Improving Chronic Disease Self-Management by Older Home Health Patients through Community Health Coaching

Effectiveness of an interdisciplinary home care approach for older adults with chronic conditions: A systematic review and meta-analysis

The effectiveness of interdisciplinary home healthcare service consisting of at least two or more healthcare providers, such as a nurse, physician and physiotherapist, for community-dwelling older adults remains unclear. This systematic review assesses the effects of interdisciplinary home care on quality of life (QOL) and health outcomes in older adults with chronic conditions using validated tools. Databases were searched using CINAHL Plus with Full Text, PubMed, EMBASE, CENTRAL, PsycINFO, and OpenGrey from inception to January 25, 2021. Eligibility criteria included (i) an interdisciplinary home care approach, (ii) participants aged 65 years and older with chronic conditions, (iii) randomized controlled trials (RCTs), and (iv) original literature in English. The study reviewer's dyad independently screened the literature and assessed the study quality using the Cochrane's Risk of Bias 2 tool. The analysis employed qualitative and quantitative integration and Grading of Recommendations Assessment, Development, and Evaluation. This study included 13 RCTs with 4709 participants. Four RCTs indicated that interdisciplinary home healthcare services reduced hospital admissions during the initial 6 months after the start of home care interventions (risk ratio [RR] = 0.73; 95% confidence interval [CI] = 0.61-0.88; p < 0.001; I2 = 0%). However, evidence certainty was moderate; QOL and mortality showed low certainty; and institutionalization and adherence showed moderate certainty of evidence. This study suggests that the interdisciplinary home care approach reduces hospital admissions but lacks effects on other outcomes. More robust studies are required to evaluate this evidence. Geriatr Gerontol Int 2024; ••: ••-••.

Promoting the empowerment and emancipation of community-dwelling older adults with chronic multimorbidity through a home visiting programme: a hermeneutical study

INTRODUCTION

Nurse-led preventive home visiting programmes can improve health-related outcomes in community-dwelling older adults, but they have not proven to be cost-effective. Home visiting programmes led by nursing students could be a viable alternative. However, we do not know how community-dwelling older adults with chronic multimorbidity experience home visiting programmes in which nursing students carry out health promotion activities. The aim of the study is to understand how community-dwelling older adults with chronic multimorbidity experience a home visiting programme led by nursing students.

METHODS

A qualitative study based on Gadamer's hermeneutics. Thirty-one community-dwelling older adults with chronic multimorbidity were interviewed in-depth. Fleming's method for conducting hermeneutic, Gadamerian-based studies was followed and ATLAS.ti software was used for data analysis.

RESULTS

Two main themes were generated: (1) 'The empowering experience of a personalised health-promoting intervention', and (2) 'The emancipatory effect of going beyond standardised self-care education'.

CONCLUSIONS

The home visiting programme contributed to the community-dwelling older adults feeling more empowered to engage in health-promoting self-care behaviours. It also improved the older adults' sense of autonomy and self-efficacy, while reducing their loneliness and addressing some perceived shortcomings of the healthcare system.

CLINICAL RELEVANCE

Older adults participating in a home visiting programme led by nursing students feel empowered to implement self-care behaviours, which has a positive impact on their perceived health status. Nurse leaders and nursing regulatory bodies could collaborate with nursing faculties to integrate preventive home visiting programmes led by nursing students into the services offered to community-dwelling older adults with chronic multimorbidity.

Rehabilitation delivery models to foster healthy ageing-a scoping review

Introduction

Rehabilitation is essential to foster healthy ageing. Older adults have unique rehabilitation needs due to a higher prevalence of non-communicable diseases, higher susceptibility to infectious diseases, injuries, and mental health conditions. However, there is limited understanding of how rehabilitation is delivered to older adults. To address this gap, we conducted a scoping review to describe rehabilitation delivery models used to optimise older adults' functioning/functional ability and foster healthy ageing.

Methods

We searched Medline and Embase (January 2015 to May 2022) for primary studies published in English describing approaches to provide rehabilitation to older adults. Three authors screened records for eligibility and extracted data independently and in duplicate. Data synthesis included descriptive quantitative analysis of study and rehabilitation provision characteristics, and qualitative analysis to identify rehabilitation delivery models.

