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Tops L, Beerten SG, Vandenbulcke M, Vermandere M, Deschodt M. Integrated Care Models for Older Adults with Depression and Physical Comorbidity: A Scoping Review. Int J Integr Care 2024; 24:1. [PMID: 38222854 PMCID: PMC10786096 DOI: 10.5334/ijic.7576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 12/07/2023] [Indexed: 01/16/2024] Open
Abstract
Objective Multimorbidity is a growing challenge in the care for older people with mental illness. To address both physical and mental illnesses, integrated care management is required. The purpose of this scoping review is to identify core components of integrated care models for older adults with depression and physical comorbidity, and map reported outcomes and implementation strategies. Methods PubMed, EMBASE, CINAHL and Cochrane Library were searched independently by two reviewers for studies concerning integrated care interventions for older adults with depression and physical comorbidity. We used the SELFIE framework to map core components of integrated care models. Clinical and organisational outcomes were mapped. Results Thirty-eight studies describing thirteen care models were included. In all care models, a multidisciplinary team was involved. The following core components were mainly described: continuity, person-centredness, tailored holistic assessment, pro-activeness, treatment interaction, individualized care planning, and coordination tailored to complexity of care needs. Twenty-seven different outcomes were evaluated, with more attention given to clinical than to organisational outcomes. Conclusion The core components that comprise integrated care models are diverse. Future studies should focus more on implementation aspects of the intervention and describe financial parts, e.g., the cost of the intervention for the healthcare user, more transparently.
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Affiliation(s)
- Laura Tops
- Academic Centre of General Practice, KU Leuven, Kapucijnenvoer 7, Box 7001, 3000, Leuven, Belgium
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Simon Gabriël Beerten
- Academic Centre of General Practice, KU Leuven, Kapucijnenvoer 7, Box 7001, 3000, Leuven, Belgium
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Mathieu Vandenbulcke
- Department of Neurosciences, Leuven Brain Institute, KU Leuven, Leuven, Belgium
- Department of Geriatric Psychiatry, University Psychiatric Centre, KU Leuven, Leuven, Belgium
| | - Mieke Vermandere
- Academic Centre of General Practice, KU Leuven, Kapucijnenvoer 7, Box 7001, 3000, Leuven, Belgium
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Mieke Deschodt
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
- Competence Center for Nursing, University Hospitals Leuven, Belgium
- Gerontology and Geriatrics, University Hospitals Leuven, Belgium
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Ziemek J, Hoge N, Woodward KF, Doerfler E, Bradywood A, Pletcher A, Flaxman AD, Iribarren S. Stakeholder perspectives on factors influencing acute care patient outcomes: A qualitative approach to model refinement. Res Sq 2023:rs.3.rs-3817903. [PMID: 38234721 PMCID: PMC10793493 DOI: 10.21203/rs.3.rs-3817903/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
Background Health systems have long been interested in the best practices for staffing in the acute care setting. Studies on staffing often focus on registered nurses and nurse-to-patient staffing ratios. There are fewer studies on the relationship between interprofessional team members or contextual factors such as hospital and community characteristics and patient outcomes. This qualitative study aimed to refine a causal model by soliciting hospital stakeholder feedback on staffing and patient outcomes. Methods We conducted a qualitative study using semi-structured interviews and thematic analysis to understand hospital stakeholder perspectives and their experiences of factors that affect acute care inpatient outcomes. Interviews were conducted in 2022 with 38 hospital stakeholders representing 19 hospitals across Washington State. Results Findings support a model of characteristics impacting patient outcomes to include the complex and interconnected relationships between community, hospital, patient, and staffing characteristics. Within the model, patient characteristics are nested into hospital characteristics, and in turn these were nested within community characteristics to highlight the importance of setting and context when evaluating outcomes. Together, these factors influenced both staff characteristics and patient outcomes, while these two categories also share a direct relationship. Conclusion Findings can be applied to hospitals and health systems across the globe to examine how external factors such as community resource availability impact care delivery. Future research should expand on this work with specific attention to how staffing changes and interprofessional team composition can improve patient outcomes.
