A systematic narrative review of consumer‐directed care for older people: implications for model development

Consumer‐directed care is increasingly becoming a mainstream option in community‐based aged care. However, a systematic review describing how the current evaluation research translates into practise has not been published to date. This review aimed to systematically establish an evidence base of user preferences for and satisfaction with services associated with consumer‐directed care programmes for older people. Twelve databases were searched, including MedLine, BioMed Central, Cinahl, Expanded Academic ASAP, PsychInfo, ProQuest, Age Line, Science Direct, Social Citation Index, Sociological Abstracts, Web of Science and the Cochrane Library. Google Scholar and Google were also searched. Eligible studies were those reporting on choice, user preferences and service satisfaction outcomes regarding a programme or model of home‐based care in the United States or United Kingdom. This systematic narrative review retrieved literature published from January 1992 to August 2011. A total of 277 references were identified. Of these 17 met the selection criteria and were reviewed. Findings indicate that older people report varying preferences for consumer‐directed care with some demonstrating limited interest. Clients and carers reported good service satisfaction. However, research comparing user preferences across countries or investigating how ecological factors shape user preferences has received limited attention. Policy‐makers and practitioners need to carefully consider the diverse contexts, needs and preferences of older adults in adopting consumer‐directed care approaches in community aged care. The review calls for the development of consumer‐directed care programmes offering a broad range of options that allow for personalisation and greater control over services without necessarily transferring the responsibility for administrative responsibilities to service users. Review findings suggest that consumer‐directed care approaches have the potential to empower older people.     

A Quality of Care Framework for Home-Based Medical Care

More than 6 million adults in the United States are homebound or semi-homebound and would benefit from home-based medical care (HBMC). There is currently no nationally recognized quality of care framework for home-based medical care. We sought to capture diverse stakeholder perspectives on the essential aspects of quality HBMC and create a quality of care framework for homebound adults. A qualitative analysis of semistructured interviews from purposive sampling of key HBMC stakeholders was performed. Leaders from 12 exemplar HBMC practices (clinicians and administrators), advocacy groups (American Association of Retired Persons, National Partnership for Women and Families, Kaiser Family Foundation), and representatives from 3 key professional medical societies associated with HBMC participated in phone interviews. Semistructured interviews were based on domains of quality developed by the National Quality Forum (NQF) for individuals with multiple chronic conditions. We identified 3 categories of quality HBMC: provider and practice activities; provider characteristics; and outcomes for patients, caregivers, and providers. Within these 3 categories, we identified 10 domains and 49 standards for quality HBMC. These included 3 new domains (comprehensive assessment, patient/caregiver education, and provider competency) as well as specification and adaptation of the NQF Framework for Multiple Chronic Conditions domains for HBMC. Notably, several quality domains emanating from the NQF Framework for Multiple Chronic Conditions (transitions, access, and patient/caregiver engagement) were applicable to HBMC. This quality of care framework serves as a guide for HBMC practices seeking to improve their care quality and as a starting point for health systems and payers to ensure value from HBMC practices with whom they work.     

英国整合型保健发展经验及启示

通过现场观察与深度访谈的定性研究方法,总结了英格兰NHS整合型保健的做法和经验,并针对我国卫生服务体系存在的碎片化问题,提出了相关的政策建议:大力发展初级卫生保健和社区卫生服务,加强以全科医生为核心的多学科服务团队建设,建立全科医生"守门人"制度,建立相关政府部门间的沟通协作机制,在社区层面横向整合多方社会服务资源等。     

The costs of care: An ethnography of care work in residential homes for older people

The cost of social care, the work conditions experienced by care workers and the quality of care provided by residential homes for older people are all linked, yet we know very little about how this relationship works in practice. Drawing upon an ethnography of two differently priced residential care homes for older people in Southern England, I examine the implications of different financial regimes for care-giving practices. I show how the scheduling and allocation of resources—conveyed, for example, in formal routines and staffing levels—structure the care workers’ time, tasks and activities in each setting. This acts to symbolically demarcate what, or who, is valued. I argue that the availability of resources facilitates and impedes the symbolic culture of care work, shapes care workers’ ability to afford dignity to the individuals in their care and affects how care workers experience, and relate to, their labour. I conclude by discussing how current practices of funding and pricing social care have effects seeping beyond the practical and measurable, and into the realm of the symbolic.     