Results

Out of 6,933 identified records, 585 articles were assessed for eligibility, and 283 studies with 69,257 participants were included. We identified six rehabilitation delivery models: outpatient (24%), telerehabilitation (22%), home (18.5%), community (16.3%), inpatient (14.6%), and eldercare (4.7%). These models often involved multidisciplinary teams (31.5%) and follow integrated care principles (30.4%). Most studies used a disease-centred approach (59.0%), while studies addressing multimorbidity (6.0%) and prevalent health problems of older adults, such as pain, low hearing, and vision, or incontinence were scarce. The most frequently provided interventions were therapeutic exercises (54.1%), self-management education (40.1%), and assessment of person-centred goals (40%). Other interventions, such as assistive technology (8.1%) and environmental adaptations (7.4%) were infrequent.

Conclusions

Focusing on primary studies, this scoping review provides an overview of rehabilitation delivery models that are used to foster healthy ageing and highlights research gaps that require further attention, including a lack of systematic assessment of functioning/functional ability, a predominance of disease-centred rehabilitation, and a scarcity of programmes addressing prevalent issues like pain, hearing/vision loss, fall prevention, incontinence, and sexual dysfunctions. Our research can facilitate evidence-based decision-making and inspire further research and innovation in rehabilitation and healthy ageing. Limitations of our study include reliance on published research to infer practice and not assessing model effectiveness. Future research in the field is needed to expand and validate our findings.

Effects of home visiting programmes on community-dwelling older adults with chronic multimorbidity: a scoping review

BACKGROUND

Chronic ultimorbidity is the most frequent and serious health problem in older adults. Home visiting programmes could be a strategy with potential benefits. However, there are no scoping reviews to date that examine the effects of home visiting programmes on community-dwelling older adults with chronic multimorbidity.

OBJECTIVE

To examine the effects of home visiting programmes on community-dwelling older adults with chronic multimorbidity.

METHODS

A scoping review was carried out following PRISMA-ScR reporting guidelines. The search was conducted in six databases (PubMed/Medline, Cochrane, CINAHL, Web of Science, Scopus and EMBASE) between October 2021 and April 2022.

RESULTS

Four RCTs with 560 patients were included. The visits were carried out by nurses, nursing students, volunteers, and other healthcare professionals. The interventions varied in the number of visits, frequency, duration of follow-up, and whether or not they were combined with other strategies such as telephone calls. Discrepancies were found in the effects of the interventions on quality of life, self-efficacy, self-rated health, and use and cost of health and social services.

CONCLUSION

This review shows that home visiting programmes could have potential benefits for older adults with chronic multimorbidity. However, its results have been inconclusive. There is a need for high quality studies involving a larger number of patients, in which home visits are the main intervention.

The relationship of chronic disease conditions to mental and physical health among cancer survivors

PURPOSE

This study examined the relationship between the presence of chronic disease conditions and mental and physical health among cancer survivors in the United States.

METHODS

We conducted a cross-sectional analysis utilizing survey data from the 2016-2017 Behavioral Risk Factor Surveillance System (BRFSS) on 65,673 eligible cancer survivors. The primary outcomes of interest were self-rated metal/physical health in the past 30 days. Descriptive statistics and multivariate logistic regression were used to examine the mentioned association.

RESULTS

15.3% and 24.8% of survivors reported having several days of poor mental and physical health (14-30 days compared to 0-13 days), and 42.4% of survivors reported having one to two chronic diseases. In multivariate analysis, survivors with one to two chronic diseases were more likely to report several days of poor mental (OR, 2.74; 95% CI, 2.22-3.38) and physical (OR, 1.95; 95% CI, 1.72-2.22) health. Survivors with 3+ chronic diseases had markedly higher odds of having several days of poor mental (OR, 6.41; 95% CI, 5.19-7.91) and physical health (OR, 4.71; 95% CI, 4.16-5.34). Among survivors with at least one chronic disease, older age, insured, and more perceived social/emotional support were negatively associated with mental health (p value <0.05). Similarly, older age was related to fewer days of poor physical health (p value <0.05) regardless of chronic disease conditions.

CONCLUSION

Having chronic diseases was associated with more days of poor mental and physical health among cancer survivors. Integrated, extensive care should include mental/physical health components and chronic disease management in cancer survivorship care.

Effectiveness of system navigation programs linking primary care with community-based health and social services: a systematic review

BACKGROUND

Fragmented delivery of health and social services can impact access to high-quality, person-centred care. The goal of system navigation is to reduce barriers to healthcare access and improve the quality of care. However, the effectiveness of system navigation remains largely unknown. This systematic review aims to identify the effectiveness of system navigation programs linking primary care with community-based health and social services to improve patient, caregiver, and health system outcomes.

METHODS

Building on a previous scoping review, PsychInfo, EMBASE, CINAHL, MEDLINE, and Cochrane Clinical Trials Registry were searched for intervention studies published between January 2013 and August 2020. Eligible studies included system navigation or social prescription programs for adults, based in primary care settings. Two independent reviewers completed study selection, critical appraisal, and data extraction.

