Effect of Continuity of Care on Hospital Utilization for Seniors With Multiple Medical Conditions in an Integrated Health Care System

PURPOSE

Lower continuity of care has been associated with higher rates of adverse outcomes for persons with multiple chronic medical conditions. It is unclear, however, whether this relationship also exists within integrated systems that offer high levels of informational continuity through shared electronic health records.

METHODS

We conducted a retrospective cohort study of 12,200 seniors with 3 or more chronic conditions within an integrated delivery system. Continuity of care was calculated using the Continuity of Care Index, which reflects visit concentration with individual clinicians. Using Cox proportional hazards regression permitting continuity to vary monthly until the outcome or censoring event, we separately assessed inpatient admissions and emergency department visits as a function of primary care continuity and specialty care continuity.

RESULTS

After adjusting for covariates (demographics; baseline, primary, and specialty care visits; baseline outcomes; and morbidity burden), greater primary care continuity and greater specialty care continuity were each associated with a lower risk of inpatient admission (respective hazard ratios (95% CIs) = 0.97 (0.96, 0.99) and 0.95 (0.93, 0.98)) and a lower risk of emergency department visits (respective hazard ratios = 0.97 (0.96, 0.98) and 0.98 (0.96, 1.00)). For the subgroup with 3 or more primary care and 3 or more specialty care visits, specialty care continuity (but not primary care continuity) was independently associated with a decreased risk of inpatient admissions (hazard ratio = 0.94 (0.92, 0.97)), and primary care continuity (but not specialty care continuity) was associated with a decreased risk of emergency department visits (hazard ratio = 0.98 (0.96, 1.00)).

CONCLUSIONS

In an integrated delivery system with high informational continuity, greater continuity of care is independently associated with lower hospital utilization for seniors with multiple chronic medical conditions. Different subgroups of patients will benefit from continuity with primary and specialty care clinicians depending on their care needs.     

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.     

Cost-Effectiveness of Care Coordination for Children With Chronic Noncomplex Medical Conditions: Results From a Multicenter Randomized Clinical Trial

ObjectivesTo assess the cost-effectiveness of care coordination, compared with standard care, for children with chronic noncomplex medical conditions.MethodsA total of 81 children aged between 2 and 15 years newly diagnosed with a noncomplex chronic condition were randomized to either care coordination or standard care as part of a multicenter randomized controlled trial. Families receiving care coordination were provided access to an Allied Health Liaison Officer, who facilitated family-centered healthcare access across hospital, education, primary care, and community sectors. Costs were estimated over a 12-month period from the perspective of the Australian health system. Health outcomes were valued as quality-adjusted life-years (QALYs). Caregiver productivity costs were included in an alternative base-case analysis, and key assumptions were tested in a series of one-way sensitivity analyses. A probabilistic sensitivity analysis was conducted to investigate the overall impact of uncertainty in the data.ResultsChildren in the intervention arm incurred an average of $17 in additional health system costs (95% confidence interval ?3861 to 1558) and gained an additional 0.031 QALYs (95% confidence interval ?0.29 to 0.092) over 12 months, producing an incremental cost-effectiveness ratio of $548 per QALY. When uncertainty was considered, there was a 73% likelihood that care coordination was cost-effective from a health system perspective, assuming a willingness to pay of $50 000 per QALY. This increased to 78% when caregiver productivity costs were included.ConclusionsCare coordination is likely to be a cost-effective intervention for children with chronic noncomplex medical conditions in the Australian healthcare setting.     

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.     