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Affiliation(s)
| | | | | | | | | | - Alix Pletcher
- University of Washington Institute for Health Metrics and Evaluation
| | - Abraham D Flaxman
- University of Washington Institute for Health Metrics and Evaluation
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Abstract
The World Health Organization's World Mental Health Report is a call for action and reminds all of the huge personal and societal impact of mental illnesses. Significant effort is required to engage, inform and motivate policymakers to act. We must develop more effective, context-sensitive and structurally competent care models.
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Affiliation(s)
- Pim Cuijpers
- Department of Clinical, Neuro and Developmental Psychology, Amsterdam Public Health Research Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; WHO Collaborating Centre for Research and Dissemination of Psychological Interventions, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands; and International Institute for Psychotherapy, Babeş-Bolyai University, Cluj-Napoca, Romania
| | - Afzal Javed
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK; and World Psychiatric Association, Geneva, Switzerland
| | - Kamaldeep Bhui
- Department of Psychiatry, University of Oxford, Oxford, UK; World Psychiatric Association Collaborating Centre, Oxford, UK
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4
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McConnell ES, Xue TM, Levy CR. Veterans Health Administration Models of Community-Based Long-Term Care: State of the Science. J Am Med Dir Assoc 2022; 23:1900-1908.e7. [PMID: 36370751 DOI: 10.1016/j.jamda.2022.10.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 10/15/2022] [Accepted: 10/18/2022] [Indexed: 11/11/2022]
Abstract
The complex care needs of older adults arising at the intersection of age-related illnesses, military service, and social barriers have presented challenges to the US Department of Veterans Affairs (VA) for decades. In response, the VA has invested in centers that integrate research, education, and clinical innovation, using approaches aligned with a learning health care system, to create, evaluate, and implement new care models. This article presents an integrative review of 6 community care models developed within the VA to manage multimorbidity, complex social needs, and avoid institutional care, examining how these models address complex care needs among older adults. The models reviewed include Home Based Primary Care, Medical Foster Home, the VA Caregiver Support Program, the Resources Enhancing Alzheimer's Caregiver Health (REACH)-VA program, the Caregivers of Older Adults Cared for at Home (COACH) program, and Veteran Directed Care. Core components and evaluation outcomes for each model are summarized, along with implications for more widespread implementation and research. Each model promotes coordinated care, integrates behavioral health, and leverages interprofessional expertise. All models are cost-neutral or incur only modest cost increases to improve outcomes. Broader implementation will require interprofessional workforce development, payment model realignment, and infrastructure to evaluate outcomes in new settings. The VA provides a blueprint for infrastructure that could be adapted to other domestic and international settings. Care models successfully implemented within the VA's single-payer system hold promise to address persistent dilemmas in long-term care, such as management of multimorbidity and social drivers of health, integration and support of family caregivers, and mental health integration. These models also demonstrate the value of incorporating care approaches that have been developed or tested outside the United States and argue for greater cross-fertilization of ideas from different health systems.
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Affiliation(s)
- Eleanor S McConnell
- Duke University School of Nursing, Durham, NC, USA; Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Health Care System, Durham, NC, USA.
| | - Tingzhong Michelle Xue
- Duke University School of Nursing, Durham, NC, USA; Geriatric Research, Education, and Clinical Center, Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - Cari R Levy
- University of Colorado School of Medicine, Aurora, CO, USA; Denver-Seattle Center of Innovation for Veteran-Centered and Value-Driven Care, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, USA
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5
