Predicting Post-Discharge Outcome

The ability of members of the multidisciplinary team and of elderly patients themselves to predict how patients will cope at home influences the successful outcome of discharge from hospital. Following the introduction of structured assessment of the physical, psychological and social function of patients on an acute elderly care unit, a study was undertaken to compare the predictive ability of the primary nurse, the patient and the occupational therapist.

Overall, results suggested a high level of accuracy of predictions. There was a trend for the occupational therapist to predict more accurately (83.6%) than the patient (80.7%) or the primary nurse (72.5%). Where the predictions were incorrect, the patients erred on the side of optimism (78% optimistic) whereas the nurses were more pessimistic (69% pessimistic). Further studies to look at the reliability of outcome predictions by health professionals and the patients themselves would be useful in the overall management of the discharge of elderly people from hospital.

Analysis and Design of the eSAP: An Integrated Health and Social Care Information System

Health care information systems are becoming more and more computerized. A huge amount of health related information needs to be stored and analysed, and with the aid of computer systems this can be done faster and more efficiently. The Agent Oriented paradigm provides an alternative way of developing medical based systems.

This article presents an initial exploration of the analysis and design of a multi-agent system to deliver the Single Assessment Process, an integrated health and social care information system for older people. The article concludes by making the following observations: Agent technology has the potential to support the development of medical and health and social care systems for older people. Nevertheless there are not many real-life agent based applications successfully applied in the health care sector. One of the main reasons is the limitation of the existing analysis and design methodologies. Thus, in order for the agent-technology to be widely accepted in the development of computer based medical information systems for older people (and in extent any medical system) it is necessary to develop a complete and mature analysis and design methodology to support the development of agent based medical systems.

A Novel Agent-Based System to Support the Single Assessment Process of Older People

Older people often have a complex mixture of health and social care needs and several different health and social care professionals are involved in their care. National policy in England is to promote the single assessment process (SAP), an integrated assessment of health and social care needs of older people. However, most of the current information systems do not adequately provide the functionality that is required by health and social care professionals. In this paper we discuss the suitability of agent technology, explaining why we selected it as offering the greatest potential for efficient and flexible information collection and sharing, and for supporting effective care planning. Also, we point out benefits derived from the use of agent technology in the development of health and social care systems, such as the minimization of health and social care professionals' workload. In addition, we describe how we have developed a model for an integrated information system, based on agent technology, for health and social care needs assessment of older people. Finally, we discuss issues, such as security and mobility, involved in the development of such a system, which will need to be designed and tested prior to its implementation in health and social care practice.

Measuring case-mix and outcome for older people in acute hospital care across Europe: the development and potential of the ACMEplus instrument

AIM

To identify case-mix variables measured shortly after admission to be included in a patient classification system (ACMEplus) that best explains hospital outcome for older people in different health care systems.

DESIGN

Observational prospective cohort study collecting patient factors (sociodemographics, functional, mental, clinical, administrative and perceived health) at different time assessments.

METHODS

Multicentre study involving eight hospitals in six European countries (United Kingdom, Spain, Italy, Finland, Greece and Poland). It included consecutive patients aged 65 years or older admitted to hospital for acute medical problems.

MAIN OUTCOME MEASURES

discharge status, hospital readmission, mortality and length of stay.

RESULTS

Of the 1667 included patients (mean age = 78.1 years; male gender = 43.5%) two-third had at least one 'Geriatric Giant' (immobility, confusion, incontinence or falls) on admission or shortly after. The most frequently affected system was cardiovascular (29.2%) and 31% of patients declared poor or very poor health. Mean length of stay was 17.9 days, 79% of patients were discharged to their usual residence; in-hospital and 1-month follow up mortality were 7.4% and 11.6%, respectively. Physical function explained the highest variation (between 8% and 21%), followed by cognitive status and number of Geriatric Giants, for almost all outcomes except readmission.