Retention of Clients in Service Under Two Models of Home Health Care for HIV/AIDS

ABSTRACT

Objective: To determine if a Transprofessional, care-management approach (experimental group) produces different patterns of retention in home treatment as compared to a Traditional treatment approach (control group). The care-management approach utilizes an interdisciplinary mix of allied health professionals who adhere to a service delivery protocol based on active medical, surgical treatment (curative services) as well as on pain, symptoms, and emotional care (palliative services). Initially, the Transprofessional Model should lead to a greater retention rate in the program as patients bond to blended care managers, but in later stages clients needing hospice should be moved off-services resulting in lower retention rates in the medical-surgical home care venue.

Data Sources and Study Setting: Data were collected from 549 AIDS patients admitted for medical/surgical home-care services to the Visiting Nurse Association of Los Angeles (VNA-LA). Demographic and disease-specific data were collected from admitting records; service-utilization data were collected from the VNA-LA's computerized data system.

Study Design: Upon admission for home-care services, patients were randomly assigned to an experimental (Transprofessional) or control (Traditional) treatment group. Service levels were comparable.

Primary Finding: In the earliest stages, Transprofessional patients tend to be more likely to stay in treatment, probably due to the greater bonding to the program. After about one year, the Transprofessional patients are more likely to leave the program as they are transitioned into hospice care.

Conclusions: An integrated model of service delivery, which is based on interdisciplinary care-management and blended modalities of service, provides a quality of life enhancing and a cost-effective method in the provision of home-care services for terminally ill AIDS patients.     

The demand for private health care in the UK

Policy change has eroded the entitlement of UK residents to free state-provided health care, with a resulting rise in the use of the private sector. This paper examines the choice between public and private health care. It models the use of private health care as a function of its costs and benefits relative to state care and no care. The results indicate a difference between users of private care and other care, and the importance of past use as a predictor of current use. But they also show considerable movement between the public and private sectors, indicating a complex relationship in public and private sector use.     

Occupational health services for farmers

There are many unmet health needs in the farming community, needs that are peculiar to the agriculture industry. Health research and regulations to protect the safety of the farmer have lagged far behind those for other sectors of our economy. At a time when health needs are increasing, there is a decreasing availability of hospitals, physicians, nurses, and other health care personnel. The ability of the rural section to pay for these services is also declining. The evidence calls for a multifaceted solution, with improved cooperation and understanding on the part of the consumer as well as the provider. The regional health network is one system that may help solve some of these dilemmas.     

Mealtimes in Nursing Homes: Striving for Person-Centered Care

Malnutrition is a common and serious problem in nursing homes. Dietary strategies need to be augmented by person-centered mealtime care practices to address this complex issue. This review will focus on literature from the past two decades on mealtime experiences and feeding assistance in nursing homes. The purpose is to examine how mealtime care practices can be made more person-centered. It will first look at several issues that appear to underlie quality of care at mealtimes. Then four themes or elements related to person-centered care principles that emerge within the mealtime literature will be considered: providing choices and preferences, supporting independence, showing respect, and promoting social interactions. A few examples of multifaceted mealtime interventions that illustrate person-centered approaches will be described. Finally, ways to support nursing home staff to provide person-centered mealtime care will be discussed. Education and training interventions for direct care workers should be developed and evaluated to improve implementation of person-centered mealtime care practices. Appropriate staffing levels and supervision are also needed to support staff, and this may require creative solutions in the face of current constraints in health care.     

老年居家卫生服务模型研究

目的：改善老年人的健康状况、提高其卫生服务可及性。方法：采用了专家研讨会和概念建模的方法。结果：老年卫生服务的目标是实现其健康老龄化和积极老龄化，途径是为他们提供连续的、全方位的、没有灰色带的、能够提高他们独立生活能力的综合性服务。老年居家卫生服务模型主要包括4个微观系统领域：自我管理支持、决策支持、递送系统设计和临床信息系统；服务内容包括初级卫生保健服务和社会服务两部分。结论：居家卫生服务对于提高老年人卫生服务可及性、提高其独立生活能力、改善其健康状况具有很强针对性。     

Recommendations to Deliver Person-Centered Long-Term Care for Persons Living With Dementia

Person-centered care (PCC) is the standard for the delivery of long-term services and supports (LTSS). In this article, we summarize the state of the science on meaningful outcomes and workforce development and discuss what is needed to ensure that person-centered LTSS becomes a universal reality. These 2 themes are intimately related: the dementia care workforce's capacity cannot be improved until care processes and outcomes that are significant to PCC are explicated. The LTSS workforce needs training in PCC as well as pragmatic measures to assess the quality of the care they provide. We conclude with several recommendations for future policy and practice-oriented workforce research.     