RESULTS

Twenty-one studies were included; studies had generally low to moderate risk of bias. System navigation models were lay person-led (n = 10), health professional-led (n = 4), team-based (n = 6), or self-navigation with lay support as needed (n = 1). Evidence from three studies (low risk of bias) suggests that team-based system navigation may result in slightly more appropriate health service utilization compared to baseline or usual care. Evidence from four studies (moderate risk of bias) suggests that either lay person-led or health professional-led system navigation models may improve patient experiences with quality of care compared to usual care. It is unclear whether system navigation models may improve patient-related outcomes (e.g., health-related quality of life, health behaviours). The evidence is very uncertain about the effect of system navigation programs on caregiver, cost-related, or social care outcomes.

CONCLUSIONS

There is variation in findings across system navigation models linking primary care with community-based health and social services. Team-based system navigation may result in slight improvements in health service utilization. Further research is needed to determine the effects on caregiver and cost-related outcomes.

Impact of the family doctor system on the continuity of care for diabetics in urban China: a difference-in-difference analysis

OBJECTIVES

Our study aimed to examine whether the family doctor system can improve continuity of care for patients with diabetes.

DESIGN

Registry-based, population-level longitudinal cohort study.

SETTING

Linked data from the administrative Health Information System and the Health Insurance Claim Databases in a sample city in eastern China.

PARTICIPANTS

30 451 insured patients who were diagnosed with diabetes before January 2015 in the sample city, with ≥2 outpatient visits per year during 2014-2017. Diabetics in the intervention group had been registered with family doctor teams from 2015 to 2017, while those who had not registered were taken as the control group.

INTERVENTIONS

The family doctor system was established in China mainly to strengthen primary care and rebuild referral systems. Residents were encouraged to register with family doctors to obtain continuous health management especially for chronic disease management.

OUTCOME MEASURES

Continuity of care was measured by the Continuity of Care Index (COCI), Usual Provider Continuity Score (UPCS) and Sequential Continuity of Care Index (SECON) in 2014-2017.

RESULTS

COCI, UPCS and SECON of all diabetics in this study increased between 2014 and 2017. A difference-in-difference approach was applied to measure the net effect of the family doctor system on continuity of care. Our model controlled for demographic and socioeconomic characteristics, and severity of disease at baseline. Compared with the control group, diabetics registered with family doctors obtained an average 0.019 increase in COCI (SE 0.002) (p<0.01), a 0.016 increase in UPCS (SE 0.002) (p<0.01) and a 0.018 increase in SECON (SE 0.002) (p<0.01).

CONCLUSION

This study provides evidence that the family doctor system can effectively improve continuity of care for patients with diabetes, which has substantial policy implications for further primary care reform in China.

Clinical Effects of Outpatient Health Education on Fall Prevention and Self-health Management of Elderly Patients with Chronic Diseases

Background

Elderly patients with chronic diseases (CDs) have a higher predilection for falls, with more severe consequences once they fall. Therefore, it is necessary to explore an effective way to prevent falls in elderly patients with CDs.

Objective

To clarify the clinical effects of outpatient health education on fall prevention and self-health management in elderly patients with CDs.

Methods

This retrospective study enrolled 102 elderly patients with CDs who received treatment in the School of Medicine, Sir Run Run Shaw Hospital of Zhejiang University, between January 2019 and December 2020. Patients intervened by routine nursing were assigned to the regular group (n = 48), and those additionally treated with outpatient health education were included in the research group (n = 54). Assessment of patients' negative emotions (NEs) adopted the Self-Rating Anxiety/Depression Scale (SAS/SDS), determination of their sense of self-efficacy employed the Falls Efficacy Scale International (FES-I), and their self-care capacity evaluation used the Exercise of Self-Care Agency (ESCA). Patients' falls, hospitalization time, fall prevention knowledge, fall prevention-related health behavior, and nursing satisfaction were recorded.

Results

After the nursing intervention, lower SAS, SDS, and FES-I scores were determined in the research group versus the regular group; the total ESCA score assessed from various dimensions was higher in the research group; the research group also exhibited a markedly lower incidence of falls, and shorter hospitalization time than the regular group, with better mastery of fall prevention knowledge, fall prevention-related health behavior and nursing satisfaction.

Conclusions

Outpatient health education intervention can prevent senile patients with CDs from falling, promote their rehabilitation, and enhance their mastery of fall prevention knowledge; moreover, it can improve patients' healthy behaviors to prevent falls, mitigate their NEs, and improve their sense of self-efficacy and self-care ability, which has high clinical application value.

