Home care program for patients at high risk of hospitalization

Objective: To assess the efficacy of a home care program designed to improve access to medical care for older adults with multiple chronic conditions who are at risk for hospitalization. Study Design: Randomized controlled trial in which participants were assigned to the home care intervention (Choices for Healthy Aging [CHA]) program or usual care. Methods: The intervention group consisted of 298 older adults at risk of hospitalization as determined by a risk stratification tool. Measures included satisfaction with medical care, medical service use, and costs of medical care. Results: The intervention group reported significantly greater satisfaction with care than usual care recipients (t test = 2.476; P = .014). CHA patients were less likely than usual care patients to be admitted to the hospital (25.6% and 37.1%, respectively; P = .02). There were no differences in terms of costs of care between the home care and usual care groups. Conclusions: Provision of home care to older adults at high risk of hospitalization may improve satisfaction with care while reducing hospitalizations. Lack of difference in medical costs suggests that managed care organizations need to consider targeting rather than using risk stratification measures when designing programs for high-risk groups.     

Acute care for elders units produced shorter hospital stays at lower cost while maintaining patients' functional status

Acute Care for Elders Units offer enhanced care for older adults in specially designed hospital units. The care is delivered by interdisciplinary teams, which can include geriatricians, advanced practice nurses, social workers, pharmacists, and physical therapists. In a randomized controlled trial of 1,632 elderly patients, length-of-stay was significantly shorter-6.7 days per patient versus 7.3 days per patient-among those receiving care in the Acute Care for Elders Unit compared to usual care. This difference produced lower total inpatient costs-$9,477 per patient versus $10,451 per patient-while maintaining patients' functional abilities and not increasing hospital readmission rates. The practices of Acute Care for Elders Units, and the principles they embody, can provide hospitals with effective strategies for lowering costs while preserving quality of care for hospitalized elders.     

Variations in the quality of care of patients with acute myocardial infarction among Swiss university hospitals.

OBJECTIVE: The objective of our study was to assess hospital variations in the quality of care delivered to acute myocardial infarction (AMI) patients among three Swiss academic medical centres. DESIGN: Cross-sectional study. SETTING: Three Swiss university hospitals. STUDY PARTICIPANTS: We selected 1129 eligible patients discharged from these hospitals from 1 January to 31 December 1999, with a primary or secondary diagnosis code [International Classification of Diseases, 10th revision (ICD-10)] of AMI. We abstracted medical records for information on demographic characteristics, risk factors, symptoms, and findings at admission. We also recorded the main ECG and laboratory findings, as well as hospital and discharge management and treatment. We excluded patients transferred to another hospital and who did not meet the clinical definition of AMI. MAIN OUTCOME MEASURES: Percentage of patients receiving appropriate intervention as defined by six quality of care indicators derived from clinical practical guidelines. RESULTS: Among 577 eligible patients with AMI in this study, the mean (SD) age was 68.2 (13.9), and 65% were male. In the assessment of the quality indicators we excluded patients who were not eligible for the procedure. Among cohorts of 'ideal candidates' for specific interventions, 64% in hospital A and 73% in hospital C had reperfusion within 12 hours either with thrombolytics or percutaneous transluminal coronary angioplasty (P = 0.367). Further, in hospitals A, B, and C, respectively 97, 94, and 84% were prescribed aspirin during the initial hospitalization (P = 0.0002), and respectively 68, 91, and 75% received angiotensin converting enzyme inhibitors at discharge in the case of left ventricular systolic dysfunction (P = 0.003). CONCLUSIONS: Our results showed important hospital-to-hospital variations in the quality of care provided to patients with AMI between these three university hospitals.     

Quality of Care for Acute Myocardial Infarction in Rural and Urban US Hospitals

CONTEXT: Acute myocardial infarction (AMI) is a common and important cause of admission to US rural hospitals, as transport of patients with AMI to urban settings can result in unacceptable delays in care. PURPOSE: To examine the quality of care for patients with AMI in rural hospitals with differing degrees of remoteness from urban centers. METHODS: This cohort study used data from the Cooperative Cardiovascular Project (CCP), including 4,085 acute care hospitals (408 remote small rural, 893 small rural, 619 large rural, and 2,165 urban) with 135,759 direct admissions of Medicare beneficiaries ages 65 and older for a confirmed AMI between February 1994 and July 1995. Outcomes included use of aspirin, reperfusion, heparin, and intravenous nitroglycerin during hospitalization; use of beta-blockers, aspirin, and angiotensin-converting enzyme (ACE) inhibitors at discharge; avoidance of calcium channel blockers at discharge; and 30-day mortality. FINDINGS: Substantial proportions of Medicare beneficiaries in both urban and rural hospitals did not receive the recommended treatments for AMI. Medicare patients in rural hospitals were less likely than urban hospitals' patients to receive aspirin, intravenous nitroglycerin, heparin, and either thrombolytics or percutaneous transluminal coronary angioplasty. Only ACE inhibitors at discharge was used more for patients in rural hospitals than urban hospitals. Medicare patients in rural hospitals had higher adjusted 30-day post-AMI death rates from all causes than those in urban hospitals (odds ratio for large rural 1.14 [1.10 to 1.18], small rural 1.24 [1.20 to 1.29], remote small rural 1.32 [1.23 to 1.41]). CONCLUSIONS: Efforts are needed to help hospital medical staffs in both rural and urban areas develop systems to ensure that patients receive recommended treatments for AMI.     