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Henschen BL, Theodorou ME, Chapman M, Barra M, Toms A, Cameron KA, Zhou S, Yeh C, Lee J, O'Leary KJ. An Intensive Intervention to Reduce Readmissions for Frequently Hospitalized Patients: the CHAMP Randomized Controlled Trial. J Gen Intern Med 2022; 37:1877-1884. [PMID: 34472021 PMCID: PMC8409268 DOI: 10.1007/s11606-021-07048-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 07/14/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND A small number of patients are disproportionally readmitted to hospitals. The Complex High Admission Management Program (CHAMP) was established as a multidisciplinary program to improve continuity of care and reduce readmissions for frequently hospitalized patients. OBJECTIVE To compare hospital utilization metrics among patients enrolled in CHAMP and usual care. DESIGN Pragmatic randomized controlled trial. PARTICIPANTS Inclusion criteria were as follows: 3 or more, 30-day inpatient readmissions in the previous year; or 2 inpatient readmissions plus either a referral or 3 observation admissions in previous 6 months. INTERVENTIONS Patients randomized to CHAMP were managed by an interdisciplinary team including social work, physicians, and pharmacists. The CHAMP team used comprehensive care planning and inpatient, outpatient, and community visits to address both medical and social needs. Control patients were randomized to usual care and contacted 18 months after initial identification if still eligible. MAIN MEASURES Primary outcome was number of 30-day inpatient readmissions 180 days following enrollment. Secondary outcomes were number of hospital admissions, total hospital days, emergency department visits, and outpatient clinic visits 180 days after enrollment. KEY RESULTS There were 75 patients enrolled in CHAMP, 76 in control. Groups were similar in demographic characteristics and baseline readmissions. At 180 days following enrollment, CHAMP patients had more inpatient 30-day readmissions [CHAMP incidence rate 1.3 (95% CI 0.9-1.8) vs. control 0.8 (95% CI 0.5-1.1), p=0.04], though both groups had fewer readmissions compared to 180 days prior to enrollment. We found no differences in secondary outcomes. CONCLUSIONS Frequently hospitalized patients experienced reductions in utilization over time. Though most outcomes showed no difference, CHAMP was associated with higher readmissions compared to a control group, possibly due to consolidation of care at a single hospital. Future research should seek to identify subsets of patients with persistently high utilization for whom tailored interventions may be beneficial. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT03097640; https://clinicaltrials.gov/ct2/show/NCT03097640.
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Affiliation(s)
- Bruce L Henschen
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Maria E Theodorou
- Division of Hospital Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Margaret Chapman
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - McKay Barra
- Division of Hospital Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Abby Toms
- Department of Social Work, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Kenzie A Cameron
- Division of General Internal Medicine and Geriatrics, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Shuhan Zhou
- Division of Hospital Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Chen Yeh
- Division of Biostatistics, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jungwha Lee
- Division of Biostatistics, Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Kevin J O'Leary
- Division of Hospital Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Doumen M, Westhovens R, Vandeputte M, Van Melder R, Van der Elst K, Pazmino S, Bertrand D, Stouten V, Van Laeken E, Creten N, Neys C, Verschueren P, De Cock D. The perception of stakeholders on the applicability of nurse-led clinics in the management of rheumatoid arthritis. Rheumatol Adv Pract 2021; 5:ii45-ii52. [PMID: 34755028 PMCID: PMC8570152 DOI: 10.1093/rap/rkab052] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 05/06/2021] [Indexed: 11/29/2022] Open
Abstract
Objectives RA should be treated to target in a process of shared decision-making with patients. Person-centred care is essential to meeting specific patient needs. Nurse-led clinics, where a nurse is responsible for care, have demonstrated added value in some countries but are still not implemented widely. This study aimed to explore stakeholders’ perceptions of advantages, disadvantages and conditions for the implementation of nurse-led clinics for RA in Belgium. Methods We performed a cross-sectional qualitative study consisting of five semi-structured focus group interviews. Rheumatology nurses, patients with RA and rheumatologists were interviewed as stakeholders. The analysis was carried out by three researchers according to the Qualitative Analysis Guide of Leuven (QUAGOL), formulating a conceptual framework of overarching themes and deconstructing this into perceived advantages, disadvantages and conditions. Results Two focus groups with nurses (total n = 16), two with patients (n = 17) and one with rheumatologists (n = 9) were conducted. The interview synthesis resulted in five overarching themes across stakeholders: efficiency of care, disease management, legal and organizational requirements, the conventional role of the nurse and the extended role of the nurse. All stakeholders perceived additional education for nurses as essential, but rheumatologists debated nurses’ abilities to lead a rheumatology clinic. Furthermore, patients preferred care protocols to guide nurses, and care providers approached this reluctantly. Generally, patients with a well-controlled disease were perceived as the ideal candidates for nurse-led care. Conclusion Nurse-led clinics could provide many benefits but require additional nurse education and a legal and organizational framework before being implemented widely and successfully.