CONCLUSION

Factors other than diagnosis (physical function, cognition and presenting problems) are important in predicting key outcomes of acute hospital care for older people and are consistent across countries. Their inclusion in a standardized system of measurement may be a way of improving quality and equity of medical care in older people.

The COPE index--a first stage assessment of negative impact, positive value and quality of support of caregiving in informal carers of older people

Data was collected in five countries from informal carers of older people (n = 577) via a common protocol. Carers completed: (1) a 17-item version of the Carers of Older People in Europe (COPE) Index, an assessment of carers' perceptions of their role : (2) a questionnaire on demographic and caregiving circumstances : and (3) three instruments included for the criterion validation of the COPE Index (the General Health Questionnaire, the Hospital Anxiety and Depression Scale, and the World Health Organization Quality of Life-BREF). Principal Component Analysis of the COPE Index was followed by internal consistency analysis of emergent components. Scales derived by summing items loading on the components were analyzed for their association with the criterion measures. Two components, negative impact and positive value, emerged consistently across countries. A third component, quality of support was less consistent across countries. Scales derived from the negative impact and positive value components were internally consistent and significantly associated with the criterion validity measures. These two scales and four items drawn from the quality of support component were retained in the final COPE Index. While further testing is required, the COPE Index has current utility in increasing understanding of the role perceptions of carers of older people.

Repeatability of standardized tests of functional impairment and well-being in older people in a rehabilitation setting

PURPOSE

The aim of this study was to establish the repeatability of standardized tests of vision (Snellen chart testing), hearing (whispered voice test), communication (Frenchay aphasia screening test), loneliness (UCLA loneliness scale), morale (Philadelphia geriatric centre morale scale), and a multidimensional instrument (EASY-care) when used in a rehabilitation setting.

METHOD

The tests were administered by a research nurse to 50 older subjects attending a day rehabilitation unit, with repeat administration one or two weeks later by a nurse on the unit. Kappa statistics were used for level of agreement for categorized data and interclass correlation coefficient were used for data based on scores.

RESULTS

Moderate repeatability for Snellen chart testing. whispered voice test; good to excellent for the FAST, UCLA loneliness scale and Philadelphia geriatric centre morale scale. Moderate to very good repeatability for all EASY-care items except communication, feeding, use of telephone and cognitive impairment, which had poor spread of data.

CONCLUSIONS

Poor repeatability for commonly used tests of vision and hearing is worrying, whereas the positive results for the other tests will increase confidence in using them more in routine practice.

UK geriatricians' attitudes to active voluntary euthanasia and physician-assisted death

AIM

To describe the views of British geriatricians on active voluntary euthanasia and physician-assisted death.

METHOD

Postal questionnaire to 742 consultant members of the British Geriatrics Society.

RESULTS

81% considered active voluntary euthanasia never to be justified ethically, although 23% supported legalization in some situations and 13% would be willing to administer active voluntary euthanasia in some situations. With regard to physician-assisted death, 68% opposed it on ethical grounds and 24% supported its legalization in some instances, with 12% stating they would be willing to provide such assistance in some situations. Free text comments frequently cited good palliative care as an important response to such issues in clinical practice.

Geriatric assessment in primary care: formulating best practice

Comprehensive geriatric assessment (CGA) is a structured approach to measuring physical, mental and social functioning of older people to identify needs and to plan care. Meta-analysis of trials of CGA suggest that it is cost-effective, but there is no agreed approach to its implementation in primary care. Our aim was to develop a best-practice model for geriatric assessment in primary care. We took an iterative approach to development, combining expert and local stakeholder opinion, and using semi-structured interviews to assess patient and practitioner experience in nine general practices in Sheffield. Patients were aged 75 and over, living at home. The best-practice model was the use of a standardized instrument (EASY-Care) to unselected patients aged 75 years and over living at home or in residential care, administered by a practice nurse in the context of an over-75s health check. There was high patient and practitioner acceptability, and significant cost savings were noted. Key beneficial features were the assessment of mental health and sources of support; goal-setting; generation of a disability score; and high patient satisfaction from contact with nursing staff. We conclude that geriatric assessment in primary care is feasible, economical and beneficial to patients and practitioners. Nursing staff are central to successful implementation of geriatric assessment in primary care.