Role of long-term acute care in reducing hospital readmission

Long-term acute care hospitals (LTACs) are health care facilities capable of admitting complex patients with high acuity that are unable to return home after hospitalization in acute care. Its defining characteristic is to accommodate patients for a length of stay greater than 25 days, however, little is known about its role of preventing hospital readmissions. Created in the 1980s, these facilities were designed to help acute care facilities improve their resource management, expenditures, and quality of care. Although these units were initially created for chronic ventilator weaning, their scope of practice has broadened. This article analyzes studies and suggests role of LTACs in reducing hospital readmissions.     

Cognitive Function Improvements Mediate Exercise Intervention Effects on Physical Performance in Acutely Hospitalized Older Adults

ObjectivesAn individualized, multicomponent exercise program is effective to reverse the functional and cognitive decline that frequently occur during acute care hospitalization in older patients. The aim was to determine whether improvements in cognition mediate improvements in physical function in acutely hospitalized older patients.DesignA single-center, single-blind randomized clinical trial.Setting and ParticipantsAcute care for elderly (ACE) unit in a tertiary public hospital in Navarre (Spain). Hospitalized patients were randomly assigned to an exercise intervention (n = 185) or usual-care group (n = 185). The intervention consisted of a multicomponent exercise-training program performed during 5 to 7 consecutive days (2 sessions/day). The usual-care group received habitual hospital care, which included physical rehabilitation when needed.MeasuresThe main endpoints were changes in cognitive function assessed by the Mini-Mental State Examination test and verbal fluency ability, and changes in physical performance by the Short Physical Performance Battery from baseline to discharge. Mediation regression models were generated using ordinary least squares with the PROCESS version 3.2 to determine links between exercise-induced improvements.ResultsMediation regression model analysis indicated a significant and direct beneficial effect of physical exercise on physical function (β = 2.14; P < .0001), and a significant indirect effect of global cognitive function on the direct effect (indirect effect = 0.26; 0.10 to 0.49). Verbal fluency ability also had an indirect effect (0.32; 0.16 to 0.53) on the positive effect of exercise-training on physical function.Conclusions and ImplicationsCognitive function enhancements mediate physical function improvements in acutely hospitalized older adults after an individualized, multicomponent exercise-training program.ClinicalTrials.gov registration (NCT02300896)     

Description and outcomes of a Medicare case management program by nurses

During the current environment of cost-cutting and restructuring, case management is viewed as a means of providing comprehensive, coordinated care while reducing costs. Studies of community-based case management have been disappointing. This study evaluates a Medicare service, Management and Evaluation of the Care Plan (MAE), as a model of nurses providing case management in the home. Three groups were compared: MAE (N = 176), non-MAE (N = 187) and newly discharged (N = 93). Utilization data was collected over one year. Overall, subjects were unmarried older women with three functional limitations, four medical diagnoses and averaged 43 home care visits and one hospitalization. MAE patients were older, had more functional and environmental limitations, less ADL independence, and a worse prognosis, yet used significantly less health care than non-MAE recipients did. Regression analysis was performed using group membership and hospital and home care utilization as dependent variables. Although the project was conducted at one site, overall the sample was similar to the national Medicare population.     

Short-stay hospitalization of elderly persons: first step toward institutionalization?

One month outcome after hospitalization was studied in 1695 persons aged 75 and over, living in the community and admitted to acute care medical units: only 9.6% of them were then institutionalized. Returning home requires a high level of independence for feeding, mental status and continence. The level of dependence of institutionalized patients was particularly high for dressing or bathing, technical care, mental status and security. A multivariate analysis showed that the only independent predictors of institutionalization were: sex, living alone, mental status and hospital type. The role played by physical disability must be counterbalanced by the effective physical assistance, brought to the elderly by institutional or informal home care after hospitalization. These results allow early identification of persons at high risk of institutionalization.     

