Abstract
BackgroundTo improve continuity and coordination of care in geriatric rehabilitation, an integrated care pathway was developed and implemented in The Netherlands. The purpose of this study was to assess the effects of this pathway on patients and informal caregivers.MethodsTwo cohorts of patients and their informal caregivers were prospectively recruited before implementation of the pathway (2011–2012) and after implementation of the pathway (2013–2014). Primary outcome measures were dependence in activities of daily living in patients (KATZ-15) and self-rated burden among informal caregivers (SRB-VAS). Secondary outcome measures were the frequency of performing extended daily activities, social participation, psychological well-being, quality of life and discharge location (patients) and quality of life and objective care burden (informal caregivers). Outcomes were measured at baseline, after three and after nine months.ResultsNo effect was shown on the KATZ-15 after three and nine months. However, a larger percentage of patients were discharged home in the care pathway cohort (83% vs 58.1% after three months and 88.6% vs 67.4% after nine months; p = 0.004). Furthermore, after three months, patients from the care pathway cohort performed more extended daily activities (p = 0.014) and informal caregivers experienced a lower self-rated burden (p = 0.05). After nine months, these effects disappeared. No differences were found for the other outcome measures.ConclusionsDue to the positive effects of the integrated care pathway, we are inclined to recommend implementing the care pathway in regular care. To have longer lasting effects among patients and informal caregivers, we suggest actively disseminating information about the pathway to primary care providers who are currently still unaware of its content.Trial registrationISRCTN90000867 (date of registration: 07-04-2016).
Highlights
To improve continuity and coordination of care in geriatric rehabilitation, an integrated care pathway was developed and implemented in The Netherlands
Because six patients in the care as usual cohort and seven patients in the care pathway cohort did not participate in the baseline measurement, these patients were not included in the analyses
This study examined if implementation of an integrated care pathway in geriatric rehabilitation resulted in lower dependence in activities of daily living among patients and decreased self-rated burden among informal caregivers
Summary
To improve continuity and coordination of care in geriatric rehabilitation, an integrated care pathway was developed and implemented in The Netherlands. Mentioned problems in these transitional phases are care plans not being communicated from one organization to the other, the transfer of medication lists which are not up-to-date or incomplete, and lack of communication between professionals from different organizations [6,7,8,9,10] Patients and their informal caregivers are often not sufficiently prepared for the transition to the home situation [5]. These problems in continuity of care could result in adverse events among patients, such as insufficient functional improvement, unnecessary hospital readmissions and permanent admission to a nursing home [6, 8, 10]. Inadequate care transitions are a substantial risk factor for high informal caregiver burden [11]
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