Transitional care of the long-term care patient

This article reviews the literature on transitional care to and from the LTC environment, highlighting strategies to improve the quality of care transitions. Several factors are vital in the improvement of systems of care dealing with transitions. Key factors include communication with and among health care providers, effective medication reconciliation, advanced discharge planning, and timely use of palliative care.     

Managed long-term care: care integration through care coordination

The New York State managed long-term care demonstration program combines traditional home, community, and institutional long-term care services with other benefits integral to maximizing overall well-being for a frail elderly population. A distinguishing feature of the model is the responsibility to coordinate both covered and noncovered services. This article, a case study of VNS CHOICE, a managed long-term care plan that serves 2,500 New York City residents, describes the program's operating structure, service delivery model, and care management strategies. By providing a capitated Medicaid long-term care benefit, VNS CHOICE can utilize a broad array of services, offer significant flexibility to care management staff, and support member and family involvement in care planning. Its broad care coordination responsibility allows it to achieve integrated care without integrated financing.     

Quality of care: do we care?

The quality of U.S. health care must improve. Practicing physicians need to become involved in generating new knowledge about what does and does not work in medical practice. Physicians might, for example, participate in building national databases on chronic and acute conditions using data from their patients or might help to enroll patients in cohort studies or experimental trials. Furthermore, our knowledge is now sufficient to support a substantial investment of funds in improving what physicians now do in medical practice and in developing publicly available standards of medical practice. Such standards or guidelines could be used by both physicians and patients as part of an explicit process to assess the medical appropriateness of expensive or dangerous procedures before they are done. In addition, the competence with which care is delivered also needs to be measured. Both of these assessments should be used prospectively by physicians to help patients choose the referral source that will maximize their preferences.     

Comparative costs of home care and residential care

PURPOSE: This paper reports on Canadian research that examined the cost effectiveness of home care for seniors as a substitute for long-term institutional services. DESIGN AND METHODS: Two Canadian cities were included in the research: Victoria, British Columbia, and Winnipeg, Manitoba. The research computes the costs of formal care and informal care in both settings and ensures comparable groups of clients in both settings by comparing individuals at the same level of care. RESULTS: The results reveal that costs were significantly lower for community clients than for facility clients, regardless of whether costs only to the government were taken into account or whether both formal and informal costs were taken into account. When informal caregiver time is valued at either minimum wage or replacement wage, there was a substantial jump in the average annual costs for both community and facility clients relative to when informal caregiver time was valued at zero. IMPLICATIONS: Nevertheless, the results reveal that home care is significantly less costly than residential care even when informal caregiver time is valued at replacement wage.     

Advance care planning in residential care

Abstract Background : To provide optimal care for our ageing population, some form of advance care planning (ACP) is essential. Overseas data suggest that the process of ACP and the use of advance care directives (ACD) is suboptimal in residential care institutions. By comparison there are few Australian data.
Aim : To study the process of ACP and the prevalence of ACD in residential care.
Methods : Cross-sectional study using a questionnaire in the Hunter area, NSW, Australia.
Results : Very low levels of formal advance directives were found (available for only 0.2%). Only 1.1% of residents had no-CPR' orders documented in the medical record, while 5.6% had a formal guardian and 2.8% had an enduring guardian.
Informal processes of advance planning were much more prevalent. Sixty-five per cent had a `person responsible' recorded to make decisions for them while in 13% of cases, there was `staff consensus' as to the optimal care for the patient. However, in 10.6% there was no clear process for medical decision making identified.
Conclusions : Advanced directives are infrequently used in residential care. Further qualitative and quantitative studies are warranted to explore current processes of decision making.     

Survey of primary care physicians and home care clinicians

CONTEXT: Providing home care in the United States is expensive, and significant geographic variation exists in the utilization of these services. However, few data exist on how well physicians and home care providers communicate and coordinate care for patients. OBJECTIVE: To assess communication and collaboration between primary care physicians (PCPs) and home care clinicians (HCCs) within 1 primary care network. DESIGN: Mail survey. SETTING: Boston. PARTICIPANTS: Sixty-seven PCPs from 1 academic medical center-affiliated primary care network and 820 HCCs from 8 regional home care agencies. MEASUREMENTS: Provider responses RESULTS: Ninety percent of PCPs and 63% of HCCs responded. The majority (54%) of PCPs reported that they only "rarely" or "occasionally" read carefully the home care order forms sent to them for signature. Further, when asked to rate their prospective involvement in the decision making about home care, only 24% of PCPs and 25% of HCCs rated this as "excellent" or "very good." Although more HCCs (79%) than PCPs (47%) reported overall satisfaction with communication and collaboration, 28% of HCCs felt they provided more services to patients than clinically necessary. CONCLUSIONS: PCPs from 1 provider network and the HCCs with whom they coordinate home care were both dissatisfied with many aspects of communication and collaboration regarding home care services. Moreover, neither group felt in control of home care decision making. These findings are of concern because poor coordination of home care may adversely affect quality and contribute to inappropriate utilization of these services.     

Complications of care in a medical intensive care unit

Objective:To determine the frequency and nature of complications of care in the medical intensive care unit (MICU). Design:Prospective, observational study. Setting:Seven-bed MICU in a teaching and referral VA hospital. Patients:295 consecutive patients admitted to the MICU during a ten-month study period. Interventions:None. Measurements and main results:Forty-two patients (14%, 95% confidence interval 13%, 16%) experienced one or more complications during their MICU stays. Compared with other MICU patients, those experiencing complications tended to be older (mean age ± SD: 63.6±10.1 years vs 59.3±14.0 years, p<0.02) and more acutely ill (mean Acute Physiology Score ± SD: 18.3±8.0 vs 12.5±8.0, p=0.0001). These patients also had significantly longer MICU lengths of stay (mean ± SD: 12.3±14.7 days vs 3.1±4 days, p<0.0001) and higher hospital mortality rates (67% vs 27%, p<0.001). The 67% mortality rate among patients with complications significantly exceeded the expected mortality rate of 46% (calculated from the APACHE risk equation). Conclusion:Complications of care in the MICU are not rare and may independently contribute to in-hospital mortality. The potential for complications must be recognized when considering ICU care.     

Standards of palliative care in a renal care setting

Palliative care has been described as the active total care of patients whose disease is not responsive to curative treatment. The principles of palliative care are applicable to patients living with non-malignant disease such as end stage renal failure. This paper describes the development of standards of palliative care in a renal care setting. It emphasises the need for a multidisciplinary basis for palliative care and specifies standards of practice in six core areas: Assessment and Referral, Pain and Symptom Control, Communication and giving information, Sexuality, Spirituality and Bereavement.     

Survey of primary care physicians and home care clinicians

CONTEXT: Providing home care in the United States is expensive, and significant geographic variation exists in the utilization of these services. However, few data exist on how well physicians and home care providers communicate and coordinate care for patients. OBJECTIVE: To assess communication and collaboration between primary care physicians (PCPs) and home care clinicians (HCCs) within 1 primary care network.