Community Health Nursing in der Stadt (CoSta)

Zusammenfassung. Hintergrund: Die Erweiterung um die Pflegeprofession in der Primärversorgung wird im deutschsprachigen Raum gegenwärtig in Bezug auf Community Health Nursing (CHN) diskutiert. Dabei handelt es sich um einen bedarfsorientierten, evidenzbasierten und lebensweltbezogenen Ansatz. Akademisch qualifizierte Pflegefachpersonen versorgen eigenverantwortlich. In anderen Ländern ist CHN langjährig verankert. In Deutschland fehlt es an Modellversuchen und Belegen, um die spezifische Wirkweise in der Anwendung zu bewerten und Vergütungsoptionen durch potentielle Kostenträger abzubilden. Fragestellung/Ziel: Das CoSta-Projekt entwickelt modellhaft ein professionelles CHN-Konzept für chronisch kranke Menschen in einem marginalisierten Stadtquartier. Methode: Die Praxisentwicklung des CHN-Konzeptes erfolgt auf Grundlage einer Literaturübersicht, einer Bedarfserhebung im Quartier und eines theoretischen Rahmens unter Beteiligung des multiprofessionellen Teams in einem Stadtteil-Gesundheitszentrum. Ergebnisse: Die Konzeptentwicklung ist abgeschlossen. Das Modellkonzept basiert auf den Komponenten Public Health, Pflegetheorie, Leitbild, rechtlicher Rahmen und Evidenzbasierung. Als Interventionen sind pflegegeleitete Hausbesuche, Sprechstunden und Schulungen vorgesehen. Ihre Wirksamkeit wird derzeit in einer laufenden Interventionsstudie überprüft. Die Ergebnisse zur Machbarkeit stehen aus. Schlussfolgerungen: Das entwickelte Konzept wird als bedarfsorientiertes Angebot eingeschätzt. Für die Intervention erscheinen kultur- und peersensible Aspekte noch bedeutsamer als erwartet.

Age-friendly interventions in rural and remote areas: A scoping review

OBJECTIVES

In 2007, the World Health Organization published a guide on age-friendly cities. However, little is known about interventions that have been implemented to promote age-friendly communities in rural and remote areas. This paper presents the findings from a scoping review undertaken to locate available evidence of interventions, strategies, and programs that have been implemented in rural and remote areas to create age-friendly communities.

METHODS

This scoping review used the Joanna Briggs Institute (JBI) methodology.

RESULTS

A total of 219 articles were included in this review. No intervention studies were referred to as 'age-friendly'. However, there were interventions (mostly healthcare-related) that have been implemented in rural and remote areas with older people as participants. There were also non-evaluated community programs that were published in the grey literature. This review identified the common health interventions in older people and the indirect relevance to the WHO age-friendly framework domains in rural and remote contexts.

CONCLUSIONS

The eight age-friendly domains were not explicitly utilised as a guide in the development of interventions for older people in rural and remote settings. Implementation of age-friendly interventions in rural and remote areas requires a multisectoral approach that is tailored to address the specific needs of individual communities. Age-friendly interventions also need to consider socio-ecological factors to adequately and holistically address community needs and ensure long-term sustainability.

Patient empowerment and self-management behaviour of chronic disease patients: A moderated mediation model of self-efficacy and health locus of control

AIMS

To explore the role of self-efficacy (SE) in the effect of patient empowerment on self-management behaviours among patients with chronic illness and to investigate the moderating effect of three types of health locus of control (HLC) in this moderated mediation model.

DESIGN

Cross-sectional design.

METHODS

Data were collected in a general tertiary hospital, and a sample of 254 patients was recruited between August and October 2020. The effect of moderation and mediation was tested by the PROCESS macro (Model 4 and Model 8) for SPSS 25.0 by Hayes using 5000 bootstrap samples.

RESULTS

Self-efficacy significantly mediated the relationship between patient empowerment and self-management behaviour with a 95% confidence interval excluding zero. The chance HLC demonstrated a moderating effect, and the interaction effect on SE and self-management behaviour was significant.

CONCLUSION

Patient empowerment may improve confidence and adherence to self-management among people with chronic illness, and such benefits were conditional on the HLC of patients.

IMPACT

This study addresses the relationship between patient empowerment and self-management behaviour in patients with different personality characteristics. This result indicated that classifying the type of HLC may enable the identification of subgroups of patients who may subsequently benefit from patient empowerment. In a patient-centred programme, nurses and other healthcare professionals correctly identifying patients' HLC type and understanding the implications and then providing appropriate health care plans for patients with different health beliefs may be useful to tailor the decision-making process.