The effectiveness of very short scales for depression screening in elderly medical patients

OBJECTIVE

To compare very short scales for screening for depression with longer, widely used scales.

METHODS

Eighty-seven patients over the age of 60 who were admitted to rehabilitation wards or were attending a day rehabilitation facility at a British teaching hospital were screened for depression using the 1-item mental health inventory, and the 4-item, 15-item and 30-item geriatric depression scales. The sensitivity, specificity, and areas under receiver operating characteristic curves were compared, with the diagnostic criteria for research of ICD-10 providing the criterion diagnosis of depressive episode.

RESULTS

All the scales had comparable sensitivity (82.4-100%), specificity (60.0-71.4%), and positive predictive values (33.3-42.9%). Comparison of receiver operating characteristic curves for each scale showed no statistically significant difference between them (range 0.80-0.88).

CONCLUSIONS

The very short scales performed just as well as the widely used longer screening scales in this population. They are worthy of further examination in elderly populations at risk of depression, and may be particularly suitable for older adults due to their brevity and ease of use.

Getting the questions right: an example of loss of validity during transfer of a brief screening approach for depression in the elderly

Screening for depression in the elderly has been advocated to improve detection and management. This article summarises the trend towards briefer screening instruments, and the integration of mental health screening with other assessments. The study aimed to validate a single question depression screen which has previously shown adequate sensitivity and specificity in a new context: a multi-faceted assessment instrument used by nurse practitioners within a community sample of over 75 year olds. The GMS-AGECAT computerised interview assessment was used as a 'gold standard' to determine the accuracy of the depression question in this new setting. Three hundred and twenty-eight patients were screened by their own nurse practitioners, of whom 100 consenting patients underwent a further interview with a research assistant using the GMS-AGECAT. The prevalence of depression was 30%, the sensitivity of the question was 67%, and its specificity 60% (compared with 88% and 71% previously). Responses indicating disability and loneliness were more closely correlated with depression than the depression screen itself. Relevant factors may include: the derivation of the question, the effect of a different sample, altered reliability when used by multiple interviewers, differing patient expectations, and the wording and context of the question within the multi-faceted screening instrument. Depression screening questions need repeated validation when used in different contexts. Patient and staff expectations may influence how screening instruments are used in practice in a way that may also alter reliability. Further studies are needed to establish the causes of loss of validity when screening approaches are used in new settings.

COPE: towards a comprehensive assessment of caregiver need

Supporting family carers is a common policy objective across Europe. However, if appropriate help is to be provided there is a need for a sensitive assessment process. This article describes the COPE project, the purpose of which is to develop a first-stage assessment tool that can be used to identify carers requiring a further in-depth consideration of their support needs.

The educational preparation of staff in nursing homes: relationship with resident autonomy

The following paper reports on a survey of nursing homes in three health regions in England which formed part of a wider study to evaluate educational preparation for the nursing care of older people. The aims of the survey were to describe the educational preparation of staff employed within nursing homes and to explore relationships between educational preparation and one indicator of quality of care. A self-completion questionnaire was addressed to the senior nurse within a random sample of nursing homes. The instrument included a previously validated scale to measure resident autonomy. A total of 976 questionnaires were posted and 676 were returned, a response rate of 69%. The survey revealed wide variation in the educational preparation of staff in nursing homes and in the degree of contact with local centres providing nurse education. Statistically significant associations were found between resident autonomy and a composite measure of educational preparation, the proportion of qualified staff undertaking continuing professional education and the degree of contact with educational centres. The findings have implications for both purchasers and providers of education in this field.