Impact of hospital discharge planning on meeting patient needs after returning home.

This study examines the contribution of hospital discharge planning in meeting the needs of patients for care after their return home. A random sample of 919 admissions (age 60 and over) to five hospitals was studied to obtain information on characteristics of discharge planning during the patients' hospital stay. Specifically, information was obtained on the involvement of a designated professional for managing and coordinating the discharge plan, and the extent to which the planning was interdisciplinary. Patient interviews conducted two weeks after discharge provided information on needs for care related to: (1) treatment, (2) activity limitations, and (3) other self-sufficiency limitations. Patients were asked about their need for care in these three areas and about whether or not these needs were being met. Overall, 97 percent reported one or more needs for care and 33 percent reported that at least one of these needs was not being met. Findings show that the involvement of a discharge planning case manager is related to a significant reduction in unmet treatment needs, but not to reductions in activity limitation, other self-sufficiency needs, or overall needs. No significant effects of interdisciplinary planning were identified. These findings suggest that treatment-related benefits result when a case manager has specific responsibility for the discharge planning of elderly patients returning home after hospitalization. These results provide insights into what is being achieved through current discharge planning practices. The meeting of specific patient needs through enhanced discharge planning may save future costs by reducing the rates of complications and hospital readmissions in an era of prospective payment, thus potentially offsetting the increased costs involved in planning and coordinating postdischarge care for older adults.     

Comprehensive Care Improves Physical Recovery of Hip-Fractured Elderly Taiwanese Patients With Poor Nutritional Status

ObjectivesThe effects of nutritional management among other intervention components have not been examined for hip-fractured elderly persons with poor nutritional status. Accordingly, this study explored the intervention effects of an in-home program using a comprehensive care model that included a nutrition-management component on recovery of hip-fractured older persons with poor nutritional status at hospital discharge.DesignA secondary analysis of data from a randomized controlled trial with 24-month follow-up.SettingA 3000-bed medical center in northern Taiwan.ParticipantsSubjects were included only if they had “poor nutritional status” at hospital discharge, including those at risk for malnutrition or malnourished. The subsample included 80 subjects with poor nutritional status in the comprehensive care group, 87 in the interdisciplinary care group, and 85 in the usual care group.InterventionsThe 3 care models were usual care, interdisciplinary care, and comprehensive care. Usual care provided no in-home care, interdisciplinary care provided 4 months of in-home rehabilitation, and comprehensive care included management of depressive symptoms, falls, and nutrition as well as 1 year of in-home rehabilitation.MeasurementsData were collected on nutritional status and physical functions, including range of motion, muscle power, proprioception, balance and functional independence, and analyzed using a generalized estimating equation approach. We also compared patients' baseline characteristics: demographic characteristics, type of surgery, comorbidities, length of hospital stay, cognitive function, and depression.ResultsPatients with poor nutritional status who received comprehensive care were 1.67 times (95% confidence interval 1.06–2.61) more likely to recover their nutritional status than those who received interdisciplinary and usual care. Furthermore, the comprehensive care model improved the functional independence and balance of patients who recovered their nutritional status over the first year following discharge, but not of those who had not yet recovered.ConclusionsAn in-home program using the comprehensive care model with a nutritional component effectively improved the nutritional status of hip-fractured patients with poor nutrition. This comprehensive care intervention more effectively improved recovery of functional independence and balance for patients with recovered nutritional status.     

Two European Examples of Acute Geriatric Units Located Outside of a General Hospital for Older Adults With Exacerbated Chronic Conditions

ObjectiveThroughout Europe, the number of older adults requiring acute hospitalization is increasing. Admission to an acute geriatric unit outside of a general hospital could be an alternative. In this model of acute medical care, comprehensive geriatric assessment and rehabilitation are provided to selected older patients. This study aims to compare patients' diagnoses, characteristics, and outcomes of 2 European sites where this care occurs.DesignExploratory cohort study.Setting and participantsSubacute Care Unit (SCU), introduced in 2012 in Barcelona, Spain, and the Acute Geriatric Community Hospital (AGCH), introduced in 2018 in Amsterdam, the Netherlands. The main admission criteria for older patients were acute events or exacerbations of chronic conditions, hemodynamic stability on admission, and no requirement for complex diagnostics.MeasuresWe compared setting, characteristics, and outcomes between patients admitted to the 2 units.ResultsData from 909 patients admitted to SCU and 174 to AGCH were available. Patients were admitted from the emergency department or from home. The mean age was 85.8 years [standard deviation (SD) = 6.7] at SCU and 81.9 years (SD = 8.5) (P < .001) at AGCH. At SCU, patients were more often delirious (38.7% vs 22.4%, P < .001) on admission. At both units, infection was the main admission diagnosis. Other diagnoses included heart failure or chronic obstructive pulmonary disease. Five percent or less of patients were readmitted to general hospitals. Average length of stay was 8.8 (SD = 4.4) days (SCU) and 9.9 (SD = 7.5) days (AGCH).Conclusions and ImplicationsThese acute geriatric units are quite similar and both provide an alternative to admission to a general hospital. We encourage the comparison of these units to other examples in Europe and suggest multicentric studies comparing their performance to usual hospital care.     