临终肿瘤病人心理护理研究现状

肿瘤病人临终和死亡问题越来越受到人们的关注,优终和优逝成为生命质量提高的一种重要体现。本文阐述了肿瘤病人临终阶段的心理特点,临终心理护理的意义,归纳了肿瘤临终病人心理变化的影响因素及该类病人心理的护理干预措施,以期为开展适合我国国情的临终护理工作提供参考。     

Evaluation of an educational program for long-term care nursing assistants

OBJECTIVES: To determine if an educational program can improve knowledge and attitude among ancillary staff on end-of-life care issues in a long-term care facility. DESIGN: A pilot study using a pre- and post-test design prior to and at the completion of an education intervention. SETTING: A long-term care facility in suburban Philadelphia that has 150 assisted living beds and 53 nursing home beds. PARTICIPANTS: Long-term care ancillary staff including certified nursing assistants (called "care managers" at this facility), social workers, recreational therapists, and food service workers. INTERVENTION: The intervention was a novel educational program consisting of five in-service lectures with accompanying take home self-study modules for ancillary staff in long-term care entitled "Dignity in Dementia." MEASUREMENTS: Ancillary staff attitudes and knowledge on end-of-life issues in dementia were assessed with a knowledge and attitude questionnaire pre- and post-intervention. One-year follow-up questionnaires were administered to assess long-term maintenance of knowledge and attitude changes. RESULTS: Thirty-two ancillary staff completed the pre-intervention questionnaires. Twenty-nine ancillary staff completed the post-intervention questionnaires (90.6%). There was a significant change in the end-of-life knowledge level of the ancillary staff (P =.0270). Specifically, there was a significant change in one question dealing with dementia as a terminal disease (P = .006). There were also significant changes in the average attitude scores of the ancillary staff. (P = .0242). One-year follow-up revealed that both knowledge and attitude changes were maintained. CONCLUSIONS: This pilot project demonstrates that a staff educational program on end-of-life care for dementia residents can improve end-of-life knowledge and attitudes among long-term care ancillary staff and that this improvement can be maintained for up to 1 year. This intervention is easily reproducible in the long-term care setting. This project is an important step in helping improve end-of-life care for dementia residents in long-term care settings by improving the knowledge and attitudes of their caregivers.     

Care management for depression in primary care practice: findings from the RESPECT-Depression trial

PURPOSE This qualitative study examined the barriers to adopting depression care management among 42 primary care clinicians in 30 practices.METHODS The RESPECT-Depression trial worked collaboratively with 5 large health care organizations (and 60 primary care practices) to implement and disseminate an evidence-based intervention. This study used semistructured interviews with 42 primary care clinicians from 30 practice sites, 18 care managers, and 7 mental health professionals to explore experience and perceptions with depression care management for patients. Subject selection in 4 waves of interviews was driven by themes emerging from ongoing data analysis.RESULTS Primary care clinicians reported broad appreciation of the benefits of depression care management for their patients. Lack of reimbursement and the competing demands of primary care were often cited as barriers. These clinicians at many levels of initial enthusiasm for care management increased their enthusiasm after experiencing care management through the project. Psychiatric oversight of the care manager with suggestions for the clinicians was widely seen as important and appropriate by clinicians, care managers, and psychiatrists. Clinicians and care managers emphasized the importance of establishing effective communication among themselves, as well as maintaining a consistent and continuous relationship with the patients. The clinicians were selective in which patients they referred for care management, and there was wide variation in opinion about which patients were optimal candidates. Care managers were able to operate both from within a practice and more centrally when specific attention was given to negotiating communication strategies with a clinician.CONCLUSIONS Care management for depression is an attractive option for most primary care clinicians. Lack of reimbursement remains the single greatest obstacle to more widespread adoption.     