The Impact of a Primary Care Telepsychiatry Program on Outcomes of Managed Care Older Adults

ObjectiveThe goal of this study was to assess the outcomes of a primary-based telepsychiatry intervention program for older managed care enrollees with depression/anxiety and with limited access to in-person psychiatric care.DesignA pre-post design was used to examine service use (n = 218) and severity of depression (n = 204). Enrollment, claims, and depression and anxiety score data were obtained from the medical group. The implementation process and self-reported outcomes were examined.Setting and ParticipantsThe program was funded by the Senior Care Action Network (SCAN) group and implemented by a large medical group serving older adults who were identified as needing outpatient psychiatric care, including those with psychiatric hospitalizations, depression/anxiety disorders, comorbid substance use disorders, or other multiple comorbidities.MethodsPoisson regressions were used to examine changes in predicted rates of outpatient services, emergency department visits, and hospitalizations up to 24 months prior and 24 months following the first telepsychiatry visit. Changes in predicted severity of depression up to 2 quarters prior and 3 quarters following the first telepsychiatry visit were examined.ResultsThe number of outpatient services declined significantly by 0.24 per patient per 6-month time frame following the first telepsychiatry visit. The number of emergency department visits and hospitalizations also declined after the first visit (0.07 and 0.03 per patient per 6-month time frame, respectively). Depression severity scores also declined in the quarters following the first visit (1.52). The medical group reported improvements in both wait time for appointments and no-show rates with the integration of telepsychiatry in primary care.Conclusions and ImplicationsThe telepsychiatry program lowered service use, depression severity, and increased better access to psychiatry care. The findings highlight the potential benefits of sustaining and expanding the telepsychiatry program by SCAN and other plans facing a limited supply of psychiatrists.     

城乡医保一体化管理对临床医生工作影响的思考

以医院医保新农合部门管理职工医保、居民医保、新农合工作中遇到的困难为切入点,充分认识城乡医保一体化管理的必要性及迫切性.强调从体制、机制上营造宽松条件,避免医务人员在研究不同医保、新农合政策上花费更多的时间,让医生们能有更多的精力致力于临床医学实践和科学研究,从而实现真正意义上的高质量、高效率地满足全民医保需要,从根本上提高全民的医疗保障水平.     

城市老年人医养结合服务需求及其影响因素分析

目的:探讨城市老年人医养结合服务需求的现状及其影响因素。方法:采用两阶段随机抽样的方法,运用“城市老年人医养结合服务需求量表”对南京市440名城市老年人进行抽样调查。结果:城市老年人的医养结合服务需求水平比较高(3.7475±0.31499);年龄、性别、收入水平和健康状况是城市老年人医养结合服务需求的影响因素(P<0.05),年龄比较大、收入水平比较高、健康状况比较差的男性城市老年人的医养结合服务需求最高。结论:积极推进医养结合服务供给侧结构性改革,面向全体老年人提供有针对性的、多元化的医养结合服务。     

军队医院集团化与一体化区域医疗服务平台的构建

随着军队卫勤保障体制改革和卫生信息化建设的不断推进,军队医院集团化发展的趋势更加明显。通过建立包括临床数据中心、实时远程会诊系统和军人电子健康档案的一体化区域医疗服务平台,并使之具备标准规范、信息共享、诊疗便捷,安全保密的特性,可有效解决基层部队医疗条件及专业技术力量不足等问题。     

VNA HouseCalls of Greater Cleveland,Ohio: Development and Pilot Evaluation of a Program for High-Risk Older Adults Offering Primary Medical Care in the Home

ABSTRACT

The need for primary medical care in the home will increase with a growing elderly and disabled population. The effectiveness of the service must be assessed in light of its relatively high costs. The aim of this study was to evaluate VNA HouseCalls of Greater Cleveland, Ohio during its first year of operations. The program targets high-risk older adults using teams of advanced practice nurses and physicians. The pilot evaluation focused on the attainment of identified program goals. Data collection techniques included clinical record review (N = 139), mailed referral source satisfaction survey, and both mailed and telephone interview patient satisfaction surveys. The results showed that the typical patient served by VNA HouseCalls was a homebound woman in advanced old age with regular family contact and both physical and mental disorders. When asked, the typical patient indicated that without the program she would not have received the care that she needed. VNA HouseCalls helped in preventing functional decline and reducing hospitalization. It received high satisfaction ratings from both referral sources and patients. Study findings suggest that primary care in the home bears further examination for addressing community need and affecting positive patient outcomes for high risk older adults.     