A Social-Ecological Approach to Identify Facilitators and Barriers of Home Modifications

Aging individuals may face difficulty with independently navigating and interacting with their home environment. Evidence-based interventions promoting home modifications are needed to support aging-in-place across the lifespan. This study identified the facilitators and barriers to implementing home modifications from the perspectives of residents and professionals (N = 16). Guided by a social-ecological model, researchers utilized directed content analysis of focus group interviews. While participants discussed facilitators and barriers mainly on the individual level, factors were presented at the relationship, community, and societal level of the model. Overall, the findings suggest a potential for targeted interventions on all levels of the model to promote adoption of home modifications.

Community health worker interventions for older adults with complex health needs: A systematic review

BACKGROUND/OBJECTIVES

The number of older adults with complex health needs is growing, and this population experiences disproportionate morbidity and mortality. Interventions led by community health workers (CHWs) can improve clinical outcomes in the general adult population with multimorbidity, but few studies have investigated CHW-delivered interventions in older adults.

DESIGN

We systematically reviewed the impact of CHW interventions on health outcomes among older adults with complex health needs. We searched for English-language articles from database inception through April 2020 using seven databases. PROSPERO protocol registration CRD42019118761.

SETTING

Any U.S. or international setting, including clinical and community-based settings.

PARTICIPANTS

Adults aged 60 years or older with complex health needs, defined in this review as multimorbidity, frailty, disability, or high-utilization.

INTERVENTIONS

Interventions led by a CHW or similar role consistent with the American Public Health Association's definition of CHWs.

MEASUREMENTS

Pre-defined health outcomes (chronic disease measures, general health measures, treatment adherence, quality of life, or functional measures) as well as qualitative findings.

RESULTS

Of 5671 unique records, nine studies met eligibility criteria, including four randomized controlled trials, three quasi-experimental studies, and two qualitative studies. Target population and intervention characteristics were variable, and studies were generally of low-to-moderate methodological quality. Outcomes included mood, functional status and disability, social support, well-being and quality of life, medication knowledge, and certain health conditions (e.g., falls, cognition). Results were mixed with several studies demonstrating significant effects on mood and function, including one high-quality RCT, while others noted no significant intervention effects on outcomes.

CONCLUSION

CHW-led interventions may have benefit for older adults with complex health needs, but additional high-quality studies are needed to definitively determine the effectiveness of CHW interventions in this population. Integration of CHWs into geriatric clinical settings may be a strategy to deliver evidence-based interventions and improve clinical outcomes in complex older adults.

Lessons learned implementing and managing the DIVERT-CARE trial: practice recommendations for a community-based chronic disease self-management model

Background

Chronic disease management models of care provide an opportunity to assist home care clients to manage their disease burden. However, pragmatic trial management practices and lessons learned from such models are poorly illustrated in the literature.

Methods

We describe the processes of implementing a community-based cardiorespiratory self-management model, known as DIVERT-CARE, across the home care programs of three health regions in Canada. The DIVERT-CARE model is a multi-component complex intervention that identifies home care clients at the highest risk of deterioration and provides them with resources and capacity to manage their conditions. We conducted a retrospective analysis of baseline participant characteristics, needs assessments, reviewed findings from site visits and a national workshop with study partners, and examined other study documentation.

Results

Three home care regions in Canada participated in the study. A robust and data-driven review of each site was necessary to understand the local context, home care caseloads, structure of local systems, and intensity of resources, which influenced study processes. The creation of an intervention framework highlighted the need to adapt the intervention in a way that was sensitive to the local context while maintaining intervention outcomes.

Conclusion

Our detailed review showcases the relevant activities and on-the-ground steps needed to manage and conduct a multi-site pragmatic trial in home care. This example can help other researchers in implementing multi-disciplinary and multi-component care models for practice-based research.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02248-0.

Perceived barriers and facilitators to chronic kidney disease care among patients in Singapore: a qualitative study

OBJECTIVE

To outline the facilitators and barriers to patients' self-management of predialysis chronic kidney disease (CKD).

DESIGN

Qualitative.

SETTING

Three polyclinics in a public primary care institution in Singapore.

