The development of a palliative care program for managed care patients: a case example

Palliative care is emerging as an important new field. Although programs are developing in hospital environments, little is known about development of programs in outpatient practices or those serving large managed care populations. This article provides a framework for the development of a comprehensive palliative care program in a large multispecialty group practice that serves managed care patients. The article addresses guiding principles, the need for obtaining baseline data, how the clinical consultation service was established, development of outcomes measures, and information on current program status. Five themes emerged as key to successful program development, most importantly the close collaboration between administrative and clinical staff in all aspects of program development.     

Referral rates of patients with diabetes to secondary care are inversely related to the prevalence of diabetes in each primary care practice and confidence in treatment,not to HbA1c level

AimsTo determine the factors affecting the referral rates of patients with diabetes from primary care to secondary care.MethodsA study based on 66 GP surgeries in the Cardiff and Vale University Health Board (population: 515,581) was conducted. We included patients who had an established clinical diagnosis of diabetes (type 1 and type 2) from September 2017 to September 2018.HbA1c outcome data of GP surgeries were obtained from the Quality and Outcomes Framework (QOF) database published for 2018. Referral rates were obtained from the electronic referral database of Cardiff and Vale University Health Board over the same period, and this was adjusted according to the number of patients with diabetes in each GP surgery. Confidence level on the treatment of diabetes among GPs was assessed as a sub-study conducted in nine GP surgeries in the same area, using a self-administered questionnaire. Linear regression was undertaken to assess the relationship between adjusted referral rate and key factors which might influence prescribing rate.ResultsThe average adjusted referral rate to secondary care in one year was 4.23% of patients with diabetes in each GP surgery, with a wide variation of 1.24% to 16.28%. The average percentage of patients with diabetes with HbA1c < 59 mmol/mol was 63.17% (range: 43.19–76.23%). The average confidence score of GPs in treating diabetes was 67% and ranged from 50–85% in the sub-study. Referral rates correlated inversely with the numbers of patients with diabetes in each practice β = ?0.32; (95% CI ?0.57, ?0.08) p = 0.01, but there was no significant correlation with the HbA1c outcome β = ?0.13; (95% CI ?0.39, 0.12); p = 0.30. Borderline significant negative correlation was observed between referral rates and overall practice size β = ?0.23; (95% CI ?0.48, 0.02) p = 0.07.ConclusionsReferral rates of patients with diabetes to secondary care are determined by the number of patients with diabetes in each practice and confidence level in treatment, not by the overall practice size or HbA1c level. Ensuring quality training in diabetes care for primary care teams as well as the development of integrated diabetes care may be the best way to optimise the volume and appropriateness of referrals to secondary care.     

Medical healthcare utilization as related to long-term care at home or in special accommodation

This study aimed to investigate medical healthcare utilization 3-5 years following the decision about long-term care at home vs. in special accommodation in older people. A total of 1079 people who were granted long-term care the years 2001, 2002 or 2003 were studied regarding the number of hospital stays and the number of contacts with physicians in outpatient care in the 3-5 subsequent years. Those living at home and those in special accommodation were compared regarding medical healthcare utilization during the 3-5 subsequent years. Data were collected through the study Good Aging in Skåne (GAS) and through the registers, Patient Administrative Support in Skåne (PASiS) and PrivaStat. Utilization of medical healthcare decreased slightly in the years following the decision about long-term care. Despite younger age and less dependency in activities of daily living (ADL), those living at home utilized hospital and outpatient care to a greater extent than those in special accommodation; these differences remained over time. Thus, it seems as long-term care needs to become more effective in the prevention of medical healthcare utilization among those cared for at home. More, older people who are granted long-term care at home may otherwise imply increased utilization of medical healthcare.     