Comprehensive care: building community alliances for care of people with HIV/AIDS

In this article we suggest that optimal care for people livingwith HIV/AIDS calls for a multidisciplinary and multisectoralapproach, which can be achieved with cooperation between thestatutory and non-statutory service systems. AIDS has both directlyand indirectly focused attention on the limitations of the servicesavailable in our communities, including those provided by theprimary and secondary health sector. However, non-statutorycommunity-based organizations have been providing vital servicesof information, counselling and care, relying on a steady streamof unpaid labour. Community control over its health care systemand environment should be encouraged and local authorities shouldacknowledge the resources provided by non-statutory bodies,supporting such groups both morally and financially. Using theHealthy Cities project network as a framework, we recommendestablishing working relationships to enhance service integration.The creation of service alliances is intended to facilitatecontinuity of care by establishing links within local governmentagencies, and the priority of the alliance should be to developa realistic, comprehensive service plan involving all interestedparties.     

Catastrophic risk associated with out-of-pocket payments for long term care in Spain

ObjectivesThis study analyses the financial burden associated with the introduction of copayment for long-term care (LTC) in Spain in 2012 for dependent individuals.Material and methodsWe analyse and identify households for which the dependency-related out-of-pocket payment exceeds the defined catastrophic threshold (incidence), and the gap between the copayment and the threshold for the catastrophic copayment (intensity), for the full population sample and for subsamples based on the level of long-term care dependency and on regional characteristics (regional income and political ideology of party ruling the region).ResultsThe results obtained show there is a higher risk of impoverishment due to copayment among relatively well-off dependents, although the financial burden falls more heavily on less well-off households. Our findings also reveal interesting regional patterns of inequity in financing and access to long-term care services, which appear to be explained by an uneven development of LTC services (monetary transfers versus formal services) and varying levels of copayment across regions.ConclusionsThe new copayment for long-term care dependency in Spain is an important factor of catastrophic risk, and more attention should be addressed to policies aimed at improving the progressivity of out-of-pocket payments for LTC services within and between regions. In addition, formal services should be prioritised in all regions in order to guarantee equal access for equal need.     

建立老年护理保险制度初探

人口老龄化使越来越多的老年人需要接受长期的护理服务,而传统家庭护理功能正逐渐削弱,老年人护理费用给家庭造成沉重负担,迫切需要建立老年护理保险制度。本文通过借鉴国外老年护理保险制度实施的经验,提出建立适合我国国情的老年护理保险制度的政策建议。     

The health centre as a location for care management

This paper examines the case for locating care management in health centres. Two related arguments are advanced. It is argued, firstly, that the close association between the health and social needs of dependent groups makes a multidisciplinary approach to community care essential. Secondly, it is suggested that the coordination of health and social care provision and the achievement of a seamless service would be achieved most readily in a setting which combined all of the main health and social care providers in one location. Other advantages include the potential contribution of general practitioners as case finders under the terms of the new GP contract and the fact that the introduction of care management to health centres would facilitate the mounting of experiments with different models of care management, particularly those involving a multiple worker approach.     

Self‐directed community services for older Australians: a stepped capacity‐building approach

Consumer‐directed care (CDC) is increasingly widespread among aged care service options in Organisation for Economic Co‐operation and Development (OECD) countries. However, the evidence base regarding the programmatic and contextual factors that affect the outcome of CDC interventions is surprisingly small. This paper reports on a self‐directed care approach for older Australians with complex care needs. A multi‐methods longitudinal comparative cohort study was employed comprising 4 survey tools and 56 semi‐structured interviews. Participation rates were around 20%. A total of 185 (98 in the intervention and 87 in the control group) older people and carers were recruited at baseline. Eleven months later, 109 participants (59 in the intervention and 50 in the control group) completed the repeat measure. Attrition rates were around 40%. Data collection occurred between July 2010 and April 2012. The data suggest that intervention group participants were likely to be more satisfied with the way they were treated (P = 0.013), their care options (P = 0.014), the ‘say’ they had in their care (P < 0.001), the information they received regarding their care (P = 0.012), what they were achieving in life (P = 0.031), that the services changed their view on what could be achieved in life (P = 0.020) and with their standard of living (P = 0.008). The evaluation suggests that while only a very small segment of older people is interested in a voucher or cash option, a substantially larger group would like to have greater say over and more direct access to their care, without, however, assuming administrative and financial responsibilities. The paper concludes that a stepped capacity‐building approach to CDC may improve the acceptability of CDC to older people and generate synergies that improve older people's care outcomes.