An evaluation of an alternative to long-stay hospital care for frail elderly patients: II. Costs and effectiveness.

This paper provides the main findings of an evaluation of a service to provide alternative care at home for patients receiving long-stay hospital care. Elderly people receiving the service were compared with a group of similar patients in an adjacent health district. The paper presents data on length of time at home and in hospital, changes in quality of life and care of elderly people, and effects upon informal carers for the two groups. Elderly people receiving community-based care had a higher quality of life, and there was no evidence of greater stress upon their carers. The community-based service, although it involved extra costs to the social services department, had lower costs for the health service and society as a whole than long-stay hospital provision. It is concluded that the model of care can effectively integrate the new approach of case management into an existing geriatric multidisciplinary team.     

Care of the dying in long-term care settings

A team of caregivers provides health care in nursing homes. This team is led by a nurse and includes a physician, nursing assistants, and other nursing home staff. Given the future demand for palliative care in this setting, the roles of all caregivers need to be supported with meaningful training, improved working conditions, and respect for each caregiver's contribution.     

Individual versus team case management in optimizing community care for chronically ill patients with dementia

Secondary analyses of a randomized trial comparing two models of case management of community residing chronically ill elderly showed that the greatest cost savings of the more intensive neighborhood-based team model, as opposed to the centralized individual model, were in the group with dementia. Estimated costs of health care in the team group were 41% lower than costs for the control group. No differences in survivorship, functional and care need status, or in caregiver satisfaction were found, suggesting no negative effect of reduction in use. Team case managers had much smaller caseloads, made many more home visits, (with much more counseling for family support), and made more referrals for medical evaluation, respite, and day care than did case managers for the control group.     

The integrated team approach to the care of the patient with cardiovascular disease

Cardiovascular disease (CVD) is a costly, worldwide problem with significant annual morbidity and mortality. Guideline-based primary and secondary prevention is effective in preventing and controlling CVD. Such prevention must be implemented by an integrated team of physician-directed health professionals, during both the inpatient and the outpatient phases of care. Appropriate team members may include, but are not limited to, nurses, advanced practice nurses, physician assistants, dietitians, physical therapists, psychologists, pharmacists, cardiac fellows, exercise physiologists, and case managers. During the acute phase of care, various teams are activated as appropriate to specific needs of the patient in the medical (invasive and noninvasive) and surgical specialties. The outpatient phase varies with diagnosis and condition of the patient and team members are involved as needed. An integrated team effort is essential to the best care for each patient regarding individual management and will assure that evidence-based guidelines, in both treatment and secondary prevention, are implemented.     

An outreach geriatric medication advisory service in residential aged care: a randomised controlled trial of case conferencing

BACKGROUND: efficient strategies are needed to provide specialist advice in nursing homes to ensure quality medical care. We describe a case conference intervention involving a multidisciplinary team of health professionals. OBJECTIVES: to evaluate the impact of multidisciplinary case conferences on the appropriateness of medications and on patient behaviours in high-level residential aged care facilities. DESIGN: cluster-randomised controlled trial. SETTING: ten high-level aged care facilities. PARTICIPANTS: 154 residents with medication problems and/or challenging behaviours were selected for case conference by residential care staff. INTERVENTION: two multidisciplinary case conferences involving the resident's general practitioner, a geriatrician, a pharmacist and residential care staff were held at the nursing home for each resident. MEASUREMENTS: outcomes were assessed at baseline and 3 months. The primary outcome was the Medication Appropriateness Index (MAI). The behaviour of each resident was assessed via the Nursing Home Behaviour Problem Scale. RESULTS: 45 residents died before follow-up. Medication appropriateness improved in the intervention group [MAI mean change 4.1, 95% confidence interval (CI) 2.1-6.1] compared with the control group (MAI mean change 0.4, 95% CI -0.4-1.2; P < 0.001). There was a significant reduction in the MAI for benzodiazepines (mean change control -0.38, 95% CI -1.02-0.27 versus intervention 0.73, 95% CI 0.16-1.30; P = 0.017). Resident behaviours were unchanged after the intervention and the improved medication appropriateness did not extend to other residents in the facility. CONCLUSION: multidisciplinary case conferences in nursing homes can improve care. Outreach specialist services can be delivered without direct patient contact and achieve improvements in prescribing.     

Cost-effectiveness of home care.

