different coordination bodies in Sweden. The analysis shows that there seems to be an imbalance between perceived influence and perceived demands from different stakeholders to account for the services. This imbalance provides an opening for a discussion of how to improve the current situation for vulnerable groups and about new perspectives on accountability and power in the modern welfare state.

Care Integration - From "One Size Fits All" to Person Centred Care Comment on "Achieving Integrated Care for Older People: Shuffling the Deckchairs or Making the System Watertight for the Future?"

Integrating services is a hot topic amongst health system policy-makers and healthcare managers. There is some evidence that integrated services deliver efficiencies and reduce service utilisation rates for some patient populations. In their article on Achieving Integrated Care for Older People, Gillian Harvey and her colleagues formulate some critical insights from practice and research around integrated care. However, the real challenge is to reconcile service integration with patient experiences. This paper argues that unless we think service integration from the patient’s perspective we will continue to fail to produce the evidence we need to support integrated care solutions to the current health system challenges.

Achieving Integrated Care for Older People: What Kind of Ship? Comment on "Achieving Integrated Care for Older People: Shuffling the Deckchairs or Making the System Watertight for the Future?"

This paper considers an implication of the idea that proposals for integrated care for older people should start from a focus on the patient, consider co-production solutions to the problems of care fragmentation, and be at a system-wide, cross-organisational level. It follows that the analysis, design and therefore evaluation of integrated care projects should be based upon the journeys which older patients with multiple chronic conditions usually have to make from professional to professional and service to service. A systematic realistic review of recent research on integrated care projects identified a number of key mechanisms for care integration, including multidisciplinary care teams, care planning, suitable IT support and changes to organisational culture, besides other activities and contexts which assist care 'integration.' Those findings suggest that bringing the diverse services that older people with multiple chronic conditions need into a single organisation would remove many of the inter-organisational boundaries that impede care 'integration' and make it easier to address the interprofessional and inter-service boundaries.