医护一体化模式在胸腰椎骨折患者护理中的应用

目的探讨医护一体化模式在胸腰椎骨折患者护理中的应用效果。方法将46例胸腰椎骨折患者随机分为对照组(n=23)和观察组(n=23)。对照组采用常规护理,观察组在对照组基础上采用医护一体化模式,两组均连续护理14 d。对比两组患者的相关手术指标、护理前后VAS评分及并发症发生率。结果观察组的术中出血量少于对照组,手术时间、住院时间短于对照组(P均<0.05)。护理前,两组的VAS评分比较差异无统计学意义(P>0.05);护理后,两组的VAS评分低于护理前,且观察组的VAS评分低于对照组(P均<0.05)。观察组的并发症发生率为8.70%,明显低于对照组的34.78%(P <0.05)。结论医护一体化模式在胸腰椎骨折患者护理中的应用效果显著,可有效减轻患者的疼痛情况,减少术中出血量,缩短手术时间和住院时间,降低并发症发生率,值得临床推广应用。     

Walking the Line: Navigating Market and Gift Economies of Care in a Consumer‐Directed Home‐Based Care Program for Older Adults

Context

Paid caregivers of low-income older adults navigate their role at what Hochschild calls the “market frontier”: the fuzzy line between the “world of the market,” in which services are exchanged for monetary compensation, and the “world of the gift,” in which caregiving is uncompensated and motivated by emotional attachment. We examine how political and economic forces, including the reduction of long-term services and supports, shape the practice of “walking the line” among caregivers of older adults.

Methods

We used data from a longitudinal qualitative study with related and nonrelated caregivers (n = 33) paid through California’s In-Home Supportive Services (IHSS) program and consumers of IHSS care (n = 49). We analyzed the semistructured interviews (n = 330), completed between 2010 and 2014, using a constructivist grounded theory approach.

Findings

Related and nonrelated caregivers are often expected to “gift” hours of care above and beyond what is compensated by formal services. Cuts in formal services and lapses in pay push caregivers to further “walk the line” between market and gift economies of care. Both related and nonrelated caregivers who choose to stay on and provide more care without pay often face adverse economic and health consequences. Some, including related caregivers, opt out of caregiving altogether. While some consumers expect that caregivers would be willing to “walk the line” in order to meet their needs, most expressed sympathy for them and tried to alter their schedules or go without care in order to limit the caregivers’ burden.

Conclusions

Given economic and health constraints, caregivers cannot always compensate for cuts in formal supports by providing uncompensated time and resources. Similarly, low-income older adults are not competitive in the caregiving marketplace and, given the inadequacy of compensated hours, often depend on unpaid care. Policies that restrict formal long-term services and supports thus leave the needs of both caregivers and consumers unmet.     

Primary Care Physician Insights Into a Typology of the Complex Patient in Primary Care

PURPOSE

Primary care physicians play unique roles caring for complex patients, often acting as the hub for their care and coordinating care among specialists. To inform the clinical application of new models of care for complex patients, we sought to understand how these physicians conceptualize patient complexity and to develop a corresponding typology.

METHODS

We conducted qualitative in-depth interviews with internal medicine primary care physicians from 5 clinics associated with a university hospital and a community health hospital. We used systematic nonprobabilistic sampling to achieve an even distribution of sex, years in practice, and type of practice. The interviews were analyzed using a team-based participatory general inductive approach.

RESULTS

The 15 physicians in this study endorsed a multidimensional concept of patient complexity. The physicians perceived patients to be complex if they had an exacerbating factor—a medical illness, mental illness, socioeconomic challenge, or behavior or trait (or some combination thereof)—that complicated care for chronic medical illnesses.