Home health care is uniformly accepted by patients, caregivers, health professionals, policymakers, and the public as a desirable way to provide care to disabled individuals and the frail elderly. Given the lack of positive impact of home care upon functional status, cost, and nursing home use, as well as documented additional cost, future research must focus upon positive aspects from past experiences. Careful targeting of patients most likely to benefit from this care has produced better results. Satisfaction with care has been shown consistently. Managed home health care may have the potential, especially the impact of physician involvement with team care on hospital use, to contain costs. The intuitive belief that home care is beneficial and a worthwhile expense, held by policymakers and health care professionals alike, needs to be fully researched by studies that carefully examine the wide spectrum of home care benefits for disabled or chronically ill individuals in relation to varying cost levels that the population and health care system can absorb. The challenge is here, and those who believe in home care need to make use of the results of these previous, rather nonsupportive studies. Additional research is needed to measure the impact of active physician participation in the team care provision of home care services and the impact of managed home care on the cost of hospital care in the population most at risk for recurrent hospitalization. This same research must document not only more effective targeting of individuals, but also the maintenance of increased satisfaction with care--strongest motive for the need to prove the cost-effectiveness of home care.     

European principles of haemophilia care

Summary.  As the management of haemophilia is complex, it is essential that those with the disorder should have ready access to a range of services provided by a multidisciplinary team of specialists. This document sets out the principles of comprehensive haemophilia care in Europe. Within each country there should be a national organization which oversees the provision of specialist Comprehensive Care Centres that provide the entire spectrum of clinical and laboratory services. Depending upon the size and geographical distribution of the population, a network of smaller haemophilia centres may also be necessary. There should be arrangements for the supply of safe clotting factor concentrates which can also be used in home treatment and prophylaxis programmes. A national register of patients is recommended along with collection of treatment statistics. As comprehensive haemophilia care is multidisciplinary by nature, the need for education and research programmes for all staff members is emphasized: Members of the Interdisciplinary Working Group not represented in the list of authors are mentioned in Section 4 of this document.     

Geriatric assessment in the home.

Home assessment of health, environmental, and social factors, and their interactions that may impair the patient's functional capabilities and quality of life can play a critical role in the care of frail elderly patients. Home assessments can reveal important new health and social problems not identified in a clinical visit. Recent information suggests that home assessment is identified with good patient outcomes. Although this type of assessment is traditionally carried out by a nurse in the context of an interdisciplinary team, an individual primary care physician can also establish an ad hoc, multidisciplinary team to help care for frail elderly patients using principles derived from a comprehensive home assessment.     

多学科团队协作模式在养老机构老年慢性病患者长期护理服务中的应用

目的探讨多学科团队协作护理模式在养老机构老年慢性病患者长期护理服务中的应用效果。方法选取泸州社会福利院老年慢性病患者120例为研究对象。组建多维度、多机构、跨专业的多学科团队,采用多学科团队协作模式进行3个月的长期护理服务。分别在实施多学科团队协作模式前后,采用问卷调查评估患者满意度,采用焦虑自评量表(SAS)和抑郁自评量表(SDS)评定患者心理状态,采用日常生活能力Barthe指数评估量表评估患者日常生活能力,采用美国医学结局研究组健康状问卷(MOSSF-36)评估患者生活质量情况。结果多学科团队协作模式实施后,老年慢性病患者的满意度评分、日常生活能力评分和生活质量评分均高于实施前(P均<0.05),患者心理状态评分均低于实施前(P均<0.05)。结论多学科团队协作模式可以提高养老机构老年慢性病患者的满意度,改善患者的心理状态,提高患者的日常生活能力和生活质量,值得推广应用。     

Quality of patient care by nurse practitioners and physician's assistants: a ten-year perspective.

A remarkable development in primary care is the recent emergence of a new class of health professional: nurse practitioners and physician's assistants. These practitioners diagnose and treat a wide variety of medical problems, usually with supervision by physicians. Their clinical competence has been evaluated in over 40 studies. Twenty-one studies in which care given by nurse practitioners or physician's assistants was directly compared with that given by physicians are analyzed. These studies show that nurse practitioners and physician's assistants provide office-based care that is indistinguishable from physician care. Because these studies were limited in scope, there is no experimental basis for extending this conclusion to care given outside the office, care that is unsupervised, or care of the seriously ill patient.     

Characteristics of home care supporting clinics providing home care for frail elderly persons living alone in Japan

To explore the characteristics of home care supporting clinics providing home care for frail elderly persons living alone (EPLA), a self-administered questionnaire was mailed to 998 home care supporting clinics in the 23 wards of Tokyo, Japan between July and August 2009. Clinics providing home care for the frail EPLA significantly collaborated with 4 or more home visit nursing stations (42.5%) and 4 or more care managers (58.7%) and had sufficient medical care equipment, such as an oxygen inhaler, ventilator, and intravenous hyperalimentation. Sixty-one percent of the clinics which provided care for the 18 patients who died at home collaborated with 4 or more care managers. Our findings suggest that the factors enabling home care for frail EPLA are as follows: (1) collaboration with care managers, (2) collaboration with home visit nursing stations, (3) sufficient medical care equipment.     