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Affiliation(s)
- Michaël Doumen
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven.,Rheumatology, University Hospitals Leuven
| | - René Westhovens
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven.,Rheumatology, University Hospitals Leuven
| | | | - Rani Van Melder
- Academic Centre for Nursing and Midwifery, KU Leuven, Leuven
| | | | - Sofia Pazmino
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven
| | - Delphine Bertrand
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven
| | - Veerle Stouten
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven
| | | | | | | | - Patrick Verschueren
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven.,Rheumatology, University Hospitals Leuven
| | - Diederik De Cock
- Department of Development and Regeneration, Skeletal Biology and Engineering Research Centre, KU Leuven
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7
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Murdoch J, Hauck Y, Aydon L, Sharp M, Zimmer M. When can I hold my baby? An audit of time to first cuddle for preterm babies (<32 weeks) pre introduction and post introduction of a Family-Integrated Care model. J Clin Nurs 2021; 30:3481-3492. [PMID: 33982368 DOI: 10.1111/jocn.15850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 10/31/2020] [Accepted: 04/26/2021] [Indexed: 10/21/2022]
Abstract
AIM The audit examined time to first cuddle between preterm babies (born < 32 weeks) and their parent pre- and post-introduction of a family-integrated care model. Secondary outcomes included time to full feeds and length of neonatal intensive care stay. BACKGROUND Parental separation due to neonatal intensive care unit admission is known to negatively affect parental and baby wellbeing. DESIGN A "before-after" design compared outcomes for babies admitted pre- (2015) and post (2018)-implementation of the model in a Western Australian neonatal intensive care unit. METHODS A retrospective medical record audit included babies from two gestational age groups in 2015 and 2018, born ≤27 + 6 weeks and 28-31 + 6 weeks. SQUIRE checklist guided reporting of the audit. RESULTS One hundred fifty-three babies were included in the audit, 79 from 2015 (≤27 + 6 weeks n = 39 and 28-31 + 6 weeks n = 40) and 74 from 2018 (≤27 + 6 weeks n = 35 and 28-31 + 6 weeks n = 39). Babies in both years were born at similar median gestational ages with comparable birthweights. Babies born ≤27 + 6 weeks in 2018 were cuddled earlier (median = 141 h old) compared with those in 2015 (median = 157 h old). Median time to reach full feeds decreased and was significant in the ≤27 + 6-week group: 288 h (12 days) in 2015 to 207.5 h (8.6 days) in 2018. Length of stay was longer for the ≤27 + 6-week gestation 2018 group (median = 64 days) and 28-31 + 6-week gestation 2018 group (median = 22 days). CONCLUSION Family-integrated care models may decrease the time to first cuddle and full feeds. Further research on outcomes such as breastfeeding, infant weight gain and length of stay can extend existing knowledge. RELEVANCE TO CLINICAL PRACTICE Family-integrated care models may offer benefits to families of hospitalised preterm babies and investigating barriers to its implementation and creation of solutions to overcome barriers warrants attention.
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Affiliation(s)
- Jamee Murdoch
- Neonatal Directorate, Kind Edward Memorial Hospital, Subiaco & Perth Children's Hospital, CAHS, Nedlands, WA, Australia
| | - Yvonne Hauck
- School of Nursing, Midwifery and Paramedicine, Curtin University, Bentley, Australia.,Department of Nursing and Midwifery Education and Research, King Edward Memorial Hospital, Perth, WA, Australia
| | - Laurene Aydon
- Neonatal Directorate, Kind Edward Memorial Hospital, Subiaco & Perth Children's Hospital, CAHS, Nedlands, WA, Australia.,Department Nursing Research, Child and Adolescent Health Service, Nedlands, WA, Australia.,Centre for Research and Neonatal Education, School of Child and Paediatric Health, University of Western Australia, Perth, WA, Australia
| | - Mary Sharp
- Neonatal Directorate, Kind Edward Memorial Hospital, Subiaco & Perth Children's Hospital, CAHS, Nedlands, WA, Australia.,Centre for Research and Neonatal Education, School of Child and Paediatric Health, University of Western Australia, Perth, WA, Australia
| | - Margo Zimmer
- Department Nursing Research, Child and Adolescent Health Service, Nedlands, WA, Australia
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Lam J, Mattke S. Memory care approaches to better leverage capacity of dementia specialists: a narrative synthesis. Neurodegener Dis Manag 2021; 11:239-250. [PMID: 33966489 DOI: 10.2217/nmt-2020-0038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Prior research suggests that a scarcity of dementia specialists could hamper access to disease-modifying Alzheimer's treatments. We describe alternative approaches on how to leverage specialist time for memory care in this narrative synthesis based on 17 semi-structured interviews and a targeted literature review on memory care approaches that leverage specialist time. We identified four types of approaches: community primary care practices empowered with better tools and training; primary care memory clinics; specialty memory clinics and; specialty memory centers. Several approaches to use specialist time efficiently have been implemented and some but not all evaluated. The optimal approach may depend on the local context.