PARTICIPANTS

20 patients entered and completed the study. Inclusion criteria were: (1) English speaking, (2) aged 40 years and above, (3) identified by clinical coding as 'DM (diabetes mellitus) nephropathy-overt' and 'DM nephropathy-incipient', by their physicians in the polyclinic, with an estimated glomerular filtration rate of less than 60 mL/min/1.73 m² (based on electronic health records) and (4) aware of their CKD illness. Exclusion criteria were: (1) receiving dialysis or had received a kidney transplant, (2) suffered from any visual, auditory or cognitive impairment which could hinder their ability to participate in the study or (3) pregnant.

RESULTS

We found that the major barriers to CKD management were a lack of knowledge and awareness of CKD, a passive attitude toward self-management and insufficient patient-physician communication. Major facilitators included patient trust and satisfaction with the physician and family support. Many patients reported that there was an overload of information and too little guidance on how to manage their condition, especially regarding dietary recommendations.

CONCLUSION

We identified several barriers and facilitators to the management of predialysis CKD among patients. A multi-pronged approach for raising CKD awareness is required: improving patient-physician communication, implementing CKD workshops and home-visits and disseminating accurate online information about CKD. Strategies should also focus on increasing patient engagement and optimising family support by involving family members in patients' care. Furthermore, clear dietary recommendations and patient-specific advice are needed to empower patients to manage their own condition.

Difficulties with health self-management by older adults: The role of well-being

The purpose of this study was to investigate the association between three aspects of well-being (positive and negative affect, self-realization, and self-efficacy and resilience) and disease self-management or difficulties in managing care. Logistic regression models were used to analyze data from a sample of community-dwelling Medicare beneficiaries 65-years or older who participated in the National Health and Aging Trends Study and responded to well-being and engagement in health care questions (n = 1663). All three aspects of well-being were significantly associated with reduced difficulties in care management for both the participants and their family and friends who assist them. Self-efficacy and resilience had the strongest association; older adults with higher levels of self-efficacy and resilience were more likely to handle care by self. Our findings highlight the importance of incorporating strategies to enhance well-being of older adults to reduce the difficulties of managing activities necessary to stay healthy.

Facilitators and barriers of managing patients with multiple chronic conditions in the community: a qualitative study

BACKGROUND

Approximately one-third of all adults worldwide are diagnosed with multiple chronic conditions (MCCs). The literature has identified several challenges facing providers and patients coping with managing MCCs in the community, yet few studies have considered their viewpoints in combination. A qualitative study involving healthcare providers and users was thus conducted to examine facilitators and barriers of managing patients with MCCs in the community in Singapore.

METHODS

This study involves 26 semi-structured interviews with 10 physicians, 2 caregivers and 14 patients seeking treatment in the polyclinics that provide subsidised primary care services. Topic guides were developed with reference to the literature review, Chronic Care Model (CCM) and framework for patient-centred access to healthcare.

RESULTS

Despite the perceived affordability and availability of the support system, some patients still encountered financial difficulties in managing care. These include inadequacy of the nation-wide medical savings scheme to cover outpatient treatment and medications. Half of healthcare users did not know where to seek help. While patients could access comprehensive services in polyclinics, those who did not visit the clinics might not receive timely care. Furthermore, patients reported long consultation waiting time. Physicians were able to propose and drive quality improvement projects to improve care quality. However, there were challenges to delivering safe and quality care with limited consultation duration due to the need to manage high patient load and waiting time, inadequate communication with specialists to coordinate care, and resource constraints in managing complex patients. Although providers could equip patients with self-management and lifestyle-related guidelines, patients' actions are influenced by multiple factors, including work requirements, beliefs and environment.

CONCLUSIONS

There were barriers on care access, delivery and self-management. It is crucial to adopt a whole-of-society approach involving individuals, community, institutions and policymakers to improve and support MCC management. This study has also highlighted the importance of considering the different viewpoints of healthcare providers and users in policy formulation and community care planning.

Improving the design of heart failure care from the perspective of frontline providers and administrators: A qualitative case study of a large, urban health system

BACKGROUND

Heart failure patients often present with frailty and/or multi-morbidity, complicating care and service delivery. The Chronic Care Model (CCM) is a useful framework for designing care for complex patients. It assumes responsibility of several actors, including frontline providers and health-care administrators, in creating conditions for optimal chronic care management. This qualitative case study examines perceptions of care among providers and administrators in a large, urban health system in Canada, and how the CCM might inform redesign of care to improve health system functioning.

METHODS

Sixteen semi-structured interviews were conducted between August 2014 and January 2016. Interpretive analysis was conducted to identify how informants perceive care among this population and the extent to which the design of heart failure care aligns with elements of the CCM.

RESULTS

Current care approaches could better align with CCM elements. Key changes to improve health system functioning for complex heart failure patients that align with the CCM include closing knowledge gaps, standardizing treatment, improving interdisciplinary communication and improving patient care pathways following hospital discharge.