CONCLUSION

This perspective of primary care physicians caring for complex patients can help refine models of complexity to design interventions or models of care that improve outcomes for these patients.     

适合社区的“医养结合”新养老模式探索

人口老龄化进程的加速,老年患病比例的增加,就医质量需求的增长,让如何养老成为了当今重要的热点社会问题。传统的养老方式无法满足现有的养老需求,促使新型养老模式应运而生。新养老模式“医养结合”的提出,已经得到各方面的积极响应。但养老机构医疗服务能力较弱、专业人才短缺,医养服务质量低、社区卫生服务中心的利用率不高、政策细则不完善、法律法规不健全等问题仍是医养结合养老模式发展面临的巨大问题和困难。该文在此基础上提出建议,构建多层次的“医养结合”服务体系、多层次专业人员培养模式,加快养老服务护理人才队伍建设、改革医疗保险方式,健全护理保险体系、完善相关法律规范,提高政策执行效率,以促进“医养结合”养老模式的迅速发展。     

智慧医疗在社区养老中的使用情况研究

目的:为促进智慧医疗在社区养老中的发展提供对策建议。方法:采用问卷调查和访谈,调查分析智慧医疗在重庆市社区老年人中的使用情况、使用意愿和使用预期,分析原因并提出建议。结果:社区老年人对智慧医疗的认知度和使用率较低,但使用意愿和预期普遍较高。结论:智慧医疗尚未渗入社区养老群体,需通过加大投入、制度规制,树立智慧医疗行业标准;立足需求,优化产品适老化设计,进行适老化改造。     

上海市黄浦区成人基本医疗素养及影响因素研究

目的 了解上海市黄浦区成人基本医疗素养水平现状及其影响因素,为制定健康教育和健康促进的政策及开展干预工作提供科学依据.方法 采用分层多阶段随机抽样的方法,在黄浦区10个街道抽取15~69岁常住人口1000人开展问卷调查.结果 2017年黄浦区成人基本医疗素养监测调查共收回有效问卷1000份.居民基本医疗素养水平为10.1%,医疗服务利用和科学就医两个维度的具备率分别为17.2%及11.7%.不同年龄、婚姻状况、受教育程度、职业、经济状况居民的基本医疗素养水平不全相同,50~60岁年龄组、离异及其他、研究生及以上学历、医生、家庭人均月收入在10000~20000元的居民基本医疗素养水平最高.多因素logistic回归分析结果显示:年龄、受教育程度、职业是影响居民基本医疗素养的重要因素.结论 上海市黄浦区成人基本医疗素养水平较低,应大力提升辖区居民的基本医疗素养水平,尤其是针对年轻人、受教育程度低、家庭人均月收入较低的群体,要开展更多的社区活动,着力加强技能培训,创造支持性环境.     

Mental Health in Primary Care: Perceptions of Augmented Care for Individuals With Serious Mental Illness

Individuals with serious mental illness are at increased risk of developing secondary physical illnesses because of lifestyle and psychiatric treatment–related factors. Many individuals with mental illness participate in primary care clinics, such as Placer County Community Clinic (PCCC), which provides primary care and medication-only psychiatric services to low-income county residents. This qualitative study describes an augmented care program provided to this population at PCCC and explores participant experiences with that program. The augmented program consisted of a full-time social worker and part-time registered nurse working as a team to coordinate care between providers, and provide psychosocial education and illness management support. Previous studies have demonstrated that similar programs result in improved clinical outcomes for people with mental illness but have largely not included perspectives of participants in these pilot programs. This article includes participant reports about medical service needs, barriers, and beneficial elements of the augmented program. Medical service needs included the need to provide input in treatment and to be personally valued. Barriers ranged from doubts about provider qualifications to concerns about medication. Elements of the augmented care program that participants found beneficial were those involving care coordination, social support, and weight management support.