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Affiliation(s)
- Jenny Lam
- Department of Pharmaceutical & Health Economics, School of Pharmacy, University of Southern California, Los Angeles, CA 90089-3333, USA.,Leonard D Schaeffer Center for Health Policy & Economics, University of Southern California, Los Angeles, CA 90089-3333, USA
| | - Soeren Mattke
- Center for Economic & Social Research, University of Southern California, Los Angeles, CA 90089-3333, USA
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9
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Flaherty E, Bartels SJ. Addressing the Community-Based Geriatric Healthcare Workforce Shortage by Leveraging the Potential of Interprofessional Teams. J Am Geriatr Soc 2020; 67:S400-S408. [PMID: 31074849 DOI: 10.1111/jgs.15924] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 01/22/2019] [Accepted: 02/13/2019] [Indexed: 12/01/2022]
Abstract
As Americans live longer lives, we will see an increased demand for quality healthcare for older adults. Despite the growth in the number of older adults, there will be a decrease in the supply of a primary care physician workforce to provide adequately for their care and health needs. This article reviews the literature that explores ways to address the primary care workforce shortage in a community-based geriatric healthcare setting, with special attention to elevating the role of nurses and caregivers and shifting the way we think about delivery of care and end-of-life conversations and planning. The shift is toward a more integrated and collaborative approach to care where medical and nonmedical, social services, and community providers all play a role. Several models have demonstrated promising positive benefits and outcomes to patients, families, and providers alike. The goal is to provide high quality care that addresses the unique attributes of older adults, especially those with complex conditions, and to focus more on care goals and priorities. The many barriers to scaling and spreading models of care across varied settings include payment structures, lack of education and training among all stakeholders, and, at the top of the list, leadership resistance. We address these barriers and make recommendations for a path forward where healthcare providers, policymakers, patients, families, and everyone else involved can play a role in shaping the workforce caring for older adults. J Am Geriatr Soc 67:S400-S408, 2019.
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Affiliation(s)
- Ellen Flaherty
- Dartmouth Centers for Health & Aging, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Stephen J Bartels
- The Mongan Institute, Massachusetts General Hospital, Boston, Massachusetts
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10
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Hart LC, Mouw MS, Teal R, Jonas DE. What Care Models Have Generalists Implemented to Address Transition from Pediatric to Adult Care?: a Qualitative Study. J Gen Intern Med 2019; 34:2083-2090. [PMID: 31410810 PMCID: PMC6816717 DOI: 10.1007/s11606-019-05226-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 03/26/2019] [Accepted: 06/13/2019] [Indexed: 01/13/2023]
Abstract
BACKGROUND The transition from pediatric to adult care is a critical period for young adults with childhood-onset conditions. General internists are tasked with participating in the care of this vulnerable population. Existing guidelines regarding transition do not fully address structural or organizational characteristics of practices that facilitate transition. Moreover, literature regarding transition has focused on pediatric subspecialty settings, leaving internists with little guidance after transfer. OBJECTIVES To better understand post-transfer transitional care by describing care models that primary care providers have implemented, and examining common features of generalist physicians' experiences providing transitional care. DESIGN Qualitative methods, semi-structured interviews. PARTICIPANTS Nineteen generalist-trained physicians from across the USA, engaged in transition-focused and/or ongoing care of adolescents and young adults with childhood-onset conditions. APPROACH Content and grounded theory analyses. KEY RESULTS Participants included nineteen physicians from seventeen institutions. Most (89%) were from academic medical centers. About 80% had completed a combined internal medicine-pediatrics residency. About 70% worked with clinic staff who were dedicated to transition. Practice structures fell into four main care models: (1) primary care in adult settings; (2) transition support and primary care in pediatric settings; (3) a blend of pediatric and adult care elements forming a bridge during transition; and (4) a transition consultative service. Most provided primary care for adults with childhood-onset conditions within larger adult-oriented primary care practices. Common features across interviews included taking extra time with patients both during and between visits and an interdisciplinary team-based approach. Shared practice strategies and philosophies emphasized care coordination, focus on the whole patient beyond immediate health concerns, and willingness to learn from practice and from families. CONCLUSIONS Participants used disparate care models. Common features and strategies among interviews highlight key functions and attributes of transitional care across settings, suggest important elements of care post-transfer, and clarify the role of generalists.