ACE units take a wholistic, team approach to meet the needs of an aging America. A fresh model for gerontology

Even in their senior years, baby boomers will pose an enormous challenge to hospitals, which must find new ways to provide comprehensive, quality geriatric care. A number of hospitals have established ACE units, which take a wholistic, team approach to treating older patients, and appear to improve outcomes, satisfaction and maybe the bottom line.     

Direct Admission to Intermediate Care for Older Adults With Reactivated Chronic Diseases as an Alternative to Conventional Hospitalization

BackgroundWhen reactivations of chronic diseases cannot be managed at home, postacute intermediate-care geriatric units (ICGUs) might provide adequate and specialized support to primary care, based on comprehensive geriatric assessment and rehabilitation.ObjectivesTo explore if direct admission to ICGUs of older adults with reactivated chronic diseases or acute common conditions superimposed to chronic diseases might be an alternative clinical pathway to conventional acute hospitalization followed by intermediate care rehabilitation.MethodsQuasiexperimental pilot study. We compared characteristics at admission and outcomes at discharge between two groups admitted to our ICGU: the first one admitted directly, and the second one admitted to complete treatment and rehabilitation after discharge from acute hospital.ResultsSixty-five patients from the same primary care area (mean age ± SD 85.6 ± 7.2, 66% women) were admitted to the ICGU for the same main diagnostics, mainly reactivation of heart failure and chronic obstructive pulmonary disease: 32 directly from home (DA) and 33 following acute hospital discharge (HD). Baseline clinical, functional, and social characteristics, as well as outcomes at discharge, including mortality and acute transfers, were comparable between groups. Global length of stay was significantly higher in HD, compared with DA (60.8 ± 26.6 vs 38.4 ± 23 days, P < .001).ConclusionsFrom our preliminary results, direct admission to geriatric intermediate care units might represent a potential alternative to acute hospitalization for selected older patients.     

家庭医疗干预对改善老年慢性病患者心理社会功能的影响

目的 以经济条件相对落后的中小城市社区为现场,实施家庭医疗干预试验,探索社区卫生服务对老年慢性疾病患者身心康复的影响。方法 以老年慢性疾病患者为对象,实施家庭医疗护理干预;以同期、同类住院病人作对照,采用多元逐步线性顺归方法分析了两组病人的心理健康恢复情况及影响因素。结果 社区病人与住院病人在症状、体征等生理机能方面的恢复,差异无统计学意义,但社区病人心理功能与社会功能的康复略优于住院病人。结论 家庭医疗护理对病人的心理社会功能恢复更有利,因此,开展家庭医疗护理干预是解决老年慢性病患者就医难、住院更难的有效手段之一。     

Factors Associated With Discharge Destination in Older Patients: Finnish Community Hospital Cohort Study

ObjectivesPrimary care physician-led community hospitals provide basic hospital care for older people in Finland. Yet little is known of the outcomes of the care. We investigated factors associated with discharge destination after hospitalization in a community hospital and the role of active rehabilitation during the stay.DesignProspective observational study.Setting and ParticipantsShort-term community hospital stays of older adults (≥65 years) living in the Kuopio University Hospital district in central and eastern Finland.MethodsData on short-term (1-31 days) hospital stays from 51 community hospitals were collected with an electronic survey between January and June 2016. Physicians, secretaries, and rehabilitation staff from each community hospital completed the data collection form. Discharge destination was defined as home, residential care or death, and active rehabilitation as frequency of rehabilitation at least once a day. Analyses were conducted using the Bayesian approach and the BayesiaLab 9.1 tool.ResultsData of 11,628 community hospital stays were analyzed. The patients' mean age was 81.6 years (SD 7.9), and 57.5% were women. A younger age (65-74 years), a high number of rehabilitation staff (>2 per 10 patients), and receiving rehabilitation at least once a day were associated with discharging patients to their own homes. Daily rehabilitation was associated with returning to home in all patient groups.Conclusions and ImplicationsOlder patients admitted to a community hospital for any reason may benefit from active rehabilitation. The role of community hospitals in the acute care and rehabilitation of older patients is important in aging societies.     