Person‐Centered Care: A Definition and Essential Elements

Improving healthcare safety, quality, and coordination, as well as quality of life, are important aims of caring for older adults with multiple chronic conditions and/or functional limitations. Person‐centered care is an approach to meeting these aims, but there are no standardized, agreed‐upon parameters for delivering such care. The SCAN Foundation charged a team from the American Geriatrics Society (AGS) in collaboration with a research and clinical team from the Keck School of Medicine of the University of Southern California to provide the evidence base to support a definition of person‐centered care and its essential elements. An interprofessional panel of experts in person‐centered care principles and practices that the AGS convened developed this statement.     

A 2020 vision of patient-centered primary care

Patient-centered care has received new prominence with its inclusion by the Institute of Medicine as 1 of the 6 aims of quality. Seven attributes of patient-centered primary care are proposed here to improve this dimension of care: access to care, patient engagement in care, information systems, care coordination, integrated and comprehensive team care, patient-centered care surveys, and publicly available information. The Commonwealth Fund 2003 National Survey of Physicians and Quality of Care finds that one fourth of primary care physicians currently incorporate these various patient-centered attributes in their practices. To bring about marked improvement will require a new system of primary care payment that blends monthly patient panel fees with traditional fee-for-service payment, and new incentives for patient-centered care performance. A major effort to test this concept, develop a business case, provide technical assistance and training, and diffuse best practices is needed to transform American health care.     

Residential care/assisted living staff may detect undiagnosed dementia using the minimum data set cognition scale

OBJECTIVES: To estimate the sensitivity, specificity, and reliability of the Minimum Data Set Cognition Scale (MDS-COGS) in screening for undetected dementia when completed by direct care staff in residential care/assisted living (RC/AL) facilities and secondarily to determine the prevalence of dementia in the sample. DESIGN: A cross-sectional study in which staff were trained to complete the MDS-COGS. Research interviewers and a neuropsychologist obtained information on each participant. Two neurologists reviewed the data and examined the participant, rendering a probable diagnosis of dementia/non-dementia diagnosis. MDS-COGS results were compared with the neurologists' determination. SETTING: Fourteen RC/AL facilities in North Carolina. PARTICIPANTS: Data were collected from 50 staff on 166 residents without a diagnosis of dementia. MEASUREMENTS: In addition to the MDS-COGS, measures included a comprehensive neuropsychological battery. Depression and other neuropsychiatric symptoms were also assessed. RESULTS: Neurologists determined that 38% of participants had probable dementia. An MDS-COGS cutpoint of 2 was highly specific (0.97) but not very sensitive (0.49) for dementia. Test-retest and interrater agreement for a negative screen were high (88% and 93%, respectively). CONCLUSION: The MDS-COGS is a simple, brief screen that RC/AL staff can complete. It will identify with high specificity a subset of residents with undetected dementia, allowing rapid identification of those likely to need dementia care. Caution needs to be exercised in light of its low sensitivity, because some with milder dementia will not be detected. Further work is needed to determine whether staff can and will use the MDS-COGS as a trigger for more-thorough assessment and to guide care and improve outcomes.     

An update on the pilot trial of consumer‐directed care for older persons in Australia

The Australian Government has commenced a two‐year pilot of consumer‐directed care (CDC) across 500 home and community aged care packages. This policy paper discusses the model being trialled in Australia in light of the UK's Individual Budgets' Pilot Programme and the USA's Cash and Counselling Demonstration. The results of these randomised controlled studies suggest that older people vary in their preferences for consumer direction and that many find the administrative tasks of implementing CDC programs difficult. The relatively restricted model of CDC that the Australian Government is trialling may minimise the problems encountered in the overseas programs, but does not allow consumers to hire family or friends which they preferred to do overseas.     