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Affiliation(s)
- Laura C Hart
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Mary S Mouw
- Division of Geriatrics, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Randall Teal
- Connected Health Applications and Interventions (CHAI-Core), University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Daniel E Jonas
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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11
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du Toit SHJ, Withall A, O'Loughlin K, Ninaus N, Lovarini M, Snoyman P, Butler T, Forsyth K, Surr CA. Best care options for older prisoners with dementia: a scoping review. Int Psychogeriatr 2019; 31:1081-97. [PMID: 31412973 DOI: 10.1017/S1041610219000681] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION The prisoner population is ageing, and consideration is needed for how to best support those with age-related health conditions in the system. Existing work practices and organizational structures often fail to meet the needs of prisoners with dementia, and prison staff experience high levels of burden because of the increased needs of these prisoners. Little is known about the best method of responding to the needs of this growing subpopulation of prisoners. METHOD A scoping review was conducted to answer the question: what are the perceived best care options for prisoners with dementia? To be included, publications had to be publicly available, reported on research findings, or viewed opinions and commentaries on care practices relevant to older prisoners with dementia. Searches were conducted in 11 databases to identify relevant publications. Data from the included publications were extracted and summarized into themes. RESULTS Eight themes were identified that could support better care practices for prisoners with dementia: (1) early and ongoing screening for older prisoners; (2) specialized services; (3) specialized units; (4) programs or activities; (5) adaptations to current contexts; (6) early release or parole for older prisoners with dementia deemed at low risk of reoffending; and (7) training younger prisoners (8) as well as staff to assist older prisoners with dementia. Besides practical strategies improving care practice, costs, prison-specific resources, and staff skills were highlighted as care barriers across all themes. A lack of empirical evidence supported these findings. CONCLUSION One of the implications of the international ageing prison population is the higher number of people living with dementia being incarcerated. Suggestions for best care approaches for prisoners with dementia now need to move from opinion to empirical approaches to guide practice.
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Abstract
Cancer patients may experience significant symptom mitigation from acupuncture. However, this service may not be easily accessible or affordable at all cancer institutions. The development of a group acupuncture program provided one institution with improved availability, lower cost to patients, and a foundation for oncology acupuncture research. This care delivery model was deployed at a large southeastern cancer institution within a multistate academic-community hybrid hospital system. The cancer institute serves >15,000 patients annually. Acupuncture is provided through the institute's Integrative Medicine section of the Department of Supportive Oncology. The purpose of this commentary is to describe the successful transition from an individual to group acupuncture model at this cancer institute. With the implementation of group acupuncture, patient visits increased 275% from individual care delivery. Although successful implementation of a group acupuncture model may be affordable and clinically positive, the authors also share unique challenges learned through the development and expansion of this program.
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Affiliation(s)
- Susan Yaguda
- Department of Supportive Oncology, Levine Cancer Institute, Atrium Health, Charlotte, NC
| | - Danielle Gentile
- Department of Supportive Oncology, Levine Cancer Institute, Atrium Health, Charlotte, NC
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Abstract
Patients with advanced chronic kidney disease (CKD), including end-stage renal disease (ESRD), have a life-threatening illness complicated by high morbidity and mortality and, therefore, should be suitable candidates for early intervention by palliative care specialists. However, the average patient with CKD does not have an advanced care plan, has multiple debilitating symptoms, and does not utilise hospice care at the end of life. In this review, we outline the scope of the problem of unmet palliative care needs for patients with advanced CKD and ESRD, barriers to improving palliative care for patients with renal failure, and possible future directions for palliative nephrology.