NETT coordinators: researchers, caregivers, or both?

The National Emphysema Treatment Trial (NETT) required the coordinated evaluation and treatment of thousands of patients with emphysema simultaneous with data collection to evaluate the safety and efficacy of surgery versus medical treatment for emphysema. These tasks were performed by a multidisciplinary team led by the clinic coordinator at each NETT center. The clinic coordinators functioned as members of the research team as well as communicators, managers, and members of the patient care team. The clinic coordinators' ability to balance these roles was instrumental to the successful completion of NETT, as evidenced by randomization of 1,218 subjects with only 10 subjects being lost to follow-up. Striving to achieve recruitment goals and working to retain study subjects was very labor intensive. The coordinator role was complicated by the study population's severity of illness combined with the complexity of the NETT protocol. Management of the study subjects' medical condition had to be balanced with the management of a multicenter, randomized clinical trial to ensure quality data collection and protocol adherence.     

Overcoming Challenges to Teamwork in Patient-Centered Medical Homes: A Qualitative Study

Background

There is emerging consensus that enhanced inter-professional teamwork is necessary for the effective and efficient delivery of primary care, but there is less practical information specific to primary care available to guide practices on how to better work as teams.

Objective

The purpose of this study was to describe how primary care practices have overcome challenges to providing team-based primary care and the implications for care delivery and policy.

Approach

Practices for this qualitative study were selected from those recognized as patient-centered medical homes (PCMHs) via the most recent National Committee for Quality Assurance PCMH tool, which included a domain on practice teamwork.

Participants

Sixty-three respondents, ranging from physicians to front-desk staff, were interviewed from May through December of 2013. Practice respondents came from 27 primary care practices ranging in size, type, geography, and population served.

Key Results

Practices emphasizing teamwork overcame common challenges through the incremental delegation of non-clinical tasks away from physicians. The roles of medical assistants and nurses are expanding to include template-guided information collection from patients prior to the physician office visit as well as many other tasks. The inclusion of staff input in care workflow redesign and the use of data to demonstrate how team care process changes improved patient care were helpful in gaining staff buy-in. Team “huddles” guided by pre-visit planning were reported to assist in role delegation, consistency of information collected from patients, and structured communication among team members. Nurse care managers were found to be important team members in working with patients and their physicians on care plan design and execution. Most practices had not participated in formal teamwork training, but respondents expressed a desire for training for key team members, particularly if they could access it on-site (e.g., via practice coaches or the Internet).

Conclusions

Participants who adopted new forms of delegation and care processes using teamwork approaches, and who were supported with resources, system support, and data feedback, reported improved provider satisfaction and productivity. There appears to be a need for more on-site teamwork training.KEY WORDS: Primary health care, Patient care team, Patient-centered medical home, Quality of health care, Practice management     

Managers' experiences of providing end-of-life care under the Home Care Package Program

Objective

The study explored the experiences of Australian aged care providers in supporting clients on a home care package to die at home.

Methods

Semistructured interviews were conducted with 13 aged care managers responsible for delivering services under the Home Care Package Program. Interviews were analysed thematically.

Results

Four themes emerged that illuminated managers' experiences: struggling to meet a preference to die at home; lack of opportunities to build workforce capacity in end-of-life care; challenges in negotiating fragmented funding arrangements between health and aged care providers; and mixed success in collaborating across sectors.

Conclusions

Aged care providers want to support older Australians who prefer to stay at home at the end of life. However, most clients are admitted to a residential facility when their care needs exceed a home care budget long before a specialist palliative care team will intervene. Budgets for health and aged care providers must be sufficient and flexible to support timely access to end-of-life care, to reward collaboration across sectors and to invest in building palliative care skills in the nursing and personal care workforce.     

Multidisciplinary coordinated care for Type 2 diabetes: A qualitative analysis of patient perspectives

Aims

To explore the patient perspective on coordinated multidisciplinary diabetes team care among a socioeconomically diverse group of adults with type 2 diabetes.

Generation: a corporate-sponsored retiree health care program.

Generation is a geriatric clinic program sponsored by Southern California Edison Company for the company's retirees and their dependents. This innovative program uses a multidisciplinary team approach, including a comprehensive health and psychosocial assessment, complete medication review, retiree advisors, health promotion programs, and case management services. In its pilot phase, Generation has served more than 175 Edison retirees and dependents aged 53-96. In addition to traditional medical care, participants receive aggressive intervention regarding polypharmacy problems, health education workshops, individual and group counseling, and access to community resources. Ongoing research seeks to evaluate the program's effectiveness in providing high-quality health care services while containing costs.     