CONCLUSIONS

The CCM can be used to guide health system design and interventions for frail and multi-morbid heart failure patients. Addressing care- and service-delivery barriers has important clinical, administrative and economic implications.

Patient self-testing in chronic disease management

Chronic disease poses a major burden to patients and health care systems. This review considers how patient self-testing can contribute to the management of chronic disease. Self-testing can only confer benefit if it occurs in the context of an empowered patient who has the skills and training to translate test results into meaningful actions. The benefits may include improved clinical outcomes, greater patient convenience and improved psychological well-being; separately and together these may contribute to reduced costs of care. As self-testing may be expensive and burdensome to patients, it is important that its use in chronic disease is supported by a robust evidence base confirming its utility and efficacy. The design of studies to assess the impact of self-testing poses challenges for the researcher and the quality of evidence presented is often variable. Randomised controlled trials (RCTs) provide more robust evidence than observational studies; the intervention under study is not just self-testing but includes the educational support to allow patients to use results effectively. This review discusses the evidence base relating to patient self-testing in diabetes, anticoagulant monitoring and in renal transplant patients and in particular highlights the impact of new technology developments such as flash glucose monitoring in diabetes.

Interventions for involving older patients with multi-morbidity in decision-making during primary care consultations

BACKGROUND

Older patients with multiple health problems (multi-morbidity) value being involved in decision-making about their health care. However, they are less frequently involved than younger patients. To maximise quality of life, day-to-day function, and patient safety, older patients require support to identify unmet healthcare needs and to prioritise treatment options.

OBJECTIVES

To assess the effects of interventions for older patients with multi-morbidity aiming to involve them in decision-making about their health care during primary care consultations.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; all years to August 2018), in the Cochrane Library; MEDLINE (OvidSP) (1966 to August 2018); Embase (OvidSP) (1988 to August 2018); PsycINFO (OvidSP) (1806 to August 2018); the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (Ovid) (1982 to September 2008), then in Ebsco (2009 to August 2018); Centre for Reviews and Dissemination Databases (Database of Abstracts and Reviews of Effects (DARE)) (all years to August 2018); the Health Technology Assessment (HTA) Database (all years to August 2018); the Ongoing Reviews Database (all years to August 2018); and Dissertation Abstracts International (1861 to August 2018).

SELECTION CRITERIA

We sought randomised controlled trials (RCTs), cluster-RCTs, and quasi-RCTs of interventions to involve patients in decision-making about their health care versus usual care/control/another intervention, for patients aged 65 years and older with multi-morbidity in primary care.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodological procedures. Meta-analysis was not possible; therefore we prepared a narrative synthesis.

MAIN RESULTS

We included three studies involving 1879 participants: two RCTs and one cluster-RCT. Interventions consisted of: · patient workshop and individual coaching using behaviour change techniques; · individual patient coaching utilising cognitive-behavioural therapy and motivational interviewing; and · holistic patient review, multi-disciplinary practitioner training, and organisational change. No studies reported the primary outcome 'patient involvement in decision-making' or the primary adverse outcome 'less patient involvement as a result of the intervention'. Comparing interventions (patient workshop and individual coaching, holistic patient review plus practitioner training, and organisational change) to usual care: we are uncertain whether interventions had any effect on patient reports of high self-rated health (risk ratio (RR) 1.40, 95% confidence interval (CI) 0.36 to 5.49; very low-certainty evidence) or on patient enablement (mean difference (MD) 0.60, 95% CI -9.23 to 10.43; very low-certainty evidence) compared with usual care. Interventions probably had no effect on health-related quality of life (adjusted difference in means 0.00, 95% CI -0.02 to 0.02; moderate-certainty evidence) or on medication adherence (MD 0.06, 95% CI -0.05 to 0.17; moderate-certainty evidence) but probably improved the number of patients discussing their priorities (adjusted odds ratio 1.85, 95% CI 1.44 to 2.38; moderate-certainty evidence) and probably increased the number of nurse consultations (incident rate ratio from adjusted multi-level Poisson model 1.37, 95% CI 1.17 to 1.61; moderate-certainty evidence) compared with usual care. Practitioner outcomes were not measured. Interventions were not reported to adversely affect rates of participant death or anxiety, emergency department attendance, or hospital admission compared with usual care. Comparing interventions (patient workshop and coaching, individual patient coaching) to attention-control conditions: we are uncertain whether interventions affect patient-reported high self-rated health (RR 0.38, 95% CI 0.15 to 1.00, favouring attention control, with very low-certainty evidence; RR 2.17, 95% CI 0.85 to 5.52, favouring the intervention, with very low-certainty evidence). We are uncertain whether interventions affect patient enablement and engagement by increasing either patient activation (MD 1.20, 95% CI -8.21 to 10.61; very low-certainty evidence) or self-efficacy (MD 0.29, 95% CI -0.21 to 0.79; very low-certainty evidence); or whether interventions affect the number of general practice visits (MD 0.51, 95% CI -0.34 to 1.36; very low-certainty evidence), compared to attention-control conditions. The intervention may however lead to more patient-reported changes in management of their health conditions (RR 1.82, 95% CI 1.35 to 2.44; low-certainty evidence). Practitioner outcomes were not measured. Interventions were not reported to adversely affect emergency department attendance nor hospital admission when compared with attention control. Comparing one form of intervention with another: not measured. There was 'unclear' risk across studies for performance bias, detection bias, and reporting bias; however, no aspects were 'high' risk. Evidence was downgraded via GRADE, most often because of 'small sample size' and 'evidence from a single study'.