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Abstract
There is an upward trend incidence of multiple chronic life-limiting conditions with a well-documented associated impact on patients and their caregivers. When patients approach the end of life, they are often faced with a challenging multidimensional burden while navigating a complex health care system. Patients and families/caregivers are faced with daily decisions, often with little or no frame of reference or medical knowledge. The “what, how, when, and where” puzzle during this challenging time can be overwhelming for patients and their families, and when clinicians do not contemplate this associated workload’s impact on patients and caregivers’ capacity for self-care, patients and caregivers scramble to find compensatory solutions, often putting their health care at lower priority. This consequently warrants the underlying importance of palliative care and integrating it into the patients’ health care plans earlier. There is increasing evidence from recent trials that supported implementing national policies regarding the early integration of palliative care and its role in improving the quality of life, increasing survival, and supporting patients’ and caregivers’ values when making decisions about their health care while possibly minimizing the burden of illness. The mission of palliative care is to assess, anticipate, and alleviate the challenges and suffering for patients and their caregivers by providing well-constructed approaches to disease-related physical treatments as well as psychological, financial, and spiritual aspects. Communication among all participants (the patient, family/caregivers, and all involved health care professionals) ought to be timely, thorough, and patient-centric. Palliative medicine arguably represents an example of shared decision-making (SDM)—facilitating a patient-centered, informed decision-making through an empathic conversation that is supported by clinicians’ expertise and the best available evidence that takes patients values and preferences into consideration. Palliative care teams often consider the burden placed on patients and their caregivers, thus treatment plans would be assessed and introduced into the patients’ lives with reflection on the related workload and the potential capacity to take on those plans. Such an approach to pause-and-examine, understand-and-discuss, and assess-and-alleviate might provide a possible example of a health care system that is minimally disruptive to patients and their families. This is an opportunity to replace the information-filled encounter with a more constructive engagement and empowerment to all major stakeholders to participate—an axiom integral to palliative care. Using the best available evidence in caring for patients while enacting SDM, palliative care, primary care, and other subspecialty clinicians need to consider the significant workload and burden that comes with health care and thus explore pathways to minimize the disruption in patients and caregivers’ lives. As we collaborate to end cancer and all other mobdeities, we a need a concurrent movement to transform this disease-centered, payer-driven health care era to a rather patient-entered, thoughtful, and minimally disruptive one will benefit patients and physicians alike.
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Affiliation(s)
| | - Robert P Shannon
- Department of Family Medicine/palliative Medicine Fellowship, Mayo Clinic Jacksonville, Fl
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15
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Boltz M, Cuellar NG, Cole C, Pistorese B. Comparing an on-site nurse practitioner with telemedicine physician support hospitalist programme with a traditional physician hospitalist programme. J Telemed Telecare 2018; 25:213-220. [PMID: 29498301 DOI: 10.1177/1357633x18758744] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Since 2010, more than 75 rural hospitals have closed in the USA and more than one-third are at risk of closure due to lower patient volumes, lower funding levels, decreased hospital revenue and lower physician employment pools. Telemedicine can provide new models of care delivery that maintain quality and reduce cost of healthcare in rural populations. The purpose of this project was to evaluate a cross-organizational pilot program by comparing a NP/telemedicine physician hospitalist programme with a traditional physician hospitalist model to assess effects on length of patient stay, mortality rates, readmission rate, Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) ratings of provider communication, and total hospital costs. METHODS The Standard for Quality Improvement Reporting Excellence (SQUIRE) guidelines were followed. Using a one-year retrospective chart review, average length of stay, mortality rates, 30-day readmission rates and provider communication ratings were compared between hospitalists that were nurse practitioners working with physicians through telemedicine support and physicians alone. RESULTS There was no statistically significant variance in average length of stay, mortality rates, 30-day readmission rates, or provider communication ratings on HCAHPS surveys compared to the NP or physician hospitalist. DISCUSSION This new model of care demonstrates that telemedicine can be used to provide safe and efficient physician support from a regional hub medical centre to nurse practitioners practising as hospitalists in rural Critical Access Hospitals at up to 58% cost savings while maintaining quality of care and increasing access to community-based physicians.