Primary care and receipt of preventive services

OBJECTIVE: To examine whether health insurance, a regular place of care, and optimal primary care are independently associated with receiving preventive care services. DESIGN: A cross-sectional telephone survey. SETTING: Population based. PARTICIPANTS: Probability sample of 3,846 English-speaking and Spanish-speaking women between the ages of 18 and 64 in urban California. INTERVENTIONS: Women were asked about their demographic characteristics, financial status, health insurance status, need for ongoing care, regular place of care, and receipt of blood pressure screening, clinical breast examinations, mammograms, and Pap smears. Women who reported a regular place of care were asked about four components of primary care: availability, continuity, comprehensiveness, and communication. MEASUREMENTS AND MAIN RESULTS: In multivariate analyses that controlled for differences in demographics, financial status, and need for ongoing care, having a regular place of care was the most important factor associated with receiving preventive care services (p<.0001). Having health insurance (p<.001) and receiving optimal primary care from the regular place of care (p<.01) further significantly increased the likelihood of receiving preventive care services. CONCLUSION: A regular source of care is the single most important factor associated with the receipt of preventive services, but optimal primary care from a regular place increases the likelihood that women will receive preventive care. Supported by Robert Wood Johnson Foundation grant 22907 and Agency for Health Care Policy Research (AHCPR) grant HSO7373. Dr. Bindman and Dr. Grumbach are Robert Wood Johnson Foundation Generalist Physician Faculty Scholars.     

临终关怀与和缓医疗

临终关怀与和缓医疗是以预期生命有限的患者及其家庭成员为中心,通过预测、预防和治疗患者的病痛,改善其生活质量.主要内容是对症状进行评估和处理、控制疼痛、进行家庭护理、减轻或消除患者的心理负担和消极情绪,帮助临终患者以舒适和有尊严的方式度过最后的时光.临终关怀不同于安乐死,即不促进也不延缓患者的死亡,而是贯穿于疾病治疗始终,重视患者生理、智力、情感、社会及精神需求,帮助患者保持自主性、获取信息并自主选择.和缓医疗是现代医学领域中新的边缘交叉性学科,是人口老龄化的需求和人类文明发展的标志;和缓医疗需要一个多学科的团队,需要良好的沟通技巧和专业技能.     

Hospice usage by minorities in the last year of life: results from the National Mortality Followback Survey

OBJECTIVES: To examine racial/ethnic variations in rates of hospice use in a national cohort and to identify individual characteristics associated with hospice use. DESIGN: Secondary analysis of the 1993 National Mortality Followback Survey (NMFS), a nationally obtained sample using death certificates and interviews with relatives (proxy respondents) to provide mortality, social, and economic data and information about healthcare utilization in the last year of life for 23,000 deceased individuals. SETTING: Hospice care. PARTICIPANTS: Individuals aged 15 and older who died in 1993. Subjects were included in this analysis if they died of nontraumatic causes (N = 11,291). MEASUREMENTS: Hospice use was dichotomized by proxy responses indicating use or nonuse of home or inpatient hospice services. The percentage of individuals using hospice services in the last year of life was calculated. RESULTS: Unadjusted bivariate results found that African Americans were less likely to use hospice than whites (odds ratio (OR) = 0.59; P <.001) and that those without a living will (LW) (OR = 0.23; P <.001) and without a cancer diagnosis (OR = 0.28; P <.001) were less likely to use hospice. The negative relationship between African Americans and hospice use was unaffected when controlled for sex, education, marital status, existence of a LW, income, and access to health care. Logistic models revealed that presence of a LW diminished the negative relationship between African Americans and hospice use, but the latter remained significant (OR = 0.83; P =.033). A subanalysis of subjects aged 55 and older showed a significant interaction between access to care and race/ethnicity with respect to hospice use (P =.044). Inclusion of income in this multivariable logistic model attenuated the relationship between African-American race/ethnicity and hospice use (OR = 0.77), and the difference between whites and African Americans became only marginally statistically significant (P =.060). CONCLUSION: In the 1993 NMFS, hospice use was negatively associated with African-American race/ethnicity independent of income and access to healthcare. The relationship is not independent of age, insurance type, or history of stroke. For subjects aged 55 and older, access to healthcare may be an important confounder of the negative relationship between African-American race/ethnicity and hospice use. Consistent with previous studies, this analysis found that African Americans were less likely to use LWs than whites. The reduced importance of African-American race/ethnicity on hospice use with the inclusion of presence of a LW in logistic models suggests that similar cultural processes may shape differences between African Americans and whites in advance care planning and hospice use.