DepRelief: training programme for primary care

We live in an ageing society. Depression is common in old age and is a major cause of reduced well-being. The DepRelief programme has been developed to improve awareness, recognition and management of depression in old age by general practitioners and general physicians in Europe. At its core is a CD ROM interactive programme designed to support seminars for groups of up to 25 participants. The programme has extensive moderator notes and a large and up-to-date reference list. It can be customised to meet the needs of of the group. Special features include video clips and the production of customised materials including a care pathway for best practice in managing depression based on participation in the programme and local knowledge. It is anticipated that the DepRelief programme will become the key resource for the relief of depression through education.

Differences in valuation of functional status components among consumers and professionals in Europe and the United States

The ratings of the importance of functional status items among geriatric experts and consumers in Europe and the United States differed in many cases between experts and consumers in both countries; the differences were more frequent among the U.S. samples. The overall correlation between consumer and expert rankings was .82 for both groups. In general consumers, rated instrumental activities of daily living (IADL) items more highly, whereas the experts rated the most dysfunctional activities of daily living (ADL) items higher than did consumers. This study suggests the gap in doctor-patient communication. As function is increasingly used as a clinical outcome, agreement is needed on how to weight the components. The differences uncovered in this study suggest a need for more dialogue about what ends are truly sought by various parties.

A better way to measure disability in older people

BACKGROUND

Health care experts, older people and carers were asked to weight 18 personal and social activities of daily living (ADLs) with regard to the importance of being able to perform them.

RESULTS

All groups agreed on the order of importance but experts gave greater weight to personal ADLs. We have used these results to produce a ratio scale.

Patient-centred performance monitoring systems and multi-agency care provision: a case study using a stakeholder participative approach

We describe the processes involved in the development of an information system which can assess how care given by a number of agencies could be monitored by those agencies. In particular, it addresses the problem of sharing information as the boundaries of each agency are crossed. It focuses on the care of one specific patient group--the rehabilitation of elderly patients in the community, which provided an ideal multi-agency setting. It also describes: how a stakeholder participative approach to information system development was undertaken, based in part on the Soft Systems Methodology (SSM) approach (Checkland, 1981, 1990); some of the difficulties encountered in using such an approach; and the ways in which these were addressed. The paper goes on to describe an assessment tool called SCARS (the Southampton Community Ability Rating Scale). It concludes by reflecting on the management lessons arising from this project. It also observes, inter alia, how stakeholders have a strong preference for simpler, non-IT based systems, and comments on the difficulties encountered by stakeholders in attempting to reconcile their perceptions of the needs of their discipline or specialty with a more patient-centred approach of an integrated system.

Coping in family supporters of elderly people with dementia

Research into supporters of elderly people with dementia has a brief but significant history. Initially, research sought to establish the nature and extent of the distress that supporters endured in the fulfilment of their caring role. More recently, researchers have turned their attention towards the identification of coping techniques used by supporters in the community. The Dundee Study of Supporters and Dementia is concerned with factors associated with the maintenance and care of the demented elderly in the community, and with the impact of dementia on family supporters. A total of 228 family supporters of community-resident elderly (50 per cent of elders with dementia, 50 per cent without) were interviewed. Part of the interview focused on self-reported coping, and identified coping strategies using open-ended questions and a revised, 31-items Ways of Coping checklist. Findings indicated that the majority of supporters of community-resident elderly relatives reported coping well. Supporters predominantly used emotion-focused coping strategies as their main way of coping. However, those supporters who reported using a problem-focused strategy were found to score better on measures of coping than those supporters using an emotion-focused strategy. The supporters' main coping strategy was not associated with characteristics of the elder-supporter dyad. Factors derived from the Ways of Coping checklist produced a pattern of associations with characteristics of the elder-supporter dyad, but the same factors were largely not associated with other measures of coping. The implications of the findings are discussed with regard to coping research, and for interventions to improve the well-being of supporters of an elderly relative with dementia in the community.