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Affiliation(s)
- Michelle Boltz
- 1 Capstone College of Nursing, University of Alabama, USA
| | | | - Casey Cole
- 2 College of Nursing, Montana State University, USA
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16
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Wullschleger A, Wosniok W, Timm J, Heinze M. Challenges and Perspectives in Bridging In- and Outpatient Sectors: The Implementation of Two Alternative Models of Care and Their Effect on the Average Length of Stay. Front Psychiatry 2017; 8:196. [PMID: 29051740 PMCID: PMC5633735 DOI: 10.3389/fpsyt.2017.00196] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Accepted: 09/20/2017] [Indexed: 11/13/2022] Open
Abstract
New models of care aimed at reinforcing the outpatient sector have been introduced in Germany over the last few years. Initially, a subscription-based model ("integrated care") was introduced in 2012 in the Immanuel Klinik Rüdersdorf, wherein patients had to actively subscribe to the integrated care program. This integrated care model was replaced after 2 years by a subscription-free "model project," in which all patients insured by the contracting insurance company took part in the program. Data showed that the introduction of the integrated care program in the inpatient setting led to an increase of the average length of stay in this group. The switch to the model project corrected this unwanted effect but failed in significantly decreasing the average length of stay when compared to standard care. However, both the integrated care program and model project succeeded in reducing the length of stay in the day care setting. When adjusting for the sex and diagnosis proportions of each year, it was shown that diagnosis strongly influenced the average length of stay in both settings, whereas sex only slightly influenced the duration of stay in the inpatient setting. Thus, in spite of strong financial and clinical incentives, the introduction of the model project couldn't fulfill its primary purpose of shifting resources from the inpatient to the outpatient setting in the initial years. Possible explanations, including struggle against long-established traditions and reluctance to change, are discussed.
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Affiliation(s)
- Alexandre Wullschleger
- Hochschulklinik für Psychiatrie und Psychotherapie der Medizinischen Hochschule Brandenburg, Immanuel Klinik Rüdersdorf, Rüdersdorf, Germany
| | - Werner Wosniok
- Kompetenzzentrum für klinische Studien, Universität Bremen, Bremen, Germany
| | - Jürgen Timm
- Kompetenzzentrum für klinische Studien, Universität Bremen, Bremen, Germany
| | - Martin Heinze
- Hochschulklinik für Psychiatrie und Psychotherapie der Medizinischen Hochschule Brandenburg, Immanuel Klinik Rüdersdorf, Rüdersdorf, Germany
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17
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Abstract
Integrated clinical care models, like Accountable Care Organizations and ESRD Seamless Care Organizations, present new opportunities for dialysis facility medical directors to affect changes in care that result in improved patient outcomes. Currently, there is little scholarly information on what role the medical director should play. In this opinion-based review, it is predicted that dialysis providers, the hospitals in which the medical director and staff physicians practice, and the payers with which they contract are going to insist that, as care becomes more integrated, dialysis facility medical directors participate in new ways to improve quality and decrease the costs of care. Six broad areas are proposed where dialysis unit medical directors can have the greatest effect on shifting the quality-care paradigm where integrated care models are used. The medical director will need to develop an awareness of the regional medical care delivery system, collect and analyze actionable data, determine patient outcomes to be targeted that are mutually agreed on by participating physicians and institutions, develop processes of care that result in improved patient outcomes, and lead and inform the medical staff. Three practical examples of patient-centered, quality-focused programs developed and implemented by dialysis unit medical directors and their practice partners that targeted dialysis access, modality choice, and fluid volume management are presented. Medical directors are encouraged to move beyond traditional roles and embrace responsibilities associated with integrated care.
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Affiliation(s)
- Thomas F Parker
- Department of Medicine, Baylor University Medical Center, Dallas, Texas; Renal Ventures Management, LLC, Lakewood, Colorado; and
| | - George R Aronoff
- Renal Ventures Management, LLC, Lakewood, Colorado; and Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky
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18
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Abstract
Multidisciplinary orthogeriatric care can enhance prompt ED diagnosis, optimal pre- and postoperative care, and functional recovery in older adults with bony injuries. Emergency care providers should be cognizant of prevalent geriatric syndromes including delirium and standing level falls to minimize fracture-related morbidity. Recognizing the implications of aging physiology, acute care physicians should be aware of effective alternatives to analgesia, procedural sedation, and definitive imaging to promote early surgical management and postoperative recovery.
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Affiliation(s)
- Christopher R Carpenter
- Division of Emergency Medicine, Barnes Jewish Hospital, Washington University in St Louis, Campus Box 8072, 660 South Euclid Avenue, St Louis, MO 63110, USA.
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