A prospective study of nosocomial infections in a chronic care facility

To elucidate the epidemiology of nosocomial infections occurring in nursing homes and chronic care facilities, the authors undertook a prospective study of patients requiring two different levels of nursing care. The overall rate of infection was higher on the intermediate care ward than on the nursing home ward (1.35 versus 0.67 infections/100 patient care days). Pneumonias and symptomatic urinary tract infections accounted for 49 per cent of all infections. Eight of ten cases of pneumonia occurring on the nursing home ward were diagnosed in the winter months, and no case was diagnosed in the summer months. Resistance to gentamicin, tobramycin, ampicillin, and trimethoprim-sulfa was common among organisms causing symptomatic urinary tract infections.     

Coordination of care for early-stage breast cancer patients

OBJECTIVE: Little is known about how care is coordinated for patients with diseases requiring multidisciplinary treatments. How complex care is coordinated may affect a patient's chance of receiving the full complement of care provided by multiple physicians. We sought to describe approaches used to coordinate care for women with early-stage breast cancer, a disease often treated by multiple different disciplines in the outpatient setting. DESIGN: Case studies of 6 hospitals with in-depth semi-structured interviews with providers of breast cancer care and their support staff. SETTING: Five hospitals in downstate New York and 1 hospital in upstate New York. PARTICIPANTS: Sixty-seven interviews were conducted including 35 physicians, 9 nurses, 4 senior clinical or quality directors, 10 administrative assistants, and 9 patient educators and navigators. MEASUREMENTS AND MAIN RESULTS: Content analysis of interviews revealed 7 different coordination mechanisms including tracking of referrals, patient support, regularly-scheduled multidisciplinary meetings, feedback of performance data, use of protocols, computerized systems, and a single physical location. No site had any systematic mechanism to track results of referrals or receipt of care provided by other physicians. All physicians used follow-up appointments to check on patients' receipt of care, but only half of the physicians had an approach to follow up missed appointments. Real-time multidisciplinary meetings with a patient management focus and systematic use of patient support programs, such as patient educators and navigators, were perceived to be valuable. CONCLUSIONS: Numerous coordination mechanisms exist. No site has the ability to systematically track care provided by multiple different specialists. The most valued mechanisms are under the hospital's aegis. Hospitals should consider implementing coordination mechanisms to improve delivery of multidisciplinary care.     

The role of physicians in home health care.

Physician involvement in home care has declined markedly over the past 50 years. By contrast, the renaissance in home care in the US over the last decade has created a pressing need for greater physician participation and new roles for physicians as members of the home care team. This article reviews these developments and identifies the need for improved medical education and physician reimbursement if the desired physician involvement in home care is to become a reality.     

Effects of a Health and Social Collaborative Case Management Model on Health Outcomes of Family Caregivers of Frail Older Adults: Preliminary Data from a Pilot Randomized Controlled Trial

Family caregiving is an important form of informal care provided to frail, community‐dwelling older adults. This article describes a health and social collaborative case management (HSC‐CM) model that aims to optimize the support given to caregivers of frail elderly adults. The model was characterized by a comprehensive assessment to identify the caregiver's needs; a case management approach to provide integrated, coordinated, continued care; and multidisciplinary group‐based education customized to the caregiver's individualized needs. A pilot study using a randomized controlled trial study design was conducted to evaluate the effects of the HSC‐CM on caregiver burden and health‐related quality of life of family caregivers of frail elderly adults. Sixty family caregivers (mean age 61.3 ± 15.5) of frail older adults recruited from a community center for elderly adults in Hong Kong were randomly assigned to receive a 16‐week HSC‐CM intervention or usual care. Case managers who conducted a comprehensive assessment of the care dyads to identify caregiver needs using a case management approach to optimize care coordination and continuity led the HSC‐CM. These case managers served as liaisons for multidisciplinary efforts to provide group‐based education according to caregiver needs. Family caregivers who participated in the HSC‐CM had significantly greater improvement on the Caregiver Burden Index (p = .03) and on the Medical Outcomes Study 36‐item Short‐Form Survey subscales, including vitality (p = .049), social role functioning (p = .047), and general well‐being (p = .049). This study provides preliminary evidence indicating that client‐centered care, a case management approach, and multidisciplinary support are crucial to an effective caregiving support initiative. A full‐scale study is required to validate these findings.