Consumer and professional ratings of the importance of functional status components

As the population ages and chronic disease becomes the more dominant form of illness, measures of functional loss and disability assume greater importance in the assessment of both quality of life and the cost-effectiveness of care. The authors studied the responses of consumers and health care professionals regarding the impact on dependency of various levels of disability. Striking differences in perception were noted, raising concerns about the ability of those providing care to assume that the recipients share their values about what is important. This study makes clear the need for more research on functional outcome measurements that incorporate the values of consumers.

Prioritizing performance measures for geriatric medical services: what do the purchasers and providers think?

We sought the views of purchasers and provider managers in the South and West Region on the relative priorities of 15 possible performance measures of a geriatric medical service. Using a postal questionnaire, subjects were asked to rank the measures in order of priority. Improving patients' quality of life was judged the most important measure by all groups except for the purchasing chief executives, who placed it second to improving patients' physical function (which was overall the second most important measure). The lowest priority was given to measurement of levels of activity and reducing mortality rates. Priorities were similar to those found with patients and geriatricians in a previous study, and supports the development and use of performance measures of disability and the quality of life of patients.

Does the use of the Geriatric Depression Scale make redundant the need for separate measures of well-being on geriatrics wards?

Patients (n = 321) on geriatrics wards were asked to complete two or three of four well-being measures: the Geriatric Depression Scale, Philadelphia Geriatric Center Morale Scale, Southampton Self-esteem Scale and the Bradburn Affect Balance Scale. Analyses, including factor analysis, correlations and box-and-whisker plots, were carried out to investigate similarities In patient profiles provided by the different scales. The GDS showed similar profiles to the other measures, particularly the self-esteem scale, discriminating at the 'high' as well as 'low well-being' ends of the scales. These results indicate that, as far as clinical practice is concerned, additional use of such well-being measures may be unnecessary. Examination of different approaches to assessing well- being in clinical practice is required, for example measures of 'life strengths'.

Developing a new metric for ADLs

BACKGROUND

Most ADL summary measures add up the number of dependencies. They assume an equal weighting among items and require an arbitrary definition of dependency.

METHODS

A panel of experts in geriatrics was asked to rate a set of ADL and IADL components in terms of the contribution of each to overall dependency using a magnitude estimation (ME) technique. The ratings were done for both domains and for levels of function within each domain. The resultant scores were compared with the usual dependency count approach.

RESULTS

The distribution of weighted items appears to have face validity. The pattern of dependency traced by the ME model was intermediate between those created by simple counts with two different definitions of dependency. The ME approach has stronger statistical properties than the ordinal scoring approach.

CONCLUSIONS

The ME approach appears to be a reasonable and workable method for creating a measure that permits meaningful statements about the mean value of functional dependencies. This result can be used for any comparison of means, such as across individuals, across aggregates of individuals, or across time.

Community care for demented and non-demented elderly people: a comparison study of financial burden, service use, and unmet needs in family supporters

OBJECTIVE

To measure and compare perceived financial burden, use of services, and perceived unmet service needs of supporters of demented and non-demented elderly people.

DESIGN

Comparison study of age and sex matched demented and non-demented elderly people and their supporters.

SETTING

25 primary health care teams in Dundee.

SUBJECTS

114 community resident elderly (age over 65) people with dementia, 114 age and sex matched comparators, and the main informal supporter of each elderly person.

MAIN OUTCOME MEASURES

Carers' perceptions of financial impact of looking after an old person, service use (from a list of locally available services), unmet service needs, and needs for three types of generic service (help with supervision, housework, or personal care).

RESULTS

Financial impact was low, except for extra household expense in the dementia group. There was significantly greater use of mainstream domiciliary and day care services in the dementia group. Dementia was nevertheless associated with a high level of unmet need, mainly for more mainstream support and help with supervision of the elderly person.