AUTHORS' CONCLUSIONS

Limited available evidence does not allow a robust conclusion regarding the objectives of this review. Whilst patient involvement in decision-making is seen as a key mechanism for improving care, it is rarely examined as an intervention and was not measured by included studies. Consistency in design, analysis, and evaluation of interventions would enable a greater likelihood of robust conclusions in future reviews.

Continuity of care interventions for preventing hospital readmission of older people with chronic diseases: A meta-analysis

BACKGROUND

Hospital readmission after discharge is a frequent, burdensome and costly event, particularly frequent in older people with multiple chronic conditions. Few literature reviews have analysed studies of continuity of care interventions to reduce readmissions of older inpatients discharged home over the short and long term.

OBJECTIVE

To evaluate the effectiveness of continuity of care interventions in older people with chronic diseases in reducing short and long term hospital readmission after hospital discharge.

DESIGN

Meta-analysis of randomized controlled trials.

DATA SOURCES

A comprehensive literature search on the databases PubMed, Medline, CINAHL and EMBASE was performed on 27 January 2019 with no language and time limits.

REVIEW METHODS

RCTs on continuity of care interventions on older people discharged from hospital having hospital readmission as outcome, were included. Two reviewers independently screened the studies and assessed methodological quality using the Cochrane Risk of Bias tool. Selected outcome data were combined and pooled using a Mantel-Haenszel random-effects model.

RESULTS

Thirty RCTs, representing 8920 patients were included. Results were stratified by time of readmissions. At 1 month from discharge, the continuity interventions were associated with lower readmission rates in 207/1595 patients in the experimental group (12.9%), versus 264/1645 patients in the control group (16%) (Relative Risk [RR], 0.84 [95% CI, 0.71-0.99]). From 1 to 3 months, readmission rates were lower in 325/1480 patients in the experimental group (21.9%), versus 455/1523 patients in the control group (29.8%) (RR 0.74 [95% CI, 0.65-0.84]). A subgroup analysis showed that this positive effect was stronger when the interventions addressed all of the continuity dimensions. After 3 months this impact became inconclusive with moderate/high statistical heterogeneity.

CONCLUSIONS

Continuity of care interventions prevent short term hospital readmission in older people with chronic diseases. However, there is inconclusive evidence about the effectiveness of continuity interventions aiming to reduce long term readmission, and it is suggested that stronger focus on it is needed.

Training Community Residents to Address Social Determinants of Health in Underresourced Communities

Disparities in chronic disease and life expectancy remain a significant public health problem and are largely attributable to social determinants of health. Community health workers (CHWs) promote health equity through individual- and community-level activities, and leadership and advocacy skills training make CHWs more likely to catalyze structural change. CHWs are increasingly being integrated into clinical practices to support care management, creating a need for new grassroots community-level advocates. We adapted for community residents an existing CHW training curriculum focused on social determinants of health and effecting community change. We offered 36 hours of training at community-based locations in New Orleans, Louisiana. We assessed baseline civic and community participation and pre- and postknowledge for each lesson. Among 43 enrollees, 42 completed the program. The majority were Black (92.7%), female (92.7%), and retired or unemployed (77.5%), with a median age of 61.5 years. In the past year, 85% of participants had volunteered, 57.1% had been involved with a community organization, and 32.4% had contacted the city council. Participants demonstrated statistically significant increases in knowledge in 5 of 6 lessons. Our success in increasing knowledge of advocacy among a civically engaged group suggests that trainees may become community leaders in addressing social determinants of health.