Assessing quality of end-of-life hospital care in a southern European regional health service

OBJECTIVES: During the final period of life, patients with cancer in the Basque Country are given treatment in different types of hospital care. This study compared the quality of care according to the type of care in one of the autonomous communities in Spain. METHODS: A retrospective study was carried out of cancer patients who died in conventional hospital services, home hospitalization services, and palliative care units. In addition to hospital stay and readmission number, variables based on the recommendations of Spanish Society for Palliative Care were studied. RESULTS: End-of-life was diagnosed in 57 percent of a sample of 486 patients, 3 days before death (median). The use of symptom control scales was only documented in the clinical records of eight patients. Sociofamily evaluation was not found. Patients in conventional hospital services were less frequently diagnosed with end-of-life and agony and were significantly different from the rest in the reasons for admission, symptoms assessed, drugs used, administration routes, and dosage forms. Pain was evaluated in 50 percent of the patients and was better controlled in palliative care units. Patients not diagnosed with agony (52 percent) were more frequently not given specific treatment. CONCLUSIONS: End-of-life in cancer patients was diagnosed too late. The quality of care in palliative care units and by home hospitalization service was better than that in conventional hospitalization. Nevertheless, there were areas for improvement in the three modalities of care.     

基于住院患者体验的地市级公立医院服务质量研究

[目的]分析地市级公立医院住院患者在医疗技术、医德医风、服务态度、流程管理、医疗费用、就医环境等方面的就医体验,对地市级公立医疗服务质量进行科学评估,为进一步提高地市级公立医院服务质量提供依据.[方法]从某市域内选取4家公立医院的518名患者进行面对面问卷调查.采用描述性分析方法、Friedman M秩和检验、Pear...     

Long-term care elderly residents in general hospitals

Long-term care facilities for the elderly have regularly to work together with general hospitals to provide care to acutely ill residents or when they require all together more complex diagnostic procedures and multi-specialty care. The decision to hospitalize a nursing home elderly resident is multifactorial and it is based on factors such as illness severity and care facility infrastructure. Hospitalizations have benefits and risks such developing iatrogenic diseases, delirium, and functional decline, which may deteriorate patients' general condition and their quality of life during and/or after hospitalization. This study aimed at addressing specific aspects of assessment, treatment and management of nursing home elderly who require to be hospitalized, especially focusing on their effective care. Common conditions such delirium, iatrogenic diseases, poor nutrition, functional decline, hospice care and special characteristics of nursing home elderly during their admission to general hospitals are discussed.     

Home care before and after hospitalization for acute myocardial infarction in Alberta, Canada

Home care services are provided to about 10% of those admitted to hospital for acute myocardial infarction and about 20% of those discharged from hospital. The use of home care in patients with an acute myocardial infarction is growing in Alberta over the brief time span of this four year study. Those that received home care prior to a hospitalization for acute myocardial infarction were "old and frail" with a high mortality rate during and after hospitalization. The provision of home care after hospitalization selected those patients that stay in hospital longer and required more hospital care. BACKGROUND: The use of home care before and after hospitalization for acute myocardial infarction is described. METHODS: Hospital discharge abstracts were used to identify patients hospitalized in alberta, canada for acute myocardial infarction which were then linked to home care administrative data. RESULTS: There were 12,648 patients with acute myocardial infarction from April 1, 1995 until March 31, 1999. Home care within 60 days prior to hospitalization was provided for 8.7% of patients with acute myocardial infarctions (n = 1097) which significantly (p = 0.023) increased from 7.6% in the fiscal year 1995/6 to 9.5% in the fiscal year 1998/9. Home care within 60 days after hospitalization was provided to 16.4% of patients with acute myocardial infarctions (n = 2076) which significantly (p < 0.000) increased from 14.1% in the fiscal year 1995/6 to 18.1% in fiscal year 1998/9. Recipients of home care were significantly older, had more comorbidities, and greater severity of illness, but were less likely to undergo coronary artery revascularization during hospitalization. After multivariate adjustment, length of hospital stay, 60 day re-admissions, and mortality were higher in those receiving home care post hospitalization. Nearly half of those receiving home care prior to hospitalization died within one year. 80% of those receiving home care prior to admission also received home care services after hospitalization. CONCLUSION: Those patients who received home care prior to a hospitalization for acute myocardial infarction were "old and frail" with a high mortality rate during and after hospitalization. The provision of home care after hospitalization selected those patients that stay in hospital longer and required more hospital care.