CONCLUSION

Supervisory care for demented elderly people should be further developed within an expanded domiciliary service to meet supporters needs.

Using a softer approach. Techniques for interviewing older people

1. There is an increasing population of older people, many of whom need health and social care. 2. It is important to obtain their viewpoints in order to provide services that meet their needs. 3. Consideration must be given to the way their views are obtained. 4. The information must be fed back to service providers.

Involving consumers in assessing service quality: benefits of using a qualitative approach

Although important to users, practice standards rarely incorporate users' views of care provided. These views are a valuable source of information, even though there are limits to their value. To improve the standards of care in a 20 bed hospital elderly care unit caring for acute medical conditions a qualitative approach was used. Patients' and carers' perceptions of care and problems with the process of care in the unit were elicited with a specially designed semistructured interview schedule in 83 separate tape recorded interviews with a research nurse in patients' homes. In all, 50 patients and 35 carers were interviewed between 6 June 1991 and 28 May 1992. Of the 50 patients, 33 were female; seven patients were aged less than 80 years, 16, 80-85; 21, 86-90; and six over 90. A total of 16 patients lived with spouses or other carers, two with non-carers, and 32 lived alone, 18 of whom received informal care. Content analysis of the interviews disclosed patients' and carers' general satisfaction with individualised professional care and planning of follow up services on discharge but dissatisfaction in the lack of information about and involvement in treatment and care and about specific staff notes. These findings have prompted remedial changes in clinical practice in the unit; they have also formed the structure of a criterion based survey of practice. The authors conclude that the qualitative approach suited elderly users and also provided the basis for the findings to be incorporated into a continuous audit cycle through a process of feedback and standard setting.

Development and evaluation of an information system for quality assurance

The aim of this study was to develop and evaluate an information system for monitoring impact of acute hospital care on health status of elderly patients, burden on carers, and consumer satisfaction with care. The study was undertaken on four acute care wards of an elderly care unit of a teaching hospital. We used a consensus-building process to achieve within-and-between-team convergence of policy and practice in the use of structured assessments on three wards, with parallel data collection by a research nurse on one ward. We describe the changes to our working practices, the costs of data collection, staff attitudes to the system and the assessment instruments, using 5-point Likert Scales, with additional in-depth interviews with senior staff for their attitudes to the system. We found that only nursing staff were able to change their practice. On admission, it was feasible to undertake functional assessment of activities of daily living (ADL), depression, perceived life quality and carer strain. Discharge assessment was only feasible for ADL. Other discharge assessments and follow-up assessments including consumer satisfaction interviews required audit assistant support. The total annual cost per ward was 6,225 pounds for the adopted system, or 6,455 pounds to incorporate follow-up assessments by audit assistant in a random sample of 50 patients. Staff attitudes to the system were positive, especially for use of the Relatives' Stress Scale, and for the value of follow-up interviews. We conclude that the participatory approach to the introduction of the information system produced a system which was perceived to be beneficial for patient care.(ABSTRACT TRUNCATED AT 250 WORDS)

Community care services: views of patients attending a geriatric day hospital

The NHS and Community Care reforms give increased emphasis to meeting the needs of patients as consumers of services, but little is known about patients' perceptions of services. In this study, we obtained the views of patients attending a geriatric day hospital about community care services and professional support; their knowledge of services, perceived unmet needs and perceptions of benefit. Forty-seven patients with a mental status score above 7/10 who attended the day hospital in a four week period were interviewed using structured questionnaires for consumer opinion, modified for this population. Patients had poor knowledge of services, especially of those which support carers and of private sources of support. When informed about the availability and purpose of local services, they recognised few unmet needs on average, less than one per patient, nearly always a need for social services, especially other forms of day care. Patients' perceptions of benefit from services and professional support were highest for day hospital care itself (98% of maximum possible benefit). There could be scope for the development of social work case management programmes in geriatric day hospitals; the methods used in this study provide a model for obtaining consumer opinion.